Dr Hamed Khan answers questions on the introduction of a GP-led triage system, how it works, and the benefits for patients
Read this article to learn more about:
- why GP-led triage was introduced at St George's A&E
- the role of GPs and other stakeholders
- the impact of the triage system on patients.
Q What prompted the introduction of a GP-led triage at St George's?
A Waiting times at A&E are continually rising throughout the UK—between October and December 2014, England saw the worst ever waiting time figures since the 4-hour target was introduced.1 Dr Clifford Mann, President of the Royal College of Emergency Medicine, described the situation as unsustainable.2 Several hospitals have had to declare major incidents purely because they have been unable to cope with the huge demand and patient numbers.
There are several reasons for this. The UK has an ageing population, with multiple complex conditions and intertwined social care needs. This is combined with a huge funding crisis for the NHS as a whole, which is being asked to make so-called 'efficiency savings' of around £20 billion by 2019–2020.3 In addition to this, there is a real staffing crisis, with one-third of the entire A&E workforce having emigrated over the past 5 years.4
At the same time, it is generally estimated that 15–40% of A&E patients do not need treatment in A&E, and could be safely treated in community settings, such as in general practices.5
The key to reducing these so-called 'inappropriate attendances' is to find ways of safely and efficiently diverting patients who do not need to attend the A&E department to service providers more appropriate for their conditions.
Q How has the GP-led triage been implemented at St George's?
A Here at St George's, the consultants, GPs, Wandsworth CCG, and Care UK have collaborated to develop an innovative GP-led triage and redirection service. This puts GPs at the forefront of identifying patients who do not need to be seen in A&E and can be treated in the community, and redirecting them to appropriate community services. The GPs work with the triage nurses in triage at the 'front door' of A&E, and so far the system has proved to be effective and well liked by patients.
The key factor is recognising and utilising the unique skills and acumen that GPs possess. In emergency care, GPs are used to seeing patients 'unfiltered', that is, being the first professionals patients see, unlike most other hospital doctors who see patients after they have been assessed by nurses or other doctors. We work within the framework of 10-minute consultations, during which we take a history, establish rapport, undertake a physical examination, and devise a list of differential diagnoses and a patient-centred management and follow-up plan. We do this while unpicking social and psychological issues intertwined with physical 'medical' problems, utilising excellent communication skills.
Working in this paradigm gives us unparalleled risk management and rapid clinical decision-making skills. As GPs who also mostly work in general practices, we are familiar with the community and the health services available in that community.
Q How did you get the relevant stakeholders on board?
A We were fortunate that all parties were positive and constructive from the outset. Credit must be given to our consultants and our commissioners who have always been keen to utilise GPs in a positive, constructive way in our Emergency Department.
Q How does the service operate?
A At the 'front door' of A&E, where patients are first seen and triaged, we have triage nurses and a GP, who identify those patients who do not appear to be acutely unwell and who may be suitable for treatment in a community setting rather than A&E. The GP will do a quick, focused assessment of such patients to decide whether they can be safely redirected to a non A&E service, such as their usual GP practice, a walk-in-centre, the out-of-hours GP, or even other services such as dentists, opticians, podiatrists, etc. If patients need urgent treatment, the GP will triage the patient and they will be directed to the right part of A&E to be seen.
If the patient can be safely redirected to a community service, the GP will explain to them why that service would be more appropriate for their needs and will organise for them to be seen there.
The administrator for this service will book the patient an appointment with the appropriate service (e.g. their own GP, or the out-of-hours GP, and other services where it is possible to book appointments) unless that service operates on a walk-in basis (as some dentists and out-of-hours GP services do). We make sure that these patients are seen on the same day so that diagnosis and treatment is not delayed. Patients who refuse this service and want to be seen in A&E despite us explaining that this would be inappropriate, are always allowed to do so.
Other health professionals are also involved in this service. The GPs support and help the triage nurses in clinical decision making to help ensure that redirection is appropriate.
Q What are the benefits of the service?
A The GP-led triage service benefits the A&E department because it decreases the number of inappropriate encounters, that is, those patients who should have been seen in a community setting. This helps decrease the overall number of patients waiting to be seen in the A&E department, and leads to lower waiting times, which is good for those patients in A&E who are acutely unwell.
It is also good for the redirected patients, as primary care problems receive better care in primary care settings than in A&E, because GPs are likely to receive more training and have more experience in dealing with these issues.
Recently we carried out a study to evaluate the service, and found that the most common categories of symptoms were musculoskeletal (such as back pain) and dermatological (skin conditions such as eczema and psoriasis).6 General practitioners are best placed to manage these types of chronic and non-acute conditions, and can also provide continuity and multidisciplinary team input, which can be hugely important.
Q What has been the impact of the GP-triage service to date?
A Our recent study involving 150 patients showed that patient satisfaction with the service is very high; 83% of patients in the study rated the service as 'very good' or 'excellent'.6 Many patients have told me anecdotally that they like having a fixed appointment rather than the understandably unpredictable waiting time in A&E.
It is also more cost-efficient to treat patients in primary care, which is hugely important considering the massive funding crisis that the NHS is facing, together with an ageing population. The full extent of the cost savings following the introduction of the GP-triage service at St George's Hospital are difficult to calculate due to the complexity of the costs for each stage of the patient encounter; however, there is no doubt that it is generally much cheaper to treat patients in the community rather than in hospital.
Q What does the future hold for the GP-triage service at St George's?
A Taking into consideration that policymakers are constantly looking for ways in which they can move care into the community, and the cost efficiency of primary care and the high quality of care it provides for primary care problems, the future of this service is very bright. I have been contacted by people working with and in other hospitals who are keen to replicate our services in their departments.
Q What advice would you give to GPs and commissioners looking to implement a similar service in their own locality?
A It is important to work collegially and collaboratively with all stakeholders, including consultants, nurses, commissioners, and GPs. It is also imperative that patient safety is always given the highest priority over logistics, cost efficiency, and other factors. My friends from the Netherlands tell me that in some systems there, patients have to see a GP before they are seen in A&E, in order to stratify and streamline patients seen in A&Es. In an ideal world I feel that this is the sort of system that we should be looking to emulate here in Britain as well.
- NHS England. A&E attendances and emergency admissions 2014–15. Available at: www.england.nhs.uk/statistics/statisticalwork-areas/ae-waiting-times-and-activity/weekly-ae-sitreps-2014-15/
- Department of Health. Review of operational productivity in NHS providers. Interim Report June 2015. Available at: www.gov.uk/government/publications/productivity-in-nhs-hospitals
- Mann C. Actions to address the significant challenges facing emergency medicine (video) The King's Fund. Urgent and emergency care conference, 22 September 2015. Available at: www.kingsfund.org.uk/audio-video/clifford-mann-actions-address-significantchallenges-facing-emergency-medicine
- Ismail S, Gibbons D, Gnani S. Reducing inappropriate accident and emergency department attendances: a systematic review of primary care service interventions. Br J Gen Pract 2013; 63 (617): e813–e820.
- Begum F, Khan H, Moss P. Solving the A&E crisis using GP lead triage and redirection. Poster no.30 presented at Implementing the Urgent and Emergency Care Vision event, 17 November 2015. Available at: www.myhealth.london.nhs.uk/system/files/30.%20Solving%20the%20A%26E%20crisis%20using%20GP%20lead%20triage%20and%20redirection_0.pdfG