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A faulty production line

Offer more same-day phone consultations for urgent patients to reduce burden on 'creaking' A&E, GPs told

GPs should offer more telephone consultations for urgent patients to ensure ‘faster and more consistent same day, every day access to primary care’ and help alleviate the intense pressure on A&E departments, a major NHS England review has concluded.

A report published today by NHS England medical director Professor Sir Bruce Keogh, which sets out plans for two-tier A&E services and a wide-ranging overhaul of urgent care, says GP surgeries provide ‘variable’ responses to patients with urgent care needs. It urges GPs, out-of-hours services, community health teams and NHS 111 to work ‘together and differently’ to ensure patients receive prompt advice and care ’24 hours a day, seven days a week’.

As part of this, the report suggests GP practices should provide ‘prompt telephone consultations’ for more patients, in order to free up additional time to spend with patients who would benefit from face-to-face advice.

Today’s report marks the first phase of Sir Bruce’s review, with the next stage due to ‘develop the tools’ for implementation of his proposals, which is expected to take three to five years. The review was launched in June in response to the perceived crisis in emergency care in England, which health secretary Jeremy Hunt said had been caused by four million extra patients attending A&E as a result of the ‘disastrous’ 2004 GP contract negotiations.

Today’s report proposed a range of new measures to alleviate the burden on A&E services, which Sir Bruce said were ‘creaking at the seams’. They include:

- a revamp of A&E departments to create two levels of emergency department: ‘emergency centres’ and ‘major emergency centres’

- increasing the use of self-care by providing greater information

- improving access for GPs to specialist advice.

Under the proposals, GPs will be expected to provide telephone advice for a ‘significant proportion’ of urgent care work in an attempt to free up face-to-face appointment slots.

The report warned: ‘At the moment, patients contacting their GP’s surgery with an urgent problem receive a very variable response, and may be directed elsewhere.’

The report said NHS England’s aim was to ‘provide faster and consistent same day, every day access to primary care and community services for people with urgent care needs.’

‘This is likely to mean general practice, out-of-hours services, community health teams and NHS 111 services working together, and differently, to ensure that patients with urgent care needs can receive prompt advice and care 24 hours a day, seven days a week.’

‘There are many innovative options to explore. The evidence for prompt telephone consultations is compelling, and can free up appointments to spend with those patients who would benefit from face to face care.’

Other innovations to free up time included GPs leading ‘integrated multidisciplinary teams to manage whole pathways of care including the exacerbations of those patients with long term conditions’, and improving GPs’ access to hospital specialists. The report also identified wider problems around GP access, warning that ‘even the simple task of ringing a GP practice to request an appointment can result in a frustrating assault course on a telephone keypad’.

Professor Keogh said that there is a feeling that this winter will be difficult.

He said: ‘We’re here, really, because A&E is creaking at the seams. It’s not broken, but it is struggling.’

‘When A&Es become busy, it means other parts of the system are creaking, that they’re under stress. It’s against that background that there’s a feeling that this winter will be difficult.’

Professor Keogh added it will take three to five years to enact the change necessary, though NHS England expect several key changes to be in place within six months.

Professor Keith Willett, national director for acute episodes of care and co-author of the report, said: ‘The public tell us there’s a lot more we can be doing out there, to improve access to primary care, that means we need to work with GPs to create the headroom for them to be able to respond differently, to give better access to primary care and to community teams.’

However Dr Agnelo Fernandes, the RCGP’s urgent care lead and a GP in Croydon, south London, said more resources were needed in order to increase capacity.

He said: ‘The workload of GPs has gone up and up. There are over 300 million consultations a year. It is by far the most used part of the NHS. However, we also know the resource of general practice has not kept pace with that. There has to be additional resource to increase the capacity.’

‘One way of increasing the capacity is by increasing consultations on the phone, but that requires adequate numbers of GPs to do that as well. You can’t do everything on the phone, you do need GPs to see people too, so you need resources to do that. There is good evidence that you can increase capacity by increasing telephone consultations but there are only so many hours in the day.’

Readers' comments (47)

  • Ashley Liston

    Hello anon 3.20.

    It works through a skilled GP who knows the patient and has their records in front of them. It utilises our greatest skills as GPs; personalised patient care based on mutual trust and risk management (not risk aversion such as NHS111 or nurse triage). If you have any doubts invite the patient to pop in (same day). Many safety netting options which patients trust if they know they can call back and speak to GP again within an hour of calling.

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  • Our practice has been operating a telephone triage system ( be doctors only) for all same day appointment requests for the last 2 years. We are inner city, deprived and many patients have poor self care skills. We also have interpreters on site to assist with patients who do not speak good English.

    Our results show:

    - reduced A/E attendance, dramatically at first and now a more steady decline
    - more continuity of care as the triage doctor tries to book complex or chaotic patients with the GP that knows them
    - matches problems to the appropriate clinician so that minor illness goes to NPs and GPs get more complex issues
    - massively enhances patient education as patients learn the red flags and when to be worried

    The system, combined with a policy of not prescribing cheap over the counter medication, has significantly reduced access demands. That said, it is exhausting and at times demoralising as you feel like a customer service advisor when you are trying to negotiate why back pain present for 6 months does not have to be seen today.

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  • I like these managers who thinks that somehow a virtual consultation is also done with no real time attached to it , the reason why this will implode is that capacity fuels demand which in turns fuel capacity and becomes unmanageable , it will also increase our indemnity which will please only lawyers and solicitors

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  • what's to be done? patient "pops" into AE cos knee was hurting while he was in town - seen and x-rayed and advised to see GP re referral to orthopaedics - arrives back at surgery (we have enough same day appointments) miffed that I suggest we a) wait for report from AE b) report on x-ray before we can discuss.

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  • Ok

    If a good safe telephone consultation takes 10 minutes from start to finish - why brother doing virtual or telephone consultation. I have known an NHS direct call taking 42 mins on my patient and then was sent to me. A lawyer would says misdiagnosis on the phone is indefensible whereas a misdiagnosis face to face is LESS indefensible because you saw and examined the patient. . I have seen a complaint devastate a GP's mental health etc etc. Even the GMC has noted suicidal rates and tendencies are higher in fitness to practice hearings. I say stay safe and protect yourself. Demands are escalating we need GPs - not telephone consultations/calls on the 'cheap'.

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  • we started phone consults and triage over a year ago to cope with a soaring patient expectation of needing to be seen immed! It started with 1 doc doing 1 hour, then quickly turned into a monster with 2 out of 3 of our doc doing 3 housr each of phone triage in the mornings, and the patients still!! complain ther are not enough tel triage appts! We do about 50-60/ morning and out new partner has just resigned- he can't take it anymore and I'm soon going to follow. The point is unrealistic patient expectations, increased demand and dumping of secondary care- this CANNOT be managed by phone consults and we're all just burning out! More telephone appts means less face to face, why can they not understand this!

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  • It IS OUR Fault. Really. ICS does not allow us to define safety in hours, patients seen or anything. We will always be expected to do more and more and more. And ICS, which 84% voted for means we can do nothing about it except whinge. Just work harder. You do 12 hour days, Well, do 13 + 24 hour cover + weekends + 8 to 8.Mustn't grumble.

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  • We do and from the drop in A&E and OOHS discharge letters it's made quite a difference in the number of patients we have who go to A&E, especially over the weekend but so far there has been no accompanying transfer of funds our way to provide infrastructure eg phone lines, receptionists hours etc and so far no sign of a Minor Injuries LES so that we can expand that side of the service as well.

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  • A couple of years ago we introduced a text reminder system which dramatically reduced DNA rates. Patients thought it was a great idea. Over time, DNA rate cried up as the novelty wore off and we are almost back to normal level.

    I suspect telephone triage will suffer the same consequence. Except you will have huge expectation to carry on making 100 calls a day. If I was looking for a post, having to spend few hours on phone would be an instant turn off....

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  • What about GPs "creaking" why is that not seen as a problem? Surely the collapse of General Practice is just as worrying as A and E? Yet no extra funding or support is forthcoming and we are supposed to bail the hospitals out?

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