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Does telephone triage reduce GP workload?

Dr Helen Cotton argues that telephone triage can ensure GPs’ time is used wisely while Dr Matt Mayer argues that it disempowers patients and is high risk

Helen cotton

YES

With ever-increasing workload GPs must use any tool available. My experience of a variety of methods of telephone triage, both in and out of hours, has convinced me that it really can work. The initial telephone contact allows a patient to be directed to the most appropriate service at the most appropriate time, freeing GPs to manage patients who need our specific skills.

But does telephone triage really reduce workload? Reducing workload could mean many things, from reducing the number of consultations for a problem to reducing the total hours worked, but I think the most important measure is a reduction in the tasks given to a GP that do not require a medical degree. An estimated 27% of GP consultations are potentially avoidable by better use of your skill mix, and telephone triage can help GPs to avoid wasting time on tasks that non-doctor healthcare professionals could do.

There is also research supporting the benefits of triage, although admittedly not much. The ESTEEM study published last year is the largest recent study exploring telephone triage. The primary outcome measure was the total number of contacts over the ensuing 28 days. At first glance, the headline data do not appear to support my argument: general practice contacts increased. However, the primary measure in this study was not GP workload and the limited data presented seem to suggest that telephone triage may have had a positive effect: face-to-face GP contacts fell by 39% with GP triage.

Other research on telephone triage further emphasises its benefits. One successful triage system quotes a reduction of 60% in face-to-face consultations, with a third of patients receiving telephone-only care and a third receiving care from another member of the primary care team. Additionally, they had a reduction in DNAs, releasing currently wasted time. So the evidence shows that telephone triage leads to a reduction in face-to-face GP appointments, with remote GP access not taking as much time, reducing total GP workload.

An argument against telephone triage is that it is not suitable for all patients. But this does not negate its value, as it is appropriate for most. Just because a nurse cannot see all patients doesn’t mean a practice nurse is not useful to have.

In my current surgery we use a mix of telephone triage, signposting and routine appointments. This allows us to direct patients to alternative clinicians, which saves GPs’ time and goes some way to reduce the unmanageable workload we currently face.

Dr Helen Cotton is a GP in Yeovil, Somerset

Dr Matt Mayer

NO

I think telephone triage is fantastic. It works on the principle that the decision of if, when and how a patient is seen is made by the person best qualified to make it – the doctor.

But before you think I’m arguing on the other side of this debate, let me clarify.

Although the system of telephone triage works in theory, and should work in practice, in today’s NHS I think it increases demand rather than reduces it. Such a system only works when you have somewhere to put the patient if they need to be seen – if I have only 10 ‘on-the-day’ appointments available but 30 people need to be seen, then I’m going to have to see 20 people, somehow, while trying to phone the other 30 or 40 or 50 who need triaging.

What’s more, patients who are frustrated they have to wait weeks to see a doctor will ask to go on the urgent list, because they’re desperate. So each day the list gets longer, and each week the waiting time gets longer.

Also, telephone triage is high risk. When the patient is in front of you, it’s easier to tell that something’s not right. Translating that ‘spider-sense’ onto the phone takes years of training and experience, which costs money.

This high cost means that triage services like NHS 111 call-centres are often manned largely by non-clinical staff, with clinicians stretched thinly across the service. Such a high-risk system will inevitably err on the side of caution and ‘overtreat’ people, to avoid missing something serious.

So people who have had a cough for two days or a sore throat for four hours will be triaged to an urgent GP appointment on a Sunday morning.

The consequences? We disempower our patients, they phone us for everything, they phone us because they simply can’t book an appointment, and they get used to having same-day access to the GP on the phone.

Telephone triage should work, and can work, but until the NHS is funded and staffed so that we can actually see the patients we’re triaging, it just focuses the demand on us like a laser beam.

Dr Matt Mayer is a GP in Buckinghamshire

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Readers' comments (19)

  • I agree with Dr Mayer.We're just rearranging the chairs on the Titanic.

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  • I agree with Dr Mayer, we tried it and got rid of it after a year of dreading going into work on triage duty days. The workload seems to have lightened, patients, receptionists and doctors seem happier and I no longer dread going to work.

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  • We have mixed feelings concerning telephone consultations.

    We do not do telephone triage, but we do a lot of GP led telephone consultations. It does increase demand by patients, who love it, once they get used to it. We have a certain number of telephone consults every morning. Once the limit is reached no more requests are taken. The list for telephone consults opens again in the afternoon. Each GP has their own conversion rate from a telephone to a face-to-face consult, just like the differences between GPs in referral rates to hospital. Unfortunately local patients tell their friends and so the demand for registration has gone through the roof. And these patients tend to be those wanting frequent GP access. However we have seen a huge reduction in face-to-face consultations.

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  • I tend to agree with Dr Mayer. We use telephone triage and it is often difficult to make a safe assessment over the phone. Most patients on triage are then seen face-to-face and usually the problem is less urgent than expressed on the telephone. I think there is certainly a degree of manipulation of this by patients who know the system, which is difficult to assess via telephone.

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  • I've seen several surgeries try this.

    All seem to have similar experiences.

    Short term: initial benefits - appear to manage workload better, reduced demand on gp's

    medium term : demand increased again - above previous levels. Surgeries then limit phone apts. increased complaints as patients see no reason why they can get

    'just a phone call'.
    same problems as before resurface.

    long term: indemnity fees hike up as MDO figure out the increase in complaints is the result of phone triage. Also some evidence of increased risk.

    Conclusion: practices drop telephone triage.
    Back to square one.

    My conclusion - terrible waste of time.

    Whatever you do - you cannot squeeze the demand of 80 patients a day into 50 slots.

    What you can do is practice safely within the limits you have and those set by society and government

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  • One area often overlooked with telephone triage is the increase in GP turnover and loss of even more organisational memory.

    I suspect it is a big unrecognised cause of early retirement and recruitment issues. Salaried GP's and many locums are actively avoiding practices that use it. A good study for someone to do?

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  • The ESTEEM trial already looked at this and drew similar conclusions to Dr Mayer. " 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." http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61058-8/abstract

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  • we are a small (9000 patients) practice and we have been using nurse triage for many years. it works great, if you do it properly. One of big pleasures of being part of a traditional partnership, is that you can actually change system till it works. we actively monitor and feed back on appointments that triage nurses book with us or home visits that they request. You will be amazed how many requests for home visits do not any visit or no clinical input at all, if you only bother calling them and asking what the problem is, are they really housebound etc. Triage is definitely helping us to keep workload to manageable levels. But you have to bare in mind what the objectives are. It is not a phone consultation, it is just that- triage, to help decide who needs seeing today, who- this week, and who can go and buy their own paracetamol.

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  • A really interesting discussion. I instinctively agree with Dr Mayer.

    GP registrar at 11:32am makes a very good point. Given the choice, most of us would rather just see the punters and get it over with - rather than playing pass the parcel and still end up seeing them. (Or worse still getting indefensible medicolegal problems by not seeing them.)

    There are now few people wishing to do GP work - so practices will have to accommodate what 'most of us' want to do.

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  • Telephone triage or consultation does work, but increasing access attracts more consultations...think commonly three consults per episodes of URTI or acute back pain

    The only answer is payment per consultation with or without co-payment. This is the normal system just about everywhere else in the world

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