As the style and funding of healthcare continues to change and evolve, one constant is the need for patients to have access to timely and credible health information. Indeed, it is probable that with the changing nature of the doctor-patient relationship, the doctor's role as the provider of information is becoming more important. Parents, in particular, need information about their children's health,¹ and information given in the context of a consultation has been shown to increase patient knowledge,² decrease anxiety and improve compliance.³

Previously, patients have relied on information and advice being supplied by their healthcare provider, but they now have access to other sources such as the popular media and the Internet.⁴ However, not all patients have the technical and literacy skills to benefit from written or computer-generated information and, even if they do, it may be difficult for them to extrapolate general information to their own specific problems. Furthermore, because medical problems are often acute and unexpected, it is impossible for patients to predict what information they will need and when they will need it.

It is therefore not surprising that the telephone now plays such an important role in healthcare delivery. The provision of around-the-clock telephone advice, especially by hospitals, has been well documented in Australia,⁵ the United Kingdom⁶ and North America.⁷

In this issue of the Journal Fatovich et al⁸ report the results of their study of telephone advice provided by a hospital emergency department. As well as assessing the usual logistic and demographic data, which can limit the generalisability of findings depending on the particular hospital studied and the community it serves, the authors have attempted to determine the appropriateness of the advice given by hospital staff and the level of patient compliance.

The results are not especially striking or surprising, but they raise some important issues for policymakers, hospitals and community-based health providers. There is a huge discrepancy between the amount of attention (and resources) devoted to face-to-face as opposed to telephone consultations. Doctors and nurses undergo extensive supervised training to provide clinical services, there is increasing emphasis on clinical guidelines and evidence-based medicine, good record keeping is considered an important component of quality services -- yet none of these standards has been applied to the provision of telephone advice. Lack of specific funding is also a major issue, especially if, as indicated by the study, emergency departments receive up to 33 phone calls per 100 attendances.

The combination of the financial pressure of maintaining a service which is not funded by government, and concern about the medicolegal implications of advice given in an ad hoc manner by relatively junior staff without referring either to medical records or generating any written documentation about the advice given, has led at least one large teaching hospital to discontinue interactive telephone advice and replace it with a recorded information service.⁹

Presumably general practitioners, community health centres and community nurses also provide telephone advice, although no data are available to estimate the absolute number and proportion of calls relative to the number and proportion received by hospitals. The fact that most calls to hospitals are made after hours may well reflect the unavailability of the patients' usual healthcare provider at this time. Nevertheless, if telephone advice is considered a core part of healthcare services, one might argue that after-hours coverage in the community could be organised in the same way as after-hours locum services. Again, the lack of any remuneration and the potential medicolegal risks are major disincentives.

In North America, telephone advice has been accepted as an inevitable part of healthcare services to the extent that individual providers have formally scheduled "call hours", when their patients can call knowing that the doctor or nurse has dedicated this time to the provision of telephone consultations. Furthermore, specific telephone protocols and guidelines have been developed^10,11 and evaluated,¹² and phone consultation is increasingly becoming part of the training of hospital staff.

Twenty-four-hour access to health information and advice has become a service that the community regards as essential. Just as essential is the need for governments and providers to begin to address some of the issues to do with funding, training, quality control and medicolegal responsibility. A possible benefit, which has not been explored systematically, could be the use of hospital telephone advice lines to publicise community-based services and encourage callers to use such services, thus minimising hospital attendances. Furthermore, systematic analyses of calls could provide important information for health promotion efforts and the organisation of health services in a region or community. These are areas that need to be explored if we are serious about developing integrated, cost-effective, "seamless" services and avoiding duplication and fragmentation.

Frank Oberklaid
Director, Centre for Community Child Health and Ambulatory Paediatrics
Royal Children's Hospital, Melbourne, VIC

1. Hall DMB, editor. Health for all children. Oxford: Oxford University Press, 1996.
2. Isaacman DJ, Purvis K, Gyuro J, et al. Standardised instructions: do they improve communication of discharge information from the emergency department? Pediatrics 1992; 89: 1204-1208.
3. Glascoe FP, Oberklaid F, Dworkin PH, Trimm F. Brief approaches to educating patients and parents in primary care. Pediatrics (In press). Vol 101. Also on the American Academy of Pediatrics "web site" <www.pediatrics.org>.
4. Carlile S, Sefton AJ. Healthcare and the information age: implications for medical education. Med J Aust 1998; 168: 340-343.
5. Oberklaid F, Bell J, Duke V. Paediatric telephone consultation -- a neglected area of health service delivery. Aust Paediatr J 1984; 20: 113-114.
6. Crouch R, Patel A, Williams S, Dale J. An analysis of telephone calls to an inner-city accident and emergency department. J Royal Soc Med 1996; 89: 324-328.
7. Perrin EC, Goodman HC. Telephone management of acute pediatric illness. N Engl J Med 1978; 298: 130-135.
8. Fatovich DM, Jacobs IG, McCance JP, et al. Emergency department telephone advice. Med J Aust 1998; 169: 143-146.
9. Royal Children's Hospital, Melbourne. Kid's Health Infoline, 1997.
10. Schmitt BD. Pediatric telephone advice. Boston. Little Brown and Company, 1980.
11. Levy JC, Rosenkrans J, Lamb GA, et al. Developmental and field testing of protocols for the management of pediatric telephone calls: protocol for pediatric telephone calls. Pediatrics 1979; 64: 558-563.
12. Strasser PH, Levy JC, Lamb GA, Rosenkrans J. Controlled clinical trial of pediatric telephone protocols. Pediatrics 1979; 64: 553-557.

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