View from the ground, by Dr Toni Hazell
‘I think I’ll take a holiday to the Vatican next year doc—after getting in to see you, the Pope should be no problem!’
Five years ago, like many GP practices, we were struggling with demand. Appointments were gone within minutes of the phone lines opening and it was depressing to get to the end of morning surgery to find a sea of names on the ‘extras’ list, all of whom had waited over an hour to be seen. Something had to change. In 2013 we were visited by a telephone triage company who offered to help us radically overhaul our system. They performed a detailed audit of demand and helped us make an evidence-based plan, which stated how many GP sessions should be offered on each day of the week, with telephone consultations used to triage all patients and establish who was most in need of a face-to-face appointment.
All too soon day one of the new system came around—and I was the Monday morning doctor on call. With some nervousness I wondered if all the appointments would be gone by half past eight, but my fears were unfounded. The new system seemed to work!
Since the triage system was launched we have made various changes and, while it is true that you can’t please all of the people all of the time, the feedback is generally good. We book almost all appointments on the day, so when I arrive I have two largely blank lists—one for calls and one for face-to-face appointments. I take the calls and decide which patients need to be seen and which could be redirected to another service (dentist, pharmacy, housing, social worker, and occasionally ‘hang up now and call 999’). I can arrange the day how it suits me and, not being a huge fan of the 10-minute appointment, I tend to put in a catch-up slot every hour with doubles for things that are likely to take more time.
Every system needs some flexibility and ours is no different. The classic order of ‘history, examination, investigation’ gets turned on its head; sometimes the tests are arranged first, then the patient sees their GP when the results are in. Patients generally like the idea as it means fewer appointments. We take calls from 8am until 10am, anything after that goes to the duty doctor and is only seen if urgent. Coil and implant fittings are booked in advance, as are post-natal checks. If a relative rings to say they’d like to accompany mum to her appointment but they don’t live locally, or they need to arrange time off work, we will pre-book. Teachers will ask us to call back in morning break and people who commute will say not to ring while they are likely to be on the London Underground. We have early morning slots for working patients and different arrangements for those who can’t phone in, including patients with hearing loss and those who are homeless or don’t own a phone. Trainees don’t take calls until the end of their training and most locums don’t take calls, but we book patients into their surgeries. Different doctors will be more or less cautious and will therefore have different rates of converting phone calls into face to face consultations.
The key to successful triage is to keep the call short if you know that you are going to see the patient. Most patients are happy to tell reception what the problem is, so before I call the patient I often have an idea about whether or not I’ll need to see them and then the conversation is simply a matter of arranging a time, and that can be done in well under a minute. Longer calls are appropriate for things being dealt with on the phone.
There is some capital investment to be made if you are considering telephone triage. Headsets are essential to avoid stiff necks and you will almost certainly need more phone lines and more people answering the phone in the mornings. It was a huge leap of faith to make such a big change but no-one in the practice would go back. With the NHS in dire financial straits, there is a strong argument that access to highly trained professionals such as GPs cannot be given without triage and I would very much recommend our system.