Primary care telephone triage does not save money

Demand for general practice appointments is rising rapidly, and in an attempt to deal with this, many practices have introduced systems of telephone triage. Patients are phoned by a doctor or nurse who either manages the problem on the phone, or agrees with the patient whether and how urgently they need to be seen.

A new large study, published in The Lancet on 4 August and funded by the UK National Institute for Health Research (NIHR), has investigated the potential value of telephone triage for patients and for the NHS.

It concluded that patients who receive a telephone call-back from a doctor or a nurse following their request for a same-day consultation with a GP are more likely to require further support or advice when compared to patients who see a doctor in person. The research concluded that ‘telephone triage’ systems did not reduce overall practice workload.

These findings, from a team led by the University of Exeter Medical School, are important as telephone triage is becoming increasingly popular in general practice as a response to managing patient care.

The research was carried out in collaboration with the Centre for Academic Primary Care at the University of Bristol, the University of Oxford, the University of East Anglia and the University of Warwick. It was funded by the National Institute for Health Research Health Technology Assessment Programme.

Overall, the ESTEEM study – one of the first robust investigations in this field – concluded that telephone triage by a doctor or a nurse only results in a redistribution of practice workload, not a reduction. It also discovered that telephone triage is no more expensive or cheaper than care provided via traditional face-to-face appointments.

The ESTEEM trial involved more than 20,000 patients across 42 doctor surgeries in England. Practices were randomly assigned to continue delivering care in their usual way, or to change to a system using a doctor or nurse to call the patient back to offer help or advice following the patient’s request for a consultation with a GP ‘that same day’ in the practice.

The research lasted for around two to three months in each practice. The researchers examined patient’s consulting patterns in the 28 days following their initial same-day consultation request.

Practices offering triage by a GP saw an increase of 33 per cent in the total number of patient contacts amongst patients who had requested a same-day appointment compared to patients seen under usual care. For practices offering nurse triage the increase in the total number of contacts was 48 per cent.

The researchers identified that there was a redistribution of GP workload associated with introducing triage. In practices providing GP triage, GPs had 39 per cent fewer face-to-face consultations, whilst in practices providing nurse triage, GPs had 16 per cent fewer face-to-face consultations. Thus introducing GP triage was associated with a redistribution of GP workload from face-to face consultations to telephone consultations, and introducing nurse triage was associated with a redistribution of workload from doctors to nurses.

Around half of the patients seen in ‘usual care’ had no further contact with the health care system in the 28 days following their initial consultation. However, 75 per cent of patients seen in practices operating a GP telephone triage systems did make further contact, and where nurse telephone triage was in operation, 88 per cent of patients made further contact.

Overall, patients reported a good experience of care provided by the study practices, although patients from practices providing nurse triage were slightly less satisfied than those from the other practices.

Professor Chris Salisbury, Professor of Primary Care at the University of Bristol, said: “Patients find it difficult to get an appointment with their GP, and many general practices are struggling to meet the demand to be seen on the same day.

“Providing telephone triage has been promoted as a solution, on the assumption this would be more convenient for patients and save time for doctors. But our study showed that telephone triage didn’t save practices time, nor were patients more satisfied.

“Practices need to think carefully before introducing major changes to their appointment systems. This study highlights the importance of evaluating proposed changes to general practice before they are introduced, as meeting the increasing demand for appointments is a complex problem which may not have a simple solution.”