FAQ

Indicative time slots are a problematic unless you can reliably stick to them. If a patient has real constraints on when they can be called back during the day e.g. work breaks, then this information should be added as free text in ‘slot notes’ in slot properties. The duty team can then prioritise this contact as necessary.

Set a policy of two attempts to contact a person, then send email (via eConsult), AccuRx message (set up a template for this) or leave answerphone message.

This should be coded, in history, NOT as a problem title in the consultation as ‘failed encounter’ as this allows a practice to capture failed encounters, a useful indicator of how effective the triage process is.

Clearly there will be times when clinicians use their discretion and try more times to contact someone, but if this policy is clearly articulated to the team and also to people accessing the service it really helps.

The golden rule here is: the longer it takes to call a patient back, the more likely you are to get a failed encounter. So, turnaround time is very important, as well as not booking in patients for call-backs on another later day.

No matter what the route in is (telephone, eConsult), you have to inform patients how long it will take to respond to develop trust in the triage system. It would depend from practice to practice on what they decide collectively. For example, some practices decide

that eConsult will be actioned on the same day if submitted before 17:30 and all phone calls will be actioned on the same day.

The idea is for practices to aim to ‘do the work of the day on the same day’ and for clinicians to complete the work arising from the consultation e.g. referral, advice and guidance, letter or test request, at the same time rather than building up tasks for action later.

There are answering scripts for admin staff and skill mix conditions list that are in this manual. There is no substitute for learning by doing. Undertaking signposting and triage work in a shared room, rather than individual clinical/admin rooms is a great opportunity to share and learn as a team. Daily huddles are an opportunity to refine the approach. Starting the session by asking:

–What did we test yesterday?

–What did we learn?

–What are we testing today?

And capture the outcomes of the huddles in brief each day will build a narrative on how the practice has improved the total triage process over time and helps with handover of information to team members working part-time.

Triage has some essential building blocks, one of which is EMIS set-up. Getting EMIS set up properly helps with processing work safely and effectively, and also with capturing data that enables teams to understand how well their system is working.

Most practices have moved to total triage at a time when demand is low compared to normal. So, the system has to be set up to be able to manage when demand increases.

People often have a fear that demand is infinite and therefore unsustainable to manage, which is where using data to inform planning can really help. Any significant changes in ways of working can be challenging. Open discussion about concerns, challenges, success and benefits of the new systems will enable teams to refine and improve their system in a way that appreciates and develops the skills of the wider team.

In the morning huddle the duty team works out each morning what the capacity is of the team that day in terms of number of contacts on the triage list. This calculation is based on approximately 25-28 contacts per session per GP and takes into account any pre-booked appointments or absent team members. The capacity calculation can also take into account the capacity of other clinical team members e.g. GP specialist trainees, pharmacists, nurse/advanced nurse practitioners, physician assistants etc.

Once booked slots reach 85% of daily capacity total it is time to try to limit contacts for the day. Tell the patients ‘We have reached our safe capacity for the day. Please can you call back tomorrow or submit an eConsult’. You can also manage flow by telling patients to call on the day that their regular GP is there, as it helps influence demand.

The 25-28 contacts figure is an estimate of clinical activity that is broadly sustainable based on lived experience and the use of different modes of consultation. Whether demand can be covered by this activity depends on how well practices plan and use their clinical capacity against predicted demand, and also, whether signposting away of non-clinical work is happening.

It’s good practice to have one list to work from. If patients are put on different lists,

patients can get missed or lost, which is risky. And even though the number of contacts may be equal, that may not accurately mean the complexity of the work distributed is equal. Total triage is a shared endeavour. Moving to this way of working is a situation where it is essential as a team to have an open discussion about expectations, transparency and trust. There will be differences in work-rate between clinicians and this is an opportunity to learn from each other and build in opportunities for personal and professional development. Data can be helpful here – looking at re-attendance rates, use of diagnostics, conversion to face- to-face and case-mix are all useful markers to balance simple data on number of patient contacts.

Undertaking triage work in a shared room, rather than individual clinical rooms is a great opportunity to share and learn as a team.

In an ideal world demand would be the same through the day, but practices usually tend to experience more demand in the morning than in the afternoon. This is partly driven by historical need for patients to call early in order to access limited GP appointments on offer on a specific day.

Is a myth. The concept of ‘same day’ or routine work is a false distinction based on supply side factors i.e. availability of appointments. In reality, actual clinically urgent demand is only a small proportion of daily activity and everything else is just work that needs to be dealt with. The choice practices have is in who does the work, where and how it is done.

One of the areas where it is useful to make a distinction between types of work is between reactive activity (i.e. most GP activity) and planned activity (e.g. antenatal, minor surgery, long-term conditions), as these systems behave differently and are driven by different needs.

The core principal of total triage is to meet demand with the right person at the right time with the minimum amount of handoff. eConsult is one route into a triage system, and the time taken to by frontline patient assistants to transcribe eConsults may mean that this is not a viable option for practices. We have not specified this approach as an essential building block of total triage. That said, it is an approach that can be tested by practice teams to see if it works for them.

In order for work, from telephone or eConsult, to flow onto the triage list in a uniform way three things are needed:

1.Use of correct slot types for booking

2.Reason for contact clearly entered in slot properties

3.Use of slot notes with more detail, if needed, in slot properties

This makes the work of triage much more straightforward for the duty team and clinicians

EMIS is not set up well to capture conversion rates, though how EMIS appointment book is configured will make a big difference on the quality of any data that can be used. Edenbridge gives the best view on this and can be seen from a practice and clinician level. Please contact Edenbridge team for support on configuration.

The manual aims to cover the essential building blocks of triage. It was developed by sourcing clinical as well as administrative perspectives to give a picture of best practice. Practices will have to adapt processes to best fit their local context, depending on multiple factors like skill mix and team capacity.

Signposting is fundamentally about empowering patient choice and using the wider skill-mix of the practice team and information that is available for patients to help themselves.

Clinical triage is a way of prioritizing and planning work according to clinical need, available skills mix, and capacity on the day. It differs from signposting in that it is clinically led process – ie signposting is done prior to this stage, filtering out work that does not require clinical input and would be best dealt with by another person or service.

Telephone answering – this can be mitigated by:

• Rota planning for predicted busy periods – look at the telephone call volume in 30minute chunks and plan accordingly. Hint – the busiest times of the day on the phones are from 08:30-09:00 and 13:30-14:00
• Use of standard scripts for answering the telephone
• Directing people to use eConsults and online bookable triage slots

Clinical triage – this can be mitigated by:

• Rota planning for predicted busy days
• Optimising the workflow of the day by using the duty team
• Planning session times around times of peak demand
• Avoid undertaking planned care on days and times where demand is high

Demand is largely predictable (within 5% tolerance) and the art of running a total triage system is planning capacity according to predicted demand. Refer to capacity and demand section for more information. If a team requires more support with capacity and demand modelling, then please contact the EQUIP team.

Triage is a means of managing risk in the system and the duty roles are critical to this. Work on the triage list needs to be managed through the day in order to prioritise according to clinical need, available skill mix and the capacity on the day.

No system of access is risk-free and it can be argued that a total triage system is more likely to identify and manage patient need than a traditional pre-bookable system, where patient need is not identified early on and the system operates usually with fixed capacity and tries to squeeze in ‘on the day’ demand.

A mindset shift for teams moving to total triage is that the role of triage is simply to get patient need met with the minimum of handoff – this might be a face-to-face appointment or an AccuRx message. This is different to the ‘on-call’ doctor in a pre-bookable system where the role is more about firefighting and trying to limit overbooking in a system that is already working at capacity.

Some anxiety when moving to a new way of working is understandable, though increasingly the ability to undertake remote consultations is increasingly an essential skill for primary care clinicians.

It is helpful to identify specific concerns and work with these. The practice is undertaking a process of change, so an open dialogue about concerns and how to mitigate them is part of the learning and adapting that needs to take place in the team. Team members working in the same room as each other creates an environment that helps with learning and development.