METHODS AND MATERIALS

A postal questionnaire was designed to assess patient satisfaction with the telephone helpline. As a pilot exercise the questionnaire was sent to 20 patients after a call to the helpline. Based on the 16 responses (80% return rate) the questionnaire was considered appropriate and was adopted unchanged for the main study. The questionnaire (table 1), accompanied by a stamped addressed envelope, was sent to all 87 patients who called the helpline during February 1999. The questionnaire was anonymous, non-coded, a single mailing was used, and the content was designed to determine a patient's expectation of, and satisfaction with, the helpline service.

An analysis of the nature and outcome of all calls taken over a particular month was made possible by recording calls in a helpline record book. The same analysis was repeated over three separate months spanning just over one year to give a representative reflection of helpline use. Calls for February 1998, October 1998, and February 1999 were analysed to determine any change in the use of the helpline with time or season. Analysis included source of the call, the subject matter of the call, the patient's diagnosis, age, sex, and the subsequent action resulting from the call.

A basic economic analysis was undertaken. From the helpline record book, a calculation of the annual average number of calls was made for a three year period and, from the patient questionnaire, an average number of “avoided visits” to GPs over each 12 month period could be calculated. From published statistics, the overall cost of a GP consultation was estimated together with an estimate of the cost of the time spent by the RNPs in processing and answering the calls and an estimated cost due to extra outpatient activity resulting from calls.

RESULTS

Satisfaction survey

Eighty seven patient satisfaction questionnaires were mailed and 63 patients responded (72% return). Of the responders, 61/63 (97%) stated the person returning the call identified themselves and 63 (100%) stated that the person responding was polite and courteous. Sixty one (97%) admitted that calls were returned within the specified 48 hours. Forty seven (75%) respondents had called the helpline previously. Twenty one (33%) respondents had not expected to have to leave a message on the answer phone; of those 21, 16 were first time callers. Sixty (95%) felt their questions were answered directly and 62 (98%) felt the call was answered to their satisfaction. As a result of their call, 10 (16%) patients were sent extra written information. Equal numbers of callers had been given the helpline telephone number by doctors and RNPs, while 8% obtained it either from the patient information leaflets or elsewhere. Had the helpline not been available, 38 (60%) would have contacted their GP for an appointment, 17 (27%) would have taken other action, and eight (13%) would have waited for their next rheumatology outpatient appointment. Sixty two (99%) patients indicated they would call the helpline again if necessary. Table 1 shows these results.

Helpline analysis

The largest group of people to call the helpline over the three representative months were the patients themselves (fig 1). The helpline was set up specifically to answer the needs of patients with inflammatory joint disease, especially patients with active RA using second line antirheumatic drugs who were already attending the department as outpatients. Over the three survey months patients with RA comprised 66% of the callers, with other callers representing the range of rheumatological diagnoses seen in outpatient departments. Figure 2 shows the age of callers and ratio of men to women. The male/female ratio was 1:3 (fig 2A), with older patients more likely to call the helpline (fig 2B). More calls were received from patients aged 66–79 than in any other age category, with callers having an age range of 17–89.

Over the three survey months approximately 10% calls were made by repeat callers; in the first survey month there were six repeat callers (four made two calls and two made three calls)—a total of 14 (12%) repeat calls from a monthly total of 120. Repeat calls were either from those patients with an acute problem requiring several updates or from a small number requiring contact for reassurance. This suggests that the helpline was more than a social support mechanism for a few dependent patients.

The apparent reason for every call was analysed by content and could be defined, broadly, by subject (fig 3). A high percentage of calls (32%) were from patients reporting worsening symptoms. In cases of worsened symptoms, all calls resulted in either an earlier outpatient appointment or a review outside clinic hours, an intramuscular injection of steroid given by the RNP to reduce the symptoms of a flare of inflammatory synovitis, or telephone advice on how to help to relieve other symptoms. No patients were admitted to hospital as a consequence of their call. In many other cases calls could be dealt with in full over the telephone with verbal advice on subjects such as prescriptions, drug management, and possible adverse effects of drugs (fig 4). An equal number of telephone calls could be dealt with by the RNP (50%) alone, as those requiring the RNP to consult a doctor before returning the call.

In their response to the questionnaire, 60% of callers stated they would otherwise have contacted their GP had the helpline not been available. Thus it would seem reasonable to extrapolate from this result and consider that 60% callers would otherwise have made at least one GP appointment if the helpline did not exist. The average number of helpline calls a year over three years was 1513, and therefore the average number of potential GP visits of 10 minutes' duration¹⁴ avoided each year by provision of the helpline is 908 (60% of 1513). Repeat callers were considered likely to have made repeat GP appointments and, accordingly, no adjustment of the estimates of GP consultation avoided was made. Total GP appointments avoided amount to 151 hours of GP time. Potential cost savings to GPs can be calculated from an estimated cost of £100 an hour for GP time,¹⁵ without an additional calculation of the cost for the time spent in appointment administration. Thus the helpline potentially represents a cost saving to local primary care of £15 100 a year. The cost of RNP time spent dealing with patient queries may be derived from the hourly pay of a G grade RGN at £11.54 and the estimated average length of time of 20 minutes spent by an RNP in dealing with a single helpline call, including time spent obtaining medical notes. Thus the total time spent each year by RNPs on helpline business (from call receipt to completion of answering call) is 1513×20=30 260 minutes (504 hours) giving a total cost per year of about £5820. It was not possible to measure the extra time or specific cost of time spent in discussion between an RNP and a rheumatologist about helpline problems. This time was incorporated into the clinical workload of the rheumatologist and usually occurred within or at the end of the time allocated to outpatient clinical work. Time and therefore notional extra costs for the doctors was minimised as clinical helpline problems were presented in a succinct and summarised form with straightforward decisions required. Indeed, it has been considered likely that the new helpline system saves time for the doctor that would have been required under previous arrangements for answering telephone clinical queries directed, for example, by doctor's secretaries. This balance of discussion time versus saved time and effort was not considered to affect the economic analysis.

RNPs were trained in house before helpline answering as part of a continuing rheumatology training programme. No official out of house programme was used and the cost of training is therefore considered negligible.

On average, 140 patients a year required an earlier outpatient appointment or were seen in addition by a rheumatologist or an RNP. These appointments may be considered to be an extra burden of care generated as a result of their helpline call. A current contract price of £35 for each follow up visit to the rheumatology department (whether the appointment was with the RNP or rheumatologist) gives a total cost per year for additional consultations of £4900. The mechanical cost of provision of the helpline is estimated at 5 pence for a daytime local call, regardless of length, giving an annual cost of 1513×5= £76.

The total cost is thus £5820+4900+76=£10 796, which when subtracted from the primary care cost saving of £15 100, gives an overall cost saving of £4303 a year to the NHS as a direct result of provision of the rheumatology helpline as a component part of an integrated rheumatology service.

DISCUSSION

Overall results from the questionnaires suggest a high level of satisfaction with all aspects of the rheumatology helpline service, but it has been possible to identify a small proportion of patients who felt dissatisfied with the helpline response. The one (2%) patient who was dissatisfied was a first time caller. This patient appeared to have a false expectation of the function of the helpline, expecting a personally answered call and immediate response and was not aware that the helpline was provided as an extra service to consolidate the quality of the outpatient response. These dissatisfied patients prompted the production of an information leaflet about the helpline which is now distributed at the time of first consultation. We must register a caveat about this satisfaction survey. Although satisfaction was assessed from the results of completed postal questionnaires, the high level of patient satisfaction may be a biased result. Patients were aware that the survey was generated from within the rheumatology department and might have been encouraged by this to give an overenthusiastic endorsement of the service.

Three times more women than men called the helpline, corresponding in some degree with the prevalence of RA between the sexes. However, it has been shown previously that women are more likely to seek medical advice than men.¹⁶ Callers aged 66–79 were most likely to call the helpline. This age distribution does not correspond with the age distribution of patients with RA attending the outpatient clinic in general. Retired people may have more time to call the helpline and it may also be true that the elderly require more reassurance about their disease than younger patients.

It is clear from the results of the questionnaire that had the helpline not been available up to 60% of callers would have sought help from their GP. Economic analysis has shown the possible cost savings to GPs, supporting the financial value of the helpline. Although the cost saving is notional, it is likely that a hospital based telephone helpline may produce real time saving in local GP practices. The helpline receives no financial support from primary care and it becomes increasingly important to demonstrate to local primary care groups that helpline services do provide GPs with time and potential cost savings that might otherwise go unacknowledged. In this department, before the development of the helpline, calls of all types were directed to the secretarial staff of the department. This led to time delays between receipt of the calls and reply from the medical staff, dissatisfaction in many instances from patients, who felt that their contact with medical staff was distant, and an overall increase in inappropriate secretarial work. No comparison of the age and sex distribution of callers can be made with the system within the department before the helpline was introduced as no records of callers or the total call numbers, destination, and patient satisfaction were made at that time. However, the considerable shift of calls away from the secretarial staff of the department has freed considerable time for more appropriate duties and has received unanimous support from the medical secretarial staff. It is not known whether the overall number of calls to the department has changed since the introduction of the helpline, but we suspect that the provision of the helpline has encouraged an increase in direct contact with the department for specialist advice.

It has been suggested that a helpline can give patients a feeling of being cared for and that they will call the service again if necessary.¹⁷ The results of this study confirm that impression. Another benefit of a helpline maybe the potential to discharge outpatients from clinic who might otherwise have required a further follow up to monitor the results of an intervention such as joint injection or to provide reassurance. Giving the helpline number to the patient may allow discharge without compromising the quality of patient care. This should allow for an increase in the ratio of new/follow up patients in the department and reduction in outpatient waiting times; no analysis of this benefit was attempted but the clinical impression to date supports the hypothesis.

The use of nurse-led telephone helplines is a relatively new concept and medicolegal implications surrounding provision of this service are still vague.¹⁸ Medicolegal worries can be confronted in several ways. Protocols and standards of practice¹⁹ may be used to ensure the maintenance of a high quality of service, examined through a series of subsequent audits. As the patient cannot be seen, or physically examined, training in telephone assessment is essential.^20,21 The need for specific telephone assessment training has been recognised within other specialties such as primary care and A&E.²² In A&E, where telephone triage has been implemented, computerised decision support systems have been developed providing a framework for assessment.²³ Helpline problems are not generally acute medical emergencies and the patients are often known to the RNPs, making assessment of the urgency of the calls easier. In this centre, RNPs are discouraged from attempting to breach the UKCC Code of Professional Conduct²⁴ by making a diagnosis from a helpline call. Where diagnostic assessment appears necessary, RNPs seek advice from a rheumatologist before returning the call. As previously mentioned, RNPs receive no specific external training in helpline support and we have considered whether the overall function of the helpline might be improved by this alteration. However, in view of the high levels of patient satisfaction with the service no external training programme has yet been undertaken

Within this study it has been shown that precise documentation of calls is important, as a record is then held from which to audit helpline activity and for any subsequent medicolegal purposes. The exact legal implications of a nurse-led helpline remain ill defined. Devising set protocols specifically for a rheumatology helpline may facilitate audit and give a framework from which to work but may be too restrictive in practice. Taping of all calls may be a future medicolegal requirement. We have, as yet, not encountered any medicolegal difficulties arising from provision of the helpline.

In summary, a telephone helpline situated in an outpatient department of rheumatology can provide clinical advice, support and, when necessary, allow specific additional interventions to be recommended to supplement the routine outpatient service. Provision of the helpline is part of a wider programme designed to adapt the service to encompass patient priorities and to make response more flexible for outpatients. This review highlights the economic and clinical benefits of a rheumatology helpline and provides evidence of a high level of patient satisfaction with the service. Some patients require specific information detailing the function and purpose of the helpline and as a consequence of this study a patient information leaflet has been produced and the content of the taped answer phone message received by the patients on initial contact has been modified. The potential cost and time savings to GPs conferred by a local helpline service have been calculated and these savings should be emphasised to local primary care groups. It has proved difficult to measure the increase in quality of outpatient care for patients with RA as a consequence of the helpline.