practice management

As NHS Direct expands nationwide, one former fundholding GP practice introduced its own telephone triage system in a bid to reduce pressure on staff. Mark Vorster explains

Pressures on general practice have been increasing steadily in recent years. It is necessary to consider new ways of working in order to respond to patients' needs and maintain staff morale.

Increasing the range of responsibilities of practice nurses to include telephone triage is one way forward. If the GP surgery provides a truly responsive service it will regain its rightful place as the first port of call, rather than being used as a local accident and emergency department. Patients who need to see a doctor will be able to see one more quickly because same-day appointments will be allocated according to clinical need. Doctors will also have more time to deal with these patients. Improved education in self-help for patients is also an investment for the future.

Our seven-doctor practice, formerly fundholding, has a list of 13,000 patients and employs a practice manager, assistant practice manager, six receptionists (four part-time), two nurses and two computer administrators. We ran a telephone triage scheme from July 1998 to March this year, funded by£10,000 from East and North Hertfordshire health authority and£3,000 from fundholder savings. We are planning to start it again this month and hope to expand it.

The service was staffed by two experienced G-grade practice nurses from 8.30am to 10.30am on Mondays and from 8.30am to 9.30am on other weekdays. An F-grade nurse was employed for six hours a week to cover the time the other nurses were working on the triage scheme. Patients were informed of the scheme in special leaflets, as well as by the receptionists when they visited the surgery. It was also mentioned in our practice leaflet.

Those phoning during the scheme's hours and requesting a same-day appointment had their details taken by a receptionist. A nurse then phoned them back. The nurses, who insisted on clear guidelines, used the Telephone Advice System software which is used by NHS Direct and large GP co-operatives.

Data was collected to assess the management of patients before and after triage was introduced. Numeric data can be easily obtained from the software programme. There was feedback between GPs and the nurses on a case-by- case basis. Discussion about individual cases was carried out to provide continuous improvements. Patient feedback was encouraged.

The scheme has resulted in more patients who request same-day appointments receiving telephone advice, and fewer face-to-face contacts. Before the scheme was introduced, 10 per cent of patients requesting same-day attention received telephone advice. This increased to 34 per cent when triage was in operation. The number of patients given a same-day appointment was reduced from 76 to 57 per cent, and the number of home visits was also reduced from 12 to 6 per cent.

The major effect on overall workload was to reduce the number of GP appointments required. An audit showed that follow-up contact after telephone advice alone was no more likely after the triage scheme started than before.

Staff views

The practice team was content on the whole, although changing roles produced initial strains and the two nurses involved admitted to suffering some stress. But they did feel reassured that a GP was on site to offer advice if needed. As a result of the scheme, doctors had more time to give patients and felt that the quality of consultations improved.

The practice nurses were satisfied that the triage aspects of their job, which they carried out anyway, have now been formalised. We believe that more appropriate use was made of available resources than before triage started. The effect would have been more marked if the system had been in operation for more hours per day.

Patients' views

We have had no complaints about the scheme and feel that patients are content to be able to speak to a health professional when they telephone. Hertfordshire University is carrying out a formal evaluation.

There is no doubt that triage changed the way patients requesting same- day attention were handled. The predominant trend was towards more advice- giving and less face-to-face contact overall.

There was an insignificant patient return rate following telephone advice. We hope this demonstrates that we were supplying a quality service that patients were happy with.

We would like to continue with the system and expand it to cover more hours as a method of maintaining an effective service for our patients.

Lessons for the future

There are grounds for suggesting that any telephone access lines should build on the present GP service, with appropriate funding, rather than presenting a new system which is unfamiliar to patients.

Primary care groups could share a GP-based nurse telephone triage service, producing savings on software, training and management. Linking practices together using computer systems could save on nursing-time costs. In addition, doctors might be able to make use of freed time by carrying out additional research or by generating income.

We feel that this sort of telephone triage system is a method of patient management worthy of further investigation for the NHS.