Helen Salisbury: Triage is for disasters, not everyday general practice

In a crisis, you need triage. The term was widely used in the first world war for sorting wounded soldiers into groups, according to the severity of their injuries. It meant prioritising those who would benefit most from early treatment, ahead of casualties who were unlikely to survive and those whose wounds were less serious and could be treated later. Outside of warfare the process is used wherever medical needs exceed available capacity, so it’s interesting to read new planning guidance from NHS England, which recommends that all general practices should embed “total triage.”12

This is not a change I’m ready to make. Out of necessity, in March 2020 we switched to a consulting model where the first contact with a clinician is by phone. Then, if the patient and doctor agree that a face-to-face meeting is necessary—and provided there are no covid symptoms—the patient is invited to the surgery later that day or at a future date, depending on urgency. Wherever possible our patients see the same clinician, who picks up from where the call ended.

This isn’t necessarily efficient, as there’s inevitable duplication of work in creating two appointments, one by phone (or sometimes video) and one face to face. Although some patients are glad of the convenience of a phone consultation, others may not feel fully assessed, and as a doctor I’m aware of the limitations. Whatever we call this “telephone first” model, it’s not triage.

Triage (away from war, plague, or natural disasters) involves the patient outlining the nature of the problem in advance, either by phone to a receptionist or on an online form, and this being directed to an appropriate staff member for action. For tech savvy patients the relative ease of submitting online may increase demand, leading to early inquiries about self-limiting symptoms, while for others the form may be so off-putting that they give up, adding to an ever widening digital divide. Arguably, the patients who need us most—older patients and those with poorer health literacy—are the least likely to fill in an e-consult form, reinforcing the inverse care law.3

Occasionally, filling in a form may help patients to organise their thoughts, thus preparing them better for a consultation, and simple questions may be answered without the need for a consultation at all. However, this doesn’t reflect most of my experience: I talk to patients about whatever symptom has triggered the appointment, what else they’re worried about, and any aspect of their health that concerns me. A consultation that starts off being about blood pressure may end up focusing on alcohol misuse, and a request for a sick note for a bad back may lead to a discussion of depression. The general practice I joined is centred on long term relationships with patients and their families; the future is very bleak if instead it involves hours of sifting through e-consult forms from patients you don’t know, the surgery transformed into a call centre rather than a clinical space. I don’t think that this will entice many young doctors into general practice, and it won’t serve our patients well.

Triage is for emergencies. Can we start planning for a time when it’s no longer necessary?