Total Triage fatigue
While Total Triage and eConsults were embraced in response to the pandemic, some GP practices are now having to switch off online services at the weekend due to the demand. In this blog, I imagine how it would look like to explain my ‘Total Triage fatigue’ to a triage platform…
Welcome to Triage2021 the digital eConsult and Total Triage platform.
This system uses state of the art computer algorithms to help you get the most from your GP, at any time of day and night, and at any level of inebriation.
Tell us how we can help you?
I think I may be suffering from Total Triage Fatigue.
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Please provide us with details of your problem.
Well, it all started with the pandemic. As you know all GPs had to move really quickly to remote consultation in order to protect our patients. We were advised to adopt "Total Triage" as a Standard Operating Procedure, with all patients being screened via phone, video or an eConsult like this one.
To be honest, it was quite nice at first. Little electronic messages would appear with detailed breakdowns of what was wrong, maybe even a photo. It was quite handy. Some could be managed without even picking up the phone – not many admittedly – but it was a start, and if nothing else for the first time in my career I actually had a good idea of what the problem was before I spoke to the patient. It felt like it might genuinely be the great shining electronic future we had been promised. Until it wasn't.
Because, of course, in those early days it's what our patients wanted too. No-one wanted to come near us because they saw us as potential plague carriers. So remote management was fine, and the numbers were manageable. Gradually though it's morphed from lifesaver to millstone.
Whilst many of our most vulnerable patients remain terrified of COVID, others imagine it's all over. To the point that they're marching in the streets demanding the end of lockdown, even though it's already ending, and despite the backdrop of terrifying escalations of infection in India. So, there's no longer any particular fear of contacting the doctor. Which means those consults are flooding in. Where before healthcare was essentially rationed by time and need, now there's a lovely big open door – and it's exhausting. We're doing 2-3 times more work, yet enforced remote working means patients think we're less available than normal.
Is this a problem your GP already knows about?
Have you tried anything to treat yourself?
Sure. We've tried doing what you're meant to do. Looking at the bazillion eConsults and either sending replies back telling the individual to book a routine appointment or giving advice. The problem is that such replies usually just result in another eConsult. Or a phone call. Or both.
We've considered just turning eConsults off entirely, but of course we're contractually obliged to keep offering them, so there they are. In the end we thought we'd just wait it out – hoping that once vaccinations kicked in and the pandemic resolved, or at least settled into a new normal, we'd be able to start bringing people down the old fashioned way. But apparently that's not an option, as NHS England is keen that they become embedded into General Practice for the foreseeable future.
Is there any particular treatment you would like to request?
The freedom to go back to doing what we did before, I suppose – working out what approaches were best for our local population, and the sustainability of the service. Rather than this bizarre "one size fits all" approach. I mean, I continue to offer video consults, but not one person has taken me up on it for 6 months now. It's not what my patients want or need at the moment.
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Would you like help from a particular person at the surgery?
It would be nice to have more of a conversation with someone about this. NHS England has insisted it's the future with little discussion or debate. The closest I've seen to an explanation was a Tweet from Nikki Kanani which read more like a combination of beat poetry, a motivational poster and those weird "Love is…" cartoons from the 70s. Here's her explanation:
Because... we want to keep patients and staff safe.
Because... we want to help get the balance right to reflect the needs of the individual and the workforce.
Because... it’s really tough out there so we need to make thoughtful decisions, at the right time.
Which is lovely, but I'm not sure Total Triage delivers on any of those things. With respect to safety, whilst remote healthcare reduces footfall in the surgery, it also risks missing diagnoses. At the height of the pandemic the risk/benefit ratio was clear, but post-pandemic I would be less certain of that. Meanwhile the idea that it helps keep the balance for individual vs workforce is evidently ridiculous if doctors are drowning in eConsults – not just because of the capacity issues, but because many of our more vulnerable patients are less able to access digital solutions in the first place, creating potential inequity in services. Yes, it's really tough, which is why perhaps, reading a consult sent by a drunk patient on a Friday night who doesn’t even remember it when you ring them on Monday morning, isn’t a great use of a doctor's time. You get the idea.
Besides, whatever happened to evidence-based medicine? Pre-COVID the evidence for this sort of stuff wasn't brilliant, and nothing's really changed:
- "Doctors conducting telephone consultations were less likely to have gathered sufficient information to exclude important serious illnesses." –BMJ Quality & Safety 2010;19:298-303
- "There was no evidence to support claims that the approach would, on average, save costs or reduce use of secondary care." –BMJ 2017;358:j4197
- "Both approaches (video and telephone consultation) appeared less ‘information rich’ than face-to-face consultation." –BJGP, 2019; 69 (686): e595-e604
It turns out, unsurprisingly, that medicine is just done better face to face. There is, maybe, possibly, some evidence that Total Triage reduces A&E attendance – though that offers little succour to exhausted GPs.
I know Matt Hancock likes doing it on his app at 3am, but he's not our average patient.
Let us make our own decisions about what will work, what is safe, what will strike the right balance.
Because… We'd really like to get back to doing our jobs properly again.
CHRIS'S ANSWERS ABOUT HIS CONDITION END HERE.
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Total Triage and the balloon that never flew
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