This week saw the publication of a paper in the Lancet ‘Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial)’ by Professor John Campbell and colleagues. We welcome this first multi-site trial across nearly 21,ooo patient consultations in 42 practices comparing the effectiveness of telephone triage by GPs or nurses in general practice with usual care for patients seeking same-day consultations in primary care. To be clear, this research looks at telephone triage – returning all calls and then deciding how to deal with them – not more focused use of telephone consultations, where patients who want to consult with a doctor or nurse over the phone can take up this option as an alternative to a face to face appointment.
The headlines (Phone consultations 'do not cut GP surgery pressures', BBC, 4th August 2014) suggested that telephone triage needs to be treated with caution rather than heralded as a one-stop solution for transforming access in general practice. GP triage was associated with a 33% increase in the mean number of contacts per person over 28 days, and nurse triage with a 48% increase, compared with usual care. The report concludes that while “Telephone triage might be useful in aiding the delivery of primary care” … “The whole-system implications should be assessed when introduction of such a system is considered”.
The Primary care Foundation has been working with practices on access and urgent care for over five years since our report to the Department of Health ‘Access and Urgent care in General Practice’ in 2009. We developed a web based tool, that takes a look at one week in the life of a practice, and makes comparisons with other practices and potential suggestions for making life easier in the practice and improving patient care. We have now worked with over 30 CCGs and PCTs and supported over 1,200 practices, so we thought it might be helpful to reflect on our experience. Below is a summary of some of the key factors we have found that practices tend to find useful when responding to demand an activity.
Reflections on improving access in general practice
Money is important, but it doesn’t explain everything
There is a great deal written about increasing demand and lack of resources and both of these are relevant across many parts of primary care. However the resourcing is an issue that has a longer-term cycle and resolution and is beyond the short-term direct control of the practice team. We may have seen some evidence of higher demand in areas of high disease prevalence possibly linked to deprivation, the age of the patient population, language or ethnicity. In most places we see a spread of practices - some managing well with less activity and some struggling with higher than expected consultation rates. We frequently see practices with matched resources and populations in the same street or health centre with very different activity profiles. One practice has high activity (and perceived high demand) while the other has a lower than expected rate of activity. When we cross reference the patient satisfaction we frequently find that the practice with the lower activity has higher levels of patient satisfaction.
The single most important factor remains good continuity of care
So what is driving the difference? In a word, continuity. Many people, especially elderly people with more complex conditions, want an appointment with their ‘own’ doctor or nurse within the next 5 working days. The perception that everyone wants a same day urgent appointment is often driven by what is available – increasingly, the choice in too many practices is an ‘urgent’ appointment today, or nothing for at least a week.
So the practice that can routinely offer an appointment or a call with the patients doctor of choice within the 5 working days tend to have lower activity levels as they don’t have patients making repeat contacts to try and get their own clinician.
It’s the system, not the patients
Access is of course in the first instance via a phone call to the practice. The most common reasons for poor phone access are the way reception staff are organised or a lack of phone lines. Patients are often seen as the problem – calling too often for unnecessary appointments and then failing to show up – whereas, in reality, the system set up by the practice is often the main source of the problem. As pressure builds, practices try and set up more barriers to protect limited appointments – appointments available when the surgery opens, appointments ‘embargoed’ until later in the day, patients told to call back later – all of which drives us into more desperate behavior to get limited appointment slots. So in an attempt to manage the pressure for appointments, the system becomes increasingly complex and patients become experts at ‘gaming’ the system that has been put in place to make life easier. Practices which have a system generating high demand inevitably have higher phone volumes and often fare less well on phone access. On rare occasions we do find lack of resources an issue but, in our experience, this tends to be an exception.
Phone or face to face?
We are great supporters of telephone consultations as an effective route of access to the practice. Its time effective for both the patient and doctor and also expands the options for patients to choose what type of access would suit them. Again continuity is a key factor so the patient must be able to get their own clinician. The important factor is choice - the more routes in to get an appointment, the more choice patients have and the more likely they are to choose the most effective route for themselves and the practice. The trick the practice has to pull off is to ensure each route of access has adequate capacity for the demand and delivers true choice.
Restricting patients to one form of access, such as exclusively through same day appointments, telephone triage, or through a duty doctor clinic, tends to lead to a bottleneck as different people will seek different solutions. Young men, mothers with young children, working adults, people whose first language in not English, and the frail elderly will want to access care in different ways. So multiple routes, including face to face care and telephone consultations, as well as booking appointments on line and increasingly email advice, will all have a part to play. The more as patients we understand there is a choice, the less pressure there tends to be first thing in the morning. So, a simple question early on in the phone call to book an appointment “would you like to see the doctor or nurse face to face, or would you like them to call you back?” could go a long way to help.
A 'silver bullet'?
We don’t have a model or template that solves all the problems but a set of analytical tools that helps the practice make choices and review how they do things while benchmarking their activity locally. There is no ‘silver bullet’ or one system that will work well in every practice. No matter how the practice uses its resources putting access to the clinician of choice at the center of their design will deliver benefits.