As the number of patient contacts in general practice steadily rises and the nature of healthcare becomes increasingly complex, it is perhaps not surprising that many practices view telephone-based consultations and triage as a way of safely managing increasing demand while also meeting patients’ understandable desires for a timely response to their requests for urgent healthcare.

Telephone triage and consultations aim to improve access to care, but what impact do they have on the workloads of practice staff?

A positive account

One practice that is very much in favour of a telephone consulting system is Little London Surgery in Walsall. With morale at rock-bottom and staff at breaking point, the practice team decided that the best option for them to help the situation was to introduce a GP-led telephone consulting service.

Speaking at the RCGP Conference, Dr Albert Benjamin from the surgery outlined that the practice management was able to make a strong case for funding to the CCG, explaining that the system would improve patient access and reduce no-shows, as well as reducing unscheduled and emergency admissions. Dr Benjamin also pointed out that, because the surgery is in a very deprived area, improving patient access would lead to improvements in health inequalities.

Productivity increase

Since implementing the telephone consulting system in April last year, the practice has seen noticeable improvements. The number of patients seen face-to-face has dropped from 93% to just 40% and waiting times have halved.

Dr Benjamin also pointed out that the flexibility of telephone consultations could lead to more flexible working hours, suggesting that spreading appointments across the day means that some staff could start at 8am and some at 10am, for example, levelling out the surge of patients wanting to come in in the morning. Workloads at the surgery may not have lessened but telephone consulting has provided the opportunity for practice staff to control and structure workloads better.

As with any major transformational change, Dr Benjamin wanted to make sure all his staff were committed to the scheme before implementing the changes. “It’s only successful if everyone is on board,” he said.

Extra demand

However, before you rush out and order your very own telephone-led consultation system for your practice, consider the findings of a research study published in the Lancet, which claimed that telephone triage led by GPs and nurses actually led to an increase in practices’ workloads.

The study randomly assigned 42 practices to GP-led triage, nurse-led triage or usual care and found that the mean number of contacts per person after the introduction of GP triage was 33% higher than in practices that continued usual care, while it was 48% higher after the introduction of nurse-led triage. GP leaders have said that the study confirmed their belief that telephone triage ‘generates substantial extra demand’.

Ups and downs

The study found that GP triage did substantially reduce the number of face-to-face GP consultations over the 28-day follow-up compared with usual care, but it increased the number of GP telephone consultations per patient ten times and also slightly increased face-to-face consultations with nurses.

Meanwhile nurse-led triage also resulted in a reduction in GP face-to-face contacts and an increase in GP telephone consultations, albeit less so than GP triage, while it led to a 100-fold increase in the mean number of nurse telephone contacts.

Despite the hikes in patient contacts, there was no change in the average overall costs of health care with either GP or nurse triage.

The study authors, who reviewed the case notes of over 16,000 patients, concluded: “Introduction of telephone triage delivered by a GP or nurse was associated with an increase in the number of primary care contacts in the 28 days after a patient’s request for a same-day GP consultation, with similar costs to those of usual care.

“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.”

In conclusion

With the above in mind, when considering introducing a telephone triage/consultation system to your practice, it’s worth reflecting on the purposes of it and the potential benefits and risks involved. Inevitably, triage overlaps with issues such as patient access, capacity and demand, appointment systems already in place, “Duty Doctor” roles, patient demographics and staffing levels, and should be considered in conjunction with these.

Ultimately, the jury is still out as to whether telephone-based systems can be the saviour of general practice as we know it.

Do you use telephone consultations in your surgery? What are the pros and cons? Let us know by commenting below or take it to the forum.