Our findings show that introducing either GPT or NT resulted in an increase in the number of primary care contacts in the 28 days following a patient’s request for a same-day consultation with a doctor when compared with practices’usual processes for handling such requests. Triage was associated with an overall reduction in GP face-to-face contacts. However, GPT resulted in an increase in GP telephone and face-to-face contacts when combined together, whereas NT resulted in a reduction in this measure. These changes reflect redistribution of GP workload from face-to-face to telephone consultations following the introduction of GPT, and redistribution of workload from GPs to nurses following the introduction of NT.
However, when considering differing patterns and duration of patient care across all three arms, there was no difference in 28-day health-care costs of patients. Triage appeared safe, and no differences in patient health status were observed across the arms. NT was associated with a small reduction in patient satisfaction compared with GPT or UC.
Primary care contacts in the 28 days following a same-day consultation request
Our primary outcome was the number of contacts undertaken in primary care settings (GP practices, out-of-hours primary care services, walk-in centres and A&E departments) in the 28 days following a same-day face-to-face GP consultation request. Our findings in relation to the primary outcome are clear. Implementing triage, whether GP- or nurse-led, resulted in additional, not substituted, workload.
In UC, 51% of patients received only one contact across the 28-day follow-up period following a same-day consultation request. In contrast, this proportion was reduced to 23% in GPT and 12% in NT.
In this study, 16,211 patients generated 39,736 consultations with a clinician in the 28 days following a same-day consultation request. Of these consultations, 22,471 (57%) took place on the index day. Across the 28-day period, only very small numbers of patients (550 in total) were seen in A&E and there was no evidence that either form of triage increased or reduced attendances at A&E.
Our main ITT analysis demonstrated that GPT resulted in a relative increase in the rate of primary care contacts across the 28-day period of 33% when compared with UC; the equivalent increase following NT was 48%. A small increase (4%) in the rate of contacts was observed when NT was compared with GPT. As to be expected, per-protocol analysis of the primary outcome demonstrated an intensification of the treatment effects of both GPT and NT. The findings of the main ITT analysis were robust to the use of imputed data for cases where primary outcome data were not available.
In recognition of the inevitable need for a proportion of patients to be seen face to face following triage, we undertook a sensitivity analysis in which we combined all within-practice contacts on the index day as just one contact. This analysis demonstrated an increased rate of contacts in GPT of 10%, and in NT of 12%, when compared with UC.
Interpreting the ITT analysis of the primary outcome in conjunction with the above sensitivity analysis, it is evident that there was an increased rate of contacts over the 28-day period in both triage arms compared with UC.
Additional sensitivity analyses were undertaken, based on dividing the primary outcome chronologically into contacts taking place on the index day only (‘day 1’) and those taking place during the remaining 27 days of the 28-day follow-up period (days 2–28). Considering only contacts taking place on the index day, the rate of contacts in GPT compared with UC was increased by 51% and in NT by 72%, largely attributable to the telephone call undertaken in triage. There was an increased rate of contacts in NT compared with GPT of 14%–again, largely attributable to the telephone call undertaken in triage. The increased rate of contacts in the triage arms was greater on the index day than on the subsequent follow-up days.
Care on the index day
Numbers of contacts and disposition of patients
In UC, a substantial majority of patients (87%) received a GP face-to-face contact, with no further primary outcome contacts on the index day. Other patient pathways were represented by substantially smaller proportions of patients.
In contrast, patients in the triage arms had more diverse patterns of patient management when compared with UC, possibly reflecting a more flexible approach to patient assessment and management in the triage arms.
Where GPT was implemented, 46% of patients received only the GP triage contact on the index day, and 36% received a GP face-to-face consultation on the index day following the initial GP triage contact; a smaller proportion (9%) of patients had a nurse face-to-face consultation on the index day following their initial GP triage contact. A small proportion (6%) of patients received a GP face-to-face consultation on the index day instead of being managed under the triage system.
Where NT was implemented, 22% of patients received only the nurse triage contact on the index day, and 56% of patients received a GP face-to-face consultation following the initial nurse triage contact; 9% of patients received a nurse face-to-face contact following nurse triage. For a small proportion of patients (9%), their first contact on the index day was a GP face-to-face consultation instead of being managed under the triage system.
Distribution of clinician time in practice
Considering workload from the perspective of the GP, the introduction of GPT was associated with a 55% reduction in the rate of GP face-to-face contacts on the index day (compared with UC), although there was a 49% increase in the rate of GP overall telephone and face-to-face contacts combined. Across the whole 28-day follow-up period, the reduction in the rate of GP face-to-face consultations was smaller (39%), reflecting the deferral of some workload from the index day to the follow-up period, whereas there was a 38% increase in the rate of GP telephone and face-to-face contacts combined.
Introduction of NT was associated with a 31% reduction in the rate of GP face-to-face consultations on the index day (compared with UC), and a reduction of 28% in the rate of GP telephone and face-to-face contacts combined. Across the whole 28-day follow-up period, there was a 20% reduction in the rate of GP face-to-face consultations, with a 16% reduction in the rate of GP telephone and face-to-face contacts combined.
In considering these observations regarding GP contacts, it is worth noting that the introduction of GPT involved GPs undertaking the work of triage in addition to the (reduced) number of face-to-face contacts; in contrast, where NT was introduced, nurses, not GPs, delivered the triage element–delivering the resulting‘gain’to GPs in reduced numbers of GP face-to-face consultations.
Taking account of both the number and type of contacts in the practice (whether with a GP or nurse, face to face or telephone) and their associated durations provided additional insight into clinician workload, which were somewhat different from those based solely on the number of contacts. In UC, the estimated duration of patient–clinician contact time within the practice on the index day (based on the first two contacts within the practice) was 9.6 minutes, compared with 10.3 minutes when GPT was implemented, and 14.8 minutes where NT was implemented. The distribution of the time by clinician was, however, markedly different across the three arms.
In UC, the substantial majority (9.1 minutes) of the 9.6 minutes estimated contact time on the index day comprised contact with the GP. Where GPT had been implemented, the estimated GP contribution to the overall workload was 9.0 out of the 10.3 minutes, with nurse contact accounting for 1.3 minutes, the latter usually resulting from nurse face-to-face contact. Where NT had been implemented, of the total 14.8 minutes of estimated contact time provided on the index day, overall, around half of this was with GPs (7.7 minutes), with the remainder (7.1 minutes) with nurses.
Resource use
Overall, the substantial majority of service use in all three arms took place in GP practice settings. Only very small numbers of contacts occurred in A&E, walk-in centres or out-of-hours primary care services over 28 days. The similarity of the rates of contact with non-practice-based services across arms provides no evidence to suggest that triage encouraged patients to seek care outside the practice.
Overall, we observed low rates of patient non-attendance compared with that reported in other studies,2
thus there was no evidence that triage may advantage practices by reduced non-attendance rates. There was also no evidence of differences in patient self-reported use of NHS Direct between trial arms– around 4–6% of participants reported using NHS Direct in the 28-day follow-up period.
Economic analysis
Overall, costs incurred were very similar across all three arms across the 28-day follow-up period. Costs incurred on the index day were observed to be lower in both triage arms; the projected cost saving relating to care on the index day (compared with UC) was approximately twice as much in GPT compared with NT, although overall the absolute differences were modest (£5.75 vs. £2.58 per patient).
Although there is a difference in the number of contacts by triage arm over the 28-day follow-up period, mean costs for primary care contacts (primary outcome) are similar for UC, GPT and NT. This indicates that the costs associated with triage are offset over the 28-day follow-up period, with the added cost of triage resulting in fewer GP face-to-face consultations in practice when patients initially request a same-day GP appointment.
The main area of contact, and cost, is associated with GP consultations in the practice, representing almost 90% of the costs in the UC arm, and data indicate few contacts with out-of-hours primary care, walk-in centre or A&E compared with the level of contact with the GP in a primary care setting.
Estimates of intervention cost for the triage interventions are an important factor in the cost analyses. Estimates of the intervention cost for triage contacts are presented in a transparent manner, and follow the methodology for unit costs in health and social care used by the PSSRU,38which are widely accepted
and used within health service research. The main cost component for triage contacts is the GP or nurse time associated with the triage contact, and this has been collected at a participant level across the ESTEEM trial, providing good quality data on which to estimate unit costs.
Base-case cost estimates, over the 28-day follow-up period, used published unit costs for primary care contacts and A&E contacts. These costs reflect the opportunity cost associated with health-care resources; however, these cost estimates may be open to some limitations. Therefore, sensitivity analyses have been presented, in estimates for the triage contact unit costs and for the estimates of 28-day follow-up cost, to address uncertainty in the use of published unit costs. Where different assumptions have been used for unit costs for health-care contacts, we specifically used lower unit cost estimates that did not include components of cost associated with the qualification costs for GP or nurse contacts, and did not include costs associated with the direct support staff for GPs. Although we saw much lower overall estimates of 28-day costs, we did not observe differences between intervention arms.
In base-case analyses, as per the prespecified analysis plan, we used published unit costs for GP contacts. In so doing, we used an assumption that within-practice GP consultations have a mean duration of 11.7 minutes,38
this being based on an allocation of GP consultation time over an estimated number of GP in-surgery consultations. However, the ESTEEM trial has considered use of triage in the subpopulation of primary care patients for whom a same-day request is made to see a GP. Trial findings indicate that the mean time for a within-practice GP consultation is shorter (estimated 9.5 minutes) than that derived for cost estimates across the broader GP patient population. The difference in the ESTEEM trial population and the data reported for the broader primary care patient group (a difference of 2.2 minutes, a difference of £8.14 at base-case cost assumptions), if supported by future research, may influence the interpretation of findings in the cost analyses presented, showing UC to be less costly than the GPT and NT intervention arms. This would be the case even where the difference in time/cost is smaller, given the estimate for the cost per minute of GP time and the relatively small total costs being compared. It is difficult to know from the trial if this estimated mean GP contact duration (UC) of 9.5 minutes will hold in a larger sample or if GP consultations in the two triage arms would have been equally different (from expected mean of 11.7 minutes). New data are required to inform this issue, as these research questions were not specified in the ESTEEM trial.
One hypothesis may be that a proportion of contacts among the requests for same-day GP consultations are indeed relatively short and could be managed via a triage telephone contact, and it is these contacts (when presenting for a face-to-face GP consultation) that drive a mean duration of 9.5 minutes that is less than expected. What we may be seeing in the triage interventions is that less complex presentations are being managed via telephone triage, and represent those contacts that are resolved at triage level and do not need a further primary care contact. However, an alternative explanation may be that the data from ESTEEM on mean contact time are not comparable to those used to estimate the unit costs for GP
consultations reported by PSSRU,38and the timings recorded in the ESTEEM trials may need to be adjusted
to include an additional allowance for non-contact activities during the consultation time allocated for GPs.
Safety
Triage appeared safe. There was no evidence of excess hospital admissions within 7 days or A&E
attendance within 28-day follow-up period in either triage arm when compared with UC. There was also no evidence of excess deaths within 7 days of the index consultation request.
Patient health status
At the point of completing a questionnaire (around 28 days following the index consultation request), patients reported similar levels of resolution of the original problem in all three arms. Interestingly, around 53–59% of patients across the three arms reported being‘much better’by the time they returned a questionnaire. Thus, around 45% of participants reported significant residual issues related to their original consultation request by the time they returned a questionnaire. Perhaps not surprisingly given these observations on problem resolution, there were no differences in self-reported health status by trial arm, as measured by the EQ-5D. Triage, whether GPT or NT, appeared to achieve similar health outcomes
Patient experience of care
Although, overall, patients’experience of care was met with high levels of satisfaction (in the order of 90% being‘very’or‘fairly’satisfied), patients in the NT arm were somewhat less satisfied than those in the GPT or UC arm. Patients reported that it was easier to get through to the practice on the phone in practices implementing GPT in comparison with UC, and that it was harder to get prompt care in NT by comparison with both GPT and UC. Patients also reported that it was more difficult to see a doctor or nurse if the patient wanted to do so in NT, but not GPT, compared with UC, and that it was harder to get medical advice in NT compared with both GPT and UC. NT was reported as being less convenient than either UC or GPT.
In summary, NT appeared to be somewhat less acceptable to patients than either GPT or UC. There was no significant difference in the acceptability to participants of GPT when compared with UC. GPT overall appeared as acceptable to patients as UC.