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Independents' Day

Telephone triaging is here to stay ­ so make it work

Regarding the news report 'Telephone triage calls cut costs but does not satisfy patients' (June 2) ­ as GPs we triage all the time. We can only survive nowadays by allocating a problem to the most appropriate member of our teams, to free us of the massive amount of non-medical work and enable us to concentrate our skills where they are most needed.... otherwise we would sink!

Triage has emerged into out-of-hours care not by choice but necessity. Most organisations have introduced triaging at times of crisis, where there is a shortage of doctors and too many patients requesting to be seen. It has become a tool to make organisation from chaos at peak times and is now here to stay. Even NHS Direct is, essentially, one vast triaging and advising service.

Successful triaging/advising is a very skilled job indeed (not for the newly qualified!) and the outcome of the telephone consultation is a balanced equation of resources available, assessment of risk, desires and feelings of the patient and prioritising of needs, all backed up with a sound scientific evidence-based knowledge. There will always be patients who insist on a face-to-face consultation for trivial reasons, but their insistence is usually based on fear which must also be built into every triage system.

Triaging is there to help us all, and it is essential the patient is satisfied at the final decision on the telephone. If the patient is not satisfied then the job has not been done properly.

We have to be realistic and realise that with the Carson standards about to be implemented, the shortage of doctors for out-of-hours work and the Carson philosophy that 'no call is a trivial call', triaging all calls will become essential.

PCTs will soon come to realise they will not have the resources to visit, or even see in surgery, everyone who telephones at the weekend. The costs would be astronomical.

When the PCT in Brighton takes over next year on a Saturday morning I estimate there will be around 300-400 calls during the morning, based on the 20-30 calls we receive in our practice of four partners in Hove. Anyone who believes all these patients can be seen face to face is not being realistic. Triage is not just desirable, it is absolutely essential unless there is to be a team of 10 doctors working at the primary care centre.

I have triaged and advised on more than 10,000 calls over the past year or so without complaint, resulting in 80 per cent of calls dealt with quickly and efficiently and (of paramount importance) safely. This has left 20 per cent who require to see a doctor ­ a doctor who has the appropriate time, is not working in chaos with a huge backlog and is ready and available when really needed.

Some of these consultations may well have been for the trivial (to us) sore finger, but nonetheless ended with a 'satisfied' patient. Most dissatisfaction comes from one of two sources: either when patients have to wait for hours on end to see a rushed doctor when they frequently did not want to see a doctor in the first place, or when patients who want a face-to-face consultation feel they have been palmed-off or denied this. Good triaging prevents the first and detects the latter.

There is no place whatsoever for the patient, doctor or any organisation to feel that triaging/advising is merely a way of palming-off work. This may have been the case 15 years ago when an exhausted doctor would do anything not to have to get up at 4am, but has no place in today's co-operatives/out-of-hours services.

By ensuring the advising doctor is removed from the workload of his decision, he will give the patient what is the most appropriate under the circumstances, and this includes an ability to detect and pre-empt patient dissatisfaction, and a genuine and warm invitation to phone back again if things aren't going to plan. So many anxieties and problems are solved by feeling there is someone you can call back in an hour or two if things don't settle.

Telephone triage is here to stay. It is a highly skilled job for which we need to set up specialist sharing of our thoughts and ideas, training, reporting of errors, protocols, feedback and so on. Keeping patients satisfied requires a caring attitude, an invitation to phone back at any time and the knowledge that if they want a face-to-face consultation, they can have one without question. Once they know that, patients are invariably satisfied and reassured that they are not left stranded without help. Fear and anger are the ingredients for complaints.

To conclude that telephone consultations result in a higher number of dissatisfied patients than face-to-face consultations implies this system is wrong and should be scrapped. Far from it.

We need to review and perfect the skill until 100 per cent satisfaction is achieved.

Dr Nick Haslam

Hove, East Sussex

and weekend triage/advice doctor for Primecare and other co-ops

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