This week a study in the Lancet concluded that phone consultations with patients who request same-day appointments generate additional work for GPs when compared to face–to-face encounters. In some ways, the study provides further evidence for the existence of induced demand – the phenomenon that widening access for health care fuels use – that we highlighted in a recent Nuffield Trust report (June 2014).
If patients can’t have all of their care needs met in the minimum possible number of GP appointments, they may be shifted around the health system, having avoidable additional encounters with clinicians.
Equally, the availability of telephone call-backs may be so convenient for patients that they phone repeatedly to check and re-check progress with minor ailments for which they would not be willing to wait in a crowded waiting room.
Patient views of these triage services are mixed. Many love it, but the system is not without challenges
The Lancet study focused on patients who requested a same-day appointment. It compared telephone with face-to-face management of clinical problems, but did not link patients to their usual GP. In many surgeries, telephone assessment by a duty doctor is offered if there are no appointments available on the day.
The telephone GP may not know the patient. Simple problems can be fully managed over the phone. However, less clear-cut symptoms may be ‘safety netted’ to exclude dangerous diagnoses until the patient can be seen by a GP who knows them.
This approach to phone consultation is different from universal telephone triage by a patient’s usual GP, which is being introduced in many practices. Here, the default arrangement is for a GP who knows that patient to undertake a preliminary phone assessment of every patient who requests an appointment and invite the patient to come to the surgery if necessary.
Patient views of these triage services are mixed. Many love it, but the system is not without challenges. Some can’t speak English well enough to participate in a telephone consultation. If called back at work, there may be no space for a confidential conversation. Some simply want a face-to-face encounter.
The triaging GPs are at liberty to sequence events in order to get the most out of a face-to-face encounter. For example, they can order tests and see the patient once the results are available. They can spot gaps in care during phone triage and arrange to address these when the patient attends the clinic.
Telephone encounters are also used to review patients with ongoing problems and long-term conditions if a physical examination is not needed.
In short, when used as part of a carefully designed, whole organisation approach to improving access, continuity and patient experience of care, telephone triage may improve efficiency within practices and increase convenience for patients.
A full evaluation of the triage approach has recently been commissioned from the RAND research group in Cambridge. The evaluation will provide much needed objective evidence on the impact universal telephone triage has on patients, clinicians and the wider health system. Until the results are available, insights into total telephone triage are available through early studies reported on the GP access web sites and in various blogs.
Nevertheless, the findings of the Lancet study do remind us to be cautious. Increased demand caused by offering unscheduled access may account for up to 30 per cent of contact in primary care systems. Up to two thirds of these additional contacts may be for minor, self-limiting health problems which will resolve spontaneously.
The challenge is to link patients quickly to a clinician with a combination of clinical skill, personal knowledge of the patient and system incentives to minimise demand. Telephone encounters – whether for triage or as an alternative to face-to-face appointments – surely have a part to play here, along with e-mail, texts and skype.
Whatever modes of access are offered, a fundamental issue remains. There is a mis-match between public expectation, need, demand and capacity in a clinical speciality with a shrinking workforce. This is a wicked problem and there are no easy answers. Honest and open public debate is urgently needed to explore how both GPs and the public can address the access problem.
Rosen R (2014) ‘The ‘wicked’ problem of access: is the telephone a solution?’. Nuffield Trust comment, 6 August 2014. https://www.nuffieldtrust.org.uk/news-item/the-wicked-problem-of-access-is-the-telephone-a-solution