Primary care can be defined as community-based healthcare.1 In addition to general practitioners or physicians, a number of healthcare professionals provide services in the primary care setting. Although there are some regional variations, these healthcare professionals commonly include nurses, pharmacists and allied health professionals, including dieticians, occupational therapists and physiotherapists.1,2 Traditionally, patients have accessed primary care services face-to-face, but increasingly telephones are being used as an initial approach; indeed, the telephone has been considered a routine mode of accessing healthcare services for more than two decades.3 The reasons for telephone use in primary care services in recent years include an increase in demand for services which places pressure on limited resources,4 an increase in demand for same-day appointments,4 and the need to manage long waiting lists.5,6
There are various types of telephone consultation referred to in the literature, each with a slightly different purpose. Telephone triage (sometimes called telephone screening) is commonly defined as a method of assessing the urgency of a patient's complaint and determining the type of healthcare required as well as how rapidly it needs to be provided.7 Telephone triage can be conducted by healthcare professionals, but in some cases it is conducted by trained, yet unqualified staff with the assistance of computer algorithms and protocols.8 Telephone triage is used in many countries across the world in out-of hours call centres (e.g. Australia, Denmark, Netherlands, UK, US).7
Initial telephone consultations (sometimes referred to as assessments) go further than triaging patients; a full clinical assessment is conducted over the telephone by a healthcare professional and decision-making regarding patient management is carried out.9 The result may include signposting to other services, urgently accessing emergency services if a serious condition (e.g. fracture) is suspected, provision of a brief or longer intervention by telephone, or arranging further face-to-face intervention. Whilst there are clearly areas of similarity between telephone triage and initial consultations,8 it can be argued that there are two key differences. Firstly, the telephone consultation is an in-depth clinical assessment whilst telephone triage is a rapid and brief determination of the patient's requirements.8 Secondly, telephone consultations are commonly pre-booked and allocated a specific duration, whilst telephone triage may be pre-booked, but are most commonly ad-hoc as in emergency out-of-hours services. Telephone consultations have been reported in several specialities including general practice,10,11 occupational health,12 outpatient physiotherapy9 and outpatient chemotherapy.13 It is these initial telephone consultations that are the focus of this review as they are increasingly being used in primary care, largely due to supply/demand issues, and are being used by an increasing variety of professional groups, such as allied health professionals6 and psychologists,14 who do not traditionally receive training in how to conduct these at undergraduate level. It is therefore appropriate to map the current evidence to inform future practice.
Despite the definitions presented here, telephone triage, consultation and assessment are at times used interchangeably in the literature.15 The proposed scoping review will focus on telephone consultations as defined here; cognisance of the varying and interchangeable definitions will be taken during the conduct of the review so that literature is not excluded inadvertently due to the authors’ use of terminology. For example, a paper that uses the term “telephone triage”, but on reading fulfils our definition of initial telephone consultation, will be included in the review.
There are many similarities between initial telephone and traditional face-to-face consultations, for example both require the following components: a beginning, questioning, decision-making and ending.8 There may however be differences in the protocols followed and documentation used,4,8 as well as the specific skills required to compensate for the lack of visual cues during the consultation,4 such as enhanced communication skills, which are often cited in the literature as important for initial telephone consultations.7-9 Due to these differences, training in the delivery of initial telephone consultations, in order to develop the enhanced skill-set required, has been recommended.4,8
The proposed scoping review will not focus on telemedicine (often referred to as telehealth), but a definition is provided here for clarity. The World Health Organization defines telemedicine as “the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries…”16(p.10) Telemedicine therefore has a particular focus on remote-rural healthcare delivery and technology-enabled care,17 and despite the prefix “tele”, is not only concerned with delivery by telephone; in this way it is distinct from telephone consultation. However, with triage, there are areas of overlap between telemedicine and initial telephone consultation, and we will similarly take steps to prevent inadvertent exclusion of relevant literature during the conduct of our scoping review.
Primary care telephone consultations have demonstrated clinical- and cost-effectiveness.6,18 It has been recognised however that enhanced skills are required for their effective conduct and that training and support are required for health professionals undertaking this role.7,13 There do not, however, appear to be any widely used standards or recommendations for training and/or support that should be provided to primary healthcare practitioners conducting initial telephone consultations. The proposed scoping review will be the first step towards developing such recommendations.
No systematic reviews (scoping or otherwise) have been conducted on the components, skills and training required for initial telephone consultations in primary care. A preliminary search of the literature (Cochrane Library, JBI Database of Systematic Reviews and Implementation Reports, MEDLINE, CINAHL) identified systematic reviews on the effectiveness of telemedicine and telemonitoring.19-22 Two systematic reviews related to secondary care were identified,23,24 and one systematic review which combined telephone consultation and triage and was conducted more than 10 years ago was also identified.15 No scoping reviews were identified. With the importance and prevalence of initial telephone consultations in primary care it is therefore appropriate for this scoping review to be conducted in order to map the current evidence on the components, skills and training required for conducting initial telephone consultations. This review will summarize the current literature and provide clinicians’ with an overview of the components, skills and training required for conducting initial telephone consultations in primary care that will inform training, support and service design. It will also identify gaps in the literature that can be addressed by future research.
This scoping review will consider studies that include any qualified healthcare practitioner (such as doctor/physician, nurse, allied health professional and pharmacist) working in primary care services. Allied health professionals will include dieticians, occupational therapists, physiotherapists and speech and language therapists.25
The intervention of interest for the proposed scoping review is initial telephone consultations in primary care, defined as a telephone consultation that includes a clinical assessment and decision-making for a new episode of care.9 This excludes telephone “triage” or “screening”, where the purpose is to determine the level of urgency and type of healthcare required, and which may be conducted by healthcare professionals or unqualified staff.7,8 This scoping review is interested in telephone consultations with the purpose of conducting a clinical assessment over the telephone, leading to some form of intervention, which might include signposting to relevant services, brief interventions (including advice-giving) or longer interventions, which might be delivered by telephone, face-to-face or via digital media.
The context of this scoping review is primary care in developed nations. Primary care includes general practice clinics, outpatient clinics and any other healthcare settings where service users are not classed as in-patients. Developed nations will be defined as very high human development (51 countries) in the Human Development Index.26
Types of studies
We will consider a broad range of published and unpublished literature in this scoping review including primary research studies, systematic reviews, reports and expert opinion. Quantitative study designs including experimental, quasi-experimental, descriptive and observational studies where any quantitative data are reported that can be included in the review will be considered. We will also consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography and action research. We will also consider government reports, expert opinion, discussion papers, position papers, and other forms of text, as they may be relevant to the review questions.
Due to time constraints, only studies published in English will be considered. In order to provide a map of reasonably recent evidence, only studies published since 2002 will be included. Furthermore, a previous systematic review15 on effectiveness and patient satisfaction of telephone consultation and triage failed to identify any literature on telephone consultation prior to 2002.
A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will be undertaken across all included databases. Thirdly, the reference lists of all identified articles and reports will be hand searched for additional studies. A detailed search strategy for MEDLINE is presented in Appendix I.
The databases to be searched include: MEDLINE, CINAHL, Embase, AMED, PsycARTICLES, ERIC, PEDro, Cochrane Library (controlled trials and systematic reviews), Campbell, EPPI-Centre (DoPHER and TRoPHI), and Epistemonikos.
The search for unpublished studies will include: Google Scholar, OpenDOAR, EThOS, websites of professional bodies such as, but not limited to, British Medical Association, Royal College of General Practitioners, British Psychological Association, Australian Medical Association, American Medical Association, Royal College of Nursing, American Nurses Association, Chartered Society of Physiotherapy, and Royal Pharmaceutical Society. A full list of professional and regulatory bodies in the 51 countries of interest will be compiled prior to commencing the search.
Initial keywords will include: telephone consultation, telephone assessment, primary care. An information scientist will assist the authors with developing the final search strategy.
Following the search, all identified citations will be collated and uploaded into Refworks© and duplicates will be removed. Titles and abstracts will then be screened by two independent reviewers for relevance to the review questions and concept as defined above. Where there is any doubt the full article will be retrieved. Studies that appear to be relevant for inclusion in the review will be retrieved in full and assessed in detail against the inclusion criteria by two independent reviewers. Full text studies that do not meet the inclusion criteria will be excluded and reasons for exclusion will be provided in an appendix in the final report. The results of the search and selection process will be reported in full and presented in a PRISMA flow diagram. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Data relevant to the three review questions will be extracted from the included studies by two independent reviewers using methods recommended by Peters et al.27,28 The data extracted will include: professional group undertaking initial telephone consultations, patient group, sample sizes, primary care setting, outcomes recorded, and findings relevant to the components, skills and training required for initial telephone consultations. Where relevant, authors of included studies will be contacted for clarification or missing information. A draft data extraction form is available in Appendix II; this will be tested on three articles and may be subsequently refined depending on the data available for extraction.
Presentation of the results
The results will be presented as a map of the data extracted from the included articles in tabular form for each review question. Each table will present the different results for each review question with a narrative summary to accompany the tabulated results. Each table will include author, date of publication, country of origin, as well as data relevant to the review questions, such as the components included in primary care initial telephone consultations, the skills required by healthcare professionals to deliver initial telephone consultations, and what training is recommended for healthcare professionals to deliver initial telephone consultations in primary care. Appendix III details draft results tables; as with the data extraction tool, these will be piloted and may be subject to amendment during the review process.
Appendix I: Search strategy for MEDLINE
Appendix II: Data extraction tool
Appendix III: Draft results tables
Components of initial telephone consultations
Skills required for delivering initial telephone consultations
Training recommended for initial telephone consultations in primary care
This scoping review has been funded by an NHS Grampian Endowment Research Grant (16/11/042).
1. NHS Digital. Primary Care [Internet]. UK: NHS Digital; 2017. Available from: http://www.content.digital.nhs.uk/primary-care
. [Accessed 30 October 2017]
2. American Academy of Family Physicians. Primary Care [Internet]. USA; 2017. Available from: http://www.aafp.org/about/policies/all/primary-care.html
. [Accessed 30 June 2017]
3. Hallam L. Access to general practice and general practitioners by telephone: the patient's view. Br J Gen Pract
1993; 43 373:331–335.
4. Dale J, Shrimpton L. Managing telephone assessments and triage. Nurs in Pract January
2011; January 20. Available from: https://www.nursinginpractice.com/article/managing-telephone-assessment-and-triage
. [Accessed 30 June 2017].
5. Carr J, Sheikh A. Telephone Consultations. BMJ
2003; 326 7396:966–969.
6. Salisbury C, Foster NE, Hopper C, Bishop A, Hollinghurst S, Coast J. A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of “PhysioDirect” telephone assessment
and advice services for physiotherapy. Health Technol Assess
2013; 17 2:1–157.
7. Dercx HP, Rethans J-JE, Knoternus JA, Ram PM. Assessing communication skills of clinical call handlers working at an out-of-hours centre: Development of the RICE rating scale. Br J Gen Pract
2007; 57 538:383–387.
8. Royal College of General Practitioners, Pygall S-A. Telephone triage and consultation. Are we really listening? RCGP Learning. 2017.
9. Bishop A, Gamlin J, Hall J, Hopper C, Foster NE. PhysioDirect: Supporting physiotherapists to deliver telephone assessment
and advice services within the context of a randomised trial. Physiother
2013; 99 2:113–118.
10. Campbell JL, Fletcher E, Britten N, Green C, Holt T, Latimer V, et al. The clinical effectiveness and cost-effectiveness of telephone triage for managing same-day consultation requests in general practice: a cluster randomised trial comparing general practitioner-led and nurse-led management systems with usual care (the ESTEEM trial). Health Technol Assess
2015; 19 13:1–212.
11. Wilkie P, Gray DP. Telephone triage for new GP consultations. Br J Gen Pract
2016; 66 647:294.
12. Darcy-Jones C, Harriss A. Telephone health assessments: good practice. Occup Health
2016; 68 5:27–30.
13. Noonan-Shearer K, Peacock T. Setting up a telephone assessment
service in a chemotherapy day unit. Cancer Nurs Pract
2010; 9 4:21–24.
14. Sheldon C, Waxmonsky JA, Meir R, Morris C, Finkelstein L, Sosa M, et al. Telephone Assessment
, Support and Counselling for Depression in Primary Care Medical Clinics. Cog Behav Pract
2014; 21 3:282–295.
15. Bunn F, Byrne G, Kendall S. Telephone consultation
and triage: effects on healthcare use and patient satisfaction. Cochrane Database Sys Rev
2004; 4 3:CD004180.
16. WHO. A health telematics policy in support of WHO's Health-For-All strategy for global health development: report of the WHO group consultation on health telematics, 11–16 December, Geneva, 1997. Geneva: World Health Organization; 1998.
17. Scottish Centre for Telehealth & Telecare. Programmes [Internet]. Edinburgh: NHS 24; 2017. Available from: https://sctt.org.uk/programmes/
. [Accessed 30 June 2017]
18. Grol R, Gieses P, van Uden C. UpDate: international report. After-hours care in the United Kingdom, Denmark, and the Netherlands: New Models: integrating telephone consultations, triaging, and physician visits or house calls offers a promising model for after-hours care. Health Aff
2006; 25 6:1733–1737.
19. Home telemonitoring and remote feedback between clinic visits for asthma. Cochrane Database Sys Rev
20. Kruse CS, Soma M, Pulluri D, Nemali NT, Brooks M. The effectiveness of telemedicine in the management of chronic heart disease - a systematic review. JRSM Open
2017; 8 3: 2054270416681747.
21. Chan C, Yamabayashi C, Syed N, Kirkham A, Camp PG. Exercise telemonitoring and telerehabilitation compared with traditional cardiac and pulmonary rehabilitation: A systematic review and meta-analysis. Physiother Can
2016; 68 3:242–251.
22. Piga M, Cangemi I, Mathieu A, Cauli A. Telemedicine for patients with rheumatic diseases: Systematic review and proposal for research agenda. Semin Arthritis Rheum
2017; 47 1:121–128.
23. Ireland S, Kent B. Telephone pre-operative assessment for adults: A comprehensive systematic review. JBI Database of System Rev Implement Rep
2012; 10 25:1452–1503.
24. Vaona A, Pappas Y, Grewal RS, Ajaz M, Majed A, Carr J. Training interventions for improving telephone consultation
skills in clinicians. Cochrane Database Sys Rev
25. Health & Care Professions Council. Check the Register [Internet]. London: Health & Care professions Council; 2017. Available from: http://www.hcpc-uk.co.uk/
. [Accessed 30 June 2017]
26. United Nations Development Program. Human Development Index Iinternet]. New York: United Nations; 2013. Available from: http://hdr.undp.org/en/content/human-development-index-hdi
. [Accessed 30 June 2017]
27. Khalil H, Peters M, Godfrey CM, McInerney P, Soares CB, Parker D. An evidence-based approach to scoping reviews. Worldviews Evid Based Nurs
2015; 13 2:118–123.
28. Peters MD, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid-based Healthc
2015; 13 3:141–146.