Introduction

There are 90,000 follow up appointments a year in this Trust in all specialities, with over 3000 of those being gynaecological patients. These figures exclude colposcopy and vulval clinic patients, who all need to be seen and examined. The aim is to reduce the number of follow up appointments seen in clinic and to enable us to see more new patients. This would hopefully result in outpatient waiting lists being less than 13 weeks.

An average of 13.6% of patients failed to attend their hospital appointments in our gynaecology department during the period from 18 December 2003 and 10 September 2008. More than half of these were follow-up appointments. Telephone follow up clinic were started as a possible method of improving the service. Many follow up patients only require a discussion which can easily be conducted on the telephone. Most of the follow up patients are seen by junior doctors, who are unable to make management decisions resulting in high rates of re-appointment. We selected the types of patients who did not need to be examined, and for whom a telephone call would be appropriate.

There are a significant number of patients who present to the acute gynaecological ward and are managed appropriately. Subsequently, they get discharged with unnecessary follow up appointments. Many of these patients only require notification of their test results.

A perceived advantage of the proposed system is that patients are saved from the stress of a hospital visit and are given the benefit of direct contact with their consultant who can address their concerns fully. This method of complete post-operative counselling and advice would also reduce the time spent by GPs in the community, as they are frequently consulted regarding postoperative follow-up.

Figure 1

Methods

The telephone follow up appointments were arranged on the computer system in the same way as an ordinary outpatient appointment. This ensured patients remained in the system for routine audit. Importantly, the patients and their GPs received letters outlining the telephone consultation. For the purposes of our study, the first one hundred patients were sent a satisfaction survey form to complete. Patients selected for telephone follow up fell into the following categories:

Figure 2

>The study was conducted between 18 December 2003 and 10 September 2008. UK South East Thames research ethical committee approval was obtained in November 2003 before starting the survey.

The clinic was conducted once a week from 8.30 am to 10.30 am with telephone calls lasting from 1.5 minutes to 5 minutes. During the telephone consultation all the patients had an explanation of their histology findings and were given the opportunity to express their concerns. They were also given the opportunity for further follow up if they wished. They were advised to obtain any treatment recommended from their general practitioner. If new symptoms had appeared, the patients were given an appointment to be seen in the clinic, or referred on to the appropriate consultant specialist.

Results

A total of 1102 were involved in this study. Of whom 576 were discharged ( treatment).We needed to review 192 in the gynaecology clinic either due to the onset of new symptoms or for further detailed discussions of the result of investigations. Eighty five were added to surgery waiting lists and 57 were referred to another speciality.

A repeat telephone call, to follow up treatment within two weeks, was required for 144 patients; of whom 85 were discharged. There was no reply from 48 patients and another telephone call was needed.

Out of the 100 survey forms 72 were returned. Of these 72 patients, 97% rated the service as good, or better, 92% said the conversation covered all they needed to know, 90% felt able to ask questions and 88% stated they felt reassured and that the follow up letter sent to them contained all the necessary information. Only 8% said they would have preferred a hospital appointment.

Figure 3

Discussion

Telephone consultations have been previously assessed in a randomised control trial ⁽¹⁾, set in general practice. ^{This was done to test the practicality of telephone consultations during day time surgery as a means of managing patient demand, particularly requests for same day appointments. This RCT included 388 patients over a four-week period and it showed that the use of telephone consultations for same-day appointments was associated with time saving, and did not result in lower PEI (Patient Enablement Instrument) scores. The short term savings however, were offset by higher rates of re-consultation and less use of opportunistic health promotion.}

In a retrospective review of 400 cases of genital Chlamydia managed with a traditional clinic follow up as compared to 400 cases with a telephone follow up appointment, Apoola et al ⁽²⁾ satisfactorily treated more patients with the telephone follow up than with the traditional clinic follow up. They also satisfactorily treated more partners with the telephone follow up system than a traditional clinic appointment system.

Badal Pal ⁽³⁾ stated that the level of satisfaction with the service (90% satisfied or very satisfied) was comparable to that shown by those attending clinic (94% satisfied or very satisfied) at an audit undertaken concurrently. Most patients considered that benefits outweighed disadvantages .Disadvantages might be overcome or minimized by careful selection of the patients for telephone follow up.

The advantages of our gynaecological telephone follow up were:

• Effectively conducted by the consultant

• Reduced non-attendees rates

• If treatment was needed, patients received a prescription from their general practitioner.

• Patient choice was preserved, patients who wished to attend clinic could choose to do so.

Cost effective: A ten minute follow up appointment in the outpatient department normally costs £82.59 while a telephone follow-up at approximately three minutes results in a cost saving of £57.75 per patient (£5,775 per 100 patients). If we exclude the patients that needed another outpatient appointment, the total saving would have been nearly £52,552 (in one consultant clinic).

An additional advantage is that car parking spaces, which are normally in great demand, can be used by other patients who need to attend the hospital.

Figure 4

Success is highly dependant on the skills of the consultant to conduct a consultation over the phone. It was found that the number of telephone follow ups increased once the scheme was underway with patients being selected directly from the outpatient clinic.

Most patients were very grateful and asked very sensible questions and were pleased that they had been telephoned which saved them an unnecessary journey. They were aware that they could have attended the clinic to see the consultant if they had wished to do so. A very few patients (1-2%) reacted unexpectedly on the telephone and did not understand what was being said to them. A small number of patients (3%) did not take the tablets they had been given, but this may have been unrelated to the method of follow up.

The current government agenda is to promote the use of alternative technologies to improve access to health care. The largest telephone consultation service within the UK is now NHS Direct, which is presently staffed by qualified nurses. However, no controlled studies of this service have been done so far ⁽⁴⁾. Telephone consultation appears to have the potential to reduce workload, however further national scrutinized evaluation is needed to assess the safety, cost and patient satisfaction.