Is telephone triage helping patients with more than one condition?

COVID-19 saw a massive increase in the number of doctors’ surgeries using telephone triage – the process whereby patients ring, speak to a receptionist, and then get a call back from a GP or other primary care professional before any appointment is made.

Before the pandemic, a small but increasing number of GP surgeries had been using this method to manage demand, but at the beginning of 2020, almost all of them introduced it. Evidence from before the pandemic suggests that telephone triage helps patients speak to someone more quickly, but not that it reduces GP workload or saves money.

We wanted to know what it meant for patients living with two or more long-term health conditions, and explored the issue with data from Understanding Society and the English GP Patient Survey (GPPS). The work was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme, as part of the Birmingham, RAND and Cambridge Rapid Evaluation Centre.

Understanding whether introducing telephone triage has a different impact for patients living with more than one long-term health condition is an important question, because these patients were a priority for the NHS even before the pandemic, and were particularly affected by Covid. Addressing health inequalities, especially in relation to access to primary care, is also a core NHS priority.

Research questions and analysis

We focused on three questions:

Looking just at people living with two or more long-term health conditions, does telephone triage affect how quickly they can speak to a primary care professional?
How does that effect compare to the impact on people who don’t have multiple conditions?
Of those with multiple conditions, are any sub-groups affected more than others in terms of how quickly they see or speak to someone?

We began by analysing GPPS and Understanding Society to understand the characteristics of people with multiple health conditions. We found that people living with multimorbidity are older, live in more deprived areas, are less likely to be employed, and are more likely to have been shielding during 2020.

Using Understanding Society, we then looked at primary care access between April and November 2020. This showed that people were less likely to try to see their GP at the start of the pandemic, but by September 2020, more than 90% of people with a problem did try to contact a GP. Of those, more than 90% got an appointment. In April 2020, only 20% of all appointments were face-to-face, but this was up to about 40% by November 2020.

Looking at GPPS data from before the pandemic, we found that there are differences in the time it takes for people to see a primary care professional before and after telephone triage is introduced – whether they have multiple health conditions or not. However, these differences are small compared to the overall improvement for all patients when telephone triage is introduced.

Unequal access to care

Using Understanding Society, we analysed inequalities in access to care. During the pandemic, people with multimorbidity were more likely to have a problem that meant they needed to see a GP than people with no long-term health conditions or a single health condition. However, we found no evidence that there was a difference between the two groups in terms of:

trying to see a GP if they had a problem
whether they could get an appointment
whether the appointment was face to face, over the telephone or online.

Using both data sets, we looked at whether there is any variation within the multimorbidity group based on age, sex, ethnicity, income, employment, shielding status, and whether their area was rural or urban. For most of these categories, we found little evidence of any differences, although people in rural areas were more likely to be offered a face-to-face appointment than those in urban areas, and men were more likely to be offered a face-to-face appointment than women. Also, patients aged 85 or more with multimorbidity were able to see a GP more quickly than others – perhaps because they are triaged more urgently, or because they are more frequent users of the service and therefore more able to navigate the system.

What do the findings tell us?

Although people with multimorbidity have a greater need for primary care, our results show that when a general practice switches to a telephone triage approach, the change has a similar impact for all the patients in that practice. In general, they all get to see or speak to a GP more quickly.

With these data sets, we’ve been able to build on previous research and suggest that when an innovation is introduced, inequalities are more likely to arise between practices, because of variability in implementation, rather than between groups of patients within the same practice.

Implications for policy and practice

There is a lot of debate around remote consultation and telephone triage, and how this is affecting patients’ access to primary care and satisfaction with the NHS. The most recent official statistics from the GP Patient Survey show significant falls in the numbers of people saying it was easy to get through on the phone (from 67.6% in 2021 down to 52.7% this year), and in their satisfaction with the appointment times available (67% down to 55.2%). We also know, from a survey by The Patients Association, that many people still prefer face-to-face consultations.

Earlier research has also shown that national inequalities are widening, with access to primary care getting worse more quickly in practices in more deprived areas.

These findings lead us to make two policy recommendations. Firstly, differences between practices could potentially be reduced if there were national models for the roll-out of innovations such as telephone triage or online consultations – and these approaches could be tested with further research and evaluation.

Secondly, more funding to support practices struggling with high levels of demand, and fewer doctors per head of the population, would also help to address disparities, especially in deprived areas.

Read the original research