OBJECTIVE: To understand patients' views on a 'telephone-first' approach, in which all appointment requests in general practice are followed by a telephone call from the general practitioner (GP). DESIGN: Qualitative interviews with patients and carers. SETTING: Twelve general practices in England. PARTICIPANTS: 43 patients, including 30 women, nine aged over 75 years, four parents of young children, five carers, five patients with hearing impairment and two whose first language was not English. RESULTS: Patients expressed varied views, often strongly held, ranging from enthusiasm for to hostility towards the 'telephone-first' approach. The new system suited some patients, avoiding the need to come into the surgery but was problematic for others, for example, when it was difficult for someone working in an open plan office to take a call-back. A substantial proportion of negative comments were about the operation of the scheme itself rather than the principles behind it, for example, difficulty getting through on the phone or being unable to schedule when the GP would phone back. Some practices were able to operate the scheme in a way that met their patients' needs better than others and practices varied significantly in how they had implemented the approach. CONCLUSIONS: The 'telephone-first' approach appears to work well for some patients, but others find it much less acceptable. Some of the reported problems related to how the approach had been implemented rather than the 'telephone-first' approach in principle and suggests there may be potential for some of the challenges experienced by patients to be overcome.