Back in April I was asked by Pulse to write an article for their debate, “Does telephone triage reduce workload?” and offered the princely sum of £120. After I’d written and submitted it as agreed in good faith, they decided that only the views of GPs would be printed. To be fair to Pulse I suppose that is logical, in the same way that I would expect only train drivers to have relevant opinions on the operation of trains.
Anyway, this week the debate appeared and you can read the views of two GPs on the above link. Interesting points, but neither has experience of GP telephone consulting enabling a demand led system. The two penn’orth I wrote as a non-GP are here:
I don’t care about telephone triage, even though I’ve been asked to write about it. What I care about is an effective and efficient primary care service, and that has been my vision since founding GP Access in 2011, “to transform access to medical care.”
But the simple telephone has proven an outstanding means to that end, when it’s used for first contact by the GP in a demand led system. The problem as we all know is workload, and too much demand for the capacity, which leads to over 100,000 patients each day being turned away from their GP despite their genuine need.
Back in 2000 the earliest pioneer GPs including Chris Barlow and Simon Coupe discovered that 2/3 of patient demands could be resolved over the phone, the other 1/3 being called in for a face to face. This ratio remains the same, and this coupled with the fact that telephone consults take half the time of face to face means that GP capacity is increased. We are proving this week after week.
Two practices launched in Belfast in April, GPs going round with big smiles saying “It’s really quiet this afternoon isn’t it?”. Another in Somerset writes after two months, “We have increased our list and our GP sessions, but now the partners go home on time, and can do the admin generally in the day. It is hard work when in and busy, but feels more satisfying and in control.”
Is it sustainable? The pioneers are still improving over 16 years. Some of those we’ve helped are approaching 5 years, and saying we’ve changed their working lives. The Elms in Liverpool, a high demand inner city practice has seen demand flatten over 4 years, even fall slightly, despite a GP response time of just 12 minutes. Our evidence gives the lie to those who say easier access increases demand. Some make patients wait 12 days, but all this does is to increase anxiety demand, booking just in case, rework and stress.
If there is unmet need, this may be uncovered when access is opened up, but the system is so efficient that for almost all practices there is still excess capacity, and demand then becomes stable and predictable to better than 10% each day.
Some imagine that it doesn’t work for all patients, but it turns out that is only a handful in each practice who can be accommodated individually. Many such questions are raised and while we have published evidence from our database of over 10 million consultations, we welcome full scale independent evaluation which is being done through Tele-First.
So what’s the secret, and why has there been criticism? A whole system demand led approach is critical. Bolting on a hybrid where prebookable face to faces are taken first does increase the workload and I’ve seen much misery result from this. Having helped 100 odd practices through change we’ve seen everything that can go wrong, and even apparently subtle deviations can wreck the system. But with good leadership, the will to succeed and the right support and measurement, the change, even in as little as four weeks, is very secure.
Is telephone triage the final answer? I’m an engineer, we don’t do final answers, we do “the current best model until we have a better one”. The next even more exciting model is online access.