Management of same-day appointments in primary care
Authors: Justin Osborn, Matthew Thompson
Journal: The Lancet (2014)

Primary care doctors worldwide could be forgiven for feeling stuck in the middle of a supply and demand crisis, with the need to balance increasingly complex care for patients with provision of same-day access for all. Optimisation of workflow within primary care is essential to maintain this balance, so that the entire primary care team can be used effectively, while providing safe, cost-effective care that satisfies patient demands. Demonstrations of access to primary care are often viewed by policy makers as a measure of overall success (or failure) of care. The UK Government has repeatedly prioritised improved access to general practitioners (GPs), partly in response to rising pressure on emergency departments.1National Health Service (NHS) EnglandTransforming urgent and emergency care services in England: urgent and emergency care review.http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.FV.pdfDate: Nov 13, 2013Google Scholar Implementation of the Affordable Care Act in the USA has further emphasised shortages of primary care providers needed to deal with increased demand.2US Department of Health and Human Services—Health Resources and Services AdministrationProjecting the supply and demand for primary care practitioners through 2020.http://bhpr.hrsa.gov/healthworkforce/supplydemand/usworkforce/primarycare/Date: November, 2013Google Scholar Indeed, reports of delays in access to care at a Veterans Administration Centre in the USA led to the resignation of Veterans Affairs Secretary General Eric Shinseki, and to national recommendations to improve access.3VA Office of Inspector GeneralVeterans Health Administration: interim report. Review of patient wait times, scheduling practices and alleged patient deaths at the Phoeniz VA Health Care System.http://www.va.gov/oig/pubs/VAOIG-14-02603-178.pdfDate: May 28, 2014Google ScholarJohn Campbell and colleagues' randomised controlled ESTEEM trial,4Campbell JL Fletcher E Britten N et al.Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis.Lancet. 2014; (published online Aug 4.)http://dx.doi.org/10.1016/S0140-6736(14)61058-8Google Scholar reported in The Lancet, compared three approaches to telephone triage of patients seeking same-day (but non-emergency) appointments in the UK: phone triage by GPs, phone triage by nurses using computer decision support, and usual care. Outcomes measured in 16 211 patients from 42 practices included primary care workload in the 28 days after the first same-day request, and costs and patient satisfaction. Practices that introduced GP triage had a 33% increase in the mean number of patient contacts per person over 28 days compared with usual care (2·65 [SD 1·74] vs 1·91 [1·43]; rate ratio [RR] 1·33, 95% CI 1·30–1·36), and those introducing nurse triage had a 48% increase (2·81 [1·68]; RR 1·48, 1·44–1·52).However, introduction of GP triage reduced the number of face-to-face contacts with GPs by about 40% (RR 0·61, 95% CI 0·54–0·69), and nurse triage reduced the number of GP face-to-face contacts by 20% (0·80, 0·71–0·90), although these findings were offset by far more phone contacts with a GP (an increase of ten times) or nurse (an increase of 100 times). Therefore, to some extent, the differences in numbers and types of contacts between practices in the three groups represented redistribution of the workload, and all three groups had similar costs (approximately £75 per patient). The fact that GP or nurse triage led to increased numbers of consultations, overall, suggests that the barrier imposed by receptionists or other non-clinical staff fielding requests for same-day consultations might be inappropriate. Patients in the practices using nurse triage were somewhat less satisfied than those in the usual-care (mean difference in overall satisfaction score of 3·94, 95% CI 1·88–5·99) and GP triage groups (2·60, 0·58–4·63), which contrasts with evidence from studies of nurse-led chronic disease management.5Berry LL Rock BL Smith Houskamp B Breuggeman J Tucker L Care coordination for patients with complex health profiles in inpatient and outpatient settings.Mayo Clin Proc. 2013; 88: 184-194Summary Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 6Rosenberg K Nurse-led teams in chronic disease management.Am J Nurs. 2012; 112: 16Google ScholarFindings from ESTEEM echo those of smaller trials of nurse triage for same-day appointments in general practice, one of which reported a reduction in same-day face-to-face GP contacts, but an increase in routine face-to-face visits to the GP, and more phone contacts and face-to-face time with nurses.7Richards DA Meakins J Tawfik J et al.Nurse telephone triage for same day appointments in general practice: multiple interrupted time series trial of effect on workload and costs.BMJ. 2002; 325: 1214-1217Crossref PubMed Google Scholar As with ESTEEM, this study also showed that the immediate workload was similar, but that tasks were redirected to others in the practice and rescheduled to later dates with nurse triage; however, unlike in the ESTEEM trial, the investigators recorded an increase in accident and emergency or out-of-hours visits, suggesting task shifting to these services.What do these findings mean for primary care practices? Many primary care practices struggle with ever increasing demand from patients accustomed to round-the-clock services (and pressure from politicians and policy makers to satisfy this demand). Mere shifting of clinicians into triage roles is unlikely to free them from other duties. Our experience with other innovations in primary care, such as electronic health records, is that many additional tasks initially claimed as time and cost saving have actually added to the daily workload. Furthermore, many patients seeking same-day appointments have complicated problems—a third of calls to a Danish after-hours service were linked to a chronic disease, and about half the patients in ESTEEM had long-standing health problems.4Campbell JL Fletcher E Britten N et al.Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis.Lancet. 2014; (published online Aug 4.)http://dx.doi.org/10.1016/S0140-6736(14)61058-8Google Scholar, 8Flarup L Moth G Christensen MB Vestergaard M Olesen F Vedsted P Chronic-disease patients and their use of out-of-hours primary health care: a cross-sectional study.BMC Fam Pract. 2014; 15: 114Crossref PubMed Scopus (16) Google ScholarAnother key message is that all triage systems offer trade-offs between different uses of staff in primary care, and none are necessarily better than others. Experience and clinical reasoning skills during triage might be more valuable than computer decision support systems (which comprised 24% of the costs in the nursing triage group of the ESTEEM trial).9Huibers L Giesen P Smits M Mokkink H Grol R Wensing M Nurse telephone triage in Dutch out-of-hours primary care: the relation between history taking and urgency estimation.Eur J Emerg Med. 2012; 19: 309-315Crossref PubMed Scopus (12) Google Scholar Dealing with acute problems is a high-risk area of primary care and one where errors in judgment can take place.10Balla J Heneghan C Thompson M Balla M Clinical decision making in a high-risk primary care environment: a qualitative study in the UK.BMJ Open. 2012; 2: e000414Crossref Scopus (17) Google Scholar Use of nurses new to triage, and use of supporting software, is unlikely to replace experienced nurses or GPs.Nevertheless, the ever rising tide of demand for appointments means that we need to find ways to encourage greater patient self-management when appropriate, new forms of consultation or advice (with email or online consultations, or by expanding the work of pharmacists), and research to guide specific triage skills and clinical reasoning in primary care.We declare no competing interests. Primary care doctors worldwide could be forgiven for feeling stuck in the middle of a supply and demand crisis, with the need to balance increasingly complex care for patients with provision of same-day access for all. Optimisation of workflow within primary care is essential to maintain this balance, so that the entire primary care team can be used effectively, while providing safe, cost-effective care that satisfies patient demands. Demonstrations of access to primary care are often viewed by policy makers as a measure of overall success (or failure) of care. The UK Government has repeatedly prioritised improved access to general practitioners (GPs), partly in response to rising pressure on emergency departments.1National Health Service (NHS) EnglandTransforming urgent and emergency care services in England: urgent and emergency care review.http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.FV.pdfDate: Nov 13, 2013Google Scholar Implementation of the Affordable Care Act in the USA has further emphasised shortages of primary care providers needed to deal with increased demand.2US Department of Health and Human Services—Health Resources and Services AdministrationProjecting the supply and demand for primary care practitioners through 2020.http://bhpr.hrsa.gov/healthworkforce/supplydemand/usworkforce/primarycare/Date: November, 2013Google Scholar Indeed, reports of delays in access to care at a Veterans Administration Centre in the USA led to the resignation of Veterans Affairs Secretary General Eric Shinseki, and to national recommendations to improve access.3VA Office of Inspector GeneralVeterans Health Administration: interim report. Review of patient wait times, scheduling practices and alleged patient deaths at the Phoeniz VA Health Care System.http://www.va.gov/oig/pubs/VAOIG-14-02603-178.pdfDate: May 28, 2014Google Scholar John Campbell and colleagues' randomised controlled ESTEEM trial,4Campbell JL Fletcher E Britten N et al.Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis.Lancet. 2014; (published online Aug 4.)http://dx.doi.org/10.1016/S0140-6736(14)61058-8Google Scholar reported in The Lancet, compared three approaches to telephone triage of patients seeking same-day (but non-emergency) appointments in the UK: phone triage by GPs, phone triage by nurses using computer decision support, and usual care. Outcomes measured in 16 211 patients from 42 practices included primary care workload in the 28 days after the first same-day request, and costs and patient satisfaction. Practices that introduced GP triage had a 33% increase in the mean number of patient contacts per person over 28 days compared with usual care (2·65 [SD 1·74] vs 1·91 [1·43]; rate ratio [RR] 1·33, 95% CI 1·30–1·36), and those introducing nurse triage had a 48% increase (2·81 [1·68]; RR 1·48, 1·44–1·52). However, introduction of GP triage reduced the number of face-to-face contacts with GPs by about 40% (RR 0·61, 95% CI 0·54–0·69), and nurse triage reduced the number of GP face-to-face contacts by 20% (0·80, 0·71–0·90), although these findings were offset by far more phone contacts with a GP (an increase of ten times) or nurse (an increase of 100 times). Therefore, to some extent, the differences in numbers and types of contacts between practices in the three groups represented redistribution of the workload, and all three groups had similar costs (approximately £75 per patient). The fact that GP or nurse triage led to increased numbers of consultations, overall, suggests that the barrier imposed by receptionists or other non-clinical staff fielding requests for same-day consultations might be inappropriate. Patients in the practices using nurse triage were somewhat less satisfied than those in the usual-care (mean difference in overall satisfaction score of 3·94, 95% CI 1·88–5·99) and GP triage groups (2·60, 0·58–4·63), which contrasts with evidence from studies of nurse-led chronic disease management.5Berry LL Rock BL Smith Houskamp B Breuggeman J Tucker L Care coordination for patients with complex health profiles in inpatient and outpatient settings.Mayo Clin Proc. 2013; 88: 184-194Summary Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 6Rosenberg K Nurse-led teams in chronic disease management.Am J Nurs. 2012; 112: 16Google Scholar Findings from ESTEEM echo those of smaller trials of nurse triage for same-day appointments in general practice, one of which reported a reduction in same-day face-to-face GP contacts, but an increase in routine face-to-face visits to the GP, and more phone contacts and face-to-face time with nurses.7Richards DA Meakins J Tawfik J et al.Nurse telephone triage for same day appointments in general practice: multiple interrupted time series trial of effect on workload and costs.BMJ. 2002; 325: 1214-1217Crossref PubMed Google Scholar As with ESTEEM, this study also showed that the immediate workload was similar, but that tasks were redirected to others in the practice and rescheduled to later dates with nurse triage; however, unlike in the ESTEEM trial, the investigators recorded an increase in accident and emergency or out-of-hours visits, suggesting task shifting to these services. What do these findings mean for primary care practices? Many primary care practices struggle with ever increasing demand from patients accustomed to round-the-clock services (and pressure from politicians and policy makers to satisfy this demand). Mere shifting of clinicians into triage roles is unlikely to free them from other duties. Our experience with other innovations in primary care, such as electronic health records, is that many additional tasks initially claimed as time and cost saving have actually added to the daily workload. Furthermore, many patients seeking same-day appointments have complicated problems—a third of calls to a Danish after-hours service were linked to a chronic disease, and about half the patients in ESTEEM had long-standing health problems.4Campbell JL Fletcher E Britten N et al.Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis.Lancet. 2014; (published online Aug 4.)http://dx.doi.org/10.1016/S0140-6736(14)61058-8Google Scholar, 8Flarup L Moth G Christensen MB Vestergaard M Olesen F Vedsted P Chronic-disease patients and their use of out-of-hours primary health care: a cross-sectional study.BMC Fam Pract. 2014; 15: 114Crossref PubMed Scopus (16) Google Scholar Another key message is that all triage systems offer trade-offs between different uses of staff in primary care, and none are necessarily better than others. Experience and clinical reasoning skills during triage might be more valuable than computer decision support systems (which comprised 24% of the costs in the nursing triage group of the ESTEEM trial).9Huibers L Giesen P Smits M Mokkink H Grol R Wensing M Nurse telephone triage in Dutch out-of-hours primary care: the relation between history taking and urgency estimation.Eur J Emerg Med. 2012; 19: 309-315Crossref PubMed Scopus (12) Google Scholar Dealing with acute problems is a high-risk area of primary care and one where errors in judgment can take place.10Balla J Heneghan C Thompson M Balla M Clinical decision making in a high-risk primary care environment: a qualitative study in the UK.BMJ Open. 2012; 2: e000414Crossref Scopus (17) Google Scholar Use of nurses new to triage, and use of supporting software, is unlikely to replace experienced nurses or GPs. Nevertheless, the ever rising tide of demand for appointments means that we need to find ways to encourage greater patient self-management when appropriate, new forms of consultation or advice (with email or online consultations, or by expanding the work of pharmacists), and research to guide specific triage skills and clinical reasoning in primary care. We declare no competing interests. Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysisIntroduction of telephone triage delivered by a GP or nurse was associated with an increase in the number of primary care contacts in the 28 days after a patient's request for a same-day GP consultation, with similar costs to those of usual care. Telephone triage might be useful in aiding the delivery of primary care. The whole-system implications should be assessed when introduction of such a system is considered. 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