In 2024, we showcased 12 GP practices in Wandsworth who had transformed their access and capacity in moving to a total triage model.
This provided a learning opportunity for those practices considering transitioning to this approach and to those who are reviewing and tailoring how they use it.
Webinar recordings from these sessions can be accessed here
Read more about these sessions including the benefits that have been realised with a total triage approach.
Total Triage Model
Practices made the move to a total triage model in order to:
- Do-away with the 8am rush, and all the appointments being booked by 8:30am
- Improve the equity of access, by prioritising appointments based on clinical need
- Improve the wellbeing and retention of reception staff who experience low morale from being the constant ‘gate-keepers’ of appointments
- Improve retention and wellbeing in GP staff who are at risk of burnout from the mismatch of capacity and demand
- Improve the sustainability of the ‘duty GP’ who is absorbing all the unmet and unmanaged demand
- Improve patient experience of accessing the practice
- Improve continuity of care
- Tackle the inappropriate use of appointments, such as chasing referrals or for ailments suitable for self-care or community services
- Break the cycle of the long wait for routine GP appointments, which then generates more ‘failure demand’ as those routine issues become urgent while waiting
- Optimise the use of different roles within the practice, such as nurses, HCAs, pharmacists, physios, physician associates, social prescribers, ANPs and other ARRS roles
- Make the most of community services such as pharmacies, minor and urgent eye care services, dentists and minor injuries units
What were the common dilemmas and decision-points when planning the transition?
If you haven’t made the move to a total triage system yet – consider this a check-list!
- Soft v. hard launch
- Who will triage – clinician v. non-clinician, in-house v. outsourced
- Form availability – core hours v. selected hours
- To ‘cap’ the number of requests that can be received in the day v. uncapped
- Whether to make any changes to slot-types and appointment books
- Deciding balance of routine v. on-the-day capacity
- If and how to capture the triage work in EMIS
- Deciding on what the advertised response time to the patients should be
- How much clinical capacity to dedicate to triage
- How to ensure equity of access e.g. digital exclusion, language barriers, frailty and vulnerability
- Every clinical request is triaged v. receptionists having a list of exemptions (e.g. child with fever <5)
- Challenging an existing patient culture e.g. “walk-in” or “the GP always phones me”
Factors for Success
- Appoint a project lead
- Have a senior GP championing triage
- Involve patients and staff from the outset
- Set time aside for staff training
- If possible, have a dedicated receptionist or team of receptionists for triage
- Consider creating a care coordinator role if you don’t already have one
- Record and make available “how to” videos for patients
- Use a script for reception to support them explaining the changes to patients
- Have a clear communications plan, using all routes – newsletter, website, social media, SMS/email campaign, posters, waiting room screens
- Use demand data to review and reconfigure appointment books
- Have an overwhelm strategy for when you’re capacity is unexpectedly short
- Know specifically what improvements you’re hoping to see and use those to measure impact
- Constantly tweak and change in response to regular feedback
Challenges after going live
| The Challenge | To Consider |
| Clinicians vary in their approach to risk and to triage | This can lead to significant variability in triage and directly impact capacity. Discuss this regularly in clinical meetings, encourage pairing less-confident triagers with more confident/experienced GPs and create opportunities to shadow each other. |
| Triage fatigue | Triaging involves making hundreds of micro-decisions which will lead to decision-fatigue, so either work in sessions/shifts or schedule in regular breaks. If you’re triaging in a team, encourage each other to get up and move around. |
| One powerful voice can undermine the integrity of the system | Try to address this early-on and only go-live when you’ve got the key stakeholders on board. |
| GP clinics will become more complex | Consider factoring this in by extending your appointment length and think about reducing the number of patients in the GP clinic. |
| Digital exclusion (real and perceived) | Those who don’t want to or can’t use the online form will understandably be your loudest critics so ensure it is very clear to them how they can access care and that they are not being disadvantaged in any way. Other patients may voice this concern about inequitable access for vulnerable patients, so it is worth ensuring this is directly addressed in your comms and the script you give to your reception team. |
| Keeping out that which does not need to be triaged | Try to avoid creating ‘failure demand’ by sending patients an SMS to book an appointment which requires them to fill out the form which will then land in the inbox for triage. If you’ve already decided how/when/if they need to be seen, give them a route to make that appointment without going through your triage system e.g. self-book links or messages they can respond to directly. |
| Keeping on top of proactive and preventative care | A common unintended consequence is over-focusing on meeting on-the-day demand when moving to a triage system, but don’t forget to carve out capacity only for proactive/LTC care, and ensure your recall system is not adversely affected by the change. |
| Misuse of the online form | Some see duplication early-on in the transition to total triage as patients fill out the form and then ring to ensure the form was received, which can potentially generate two appointments. There will be a handful of patients who submit multiple forms, or request advice when they’re out of the country, but such behaviour existed before access to an online form and should be managed as you did previously. |
| Remembering to ask for feedback | It can be tempting in the distraction of transformation to not seek formal feedback, but this is essential for ongoing iterative changes. Set a schedule of when/how you will seek feedback from patients and staff and try to stick to it. |
A few specific to Accurx
| The Challenge | To Consider |
| When to use more structured information gathering e.g. Questionnaires | Consider picking 2-3 conditions initially that you find most useful when triaging, e.g. UTI, sore throat and skin lesion. Requesting a questionnaire for every form will become overwhelming. Consider when more information is going to make a difference to the triage decision. |
| Some limitations in functionality | e.g. self-book links can only be sent via SMS not email; and patients cannot select themselves if they would like a telephone or F2F (if we have triaged either as appropriate). Bear this in mind when deciding how to use self-book links. |
| Outcome data is not easy to measure | One way that works well is to dedicate a specific day as “audit day” and capture the outcome data from every request as a snapshot (if using Accurx you can use their mini outcome questionnaire which appears when you click ‘done’) |
What benefits have been realised with a total triage approach?
Increased capacity
In some practices, up to 35% of capacity was released due to more appropriate use of appointments, including those for ARRS roles and community services, reduced duplication, reduced reattendance rates, the ability to signpost and advise those who don’t need an appointment at all, and minimising failure demand
Improved safety
The increased capacity allows us to absorb most – if not all – urgent/on-the-day demand and patients are prioritised within the day based on clinical need
Increased fairness
All patient demand is captured into a single workflow, with no bypass by pressurising reception or working-the-system
Reduced phone call volumes
For most practices, call traffic fell by 30-40%, leading to shorter wait times and receptionist redeployment to other tasks. Many report they can then spend the time required to support those who can’t use a smartphone or computer, and so the calls that are answered do take longer to complete
Improved patient satisfaction re access (depending on what the baseline was!)
Most practices report that patients are delighted by the same-day response and not being turned away to try again the next day, plus the wait for a routine appointment is generally drastically reduced
Safer supervision
By determining at the point of allocating an appointment that a patient’s presenting issue is suitable for a particular member of staff, such as a PA, ANP, physiotherapist or pharmacist, then the clinical supervision of that clinic becomes much more straightforward, minimising both risk and duplication of work.
More opportunity for continuity of care
If we are reading and honouring patients’ requests to see or speak to a specific clinician or are briefly checking in the notes when triaging the request if it’s obviously a follow-up and suggesting they are booked in with someone who has seen them before, then continuity will improve. The challenge is that this needs to be offset against the clinical time given to the triage process itself.
More opportunity to focus on proactive and planned care
By releasing capacity from on-the-day demand, we can spend more time with more complex patients and those with long-term conditions ensuring better quality of care and reducing the need for urgent care in the future
A feeling of calm and control
Many practices reported a sense of calm, as both the demand and capacity is spread more evening throughout the day rather than gone in the first chaotic hour. Demand is both stable and predictable, so being able to see the demand in one place, plan for it and flex for it in real-time has had huge advantages for all those working this way.
Improved staff wellbeing and retention
This is certainly the aim and the most telling feedback we heard across the 6 webinars was the phrase “we definitely wouldn’t go back to the way we were working before”. There are still many factors that affect wellbeing but we have heard most practices say the move to triage was positive for staff. This is most marked in practices that triage in a ‘hub’ system with all the triaging team (clinical and non-clinical) in a room together, discussing triage decisions in real-time and regularly liaising with the reception team to carefully manage the remaining capacity of the day and week.