Objective. To evaluate a ‘telephone first’ approach, in which all patients wanting to see a GP are asked to speak to a GP on the phone before being given an appointment for a face to face consultation. Design Time-series and cross-sectional analysis of routine healthcare data, data from national surveys, and primary survey data. Participants 147 general practices adopting the ‘telephone first’ approach compared to a 10% random sample of other practices in England. Intervention Management support for workload planning and introduction of the ‘telephone first’ approach provided by two commercial companies. Main outcome measures Number of consultations, total time consulting (59 ‘telephone first’ practices, no controls). Patient experience (GP Patient Survey, ‘telephone first’ practices plus controls). Secondary care utilisation and costs (Hospital Episode Statistics, ‘telephone first’ practices plus controls). The main analysis was intention to treat, with sensitivity analyses restricted to practices believed to be closely following the companies’ protocols. Results Following the introduction of the ‘telephone first’ approach, face-to-face consultations decreased considerably (adjusted within-practice change -38% 95% CI -45%,-29%, p<0.001). An average practice experienced a 12-fold increase in telephone consultations (adjusted within-practice change 1204% , 95% CI 633%, 2290%, p<0.001). The average duration of both telephone and face-to-face consultations decreased, but there was an overall increase of 8% in the mean time spent consulting by GPs, albeit with large uncertainty on this estimate (95%CI -1%,17%, p=0.088). These average workload figures mask wide variation between practices, with some practices experiencing a substantial reduction in workload and others a large increase. Comparing practices using the ‘telephone first’ approach to other English practices in the national GP Patient Survey, there was a large (20.0 percentage point, 95%CI 18.2,21.9, p<0.001) improvement in length of time to be seen. In contrast, other GP Patient Survey scores were slightly more negative. Introduction of the ‘telephone first’ approach was followed by a small (2.0%) increase in hospital admissions (95%CI 1%,3%, p=0.006), no initial change in A&E attendance but a small (2% per year) decrease in the subsequent rate of rise of A&E attendance (95%CI 1%,3%, p=0.005). There was a small net increase in secondary care costs.

Conclusions The ‘telephone first’ approach shows that many problems in general practice can be dealt with on the phone. The approach does not suit all patients or practices and is not a panacea for meeting demand. We found no evidence to support claims that the approach would, on average, be cost-saving or reduce secondary care utilisation.