“Telephone triage increases demand on GP practices” followed with “…an increase in practices’ workloads”. Thus did Pulse headline the long awaited Lancet paper from the ESTEEM trial. We don’t want anything like that, no thank you. As you were, chaps.
A year later, the same data is rehashed and published in BJGP Telephone Triage Systems in UK General Practice.
The funny thing is that GPs who take a system approach around telephone consulting have been lining up to say precisely the opposite. Tweet from @amitbhargava “We have 35% decrease, consistently over 5 years”. Professor Aneez Esmail told me they were 30% more productive in their practice. I don’t want to overexcite people but many GPs tell me they are 20% more efficient. Peter Swinyard “cuts surgery pressure and puts GP in control of workload”. Chris Peterson “staggeringly more efficient – we are never going back” More GP views added here.
The crucial differences are listed here. ESTEEM tested a component, not a system. GP triage for same day requests only, for a period of 4 weeks run in and 5 weeks data capture (total 6658 phone consultations in 13 practices). The purpose was to run a trial, not to strive for improvement. And this component trial showed a GP telephone resolve rate of 25%, so 75% of those spoken to saw a GP face to face within 28 days. No wonder the workload went up (though costs were similar), as announced by University of Exeter.
Compare a system where the GP telephones substantially all patients as a first response, and sees them as needed. The purpose is “How can we help the patient?” The telephone is not for technology’s sake, but a means to an end, currently the most efficient known means, which may change in time.
The key measures for patient service and satisfaction are
- response time to the patient (minutes)
- a choice of named GP (if requested)
- how soon before a face to face (if needed, usually same day).
None of these measures is quoted in the ESTEEM study, nor is any estimate of total demand given. Only the supply side of contacts made is reported.
A system approach works by understanding and predicting demand, then matching capacity to meet it. Why does it end up as less work? Our database of 66 practices and 1.6 million phone consultations shows GPs are typically resolving 60% of problems over the phone. Most of the remaining 40% they see themselves, or refer to a nurse. They feel in control. It’s sustainable because it’s efficient and rewarding professional practice. Useful measures for GPs include:
- duration of consultations, phone and face to face
- resolve rate at first phone contact
- GP-patient relationship continuity (evidence links to lower emergency admissions)
The tragedy now is that selective headlines from a small scale study are seized upon by skeptics to deny that a system can work, when it hasn’t been tested. The paper quotes the need for system level implications, but doesn’t provide them.
The good news is that an NIHR funded study of the system, led by Professor Martin Roland, starts in September. Hard pressed GPs, frustrated patients and a financially squeezed NHS need help now, and there is still time to join the study by going through our Launch programme.
Read the detail on why ESTEEM results contrast so much with ours.