Phone consultations do not reduce GP workload
Over-the-phone medical consultations “don’t cut the pressure” on busy GP surgeries, BBC News and The Daily Telegraph report.
They were reporting the findings of a two-year study into the effectiveness of phone consultations with a GP or a nurse instead of face-to-face appointments.
Telephone consultations, or triage, are increasingly used to try and manage workload in general practice and cut down on unnecessary consultations.
Around 12% of GP consultations are now done over the phone – representing a four-fold increase over the last 20 years.
Researchers looked at how many follow-up contacts were made with the GP surgeries over a 28-day period after a patient called to request a same-day appointment.
The study, which included 42 practices caring for nearly 21,000 patients, found that instead of saving time and money, the phone service actually increased the workload.
People who had received a call from their GP or nurse made significantly more contacts with health professionals at the surgery over the following 28 days (average 2.65 and 2.81 contacts respectively) compared with patients in the surgeries providing usual care (1.91 further contacts).
Following a call from the GP, there was a decrease in the number of face-to-face consultations with the GP, but the number of further telephone conversations increased ten-fold.
The healthcare costs incurred by the surgeries operating a phone consultation service over the 28 days was roughly the same as those who didn’t.
It is worth noting that although the phone service did not reduce the workload for GPs, the study found no difference in terms of quality of care.
This is a well-designed randomised controlled trial that provides much needed information on the value of telephone triage by GP surgeries – an area where evidence has been lacking.
As the researchers conclude, telephone triage may well be useful in helping delivery of care in general practice, but the possible implications for the whole system should be assessed when considering introducing such a scheme.
Where did this come from?
The study was carried out by researchers from University of Exeter Medical School and the Universities of Oxford, East Anglia, Bristol and Warwick. Funding was provided by the National Institute for Health Research Health Technology Assessment Programme, and the study was published in the peer reviewed medical journal, The Lancet.
The media’s reporting is a fair representation of the findings of this study. However, it is important to note that reports of telephone triage being “ineffective” should not be wrongly interpreted to mean “poor patient care”. This study examined effectiveness mainly in terms of GP surgery workload and costs. It found no difference in terms of the quality of health care provided.
What kind of research was this?
This was a randomised controlled trial spanning two years, which looked at the clinical and cost effectiveness of telephone triage by GPs or nurses when patients ring their GP to request a same-day appointment.
Telephone triage involves a GP or nurse calling a patient at home to assess their symptoms, offer advice and judge whether a consultation in person is needed. This method is increasingly used to try and manage workload in general practice and cut down on unnecessary consultations.
The researchers report that currently around 12% of GP consultations are done over the phone – an increase of four times the level seen around 20 years ago. Most studies assessing the effectiveness of telephone triage have looked at nurse triage, but few studies have looked at the value of GPs calling. Despite this lack of evidence, many practices operate GP or nurse triage systems.
This study therefore aimed to provide further evidence on whether GP or nurse-led telephone triage are of any benefit compared with usual care for patients ringing to request same-day appointments.
What did the research involve?
The study randomised 42 GP surgeries between March 2011 and March 2013, all of which were operating a triage system. The practices were randomly assigned to operate GP triage (13 practices), nurse triage (15 practices) or usual care (14 practices).
Eligible patients were all those phoning to request a same-day, face-to-face GP consultation, unless they were seeking emergency care. Teenagers between the ages of 12 and 15 were excluded due to parent confidentiality issues (parents completed follow-up questionnaires for children under 12; those aged 16 and over completed them themselves).
Prior to the study period, the intervention practices making doctor or nurse triage calls were trained in delivery of triage by an expert trainer.
During the study period receptionists in the intervention practices asked for a contact number and advised that a GP or nurse would call the patient within one to two hours. The doctor or nurse recorded the start and end times of each phone consultation and could give self-care advice, book the patient in for a face-to-face appointment or a further telephone appointment with a doctor or nurse.
In usual care practices, care continued as normal when the patient rang for an appointment. The patient (or parent if it was a child) was told that a questionnaire reviewing their care experience would be sent to them four weeks later, and they were asked for consent to review their medical records about 12 weeks later (to allow all relevant information following on from their initial consultation to reach the notes).
The main outcome examined was GP practice workload – that is the total number of general practice contacts taking place in the 28 days following the individual patient’s initial appointment request and triage call. This included further contacts with a GP, nurse or other health professional (face-to-face, telephone, home visits, or mode unspecified), or attendances at walk-in centres or A&E.
Other outcomes examined included specific patient health outcomes, such as deaths or urgent hospital admissions in the week following the triage call, and the patient’s care experience reported in the questionnaire, such as overall satisfaction ratings.
The economic evaluation compared costs incurred in the two interventions and usual care practices over 28 days.
What were the basic results?
During the study, each of the three groups of practices made around 7,000 triage calls or equivalent in those allocated to usual care.
Looking at the main outcome of individual patient contacts in the 28 days following their initial appointment requests, there was an increase in the number of further contacts by people who received doctor or nurse triage compared to those who received usual care in the 28 days after the initial appointment request.
The average number of healthcare contacts in the following 28 days was 1.91 by patients in usual care, 2.65 by patients in GP triage and 2.81 by patients in nurse triage.
This meant that the number of patient contacts that each person made after GP triage was increased by a third compared to usual care (RR 1.33, 95% CI 1.30 to 1.36). The increase following nurse triage was even greater: a 48% increase in the number of contacts following nurse triage compared with usual care (RR 1.48, 95% CI 1.44 to 1.52). There was also a statistically significant, but small, increase in the number of consultations in practices assigned to nurse triage compared with practices assigned to GP triage (RR 1.04, 95% CI 1.01 to 1.08). Following GP triage there was a decrease in the number of face-to-face consultations in the following 28 days compared with usual care, but the number of further telephone conversations went up ten-fold.
There was no significant difference in the number of hospital admissions between groups, though as the researchers acknowledge, numbers of admissions were small in all groups. There were only eight deaths overall across all groups in the study, and none were considered to be related to the care given.
Patients in the GP-triage group reported that it was easier to get through to the practice on the telephone compared with usual care. Patients receiving nurse triage generally had lower satisfaction levels than the other groups and considered their care less convenient.
The total GP surgery costs were roughly the same in the three groups: £75.41 (per patient) in usual care practices, £75.21 in GP triage practices and £75.68 in nurse triage practices.
How did the researchers interpret the results?
The researchers conclude that “Introduction of telephone triage delivered by a GP or nurse was associated with an increase in the number of primary care contacts in the 28 days after a patient’s request for a same-day GP consultation, with similar costs to those of usual care”.
They consider that telephone triage might be useful in helping delivery of care in general practice, but the possible implications for the whole system should be assessed when considering introducing such a scheme.
Conclusion
This is a well-designed randomised controlled trial assessing the cost and effectiveness of GP or nurse led telephone triage compared with normal face-to-face consultations for patients requesting same-day appointments.
It found that GP or nurse-led triage didn’t cut GP workload, and the healthcare costs incurred by the GPs over the 28 days were essentially the same. This may be surprising for some: as the researchers point out, many GP surgeries have implemented triage, at least in part, to reduce an increasing workload.
However, this study suggests that this rationale may be wrong. People who received a call from their GP or nurse made significantly more contacts with health professionals at the GP surgery over the following 28 days compared with patients in the surgeries providing usual care. Following a call from the GP there was a decrease in the number of face-to-face consultations with the GP, but the number of further telephone conversations increased substantially.
It is worth noting that media reports that GP telephone triage is “ineffective” should not be wrongly interpreted to mean that patients “receive poor care”. The main outcome this study examined was whether telephone triage had any effect on workload in terms of the number of further healthcare contacts made.
For the main patient health-related outcomes examined, there was no difference between any of the groups allocated to GP or nurse triage or usual care. For example, there was no difference in the number of hospital admissions in the following 28 days (though the numbers of admissions were very small in all groups so this may not be a reliable comparison). Also, there were only eight deaths overall across all groups in the study, and none were considered to be related to the care given.
Further studies exploring other patient health and satisfaction outcomes with telephone triage would be valuable to see whether triage has any meaningful benefits or drawbacks in terms of patient care.
Overall, this study provides useful evidence on the value of telephone triage by GP surgeries in terms of workload and costs. As the researchers aptly conclude, telephone triage may well be useful in helping delivery of care in general practice, but the possible implications for the whole system should be assessed when considering introducing such a scheme.
