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Wednesday 28 September 2016
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The rise of telephone triage

The rise of telephone triage
As practices seek to adjust to new responsibilities, telephone triaging is becoming increasingly integrated in healthcare access despite concerns over the quality of telephone triage being provided
As general practice grapples with a squeeze on income and new responsibilities brought about by the Health and Social Care Act, increasing efficiency, without reducing access, is a key issue. 
With this in mind Cogora, publisher of Management in Practice, has published a report, On the line: Access to Primary Care in which 1,195 GPs, nurses and practice managers were polled. 
It shows that telephone triage is increasingly being used as a means to access healthcare.
Of the practice managers polled, 56% used some form of telephone triage. Most practices (28%) triaged up to 10% of patients, and 9% of practices triaged all their patients (see Figure 1).
This seemed to be considered a convenient and efficient way of providing healthcare with 95% of respondents rating it as either ‘moderately’ or ‘extremely’ successful. 
Furthermore, 74% of respondents felt that it made things run more efficiently and over half of respondents (55%) gave it a rating of four or five out of five for how useful they found it (seeFigure 2). 
Commenting on the perceived popularity of telephone triage, British medical Association (BMA) GP Committee chair, Dr. Chaand Nagpaul told Cogora: “I have heard many GPs say that it has helped them to manage their workload better, for example, in being able to divert calls that can suitably be dealt with by other members of their team.” 
It also received a ringing endorsement from patients, with respondents estimating that a median of 40-50% of patients rated it quite positively and that just a median of 1-10% of patients rated it quite negatively.
Nagpaul said: “Most people these days have mobile phones, and telephone triaging is very convenient for adults who have a busy lifestyle and provides an alternative way to access healthcare for those who travel a lot.”
Jayne Tabor, practice manager and partner of The Arnewood Practice said that the widespread use of telephone triage is partly a response to a rising number of patients who are requesting for more information about a range of health conditions.
“More and more patients are asking for information about their health for which face-to-face contact isn’t required. This is due to a mixture of the increase in long-term chronic conditions coupled with an increasing demand from patients,” she said. 
While our survey shows that the value of telephone triage in providing a convenient and efficient alternative to accessing healthcare is clearly recognised, the picture is not clear-cut. 
Under half (44%) of practices reported an ability to see more patients since undertaking telephone triage while problems were resolved to varying extents across practices, calling into question the overall quality of telephone triage.
Our poll showed that although GPs and nurses appeared to carry out the bulk of telephone triage, with GPs found to be involved in telephone triaging across 83% of practices and nurses involved across 35% of practices, a noticeable proportion of practices (13%) also recorded receptionists without a medical background being involved (seeFigure 3). This group included a handful who practiced telephone triage without the help of a GP or nurse. 
Fiona Dalziel, co-lead at General Practice Foundation at the Royal College of General Practitioners said: “Anecdotally, receptionists are quite good at differentiating urgent from non-urgent situations. However, they have had no medical training and are frequently not working to a decision-making protocol and so that leads to increased patient risk.”
Nagpaul said that while it was acceptable for receptionists without a medical background to be involved in purely administrative functions such as handling repeat prescriptions or forwarding a list of patients requesting emergency appointments for the GP, they shouldn’t be involved in aspects of triaging which require clinical judgement. 
Although from the survey, it is not clear exactly what functions the receptionists played in triage, the issue of receptions guarding the gateway to healthcare seemed to strike a chord with many members of the public. 
London’s LBC 97.3’s Drive, presented by Iain Dale, talked about this study in some depth, with numerous members of the public calling in to share their experiences of being denied healthcare by receptionists including the case of a woman who suffered bleeding related to a difficult pregnancy. Similarly, an article about the study in The Telegraph generated a lot of discussion among readers with a range of problems dismissed by receptionists ranging from symptoms of bronchitis, and dangerously low blood sugar of a diabetic.
Katherine Murphy, chief executive of the Patients Association said: “We are deeply concerned about this and it is something that we think is becoming more widespread.” 
“Patients’ lives are put at risk by decisions to cut costs in this kind of way; there is a huge risk of symptoms being missed when the assessment is being made by an un-trained person who can’t even see the patient,” she said.
Furthermore, of the practices involved in telephone triage, close to half (48%) had received no training (see Figure 4). 
Although Nagpaul said that GPs’ medical training covers how to triage, trainer and consultant of Telephone Consultation Services, Sally-Anne Pygall, who trains on behalf of the RGCP, said that a lot of information usually provided by visual cues is lost over the telephone, which is something that typical triage training doesn’t cover.
“The lack of visual cues often opens up areas of vulnerabilities in both patients and doctors. For example, during a telephone triage, there are often assumptions 
that things have been understood on the part of both patients and clinicians when this may not be the case. Telephone triage training focuses on telephone communication skills, which is key to engaging patients and gaining clarification in the absence of visual cues. As a GP, they may receive telephone triage training for out-of-hours placements, but this is often done by other GPs who have not themselves been specifically trained in telephone triaging,” Pygall said.
Research in telephone consultation has commonly found that tonality is very important. 
Up to 84% of verbal communication is down to tonality which in turn has a strong impact on how likely patients are willing to accept the advice of GPs, highlighting the importance of being trained in the subtle elements of verbal communication. 
Pygall also said that training was likely to affect how efficiently telephone triage was carried out and its overall success by increasing GP confidence in their judgement over the phone, which in turn, leads to fewer incidences of booking face-to-face appointments for those that don’t need to be seen.
Indeed in our research, we talked to various practices that stopped doing telephone triaging due to the number of patients they were having to call back for face-to-face appointments, thereby increasing overall consultation time and decreasing efficiency. 
Furthermore, with the extent to which problems were resolved ranging from 1-over 60%, fairly evenly distributed among practices (see Figure 5), it could reflect the different models and quality of telephone triage that exist. Our survey also draws attention to a category of patients who seek the counsel of medical practitioners despite there not seeming to be an obvious medical need.  
While healthcare practitioners are careful not to disregard the needs of such patients, with GPs seeing a median of 6-10 such patients a day, this no doubt takes a toll on NHS resources. If a GP sees six people a day, who could be better helped else where, for a ten minute consultation this could take up a quarter of their time looking at the minimum undertaking of four hours a day. 
Based on the lower end of hourly rates for locums, £50, this could cost the NHS of £836.5 million a year across the UK’s 63,854 GPs. 
Joe McGilligan, GP partner at Greystone House Medical Practice and chairman of East Surrey Clinical Commissioning Group, said: “We have a cradle to grave responsibility, so obviously people feel we are the point 
of call for all their woes even if it is not what we are trained for nor adequately resourced in expertise or knowledge. 
“I never see patients as wasting my time, just misdirected in what I can offer. Having social workers in the practice as well as health visitors could go a long way to improving everyone’s perception of a good job done.”
Victoria Vaughan, the company’s editor in chief of primary care said: “Clearly NHS money can be better used in primary care by making sure patients are seen by an appropriate professional and that they have the confidence and opportunity to request or be directed to an allied health professional where appropriate.”
As healthcare providers seek to adjust to new responsibilities and telephone triaging becomes increasingly integrated in healthcare access, this survey paints a rough picture of how general practice is responding to changes and raises questions about the standardisation and management of risk in telephone triage. 
 
Cogora thanks all the participants of the survey. The Winner of the iPad is Patient Services Manager of The Adam Practice, Lisa Falls.  The winner of £25 M&S vouchers is GP Tom Bull. For more information on Cogora research, please contact Alex Beaumont at by email at alexbeaumont@cogora.com.