Is total triage embedded?

Your smart phone will see you now

There has been an inevitable backlash to the speed of medical digital implementation and remote 'total triage'. GPs say they are outraged by NHS England's lack of understanding, and NHS England claim they have to take concerns over the lack of access to face-to-face meetings seriously. Patient groups have also expressed concern about the current situation, and cite patients who have been unable to book appointments.

Involving patients in total triage

As the Telegraph reports, the arguments around total triage has now escalated into total furore. The doctor's union have passed a vote of no confidence in NHS management and the head of NHS England, Dr Kanani responds saying, "we need to bring patients with us, and although we know over 50 per cent of appointments are now face-to-face, and as GP teams you have been working constantly throughout, some patients have still struggled to get access to their GP. Both Healthwatch and the Patients’ Association have reported challenges which we cannot ignore".

The speed of digital implementation has understandably overtaken the usual patient consultation process. As reported previously, the implementation of digital triage systems accelerated during lockdown, with 71% of consultations being delivered remotely. Remote consultations were embraced by GPs as a way to keep safe and prevent the spread of COVID-19 while still allowing patients to receive the care they need. However, with the end of lockdown, patients will inevitably expect a resumption of normal services - at least to a degree.

Total triage does now seem to be embedded, with around half of the GP practices in the UK having now substituted all front-end patient engagement with e-Consult. The digital process gathers clinically relevant information in the patients' own time, channels the questions according to response and responds using an appropriate modality such as telephone, video, text or online messaging. 

The general feeling is that digital triage in future will be essential to manage workload. In an opinion piece for the BMJ, Dr Simon Hodes says,"With over 300 million general practice consultations a year (compared with 23 million in A&E), we all rely on our GP practice at some stage". Dr Hodes goes on to point out, "However, it is very unclear how, or if, patient groups have been involved in a “total triage policy.”

Total triage is not for everyone

Dr Helen Salisbury in a separate opinion piece explains how the concept of 'triage' was developed during the First World War in order to have a process in place for ensuring that top priority patients were seen first. However, she makes the point that regardless of how appropriate the process of triage might be on the battlefield, it is a less than satisfactory method for managing and seeing her patients. Dr Salisbury is concerned about the widening digital divide and says, "Arguably, the patients who need us most—older patients and those with poorer health literacy—are the least likely to fill in an e-consult form, reinforcing the inverse care law". Pointing out that 'total triage' is great for emergencies, she concludes staying, "The future is very bleak if instead it involves hours of sifting through e-consult forms from patients you don’t know, the surgery transformed into a call centre rather than a clinical space. I don’t think that this will entice many young doctors into general practice, and it won’t serve our patients well".

Replacing the need for face-to-face consultations?

The Royal College of GPs (RCGP) say that ‘total triage’ should not be extended as it may ‘exacerbate health inequalities’. The College suggests that the Government should continue to invest, "£1bn in digital infrastructure for general practice by 2024" on the basis that "the benefits of remote consultations where they add value should be harnessed", but go on to stress that "face-to-face care must remain a core element of general practice". It does seem as though the College wants to have its cake and eat it, especially as they then pass the buck onto the individual practices by saying that the decision to move to total triage should be down to them.

Sitting firmly on the fence, as reported by Pulse today the RCGP say that they do not want to see general practice, "Become a totally, or even mostly, remote service". Instead it, "needs to be down to individual GP practices to be able to decide how they deliver services, based on their knowledge of their patient population".

The plain fact is that some patients (and probably the majority) will happily adopt the new triage approach provided that it works and their concerns are responded to swiftly. The technologies will continue to improve and it is likely that much of the traditional primary care work can be replaced by artificial intelligence and digital algorithms. However, there will always be some patients for who this approach will not work. There therefore always has to be the necessary flexibility in place to be able to provide additional levels of service - especially for the elderly and for those patients who really do need to see a doctor. Except for in times of war or plague when time is of the essence, it is only due courtesy to involve patients and patient groups in the process, and their feedback should be welcomed.

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