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Evaluation of telephone first approach to demand management in English general practice: observational study

BMJ 2017; 358 doi: (Published 27 September 2017) Cite this as: BMJ 2017;358:j4197

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Re: Evaluation of telephone first approach to demand management in English general practice: observational study

Vaona et al raise an entirely legitimate question in respect of training of staff delivering telephone triage as a potential determinant of the outcomes observed by Newbould et al, but also in ESTEEM.

In ESTEEM [1] [2] - the largest randomised controlled trial of telephone triage to date - we were careful in respect of the training provided to practice personnel, and have documented this fully and in detail in our published monograph[3] (pages 7-10 & Appendix 14) as well as in the main paper emanating from the study. In particular, training for nurses delivering triage was provided by qualified trainers, followed by a 1-month period of 'settling-in' use, and then an assessment of proficiency of nurses undertaken by training staff prior to their involvement in delivering the study intervention. We acknowledge the heterogeneity of nurse experience amongst nurses participating in ESTEEM, and we have provided evidence[4] that more experienced nurses were substantially less likely to recommend follow-up for telephone-triaged patients than were practice nurses (both groups having received the same training in trial procedures). We also acknowledge that some nurses and GPs may have already received training in telephone consulting prior to participation in the trial – for example, we have reported that a greater proportion of nurse practitioners felt they were ‘well prepared for triage’ when compared with practice nurses.

GPs delivering telephone triage received no additional clinical training since such care is a routine part of primary care delivery and we wished to assess a ‘doctor-first’ approach in the GP-triage arm of the trial, drawing on the usual clinical care approaches being adopted as a component of this complex intervention. In addition, practice teams did receive training in the introduction and delivery of study interventions, research procedures, and practice-system implications of introducing triage.

Given this approach, we feel it is unlikely that the variation we observed in increased workload in the intervention arms is attributable to shortcomings in our carefully implemented training procedures included as part of the trial. Future research regarding telephone triage should, however, include a careful consideration of the points raised by Vaona and colleagues.

John Campbell, professor, University of Exeter, UK
Emily Fletcher, trial manager, University of Exeter, UK
Fiona Warren, statistician, senior lecturer, University of Exeter, UK
Anna Varley, senior research associate, University of East Anglia, UK

1. Campbell, J.L., et al., The effectiveness and cost-effectiveness of telephone triage of patients requesting same day consultations in general practice: study protocol for a cluster randomised controlled trial comparing nurse-led and GP-led management systems (ESTEEM). Trials, 2013. 14(1): p. 4.
2. Campbell, J.L., et al., Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis. Lancet, 2014. 384(9957): p. 1859-1868.
3. Campbell, J.L., et al., The clinical effectiveness and cost-effectiveness of telephone triage for managing same-day consultation requests in general practice: a cluster randomised controlled trial comparing general practitioner-led and nurse-led management systems with usual care (the ESTEEM trial). Health Technol Assess, 2015. 19(13).
4. Varley, A., Warren, F.C., Richards, S., Calitri, R., Chaplin, K., Fletcher, E., Holt, T.A., Lattimer, V., Murdoch, J., Richards, D.A., Campbell, J., The effect of nurses' preparedness and nurse practitioner status on triage call management in primary care: A secondary analysis of cross-sectional data from the ESTEEM trial. International Journal of Nursing Studies, 2016. 58: p. 12-20.

Competing interests: No competing interests

10 November 2017
John L Campbell
Professor of General Practice and Primary Care
Emily Fletcher, Fiona Warren, Anna Varley
University of Exeter Medical School
St Luke's Campus, Exeter UK