We’re enjoying the sunshine, working a lot from home, and asking, how much has changed in primary care in a year, and how much hasn’t?
It seems quite a lot, as this sounds at face value rather like what we’ve been saying for ten years or so. NHS England planning guidance assumes that “total triage” should be embedded, and they mean permanently. Ah, but in the previous paragraph, they want 50 million more GP appointments! Well, that’s still based on supply led thinking, and I would so love to see a change of perspective, beginning with understanding demand.
Demand led thinking starts with the patient request, infinitely variable in every detail but conforming to quite predictable patterns both of timing and content. When access is constrained, it can be difficult to measure demand (because patients can’t get through), but trying to manage slots risks the wrong kind of supply and the wrong timing.
Unfortunately recent efforts to measure supply, requiring the generation of appointments, have served to exacerbate the problem by focussing minds on the numbers. “What gets rewarded, appears to get done. What gets punished, appears not to get done.” Human nature hasn’t changed, I think we can be pretty sure of that.
Yet the “total triage” tag has generated opposition, Helen Salisbury asking in BMJ “Triage is for emergencies. Can we start planning for a time when it’s no longer necessary?”
The origins of triage lie in war and emergency, from the French trier, to sort or select, and so “routine triage” may sound like an oxymoron. Before looking for a different word, it’s worth considering what is intended and what is the alternative.
The point of primary care is to cope with undifferentiated demand, and the NHS promise is for patients to have universal and free access. So long as they provide that access to their patients, GMS gives GPs full professional discretion as to how they do so. Reality bites because there will never come a time when there is sufficient capacity to give every patient exactly what they want, when they want, with whom they want and in the way they want.
As we’ve seen time after time, if patients have completely unlimited access to book a face to face consultation, while many use it well, some abuse it, but the problem is that you can’t know in advance who they are. More often, it’s not deliberate abuse but simply not knowing what’s needed, or from which clinician. Human nature again plays a part, scarcity ramping up demand. If it’s a long wait to get an appointment, I’d better book early “just in case”, and while medical need is unchanged, demand appears to rise.
That alternative reality inevitably means that patients must queue for as long as it takes, and we well remember the four, five and six week waits for appointments. I’m glad to say that particular noise has much abated this year, and however it is labelled, it’s thanks to GPs changing how they work. Still, it’s worrying to hear now of some patients waiting two weeks for a telephone call, which could still be called triage but is firmly based in a supply led system.
I suspect that much of the opposition to triage is that it is seen as a bolt-on rather than thinking and system change, which then means a gruelling experience of the process. Zoom fatigue, or telephone fatigue, is a reality. We need variety in the day, and we need human contact. Equally, wading through lengthy questionnaire forms is tiring on the brain both for patient and GP, where with too much information the first task is to sort the wheat from the chaff.
Returning to the goal of the system, we want to meet the patient’s need, in the most efficient way for the GP. Starting the process online is the best way we know for the vast majority of people, as in other spheres of life. We’ve found trusting the patients to use their own words in askmyGP has three key advantages:
– it’s simple and the computer never says no, so typically 70 – 80% of all patients will use it online.
– it’s fast to assign to the right clinician
– the GP has sufficient information to know the best approach, even if that needs a change later on. Time is only committed appropriate to need.
It’s never easy to change language and I don’t know whether “sort” is an improvement on “triage”, which at least has a medical association. Perhaps we should settle for describing the alternative as “unsorted”. I don’t think anyone wants to return to the waste of precious time seeing the wrong patients while the right patients were hanging on the phone trying to get through. GPs tell me a year since making the change, it came at exactly the right time and we’re never going back.
Triage – do we need a new word?
We’re enjoying the sunshine, working a lot from home, and asking, how much has changed in primary care in a year, and how much hasn’t?
It seems quite a lot, as this sounds at face value rather like what we’ve been saying for ten years or so. NHS England planning guidance assumes that “total triage” should be embedded, and they mean permanently. Ah, but in the previous paragraph, they want 50 million more GP appointments! Well, that’s still based on supply led thinking, and I would so love to see a change of perspective, beginning with understanding demand.
Demand led thinking starts with the patient request, infinitely variable in every detail but conforming to quite predictable patterns both of timing and content. When access is constrained, it can be difficult to measure demand (because patients can’t get through), but trying to manage slots risks the wrong kind of supply and the wrong timing.
Unfortunately recent efforts to measure supply, requiring the generation of appointments, have served to exacerbate the problem by focussing minds on the numbers. “What gets rewarded, appears to get done. What gets punished, appears not to get done.” Human nature hasn’t changed, I think we can be pretty sure of that.
Yet the “total triage” tag has generated opposition, Helen Salisbury asking in BMJ “Triage is for emergencies. Can we start planning for a time when it’s no longer necessary?”
The origins of triage lie in war and emergency, from the French trier, to sort or select, and so “routine triage” may sound like an oxymoron. Before looking for a different word, it’s worth considering what is intended and what is the alternative.
The point of primary care is to cope with undifferentiated demand, and the NHS promise is for patients to have universal and free access. So long as they provide that access to their patients, GMS gives GPs full professional discretion as to how they do so. Reality bites because there will never come a time when there is sufficient capacity to give every patient exactly what they want, when they want, with whom they want and in the way they want.
As we’ve seen time after time, if patients have completely unlimited access to book a face to face consultation, while many use it well, some abuse it, but the problem is that you can’t know in advance who they are. More often, it’s not deliberate abuse but simply not knowing what’s needed, or from which clinician. Human nature again plays a part, scarcity ramping up demand. If it’s a long wait to get an appointment, I’d better book early “just in case”, and while medical need is unchanged, demand appears to rise.
That alternative reality inevitably means that patients must queue for as long as it takes, and we well remember the four, five and six week waits for appointments. I’m glad to say that particular noise has much abated this year, and however it is labelled, it’s thanks to GPs changing how they work. Still, it’s worrying to hear now of some patients waiting two weeks for a telephone call, which could still be called triage but is firmly based in a supply led system.
I suspect that much of the opposition to triage is that it is seen as a bolt-on rather than thinking and system change, which then means a gruelling experience of the process. Zoom fatigue, or telephone fatigue, is a reality. We need variety in the day, and we need human contact. Equally, wading through lengthy questionnaire forms is tiring on the brain both for patient and GP, where with too much information the first task is to sort the wheat from the chaff.
Returning to the goal of the system, we want to meet the patient’s need, in the most efficient way for the GP. Starting the process online is the best way we know for the vast majority of people, as in other spheres of life. We’ve found trusting the patients to use their own words in askmyGP has three key advantages:
– it’s simple and the computer never says no, so typically 70 – 80% of all patients will use it online.
– it’s fast to assign to the right clinician
– the GP has sufficient information to know the best approach, even if that needs a change later on. Time is only committed appropriate to need.
It’s never easy to change language and I don’t know whether “sort” is an improvement on “triage”, which at least has a medical association. Perhaps we should settle for describing the alternative as “unsorted”. I don’t think anyone wants to return to the waste of precious time seeing the wrong patients while the right patients were hanging on the phone trying to get through. GPs tell me a year since making the change, it came at exactly the right time and we’re never going back.
Harry Longman
Photo: Otis Historical Archives Nat’l Museum of Health & Medicine
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