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PRIMARY CARE: David A Richards, Lesley Godfrey, Jane Tawfik, Mike Ryan, Joan Meakins, Evelyn Dutton, and Jeremy Miles NHS Direct versus general practice based triage for same day appointments in primary care: cluster randomised controlled trial BMJ 2004; 329: 774 [Abstract] [Full text]

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Out of Hours telephone consulting by nurses and doctors

Stephen E Hugh   (5 October 2004)

Precise method of nurse triage is crucial

Mark A Vorster, David Stott   (11 October 2004)

Out of Hours telephone consulting by nurses and doctors 5 October 2004
Stephen E Hugh, GP & Medical Manager, Shropdoc Shropdoc, Prospect House, Belle Vue, Shrewsbury. SY3 7NR Send response to journal: Re: Out of Hours telephone consulting by nurses and doctors	This article highlights a very important difference between NHS Direct and Primary Care - how a nurse consults and the previous professional experience of the nurse. The future of out of hours Primary Care is planned with NHS Direct playing a major role in fronting the service for patients. Experience at a number of larger Exemplars in which large GP co-operatives and NHS Direct have developed joint working protocols has shown similar findings to this study. These are: 1 The pathway to face to face care for patients is longer and more complex when NHS Direct takes the call. 2 The decision making by NHS Direct is more cautious than the decision making by doctors and nurses that work in Primary Care. This leads to a higher referral rate to other agencies, including GPs, A&E and the ambulance service. 3 The cost per patient contact is much higher when NHS Direct front end out of hours calls. NHS Direct can be up to 5 times as expensive as a GP co-operative. 4 There is little or no professional feedback of decisions made within NHS Direct. There is little or no on-going learning that is related consultation experience. The experience of the co-ops involved has not been properly reported and shared. Lessons that need to be learned have not been reported. The future of out of hours care needs to take account of normal working practice in Primary Care. The introduction of NHS Direct and the CAS decision making software introduces a new way of working for nurses. It is different to the rest of Primary Care and large co-ops do not have faith in NHS Direct to be able to deliver high quality Primary Care triage. Telephone consulting is a skill that is developing in Primary Care, in both doctors and nurses. The requirement to follow computerised algorithms at NHS Direct conflicts with the need to use good communication skills, which are so important in dealing with potentially distressed patients. Triage is an important tool in the filtering process that many parts of the NHS require. Telephone consulting allows triage to take place with great convenience for the patient. The communication skills so highly prized in Primary Care are a much better starting place for patient care than computerised algorithms. Competing interests: None declared
Precise method of nurse triage is crucial 11 October 2004
Mark A Vorster, General Practitioner Regal Chambers, 50 Bancroft, Hitchin, Herts SG5 1LL, David Stott Send response to journal: Re: Precise method of nurse triage is crucial	Dear Sir Regarding the recent paper by Richards et al (1), there may be a risk of viewing the term ‘nurse triage’ as a monolithic concept. It is unfortunate that to many health workers nurse telephone triage equates to NHS Direct. We thought it would be pertinent to describe our experience of nurse telephone triage within general practice using non algorithmic computerised decision support (CDS). At Knebworth surgery in Hertfordshire we used TAS CDS (2) from 1998 to manage patients requesting same day attention. Our initial experience was published (3) and also presented at the Annual Conference of UK Federation of Primary Care Research Networks in 2000. One question that arose was the financial implications to the practice. In 1999 we carried out a randomised controlled trial with randomisation at the point of initial patient contact (191 patients had nurse telephone triage vs 183 granted their initial request) with a follow up period of 28 days. A time and cost analysis (using costings current at the time from PSSRU (4)) was conducted including all contacts with personnel funded by the practice and prescription costs. Results were based on complete data for 135 triaged and 141 control subjects and showed a significant reduction in GP time per patient from a mean (SD) of 13.03 (13.19) minutes in the control group to 7.36 (10.27) minutes in the triaged group. Costs were significantly reduced in the triaged group by £8.70 per patient (95% bootstrap C.I. -14.15 to -3.17). Despite some limitations of our study such as insufficient analysis of contacts external to the practice, and a small sample size we feel that the indication of cost savings to the practice with nurse telephone triage with CDS was a strong possibility. Our patients and nurses indicated support for this ‘near patient’ triage method. References 1. Richards D et al NHS Direct versus general practice based triage for same day appointments in primary care: cluster randomised trial BMJ 2004;329:774 (17th September) 2. Telephone Advice System v5 (from Plain Software) www.plain.co.uk 3. Vorster M Behind the lines Health Serv Journal 20 May 1999 pp24-25 4. Netten A, Curtlis L Unit costs of health and social care. Canterbury: University of Kent at Canterbury, Personal Social Services Research Unit 1998 Mark Vorster FRCS (Eng) MRCGP General Practitioner Regal Chambers, 50 Bancroft, Hitchin, Herts SG5 1LL e-mail: mark.vorster@GP-E82075.nhs.uk David Stott BA D.Phil MSc Statistician Health Research and Development Support Unit, University of Hertfordshire, College Lane, Hatfield, Herts AL10 9AB e-mail: d.j.stott@herts.ac.uk Competing interests: Mark Vorster: Clinical Consultant for Plain Software since 2000