The role of triage in Modern General Practice, Park Surgery, Driffield, East Yorkshire

The team at Park Surgery introduced a new triage system in April 2022 to ensure patients in need of urgent GP appointments could be seen, while managing a reduction in the number of appointments available.

Adopting modern ways of working in the rural Driffield practice has significantly improved patient appointment allocation, reduced complaints, and enhanced staff retention.

 Says GP partner Natalie Martin,

“We’ve got a broad variety of clinicians here and people would often be allocated a session with a clinician that didn’t match their needs – their problem wouldn’t be solved, and they would have to come back and use another appointment.

“We were already tight on capacity and due to a number of GP partners leaving the practice we knew we were going to get tighter, so we really wanted to get patients in with the most appropriate staff member’”

The team had heard about the new triage systems available and thought it might help them make best use of the appointment slots available.  The practice already offered online consultation, but they were experiencing some issues.

Natalie’s fellow GP partner at the semi-rural East Yorkshire practice, Jess Airey, explains:

“Usually all of the appointments were gone just after eight…Half of our appointments were being filled from online consultation forms before we’d even turn the phones on.”

“These more tech-savvy people were often our younger and healthier patients. Those that were even more in need would contact us later in the day and we’d have nothing left to offer them.”

The team also hoped a new system would address other issues such as the high turnover of reception staff and complaints about the telephone system.

Natalie adds: “the phone queue was sometimes up to two hours. We were getting more than 2000 calls a day. Lots of them were being abandoned and we were being slated for that on local social media groups.”

Preparation for a new system

Change at the market town practice, which has a list size of around 15,000 patients, began with research. Natalie recalls:

“I audited a month’s worth of appointment data for to see what the problem was.”

“Who appointments got put in with, whether I felt that was right – what the time gap was between booking and appointment was and what I thought would be an appropriate timeframe for it to wait. That allowed me to understand our demand and would later inform what slots to create when creating the new triage system.”

“I also looked at the number of people being directed to the urgent care centre because we were full and in one week we sent 293 people.”

After their consultation with patients via the Patient Participation Group (PPG) the practice continued to interact with patients and keep them informed about what was happening every step of the way.

Natalie explains:

 “We took it in stages, so one month before we went live, we posted on social media to tell patients what was happening and answer their questions. We showed them examples of the system we were going to use, and we worked with our local paper on an article about the changes we were making. We changed the phone message. We changed the website. We communicated with staff and did some training with reception.”

The practice repeated the same steps one to two weeks before the new system went live. They also created guidance materials that could be sent to patients who needed advice rather than an appointment.

It took just six weeks for staff to feel the benefit of the changes in terms of patient behaviour. Despite their patient population previously being averse to change, they have adjusted well to the new ways of working. She says:

“We’re not getting queues outside reception. We’re not getting children turning up ill at 5.00pm. I think they present less with minor issues than they used to do because we’ve been sending them texts with information and trying to educate them about what they can self-manage.”

Natalie adds that “at the beginning, we used to have to go back and ask more clarifying questions. But now they mostly provide the information you need, and patients are used to it – they’re proactive. So, they will send you a photo of their poorly toe or their rash before you’ve asked for it.”

Challenges along the way

 In a normal week, the triage is shared between three GP partners.

“Triaging is a skill that not everybody finds easy, and some people are definitely better suited to it than others” explains Jess

“You need to be able to make decisions quickly and move on. GPs doing triage can deal with quite a lot of requests at source, including providing information around a certain condition, so it doesn’t need an appointment.”

The team have learned a lot along the way.

“People would sometimes make multiple submissions which sometimes could lead to appointment wastage” says Jess

“So we learned to check if people had already got an appointment in the system before giving another one. I think we quite quickly cottoned on to the fact parents with children will often try to submit one online request for multiple people. Because you can only save it in one set of notes each individual person needs their own submission for you to be able to process it.”

The practice also learned to check contact details on the system were correct for each patient, including mobile numbers and consider the type of contact they were using.
Natalie adds:

“A 15-year-old child had an appointment and they’d left their mum’s number on. So the mum got called, but the mum didn’t actually know about the appointment.”
“There are also times when people just need to have a phone call rather than a text, so we are trying to train our team to do that.”

“But to be honest, every problem we had was minor.”

Sticking to a set process was also vital to the teams eventual success. Jess continues:

“One of the key things is making sure that colleagues do not override the parameters you’ve set, because everything’s carefully calculated to deliver the appointments that you expect to need.”

“If people start overriding those appointments, then you haven’t got any left quite quickly. For example, our clinical staff have their own follow up slots and need to use those with their patients. If they start sending self-booking links instead that can derail the system.”

Statistics for success

The positive impact of the changes the team made are evidenced by the figures.

“We would never ever go back in a million years” says Natalie.

“I looked at the urgent care centre referral figures a year after we went to our new triage system and In that same week, a year on it was just seven people in comparison to 293.”

“Our average phone calls per day is now 300 and average wait time on the calls is 7 minutes. We feel like people are getting in with the right professionals. And we’ve got much more control over how we use our appointments.”

The appointment data is also informing recruitment decisions. The team now includes two pharmacists, and they have started training their own nurse practitioners to help meet the demand they are seeing.

The role of data in community working

The new systems mean that the practice team can also keep a watchful eye on emerging healthcare trends in the local area. Natalie explains:

“…we’re perfectly placed to make system changes.”

“We can see what the need is …I know exactly what’s needed in my community because I can see it all coming through here.”

The knowledge of the demand in the community the practice has received through the triage system means the practice have been able to inform community initiatives such as the Acute Respiratory Infection (ARI) hub which gives a holistic respiratory service. This includes spirometry which the practice team feel will improve asthma check uptake for patients, without the need to travel 45 minutes to the local hospital.

Natalie is also the lead for one of the local Integrated Neighbourhood Teams (INTs) – a partnership delivering health projects across the local community. She continues,

“We were looking at young children who often came into practice and working out how we could improve their care.”

“There was a lot of respiratory illness, so that’s how the idea of the respiratory hub came about.”

The team are working collaboratively with their local council this Autumn to show parents how to manage simple illness.  Based on their learnings around the respiratory hub, they are now looking at setting up similar provision for those living with chronic pain.

“We’re looking at people with chronic pain and chronic fatigue, because that’s a big problem in our area. We’re currently reviewing the pain service and potentially trying to set up a new pain hub” Natalie explains.

The information provided by the triage system has also led to a reduction in high dose opioid prescriptions and the practice are also in the top quartile of practices in the local area for appropriate antibiotic prescribing.

The team are also working with seven care homes in the area to reduce duplicative visits and enable them to call on other relevant services in the neighbourhood.

“We’re trying to help them to manage patients more effectively within the care home and to know what’s normal. This means we can spend more time with those that really need it.” adds Natalie.

The meaning of modern general practice

The team feel that the Modern General practice approach helps them meet current demand, given the escalating numbers of people with chronic conditions, increased life expectancy and decreasing number of practitioners.
Natalie concludes: “The triage allows continuity where it’s needed”

“I don’t think you always need to see the same clinician or doctor, because you might have something minor… But if you’ve got complex heart failure and multiple things going on, then you absolutely do. And with the right people doing the triage, recognising complex needs and looking at who the patient has seen before– this can be done.”

For more information about Modern General Practice visit NHS England » Modern general practice model