Practices are being expected to do more with the same or fewer resources. Effectively managing same-day appointments is becoming more important than ever, and nursing teams are being expected to play an ever greater role, say Jeremy Dale and Lynn Shrimpton.
One in five GP consultations involve minor ailments that patients could treat themselves – that’s 57 million consultations in England alone, more than an hour a day for every GP.1 Practices face the growing pressures associated with an ageing population and the management of increasing numbers of patients with complex and long-term conditions.
Along with the changes resulting from the white paper, this increasingly becomes time that practices can ill afford. With the need to make cost savings across the NHS, the pressure will only grow and more effective ways to manage demand for same-day appointments will be needed.
Many practices have already started to introduce new ways of working to manage demand for same-day appointments. Options include having a nurse or GP available for triage, either face-to-face or over the phone, with receptionist prioritisation also becoming more commonplace.
The evidence regarding feasibility, safety, user acceptability, costs, and workload implications of telephone triage is mixed. Most derives from service models involving nurse triage; less research has been carried out addressing the value of GP telephone triage. Previous studies suggest that around 50% of nurse-triage calls may be handled by telephone advice alone, but most have been small or focused on out-of-hours care.2
Telephone triage and advice has been shown to be acceptable to most patients, offering reassurance and advice without the inconvenience and disruption of a surgery appointment. Use of telephones is now virtually universal in Britain, and telephone consultations have quadrupled from 3% workload in 1995 to 12% in 2008.3
There are growing concerns about how to ensure advice is given reliably and that risk is managed, especially if less experienced nurses are undertaking telephone consultation. Telephone consultation intrinsically involves risk because of the lack of visual cues. Paradoxically, it often lacks the structure, consistency and quality of documentation that is the norm for face-to-face consultations, leaving the practice and the practitioner at risk of complaint.
Skills and safeguards
The quality of telephone consultations has been found to be variable, even within the same practice, whether by practice nurses or GPs.4 Information gathering is often incomplete when delivered without computerised decision support, relying only on clinical protocols. Inappropriate advice may result from poor communication and decision making, sometimes with serious adverse outcomes.
Key skills and processes are required for an effective telephone service, whether for triage alone or full clinical assessment and advice, with or without computerised decision support. Out-of-hours services generally have explicit standards for telephone consultation, ensuring that staff have been appropriately trained and that the quality of consultations, including documentation, is defined.
Without such safeguards it may be difficult to defend the quality of telephone consultations. Patients increasingly turn to lawyers when dissatisfied with advice they have been given. Practices need to be prepared to defend their procedures as being of a demonstrable standard and quality.
Practice-developed protocols can enhance the quality of consultations, but there is considerable work involved in developing and maintaining them to ensure that they are evidence-based.
However, computerised decision support systems are now commercially available that are specifically designed for general practice, providing up-to-date, evidence-based guidance and support to cover the full range of patients requesting a same-day appointment. Routinely updated, such systems also support systematic documentation and reporting of the call content, so producing a medicolegally defensible record that can be easily audited.
Ensuring safe, effective processes for patient prioritisation at reception
Reception is potentially the point of highest risk, requiring identification of patients needing urgent attention. Written protocols or templates can usefully guide receptionists and may be effective, especially for straightforward cases.
Urgent problems, however, often present incompletely or vaguely and may get missed at reception because they “don’t fit” the protocol. It is difficult to audit and quality-assure reception prioritisation, as the history taken is seldom recorded or fully documented.
Paper protocols can be helpful in some cases. However, electronic decision support tools guide receptionists and support documentation through recording a few basic symptom-related questions to help distinguish between, for example, the patient who may have epiglottitis rather than a simple sore throat, or a subarachnoid haemorrhage rather than a tension headache. This type of tool embeds within major GP systems, ensuring that documentation of reception assessments is incorporated into the patient’s record, guiding care pathway selection and minimising risk of miscommunication or error.
Introducing nurse telephone triage, assessment and advice
It is worth reminding ourselves here of the NMC code of practice, which emphasises issues that need to be considered when introducing wider issues of telephone triage. Specifically, the nurse needs to be able to demonstrate that they have made use of the best available evidence in the care they provide, and that any evidence given over the phone reflects best practice. Clear and accurate records, in sufficient detail, for all telephone consultations, must be kept to ensure that the decisions made and advice given can be defended, should this later become necessary. The following issues may need to be considered:
- First, being clear about the aim: this might be to quickly and safely triage patients either to a timely appointment and/or offer telephone assessment leading to appropriate self-care management advice, freeing up appointments for other, more “essential”, work.
- Publicising and explaining the new systems to patients in a way that is positive and secures engagement.
- Making use of protocols that are structured to enable consistent, safe prioritisation on the telephone, which can be easily audited to demonstrate intervention against an explicit quality standard.
- Managing the who/when/what/why in relation to updating protocols to ensure that they have been regularly reviewed and updated when the evidence base or guidance has changed.
- Agreeing documentation standards for calls that define the level of detail required in the patient record. Identify (as a minimum) that “red flag” issues have been considered and addressed, ensuring documentation of calls has sufficient detail to withstand scrutiny.
- A practice nurse in the UK was suspended for six months in August 2008 for failing to keep accurate records of the care provided to a patient.5 This highlights the need for consistent and accurate record keeping at all times.
- Making use of consistent criteria to determine how soon patients will be seen, or offered self-care advice.
- Routinely providing and documenting the delivery of consistent “safety-netting” advice and that the patient is safe and happy to manage with self-care advice.
- Ensuring that you receive appropriate training in the specifics relating to telephone triage and consultation; a new set of skills is required to compensate for the loss of visual cues.
- IMS Health. Driving the Self Care Agenda. Available from: www.imshealth.com 2008
- Lattimer V, George S, Thompson F et al. Safety and effectiveness of nurse telephone consultation in out of hours primary care: randomised controlled trial. BMJ 1998;317:1054-9.
- NHS Information Centre [internet homepage]. Available from: www.ic.nhs.uk/about-us
- Carson D, Clay H, Stern R. Urgent Care – a practical guide to transforming same-day care in general practice. Primary Care Foundation; 2009.
- Nursing and Midwifery Council (NMC). For the record. Available from: www.nmc-uk.org/Documents/NMC-News-NMC-Update/nmcNewsIssue29August2009.pdf