Dr Toni Hazell offers top tips for triaging patients by phone and what to consider when setting up remote consultations

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Dr Toni Hazell

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Read this article to learn more about:

  • how to conduct effective phone triage ahead of consultations
  • when a video consultation may be more appropriate
  • important considerations when setting up a remote consultation service.

Read this article at: GinP.co.uk/apr20-phonetriage

In 2018, I wrote about our switch to full telephone triage for every GP appointment—something my GP practice has been doing since 2013.1 With the outbreak of coronavirus (COVID-19), the need to reduce face-to-face contact, phone, video, and online consultations have become even more relevant, and it may be that more of our consulting is done remotely, even when the current pandemic is just a memory. This article includes 10 tips for triaging patients by phone, including how to adapt this to suit your practice, who can do it, and when to see patients either by video or face to face.

1. Identify where phone triage saves time

I often get asked if phone triage is efficient—doesn’t the time taken to make the call outweigh the time savings made from not seeing some people? In my experience, this isn’t an issue as long as the receptionist has asked the reason for the call. If you know that you’re going to have to see the patient (new rectal bleeding, for example), then the call will take well under a minute, and is really to arrange a time for the appointment. I find that only a handful of patients refuse to give the reason, and they are almost always calling about mental health, gynaecology, or to request a termination of pregnancy. Dealing with a patient who I won’t need to see usually takes well under the 10 minutes that I would spend on a face-to-face appointment, so there is an overall time saving. Having said that, a recent UK study found that GP triage does not save GP time.2 Crucially, in this study, the patient wasn’t always seen by the doctor who triaged them; I find performing both the triage and the appointment to be a big time saver, because I have already taken some of the history on the phone. A larger study showed that phone triage doesn’t save money, but does significantly reduce face-to-face appointments with GPs (by 39%), with no subsequent increase in the use of the emergency department or out-of-hours doctors.3

2. Ensure that the system fits your practice

We have always been a ‘morning-heavy’ practice, with more patient contact in the mornings and more meetings/admin and less patient contact in the afternoons, but the phone triage company who helped us set up wanted patients to be able to ring at any time and see a doctor the same day. This arrangement didn’t suit us, so we adapted it: now, the main hours for calls, unless urgent, are in the morning. A system that doesn’t fit your practice won’t work in the long term.

3. Customise the structure of your day

I hate 10-minute appointments. The ability to achieve them is seen as a badge of honour when training, but let’s face it, with the increasing complexity of patient problems and the hiving off of simple consultations to nurses and pharmacists, they are not really fit for purpose. Phone triage means that I can structure the day how I want it. I allot 20 minutes for face-to-face appointments involving gynaecology, mental health, interpreters, or more than one problem. In contrast, if I have a family of five children with the same rash, I might put them all into a single 20-minute slot. I generally put in a catch-up slot at least once per hour, and I space my appointments out more in the afternoon, recognising that I will be more tired towards the end of the day.

4. Triage for yourself where possible

Triage only works if the person triaging applies sensible thresholds, so that not everyone gets seen. I am a firm believer that the best systems involve the triaging clinician later seeing most of the patients that they have triaged. We are all human, and if you don’t feel the consequences of your own triaging decisions, then those decisions won’t be as good. Having said that, there has to be some slack in the system. Some days it feels like everyone needs to be seen, and some days almost no-one, so the number of face-to-face appointments available has to acknowledge that day-to-day variation.

5. Consider who should, and who shouldn’t, triage

Triage systems fail when the most junior person is doing the triage. It isn’t easy, and triage needs an experienced person. In my surgery, foundation year 2 doctors don’t do phone triage, and registrars only do it at the very end of their training. Some locums are happy to, and others aren’t. It’s fine to run a mixed system—I take more calls if there are non-triaging doctors in, because I can book into their clinics (I know I have just contradicted point 4, but sometimes needs must!).

6. Don’t be afraid to tell people that they don’t need a doctor

I sometimes despair about the level of medical knowledge among the general public. When a fit, healthy adult rings to tell me that they have had a sore throat for 5 hours, for which they have taken no over-the-counter remedies, I sometimes have to bite my tongue to avoid a complaint. I tend to go for the ‘robust but polite’ approach, saying that I’m sure that, as an adult, they know that most coughs/colds/sore throats are viral and self-limiting, and that the best person to see is a pharmacist. I don’t give paracetamol or other over-the-counter medicines on prescription, happy that I am acting on NHS England guidance,4 and I end the conversation by saying ‘I hope this has been helpful—next time you’ll know to go straight to the pharmacy instead of ringing us’. Education is slow, but if done with a consistent message, it can work.

7. Recognise when a video call would be more appropriate

Be honest—how often does listening to the chest of a febrile/coughing child change your management? Almost never. Seeing them race around the waiting room (or lie drowsy in their parent’s arms) is much more useful.5 The accuRx software (accuRx Ltd, London, UK) that many of us use for text messages can do video calls, so you can look at the child without having to bring them in.

8. Think about confidentiality

Landlines are shared; mobiles are usually personal, but may be seen by others. If you leave a message, consider what to say. ‘This is Dr Smith from the surgery—please call back when you can’ is better than ‘This is Dr Smith calling for Joe Bloggs’ because Joe may not want anyone else in his family to know that he has rung the GP, and can claim that it was a wrong number if someone else hears the message first.

9. Do your homework before you work for a private online provider

Private providers of online consultations have been in the news lately after their algorithms were tested and concerns raised about their safety.6,7 The Royal College of General Practitioners (RCGP) has responded to these concerns by publishing advice for GPs considering working for similar companies.8 As well as the basics—checking the company’s Care Quality Commission registration and whether you will have access to patients’ medical records—they suggest looking at prescribing rates (are you under pressure to dole out antibiotics?) and what policies are in place for raising a safeguarding concern.

10. Refer to established information about online consultations

NHS England has produced an implementation toolkit for online consulting,9 which contains information for individual practices and for commissioners. There are lots of variables, such as whether the first-line triage is done automatically or by a human being, whether the service works in real time or the practice contacts the patient after a time lag, and how much free text you allow the patient. Get the most tech-savvy doctor to read the guidance if you are thinking of starting.

Dr Toni Hazell

Part-time GP, Greater London

COVID-19 considerations

  • Many patients don’t need seeing. Trust your clinical intuition—if the person looks well on a video call, ask yourself how much you will gain from a face-to-face examination
  • Document that your decisions are being made in the context of the COVID-19 pandemic
  • Many patients are ringing for education or reassurance. Not all patients will know the basics about home management and self-isolation—take the opportunity to educate them.

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources. 

  • Recognise that in the current COVID-19 pandemic, telephone triage and consultation are key to reducing the risk of virus transmission to both patients and doctors in healthcare premises
  • Identify what proportion of outpatient consultations could be conducted over the telephone, especially during the COVID-19 pandemic
  • Try to implement a system where the clinician who consults on the telephone is also the clinician who later sees the patient if they need a face-to-face consultation
  • Evaluate the potential for video consultation to allow extra information to be gathered from visual cues (e.g. cyanosis, respiratory rate, children’s behaviour) and consider switching to this mode of consultation if symptoms suggest that it might be helpful
  • Remember telephone consultations are not all about triage but also play an important role in planned care too, particularly for review after face-to-face examination or investigations.

STP=sustainability and transformation partnership; ICS=integrated care system

References

  1. Hazell T. The doctor will call you now. Guidelines in Practice 2018; 21 (3): 40. Available at: www.guidelinesinpractice.co.uk/view-from-the-ground/the-doctor-will-call-you-now/454043.article (accessed 26 March 2020).
  2. Holt T, Fletcher E, Warren F et al. Telephone triage systems in UK general practice: analysis of consultation duration during the index day in a pragmatic randomised controlled trial. Br J Gen Pract 2016; 66 (644): e214–e218.
  3. Campbell J, Fletcher E, Britten N et al. The clinical effectiveness and cost-effectiveness of telephone triage for managing same-day consultation requests in general practice: a cluster randomised controlled trial comparing general practitioner-led and nurse-led management systems with usual care (the ESTEEM trial). Health Technol Assess 2015; 19 (13) doi: 10.3310/hta19130
  4. NHS England. Conditions for which over the counter items should not routinely be prescribed in primary care: guidance for CCGs. London: NHS England, 2018. Available at: www.england.nhs.uk/publication/conditions-for-which-over-the-counter-items-should-not-routinely-be-prescribed-in-primary-care-guidance-for-ccgs/
  5. Greenhalgh T, Seuren L, Wherton J on behalf of the IRIHS Research Group, University of Oxford. Video consultations: information for GPs. University of Oxford, 2020. Available at: elearning.rcgp.org.uk/pluginfile.php/148915/mod_resource/content/3/NHS_VC_Info%20for%20GPs_v06.pdf
  6. Philpotts E. Babylon launches ‘troll’ attack on doctor who tested AI app. www.pulsetoday.co.uk/news/babylon-launches-troll-attack-on-doctor-who-tested-ai-app/20040206.article (accessed 26 March 2020).
  7. Das S. It’s hysteria, not a heart attack, GP app Babylon tells women. www.thetimes.co.uk/article/its-hysteria-not-a-heart-attack-gp-app-tells-women-gm2vxbrqk (accessed 26 March 2020).
  8. Royal College of General Practitioners. Online consultations in general practice: the questions to ask. London: RCGP, 2018. Available at: www.rcgp.org.uk/-/media/Files/Policy/A-Z-policy/2018/RCGP-online-consultations-questions-to-ask-march-2018.ashx?la=en
  9. NHS England. Using online consultations in primary care: implementation toolkit. London: NHS England, 2020. Available at: www.england.nhs.uk/wp-content/uploads/2020/01/online-consultations-implementation-toolkit-v1.1-updated.pdf

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