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Telephone triage increases demand on GP practices

Telephone triage led by GPs and nurses led to an increase in practices workloads, a study carried out across four different areas in the UK has revealed.

The study randomly assigned 42 practices to GP-led triage, nurse-led triage or usual care and found that the mean number of contacts per person after the introduction of GP triage was 33% higher than in practices that continued usual care, while it was 48% higher after the introduction of nurse-led triage.

It comes as NHS England has promoted the use of telephone consultations, with medical director Professor Sir Bruce Keogh calling on GPs to offer same-day telephone consultations as a way of freeing up time and reducing the pressure on A&E departments.

GP leaders have said that the study confirmed their belief that telephone triage ‘generates substantial extra demand’.

The study, published in the Lancet, found that GP triage did substantially reduce the number of face-to-face GP consultations over the 28-day follow-up compared with usual care, but it increased the number of GP telephone consultations per patient ten times and also slightly increased face-to-face consultations with nurses.

Meanwhile nurse-led triage also resulted in a reduction in GP face-to-face contacts and an increase in GP telephone consultations, albeit less so than GP triage, while it led to a 100-fold increase in the mean number of nurse telephone contacts.

Despite the hikes in patient contacts, there was no change in the average overall costs of health care with either GP or nurse triage.

The study authors, who reviewed the case notes of over 16,000 patients, concluded: ‘Introduction of telephone triage delivered by a GP or nurse was associated with an increase in the number of primary care contacts in the 28 days after a patient’s request for a same-day GP consultation, with similar costs to those of usual care.

‘Telephone triage might be useful in aiding the delivery of primary care. The whole-system implications should be assessed when introduction of such a system is considered.’

Dr Richard Vautrey, deputy chair of the GPC, said the findings confirmed GPs’ reports to the BMA that telephone triage had ‘generated substantial extra demand’ and said GP practices needed more support to keep pace with patients’ needs.

Dr Vautrey said: ‘More and more surgeries are offering telephone consultations and triage services and it is possible for these to be effective, as they allow GPs to manage demand for appointments and improve access for patients who don’t necessarily need a face-to-face consultation.  

‘However, practices are also aware of the potential significant issues with the increased use of telephone consultations. A key problem is that general practice as a whole is under real pressure from soaring patient demand and falling funding, which often means that practices don’t have enough GPs or nurses to operate these services in addition to managing their current workload.’

‘Where they are being used GPs have reported to the BMA the outcome that this study confirms, that they often generate substantial extra demand as some patients use them more frequently than they would normally have contacted the practice, whilst other patients would have self-cared without the need to contact the health service at all.’

Lancet 2014; available online 4 August



Readers' comments (18)

  • Why is no body surprised by this? did the terms "I told you so" not have any meaning any more? Please please add skype and also email consultations as they will all be quick and easy and require no further follow up. Go the DOH and thanks a lot the GPC for standing up for general practice.

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  • I wonder how many PCTs/CCGs who bought into doctor first system and who have they benefited? As far as I'm aware they are private company selling private products. If I remember correctly their statistics showed a vastly different out come.

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  • We were part of the ESTEEM study (which is probably the study that this is based on). We were given the Doctor led triage system, which did not suit our practice in terms of the restrictions of the study criteria. although patients loved the idea of speaking with the GP on the phone, we had to triage people that we knew it would not work for.

    Now we are using triage as a way to manage demand, led by a nurse practitioner who has much experience in out of hours.. This suits our practice well, and the locums who have helped us so far over the summer holidays think it is fabulous. The majority of patients are happy, and there are always GP appointments when we triage for those who really need to see one.

    The dissenters are always there, no matter what system is in place - and some of those who do not like triage are also the ones most vocal about shortage of GP appointments when we don't triage.

    We are still refining the system - we want to only triage those for who the system is most suitable (e.g. under fives get a face to face appointment, no follow ups to be triaged and rashes are obviously not suitable) but that is a training issue for reception.

    We have other practice across the patch using Doctor First, and for them it works well. As with any system, try it, if it don't work don't use it. Tweak it if you wish, make it work for you.

    Bad press to generalise failing in all aspects of the NHS is rife at the minute as it fits in with the government agenda.

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  • Harry Longman

    This study is clearly of interest but crucially it looks at the component level of triage rather than the system level - even calling for whole system implications in the abstract. It's very small in size, just 13 GP triage arm practices and 6696 consultations over 4 weeks. We have over 2m telephone consultations in our database of 109 practices, and the whole system results are quite different. They include around 20% increased GP productivity, which comes mainly from 60% of phone calls resolving the patient's problem. In this short term study of "same day only" requests, the resolve rate is only 24%, which saves no time. We have series over 2 years which show no increase in demand. We show greater continuity as well as easier access, and patient satisfaction at 70% saying the new system is better, vs 10% worse. Time to see a GP drops typically 80%. These benefits can be swiftly achieved but only with a whole system intervention.
    It is sad to see selective soundbites from a partial study used to undermine a change which is at last bringing hope to hard pressed practices.
    Declaring an interest,

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  • Harry Longman | Other healthcare professional | 04 August 2014

    I appreciate you have declared your financial interests as you run a company promoting phone triage.

    One of the nice things about medicine is the use of evidence in a trial settling and the power it has to show real clinical benefit. Access to your database of information with respect has absolutely no relevance at all. If you had any confidence in telephone triage then publish all your data, commit to trials.

    Your anecdotal reply to the evidence does sound desperate. Like so many fads in medicine they arrive with great fanfare and disappear as the evidence mounts. It is tough for your company.

    I know several practice s who are now starting to drop the mainly telephone triage, as it has been disastrous and interestingly tallies with the findings of this study.

    However the good news for you is that governments and NHS England have never let evidence get in the way of their dogma!

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  • Telephone triage works well in our practice in ensuring that appointments are only taken up for those patients whose clinical needs have been assessed and then booked to see appropriate clinicians at appropriate times. It has however had no impact on demand, in fact it continues to increase as a result of politicians over promising and under delivering. General practice needs sustainable investment in it's long term future for the benefit of patients. The demand isn't growing due to telephone triage, it's just growing!

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  • Harry Longman

    Dear Jo
    I run a company with the vision to transform access to medical care. Telephone consulting is the current best means that we have found to do that, and we keep looking for better ways. It's a means to an end.

    Take a look at our website and you will find we have been committed to evidence from the outset, not to phone triage. I have tried very hard to get our evidence independently evaluated and I'm delighted to say it will be, in a full scale NIHR funded study.

    You say my reply is anecdotal. We have data from 109 practices, a total of 9.5million consultations (2 million by phone). This study is of 6696 GP telephone consults in 4 week periods, which were not part of a system wide intervention in the practice, so testing something quite different. Want to revise your view?

    You know practices who have tried and are failing. A few of ours are too, but the vast majority are succeeding and providing a much better service, many of them saving a lot of GP time too. They aren't going back. The difference is an understanding of the system as a whole, knowing what and how to improve, and of course leadership.

    One crucial difference, for example: the study shows a resolve rate of 24% by phone. We typically see 60%, and that really does save time.

    Yes, it's tough being an independent company leading change, but there was no other way, and I tried. You mention governments and NHS England - it's extraordinarily difficult to get them to examine and understand evidence, but we aren't giving up.

    Your cynicism suggests you'd rather sit around and wait for something on a plate, than take action yourself. Look, this pretty much is on a plate. Give me a call.

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  • Harry Longman | Other healthcare professional | 04 August 2014 6:22pm

    The core failing with your data is that it is a database collecting data which will be selective -i.e not prospective datasets designed in a trial setting with strictly defined parameters.

    The data you have will have limited validity, but if you have confidence in it - publish and allow it to be scrutinized.

    You shouldn't confuse cynicism with critique. The problem with peer reviewed research is that it breaks through dogma. In an area where there many vested interests pushing telephone consults or skype consults ( without any published evidence supporting it).

    Some things in medicine are really simple, safe productive consulting should be face to face largely. when Skype introduces 4k resolution 3d cameras with real time physiological monitoring I may reconsider !

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  • We had a look at this and saw case study on website promoting patient access:

    I then made a very rough estimation of increase in workload coming from introduction of the system. I did admittedly draw a very aproximate line through the numbers and ignored a wierd spike. Anyway, workings as follows:

    Pre system introduced, Can draw a line roughly through through 500 (I have ignored a weird spike) face to face appmts per week and aprox 150 tel calls per week = 650 appointments/week

    After system introduced, can draw a line through 400 face to face appmts/week and 750 tel calls/week = 1150 appointments/week.

    Therefore total reduction in face to face appointments very aproximately 20% reduction but total increase in tel calls seems to be 400%!

    Total increase in all appmts (face to face plus telephone) = 77%

    Therefore, is it is no wonder that patients are happy as it seems to represent a lot of additional work, unless I am mistaken?

    Ps I accept no liability for the accuracy of my calculations. Anyone should be able to call up the PDF.

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  • Harry Longman,

    I assume your database is precisely that - it's numbers obtained from pro telephone triage practices. It's not a research with unbiased selection of data, no is it a pool of all the information which may not be favourable to you. As Jo suggested, it is difficult for anyone to make a comment on data that is not fully published so if you disagree with the above, all data has to be analyzed inorder for it to be validated.

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