Telephone triage in primary care
Changes to the GP contract for 2023-24, designed to improve patient access, mandated an assessment of need at the initial point of contact with a practice.1 This first point of contact is typically in the form of a telephone call – but how should you handle the call?
Telemedicine is a well-established concept, especially where geographic challenges exist in the delivery of health care, and can take many forms – from a simple phone call to a full, online video consultation. Digital delivery of primary care services was accelerated by the COVID-19 pandemic, when remote consultations became the norm. Despite a gradual return to face-to-face appointments, access to general practice has been a thorny subject ever since, prompting Government action to make it easier for patients to contact practices.2 The General Practice Improvement Programme introduced in May 2023 aimed to provide patients with easy and equitable online and telephone access.2
INITIAL CONTACT
That initial phone call to the practice still represents the most widely-used medium for patient access. An important point to make at this stage is that whether that call is considered triage or a consultation, it represents patient contact. Don’t get caught up as to the difference in terms of your approach. The call itself will involve history taking and identification of any signs or symptoms of concern.
A ‘full’ consultation will inevitably lead to a more detailed discussion, whereas triaging is more likely to result in promotion of self-care or sign-posting to a more appropriate service. It may also lead to a further telephone call or the much sought after face-to-face consultation. The same also applies as to whether that first point of contact is a phone call or video consultation – there may be differences in how the consultation is conducted but preparation is the key.
Initial considerations will centre around whether you are conducting the phone call at home or in your place of work. Ensure that you are holding the call in a private place and as free from interruptions as possible. While you may well be used to holding conversations in a busy practice, this may be alien to the patient and may not come across well on the other end of the receiver if the patient is made to feel they are not the sole focus of your attention. Remember, shared decision-making is key and you are less likely to achieve this if the patient is not fully engaged with the process.
Another common frustration for both clinicians and patients is poor telephone reception. Mobile phones may come in all shapes and sizes these days and have more pixels than the Hubble telescope, but a broken call or poor connectivity can lead to misunderstandings, key pieces of information being missed (by all participants) and mutual frustrations, which may impact on the constructive nature of the call.
Is the patient aware they will be getting a call? Does your practice operate a policy of a allocating a specific time for the call or are patients simply told that they will get a call sometime in the morning or afternoon? Expectations need to be clearly set out and understood or the call is likely to get off to a bad start – making your job as a clinician that little bit more difficult to reach an agreed outcome.
Another pitfall to avoid is with your outbound call having ‘caller ID withheld’ as many practices have, and similarly, patients whose telephones are set up to automatically reject withheld numbers. It may be a simple thing but it’s one that causes no end of annoyance to all parties and can result in an urgent clinical need not being met. Many patients will have call-screening set up on their home phones to avoid being sold double-glazing and PPI every five minutes, so I would encourage you to work with this and respect the patient’s decision to have this function enabled – it doesn’t add that much to the call duration.
Providing an estimate as to the likely duration of the call can be tricky. That very much depends on the clinical query and the capacity of the patient/caller to articulate their symptoms or concerns. Be careful not to get dragged into discussing multiple complaints or undertaking a comprehensive consultation if the phone call is for triage purposes. This may be easier said than done but try to remember the purpose of the call.
Be mindful also of the number of patients you are likely being asked to triage on a given day. The tsunami of patient demand and complexity of some cases will leave you tired and as with face-to-face consultations, will make you more prone to error. Be kind to yourself as well as the patients. Take regular breaks and build that into your triage list. Keep hydrated and don’t forget to smell the roses (even in urban practices as I work in) – get some fresh air and stretch your legs every once in a while.
Recording of telephone conversations is a contentious issue, and many practices don’t do this (although calls to the reception team are more likely to be recorded) but if they are, the patient should be made aware of this. Another increasing requirement for many clinicians is to determine whether interpretation services are needed. Please don’t short-cut this step as the potential for misunderstanding is obvious. My preference would be to avoid friends or next of kin acting as an interpreter as the accuracy of what you’re communicating to them (and vice versa) cannot always be assured. And that’s before you consider any potential safeguarding concern. Finally, if you have requested a picture of a particular thing before the call, has the patient sent it to you or is the patient unable to do so? Don’t waste time on a triage call guessing what the patient is trying to describe – either review a picture or bring the patient in.
STRUCTURE OF THE CALL
Start
The opening sequence is often referred to as ‘the technical phase’. First impressions and rapport are harder to establish as you don’t have the benefit of facial expressions or professional dress code. Your formal introduction (including your professional role) should be followed by confirmation that the acoustics are acceptable to the caller. I avoid saying ‘patient’ as you need to confirm with whom you are speaking – is it the patient, next of kin, carer, friend or person with lasting power of attorney? If not the patient, has prior consent been given? Don’t forget those ID checks. Finally, establish the reason for call – what is the central clinical question?
During
If you are anything like me, you can be prone to talking too quickly (my moderated Dundee accent can be tricky at the best of times). Be conscious of pacing and tailoring your dialogue to the person on the other end of the phone. Please be mindful of your tone of voice and that of the caller, as you will need to utilise all of your telephony skills to pick up any obvious emotion, coherency, repetition and background noises.
Can the caller talk in full sentences, do they have any obvious cough or wheeze? Are they alert, orientated and do they engage constructively on the call? What does the caller consider to be the most important thing – they are likely to mention this first and repeat it throughout the call. Avoid closed questioning (as with face-to-face) and do be aware that as you conscientiously scribble notes or type on a keyboard, this may become a distraction to the caller.
Another important point is that of presentation fatigue. It exists on the phone as it does face-to-face. The conveyor belt of presenting complaints relating to sniffles and viral illnesses does not negate the presence of a more sinister underlying pathology. You need to go to work here to ensure you capture all salient points of a clinical history, including risk factors. Don’t forget to give your head a rest during a triage session. It can be relentless.
Closure
As with any other mode of consultation, summarise the discussion and agree an outcome where possible, be it self-care, escalation of care or schedule a further appointment. Check for understanding and most important of all, agree a review mechanism and safety net (as you would do any normal consultation). Do be careful of a common medico-legal pitfall here. All of us clinicians understand the concept of a ‘red flag’ but does the patient? If you make reference to this during your consultation, ensure you are specific as to what these are e.g., change to colour/viscosity of sputum, worsening shortness of breath, persistently raised temperature (even with paracetamol) or worsening wheeze and/or chest tightness. Please make sure you articulate what the specific ‘red flags’ are with the patient and check their understanding of them, and document it.
Clerking
As if you needed any reminder, this should be accurate and contemporaneous and applies to telephone triage as it would any other mode of consultation. Ensure it is of a legally defensible standard. Notarise that it is a telephone call, the purpose for the call and document any non-verbal clues or IT difficulties experienced during it. Detail any follow-up arrangements and, if you feel that a telephone consultation is not appropriate, don’t be afraid to document this and arrange an alternative mode of consultation (including timescale). Any safeguarding concerns should be detailed, including specific risk factors. Think about who else was involved during the call and where the call was being held. This isn’t a science and telephone calls can be limited here. Know the patient and interpret the context – use your clinical skills and professional judgement, just don’t forget to document them.
Communication skills
As you would any other inter-personal skill, develop your telephone manner. Direct the conversation and set the tone. Active listening becomes more important due to the absence of other communication tools permitted by personal contact, so try to avoid talking over the caller. Remember also that you can still demonstrate empathy during triage and on the telephone. Don’t underestimate the importance of this, as you are likely to be the first point of clinical contact for the patient – it can significantly influence the outcome both clinically and personally.
Safety-netting
A cautionary tale: a patient made multiple phone calls for a suspected ear infection but died from a brain abscess.3 Granted, this was during COVID-19 restrictions where face-to-face appointments were limited, but it does serve as a reminder about the risk threshold for reviewing patients in person with repeated and/or multiple contacts with a practice. Sadly, this does not appear to be an isolated incident.4-8 I like the ‘three strikes and you are in’ approach advocated by Rosen and Greenhalgh,9 which works on the premise of two previous remote consultations for a particular complaint necessitates that the patient now needs to be seen. Any clinician involved with triaging should have a good understanding of ‘red flag’ presentations or other clinical symptoms of concern, many of which can be identified on a telephone call. Not always as easy as reviewing a patient in person but telephone triage can act as an effective filter if undertaken properly.
ADVANTAGES AND DISADVANTAGES
Telephone triage is not appropriate for all patients. Those on low incomes, have some form of cognitive impairment or learning difficulty (especially those characterised by sensory/auditory features) may struggle with telephone triage. Think about older people, those with no fixed abode or patient preferences for face-to-face: these things also need to be taken into consideration. Further factors to take on board include the increased time it takes to undertake remote triage compared to face-to-face,10 language barriers, males being less likely to use this mode of triage and whether a remote consultation is appropriate for delivering or discussing bad news. And for those patients with complex clinical needs, has a relationship already been established with a particular clinician or do they have a specific escalation plan necessitating a physical review or assessment?
That being said, telephone triage does allow a degree of flexibility for both clinician and patient and is more accessible than face-to-face. Increasingly restrictive travel costs, transport difficulties and environmental considerations favour telephone triage. Remote consultation may also be more suitable for patients who are housebound or receive support from family members at home. It also permits practices to demonstrate their commitment to a diversity of healthcare provision and the national strategy as outlined previously.
THE FUTURE?
Digital delivery of health care remains a key policy focus within the UK.12 With a stagnation in the increase in GP numbers since 2015, attributed in part to Government recruitment targets not being met,13 alternative models of delivery of primary care services need to be considered.
Triage is essential, not only for those on an emergency/same day list, but also, and more specifically, for identifying those patients who need to be seen in person and those for whom a remote consultation is appropriate. Training for clinicians to undertake remote triage and recognise red flag presentations must now become a core strategy, as is a review of the ratio of face-to-face vs remote consultations. Length of appointment times, the link between primary and secondary care and medico-legal considerations also contribute to the design of telephone triage systems, all of which need to be reviewed with robust clinical data to support this model and the all-important impact it has on clinical outcomes.
REFERENCES
1. NHS England. Changes to the GP Contract 2023/24. https://www.england.nhs.uk/long-read/changes-to-the-gp-contract-in-2023-24/#access-requirements
2. NHS England. National General Practice Improvement Programme. https://www.england.nhs.uk/gp/national-general-practice-improvement-programme/
3. Courts and Tribunal Judiciary. David Nash: Prevention of future deaths report
4. Courts and Tribunals Judiciary. Maurice Leech: Prevention of future deaths report. https://www.judiciary.uk/prevention-of-future-death-reports/maurice-leech/
5. Courts and Tribunals Judiciary. Brian Mottram: Prevention of future deaths report. https://www.judiciary.uk/prevention-of-future-death-reports/brian-mottram/
6. Courts and Tribunals Judiciary. Steven Allen: Prevention of future deaths report. https://www.judiciary.uk/prevention-of-future-death-reports/steven-allen/
7. Courts and Tribunals Judiciary. Stanislaw Zielinski: Prevention of future deaths report. https://www.judiciary.uk/prevention-of-future-death-reports/stanislaw-zielinski-prevention-of-future-deaths-report/
8. Courts and Tribunals Judiciary. Fadhia Seguleh: Prevention of future deaths report. https://www.judiciary.uk/prevention-of-future-death-reports/fadhia-seguleh-prevention-of-future-deaths-report/
9. Rosen R, Greenhalgh T. How can remote GP consultations be safer?. BMJ 2022;24;379.
10. Newbould J, Abel G, Ball S, et al. Evaluation of telephone first approach to demand management in English general practice: observational study. BMJ 2017;358;j4197
11. Javid S. Speech on the plan for digital health and social care at the Policy Exchange; 29 June 2022
https://www.gov.uk/government/speeches/health-and-social-care-secretary-speech-to-policy-exchange
12. British Medical Association. Pressures in general practice data analysis; 28 September 2023. https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressures-in-general-practice-data-analysis
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