During April, the Digital Health and Care Alliance (DHACA) in partnership with the AHSN Network ran two webinars to explore how practices are implementing ‘total triage’ solutions during COVID-19. The webinars featured representatives from some of the companies supplying total triage systems (eConsult Health, Klinik UK and AskmyGP), as well as patients, GPs and practice staff.

Charles Lowe (Chief Executive of DHACA), Mary Hudson (Deputy Director for Digital First Primary Care at NHS England and NHS Improvement) and Guy Boersma (National Lead for Digital and AI for the AHSN Network) all took part in the sessions.

Here Charles Lowe, Mary Hudson and Guy Boersma reflect on the speed at which practices have adopted online contact systems since the start of the pandemic and the range of benefits already being realised.

The move to greater use of online triage and video consultation in general practice has long been on the cards and in many areas was already underway, but since COVID-19 it has been rapidly accelerated.

There is an obvious need at the moment to minimise footfall into practices in order to reduce risk of infection for both staff and patients, and NHS England and NHS Improvement have therefore asked all practices to triage all initial patient contact.

Prior to the outbreak, the vast majority of general practice work was face-to-face. This has seen a dramatic reversal, with indications that more than 90% of patient enquiries and requests are now being dealt with remotely. While GPs might not maintain such a high level of remote contact post COVID, it’s safe to say the increased use of online systems is here to stay.

The benefits of total triage

During our webinar, clinicians and patients highlighted five main areas of benefit they are already experiencing.

1. Resilience and reliability

GPs stressed how online triage has hugely improved both resilience and resulting reliability. The online systems are flexible enough to cope with self-isolating doctors, self-isolating patients and even temporary loss of practice premises (for instance when a practice was taken over as a COVID-19 control centre). For practices with premises spread over a wide geography, this benefit extends to the ability to switch resource usage quickly, such as when staff in one area are forced to self-isolate or, as quoted by Dr Sanjay Kotegaonkar (Clinical Lead for Information Management and Technology at Bury CCG), when one of their doctors had a car crash.

2. Access

There has been a significant and immediate reduction in patient waiting times for GP contact. Dr Tim Dalton (Clinical Chair at Wigan Borough CCG) said that waiting times at his practice reduced from three weeks down to one day on implementation of their system, and has now further reduced to just 30 minutes. In the experience of Dr David Brandon (Lead GP at Christmas Maltings & Clements Practice in Haverhill, Suffolk), this reduction has generated additional benefits: patients no longer vent frustration on the GP for the time taken to access them, saving even further time and improving the experience for both staff and patients.

Dr Thomas Patel-Campbell (GP Partner at the Haxby Group in York and Hull) explained that as their reception team now works more closely with the clinicians in channelling patient requests to where they can be best resolved, both staff and patients are much happier, and staff are more committed.

3. Time to care

Possibly the most surprising finding shared by those on our webinars is that online triage and remote consultation are especially beneficial for those who are vulnerable, need extra care, and do not like using electronic devices. This is because the system frees up both the phones (calls are down over 50%) and clinician time and, as Dr David Brandon put it, changes prioritisation from a “want system” (where those shouting loudest get priority) to a “need system” (where medical condition determines priority).

The result is that there is now more time “to look after your most needy patients better”. Examples included being able to contact patients proactively, to make regular blood pressure checks for example, rather than being reactive.

As the purpose of each consultation is set in advance, an additional benefit observed by Dr Sanjay Kotegaonkar is that GPs no longer get “58 problems thrown at me in one 10-minute consultation”. Sanjay reports that his patients seem more relaxed now as they know they can get through to him if they need to and aren’t ‘saving up’ lots of issues for a single appointment. This feeling of security for patients through knowing they can get a service when they need it is a newly-identified benefit.

From the patient perspective, Christine Gratus, member of the Patient Participant Group (PPG) from Florence Road Surgery in Ealing observed that online “gives you time to get your thoughts in order” so you can, for example, work out when the pain first started rather than guessing because you are time constrained in a face-to-face consultation. She summed it up as “one of the best things that’s happened to the practice in the 37 years I have been with them”.

Christine also welcomed the option to receive a response other than by phone, as GP phone calls often seem to come at awkward moments. This opportunity for asynchronous dialogue also allows patients to think through the questions they want to ask and the histories they want to give. Patients report feeling empowered by this.

4. Improved satisfaction

Two important points surfaced during our webinars. The first is the ability to widen the contribution of professional staff by creating a multidisciplinary triage hub. This means patients receive improved quality of care by a greater range of specialist services sharing the decision-making.

The second is that the improvement in speed of response and resulting improvement in patient outcomes affects patients, practice staff and clinicians equally. Raxa Popat, Chair of the PPG at Florence Road Surgery, commented that GPs in her practice specifically mentioned improvement in job satisfaction resulting from managing an issue from start to finish, and from always being prepared because they know who is coming through the door next.

5. Improved efficiency

Finally, efficiency improvements were highlighted by all the webinar participants. Dr Tim Dalton made an interesting observation about his practice where the change to total triage has enabled a review of all their processes, leading to even more benefits. Tim specifically mentioned lower locum bills, and the reduced need to employ staff.

Case study

Dr Peter Devlin, GP Partner, Benfield Valley Health Hub

“The introduction of the Klinik system has been a game changer for us. What has been most striking has been the quality of the information that patients submit in their online request, often not just giving a comprehensive history of their presenting condition, but also indicating what matters to them most. This is at least in part because of the design of the user interface, which replicates good history taking and clinical assessment algorithms. This radically reshapes the flow of the subsequent consultation, allowing for much more time to be spent on shared decision making and collaborative problem solving.

“The dashboards, for the first time, give the whole practice team visibility of the flow and type of demand that we experience, broken down by hour of the day, which enables us to flex our capacity and responsiveness in a way that we simply could not have begun to do under our old systems.

“The implementation process could not have been smoother, and the Klinik team could not have been more responsive and helpful to us.”

Final thoughts

Huge credit must be given to practices around the country for making these changes at such speed. But it’s important to note that the move to total triage is not just about the technology and ‘turning on’ a system. This has to be an improvement journey.

Even when a system is in place, practices need to optimise to how they use it and get the most out of it, continuing to develop their system to improve patient contact, experience and pathways. Colleagues from AHSNs, NHSX, NHS England and NHS Improvement have a key role to play here in working with local commissioners to provide this support and capability building to practice teams in the coming weeks and months.

Join the next DHACA webinar

In the next webinar, hear from some of the winners of the TechForce19 challenge who are developing their digital solutions to support the vulnerable or isolated during COVID-19. Full details and how to book here.