1. Telephone Consultation

2. Growth Area There has been an explosive growth in the use of the phone in all areas of life, from telephone banking, insurance, shopping and not least medicine. GP co-operatives have accelerated the shift from home visits to telephone advice. NHS direct is another push in the direction of telephone health care provision.

3. Out of Hours It is argued that a high proportion of out of hours calls can be dealt with over the phone.

4. Out of Hours There is little evidence that patients are satisfied with this. One study showed 33% who got telephone advice had originally wanted a home visit, of all the patients who got such advice, including the ones that were expecting it, 25% were unhappy with the telephone advice. And over all 49% of callers would have preferred a home visit.

5. Concerns Concerns have also been expressed with the performance of providers of telephone primary care. The main concerns have been the adequacy of data collected, premature conclusions drawn and communications unclear.

6. Anxieties GPs have also expressed anxiety about providing telephone consultations, particularly to patients they do not know. Telephone consultations require specific skills to compensate for the lack of visual clues and to manage patient expectations for a home visit.

7. Anxieties GPs have also expressed anxiety about providing telephone consultations, particularly to patients they do not know. Telephone consultations require specific skills to compensate for the lack of visual clues and to manage patient expectations for a home visit.

8. Anxieties Undergraduate medical education and vocational training have tended to overlook these needs

9. Anxieties Nothing has changed? So prove how up to date we! This wonderful letter to the lancet appears to be the first record in the medical literature of telephone consultations

10. Practice by Telephone The Yankees are rapidly finding out the benefits of the telephone. A newly made grandmamma, we are told, was recently awakened by the bell at midnight, and told by her inexperienced daughter, "Baby has the croup. What shall I do with it?" Grandmamma replied she would call the family doctor, and would be there in a minute. Grandmamma woke the doctor, and told him the terrible news. He in turn asked to be put in telephonic communication with the anxious mamma. "Lift the child to the telephone, and let me hear it cough," he commands. The child is lifted, and it coughs. "That's not the croup," he declares, and declines to leave his house on such small matters. He advises grandmamma also to stay in bed: and, all anxiety quieted, the trio settle down happy for the night. The Lancet Nov. 29, 1879. Page 819

11. Telephone Versus Face to Face Consultations Lack of non-verbal clues No direct observations No direct examination No diagnostic tests No smells Active listening Third party consultations

12. Telephone Versus Face to Face Consultations Different anxieties of patient Different ways of expressing those anxieties Manifest versus underlying problem Secondary dialogue ExpectationsImpact of taping calls AccessTypes of problems - eg parasuicide, hoax, abusive etc Different endings

13. Telephone Versus Face to Face Consultations Cultural and language obstacles aggravated Hearing difficulties Technical difficulties Accents Speed of access Access to advice for people with restricted mobility

14. Telephone Versus Face to Face Consultations Easy access to advice as circumstances change Time efficient for all parties Patients may feel less guilty/defensive at taking up doctor's time