Scientific background and review of current literature
Demands on UK primary care are increasing. The introduction of a new General Medical Services contract in 20041 was followed by an estimated 25% increase in primary care workload.2 For many practices and staff, addressing this increase in workload has involved an exploration of alternative ways of managing patients, in an attempt to respond to government and societal expectations while continuing to deliver safe, high-quality care.
The introduction of UK NHS walk-in centres, the 24-hour nurse-led telephone advice service NHS Direct and the more recent NHS 111 service, the increased diversity of staff skill mix and the use of remote consultations in primary care all represent organisational responses aimed at increasing the range of services available to patients and improving access to primary health care. When combined with telephone consultation, telephone triage is believed to provide rapid access to health-care advice for patients while freeing up opportunities for face-to-face consultation. Previous research3 has demonstrated the utility of nurse-led telephone triage (NT) of patients requesting same-day appointments in UK general practice. An ‘average’ practice (7000 patients) might be expected to manage around 20 patients each day requesting a same-day appointment request, representing around 35% of general practitioner (GP) workload.4
Some research evidence exists regarding the feasibility, workload implications and cost of telephone triage, and patient experience of care, safety and health status following telephone triage. Most evidence derives from models involving nurse triage; less research has been carried out to address the impact of GP telephone triage to date. There have been no large-scale multipractice studies examining the potential value of general practitioner-led telephone triage (GPT) or NT of patients requesting same-day consultations.
Feasibility of telephone triage
Previous studies suggest that around 50% of nurse triage calls in out-of-hours primary care settings may be handled by telephone advice alone.5–8 However, such studies have been small or focused solely on out-of-hours primary care. Use of telephones (fixed or mobile) is now almost universal in the UK,9 and recent years have seen a near quadrupling in the proportion of GP consultations conducted on the telephone.10
Primary care workload
In the short term, telephone triage, whether by doctor or nurse, appears to reduce GP contacts by around 40%,3,11 but it could be that this shifting of GP workload may result in the work undertaken by GPs comprising the more complex cases.12 The reduction also appears to be associated with an increase in later return consultations of a roughly similar magnitude (30%,3 50%13 between 2 and 4 weeks following a same-day appointment request), in effect smoothing out the peaks and troughs of GP workload that are associated with same-day appointment requests. Although this level of return consultations following triage may raise concerns regarding patient safety, convenience of care and cost-effectiveness, it has been suggested that a proportion of return consultations may be planned routine appointments, resulting from a downgrading of urgency following triage.
Cost
Equivocal results on costs of telephone triage and associated resource service use have been reported across three trials. NHS Direct nurse triage was more expensive than practice nurse triage of patients making same-day consultation requests14 but similar costs have been reported elsewhere between standard management and practice NT of same-day consultation requests.3 NT in out-of-hours primary care may reduce long-term NHS costs but may not be cost-effective at all times of the day.15,16
Patient experience of care
Equivocal results on patient acceptability and satisfaction have been derived from small studies. One study13 reported no difference in satisfaction between telephone and face-to-face consultations. Jiwa et al.11 reported that 80% of patients were satisfied with GP telephone management of same-day consultation requests, and Brown and Armstrong17 have suggested that patients who elect to use GP telephone consultations may do so as an alternative to face-to-face consultations in primary care.
Patient safety
Telephone consultation appears safe and effective.18,19 A UK equivalence trial (in which death within 7 days of contact was the primary outcome) established the safety of out-of-hours primary care NT by experienced nurses using computerised decision support software (CDSS) in comparison with usual care (UC).5 This is supported by work in the UK by the Richards et al.20 study, in which audio tapes of nurse triage consultations to assess decision-making revealed that decision-making was rated by GP or nurse practitioner review to be mostly good, with minimal risk from poor nurse triage decisions. However, one Swedish study19,21 noted that nurses often used self-care advice and also over-rode software-determined recommendations on management. A recent Dutch study22 highlighted concerns regarding information-gathering in telephone triage when delivered without the use of CDSS, relying only on clinical protocols. Studies8,21,23,24 have highlighted the importance of training in the use of CDSS to address patient safety issues. Nurse telephone triage delivered within a framework of national guidelines (but not with CDSS) was judged to be efficient, although some concerns were raised with respect to patient safety.25 One study,3 adopting a triage system involving ‘computerised management protocols developed by the practice’ identified a substantial increase in accident and emergency (A&E) attendance, although actual numbers were small. Although computerised, such a system did not provide CDSS (DA Richards, Institute of Health Research, University of Exeter Medical School, 2008, personal communication) such as is now available within a number of NHS primary care computer systems, and which we propose to examine in this study.26 The other trial by Richards et al.14 used CDSS for NHS Direct triage nurses, but not for nurses acting in primary care. A systematic review27 of nine studies of telephone consultation and triage noted that it is unclear if telephone management simply delays visits and thus also the provision of definitive care.
Patient health status
Several randomised studies (but none involving telephone triage) have compared the health status of primary care patients following consultations with a doctor or a nurse by patients with minor problems or after a same-day consultation request. One study28 identified no difference in health status [Short Form questionnaire-36 items (SF-36) scores] between the intervention groups when followed up after 2 weeks. Similar findings have been reported with respect to resolution of patients’ symptoms and concerns after 2 weeks,29 or in the proportion of patients reporting themselves as ‘cured’ or ‘improved’ 2 weeks after a consultation with either a doctor or a nurse.30
Rationale for the research
The four UK-based trials3,5,11,13 of primary care telephone consultation and triage have been conducted in relatively small populations and/or in limited numbers of practice settings (i.e. urban, rural), and most studies examining NT without the use of CDSS, although research undertaken by Lattimer et al.5 did involve out-of-hours primary care nurse telephone consultations using the CDSS ‘Odyssey TeleAssess’, provided by Plain Healthcare Ltd. Despite uncertainty about the benefits and costs, many practices operate GPT or NT systems as a way of providing fast access to care for patients and in order to manage practice workload, as demonstrated by the almost fourfold increase in proportion of consultations conducted over the telephone.10 As an example, in 2008, the NHS Institute for Innovation and Improvement31 promoted a model of GPT – the Stour Access system – within which GPs triage all patient requests for care by telephone but without any robust evidence about benefits. We therefore proposed to address this important agenda in a large-scale experimental study of two forms of triage currently being promoted by the NHS for use in UK primary care. Our findings may be generalisable to other health settings, especially those with strong primary care-based health-care systems.
Aims and objectives
The overarching aim of this trial was to assess, in comparison with UC, the impact of NT and GPT mechanisms on primary care workload and cost, patient experience of care, and patient safety and health status for patients requesting same-day consultations in general practice.
The specific research objectives were as follows:
Pilot and feasibility study To undertake an external pilot randomised controlled trial (RCT) in six practices to:
confirm the ability of practices to implement the GPT and NT systems
confirm the proposed process for recruitment of practices
review the assumed level of clustering of outcomes
check data collection systems, and
identify potential difficulties in implementing the triage systems.
Main trial To undertake a three-arm pragmatic cluster RCT comparing, for patients requesting a same-day consultation in general practice, the effects on primary care workload and cost, and on patient experience of care, safety and health status of:
GPT compared with UC
NT compared with UC
GPT compared with NT.
The funding arrangements for this trial through the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme involved the delivery of the 1-year pilot study and satisfying a number of key stopping rules (see Appendix 1), before progression to the main trial phase.
