Patient satisfaction after
the introduction of
Doctor First telephone triage
appointment system
Ewan Thomson
MBChB Year 5
Elective Project Report
Section 4: March-April 2014
Matriculation Number 50901346
Patient satisfaction after the introduction of Doctor First telephone triage appointment system
TABLE OF CONTENTS
Acknowledgements...................................................................................................................................................................................................................................... 2
List of Abbreviations................................................................................................................................................................................................................................ 3
Abstract..........................................................................................................................................................................................................................................................................4
Chapter 1
1.1
1.2
1.3
1.4
1.5
1.6
BACKGROUND............................................................................................................................................................................................................................6
DOCTOR FIRST..........................................................................................................................................................................................................................8
TELEPHONE TRIAGE APPOINTMENT SYSTEMS – THE EVIDENCE...............................................................11
DENBURN MEDICAL PRACTICE DATA................................................................................................................................................ 14
AIMS.....................................................................................................................................................................................................................................................15
RESEARCH QUESTIONS..............................................................................................................................................................................................15
Chapter 2
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
Results..........................................................................................................................................................................................................................21
CHARACTERISTICS OF STUDY COHORT............................................................................................................................................... 21
OUTCOME OF PHONE CONSULTATION....................................................................................................................................................23
PHONE COMMUNICATION.........................................................................................................................................................................................24
CONTINUITY OF CARE....................................................................................................................................................................................................27
CONVENIENCE OF CALL BACK..........................................................................................................................................................................29
PATIENT ACCESS & EFFECT ON GP WORKLOAD....................................................................................................................... 32
OVERALL SATISFACTION & COMPARISON TO PREVIOUS SYSTEM..............................................................35
ADDITIONAL COMMENTS..........................................................................................................................................................................................38
Chapter 4
4.1
4.2
4.3
Methodology......................................................................................................................................................................................................16
LOCATION.......................................................................................................................................................................................................................................... 16
LITERATURE REVIEW......................................................................................................................................................................................................16
ETHICAL APPROVAL........................................................................................................................................................................................................... 16
QUESTIONNAIRE DEVELOPMENT ...................................................................................................................................................................16
STUDY DESIGN...........................................................................................................................................................................................................................17
STUDY CONDUCT...................................................................................................................................................................................................................18
CONSENT............................................................................................................................................................................................................................................19
STATISTICAL ANALYSIS..............................................................................................................................................................................................20
Chapter 3
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
Introduction............................................................................................................................................................................................................6
Discussion...............................................................................................................................................................................................................39
PRINCIPLE FINDINGS & COMPARISON WITH PREVIOUS RESEARCH..........................................................39
STRENGTHS AND WEAKNESSES........................................................................................................................................................................50
IMPLICATIONS FOR CLINICAL PRACTICE & RESEARCH...............................................................................................53
Chapter 5
Conclusions..........................................................................................................................................................................................................57
Chapter 6
References.............................................................................................................................................................................................................58
Chapter 7
Appendices...........................................................................................................................................................................................................61
APPENDIX 1 – QUESTIONNAIRE..........................................................................................................................................................................................61
APPENDIX 2 – PARTICIPANT INFORMATION SHEET............................................................................................................................62
APPENDIX 3 – COVER LETTER.............................................................................................................................................................................................63
APPENDIX 4 – LETTER CONFIRMING ETHICAL APPROVAL........................................................................................................64
APPENDIX 5 – LETTER CONFIRMING R&D APPROVAL......................................................................................................................65
APPENDIX 6 – ADDITIONAL COMMENTS TABLES...................................................................................................................................66
APPENDIX 7 – SUMMARY OF ELECTIVE EXPERIENCE...................................................................................................................... 70
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ACKNOWELDGEMENTS
I would like to thank both of my supervisors, Dr. Abdulrashid Siddique and Dr. Fiona Garton,
for giving me the opportunity to work on this project and for their tremendous support with
gaining ethical approval prior to the start of my elective.
I would like to thank Mr. John Lemon at the University for helping me use the computer
software, editing and formatting the questionnaire, and for his advice regarding the statistical
aspects of my project.
I would like to thank all GPs at Denburn Medical Practice for identifying study participants.
Special thanks go to Dr. Abdulrashid Siddique for ensuring all staff were aware of my
project, for helping me coordinate my research method with practice staff, for allowing me
the opportunity to accompany staff to the RCGP conference in May 2014 to present my
research findings, and for proofreading my final written report. I would also like to thank all
practice staff at Denburn Medical Practice for making me feel very welcome and for their
assistance with my project.
I would like to thank my father, Dr. Bruce Thomson, for his continued support and advice
throughout the preparation and organisation of my elective project.
Finally, I am extremely grateful to all of the study participants who took the time to complete
my questionnaire.
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LIST OF ABBREVIATIONS
BBC
British Broadcasting Company
BJGP
British Journal of General Practice
BMJ
British Medical Journal
COC
Continuity of Care
DNA
Did Not Attend (for appointment)
DoH
Department of Health
GP
General Practitioner
IRAS
Integrated Research Application System
NOSRES
North of Scotland Research Ethics Service
OOH
Out Of Hours
PPC
Productive Primary Care Ltd
QOF
Quality and Outcomes Framework
R&D
Research and Development
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ABSTRACT
Introduction
The use of telephone triage appointment systems (such as Doctor First) in primary care to
manage rising demand for same day appointments are becoming increasingly popular as
they have shown to reduce the number of patient appointments, DNA rates and A&E
attendance; however it is unclear whether patients value such a system.
Aim
This project aims to use questionnaires to evaluate patient satisfaction with different aspects
of Doctor First in Denburn Medical practice. Results will be compared with the previous
system, across separate study groups and between different cohort characteristics.
Method
Participants fell into one of three study groups: those dealt with entirely on the phone
(Group1); those unable to be contacted (Group 2); and those offered an appointment in
person (Group 3). Consenting patients were either posted a questionnaire pack at random
(Groups 1 and 2) or handed a questionnaire in person on arrival to the practice. Responses
were entered electronically using SNAP software and interpreted using SPSS software.
Results
Overall, 70% of patients were either satisfied or very satisfied with Doctor First compared to
only 45% with the previous system. 89% were satisfied with their outcome and 94% of
patients seen in person were given an appointment either the same day or on an alternative
suitable day of their choice. 80% were reassured by having earlier contact with their GP and
53% admitted that Doctor First has encouraged them to contact the practice more often.
88% of all patients were able to receive a telephone call whilst 58% considered Doctor First
to be more convenient than the previous system. 61% of patients considered communication
to be equally as effective on the phone as it is in person; however 23% considered phone
communication to be problematic. 45% of patients thought the phone consultation was less
private than an appointment in person and this influenced the information that 41% of
patients shared with their GP.
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Conclusion
Statistics were similar between Groups 1 and 3 who preferred Doctor First; however Group 2
on a whole preferred the previous system because for these patients the benefits of Doctor
First were outweighed by the inconvenience of the call-back service. Doubt remains
regarding the safety of phone consultations and their impact on continuity of care, however
this may be negatively influenced by numerous misconceptions. This study’s results were
overall positive and in favour of Doctor First which justifies further research to confirm and
add weight to these findings. There may be a place for Doctor First in Primary Care thus
practices should consider exploring such a system further.
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CHAPTER 1
1.1
INTRODUCTION
BACKGROUND
Patient Access & Associated Pressure on GPs
There is an increasing demand on primary care for same day appointments, and GP
practices are finding their appointment systems under inordinate amounts of pressure.
The rising population along with the transfer of many hospital based services into the
community has seen GP workloads increase dramatically without the necessary resources
to successfully deliver these services. RCGP has reported an increase in total number of GP
consultations across the UK from approximately 300million in 2008 to 340million in 2012,
with an estimated rise of over 60million by the year 2017. Simultaneously, there has been a
cut of £9.1billion in government funding for GPs since 2004 when taking inflation into
count.1 GPs have been working longer and harder to meet demand by providing more
emergency care appointments and evening consultations. A BMA survey has revealed that
nine out of 10 GPs regularly work beyond their normal hours, almost six out of ten GPs are
considering an early retirement and more than a third are actively planning early retirement
due to the sheer workload and plummeting morale.2 Some practices have already been
forced to close due to the growing workloads and the RCGP states that general practice is
“now under severe threat of extinction”.3
As a result of this increasing workload, patients are waiting increasing lengths of time to be
seen by a GP. According to the National GP Survey in England, one in six patients need to
wait a week until the next available appointment, and one in four will resort to attending A&E
if they deem their appointment not soon enough. According to Anna Bradley, chair of
Healthwatch, one in five patients also admit to misusing A&E for non-emergency treatment
as a result of poor access to their GP. This inappropriate use of emergency services in
costing GP practices substantial amounts of money and many are looking for a solution to
the problem.4
The growing emphasis on enhancing patient access to their GP has encouraged many
practices, both in the UK and internationally, to adopt the use of telephone consulting in an
attempt to achieve government targets and improve access.5 Telephone triage appointment
systems involve receiving, assessing and managing phone calls from patients with a
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healthcare problem, either through offering advice or through referral to a more appropriate
service. These appointment systems are now a popular solution to managing increased
workload. They are used routinely in several countries to manage OOH care as it has been
estimated that more than half of OOH calls can be dealt with by telephone advice alone.
Recently however, telephone triage appointment systems are being used more and more
during daytime hours to also manage growing requests for same day appointments.6 Letters
in the BJGP discuss the potential effect of phone consultations in clinical practice. In these
letters many GPs believe that phone appointments will improve access for their patients and
help them reach their targets, however any benefit that phone consultations have is likely to
be compromised if the government imposes unrealistic targets.7,8
Government Strategies & Policies
The Department of Health support the current and future use of technology to manage
increasing demand. In 2011 the Digital First initiative was released with a view of improving
healthcare specifically with regards to the following aspects:
1) “Fit in with people’s busy lives and deliver faster and more convenient services
2) Improve patient choice and satisfaction levels and enhance quality of care
3) Help to deliver efficiency gains by reducing face-to-face interaction
4) Empower patients to take control of their own health and promote self-care
5) Improve collaboration across healthcare, social care and industry
6) Help to cut carbon emissions by reducing unnecessary travel to appointments” 9
More recently in 2012, the DoH published a document – The Power Of Information –
detailing a strategy to promote the use of technology in healthcare with particular emphasis
on sharing information, booking appointments and ordering repeat prescriptions. 10
Quality and Outcomes Framework
QOF is a government initiative which offers GPs a financial incentive if certain criteria are
met. There are several indicators integrated into QOF, each with a different value of points.
The greater the number of points achieved, the more funding a practice receives. The
revised GP Contract in Scotland for 2014/2015 weighs heavily on improving and reviewing
patient access with 25 QOF points on offer. The new contract sees the addition of an
indicator that requires practices to undertake an annual assessment of current demand,
assessing met and unmet need. These changes differ in comparison to other countries
within the UK.11
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1.2
DOCTOR FIRST
General Information
‘Doctor First’ is a doctor-led telephone triage appointment system produced by Productive
Primary Care Ltd., a private company working with the NHS to help GP practices identify
areas for improvement in their appointment systems. According to Dillon Sykes, Managing
Director of PPC, GP practices needlessly spend thousands of pounds in order to meet
demand (i.e. number of appointments requested) by employing locums to increase their
capacity (i.e. number of appointments available), when instead they should be managing
their demand more efficiently. Doctor First is a demand-led approach to managing
appointments where clinicians talk to and assess all patients on a clinical priority basis.
Doctor First is mentioned in the aforementioned Government initiative, Digital First, as a
simple but effective tool which General Practice can use to assist with decreasing the
number of unnecessary face to face appointments. The initiative’s purpose is to promote the
reduction of unnecessary or inappropriate face-to-face contact between patients and
healthcare professionals by incorporating technology into these interactions. These
appointments include, for instance, receiving a negative test result or simply being offered
advice, both of which could have been communicated over the phone or via email. The
initiative is not suggesting that healthcare professionals should be replaced with technology,
instead it is advocating the use of technology to provide patients with equivalent high
standards of healthcare but in a more flexible and convenient manner. Technology can also
significantly lower the cost of providing healthcare – in 2011 face to face interactions
accounted for nearly 90% of all healthcare contact, and the initiative states that every 1%
reduction in face to face interaction could save up to £200m.12
The Doctor First appointment system can be illustrated with the following process.
1) If a patient wants an appointment with their doctor they call the practice and speak to
a receptionist as usual.
2) The receptionist will ask the patient for their name, telephone number and brief
general description of their health problem. They will then immediately add the
patient to the doctor’s phone call list.
3) The doctor will call the patient back on the number they provided either immediately
or as soon as possible depending on current workload. The patient can then talk to
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
the doctor about their health problem in the same way they would if they were in the
practice attending an appointment in person.
4) If the doctor thinks the patient needs to come into the surgery to be seen (or the
patient wants to be seen in person) then the doctor will arrange a face to face
appointment with the patient at a day and time that is suitable and convenient for
them (usually later that same day).
A few key points to note about the system are as follows:

If a patient needs to speak to a doctor urgently (e.g. if it is an emergency situation)
then they can tell the receptionist straightaway who will then inform the doctor to call
them back immediately.

Patients do not need to inform receptionists of their health problem if they do not
want to. By asking for this information, it helps the doctor to decide whom to prioritise
for a call back based on clinical need.

If either the doctor or patient needs or wants to see the other then a face to face
appointment is booked without question

If patients want to talk to a specific doctor they can request this with the receptionist
on the phone who will arrange this wherever possible.

If patients want the doctor to call them back between certain times then they can tell
the receptionist who will state this beside their name on the doctor’s phone call list.

Patients are still able to request home visits from the doctor whilst on the phone who
will then decide whether or not the patient needs a home visit, and if so arrange this.

Patients are still able to book appointments in advance, however because
appointments are available on the day you call, patients shouldn’t need to book
ahead.
Reported Benefits of Doctor First
Productive Primary Care’s rationale for Doctor First derives from improvements in three
broad areas: clinically for patients, financially for the practice, and personally for GPs
themselves. The following benefits have been reported from PPC and have been
collaborated from practices across the UK that are currently using Doctor First.
Financial benefits
The system has shown to be cost-effective by sparing an estimated £100,000 through a
significant reduction in the number of emergency admissions via A&E and inappropriate
emergency service use, while DNAs have also dropped to virtually zero. This combined
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
effect allows practices to increase their efficiency and in turn spend less money employing
locum GPs.13
Clinical benefits
The system allows patients to be seen by the doctor of their choice at a date and time that
suits them, improving both access and continuity of care. Furthermore, patient waiting time
for a GP appointment has dropped substantially to a median duration of under 30 minutes
between contacting the practice and receiving a phone consultation. Altogether, Productive
Primary Care Ltd. claims patient access has improved by 200% in practices using their
system. Dr. Steve Clay, a GP in Leicestershire and Clinical Director of PPC, has
implemented Doctor First in his practice. His research has shown that only half of patients
want to see a doctor in person. The remaining patients are dealt with directly over the phone
which frees up time to allocate slots of longer length to patients that need more time with the
doctor. The quantity of available appointments means that reception staff can now facilitate
patients on the phone as opposed to acting as the usual barrier to doctor access. In addition,
there is no need with Doctor First for receptionists to make clinical decisions beyond their
knowledge base regarding degree of urgency about a patient’s medical problems because
all patients receive a call back from the doctor. The system thus allows GPs to prioritise
patients who are very ill meaning a huge potential increase in patient safety.13
Personal benefits
GPs using Doctor First have reported many benefits for their personal lives, most notably
that they earn more money and work less hours. On average, each GP using Doctor First
will save approximately 1 hour per surgery session and encounter a 42% reduction in home
visits. Furthermore, they experience a considerably diminished average consultation length
of three minutes compared to the typical ten minute appointment, and there is strong
evidence to support this claim.14,15 This, combined with the ability to determine what their
daily workload is in advance, gives GPs greater control over their working lives. This in turn
renders it far easier for doctors to leave on time at the end of each day, as clinics are much
less likely to overrun. All of this in combination provides GPs and staff with far greater job
satisfaction and a happier work environment as they are subject to less stress.13
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1.3
TELEPHONE TRIAGE APPOINTMENT SYSTEMS – THE EVIDENCE
Evidence of Benefits
Personal benefits – GP workload
Evidence indicates that phone triage systems are overall more time efficient for doctors16,
and this is also the case for nurse-led triage which has been shown to reduce GPs
workload.17 There is strong evidence to support a considerable drop in average appointment
duration following introduction of a phone triage system with 93% of calls being under 5
minutes in length.14,15 Jiwa et al. reveal that demand for face to face appointments dropped
by 39% following the integration of a phone triage system. This is supported by similar
findings in other studies where numbers of home visits and face to face appointments
decreased.7,18
Despite the above evidence, doubt remains whether or not increased use of the phone
service balances this out for GPs.19 There have been many studies looking into whether or
not this is the case. Clinicians have reported that their phone triage systems have actually
encouraged patients to call about minor issues that they would normally have either sought a
pharmacist’s advice for or simply put up with until symptoms improved.7 One study
confirmed these findings by eliciting that 12% of patients would not have phoned the practice
at all (whether to book an appointment or merely ask advice) if the phone triage system was
not available.18 However on balance the authors in this study felt that workload was still
reduced overall due to the considerable decrease in average appointment duration. Results
from Hewitt et al. reveal that phone systems may not save time for patients with new or
acute problems as most of these presentations are seen face to face anyway.6 The degree
of contradiction amongst current published studies implies that further research is therefore
required in this area.
Clinical benefits – patient satisfaction
Studies have shown many advantages for patients with phone triage systems. With regards
to service use, evidence indicates patients in general prefer telephone consultations over
face to face appointments and are satisfied with such a system14,18, although this varies
depending on a patient’s individual desired outcome following the phone call (i.e. those
simply wanting advice will be more satisfied than those wanting to book an appointment in
person).7 However as far as the author can tell, no comparisons in satisfaction levels have
been made between patients offered a face to face appointment and those dealt with entirely
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
on the phone. Aside from service use, there are additional benefits that phone triage
systems bring for patients. These include reduced travel costs, less time absent from work,
and general time saving as patients have the advantage of an immediate consultation
without needing to wait in the surgery.15,20
Clinical benefits – communication
Communication across the phone, including quality of safety netting advice, has been shown
to be equally as effective as in person.6 The researchers in this study however were
assessing doctors and so these results only apply to the quality of a GP’s communication.
The author of this research was unable to discover any papers that discuss how patients feel
and whether or not they agree with communication being as effective as in person.
Evidence of Drawbacks/Concerns
While there are many reported benefits of the Doctor First system, there have been a
number of studies which have cast doubt on the value of telephone consultations over face
to face appointments, with particular emphasis on quality and safety of care.
Communication
One study found that phone appointment systems result in a poorer doctor-patient
relationship as both parties are unable to build the same rapport over a phone than they can
in person. The author has been unable to find any research looking into whether or not this
lack of rapport affects what information patients choose to confide in their GP. 6 There have
been suggestions that it is more difficult for patients to talk about multiple issues on the
phone than in person. The same study’s results also highlighted that doctors don’t prompt
patients on the phone for additional medical problems however there is no evidence to prove
that this behaviour limits disclosure of patient complaints on the phone.6 Although there is
strong evidence that phone consultations are half the duration of face to face appointments
and that this time appears to not limit the doctor from covering their agenda, studies do not
mention whether or not patients feel there is enough time on the phone to communicate their
own agenda.14,15 Research has indicated that doctor and patient disagree in 95% of
consultations with regards to whether or not the complaint could be dealt with over the
phone. This however should not be an issue with the Doctor First system because as long
as the patient wants a face to face appointment following their phone consultation then they
will be offered one.21
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Satisfaction
A considerable doubt remains amongst GPs as to whether or not patients value telephone
triage appointment systems, and more importantly the specific reasons contributing to their
overall satisfaction levels. One study demonstrated higher re-consultation rates amongst
patients dealt with over the phone suggesting dissatisfaction with the service although no
indication was mentioned as to the cause of dissatisfaction.14 Several misconceptions also
exist about phone systems, the most notable of which is that they are typically viewed as a
barrier to accessing the doctor.7 There is therefore an agreement amongst researchers in
this area that more in-depth research is required to determine patient satisfaction levels with
different aspects of the phone triage service.19
Booking Appointments
There has been some research proposing that booking an appointment under phone triage
systems is a complex process and that practices should be explicit about how appointments
are made.22 Study findings have demonstrated that patient satisfaction decreases with rising
numbers of same day appointments, suggesting that same day appointments do not suit
certain groups of patients, although this has not been analysed. Indeed it may not be
convenient for chronic patients who are used to booking review appointments in advance so
that they can record the date/time in their calendar and plan their days accordingly. Although
the Doctor First system allows appointments to be booked on the same day that one is
desired, the system relies on patients regularly remembering to phone the practice to make
review appointment after an appropriate length of time. Patients have voiced repeated
concerns about the lack of ability to book appointments in advance.23
Continuity of Care
Some GPs are worried that providing rapid access for patients is substituting continuity of
care, and it is not clear whether patients feel speed of access is more important than other
aspects of primary care.24,25 Rubin et al. found that for many patients, reduced waiting times
were of less importance than choice of GP and convenience of appointment, however speed
of access did outweigh other aspects of care if the appointment was for a child or a new
health problem.25 There is contradictory evidence however that implies phone systems do in
fact improve continuity of care.20
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Safety
Concerns have been voiced by clinicians regarding the safety of phones as a consulting
method, with particular focus drawn to confidentiality, privacy and absence of examination.
Responses to these issues have been vague and varied. A password-protected system has
been suggested as a means of ensuring confidentiality over the phone however it is not clear
whether patients would value such a system, and to what extent it would be used.26 Phone
triage systems have been heavily criticised for not having the privacy of a face to face
consultation and for providing patients with a diagnosis without the appropriate
examination15,20, however examination is not always necessary as many patients are simply
looking for medical advice regarding their current health. Evidence has shown that
pharmacists and nurse practitioners are equally as safe and effective in the management of
common conditions as a face to face appointment with the doctor.27 Despite this, some
clinicians recommend only using phone consultations for management of follow-up
appointments20, even though research has shown that it is those patients with an acute
problem who particularly value the quick access that phone appointments provide.25
1.4
DENBURN MEDICAL PRACTICE DATA
Productive Primary Care have carried out their own research showing that other practices
using Doctor First have had very positive feedback about the system, including reductions in
patient appointments, DNA rates and A&E attendance. Since implementing Doctor First in
February 2013, Denburn Medical Practice has also experienced these benefits. The practice
has saved more than £20,000 in DNAs which equates to two or three GP sessions a week,
and has seen a 38% reduction in emergency admissions. Moreover, the practice reports a
greater than 20% reduction in out-of-hours presentations between the summer months of
2012 and 2013. Weekly patient contact has risen by over 100% (from 100 to between 200
and 240) however because the conversion rate of telephone contact to face-to-face
consultation is only I in 3, combined with the reduction in number of DNAs, there has been
no backlog since introducing Doctor First which means the practice is able to help many
more patients than beforehand and can allocate longer time slots of 20-30 minutes to
patients who need more time.28
However the practice has not successfully carried out formal research into patient
satisfaction with their new system, and as such there is currently no data to suggest that
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
patients are experiencing their own benefits from Doctor First. This gap in information is
considered vital to the future success of the system within the practice. This project aims to
use questionnaires to evaluate patient satisfaction with Doctor First in Denburn Medical
Practice.
1.5
AIMS
1) To evaluate patient satisfaction with different aspects of the new Doctor First
telephone triage appointment system in an inner city GP practice
2) To compare patient satisfaction between the traditional appointment system and the
new telephone triage system
1.6
RESEARCH QUESTIONS
1) Are patients overall more satisfied with Doctor First than the previous system?
2) Is there a difference in satisfaction between patients who receive a face to face
appointment and those who do not?
3) Is there a difference in satisfaction between patients who were successfully
contacted by phone and those who were not?
4) How does the new system impact continuity of care?
5) How does enhanced access to the GP influence patient satisfaction?
6) Does the new system allow patients to be seen when they want or need to be seen?
7) Has the new system encouraged patients to contact the practice more often?
8) Are telephone appointments convenient for patients?
9) Do patients feel communication is impaired over the phone as opposed to in person
and, if so, is this a problem?
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CHAPTER 2
2.1
METHODOLOGY
LOCATION
The elective project took place during March and April 2014 within Denburn Medical
Practice, a GP surgery in the heart of Aberdeen city with a practice size of 10,500 patients.
2.2
LITERATURE REVIEW
A comprehensive literature review was carried out prior to questionnaire design to discover
any prior research on similar topics. Databases searched were Ovid Medline, The Cochrane
Library and PubMed. Reputable websites were also investigated including BMJ, BJGP and
Productive Primary Care Ltd. The bibliography sections of relevant papers were also
checked. Keywords searched for included: patient satisfaction, questionnaire, survey,
appointment, GP, general practice, primary care, phone, telephone, triage and doctor first.
The search limits ‘Humans’ and ‘English Language’ were applied in order to retrieve relevant
results. Furthermore, Boolean operators were utilised to combine specific search results and
obtain the desired literature. By employing this systematic search technique it was ensured
that a relevant, well-defined and comprehensive literature collection was carried out.
2.3
ETHICAL APPROVAL
Ethical approval was granted by NOSRES in February 2014 and the project received
Research & Development Management Permission from the NHS Grampian R&D Office.
Letters confirming these approval processes can be found in the Appendices section of this
report.
2.4
QUESTIONNAIRE DEVELOPMENT
Questionnaire content was decided upon following consultation with both supervisors (both
of whom are GPs) and was based on the author’s own knowledge after reading relevant
literature. Productive Primary Care had developed their own questionnaire to assess the
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impact of Doctor First on patients however it was decided that this did not cover certain
aspects which the author wanted to enquire about, thus the author developed a new
questionnaire to be used instead. Questionnaire comprehension and content validity was
assessed by a University statistician, two academic supervisors, non-related lay persons and
NOSRES. The questionnaire was designed to take approximately 5 minutes to complete for
the convenience of patients in the hope that this would return more completed
questionnaires for analysis. Questionnaires were piloted during a ‘Test Run’ during the first
day of the research study. The aim of the ‘Test Run’ was to discover how well patient’s
completed the questionnaire, whether or not they could complete it appropriately, and to
improve the instruction technique given by practice staff when handing patients the
questionnaires to fill in. The pilot questionnaires were not included in the analysis process,
however they highlighted areas which were not completed correctly thus patient instructions
for completion of questionnaires were modified to limit this occurring for future
questionnaires. SNAP 10 Professional survey software was used to design the
questionnaires. Paper versions were printed for patients and an online version was created
and used by the author to input data for analysis.
2.5
STUDY DESIGN
Study Description
This was questionnaire-based research to ascertain patient satisfaction with the new
telephone triage appointment system in comparison to the previous traditional appointment
system.
Participants
Patients in contact with the practice who sought an appointment fell into one of three study
groups for this research. Group 1 consisted of patients who received a phone consultation
but were not arranged to be seen for a face-to-face appointment. Group 2 consisted of
patients whose call-back attempt was unsuccessful. Group 3 consisted of patients who
received both a phone consultation and a face-to-face appointment in the practice. Inclusion
and exclusion criteria were as follows.
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Inclusion criteria
1) Participant must be a patient or parent/guardian of a patient at Denburn Medical
Practice
2) Participant must contact the GP Practice during the research period
3) Participant must be either an adult aged 16 or over, or a parent/guardian of a child
aged 12 or younger
Exclusion criteria
1) Participant is aged 13-15 inclusive
2) Participant has special needs including patients with a learning disability or additional
communication needs
3) Participant cannot read or understand the English language
2.6
STUDY CONDUCT
Recruitment
Starting the first week of the project, GPs obtained initial verbal consent from all patients on
the phone that met the above research criteria to participate in the research project. Patients
in Groups 1 and 2 were selected as follows. Using the Practice’s computer system, GPs
noted the time they concluded their phone consultation with all consenting patients who fell
into the category of Group 1 and electronically flagged these patients as possible
participants. Practice staff identified the first 30 of these patients to be contacted (i.e.
chronological order) and a questionnaire pack (containing the questionnaire, a cover letter, a
pre-paid envelope and an information sheet) was posted to this study group. A similar
method was also used for Group 2 patients. GPs electronically flagged patients who they
were unable to make contact with and recorded the time of the failed attempt. Practice staff
identified the first 30 patients and this study group was posted a questionnaire pack. All
questionnaires posted were marked with a group number (i.e. 1 or 2) in order to identify
which group a returned questionnaire initially belonged to.
After 3 weeks the total response rate for postal questionnaires was only 4 and so the
practice decided to post a further 25 questionnaire packs to each group using the same
method as above in the hope that this would improve data analysis. Once 55 patients were
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
identified in each group and posted a questionnaire pack, GPs stopped identifying further
patients.
Patients in Group 3 were selected as follows. GPs electronically flagged consenting patients
who fell into the category of Group 3. On arrival to the practice, these patients were given a
questionnaire from reception to complete and return to reception at their next convenience.
Data Collection & Management
The questionnaire was anonymous however included responder details such as age, gender
and occupation for analysis purposes. Confidentiality was therefore assured throughout the
duration of this research. Questionnaire responses were collated by the author and entered
manually into an electronic database created using SNAP software. Questionnaires that
were less than 80% complete were considered to be ‘spoiled’ and thus were not included in
the analysis. Once data collection had ceased, the dataset was exported directly into an
SPSS database for analysis. This database was stored safely on a password protected
laptop and the university computer system. Whole group and sub-group analysis was carried
out assessing patient satisfaction with the new appointment system and a comparison to the
previous appointment system was made. This analysis included how many patients could
receive telephone calls during surgery hours, how convenient the telephone consultation
was, whether or not patients received continuity of care and patient satisfaction with the
outcome of the telephone consultation. The results were then compared with those in
published studies, conclusions were drawn and recommendations were made.
2.7
CONSENT
Following discussion with Research Governance, it was decided that because the
questionnaire was short, anonymous and contained only questions that were deemed
unobtrusive, that there was no need to gain full informed consent by asking the participant to
complete a consent form. Instead, consent was implied from the participant completing the
questionnaire. By choosing not to take written consent, it was ensured that no identifiable
data would be collected during the study. For participants in Group 1, the GP asked
permission over the phone to post these participants a questionnaire pack. Those who did
not give their permission were not posted a questionnaire pack; however this was not
possible for Group 2 as these patients were unable to be contacted.
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2.8
STATISTICAL ANALYSIS
Results were obtained, compared and illustrated by utilising appropriate statistical tools and
functions available within the ‘IBM SPSS Statistics 21’ software. Frequencies and
percentages of responses were examined, and filters were applied to specific cases to allow
the study and comparison of separate responder sub-groups. Crosstabulation tables were
used to evaluate multiple responses simultaneously and identify patterns in select cases.
Missing data was handled by applying a non-response value and was excluded from the
analytical process in order to obtain more accurate results. Where appropriate, this report
states any significant number of respondents that did not answer a certain question and
discusses the reasons as to why this may have been the case.
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CHAPTER 3
3.1
RESULTS
CHARACTERISTICS OF STUDY COHORT
Number of Respondents / Group Numbers
The study returned a total of 231 completed questionnaires, of which 195 were collected in
the practice building (i.e. Group 3) and the remaining 36 were returned by post (19 in Group
1 and 17 in Group 2). A total of 110 questionnaires were posted out at the beginning of the
study (55 to potential Group 1 participants and 55 to potential Group 2 participants) giving a
combined postal response rate of 33%.
Gender and Age Group
Graph 1 shows the distribution of genders across all age groups. Overall 58% of
respondents were female and 42% were male. Almost half of all respondents (47%) were
aged 35 or younger.
Graph 1
Employment Status
Graph 2 illustrates that most respondents were full-time workers (40%), 19% were retired,
13% were students, 11% were part-time workers, 9% were unemployed and 8% were
housewives.
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Graph 2
Outcome of Most Recent Telephone Consultation
Graph 3 demonstrates that the vast majority of respondents were given a face to face
appointment in the practice, either with a GP (n=161) or a nurse (n=38). Of the remaining
patients, 14 were given a prescription, 6 were referred to another service, 4 were offered
advice or information only, 2 were arranged for a house visit and 5 received another
unspecified outcome. Only 1 patient indicated that they were unable to receive a phone
consultation despite there being 17 respondents in Group 2. This will be deliberated in the
discussion section of this report.
Graph 3
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3.2
OUTCOME OF PHONE CONSULTATION
Overall
Research findings reveal that 89% of all patients were satisfied with the outcome of their
phone consultation, whilst only 76% of patients felt they needed to be seen in person. Of the
76% overall that felt they needed to be seen in person, 93% of these patients were seen in
person while half of the remaining 7% were satisfied with their alternative outcome. This
means that only a small number of patients (3.5%) were displeased about not being seen in
person by a GP or nurse.
Inter-Group Analysis
Those who received a GP appointment were satisfied the most (94%) closely followed by
those offered a prescription (86%) and a nurse appointment (84%). Patients with other
outcomes were much less satisfied (67% referral, 50% advice, 0% house visit).
These statistics are similar when comparing Group outcomes. Group 3 were satisfied the
most (91%) closely followed by Group 1 (84%) however only 65% of Group 2 were satisfied
with their outcome (see Graph 4 overleaf). Further in-depth analysis of Group 2 outcomes
revealed that 100% of patients in this group were satisfied with a face to face appointment
(whether this was with the GP or the nurse) while 0% were satisfied with advice or
prescription alone. Graph 5 overleaf confirms that the vast majority (79%) of Group 1
patients felt that they did not need to be seen in person. Furthermore, of the remaining
patients only 2 (11%) were unhappy about not receiving a face to face appointment. Patients
in Group 2 that were not seen face to face despite feeling that they needed to be seen in
person were more likely to be unhappy about this than patients in Group 1.
A trend was identified when comparing age groups – as age increases less patients feel they
need to be seen in person (Age<36 = 82%, Age 36-55 = 74%, Age >55 = 67%). Older
patients were more likely to be dissatisfied with not receiving a face to face appointment than
younger patients (Age >55 = 10%, Age 35-55 = 7%, Age <35 = 1%) however these
percentages are still very low across all age groups. Interestingly, nobody under the age of
25 was displeased about not receiving a face to face appointment. There was no relation
between age groups regarding satisfaction with outcome alone.
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
Graph 4
3.3
Graph 5
PHONE COMMUNICATION
General Communication
Overall 90% of patients claimed the doctor understood what they were saying on the phone
and there were no major differences found between patient demographics. 61% feel
communication over the phone is equally as effective as it is in person. When asked if
communication was a problem to the extent that it negatively influenced the outcome of the
phone consultation, 77% said ‘No’ meaning that although 39% of patients did not think
communication was as effective as face to face, only 23% thought it was a problem. These
statistics were similar across all 3 study groups although Group 3 patients felt the doctor
understood them the most (91%) while Groups 1 and 2 still had high percentages of patients
in agreement (79% and 88% respectively).
There seems to be a trend in Graphs 6 and 7 (overleaf) that increasing age is accompanied
with a perceived decrease in effectiveness of phone communication alongside a higher
likelihood that communication will be a problem to the extent that it negatively influences the
outcome of the phone consultation (with the exception of the >75 group).
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Graph 6
Graph 7
Graph 8 below shows the opinions of different employment statuses regarding the
effectiveness of communication over the phone. Students and retired patients doubted
communication effectiveness the most however despite this, the majority of patients within
each separate employment status subgroup agreed that communication was not a problem.
Graph 8
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
Preference of Consulting Medium
Overall 84% of patients prefer to talk about problems in person. There was no difference
between study groups, and this statistic was also similar across all employment statuses
with the exception of unemployed patients (only 63% prefer in person) and housewives who
liked both consulting mediums equally (50%). Slightly more females prefer to talk on the
phone than males (19% vs. 13%) and in general as age increases more patients prefer to
talk in person (80% of under 45’s vs. 90% of over 45’s). It was noted that 12 patients did not
state a preference, and through reading additional comments this is probably due to some
patients either having no preference OR the preference depends on the specific problem
(e.g. most comments agreed that sexual health issues are better discussed in person).
Time on Phone
85% of patients overall felt there was enough time on the phone to discuss everything they
needed to with the doctor, which confirms that the phone consultation method is more time
efficient for both doctor and patient. Patients in all three study groups agreed with the overall
statistic (Group 1 = 89%, Group 2 = 71%, Group 3 = 86%).
Privacy
45% of all patients thought that phone consultation was less private than an appointment in
person; moreover 41% of all patients thought the privacy influenced what information they
shared with the GP. Results were consistent between genders and across all age groups
except the 46-55 group where 71% of females thought the phone consultation was less
private. Graph 9 overleaf reveals that the majority of students and part-time workers found
the phone consultation less private while housewives were the least concerned about
privacy. Further analysis revealed that phone privacy had most influence over the
information that unemployed patients shared with their GP, while retired patients were
influenced the least by privacy.
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
Graph 9
Study Group 1 was the least concerned about privacy (32%), followed by Group 2 (41%) and
Group 3 was the most concerned about privacy on the phone (47%). Perhaps this is
because patients who have a more personal problem that justifies an appointment in person
are more likely to have an issue with privacy on the phone than patients who simply want a
prescription or advice about a minor issue. The postal groups were also less influenced by
privacy than Group 3 with regards to the information they chose to confide in their GP,
particularly Group 1 (21% vs. 43% Group 3)
3.4
CONTINUITY OF CARE
Overall
Results show that 39% of patients claim to have been given the option to speak to the doctor
of their choice, and only 34% of patients spoke to the same doctor they normally speak to
(i.e. received continuity of care). Despite this, only 68% of patients considered continuity of
care important to them and 87% were happy with the specific doctor they spoke to
regardless of whether or not this was the same doctor they normally speak to. Further
analysis discovered that 41% of all patients didn’t receive continuity of care (COC) despite
this being important to them. However on another note, 82% of patients that didn’t receive
continuity of care were happy with the specific doctor they spoke to anyway. These findings
stimulate the question of how many patients might consider COC as a potential cause of
dissatisfaction with Doctor Fist overall.
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
Therefore, as a means of identifying this accurately, more in depth analysis was carried out
which discovered that 21 respondents (9% of all patients) didn’t receive COC despite this
being important to them and were not happy with the specific doctor they spoke to.
Furthermore, only 8 of these 21 patients were very dissatisfied / dissatisfied with Doctor
First. This in short means it can be assumed that a maximum of 3% of all patients could
reasonably attribute COC as a potential cause of dissatisfaction with Doctor First.
Inter-Group Analysis
Results show that COC is important to the majority of both males and females, however
females value COC slightly more (71% vs. 65%). Graph 10 below illustrates that the majority
of patients in all age groups considered COC important to them and their level of care,
however it is clear that those aged 46 and above valued COC much more than those aged
45 and under.
Graph 10
Graph 11 overleaf demonstrates that COC was important to the majority of patients within
each and every employment status. There is a clear trend that those who are working or
studying on the right hand side of the graph value COC less than those who are not (on the
left hand side of the graph). 100% of unemployed patients considered COC important to
them and this was agreed by 80% of retired patients and 79% of housewives. Only 60% of
students and 58% of full-time workers valued COC.
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
Graph 11
3.5
CONVENIENCE OF CALL BACK
Overall
88% of all patients were able to receive a telephone call during surgery hours (12% were
not) but only 77% said it was convenient for them to receive a call during surgery hours.
Specifically, almost a fifth (18%) of the people that were able to receive a call said it is not
convenient to receive that call. 84% of all patients said they were able to receive a call and
that it was convenient for them to receive that call. Despite this, only 58% of patients overall
agreed that the new system (Doctor First) is more convenient for them than the previous
system, which means 42% still think the previous system was more convenient.
Inter-Group Analysis
Graph 12 overleaf shows that the vast majority of every age group were able to receive a
call during surgery hours. Those aged 66 and over were most likely to be able to receive a
call whilst those aged between 46 and 65 were least likely to be able to receive a call.
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
Graph 12
Graph 13
Graph 13 above illustrates that although Doctor First is more convenient than the previous
system for the majority of patients within almost all age groups, in general Doctor First is
more convenient for those aged 45 and under (62% average) than for those aged 46 and
over whose answers were almost evenly split (53% average).
Graph 14 overleaf shows that although the vast majority of patients across all employment
statuses were able to receive a call during surgery hours, retired and unemployed patients
were most likely to be able to receive a call, whilst part-time workers and housewives were
least likely to be able to receive a call. Graph 15 overleaf shows that Doctor First was most
convenient for full-time workers and housewives (67% and 74% respectively). It also
illustrates that despite being most able to receive a call, retired and unemployed patients
were both almost evenly split as to which system was more convenient for them (55%).
Interestingly, the majority of students and part-time workers considered the previous system
more convenient than Doctor First.
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
Graph 14
Graph 15
Between study groups, there was very little difference both in the percentage of patients able
to receive a call (Group 1 79%, Group 2 82%, Group 3 90%) and the percentage of patients
who consider the call back convenient for them (Group 1 74%, Group 2 71%, Group 3 78%).
Nevertheless Graph 16 below illustrates that when comparing Group 2 (those who were
unable to be contacted) with Groups 1 and 3 it was found that as little as 35% of Group 2
thought Doctor First was more convenient than the previous system, whereas a much higher
percentage of Groups 1 and 3 considered Doctor First more convenient (63% and 60%
respectively).
Graph 16
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
3.6
PATIENT ACCESS & EFFECT ON GP WORKLOAD
Reassurance by having earlier contact with GP
Overall, 80% of patients were reassured by having earlier contact with their GP. Graph 17
below indicates that while each employment status had the majority of patients reassured,
that in fact housewives and unemployed patients valued enhanced access to their GP the
most, whilst students valued this least. Group 3 were reassured by earlier contact the most
(82%), followed by Group 1 (74%), while only 65% of Group 2 were reassured.
Graph 17
Graph 18
Length of time to return call
87% of all patients were satisfied with the length of time it took for the practice to return their
call. Graph 18 shows very similar results as Graph 17 in that the majority of every
employment status was satisfied with the length of waiting time before receiving a phone
consultation. Again, housewives, unemployed patients and full-time workers were satisfied
the most whilst students were satisfied the least. An extraordinary 100% of Group 1 patients
were satisfied with the length of time taken to receive a call back from the practice. Groups 2
and 3 were also very satisfied on a whole (76% and 87% respectively).
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Face to face appointments
Only 207 participants answered the questions in this section of the questionnaire as it did not
apply to everyone. As mentioned earlier in the method section of this report, missing data
was excluded from analysis in order to obtain accurate results.
The decision to have a face to face appointment in most cases was a joint decision (49%)
however 29% of appointments were the clinician’s decision and 23% were the patient’s
decision. The study found that 89% of patients received an appointment on the day of their
choice and 72% of all appointments were booked on the same day as the telephone
consultation. By combining answers to these two questions, analysis revealed that 94% of all
patients who received a face to face appointment were given one either the same day or on
an alternative suitable day of their choice. Surprisingly 10 patients (7%) of those given a
same day appointment said that this was not the day of their choice (i.e. would have
preferred to come in a later day for an appointment). Despite this, 94% of patients given a
same day appointment were satisfied with their outcome.
Effect on GP workload
Overall 53% of patients admitted that the new system (Doctor First) has encouraged them to
contact the practice more often when they have a medical problem. Graph 19 overleaf
confirms a distinct change in opinion between those aged 45 or under and those aged 46 or
over, in that this is more the case for younger patients (60% average) than for older patients
(40% average). Graph 20 overleaf uncovers that housewives and unemployed patients are
far more likely to contact the practice more often as a result of the new system than those
who are working or retired. Groups 1 and 3 had similarly high percentages of patients (47%
and 55% respectively) encouraged to contact the practice more often, however only 29% of
Group 2 patients agreed with this statement. This finding is supported by analysing
additional comments at the end of the questionnaire where numerous patients in Group 2
stated they now contact the practice less often as a result of implementing Doctor First.
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
Graph 19
Graph 20
As a means of postulating why patients contact the practice more often, more in-depth
analysis was carried out by cross-comparing individual case answers to this question with
different questions such as convenience of the system, access to the doctor and outcome of
the phone consultation. Findings revealed that of the patients who felt encouraged to contact
the practice more often, 78% also indicated that Doctor First was more convenient for them
than the previous system whilst 93% also indicated that they felt reassured by having earlier
contact with the GP. Moreover, almost all this group of patients (98%) also indicated that
they were happy with the outcome of their phone consultation. The high rates of correlation
between these answers suggest that all three of these aforementioned factors could have
influenced patients to contact the practice more often, although it is most likely due to either
improved satisfaction with outcomes or speed of access to GP rather than the sheer
convenience of the system alone.
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
3.7
OVERALL SATISFACTION & COMPARISON TO PREVIOUS SYSTEM
Full Cohort
Graph 21 below draws a direct comparison in overall satisfaction levels between Doctor First
and the previous system. It illustrates that 70% of all patients were either satisfied or very
satisfied with Doctor First, whereas only 45% of all patients could say the same about the
previous system. It also shows that more patients were either dissatisfied or very dissatisfied
with the previous system than with Doctor First (23% vs. 18%). Further analysis revealed
that 45 out of 53 patients that disliked the previous system (i.e. dissatisfied or very
dissatisfied) were either satisfied or very satisfied with Doctor First, meaning that 85% of
these patients saw an improvement and thus much preferred the new appointment system.
Graph 21
100
90
80
70
Count
60
50
Previous system
40
New system (Doctor First)
30
20
10
0
Very
Dissatisfied
Dissatisfied
Neither
Satisfied
Very Satisfied
Overall Satisfaction
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Study Group
Graph 22 below compares satisfaction levels with Doctor First between different study
groups. It shows that the majority of all three groups were either satisfied or very satisfied
with Doctor First (i.e. liked the new system). Group 1 liked the new system the most (79%)
closely followed by Group 3 (70%) however much less patients in Group 2 liked the new
system (53%). These results are reversed with regards to satisfaction with the previous
system as displayed in Graph 23. A minority of Groups 1 and 3 liked the previous system
(37% and 44% respectively) whilst Group 2 liked the previous system the most with 59%
being either satisfied or very satisfied. In summary, Groups 1 and 3 much preferred Doctor
First to the previous system, whereas Group 2 slightly preferred the previous system despite
disliking both systems equally.
Graph 22
Graph 23
Gender
Males and females felt similarly about the previous system. However more females disliked
Doctor First than males (22% vs. 12%) and more males liked Doctor First than females (73%
vs. 67%) meaning Doctor First was slightly preferred by males over females.
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
Age Group
Table 1 below displays the percentage of patients within each age bracket that liked Doctor
First (i.e. were either satisfied or very satisfied) and compares this with the previous system.
It shows that while all age groups preferred the new system to the old system, Doctor First
was liked by the younger age groups the most and the previous system was liked by the
older age groups the most
Table 1
AGE BRACKET
% that liked
Doctor First
% that liked
previous system
<25
25-35
36-45
46-55
56-65
66-75
>75
80
69
71
62
60
71
63
43
42
37
50
44
65
42
Employment Status
Table 2 below displays the percentage of patients within each employment status that liked
Doctor First and compares this with the previous system. It shows that while all employment
statuses preferred the new system to the old system, Doctor First was liked by housewives,
full-time workers and students the most and the previous system was liked by part-time
workers and retired patients the most.
Table 2
EMPLOYMENT
STATUS
% that liked
Doctor First
% that liked
previous system
Full-Time
Part-Time
Student
Housewife
Unemployed
Retired
74
56
73
79
60
64
41
52
43
47
44
50
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
3.8
ADDITIONAL COMMENTS
When analysing additional comments, responses were separated into groups of similar
content and frequencies of each content group were tallied in order to determine the validity
of the responses.
The vast majority of positive comments were based on improved speed of access to the GP,
the availability of same day appointments and the convenience of the telephone
appointment.
The most frequent negative comments were associated with safety concerns (including
confidentiality, patient identification and privacy of phone appointments), ineffective
communication on the phone and the inconvenience of phone appointments, particularly not
being able to choose a suitable time to receive the call-back.
To view the full list of additional response content, frequencies and sample quotes extracted
directly from patients’ responses, please refer to the additional comments tables in
Appendix 6.
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CHAPTER 4
4.1
DISCUSSION
PRINCIPAL FINDINGS & COMPARISON WITH PREVIOUS RESEARCH
Previous researchers have agreed that more in-depth research is required to determine
patient satisfaction levels with different aspects of the phone triage service19 and this is what
this study seeks to address. Although the author is unsure whether results can be
generalised to the UK public, the findings certainly offer a good insight into patient
satisfaction with different aspects of a phone triage appointment system.
Characteristics of Study Cohort
Despite having a total of 231 participants, cohort characteristics were unevenly balanced for
certain analytical groups including age range (majority were younger), outcome of phone
consultation (vast majority were GP appointment) and study group (vast majority were Group
3). This would result in a tendency for findings to be biased in favour of the opinions of these
larger subgroups however in order to negate this bias, the author has reported percentage
statistics for responses within each analytical group rather than reporting percentages of the
entire cohort. This means that although results are not affected by balance and are thus
unbiased, that statistics within certain groups will be more valid than statistics in other
groups depending on the total number of respondents within that analytical group.
Outcome of Phone Consultation
Productive Primary Care have displayed patient satisfaction data from their most recently
converted practice, stating that 85% of all patients were satisfied with the outcome of their
phone consultation. This study supports this statistic as it found a similarly high figure of 89%
being satisfied with their outcome. The author hypothesised that since most patients are
arranged to be seen in person that this finding might not accurately represent patients dealt
with entirely on the phone. Furthermore, the author could not find a previous study that
directly compared satisfaction levels (with regards to outcome) between patients offered a
face to face appointment (represented by Group 3 in this study) and those dealt with entirely
on the phone (represented by Group 1 in this study). Findings from this study showed that
satisfaction levels between these two groups were in fact very similar (91% vs. 84%
respectively). This is supported by the additional findings that almost a quarter of all patients
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
felt they did not need to be seen in person, whilst only 2 patients in Group 1 were unhappy
about not receiving a face to face appointment. This strongly suggests that there is a place
for telephone consultations as they are widely accepted as an effective alternative method of
dealing with these patients that may not need to be seen in person. This study found that
patients offered a house visit, a referral to another service or advice only on the phone were
much less satisfied than those offered a prescription on the phone, however results for these
three outcomes should be accepted with caution as they were calculated based on very few
numbers of patients with these outcomes.
Previous research has indicated that doctor and patient disagree in 95% of consultations
with regards to whether or not the complaint could be dealt with over the phone.21 This
however should not be an issue with the Doctor First system because as long as the patient
wants a face to face appointment following their phone consultation then they will be offered
one. In addition, the fact that only 3.5% of patients overall were displeased about not being
seen in person strongly implies that the system is working well for patients. There were also
patients who felt they needed to be seen in person but were satisfied with having been dealt
with entirely on the phone.
Findings revealed that younger patients feel they need to be seen in person more than older
patients. The author hypothesises that this could be due to older patients having chronic
disease for which they consult the doctor regularly usually seeking either management
advice or test results thus a phone call will suffice. The need to examine would only be at the
early diagnosis stage or during any exacerbation. Whereas younger patients see the doctor
less but will tend to have acute symptoms warranting a diagnosis which may require an
examination – even if it is likely to be a simple self-limiting infection.
Phone Communication
General Effectiveness of Communication
The quality of GP communication over the phone, including safety netting advice, has been
shown to be equally as effective as during face to face interactions.6 Nonetheless, the author
of this study was unable to discover any previous papers that researched whether patients
think phone communication is as effective from their point of view. The results from this
study are therefore quite interesting. A promising 61% of patients considered communication
to be equally as effective as in person; although a concerning 23% thought communication
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
was a problem to the extent that it negatively influenced the outcome of their phone
consultation.
This may be because these patients feel less comfortable on the phone and therefore
struggle to explain their symptoms without showing the doctor in person. This hypothesis is
supported by many additional comments elicited in this study, with numerous patients
reporting that they get “tongue-tied” or “flustered” on the phone.
It might also be due to a poorer rapport between doctor and patient which could influence
levels of trust and in turn negatively impact the information a patient chooses to confide in
their GP. Previous research has found that phone appointment systems result in a poorer
doctor-patient relationship, however the author has been unable to find any research looking
into whether or not this lack of rapport affects what information patients choose to confide in
their GP.6
Results show that 90% of patients felt the doctor understood them on phone, however
additional comments were made regarding the ability of the patient to understand the doctor
(i.e. the reverse). For example, some patients drew attention to a language barrier on the
phone particularly due to the doctor’s accent and that this hindered their treatment.
For older patients, problematic communication could also be due to hearing problems across
the phone, as elicited by some patients in the additional comments section. This would
complement the finding that increasing age is accompanied with a perceived decrease in
effectiveness of phone communication alongside a higher likelihood that communication will
be a problem to the extent that it negatively influences the outcome of the phone
consultation. Past research has indicated that doctor and patient disagree in 95% of
consultations with regards to whether or not the complaint can be dealt with entirely over the
phone.21 Therefore it is fair to assume that the aforementioned trend illustrated in this study
could also be due to younger patients being more able to push for an appointment in person
if they disagree with the doctor’s judgement. This however should not be an issue with the
Doctor First system because as long as the patient wants a face to face appointment
following their phone consultation then they will be offered one. Patients need to be made
aware of this.
This study discovered that amongst all employment statuses, students and retired patients
considered phone communication to be the least effective. The author reasons that this is
probably due to the nature of medical problems that the majority of students present with to
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
their GP (i.e. a high presentation of sexual health related issues including contraception). For
retired patients however, this could be due to any selection of the aforementioned issues
responsible for problematic phone communication.
Preference of consulting medium
Nagle et al. found that the majority of patients preferred to talk on the phone rather than
during a face to face consultation.18 On the other hand, the findings of this study differ in that
overall 84% of patients preferred to talk about their medical problems in person although, as
mentioned in numerous additional comments, this is dependent on what the specific medical
problem is (e.g. most comments agreed that sexual health issues are more difficult to talk
about over the phone when compared to other problems).This finding is supported by
Professor Brian McKinstry in an RCGP Letter who states that those who simply want advice
are more likely to prefer to consult on the phone than other patients.7 This study found that in
general older patients are less comfortable talking about medical problems on the phone
than younger patients, and this is probably due to how often these age groups use the
phone in their day to day life.
Time on the Phone
Numerous studies have confirmed that phone consultations are generally half the duration of
face to face appointments (5 minutes vs. 10 minutes) and there is strong evidence that this
shorter time does not limit the doctor from covering their agenda on the phone.14,15 However
the author could not find any published papers researching whether patients consider there
to be enough time on the phone to communicate their own agenda, especially since there
has been research suggesting that it is more difficult for patients to talk about multiple issues
on the phone than in person, where they have on average double the time.6 This study
establishes that 85% of patients felt there was enough time on the phone to discuss
everything they needed to with the doctor, and this statistic was similar amongst different
study groups. This confirms that the phone consultation method is more time efficient for
both doctor and patient. This finding infers that a significant proportion of face to face
appointment duration is spent engaging in ‘small talk’ in order to build rapport, whilst phone
appointments appear to be more clinical in that communication is more direct and to the
point. This is mentioned in research conducted by Hewitt et al. which concluded doctors do
not prompt patients on the phone for additional medical problems like they do in person.
According to the same study, there had been no evidence to prove that this behaviour limits
disclosure of patient complaints on the phone. Findings from this study can contribute to this
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
by strongly suggesting that this behaviour does not limit patients disclosing additional
medical problems on the phone.6
Privacy of Phone Consultation
Almost half of all patients thought the phone consultation was less private than an
appointment in person, and this lack of privacy influenced the information that more than a
third of all patients confided in their GP on the phone. This has the potential to impact the
safety of phone consultations as a patient’s failure to divulge particular symptoms on the
phone could directly affect their GP’s decision of whether or not they need to be seen in
person. All GPs are trained on how to make correct clinical decisions on the phone before
they start to use phone consultations; however there have been media reports concerned
about whether or not this training is robust enough.29 As mentioned in the introduction
section of this report, there has been heavy criticism on the safety of phone consultations,
particularly with regards to privacy and obtaining a diagnosis without appropriate
examination, however as elicited earlier in this report examination is not always
necessary.15,20 The statistics stated in this report are unable to rid of any previous concerns
regarding the privacy and/or safety of phone consultations; however findings also revealed
that many patients hold misconceptions regarding the call-back service including the inability
to choose a suitable time to receive the call (e.g. a time and place that it is foreknown
privacy will not be an issue). Therefore the author postulates that increasing patient’s
knowledge of the system and its common misconceptions might alter these results
significantly and change the opinion of patients regarding the privacy of the phone
consultation.
Continuity of Care
Concerns have been reported in previous research that providing rapid access for patients is
substituting continuity of care, and it is not clear whether patients feel speed of access is
more important than other aspects of primary care.24,25 Results from this study state that
39% of patients claim to have been given the option to speak to the doctor of their choice,
and as a consequence only 34% of patients actually received continuity of care (i.e. spoke to
the same doctor they normally speak to). It is hypothesised that this is because receptionists
will simply book the earliest available phone appointment unless the patient specifies a
particular doctor of their choice. Therefore it is suggested that Denburn Medical Practice
make their patients more aware of this scenario. On the other hand, it was found that only
68% of patients considered continuity of care important to them and 87% were happy with
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the specific doctor they spoke to anyway. These findings suggest that continuity of care
might be ‘a thing of the past’ and that patients rank other aspects of primary care more
important such as speed and ease of access to their GP. This differs from one study’s
results which state that for many patients, reduced waiting times were of less importance
than choice of GP and convenience of appointment, except if the appointment was for a
child or a new health problem.25 Careful analysis did reveal a reasonable assumption that a
maximum of 3% of all patients could attribute continuity of care as a potential cause of
dissatisfaction with Doctor First. The author accepts in hindsight that the questionnaire and
associated analysis would have been improved by the addition of a question where
respondents could rank these individual aspects in order of importance and their influence
on overall satisfaction with Doctor First. Nonetheless, what this research strongly suggests is
that phone systems do not improve continuity of care unless the system is explained
properly to patients (i.e. patients understand that they can ask to speak to the GP of their
choice). If this is the case, in theory this should improve continuity of care greatly when
compared to traditional appointment systems, as implied in previous research by McKinstry
et al.20
Findings also reveal that those aged 45 and over valued continuity of care more than those
under 45 years of age. It is predicted that this is due to older patients having multiple
morbidities for which it is inconvenient to repeatedly explain to a variety of doctors. Instead it
is easier to see the same doctor who already knows and understands the holistic view of
these patients.
Interestingly, when comparing opinions of different employment statuses, the graph in the
results section of this report shows a clear trend from left to right that the more occupied a
patient is (whether as a result of work or studying), the less they care about seeing the same
doctor every time. This suggests that patients who are working or studying prioritise another
aspect of care such as speed of access or convenience of appointment in place of continuity
of care.
Convenience of Call Back
The study revealed that 88% of all patients were able to receive a telephone call during
surgery hours. While this is remarkably high, the question remains about what happens to
the remaining 12%. It is presumed that these patients either work a full day from 8:00am to
6:00pm or are patients who do not have a personal phone to be contacted on. The system
allows for these patients to explain their situation to the receptionist whilst on the phone who
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
is then able to book an appointment in person directly without the patient needing to go
through the triage system. A similar protocol is in place for those who do not have a phone.
These patients can walk into the practice when they have a medical problem and the
receptionist will inform the duty doctor on call of the patient’s situation. In this circumstance,
patients are seen as soon as possible without needing to leave the practice building however
if the doctor is unavailable at that time, then a face to face appointment will be booked at a
mutually convenient time without the need to go through the triage system.
Almost a fifth (18%) of people able to receive a call said it is not convenient to receive that
call. The reasons for this are highlighted when analysing additional comments. They include
not being able to take time off work, the hassle of carrying around a mobile phone, not being
able to choose a suitable time to receive the call back, and the inability to plan out the day
ahead. In reality, most patients are called back within minutes of contacting the practice
however these comments further highlight the importance of providing further education
about Doctor First to patients of Denburn Medical Practice as many of these reasons are
misconceptions. Nevertheless, for the aforementioned reasons, 42% of patients considered
the previous system to be more convenient for them than Doctor First.
The fact that the call back was more convenient for younger age groups than older age
groups suggest the reason is because younger patients are more occupied during the day
(whether working or studying at university) and therefore do not need to wait at home for a
call back, instead they will carry their mobile round with them during the day. This would also
explain the viewpoint of older patients as they are more likely to need to wait at home for a
call back and less likely to carry around a mobile all day.
Interestingly, the majority of students considered the previous system more convenient than
Doctor First. This is probably because university timetables change every day of every week
and so by booking a face to face appointment in advance you can always make it for a day
and time that suits.
When comparing study groups, the key finding was for that of Group 2 as these were the
patients that could not be contacted on at least one attempt. The result is promising in that
Group 2 were almost equally as satisfied as the other two groups with regards to their ability
to receive a call and the convenience of receiving a call however, despite this, Group 2
thought the previous system was much more convenient for them (unlike Groups 1 and 3).
This is probably simply due to the fact that they missed at least one call from the doctor
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which caused a degree of frustration, or worry as indicated by one patient who left the
following additional comment:
“It’s not clear whether or not (the) doctor would only call once so (it) resulted
in me needing to call (the) practice again”
This comment further emphasises the growing theme throughout this discussion section that
Denburn Medical Practice need to further educate their patients on what happens in these
circumstances.
Enhanced Patient Access & Effect on GP Workload
Enhanced Patient Access
Results indicate that students valued enhanced access the least and were the least satisfied
with the length of time it took for the practice to return their call. This suggests that students
value the suitability and convenience of their appointments more than speed of access to
their GP due to the unpredictability of the university timetable. It is probably also due to
students’ limited availability during the day to answer their phone as most will miss a call
back during a lecture that they either cannot excuse themselves from or have no phone
signal to receive the call in the first place. On the whole, all other employment statuses will
be more able to take a small break from what they are doing in order to receive a call.
Group 2 were the least reassured by having earlier contact with the GP and were also the
least satisfied with the length of time it took to receive a call back. This is obviously due to
the fact that this group’s speed of access was reduced when compared to the two other
groups as they could not be contacted on at least one attempt. However it is promising to
note that despite this, overall a large majority of Group 2 still valued having enhanced
access to their GP and were also satisfied with the duration of time between phoning the
practice and receiving a phone consultation. This suggests that the benefits of the system
outweigh the detriments, even for patients that experience the system at its worst.
Face to Face appointments
Results confirmed that almost all patients (94%) who received a face to face appointment
were given one either the same day or on an alternative suitable day of their choice. This
highlights one of the main benefits of the system which is the ability to be seen when you
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want or need to be seen. It is unclear what happened to the remaining 6%. The availability of
same day appointment was the most frequently stated positive comment about Doctor First.
Other than the obvious benefits this brings (e.g. being treated earlier etc.) the availability of
same day appointments has also changed the way patients feel about themselves:
“(Being seen the same day) made me feel valued rather than waiting
days…before it was a nightmare”
Previous research by Sampson et al. shows that increasing the number of same day
appointments results in reduced patient satisfaction23 however this study’s findings
contradict this conclusion. 72% of patients seen in person were booked a same day
appointment and almost all (94%) of these patients were satisfied with this outcome.
Sampson et al. do however infer that same day appointments do not suit certain groups of
patients, and this study confirms that this was indeed the case for 10 patients (attributing to
7% of patients given a same day appointment) that indicated a same day appointment was
not the day of their choice. It is presumed that these 10 patients did not have an urgent or
serious medical problem and could therefore afford to wait before being seen; otherwise a
same day appointment would have been preferred. Nonetheless, this is another clear
indication that Denburn Medical Practice would benefit from educating their patients, on this
occasion regarding the ability to choose a suitable date and time to be seen in person.
Effect on GP workload
Existing evidence has indicated that phone triage systems are overall more time efficient for
doctors16 as they are shorter in duration and result in reduced numbers of home visits and
face to face appointments,7,14,18 thus overall decreasing GP workload. However significant
doubt remains as to whether or not increased use of the phone service negates this benefit
for GPs.19 More than half of all patients in this study admitted that Doctor First has
encouraged them to contact the practice more often than they used to. This finding is
supported by results from previous studies describing that as many as 12% of patients would
not have contacted the practice in the first place had the phone triage system not been
available.18 This demonstrates that phone triage systems not only encourage greater
numbers of re-consultations, but also encourage greater numbers of initial consultations
about minor symptoms that patients would normally have sought a pharmacist’s advice
about or simply put up with.7
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The effect phone consultations have on GP workload needs to be accurately calculated, and
will depend on the total number (or proportion) of patients presenting with new problems that
are able to be dealt with entirely over the phone as well as the total number (or proportion) of
these patients who end up being seen in person anyway following the phone consultation.
For instance, once a patient calls twice they have effectively used the same amount of a
doctor’s time as they would if they just saw the doctor once in person straight away (as with
the previous system). Research has already been published by McKinstry et al. showing that
40% of patients are seen in person following a phone consultation regardless of whether
they needed to or not, simply because either the GP or patient wanted the personal
contact.16 The same study also demonstrated that 50% of patients dealt with entirely on the
phone received a second phone consultation within the fortnight either due to being unsure
of the initial advice given or worried that symptoms had not disappeared. This finding
combined with the statistic uncovered in this study infers that phone consultations inevitably
increase GP workload. Other studies have reported that phone systems may not save time
for doctors or patients with new/acute problems as most of these presentations are seen in
person anyway.6 On balance, most researchers are currently of the opinion that phone
consultations do in fact decrease workload for GPs overall, however the findings from this
study add to the already existing degree of contradiction amongst published statistics thus
further and more in-depth research is required to accurately calculate whether or not this is
indeed the case.
Younger patients are more likely to feel encouraged to contact the practice more often than
older patients. This is perhaps because a greater proportion of older patients only contact
the doctor when they need to whereas younger patients are more likely to take advantage of
the enhanced access for a quick opinion about a minor issue. Alternatively this finding could
suggest that the majority of patients calling about minor issues under the previous system
were older patients as they could afford to wait to be seen, whereas now that an
appointment can be booked earlier on a date and time that suits, younger patients are now
calling about minor issues that they wouldn’t normally have called about in the past, as they
no longer need to wait to be seen and experience the added benefits of not needing to
simply put up with their symptoms and an opportunity to immediately disregard any concern
they have about their health.
Study Groups 1 and 3 are more likely to contact the practice more often than patients in
Group 2. This is probably because Groups 1 and 3 value the benefits of the system greatly
such as same day appointments, quicker advice and ease of obtaining a prescription. For
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Group 2 however these benefits are probably outweighed by the inconvenience of the callback service.
In-depth analysis was carried out by cross-comparing individual case answers between
different aspects of Doctor First. It was interesting to discover that whilst the sheer
convenience of the system encouraged patients to contact the practice more often, that
actually a far greater influence derived from improved outcomes and enhanced access to the
GP. This means that a big reason why patients are contacting the practice more often is
because they feel they are being managed more appropriately, whilst being seen quicker is
resulting in patients feeling more valued. These findings also place faith in researchers that
the sheer convenience of the system alone is not responsible for the increased numbers of
phone consultations.
Overall Satisfaction & Comparison to Previous System
Results show that the vast majority of patients were satisfied with Doctor First (70%)
whereas a minority of patients were satisfied with the previous system. This confirms quite
clearly that Doctor First is preferred by patients of Denburn Medical Practice. This result was
very similar between patients dealt with in person and those dealt with entirely on the phone,
proposing that outcome did not make a difference to overall satisfaction. The opinions of
Group 2 patients were more balanced between the two systems, but perhaps slightly
preferred the previous system. The vast majority of patients overall are contacted on the first
call-back attempt thus this lone finding should not sway practices against Doctor First.
Doctor First was slightly preferred by males over females. This perhaps links with the
common illusion that males are less likely to see a doctor when they have a medical
problem, as Doctor First provides males with a method of contacting the doctor for medical
advice without the embarrassment of seeing them in person about something minor or the
general inconvenience of getting to the practice for an appointment in person. This remains
unclear however as this study discovered earlier that the majority of males prefer to talk
about medical problems in person. According to this research, younger age groups like
Doctor First more than older age groups, therefore it is possible with regards to the findings
above that the main difference here lies with young males as opposed to older males. This
would fit in with the finding that students like Doctor First much more than retired patients.
Interestingly, the author noticed that patients who are actively working or studying liked
Doctor First more than patients who are not currently working or studying. This is probably
as a result of two main aspects of the system: greater convenience of the system (to fit
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around work and lectures); and quicker advice from the doctor without needing to be absent
from work or university. The added benefits of these aspects have less of an effect on those
who are not currently working or studying.
Through reading the additional comments, it has become apparent that a significant
proportion of patients have misconceptions about Doctor First that portray the system in an
inaccurate and negative light. It is therefore possible that these patients’ answers negatively
influenced results with respect to accuracy of overall satisfaction levels.
4.2
STRENGTHS & WEAKNESSES
This study acknowledges several limitations, however the author attempted numerous
measures to minimise bias wherever possible in order to achieve valid results.
Study Design + Conduct
Patients in Groups 1 and 2 were able to fill out the questionnaire in their own time within the
comfort of their own home, without enduring a financial burden of needing to pay postage to
return their questionnaire. This was considered to be a strength with respect to study design.
All patients in Group 3 returned their questionnaire to reception before leaving the practice.
This suggests that they too had plenty of time in the practice whist waiting to be seen to
complete the questionnaire.
In order to maintain anonymity of respondents and reduce researcher bias, NOSRES and
the author made a joint decision that the author would have no involvement in the selection
process, instead it was decided that GPs would take initial consent from patients on the
phone to identify potential participants, whilst practice staff at reception would handle any
confidential or identifiable data including names and addresses for postal questionnaires. As
mentioned earlier in the Method section of this report, by choosing not to take written
consent it was ensured that no identifiable data would be collected or stored throughout the
duration of the study.
A potential source of unforeseen and unpredictable bias lies with the GPs, in that there was
no record of which GP patients had contact with. All GPs participated with regards to
identifying potential participants; however some may have contributed more effort to this task
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
than others. If this was to happen it would result in overall patient views being unfairly
weighted towards the performance of the GP who identified the most participants. This bias,
if present, would apply more to Groups 1 and 2 because these are the only Groups that were
limited in terms of number and selection of participants.
Participants
Three exclusion criteria were set and GPs were responsible to enforce these criteria on the
phone when recruiting potential participants. The first criterion was patients aged between
13 and 15 inclusive. This is because these patients have complicated ethical considerations
regarding ability to consent for themselves in order to participate in the study. This therefore
had the potential to introduce a small degree of selection bias to the results. The second
exclusion criterion was patients who have special needs (including additional communication
needs or a Learning Disability). This is because these patients might encounter difficulty
when trying to complete the questionnaire, and no arrangements were put in place to assist
these patients with filling out the questionnaire. This therefore also had the potential to
introduce a small degree of selection bias to the results. The final criterion was patients that
cannot read or understand the English language. This is because these patients would be
unable to complete the questionnaire. In order to minimise selection bias, patients of all
nationalities/ethnicities/languages were assumed to be able to read and understand the
English language provided the GP was not aware of any obvious language issues and that
they returned a correctly completed questionnaire. It is however possible that some
questions were more difficult to understand for patients with a primary language other than
English, thus there was potential for these patients to have a slightly negative impact on
result accuracy. By using this method to enforce this exclusion criterion, the author did not
unnecessarily exclude patients of differing nationalities that could otherwise read and
understand English sufficiently.
Questionnaire Design
The questionnaire was designed to be simple to understand and easy to complete in order to
achieve accurate answers. The text used was a legible black font and questions were clearly
divided into sections with explanatory instructions to aid completion. Individual questions
consisted mainly of single selection tick boxes – almost all of which were a simple choice of
‘Yes’ or ‘No’ response. There were two Likert style questions to determine a more accurate
picture of overall satisfaction with both systems. There were also two free text boxes for
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participants to explain their opinions honestly and in their own language so as to not miss
any important feedback or comments regarding either system (whether positive or negative).
The questionnaire was designed to take a maximum of 5 minutes to complete in order to
improve the likelihood of participation. Furthermore, potential participants were reassured
that the questionnaire was completely confidential and that no method existed to be able to
personally identify respondents or match them with the answers they gave. This allowed
respondents to be completely honest with their responses and opinions, which in turn
provided more accurate results.
A pilot study (or ‘test run’) was carried out during the first day of the elective project in order
to assess and improve the validity of the questionnaire before commencing the proper study.
Responses from this day were not included in the final analysis; however the author was
able to identify certain areas of the questionnaire that were not completed correctly and
improve instruction technique when handing patients the questionnaire before attempting to
complete it. The questionnaire was also independently reviewed by two academic
supervisors, a university statistician and non-related lay-persons with regards to content,
format and general comprehension.
When reading the additional comments provided by participants, it is clear that the
questionnaire would have benefitted from the addition of an ‘Unsure’ tick box for certain
questions that were left un-answered by some patients. The author also regrets in hindsight
not including certain questions in the questionnaire which would have improved analysis and
general findings. An example is a question asking respondents to rank in order of
importance the individual factors which influence their decision with regards to overall
dis/satisfaction with Doctor First. These factors include continuity of care, speed of access to
the GP, effective phone communication, phone privacy, preference of consulting medium,
satisfaction with outcome and availability of same day appointments. This would have
allowed the author to determine which aspects patients value the most.
Sample Size + Recruitment
The author was pleased with the total number of respondents (n=231) especially considering
the time limitations of the elective period, however it is clear that this sample size is smaller
than that of some previous studies researching a similar topic. The author is therefore
unsure as to whether or not the results from this study can be attributed to a wider
population such as the UK population. Nevertheless, the results certainly provide interesting
information for which future research can be based on.
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Unfortunately, there was a high percentage non-response rate (66%) for the postal
questionnaires in Groups 1 and 2. This resulted in relatively small sample sizes for these
particular groups of patients when comparing to Group 3 respondents which suggests that
cross-sectional analysis between study groups might not be able to be generalised to the UK
population. Groups 1 and 2 alone however were almost equally weighted, and contained a
sufficient sample size to provide a reasonable snapshot of these patient’s opinions in
comparison to Group 3 patients. Other measures could have been taken to improve postal
questionnaire response rates such as a financial incentive or entry into a draw to win a
reward for completing the questionnaire, however this was not possible due to lack of
necessary funding, and in addition would have complicated ethical approval.
4.3
IMPLICATIONS FOR CLINICAL PRACTICE & RESEARCH
Recommendations for Future Research
One of the main drawbacks of this study is the sample size therefore it is recommended that
similar research is carried out on larger numbers of patients, particularly with respect to
study groups 1 and 2, so that similar findings can easily be generalised to the UK population.
Also the author believes that patients’ misconceptions about Doctor First could have
negatively influenced patients’ opinions of the system, thus it is suggested that research be
carried out to determine if increasing patient knowledge improves satisfaction levels with
regards to any particular aspect of the phone triage system.
The author advises there to be research to determine the relative importance of different
aspects of phone triage systems. This would inform GP practices using phone triage
systems about what factors influence satisfaction the most and will allow them to adapt their
system accordingly so that their patients’ satisfaction levels can be maximised. These
factors include the following:
-
Continuity of care
-
Speed of access to GP
-
Convenience of phone consultation
-
Availability of same day appointments
-
Duration of phone consultation
-
Preference of consulting medium
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-
Privacy (or other elements of patient safety) of phone consultation
-
Effectiveness of phone communication / rapport building
-
Outcome of phone consultation
A considerable proportion of patients in this study thought communication was a problem to
the extent that it negatively influenced the outcome of their phone consultation. More
research is needed to determine which aspects of communication were primarily responsible
for this.
Additional comments were made regarding the ability of the patient to understand the doctor
on the phone due to a language barrier particularly with respect to the doctor’s accent.
Despite some indicating that this hindered their treatment, it remains unclear exactly to what
extent this influenced the care of these patients and/or the outcome of their phone
consultation. As such further research is required in this area.
Almost half of all patients were concerned about the privacy of the phone consultation, and
more than a third felt this lack of privacy influenced the information they chose to confide in
their GP. While this has the potential to adversely affect the safety of phone consultations,
there needs to be stronger research to confirm that this is the case, and the research needs
to consider the level of patient knowledge with regards to requesting a call back to occur at a
suitable time.
Further research is recommended to accurately determine whether or not decreased GP
workload as a result of reduced appointment times is compromised by increased use of the
phone triage service. Moreover, the author proposes that research be carried out in the long
term to elicit GP satisfaction with spending a large proportion of their working lives on the
phone.
Lastly, stronger evidence is required to accurately discover the reasons why patients feel
encouraged to contact the practice more often than they used to. For instance, whether it is
primarily due to improved outcomes or quicker access to the GP, or whether it is simply due
to the sheer convenience of the system alone.
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Implications for Clinical Practice
Using the phone as a method of managing increasing demand for appointments is becoming
more and more popular. A recent RCGP report forecast the following:
“The GP of the future will need to be skilled in using a suite of new and flexible tools
for communicating with patients, including telephone, email and various online forms
of consultation” 30
This is in line with current Government strategies and policies such as ‘Digital First’ and ‘The
Power of Information’, both of which encourage increased use of technology for current and
future healthcare. The author can therefore foresee Doctor First and similar appointment
systems being a central focus of future General Practice.
The findings from this study support Productive Primary Care’s claim that Doctor First is a
successful and effective method of improving patient access. Statistics from this study
confirm an improvement in patient outcomes, an improvement in patient satisfaction levels
and a significant improvement in availability of same day appointments. The only aspect of
the system that this study could not confirm was its positive effect on continuity of care as
mentioned in previous research and quoted by Productive Primary Care, however this was
probably as a result of lacking patient knowledge of the system at Denburn Medical Practice.
Doubt remains as to whether or not patient safety is being compromised by using phone
consultations. Although this study elicited that some patients withhold crucial information
from their GP on the phone as a result of decreased levels of privacy, the author believes
that by increasing patient’s knowledge of the system and its common misconceptions, that
this will no longer happen as patients will know they can request the phone consultation to
occur at an appropriate time when privacy will not be an issue. Stronger evidence is needed
to confirm this hypothesis.
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Recommendations for Future Practice at Denburn Medical Centre
A clear theme has emerged throughout writing this research report which is that numerous
patients have misconceptions regarding the Doctor First system. These incorrect opinions
are having a direct negative impact on these patients’ satisfaction levels with regards to
various aspects of the system. The author therefore highly recommends that Denburn
Medical Practice investigate means of further educating their patients about the system with
particular respect to the following common misconceptions:
-
Patients cannot choose which doctor they would like to speak to on the phone or see
in person
-
Patients who need to be seen in person following a phone consultation cannot
choose which day or time they would like to receive a face to face appointment (i.e.
must be available the same day)
-
Patients cannot specify what time they would like / are available to receive a callback from the GP
-
Patients cannot be seen in person unless they go through the triage system first
-
Patients are only attempted to be contacted once by the GP and if they miss the call
then they need to call the practice again
-
Patients need to be able to explain their medical problem over the phone
-
Patients need to inform receptionists about the nature of their problem
-
Patients cannot be seen in person unless the doctor agrees that there is a need for a
face to face appointment
-
Phones are the only available method of contacting the practice
-
Patients cannot book routine appointments in advance
This could be a patient information leaflet entitled ‘Common Misconceptions with Doctor
First’ detailing example scenarios of the above situations and an explanation of how patients
can overcome these problems.
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CHAPTER 5
CONCLUSIONS
The findings from this study support Productive Primary Care’s claims that Doctor First is an
effective method of improving patient access, while also improving outcomes, numbers of
same-day appointments and patient satisfaction. The study was however unable to confirm
the effect that the system has on continuity of care due to patients’ lack of system
knowledge. A significant doubt remains as to whether or not problematic communication
and privacy of phone consultations are compromising patient safety and this study’s findings
add to these concerns; however the author believes that increasing patient’s knowledge of
the system and its common misconceptions will improve results and in turn neutralise these
concerns.
In summary, this study’s results were largely in favour of the Doctor First system however
ultimately the statistics do not have the power to justify the implementation of Doctor First
across all practices in the UK. Further research with larger sample sizes is recommended,
particularly to determine the system’s effect on GP workload. Moreover the author advises
future research to assess whether or not GPs are satisfied in the long term with spending a
large proportion of their working lives on the phone.
As things stand, the author advocates that practices consider exploring the possibility of
implementing a telephone triage appointment system such as Doctor First. This research
produced many positive findings that show promise for the future of Doctor First. The author
therefore believes that these results justify future research and recommends that the results
are validated by carrying out similar research across a larger cohort of practices from
different geographical areas and socio-economic demographics. If similar results are elicited
this would add significant weight to these findings and in turn rationalise the use of such a
system in practices across the UK.
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CHAPTER 6
(1)
REFERENCES
Royal College of General Practitioners. Funding for general practice set to plummet by fifth by
2017, while patient consultations to increase by 69m [Internet]. RCGP Press. 2014 Apr 2 [cited
2014 Apr 24]. Available from: http://www.rcgp.org.uk/news/2014/april/funding-for-generalpractice-set-to-plummet-by-fifth-by-2017.aspx
(2)
British Medical Association. GP morale damaged by workload, says survey [Internet]. BMA
News. 2014 Mar 24 [cited 2014 Mar 26]. Available from:
http://bma.org.uk/news-views-analysis/news/2014/march/gp-morale-damaged-by-workloadsays-survey
(3)
Royal College of General Practitioners. Majority of public believe GP workloads are threat to
the level of patient care [Internet]. RCGP Press. 2014 Mar 23 [cited 2014 Apr 24]. Available
from: http://www.rcgp.org.uk/news/2014/march/majority-of-public-believe-gp-workloads-threatto-level-of-patient-care.aspx
(4)
Triggle N. One-fifth of patients ‘admit to misusing A&E units’ [Internet]. BBC News. 2014 Mar 4
[cited 2014 Mar 23]. Available from: http://www.bbc.co.uk/news/health-26425453
(5)
Innes M, Skelton J, Greenfield S. A profile of communication in primary care physician
telephone consultations: application of the Roter Interaction Analysis System. Br J Gen Pract
[Internet]. 2006 [cited 2014 Mar 23]; 56: 363-368. Available from:
http://bjgp.org/content/56/526/363.full.pdf+html?sid=2563097e-3d43-432b-b0d6-1228981e608a
(6)
Hewitt H, Gafaranga J, McKinstry B. Comparison of face-to-face and telephone consultations in
primary care: qualitative analysis. Br J Gen Pract [Internet]. 2010 [cited 2014 Mar 23]; 60: e201e212. Available from: http://bjgp.org/content/60/574/e201.full.pdf+html?sid=0d3783e7-8afc431a-a0dc-632e34eadb65
(7)
Joesbury H, Doublet-Stewart M, Innes M, McKinstry B. Telephone consultations. Br J Gen
Pract [Internet]. 2002 [cited 2014 Mar 23]; 52: 501-502. Available from:
http://bjgp.org/content/52/479/501.2.full.pdf+html?sid=4e90a6a6-188b-4279-81e6eec84314e799
(8)
Doublet-Stewart M. Improving access in primary care. Br J Gen Pract [Internet]. 2001 [cited
2014 Mar 23]; 51: 930-931. Available from:
http://bjgp.org/content/51/472/930.2.full.pdf+html?sid=eabc6572-b300-4537-82c4610aa583466a
(9)
Department of Health. Digital First in the NHS [Internet]. http://digitalhealth.dh.gov.uk/digitalstrategy/a-digital-health-and-care-system/digital-first-in-the-nhs/ (accessed 18 Apr 2014)
(10)
Department of Health. The power of information: Putting all of us in control of our health and
care information we need [Internet]. 2012 May 21 [cited 2014 Apr 25]. Available from:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213689/dh_1342
05.pdf
Matriculation No. 50901346
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58
Patient satisfaction after the introduction of Doctor First telephone triage appointment system
(11)
British Medical Association. Scottish GMS contract 2014-2015 [Internet]. BMA. [cited 2014 Apr
24]. Available from: http://bma.org.uk/working-for-change/negotiating-for-the-profession/bmageneral-practitioners-committee/general-practice-contract/contract-agreementscotland/scotland-qof-changes
(12)
Department of Health, NHS Improvement & Efficiency Directorate, Innovation and Service
Improvement. Innovation Health and Wealth, Accelerating Adoption and Diffusion in the NHS
[Internet]. Department of Health. 2011 Dec 5 [cited 2014 Apr 25]. Available from:
http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum
_dh/groups/dh_digitalassets/documents/digitalasset/dh_134597.pdf
(13)
Productive Primary Care Ltd. Doctor First [Internet].
http://www.productiveprimarycare.co.uk/doctor-first.aspx (accessed 23 Mar 2014)
(14)
Jiwa M, Mathers N, Campbell M. The effect of GP telephone triage on numbers seeking sameday appointments. Br J Gen Pract [Internet]. 2002 [cited 2014 Mar 23]; 52: 390-391. Available
from: http://bjgp.org/content/52/478/390.full.pdf+html?sid=d2081b10-ffd2-4a2d-893e1fc5d49fefce
(15)
Bhopal J S, Bhopal R S. Outcome and duration of telephone consultations in a general
practice. Br J Gen Pract [Internet]. 1988 [cited 2014 Mar 23]; 38: 566. Available from:
http://bjgp.org/content/38/317/566.1.full.pdf+html?sid=a6c4179b-bacd-418b-8b793be79370c4a0
(16)
McKinstry B, Walker J, Campbell C, et al. Telephone consultations to manage requests for
same-day appointments: a randomised controlled trial in two practices. Br J Gen Pract
[Internet]. 2002 [cited 2014 Mar 23]; 52: 306-310. Available from:
http://bjgp.org/content/52/477/306.full.pdf+html?sid=f6247e29-1666-404f-9e44-c13d5671a885
(17)
Gallagher M, Huddart T, Henderson B. Telephone triage of acute illness by a practice nurse in
general practice: outcomes of care. Br J Gen Pract [Internet]. 1998 [cited 2014 Mar 23]; 48:
1141-1145. Available from: http://bjgp.org/content/48/429/1141.full.pdf+html?sid=1b30e716bbc8-4b45-aaa0-80b097cf4635
(18)
Nagle J, McMahon K, Barbour M, et al. Evaluation of the use and usefulness of telephone
consultations in one general practice. Br J Gen Pract [Internet]. 1992 [cited 2014 Mar 23]; 42:
190-193. Available from: http://bjgp.org/content/42/358/190.full.pdf+html?sid=5eb975be-28b24848-9c06-020fece9ceab
(19)
Bunn F, Byrne G, Kendall S. The effects of telephone consultation and triage on healthcare use
and patient satisfaction: a systematic review. Br J Gen Pract [Internet]. 2005 [cited 2014 Mar
23]; 55: 956-961. Available from:
http://bjgp.org/content/55/521/956.full.pdf+html?sid=ae2dce96-7848-4393-9d94-fcbd0f459b16
(20)
McKinstry B, Watson P, Pinnock H, et al. Telephone consulting in primary care: a triangulated
qualitative study of patients and providers. Br J Gen Pract [Internet]. 2009 [cited 2014 Mar 23];
59: e209-e218. Available from:
http://bjgp.org/content/59/563/e209.full.pdf+html?sid=912a5d63-67fe-4deb-966ec856c26dc5eb
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
(21)
Stevenson M, Marsh J, Roderick E. Can patients predict which consultations can be dealt with
by telephone? Br J Gen Pract [Internet]. 1998 [cited 2014 Mar 23]; 48: 1771-1772. Available
from: http://bjgp.org/content/48/436/1771.full.pdf+html?sid=bf1b97af-159d-4a12-b736a9812a3b234f
(22)
Gallagher M, Pearson P, Drinkwater C, et al. Managing patient demand: a qualitative study of
appointment making in general practice. Br J Gen Pract [Internet]. 2001 [cited 2014 Mar 23];
51: 280-285. Available from: http://bjgp.org/content/51/465/280.full.pdf+html?sid=a0f31a5a1811-4cc9-b410-562e9e26cc68
(23)
Sampson F, Pickin M, O’Cathain A, et al. Impact of same-day appointments on patient
satisfaction with general practice appointment systems. Br J Gen Pract [Internet]. 2008 [cited
2014 Mar 23]; 58: 641-643. Available from:
http://bjgp.org/content/58/554/641.full.pdf+html?sid=e7cb7010-6237-4d29-8ffb-8d9e99c7a4c0
(24)
Pickin M, O’Cathain A, Sampson F, et al. Evaluation of Advanced Access in the National
Primary Care Collaborative. Br J Gen Pract [Internet]. 2004 [cited 2014 Mar 23]; 54: 334-340.
Available from: http://bjgp.org/content/54/502/334.full.pdf+html?sid=bce856c3-78d1-4d89881d-46977ec8eb4e
(25)
Rubin G, Bate A, George A, et al. Preferences for access to the GP: a discrete choice
experiment. Br J Gen Pract [Internet]. 2006 [cited 2014 Mar 23]; 56: 743-748. Available from:
http://bjgp.org/content/56/531/743.full.pdf+html?sid=d089f37a-3f45-4b71-9e1f-b14314e5e77c
(26)
Sokol D, Car J. Protecting patient confidentiality in telephone consultations in general practice.
Br J Gen Pract [Internet]. 2006 [cited 2014 Mar 23]; 56: 384-385. Available from:
http://bjgp.org/content/56/526/384.full.pdf+html?sid=4cec532f-d861-4bfb-b347-c451976ce327
(27)
Chapman J, Zechel A, Carter Y, et al. Systematic review of recent innovations in service
provision to improve access to primary care. Br J Gen Pract [Internet]. 2004 [cited 2014 Mar
23]; 54: 374-381. Available from:
http://bjgp.org/content/54/502/374.full.pdf+html?sid=60cc1546-12ec-4f0b-8d0e-8f7cf84b69ed
(28)
Productive Primary Care Ltd. Denburn Medical Centre Case Study [Internet]. Download
available from: http://www.productiveprimarycare.co.uk/case-studies.aspx (accessed 23 Mar
2014)
(29)
Buckland D. Are GPs putting patients at risk by diagnosing them on the phone? Daily Mail.
2014 Apr 8: 32.
(30)
Royal College of General Practitioners. The 2022 GP: A Vision for General Practice in the
future NHS [Internet]. 2013 [cited 2014 Apr 24]. Available from:
http://www.rcgp.org.uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z-policy/The-2022-GPA-Vision-for-General-Practice-in-the-Future-NHS.ashx
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CHAPTER 7
APPENDICES
APPENDIX 1 – QUESTIONNAIRE
(Please See Overleaf)
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APPENDIX 2 – PARTICIPANT INFORMATION SHEET
(Please See Overleaf)
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
APPENDIX 3 – COVER LETTER
(Please See Overleaf)
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APPENDIX 4 –
LETTER CONFIRMING ETHICAL APPROVAL
(Please See Overleaf)
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
APPENDIX 5 –
LETTER CONFIRMING R&D APPROVAL
(Please See Overleaf)
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
APPENDIX 6 – ADDITIONAL COMMENTS TABLES
POSITIVE COMMENT CONTENT GROUPS
Quicker Access to Doctor
Same Day Appointments
Convenience of Telephone Appointment
Time-saving for Doctors
Time-saving for Patients
Improved Mood of Practice Staff
“I used to have to wait a week maybe
more for an appointment. Now I’m
seen the same day”
“The doctor can get through more
people this new way (see more
patients sooner)”
“With old system I found I was
normally better by the time my
appointment arrived (i.e. a week later
than when I booked)”
“Made me feel valued rather than
waiting days”
“Never happened with old system”
“Eliminates unnecessary visits”
“New system is easy to use”
“GP was unusually relaxed, unrushed
and a good listener”
“Before it was a nightmare”
“Appointments are more available”
“More appointments available to
choose from”
Choice of Appointment Date & Time
Choice of GP
Ease of Obtaining Prescription
“Quick and efficient system for
prescription/advice”
“I have no preference talking about
medical problems on phone or in
person”
Preference of Consulting Medium
Money-saving for Patients
Provides Reassurance at an Early Stage of
Illness
Flexibility of System
No Phone Queues To Speak To Reception
Always Get To Speak With A Doctor
Speaking With Doctor Beforehand Increases
Understanding Of Problem
Easier To Get Home Visit
Very Good For Mums With Young Children
General Effectiveness
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SAMPLE QUOTES
FREQUENCY
31
25
17
8
8
6
5
4
3
3
2
2
“Can request to be phoned back after
a certain time - good for lectures”
“No constantly engaged tone”
“A very effective way to deliver
patient care”
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1
1
1
1
1
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
NEGATIVE COMMENT CONTENT GROUPS
Inconvenience of Phone Appointment
Safety Concerns
Including Lack Of Confidentiality / Patient
Identification & Privacy Issues (if receiving call
in public place or at work)
Phone Communication is Ineffective or
Uncomfortable
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SAMPLE QUOTES
“Don’t know when (phone call) will
come and so can’t plan day”
“Hassle to carry around mobile”
“Need to wait in to receive phone
call”
“As a taxi driver its very
inconvenient (a hassle) to receive
calls during working hours while
driving as have to stop and call back
and then same thing happens
again”
“Just does not work. I tried 4 times
over 3 weeks to even get a call
back!”
“Much easier for doctor not to see
patients… I put my back out last
year, rather than see me the doctor
just left a prescription for very
strong painkillers at desk. Very
convenient if all I want is strong
pills!”
“As I am having to call from my
office there is no privacy surely it is
up to me whether or not I see a
doctor - potential for mis-diagnosis”
“Private information shared over
phone is unnerving”
“The new system has changed a
"Health Centre" into a "Call Centre".
Last 2 prescriptions given over the
phone turned out disastrous. Had to
stop taking the medication.”
“All patients should have a yearly
examination. For patients over 60
years old it is too easy to hide
problems on the phone.”
“GP is more likely to…find
something important if you are face
to face - rely on doctor to find
something I don’t”
“Some people…get tongue-tied and
flustered”
“More difficult on phone to explain
problem”
“Telephone communication is not
easy for some people”
“Difficult for patients who aren’t
articulate in describing their
symptoms”
“I always need a face to face
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FREQUENCY
20
19
13
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Patient satisfaction after the introduction of Doctor First telephone triage appointment system
Lack of Continuity Of Care / Choice of GP
Phone Call Feels Impersonal /
Lack of Doctor-Patient Rapport
Incomprehensible Communication Due To
Language Barrier On Phone
Informing Receptionists Of The Problem
Inappropriateness Of Some Topics On Phone
(complicated or sensitive issues e.g. regarding
sexual health)
Unable To Book Appointments In Advance
General Opinions
Only One Method Is Available To Contact
Practice (including unreliability of phones)
Matriculation No. 50901346
appointment to understand what
doctor is telling me”
“I don’t like speaking to a stranger
on a phone”
“Unable to speak to usual doctor”
“Continuity with same doctor… is
probably ’a thing of the past’”
“Sometimes don’t see the same
doctor you speak to on the phone”
“Have not seen own doctor for over
one year at practice”
“Feels like I’m speaking to the
phone (an item) rather that the
doctor”
“No healing touch”
“Creates no relationship between
doc + patient, which deters me from
visiting doc”
“Language barrier may hinder
treatment of some patients”
“You have to tell receptionists why
you want to speak to the doctor”
“Some things require face-to-face
contact”
“I don’t want to tell my problems
over the phone”
“GP asks for you to make
appointment for bloods at reception
but then reception tell you, you
have to phone up & speak to a GP
before this appointment can be
made”
“If you have to see doctor every
month I sometimes forget (to make
appointment) as I would normally
have wrote it down.”
“System needs better explained to
us”
“I think both options (phone and
direct face to face) should be made
available to book (mixed system)”
“Seems like prolonged version of old
system as usually get appointment
anyway”
“(Call-back is) time consuming and
pointless”
“I lost my phone (so how am I
meant to contact practice)?”
“I don’t have phone at home due to
cost of bills (pensioner)”
“What if I have no money on my
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9
8
8
7
6
6
5
68
Patient satisfaction after the introduction of Doctor First telephone triage appointment system
Unable To Book Appointments On Date/Time
That Suits
Cannot Hear Doctor On Phone
Possibility Of Missing Phone Call
Duration of Phone Consultation
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phone?”
“Difficult to get a face to face
appointment early morning. That
would help me to slot it in with my
work routine”
“I have a hearing aid and struggle
to hear doctor on phone”
“I worry about when I receive the
call because I might miss it due to
having a bad signal or bad hearing”
“I was unsure when I would get a
call back and missed the call as was
in the bathroom. It’s not clear
whether or not doctor would only
call once so resulted in me needing
to call practice again”
“Feels rushed”
“Phone useless for multiple
problems as not enough time to
explain”
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3
3
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APPENDIX 7 – SUMMARY OF ELECTIVE EXPERIENCE
My elective project topic was decided upon following consultation with both of my academic
supervisors and was based on my own ideas of what I wanted to research. I have gained
many valuable skills during my elective project that will be very useful for the future.
With the help of Mr. John Lemon, I learned how to design, develop and format a
questionnaire using SNAP software. Furthermore I enjoyed working through self-learning
tutorials to learn how to use SPSS software so that I could thoroughly analyse my results to
the desired depth. This involved how to use the data editor, how to handle and code missing
data, how to examine summary statistics from individual and multiple variables
simultaneously, how to compile cross-tabulation tables to compare variable sets, how to
create and edit charts and how to control output data including use of the pivot table editor.
I learned about the ethical approval process involved with any primary research carried out
in the UK and spent a significant amount of time prior to starting my elective completing the
necessary IRAS form online in order to apply to NOSRES and NHS Grampian R&D
Department. During this process I encountered numerous difficulties and with the help of
both academic supervisors learned how to overcome these. I personally wrote all
documentation required for the project including the study’s Protocol, Participant Information
Sheet and Cover Letter. I also made any changes to these documents required by the ethics
committee.
I have been given permission to upload and display my research findings on Denburn
Medical Practice’s website for patients to view. Moreover, I have been invited to accompany
practice staff to the RCGP conference in May 2014 to present my research findings. I also
plan to submit my research to be published in BJGP.
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