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
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
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