1. Consulting on the Telephone OOH GP Training Day

2. Learning Objectives Review our approach to consulting on the phone Address concerns over this format Consider different styles of approaching a consultation Review a simple structure for consultations

3. Consulting on the Telephone OOH GP Training Day Does telephone consulting work? Little evidence that patients are satisfied 33% of patients given telephone advice had wanted home visit 25% unhappy with advice given 49% would have preferred to have a visit

4. Consulting on the Telephone OOH GP Training Day Does telephone consulting work? Little evidence that patients are satisfied 33% of patients given telephone advice had wanted home visit 25% unhappy with advice given 49% would have preferred to have a visit Inadequacy of performance on telephone consultations by doctors Data collected inadequate Premature conclusions drawn Communication unclear

5. Consulting on the Telephone OOH GP Training Day Doctors Concerns Not knowing the patient Lack of records Patients expectations of home visit Medico-legal worries

6. Consulting on the Telephone OOH GP Training Day Medico Legal Position Clear, contemporaneous notes Making a diagnosis and responding appropriately is doctors responsibility Can hand responsibility to another principal All practical arrangements that need to be made not to miss a serious issue can be seen as doctors responsibility If in doubt about ability to diagnose and treat over the phone and patient will not attend, must arrange a home visit.

7. Consulting on the Telephone OOH GP Training Day Medico Legal Position A GMC professional misconduct action could be brought for having failed to be "in a position to make a reasonable judgement of the patient's condition" by not examining the patient. The GMC defines a good standard of medical care as: a conscientious assessment of the history, symptoms and signs of a patient's condition; sufficiently thorough professional attention to, examination... action upon evidence suggesting the existence of a condition requiring urgent medical intervention:

8. Consulting on the Telephone OOH GP Training Day Medico Legal Position A civil court may find against a doctor if they do not attain the standard as judged by a responsible body of medical opinion,' as acceptable current practice and, as many GPs now regularly give telephone advice it would be assumed that this would now pass the test. To ensure an effective defence if challenged in a court of law, clinical information must be recorded in the form of clear, hand-written, contemporaneous notes.

9. Consulting on the Telephone OOH GP Training Day Six categories of intervention A Consultation model by John Heron Doctor Centred Prescriptive Informative Confrontational Patient Centred Cathartic Catalytic Supportive

10. Consulting on the Telephone OOH GP Training Day Doctor Centred Prescriptive Informative Confrontational Patient Centred Cathartic Catalytic Supportive Give advice - be judgemental, critical or evaluative. A prescriptive intervention is one that explicitly seeks to direct the behaviour of the patient especially, though not exclusively, outside the consultation. e.g. Go to bed for a week, I think you should leave your job Take these tablets four times a day

11. Consulting on the Telephone OOH GP Training Day Doctor Centred Prescriptive Informative Confrontational Patient Centred Cathartic Catalytic Supportive Inform - be didactic, instruct, or interpret. An informative intervention endeavours to give new knowledge to the patient. e.g.You have pneumonia Your ECG was normal

12. Consulting on the Telephone OOH GP Training Day Doctor Centred Prescriptive Informative Confrontational Patient Centred Cathartic Catalytic Supportive Give feedback - be challenging, give direct feedback. A confronting intervention directly challenges the attitudes, behaviour or belief of the patient. e.g.I can see you find it difficult to talk about your mothers death You dont seem to hear what Im saying Have you taken any of your tablets?

13. Consulting on the Telephone OOH GP Training Day Doctor Centred Prescriptive Informative Confrontational Patient Centred Cathartic Catalytic Supportive Encourages the patient to talk about what worries him/her It does not direct and is not judgemental. A catalytic intervention is enabling, it encourages self-direction and allows the patient to go the way he wishes to. e.g.An open ended manoeuvre is simply reflecting back to the patient key words, his last word or phrase (echoing) or non-verbal signals.

14. Consulting on the Telephone OOH GP Training Day Doctor Centred Prescriptive Informative Confrontational Patient Centred Cathartic Catalytic Supportive Is approving, validating, confirming, appreciating. A supportive intervention affirms the worth and value of the patient. e.g.I understand. You have had a tough time You seem to have coped extremely well or a nod of the head, supportive grunts etc.

15. Consulting on the Telephone OOH GP Training Day Consultation format Obtain any records Avoid preconceptions Greet the patient -name, age etc and Introduce ourself Enquire about the reason for the call Elicit any other relevant information & establish the clinical picture Give and receive verbal cues Clarify and agree a mutual management plan Follow patient if appropriate Record consultation in notes at the time

16. Consulting on the Telephone OOH GP Training Day