How to do a consultation on the phone
Delivery of the new medicine service (NMS) includes the option to carry out the intervention and follow-up interviews with patients by telephone. It is unlikely, however, that most pharmacists have had much training or experience of providing consultations in this way. (Granted, medicines use reviews for housebound patients can be by telephone but not many pharmacists will have done this.) In fact, it would be fair to say that not many healthcare professionals are trained specifically to undertake telephone consultations and there is a lack of guidance.
Be aware of what you could miss
When I joined NHS Direct as a pharmacist adviser a few years ago, it was evident that this new way of working would bring its own challenges for the pharmacists involved. Up to that point, I had dealt with patients predominantly face to face. In a telephone consultation a whole variety of non-verbal communication components that we often take for granted are missing.
• If any information is to be left on an answering machine, you must obtain the patient’s permission beforehand.
For a start, you cannot see the physical attributes of the patient, such as age, weight and general fitness. When a call comes through to NHS Direct the immediate needs of the patient are addressed and basic details (eg, date of birth) are recorded, but we have learnt from experience not to request certain facts unless they are relevant to the query. Such a structured call process helps manage calls efficiently. With respect to medicines consultations, without the visual cues, factors such as pregnancy, breastfeeding and weight may have to be asked about sensitively.
Other factors that may be apparent in a face-to-face consultation and that cannot easily be established over the telephone include a patient being unkempt or smelling of alcohol. And there are specific examples where a face-to-face meeting may be an advantage in consultations on adherence, such as being able to inspect a rash that might be a side effect of a medicine, looking at blister packs to see what has been taken or not and assessing inhaler technique.
In many situations, however, using a telephone for semi-structured compliance interviews could be as effective as a face-to-face consultation if the service is set up correctly, with due consideration of external factors. And, in fact, the studies that the NMS is based on involved telephone consultations.
One of the most important aspects of a new service is to manage the expectations of both patients and professionals. It would be important to provide patients with information regarding the service — patient leaflets outlining the service, including the telephone option, would be helpful.
Issues to consider
A telephone consultation, like any other consultation, needs to be semi-structured, with the aim of building a picture of the patient and, in the case of the NMS, his or her adherence.1 The Panel (p250) lists the questions to be asked in the intervention stage of the service. According to the Pharmaceutical Services Negotiating Committee, these have been carefully structured, with academic input from pharmacy and psychology, to enable pharmacists to get the maximum amount of information from the patient’s perspective. It adds: “The style of delivery will be key in making sure the patient feels relaxed and that they will not be judged by their responses.” Notes to accompany each question and questions for the follow-up stage of the service are available on the PSNC website.
When delivering NMS interventions, pharmacists will have access to the patient’s medication record so should be in a position to anticipate some of the likely issues. However, essential questions to ask before delivering the service by telephone include:
• How will you establish when a telephone consultation is appropriate? (The patient will need to be informed of the scope of the service and give permission for you to call at an appropriate time.)
• While on the telephone, will you be away from distractions and background noise?
• How will you maintain confidentiality and privacy throughout the interview? (ie, Is your telephone within earshot of other staff or customers? Will you make the calls from your consultation area? Walking around the dispensary making calls on a handset would not be appropriate because the environment is not private and is full of distraction.)
• Will you have access to patient records and be able to store patient specific information confidentially while on the telephone?
• Will you have time to undertake the review without rushing the caller, allowing you to make sound clinical judgements?
• What is your telephone manner like? Are you empathetic and reassuring? (Often in face-to-face consultations we develop rapport using eye contact, nodding and smiling, but over the telephone we have to use words or noises of encouragement to show we are listening. It is also important that we can hear the patient clearly and that we speak clearly.)
• How will you provide clear and concise advice and guidance?
• How will you provide follow-up information or adherence aids (eg, medication reminder charts) if needed?
• How will you evaluate the patient’s understanding of the advice and action plan (if any) resulting from the consultation?
• Should you install a second telephone line for the convenience of your other patients and business needs?
You will need to consider when calls are going to be made so that they are expected by the patient but also manageable within your workload. Furthermore, if the patient is unavailable, how many times should you call back? The service specifications require at least once. If a message can be left it would be advisable to script this so that it is consistent and clear. And if any patient specific information is to be left on an answering machine, you would need to obtain the patient’s permission beforehand (ie, at the time patients give you their telephone number and permission to call). You might decide not to mention the NMS in the message. And if you will be calling from a withheld number, you might want to let the patient know.
Generally, telephone consultations require more concentration because you are listening for non-visual cues and it is harder to establish the comprehension of the patient.
Managing time-consuming calls, where the patient has a multitude of complex needs or requires a large amount of time to articulate problems, can be challenging. You will need to decide how long to allocate to each call. Although the semi-structured interview questions can help to develop rapport with the patient, the structure is also necessary in order to stay in control of the conversation by leading the interview process. Nevertheless, it may be necessary to call a patient back if it becomes apparent that more time is needed. Rushing a call is unlikely to provide a satisfactory review.
At the end of the call it is important to reiterate the decisions made and agree any actions that need to be taken forward and by whom alongside any plan for further review.
Questions to ask at the NMS intervention stage
1. Have you had the chance to start taking your new medicine yet?
2. How are you getting on with it?
3. Are you having any problems with your new medicine, or concerns about taking it?
4. Do you think it is working?
5. Do you think you are getting any side effects or unexpected effects?
6. People often miss taking doses of their medicines, for a wide range of reasons. Have you missed any doses of your new medicine, or changed when you take it?
7. Do you have anything else you would like to know about your new medicine or is there anything you would like me to go over again?
Documentation that is both accurate and up to date is an essential requirement of any reputable service to meet both legal and good practice obligations. It would be advisable to outline the decision-making process and any actions agreed. This would serve as both an audit trail of a telephone consultation and as a review tool for reflection on the outcomes of the service. Overall documentation would lend itself well to the continuing professional development process of review and reflection in order to improve the service.
Once all the details of the NMS are available, there would need to be some focus on establishing a standard operating procedure in the pharmacy that reflects on the issues surrounding NMS telephone interactions and to look at risk management. It might not be possible to explore every eventuality, but some scenarios are likely to occur with sufficient regularity to deserve consideration. During a telephone consultation not only are you reliant on auditory rather than visual clues, but patients also vary in their ability to communicate their symptoms and medical history, be it due to language issues or physical or cognitive impairment. It is necessary to consider how you would deal with people with language difficulties, those who are deaf or those who find using telephones difficult. There will need to be an acceptance that the service may not be suitable for some patient groups.
Another issue to consider is how you will evaluate each interaction to ensure no patient needs have been left unaddressed.
Look at this as an opportunity
At NHS Direct we answer 12,000 calls every day and it is estimated that this saves up to 1.6 million appointments with other healthcare providers each year.2 There is now experience showing that telephone consultations are valued by the public and are an important service option that can help promote patient empowerment. Over the two years since pharmacists joined the front-line teams at NHS Direct, the expert knowledge and skills that they bring has become highly valued by patients, other NHS Direct advisors, nurses, dental nurses and health information staff. We have come into our own. We use our unique pharmacy skills to add value to the calls for which we provide advice. Similarly, the NMS is an opportunity for community pharmacists to display their expertise. It is a chance for them to present themselves as professionals and promote the profile of their pharmacy, be it face to face or by telephone.
1 Edwards B. Seeing is believing — picture building: a key component of telephone triage. Journal of Clinical Nursing 1998;7:51–7.
2 NHS Direct. Facts and figures, Available at www.nhsdirect.nhs.uk (accessed on 15 August 2011).
• Pettinari C J, Jessop L. Your ears become your eyes: managing the absence of visibility in NHS Direct. Journal of Advanced Nursing 2001;36(5):668–75.
• Royal College of Nursing. Telephone advice lines for people with long term conditions: guidance for nursing practitioners 2006. Available at www.rcn.org.uk (accessed on 15 August 2011).
Citation: The Pharmaceutical Journal URI: 11083378
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