Demand for general practice appointments is rising rapidly, and in an attempt to deal with this, many practices have introduced systems of telephone triage. Patients are phoned by a doctor or nurse who either manages the problem on the phone, or agrees with the patient whether and how urgently they need to be seen.
A new large study, published in The Lancet on 4 August 2014 and funded by the UK National Institute for Health Research (NIHR), has investigated the potential value of telephone triage for patients and for the NHS. It concluded that patients who receive a telephone call-back from a doctor or a nurse following their request for a same-day consultation with a GP are more likely to require further support or advice when compared to patients who see a doctor in person. The research concluded that 'telephone triage' systems did not reduce overall practice workload.
These findings, from a team led by the University of Exeter Medical School, are important as telephone triage is becoming increasingly popular in general practice as a response to managing patient care. Overall, the ESTEEM study - one of the first robust investigations in this field - concluded that telephone triage by a doctor or a nurse only results in a redistribution of practice workload, not a reduction. It also discovered that telephone triage is no more expensive or cheaper than care provided via traditional face-to-face appointments.
The ESTEEM trial involved more than 20,000 patients across 42 doctor surgeries in England. Practices were randomly assigned to continue delivering care in their usual way, or to change to a system using a doctor or nurse to call the patient back to offer help or advice following the patient's request for a consultation with a GP 'that same day' in the practice. The research lasted for around 2-3 months in each practice. The researchers examined patient's consulting patterns in the 28 days following their initial same-day consultation request.
Practices offering triage by a GP saw an increase of 33% in the total number of patient contacts amongst patients who had requested a same-day appointment compared to patients seen under usual care. For practices offering nurse triage the increase in the total number of contacts was 48%.
The researchers identified that there was a redistribution of GP workload associated with introducing triage. In practices providing GP triage, GPs had 39% fewer face-to-face consultations, whilst in practices providing nurse triage, GPs had 16% fewer face-to-face consultations. Thus introducing GP triage was associated with a redistribution of GP workload from face-to face consultations to telephone consultations, and introducing nurse triage was associated with a redistribution of workload from doctors to nurses.
Around half of the patients seen in 'usual care' had no further contact with the health care system in the 28 days following their initial consultation. However, 75% of patients seen in practices operating a GP telephone triage systems did make further contact, and where nurse telephone triage was in operation, 88% of patients made further contact.
Overall, patients reported a good experience of care provided by the study practices, although patients from practices providing nurse triage were slightly less satisfied than those from the other practices.
Lead author Professor John Campbell, of the University of Exeter Medical School, said: "Up to now, it has been widely thought that introducing a triage system might be an efficient way of providing same-day access to healthcare advice. However, our study suggests that introducing triage may not represent the most efficient use of doctor or nurse time. Patients who receive over-the-phone support are more likely to seek follow-up advice, meaning that the workload is only redistributed, whilst the costs are the same.
Practices thinking about introducing triage might benefit from looking at our findings carefully, and considering whether introducing triage is really likely to be of benefit to their patients, or to the primary care practice team. Healthcare managers should consider the implications across the whole system of introducing triage on a wider scale, especially given the staffing constraints and challenges faced by the NHS."
The study also involved collaborators from the University of Oxford, the University of East Anglia, the University of Bristol, and the University of Warwick. It was funded by the National Institute for Health Research Health Technology Assessment Programme.
Demand for UK primary care is rising, with an estimated increase in workload of around 62 per cent between 1995 and 2008.
GPs in an average UK practice of approximately 6,483 patients (3.8 doctors) manage around 65 patients each day. Of these 65 patients, around 20 are requesting a same-day appointment, representing around 30 per cent of GP workload. There are around 1 million patient consultations conducted every working day by NHS GPs and their teams.
Around 12 per cent of GP consultations are conducted on the telephone, a quadrupling since 1995.
This is the first large-scale study in the world to identify the potential value and implications of introducing GP-led or nurse-led triage of patients requesting same-day consultations.
The study was supported by the NIHR South West Primary Care Research Network and the NIHR Peninsula Collaboration for Leadership in Applied Health Research and Care