How a practice in Northumberland brought in telephone triage and reduced practice workload
For years, a moderate sized surgery in Northumberland had operated a model of an open appointment or ‘walk-in’ system each morning and afternoon, with additional appointments for ‘urgent cases’.
GPs began to complain more often about seeing ‘non urgent’ cases during urgent slots, whilst receptionist staff found patients often waited a couple of hours to be seen. This would lead to a noisy environment and problems with parking, as well as a lack of ‘urgent’ appointments as some patients preferred to use these appointments rather than sit and wait.
Inappropriate uptake of urgent (i.e. same day) appointments was further compounded by the prioritisation system or ‘triage’ that was in place, which consisted of simply asking if the patient thought it was urgent.
The surgery decided to introduce a new practice model based on a choice of access i.e. a telephone consultation or an appointment. The project was planned very carefully over a period of six months and included:
• training for all staff (all GPs and nursing staff underwent telephone triage skills training and all administration staff were trained in communication skills, prioritisation and managing difficult callers);
• a communication strategy for patients and staff;
• developing a new appointment system
• upgrading their phone and IT system
The new model involved the introduction of a full appointment system which included telephone consultation slots for each GP. The duty doctor would be available for urgent appointments and urgent home visits (screened by the receptionist using a prioritisation criteria).
Once urgent appointment slots were full, the receptionist could offer the caller a telephone consultation with a GP, who would then decide on the appropriate outcome. Finally, some appointment slots were embargoed to allow for any excess demand for same day appointments.
Prior to the training, some GPs expressed concern about telephone triage. Some seriously disliked it due to a lack of confidence and recognition of their limited ability; admitting to seeing patients not necessarily because they needed to, but because they were frightened not to. Post training, they felt more comfortable with telephone triage and agreed that further experience with patients would enhance their newly acquired skills.
The surgery implemented a full communications plan with their patients that included writing to everyone about the changes. They placed posters throughout the surgery weeks before ‘go live’ and patients were warned the receptionists would be asking more questions than previously when making an appointment.
There were frequent team meetings to iron out any concerns and a consultation service was asked to provide support to the receptionists during their first week using telephone prioritisation and triage, as some staff were nervous of the new system.
The receptionists were also given a script for the new system which included asking the patient for an ‘indication of what the problem was’, as this would allow them to manage urgent appointment requests. This proved very useful, but if patients were reluctant to provide the receptionist with details, they were asked to speak to a GP on the phone in order that they could then assign the right priority.
The impact of the new triage and system was felt almost immediately. The first noticeable difference was in the atmosphere in the surgery. The waiting room was no longer full at 8.30 in the morning and it continued to remain quieter throughout the day. It was a much calmer atmosphere as one member of staff put it. The phone was ringing more with requests for appointments, but the additional phone lines and appointments made the task easier. Only 2 patients refused to tell the receptionist why they needed an appointment but most actually volunteered the information, as they had been informed that the receptionist would be asking and pre-empted this!
The receptionists felt more comfortable enquiring what the problem was once they realised patients weren’t averse to being asked. Some calls were more challenging when it came to prioritising but by referring back to the prioritisation criteria, staff were reassured their decision making was appropriate.
The GPs stated that they felt that all of the ‘urgent’ appointments were valid and that having time for telephone consultations set aside was much better than having to fit in phone calls around appointments. Both GPs and receptionists reported they had more time available to them to do tasks which they had previously ‘squeezed in’ or neglected.
Although a full evaluation has yet to take place, which would include a quality audit of the triaged calls, the indications so far are that the new system has been a resounding success.
The embargoed appointments have been reduced to facilitate more routine appointments as patients begin to accept that they may not need to be seen on the day (classed as urgent).
Staff are happy with the atmosphere within the surgery and more importantly, feel that the work load is more manageable and organised with access to GPs at allocated times.
Case study provided by Telephone Consultations Services Ltd; www.telephoneconsultationservices.co.uk
Telephone triage In Depth