Kamal R Mahtani on telephone triage: The scale-up of innovations must have a robust evidence base
13 February 2018
Published in the BMJ Opinion on 13 February 2018
Telephone triage has been hailed as a way to let GPs work smarter, not harder, but is its widespread diffusion justified?
As clinical workloads rise and patients wait longer to see fewer GPs, it’s clear that we need new strategies to meet the present and future needs of primary care. NHS England has described 10 high impact actions as a means to “improve workload and care through working smarter, not harder.” Every GP practice will have to implement at least two of these actions by March 2019. This may include developing new consultation types: for example, phone consultations, which, it’s said, has the potential to free up GPs’ time from face to face consultations and to triage patients. Reports suggest that about two thirds of practices now offer some form of telephone consultation. But is it the universal panacea to improve workload it’s made out to be? The evidence suggests not.
The NHS’s General Practice Forward View describes a series of case studies, including one of a super-partnership community provider in Birmingham, which reportedly handles up to 1300 calls per day, “with most patients now given advice or treatment without visiting a surgery.” Several other NHS England case studies paint a similar picture. However, individual case studies provide limited evidence, and should not be used alone as the basis for policy—particularly when better quality evidence exists.
The ESTEEM study, for example, was a UK based cluster randomised controlled trial that took place across 42 practices in four regions of England. The trial compared the effectiveness of telephone triage, either GP led or nurse led computer supported, with standard care for managing same day consultation requests. The study, funded by the National Institute for Health Research (NIHR), showed that compared with usual care, both forms of triage led to an increase (of about one third) in the number of patient contacts with primary care over the next 28 days. GP triage also increased the total number of patient contacts with a GP, although it reduced face to face contact. The overall duration of clinician-patient contact during the day of the request was no shorter in the triage groups. Telephone triage did not reduce costs either, although no harms were identified and patients found it generally acceptable.
Several practices have invested in phone management support software systems from commercial providers, such as “Doctor First” and “GP Access”—both mentioned in NHS England documents. In another NIHR funded evaluation published last year, 147 English practices that had adopted either of these schemes, taking a “telephone first” approach to triage, reduced the average need for face to face consultations by about one third. However, there was a substantial increase in the use of telephone consultations (from about three to 12 consultations per day per 1000 patients). The authors concluded that on average the approach increased GP workload; although not for all practices. They found no evidence of substantial cost savings or reduced use of secondary care. A significant proportion of patients reported that telephone triage improved the time it took to be seen, while some reported that it made it harder to speak to their preferred GP.
Last month, another NIHR funded study echoed the uncertainty of this innovation. The authors concluded that alternatives to face to face GP consultations, such as telephone consultations, were unlikely to improve universal patient access to primary care, or reduce GP workload. In response, NHS England commented that “This is a tiny study based on data that is almost two years old.” This is a particularly interesting response given that most of the examples provided in the General Practice Forward View are relatively small case studies that are almost two years old.
What can we learn from all this? Three points emerge. Most general practices do not have the capacity to manage growing demand using traditional approaches to access. A large proportion of patients’ concerns could be managed by telephone, and patients appear to be fairly satisfied with this method. However, phone consultations are unlikely to provide universal improvements in GPs’ workload. The characteristics of those practices most likely to benefit are unclear and need further exploration.
Secondly, it is telling that all three of the studies described above were reviewed, approved, and funded by the research arm of the NHS itself. Yet all three produced evidence that contrasted with current NHS policy. As others have previously pointed out, researchers and service leaders must become more engaged with each other to support service changes that are timely, have an evidence base, and meet users’ needs.
Finally, we’ve recognised that many healthcare innovations can struggle in the scale-up and adoption stages. Confirming that the innovation itself has the desired outcome is a critical starting point. Any NHS policy that advocates the mainstreaming of innovations must be based on systematically derived, robust evidence from the outset or risk failing to live up to its promises of improvement.
As Alexander Graham Bell, who invented the telephone, said, “Before anything else, preparation is the key to success.”
Kamal R Mahtani is a GP and deputy director of the Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford. You can follow him on Twitter @krmahtani
Disclaimer: The views expressed in this commentary represent the views of the author and not necessarily anyone else mentioned in this article, the host institution, the NHS, the NIHR, or the Department of Health.
Acknowledgements: Tim Holt, Jeffrey Aronson, Kelly Brendel, David Nunan, and Meena Mahtani for helpful discussions in the preparation of this article.
Competing interests: I receive funds from the NHS NIHR to conduct independent research and chair the NIHR HTA primary care panel. I work in a practice that offers telephone consultations.