The new Health Secretary’s expectation that everyone who needs a GP appointment can get one within two weeks assumes that we can create enough capacity to match demand. By also saying that “people with urgent needs should be seen on the same day”, she assumes that practices have effective ways of identifying patients with acute or serious problems to judge urgency of need.
Until we have enough GPs to meet demand for appointments, we require ways to identify and prioritise those with urgent and serious problems, yet her statement said nothing about the ‘triage’ arrangements (methods for rapidly assessing and prioritising patients) arrangements needed to do this.
At their best, triage systems serve to separate patients needing urgent care from those who can wait, steer patients needing continuity to a GP who knows them, and channel patients with simple and clearly specified problems (such as a medication request or a sprained ankle) to a non-GP clinician with the skills to address their needs. They can also filter out administrative issues for which an appointment isn’t needed.
What do we already know about triage in general practice?
Research into the impact of online and telephone triage has reported reasonable patient satisfaction, but also a range of unintended consequences, including reduced access for people who can’t use digital technologies, as well as increased GP workload. There are also various patient concerns about online services, including uncertainty about how to describe their problems and what response to expect.
Much depends on how practices organise triage, with many patients frustrated if not offered the type of appointment they want or not given a specific time for an appointment. Without careful design, triage can result in reduced continuity of care as well as inefficiency and duplication if a telephone call is followed by an in-person consultation. It can also bring stress for reception and clinical staff.
Until appointment capacity in practices increases, the need to assess and prioritise appointment requests is unavoidable. A policy workshop for the Remote by Default 2 study held in May this year drew on emerging findings from the study about triage and access, to explore what generates trust in triage decisions and how to ensure they offer fair access for all. Paradoxically, among almost 50 workshop participants with expertise in GP access, many were unclear how to book an appointment with their own GP – citing confusing websites and complicated online triage tools as common problems.
How to ensure that triage and access to GP appointments work well
Four themes emerged from the workshop to strengthen triage:
- Patients and their carers need access to clear, simple information in multiple formats, including through simplified practice websites about how to access clinical care; which clinicians to see for different conditions; and the criteria or rules of thumb through which appointments are allocated.
- Reception staff and clinicians need sufficient skills in inquiry, negotiation and communication to assess patients’ ability to consult remotely; to assess patients’ needs and preferences; and to offer an appropriate appointment type or explain why this cannot be done. Data from the Remote by Default study suggest that, to date, training for remote working has been patchy and insufficiently focused on assessing and responding to individual needs.
- Triage arrangements must support a continuity of relationship with clinicians for patients with complex problems and with other practice staff – including receptionists – for people who are unable to describe their problem (for reasons such as intellectual impairment and lack of access to a confidential space), so the practice can get to know their individual needs and how to accommodate them.
- Ultimately, patients’ trust in triage and appointment booking will only emerge through positive experiences in which either their expectations are met or the reasons for not being able to meet them are adequately explained. Without trust in these arrangements, frustrated patients will find other routes into care – too often through already overcrowded A&E departments.
Policy options to improve access
From a national policy perspective, five approaches could support practices to improve access fairly, and respond to both clinical need and patient preference.
First, ensure that practices offer flexible access routes and appointment types which can be tailored to the individual needs and capabilities of each patient. Avoid specifying a right of access to any particular appointment type.
Second, and to build on the announcement of funding for extra practice support staff, consider professionalising their role through an extended training programme similar to that in Germany and the Netherlands, with a focus on training in communication and negotiation alongside other skills. This will equip them to support patient triage and reduce patient frustration with appointment booking.
Third, introduce measures to improve continuity. The starting point should be to require routine reporting of the proportion of patients experiencing continuity. Over time, systems to support triage and increase clinical safety by identifying patients with complex problems who need continuity should become a requirement for all GP record systems.
Fourth, consider introducing standards for the design and content of practice websites and online consultation forms to improve information about accessing care. This would also avoid the challenge of working out how to get an appointment every time a patient changes their GP practice.
Fifth, launch a national information campaign about new ways of consulting in general practice and the skills of multi-professional teams working with GPs to reduce the chance of patients who are disappointed with the appointment they are offered attending a different service.
These actions must be in conjunction with efforts to recruit more GPs and other primary care clinicians and to develop multi-professional working as set out in the Fuller report. But these changes will take time, and there is a more immediate imperative to ensure current GP appointments are available to those who most need them. Short-term actions on triage and access are needed.