Practical case study: Development of a Telephone Triage Service
St Lawrence Surgery, Worthing, West Sussex
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Background
The driver behind this initiative was to reduce face-to-face consultations for general advice and for guidance on minor ailments and to make sure that patients are signposted to the most appropriate member of the team and in doing so to offer a more responsive service. |
Once the telephone triage idea was agreed in principle it was discussed in detail at our practice team meetings. This was to ensure that everyone clearly understood the rationale for the project, how it would affect them and the contribution that they could make to ensure its success as well as identifying local suppliers. As a first step, all our practice nurses attended a triage course, which cost £200. The new system was piloted initially.
How it works in practice
When patients call the surgery our receptionist proactively asks them “is it something our triage nurse or doctor can help with over the telephone?” If they say yes, their details are taken and our target is for either our triage nurse or triage doctor to respond within one hour. If they say no, they are booked in with the doctor or nurse for a face-to-face consultation.
We actively promoted this new service to our patients through:
- Posters in the waiting room
- Information on our website
- Messages on prescriptions
- Patient participation groups
- Via district nurses and other community based team members
- During every telephone call
We then collected feedback from patients via satisfaction surveys, direct comments to doctors and staff and written comments in our book.
Key learning and benefits
During our pilot week, we realised that we could not force triage on all our patients and they still needed to have the choice of a one-to-one consultation so we revised our procedures to take this into account. We also organised for a GP and nurse to sit opposite each other for education and support and ensured that everyone in the practice understood the importance of the project.
We have realised that nurse triage is a very important service and one that patients respond to well. Often patients are more than happy, if not happier to talk to a nurse with the proviso that they can see the doctor or nurse of their choice for appointments.
Benefits:
- Face-to-face consultations for minor ailments have reduced
- We have just one GP and one nurse triaging patients
- We can put two telephone consultations into a ten minute slot
- We have hit our access targets easily
- We have eliminated patient complaints re not being able to make an appointment
- We have very positive feedback from our patients
- Excellent for extra busy times such as flu vacs
- Other staff members can help with telephone triage during DNAs.
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Making nurse-led care for minor ailments a reality
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Background
Dr Simon Fradd has worked at a practice in Nottingham for the past two decades and also now runs two practices in East Dulwich and Camberwell. He is a champion of promoting self care for minor ailments and his view is that extending nurse roles has a dramatic impact on capacity within general practice. The key driver behind this initiative was Simon’s firmly held belief that his 'first-contact nurses' which is what he calls his nurse practitioners can significantly reduce GP consultations for minor ailments. |
Working in practice
Nurse practitioner Sonia Hall was closely involved with setting up the system and has this advice. “The key to successfully introducing a nurse led triage system is ensuring that your patients really understand why you are doing it and that it is all about improving the service you can offer them. The first action we took was to send all our patients a letter outlining how the scheme would work in practice and the benefits to them. We also got our patient participation group, which is very active anyway involved before we ran a trial for two months.”
Nurses at the East Dulwich practice, which has around 7,800 patients, have been handed control of all same-day GP appointments and triage all callers. Now when patients call the practice they are automatically referred to a ‘first contact nurse or triage GP for a four minute telephone consultation. “During that time we have access to their records which of course helps us to put their call into context. Once we have eliminated all the red flags we work out if they are calling about something that requires a consultation and if that is the case we will make an appointment. Otherwise we will reassure the patient that their symptoms are quite normal and advice with home care/OTC options,” Sonia explains.
Key learning and benefits
- As a result of our trial period we increased the time allowed for each telephone consultation from 3.5 minutes to 4 minutes with a half hour catch up built in at the end of each session.
- We would recommend introducing the system during the summer when demand is lower and so that it is fully embedded by the busy winter season
- We created extra clinical capacity the week before we introduced the system so that we could start with a blank canvas and there was no backlog
- We had team briefings every lunchtime for the first two weeks so any problems were ironed out without delay
- An audit of more than 1,000 calls showed that the nurses were able to resolve half of all the issues on the telephone.
- Of the rest, some attend for face-to-face appointments with the nurse or another member of the practice team. Just 13 per cent end up having a face-to-face GP consultation.
- GPs can spend more time on complex consultations and in addition can devote one appointment per hour to offer advice to their nurse practitioners.
Sonia’s top tips:
- Sore throats are our one of our greatest challenges – patients find it difficult to believe that an antibiotic isn’t the answer. We invite them in and take a swab with results within 48 hours proving nine and half times out of ten that it was a virus.
- With more reluctant patients it’s a great opportunity to invite them in for a general health check as part of your focus on maintaining health.
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Introduction of a Self Test Blood Pressure Machine
Dawlish Medical Group, Devon
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Background
With today’s focus on helping patients to keep well and look after themselves Dawlish Medical Group decided to install a freestanding machine that would enable patients to test their own blood pressure. This service is freely available so patients who are passing can just ‘pop in’ as part of their own self care or blood pressure readings can be taken before a consultation and the results reviewed.
Working in practice
As Janine Payne, Practice Manager explains, “It’s a great service to offer our patients and has very wide application from the ‘worried well’ who just want to check up on themselves to people with known high blood pressure conditions. Equally we have young women running out of the contraceptive pill who can take their blood pressure and if they are within normal limits we can give them a prescription for a month.” |
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The cost of the machine is around £2,000 but Dawlish has a very active League of Friends that funded the purchase. The machine is very simple to use. The reading is immediate and arrives on a slip of paper, the practice ask the patient to put their name, date of birth and smoking status on the slip so their computer record can be updated and GPs can be alerted to any problems.
The risks of installing the machine included:
- Abuse of the machine as it is housed in a public area
- Children keen to play around with it
- Cost of maintenance is high
- Hygiene – there is a risk of cross infection
Key learning and benefits:
The blood pressure machine is an expensive item that needs to be respected and used carefully if it is to provide true blood pressure readings for patients. Feedback from our patients is very positive particularly as we have a high proportion of over 65s in our population. It’s not an alternative to seeing a health professional but it is a really effective add on service that underpins the Government’s call to individuals to take greater responsibility for their own health issues.
- Patients enjoy being able to take their own blood pressure
- Results are fed into patient records
- We can use it to provide emergency contraceptive pills
- We are proactively promoting blood pressure monitoring
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The Explanation Prescription
The Oulton & Marine Surgeries in Lowestoft
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Background
The Oulton & Marine Surgeries in Lowestoft were concerned that around a quarter of their GP consultations were concerned with minor ailments plus the fact that so many patients expected to receive a prescription. In a bid to address this issue and to help their patients to understand more about the different options available to them the practice team looked at different ways to work with their patients on a practical basis. Underpinning their thinking was the knowledge that time invested talking to patients pays dividends because it’s important to understand patients’ real concerns and personal agendas.
One of the key groups identified by the practice as having a significant effect on the way families self care is mothers and grandmothers so they decided to focus on this group. |
Working in practice
The practice works hard with young mothers to help them understand how best to look after their own and their children’s health, sometimes reversing patterns of behaviour of 20 years or more. According to Dr James Kennedy GP Principal at the practice, “we decided to create what we have called an ‘explanation prescription’ and the following example shows how it works in practice.”
- A young mum whose own mother had brought her in as a child every year with ‘her annual tonsillitis doctor’ believed would only get better with antibiotics
- Based on her own experience, the young mum began to bring in her children every time one of them had a sore throat.
- We explained that most cases of tonsillitis are viral – and more importantly, proved this to her by examining the child’s throat over three visits and taking a swab where necessary,
- We were able to explain and demonstrate, to her that unless the child had some clear clinical signs of a bacterial infection (pyrexia, pus in tonsils, etc) antibiotics would be ineffective and it would be better to self care
- Now not only does she manage her children’s sore throats herself but she has educated her mother and sisters and improved their management of sore throats.
Key learning
- What most people want is an explanation and advice and to know it’s OK to ask simple, sensible questions that will be answered accurately.
- All members of the team need to have a consistent approach and strive to have the same conversation.
- The approach of explanation prescribing is suitable for all types of consultations, including telephone consultations.
Benefits
- Reduced minor illness consulting and earlier recognition by patients and carers of atypical and serious illness
- Investment in an explanation prescription has very positive benefits for doctors and patients.
Top tips
- Most people respond very positively to a reasonable explanation as long as it addresses their underlying fears, concerns and health care beliefs.
- Maybe it does take a minute or two longer to give than a medical prescription but those few minutes often save hours in the future
- If you improve the relationship with your patient, then it’s time well spent.
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