1. TELEPHONE COMMUNICATION “MOST PEOPLE DO NOT LISTEN WITH THE INTENT TO UNDERSTAND; THEY LISTEN WITH THE INTENT TO REPLY.” ― STEPHEN R. COVEY, THE 7 HABITS OF HIGHLY EFFECTIVE PEOPLE:STEPHEN R. COVEYTHE 7 HABITS OF HIGHLY EFFECTIVE PEOPLE:

2. Today we are going to look at TELEPHONE CONSULTATION

3. Activity :1 Think of a telephone consultation you have done or witnessed lately where there was a problem - for the patient or the doctor (maybe a receptionist or a Nurse ) IN pairs 3 minutes each : What are the problems for YOU and the Telephone in General Practice. ?

4. Activity 2 Patient Perspective Think of an occasion when you or a relative arranged to speak to a Doctor or surgery on the Telephone How were you feeling ? As you dialled … Start of the conversation ? What went well ? What did you feel the doctor needed to do to make it work ? Alternatively think about occasion when you have phone a patient back ? What were you thinking as you dialled ? How did the patient receive the call ? What went well ?

5. Context Why do we use the Telephone ? Patient Demand/Preference Reduce workload Manage workload

6. “GP phone consultations 50pc more likely to need follow- up GP telephone consultations fails to reduce workload and is no cheaper, despite a drive from Health Secretary Jeremy Hunt, a study has found” “Telephone blunders behind out-of-hours deaths Out of hours GPs services are causing deaths because of critical errors during telephone consultations, major new research has found.”

7. Telephone consultations, or triage, are increasingly used to try and manage workload in general practice and cut down on unnecessary consultations. Around 12% of GP consultations are now done over the phone – representing a four-fold increase over the last 20 years. RCT study ESTEEM trial (2014) “Introduction of telephone triage delivered by a GP or nurse was associated with an increase in the number of primary care contacts in the 28 days after a patient’s request for a same-day GP consultation, with similar costs to those of usual care”. http://www.thelancet.com/journals/lancet/article/PIIS0140- 6736(14)61058-8/abstract

8. What Interactions could you use it for ? Or What is the best use of the telephone ? How does the patient learn how to use the telephone as a service ?

10. What Skills do you need to draw upon ? Be wary of the stoical patient Be wary of the anxious patient Minimise risk from triage whilst being effective Empathise Negotiating conflict How to recognise and deal with your own anxieties Being suitably assertive. Demonstrate confidence.. Listen back to yourself. Are you convincing ? Telephone communication can take time …Management of workload. Record Keeping and safety netting recording.

11. Common errors in telephone consultations [22]22 Type of errorCommon examplesTechniques to prevent error Information gathering Inadequate drug and allergy history Absence of key questions Open question Triage protocols Checklist Relationship building Clinician anger and frustration with psychosocial problems Patient anger over unmet expectations Attentiveness to verbal and non-verbal cues Overt expression of empathy Clarify reason for call Supervision and feedback from regular call recordings. Decision making Premature decision-making or too early closure in the consultation Absent diagnosis Wellness bias Frame problems in terms of disease and illness Involve patient in decision-making Explanation and planning Unclear instructions and treatment explanation Smaller chunks of information. Ask patient to repeat information to check understanding Safety-netting

12. Communication Style An individual's personal style of communication can be considered as their preferred way or ways of interacting. Each of us will have a different range or repertoire of skills which we are inclined to draw upon in combination during any interpersonal interaction. Furthermore, our inclination to initiate certain types of interaction during a consultation may be influenced by the communication techniques we are skilled in using.

13. Heron's six category intervention analysis (adapted) A model of looking at your behaviours in a telephone consultation. AUTHORITATIVE Simple Informational seeks to impart or gather straightforward knowledge and information Prescriptive or advisory seeks to direct the behaviour of the patient Confronting seeks to raise the consciousness of the patient about some limiting attitude or behaviour of which he is relatively unaware. FACILITATIVE Cathartic seeks to enable the client(patient) to discharge, to abreact painful emotion, primarily grief, fear and anger Catalytic seeks to elicit self-discovery, self-directed learning, living and problem-solving in the client (patient) Supportive seeks to affirm the worth and value of the patients person, qualities, attitudes or actions he focus by ruling in or out specific options

14. SPECIFIC TECHNIQUES Summarising to reassure the caller that you are listening to clarify what you have heard to signal moving on to another phase of the call Reflecting the caller's own words as a verbal nod to probe gently to offer a challenge Questioning choosing open constructions to allow a wide exploration of the caller's concern or closed questions to narrow the focus by ruling in or out specific options

15. Stage 0PREPARATION  any available information about the caller  anticipate time delay  note taking Stage 1TRUST  identify yourself  tone of voice  acknowledging caller's emotions  acknowledging caller's previous experience of health services  letting the caller know that they are being heard * empathy Stage 2EXPLORATION  questioning choosing open or closed forms  probing through reflection A Structure to Follow

16. Stage 3CLARIFICATION  caller's agenda  caller's understanding  reflecting  summarising and paraphrasing  allow time for the caller to talk including silences Stage 4ACTION  empower the caller to take action where possible  clarify what action you will take on their behalf  check that agreed plan is understood Stage 5END  when the caller feels heard, respected and understood  end the call for the caller not for yourself

17. Stage 6AFTER THE CALL  time to reflect  note taking  other action