Advice on how to establish a remote ‘total triage’ model in general practice using online consultations

Contents

 

Publications approval reference: 001559

15 September 2020, Version 3

This guidance is correct at the time of publishing. However, as it is subject to updates, please use the hyperlinks to confirm the information you are disseminating to the public is accurate. Any changes since version 2 (April 2020) are highlighted in yellow.

Introduction

In response to the COVID-19 pandemic, NHS England and NHS Improvement have produced this guide to support all general practices in England with the rapid implementation of a ‘total triage’ model using telephone and online consultation tools.

Total triage means that every patient contacting the practice first provides some information on the reasons for contact and is triaged before making an appointment. It is possible to do this entirely by telephone but using an online consultation system is likely to leverage further efficiency and benefit. Total triage is important to reduce avoidable footfall in practices and protect patients and staff from the risks of infection. This information accompanies a walkthrough webinar.

Key messages

  • All practices should be using a total triage model to protect patients and staff from avoidable risks of infection.
  • All practices must have access to an online consultation system to support triage.
  • Patient requests should be triaged wherever possible to decide on what the most appropriate mode of care delivery is for that patient and to enable care to be provided by the right healthcare professional with the right level of urgency.
  • Practices should continue to provide remote consultations (online, phone, video) alongside face to face care for those that need it. The approach should be tailored to the person, the circumstance and their needs.
  • Information for patients about how they can access services should be clear; with explanation of triage, the modes of communication available to them and reassurance that face to face care always remains available when clinically appropriate and provided in line with the standard operating procedure to keep patients and staff safe.
  • There is no one size fits all approach. Adjustments will need to be made to ensure those who are unable to access or engage with services remotely can still access appointments and care. Digital channels should be available alongside other routes to access services (telephone, in-person).
  • The number of face-to-face contacts that a patient requires should be minimised by co-ordinating care so that as much as possible is done in a single consultation.
  • In general, online pre-bookable appointments should not be used so that all demand goes through triage, however, there may be some exceptions to this – such as flu clinics.
  • Practices should continue to encourage use of other online patient-facing services, e.g. repeat prescription ordering and patient access to medical records.
  • Appointments made available to NHS 111 for direct booking should be set up as remote appointment slots or as an un-timed ‘worklist’ to enable further clinical review by the practice.
  • Implementation resources and capacity are available to ensure practices and primary care networks (PCNs) are fully supported to deliver the changes required for a successful total triage model and optimisation of digital first pathways. These can be accessed by contacting your CCG or your NHS England and NHS Improvement regional team via england.digitalfirstprimarycare@nhs.net

Dr Minal Bakhai | Deputy Director and National Clinical Lead for Digital First Primary Care | NHS England and NHS Improvement | General Practitioner

How to implement total digital triage

In response to the COVID-19 pandemic we have seen an acceleration in the adoption of digitally supported triage (total digital triage) and, where appropriate, the use of remote consultations to maintain safe service delivery and protect our patients and staff.

Total digital triage uses an online consultation system to gather information and support the triage of patient contacts, enabling care to then be provided by the right person, at the right time, using a modality that meets the patient’s needs. Non-digital users may be supported by carers or are taken through the same online form or a short template by administrative staff over the telephone or in person (with some agreed exceptions, for example, vulnerable patients). Practices are then able to manage demand via a single workflow, prioritising care based on need, rather than on a first come, first served basis. This approach helps to ensure equity of access for digital and non-digital users. It can also free up the phone lines for those who cannot or choose not to go online. Digital channels are an additional way of supporting patients and should be used to augment traditional models of care delivery , providing increased choice for patients in how they interact with their general practice.

With a need to minimise footfall in practice and reduce the risk of infection, the relative advantage of remote consultations has changed dramatically. Data suggests that practices using total digital triage were better able to respond flexibly to variations in demand for care during the initial stages of the pandemic (The Health Foundation, July 2020).

Data also show that digital triage systems can enable about a third of all patient requests to be closed with an electronic message (askmygp. Consultation use data issued by askmygp 2020). The online consultation system captures the patient’s history and symptoms asynchronously (completed by the patient in their own time), allows patients to send pictures and offers signposting to self-help or local services. The systems increase resilience by enabling more adaptable working patterns (i.e. customised appointment lengths) and giving staff more control over managing their time and workloads (e.g. prioritising activities to maximise use of resources/capacity and working flexibly). Staff working remotely (e.g. if they are self-isolating) can use digital triage systems from home. Research shows online (written) consultations can remove barriers for some people traditionally marginalised from access to general practice, including those with a physical disability, hearing loss, carers and people who feel apprehensive about accessing health services – e.g. for a mental health, sensitive or embarrassing problem.* ** However, there is ‘no one size fits all’ and a blended approach to communication should be offered and matched to the patient and their needs.

*Atherton et al (2018) Alternatives to the face-to-face consultation in general practice: focused ethnographic case study.

**Atherton et al (2018) The potential of alternatives to face-to-face consultations in general practice, and the impact on different patient groups.

This is the recommended model for practices to move to, enabling requests to enter through a single workflow and matching the approach for providing care to the person, the circumstance and their needs.

Moving to a total triage model may represent a significant change in how a practice or PCN functions. To deliver any change like this successfully, it is essential to consider organisational culture and to support people through the change process. Resilience resides in teams, particularly in complex and ambiguous times. It is important to remain flexible and supportive of one another in order to realise benefits and build effective new ways of working.

Summary

Plan
  • Practice planning and cultural change
  • Capacity planning, workflow redesign, continuity of care
Support
  • System resilience
  • Training and trying it out
Change
  • Change your appointment system, adapt your staff rota
  • Update website, telephone messages and other comms
  • Information governance
Use
  • Go live
  • Monitoring

All practices must have access to an online consultation (OC) system to support total triage. Many practices already have OC systems but may have used them only for a small proportion of patient contacts. This guide will help you to use your OC system to manage your entire workflow.

If there is no OC system in your practice, please contact your commissioner for advice. Commissioners should contact their NHS England and NHS Improvement regional digital team or contact the commercial procurement hub. For more information on procurement, funding and assurance of supplier* systems see here.

*For clarity, the term ‘supplier’ in this guidance refers to your online consultation supplier.

For information on the different types of online consultation system, see the summary implementation toolkit section on getting started.

NHS England and NHS Improvement have produced templates and resources to help practices and commissioners safely implement and optimise the use of online and video consultation systems. Clinical safety risk management is a joint responsibility of commissioning and deploying organisations, and the resources developed give advice on how CCGs and practices should work together to mitigate risk and clarify the responsibilities of commissioners and practices according to the route of procurement.

Start planning

Practice planning
  • Rapidly set up a team with project management input to lead the change.
  • This group requires clinical oversight but should not need every decision to be ratified by the partners.
  • Ensure all members of the practice are aware of how it will work – use Microsoft Teams or similar for team discussions if staff are self -isolating.
Cultural change
  • Involve all staff and listen to their concerns. Ensure they understand why the system is being introduced.
  • Encourage and support your champions.
  • Don’t worry if it doesn’t work first time – learn, adapt and improve.
  • Connect with your local digital first lead and total triage champions.
  • Check how likely your patients are to be digitally excluded* **. Work with your PCN, commissioner, community organisations, patients and carers on practical steps to improve digital inclusion locally. If you have the space and resources, consider providing a safe space for patients to access a computer at your practice.

*Get Digital Heatmap and the Consumer Data Research Centre map of neighbourhoods

**Video consulting – a quick guide for patients and Health at Home campaign
Capacity planning
  • Predict the volume of expected contacts at the practice at different times, ideally using a demand and capacity tool. Usually there is a clear pattern of activity.
  • Shift sessions around to address demand-capacity mismatches.
  • Optimise over the following weeks using data from your supplier.
Workflow redesign
  • Map the current process to identify bottlenecks and opportunities, ideally with input from patients/carers.
  • Design new workflows (admin and clinical) in collaboration with your staff and supplier.
  • Work through how the OC system will interface with your clinical system.
  • Agree who will check for new OC requests and how often, how OC requests will be distributed and by whom, and how you will know you have OCs allocated (including how clinicians will be alerted to urgent requests). Map team responsibilities and scope of practice.
  • Agree a turnaround time for responding.
  • Design for equity and ensure there are routes for non-digital users. Admin staff can use a short web form or template in the clinical system (provided by your supplier) to take non digital users through the same process over the phone or in person – agree exceptions for direct appointment booking.
  • Use a template* or quick codes to code OC requests** consistently.
  • Pay special attention to urgent and red flag cases, using both existing and COVID-19 specific protocols.
  • Your admin and clinical teams will need to be familiar with how these processes work.

*A data collection template may be provided by your OC supplier

**VC: SNOMED CT ID = 325921000000107 (consultation via video conference) and OC: SNOMED CT ID = 32591100000010 (consultation via multimedia encounter type)
Continuity of care
  • Use a pop-up in the clinical record to aid continuity, passing requests to the regular clinician/team, unless urgent. Consider markers such as:
    • frequency of contacts with the practice
    • presence of chronic disease
    • frailty index
    • number of prescriptions

Clinicians may update the record if they decide the patient needs reallocating after a consultation. Alternatively, some practices use a personalised list.

Support and training

System resilience
  • Ensure there are sufficient phone lines, equipment (eg staff should ideally have headsets and two screens), website functionality and network bandwidth. Speak to your commissioner if you have concerns.
  • Check internet connection at every location from which staff will consult – including outside the practice (eg clinician at home).
  • Work with your supplier to plan for contingencies: eg temporary disruption to the OC system or where capacity becomes depleted.
  • Update practice website messages or use automated messaging from the OC system to inform patients of important changes.
Training
  • Suppliers will provide remote training to all staff on deploying and using the software. They will explain the process for reporting incidents or issues and provide you with a point of contact.
  • Ensure staff are aware of how and where they can access resources: e.g. guidelines, protocols, IT support, supplier contacts.
  • Ensure everyone is clear about their roles and responsibilities, and specifically acknowledge the new role for reception staff.
  • Ask about digital literacy, training and development needs.
  • Provide team and peer-led training (confident users support others) and a go-to person for support/queries.
  • Access clinical training resources provided nationally and from your supplier (see resources).
Trying it out
  • Use ‘test patients’ and team simulations to get familiar with the system and check IT/logins are working.
  • Encourage staff to submit their own test OC requests to see how it works from the patients’ perspective.

Make changes

Change your appointment system
  • Confirm the go-live date and work towards it – turn off any pre-booking of routine appointments.
  • Convert any already pre-booked appointments to remote appointments and let affected patients know (and amend SMS reminders for these slots).
  • Agree how you will view and manage your clinical workflow e.g. within your OC system or using the clinical system.
  • Create ghost slots in your appointment book labelled ‘online consultation’. The time of the slot is generally irrelevant. Use these slots for distributing OCs amongst the team and recording clinical interactions. Turn off SMS reminders for these slots (see resources for example appointment templates and guidance on recording clinical interactions resulting from OCs in the appointment book).
Adapt staff rotas
  • Consider having all staff available for go-live if possible.
  • Dedicate staff to triage especially at peak times. The busiest part of the day for incoming OC requests is 8am to 10am, so triage must start early. Only follow up with emergencies in this time if possible.
Update the practice website and telephone messages
  • Make sure the practice website is accessible and works on multiple devices to maximise access. Speak to your commissioner for support.
  • Put a banner about OC prominently on the practice website (your supplier will help), explaining the change, the benefits and linking to up- to-date advice on COVID-19.
  • Amend your automated telephone message – with a senior GP explaining the use of the online system.
  • Clearly state the expected response times (in-hours and out-of-hours including over weekends and bank holidays) to set expectations and avoid patients unnecessarily phoning up the practice.
  • Provide information on how to get help for an urgent clinical query, some systems will allow you to customise the messaging displayed, e.g. in the late afternoon, some practices instruct patients to call if they have not received a response to an urgent query within half an hour, or to use 111 online.
  • Provide clear guidance to patients on how to use the service, what to expect and what happens behind the ‘scenes’ e.g. who will see the OC, how to expect a response. Share links to supplier patient guides or videos on how OC and VC systems work.
  • All assured online systems must advise patients not to use online consultations for a medical emergency.
Update other communication methods with patients
  • All staff need to encourage use of the online system.
  • Prepare all staff to brief patients using an agreed ‘script’.
  • Reassure patients about how they can access services and that face to face care always remains available when clinically appropriate. Explain the benefits of a triage approach to improve access to care from the right person at the right time, using a consultation approach that is personalised to their needs (and that this may not be online).
  • Send an SMS to all patients with the same wording. Inform your PPG, patient groups and other stakeholders. Use social media or webinars to explain the new system and help familiarise patients with the technology. Consider how you will raise awareness within your local communities.
  • Attach a message about the OC service to repeat prescriptions.
  • Update posters and messaging given by other HCPs e.g. community nursing, PCN services
  • Tailor language and messaging to fit with your practice population needs, avoiding technical wording. Promotion needs to be sustained.
  • Use local champions and social prescribers as facilitators to support patients with the technology. Find out what support is available locally to help patients go online.* ** ***
  • Advise patients to use online prescription ordering and to nominate their pharmacy. Encourage use of GP Online self -serve services e.g. viewing test results online.
  • Inform patients that their letters, reports and sick notes will be sent electronically or posted if this is not possible

* Online Centres Network, Barclays online resources, AgeUK resources

** Get online @ home – access to low cost computers, laptops and tablets

*** Learn my way – signpost those with access to IT but lacking in confidence or skills to free courses on how to use the internet.
Information and clinical governance
  • Update your data protection impact assessment and privacy policy (see resources).
  • Patients need to know if decision-making is being automated (where a person is not involved in the process) and agree to it – they must have the option to have the decision reviewed manually.
  • Work with your CCG to mitigate clinical safety risks. A clinical safety risk assessment DCB0160 should be carried out by the CCG on behalf of their practices, with individual practices working collaboratively with the local clinical safety officer (see resources for templates).
  • Update your safeguarding and chaperone policies to include remote consultations.
  • Make sure you are familiar with guidance on remote intimate clinical assessments.
  • Ensure all staff know how to identify and escalate incidents and concerns. Adapt existing processes for recognising, analysing and learning from critical incidents.

Using total triage

Going-live
  • Avoid launching the service on a Monday or Friday.
  • Provide a copy of the new workflow to all staff.
  • Aim to have a floor-walker to troubleshoot on launch day.
  • Have the phone numbers for your supplier and local IT support to hand.
  • Launch when you are expecting to have a full team.
  • Consider extra clinical cover for the first few weeks to have a capacity that exceeds demand for a period of time to ‘work off’ the backlog.
Monitoring
  • Use data provided by your supplier to:
    • monitor demand patterns and keep staff rotas under review
    • review high level data on how patients are being triaged – this will support the rapid identification of issues within the model for clinicians
    • understand who is and isn’t using the system
  • Seek feedback from patients, carers and staff to improve the service.
  • Share feedback with your supplier to improve the user experience.
  • Have a daily team catch-up initially to maintain momentum, keep staff motivated, share feedback and agree any further changes.
  • Monitor clinical safety risks and how well risk management activities are working.
  • Ensure the service is being delivered in a consistent way. Feedback to staff and regularly refresh staff training.
  • Optimise with support from regional/local implementation resource (treat it like a service improvement initiative).
  • If your practice struggles to meet patient demand within your available resources, speak to your local digital first leads or PCNs for shared learning and your commissioners and local implementation teams for further support. Look for failure demand and avoidable contacts.

Implementing total triage across primary care networks

Collaboration between practices, primary care networks (PCNs) and community services has supported sustainability of services as pressure on the health system has escalated. Setting up a virtual hub offers practices the opportunity to share staff, resources and workload (both administrative and clinical) within their PCN(s) and wider. Remote consultations could be managed centrally by a group of clinicians working on behalf of the PCN(s), provided there is appropriate technical infrastructure. Clinicians need to be able to triage and consult as if they were physically present in a GP practice. Record sharing and smart card access should be enabled across PCNs/sites if it is not already.

For resources on virtual hubs see the online consultations implementation toolkit section on the eHub under practice implementation (page 52).

Appendix 1: Practical guidance for reception staff in managing workflow

1 When patients make contact

  • When a patient telephones the practice, encourage them to use the online system instead (follow-up with an SMS link to the website). Research shows that encouragement from practice staff increases willingness to
  • Encourage support from carers/relatives/proxies in using the digital
  • For non-digital users, reception staff can fill in the online form on the patient’s Depending on the online system used, suppliers may offer a very short version of their online form as a template within the clinical system for administrative staff to use.
  • Avoid directly booking patients who telephone the practice into an appointment (although there may be some agreed exceptions). This prevents disincentivising use of the online system. Explain to patients how the information they provide will help the clinician. It is more complex to manage contacts if they come into the practice through multiple As patients feel confident about accessing help when they need it, they seem to manage their demand better.
  • Discourage patients from attending the practice to book appointments. If they do attend in person, demonstrate the process using a smartphone or kiosk (after following COVID-19 protocols).
2 Doing the signposting

Agree who and how often staff will monitor either a dedicated inbox or the online system for incoming online requests. Admin staff should go through incoming online requests, validate the patient’s details against the clinical record and take the following steps:

  • Filtering – identify admin queries and pass these to the correct member of
  • Red flags – identify obvious red flags that indicate the need for an emergency response using existing protocols and escalation Approved OC platforms advise patients not to use online requests in an emergency and some automatically redirect ‘red flags’ to urgent and emergency services.
  • RAG rating – if a problem appears very urgent, the reception staff should flag it as urgent and ensure it is seen by a clinician within Some OC platforms will flag these automatically for the admin staff and/or direct to NHS 111 out-of-hours.
  • Distribute workload – send the request to the appropriate member of the team or Ensure everyone knows which work goes where, including nurse, pharmacist, administrative (urgent and non-urgent) and GP staff, to make best use of expertise.
3 Clinician triages the request and responds to the patient using the method that best meets their needs (online, phone, video, face to face)

  • Consider the patient’s level of confidence with different consultation formats, access to technology and preferred method of engagement, matching the mode of appointment to their needs.
  • When booking an appointment, send the patient an SMS or consider a quick Some people don’t check their emails and then inadvertently do not attend.
  • For telephone or video appointments, give patients a precise time frame during which the clinician will call, or an exact appointment The message should tell the patient to call the practice if they think they need more urgent attention.
  • Regularly check with the patient that you have the correct mobile number. Patients should be advised to use a private mobile

Due to the risks of COVID-19, the current recommendation [GP Standard Operating Procedures, August 2020] is that all requests are triaged by a member of the practice team first to manage any infection risk before a face-to- face appointment is offered.

Appendix 2: Top tips on online consulting

1. Aim to respond promptly

Experience shows that a prompt initial response to clinical requests, ideally within two hours (as opposed to an ‘end of next working day’ response), even if it is simply letting the patient know their consultation is being reviewed, leads to greater patient satisfaction, safer identification of urgent problems and avoids duplicating work (such as failed encounters, the patient calling the practice thinking they have been ignored, or trying to bypass the system). Some forms allow practices to communicate bespoke response times for different types of queries. Set expectations that are feasible and according to safe clinical thresholds.

2. Don’t be daunted if you see a lot of requests

A list of OC requests can usually be done very quickly. Use messaging where possible. If arranging a face-to-face review, consider whether it will change the intervention – discuss dilemmas with colleagues and make decisions collectively. If phoning patients or using video, make use of all the information available. Provide a precise time window for appointments so patients can prepare and find a quiet, safe and private location for the consultation, provide the name of the clinician who will be calling and let patients know if there is a delay. We have learnt that you can save a lot of time by:

  • trying to avoid repeating data collection and instead summarising the information you have and clarifying if anything has changed or checking specifics
  • arranging next steps remotely when possible (eg requesting 2-week wait referrals where indicated)
  • asking patients to use online/remote consultations for follow-up (consider scheduling a diary entry as a safety net)
  • keeping calls short if it becomes clear that a face-to-face review will be needed
  • following up with a short summary or link to key points via an electronic message

3. When communicating with a patient online

  • Be clear about who is responding – e.g. give your name and role in the practice and be clear if admin staff are responding on behalf of a clinician.
  • Check the patient’s understanding of management plans and provide appropriate safety netting with specific instructions that the patient can refer back to.
  • Make sure patients are told how they can ask questions, query a decision or discuss something further.
  • Before sending clinical information by SMS, ask the patient if they are happy with this mode of communication (but avoid using this route for sensitive or urgent issues).
  • Consider the wording of messages and how this may be received by the patient – think ‘how would I feel if I got this response?’
  • Be alert to written cues: e.g. you might be able to identify a patient’s concern through the language they use.
  • Avoid jargon and acronyms, use large text, keep sentences short. Structure your response.
  • Provide information and/or a demonstration (e.g. via online videos or champions) for patients on using the online and/or video consultation system including a code of conduct. Guidance should include advice on what to do if the technology is not working. Receiving information in advance helps patients feel prepared and supported.

4. Pass the online consultation to the patient’s regular clinician

  • If the request is non-urgent, pass it to the patient’s usual clinician.
  • If a patient later requires a further consultation, pass this to the clinician who originally dealt with the online consultation.

5. Quick wins

  • Add links to advice on NHS.uk, send attachments or digital leaflets to your messages.
  • Use pre-set messages or questions that you can customise.
  • Code using templates provided by suppliers.
  • Update any outstanding QOF items.

6. Try to do today’s work today

  • If a patient needs to be contacted, book this for the current session rather than a future date wherever possible (also consider continuity). This is more sustainable than having a surge of appointments later.

Resources