DR MIKE SMITH: Phone appointments aren’t saving GPs time as two thirds of patients still come in

The patient is a 70-year old woman. It’s a phrase I hear on an almost daily basis. 

My job as a GP is to find out if that’s really the case. She’s been having headaches ‘for a week or so’.

She proceeds to diagnose herself: ‘I know I don’t drink enough water, and I’ve been quite stressed. That’s probably it.’

Headaches aren’t usually anything sinister. But that doesn’t mean they should be dismissed. 

Did she feel sick or have been sick in the past? Was there any vision problems or difficulty sleeping? 

Yes, yes and again. Yet, I remain skeptical. It’s well known that some patients, particularly older patients, play down symptoms. 

After 15 or so minutes on the phone, I’m not satisfied we’ve got to the bottom of things, so I ask her to come in. 

And when she finally sits down beside my desk, I’m glad I did.

She’s practically green, and looks exhausted and frail. She insists nothing much is the matter, ‘just this funny headache’. It was worrying.

The vast majority of my phone appointments end up becoming face-to-face because, frankly, it’s often impossible to make a proper diagnosis without actually clapping eyes on a person. [File picture]

I write the clinical term ‘cachectic’ – used to describe someone who looks so unwell we suspect they might have advanced cancer – on the referral to the local hospital.

I hope she doesn’t have a brain tumour. But at least now we’ll know – and I’m glad I didn’t take her word for it when she told me: ‘I feel fine, really. I don’t want to be any bother.’

While the details may differ, this kind of thing happens every day – over and over. 

Sometimes I spend up to 20 minutes talking with a patient over the telephone, just to get them to visit me in person.

Like all GP surgeries, the practice where I work in Hertfordshire is still running a ‘phone first’ system, which was brought in as an emergency measure almost two years ago at the start of the pandemic.

Patients are unable to make appointments face-to–face. Patients must book in. 

Sometimes they’re booked in without triage, for a review of their diabetes or asthma, for instance. The majority of patients book their appointments over the next couple days or on the day they require.

But cases such as the one I’ve described, and countless more like it, have convinced me that this approach simply isn’t working.

The vast majority of my phone appointments end up becoming face-to-face because, frankly, it’s often impossible to make a proper diagnosis without actually clapping eyes on a person. 

If I’d seen them in person in the first instance, it would have saved a whole lot of time. Time is a scarce commodity in practice right now.

It’s no secret that GP services are heaving at the seams – hit by staff shortages and surging demand.

In October, a record 34 million GP appointments took place – four million of which were Covid vaccinations. 

Drs, nurses, and support staff have all been burned. 

There has been widespread criticism of the Government’s attempts to increase the number of face-to-face appointments we do, with many of my colleagues insisting they want to stick to the current approach. 

But I’m convinced that telephone consultations, far from being a solution, are creating a rod for our backs.

On Tuesday – a particularly bad day – I conducted 65 appointments, with 18 of them face-to-face, in total. Photo by Dr Mike Smith

NHS Digital released figures that show 64% of all consultations conducted in September was face-to–face. 31% of those were by telephone. The rest were either online or at home.

But these numbers hide the true story: if a patient is spoken to on the phone, and is then asked to come in, it’s counted as two separate appointments – one telephone and one face-to-face appointment.

But really, to all extents and purposes, it’s a single appointment that’s just taken a rambling and unnecessarily long route.

When an appointment is logged on the computer system, it’s given a code. This is what’s passed to NHS Digital, allowing it to track what sort of consultation was given, whether it was a doctor, nurse or otherwise, and some other basic details, such as how long a patient had to wait for the appointment.

But patients’ names aren’t handed over, for confidentiality reasons. So it’s impossible to know exactly how many double-counts there are nationwide. 

In a practice with over 500,000 patients, I was able to work in an environment where two-thirds the phone visits were face-toface.

It means that although we are frantically busy, carrying out more appointments than ever, we’re also seeing fewer patients than ever, as so many patients effectively need to be dealt with twice.

Each morning begins the same. 

I turn on my computer, then leave to make a cup of tea – another casualty of poor investment in general practice is our very old computers take more than ten minutes to boot up. There’s always a part of me hoping it’ll be a quieter day. It’s never quiet.

Burned out doctors, nurses and support staff. But I’m convinced that telephone consultations, far from being a solution, are creating a rod for our backs

The appointment screen appears. Each practice is different, so in an average session, there are 15 phone slots, seven face-toface appointments, and then we can work together.

Every telephone appointment is filled within fifteen minutes. Four face-to–face appointments are usually reserved for urgent cases. However, these appointments are allocated within the first hour.

However, when people require to be spoken to or seen we do our best to accommodate them. 

On Tuesday – a particularly bad day – I conducted 65 appointments, with 18 of them face-to-face, in total. 

The ones I call who I can’t see that day, I book in for the next day or the day after, and so things pile up, and up, and up. One of my colleagues recently saw 93 patients in a single day.

There are no lunch breaks, and a constant worry that we’re going to miss something vital. 

I am also aware that many patients experience frustration and are frustrated. They feel ignored, shut out and fobbed-off.

My colleagues incorrectly claim that telephone appointments take longer than in person ones. 

It is actually 16.7 minutes for a telephone appointment, while an average face-to–face meeting takes approximately 12 minutes. I’m not surprised. 

At medical school, we learn to make a diagnosis by looking for signs – things we can see – as well as listen to what patients tell us about their symptoms. 

You only get half of the image on the phone. This means that you need to ask more questions. 

And some patients can’t reliably tell you their symptoms – as in the case I outlined above. 

It’s no secret that GP services are heaving at the seams – hit by staff shortages and surging demand. In October, a record 34 million GP appointments took place – four million of which were Covid vaccinations 

People with mental disorders are another possible example. This is part of medicine where non-verbal clues – body language, movements and behaviours, and general appearance – are a key part of diagnosing and managing the problem.

For instance, a patient called me for help with insomnia – but it’s only when I called her in for a face-to-face appointment that I got a real measure of the problem. 

Her depression was obvious from the moment she walked in. She looked dishevelled and she had lost a lot weight in the two years since her last visit.

This prompted me ask an important question. It turned out that there had been any traumatic incidents in the last few months. It was yes. 

An old friend died and her grief was allconsuming. So much so, she’d shut herself away from the world, including loved ones. 

She was referred to me for therapy, and we reached an agreement on antidepressants after long discussions.

I’d be none the wiser of these crucial details if we’d just spoken about sleeping problems over the phone.

Then there’s the worry-stricken parents. The other day, I spoke to a frazzled mother of a two-year-old with cerebral palsy who’d just been discharged from hospital. 

It was frighteningly worrying that her daughter, who had an unusually high temperature, seemed to be more restless than usual. 

Again, it was a long phone conversation that ended in me saying: ‘You’d better come in and see me, just to be sure.’

 By the time they arrived, the child had perked up, and I decided things weren’t too worrying. 

We scheduled an appointment for next week with the specialist and told her to contact me if she had any questions.

Again, if she’d just been able to book in to see me in the first place, it would have saved us all time – and her, no doubt, some worry.

Oh, and there’s also the shambles that’s the online consultation system. Patients can fill out forms online, detailing their symptoms, and asking for clarifications. 

The doctor must then take the time to review the comments and reply. They will usually book the patient an appointment by phone. 

Some patients will spend up to 20 minutes filling out a questionnaire, while a GP then spends another 20 minutes looking through it. A third GP takes 15 minutes calling the patient to discuss their concerns, before telling them to visit for another 15 minute face-to-face appointment.

This could all be handled in one consultation. It is such a waste.

Given all this, it surprises me that I’m something of a lone voice in criticising the current system.

My GP colleagues become incredibly defensive whenever this subject is raised in the media and on social media. 

But I don’t feel that people are accusing me of not working hard. It’s the way we work that needs to change, for all our sakes. 

Aside note: I find the threat of industrial action by some GPs regarding the Government’s drive to increase the number of consultations in person ridiculous. 

For a start, we’re self-employed business owners. We can’t strike.

Some GPs are afraid of returning to a primarily person-based service, but I do believe that this is a valid concern. 

It is all very clear to me. We were on our own, without any guidance and with no PPE, when Covid struck.

It was very humid in Victorian buildings and there were some patients who needed to be protected. 

It was like staff members were dying. In April, our own office had to close due to Covid. Every GP and every nurse in the practice were affected. Some got quite sick. It was terrifying.

To protect patients and staff, the best way was to pull up the drawbridge. Things have changed. 

We’re all triple-jabbed, and much better at taking precautions around Covid.

The risk, although still there, just isn’t the same.

Many people believe that simply returning to the older system (where patients could email or call and make a face-toface appointment) would lead to a complete meltdown of the service. However, I disagree.

This will depend on how fast it happens.

Perhaps specific, more in-need patient groups – such as those over the age of 65, parents of young children, or those with chronic illnesses – could be offered the option of self-booking face-to-face appointments first. 

And some element of phone services should remain – my younger patients like calling, or having video consultations, because it means they don’t need to take time off work. However, our offer must be inclusive of all types of patients.

You should not use online forms for any other tasks than the most basic, like booking routine hospital referrals and providing sick notes. 

My conviction is that a long-term approach to moving GPs from the telephone would make it easier for doctors, and also provide patients with a better experience.

The workforce crisis was mentioned earlier. A shortage of GPs is making matters worse. We need to attract more medical students into the speciality – as so many GPs plan to retire the moment they can. 

Will there ever be someone to take their place?

A few months back, a medical student was seated with me at a phone clinic. It was evident in her expression. Bored.

General Practice wasn’t going to be the speciality for her. It’s not like that, anyway.