Skip to main content

Main menu

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers

User menu

  • Subscriptions
  • Alerts
  • Log in

Search

  • Advanced search
British Journal of General Practice
Intended for Healthcare Professionals
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers
  • Subscriptions
  • Alerts
  • Log in
  • Follow bjgp on Twitter
  • Visit bjgp on Facebook
  • Blog
  • Listen to BJGP podcast
  • Subscribe BJGP on YouTube
Intended for Healthcare Professionals
British Journal of General Practice

Advanced Search

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
Editorials

Triage and remote consultations: moving beyond the rhetoric of access and choice

Hilary Pinnock, Gaylor Hoskins, Ron Neville and Aziz Sheikh
British Journal of General Practice 2005; 55 (521): 910-911.
Hilary Pinnock
Roles: Clinical Research Fellow
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Gaylor Hoskins
Roles: Research Fellow
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ron Neville
Roles: GP and a Chief Scientist Office PCRCA Fellow
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Aziz Sheikh
Roles: Professor of Primary Care Research & Development
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info
  • eLetters
  • PDF
Loading

Bunn et al, in their systematic review published in this issue of the Journal,1 review the evidence underpinning the role of telephone consultations in triaging access to health care.1 Remote consulting, however, has the potential to impact far more broadly on clinical practice than simply facilitating triage, and, in so doing, raises important issues around the political imperatives of access and choice. In this editorial, we consider these issues and discuss a number of practical points that need to be resolved.

The telephone is increasingly used to access advice from both general and disease-specific helplines (for example, NHS Direct, Terrence Higgins Trust and Asthma UK) and there is also growing interest in telephone consultations as an alternative to traditional face-to-face reviews of people with long-term diseases.2,3 ‘Texting’ may encourage teenagers and young adults, to use the health service.4 Although use of e-mail consultations is currently limited, the majority of people with internet access (now approximately 60% of the UK population) express interest in using it to communicate with their healthcare provider.5–7 Plans for electronic patient records, linked with the patient's personal internet account (available to UK residents at www.healthspace.nhs.uk) will offer further innovative possibilities for interacting with healthcare professionals.

In parallel with the imperative to improve access, policy rhetoric implies that alternative modes of consultation will offer patients choice about when, with whom, and how they consult.8,9 This may not always be the case. Telephone triage may actually reduce choice as requests for face-to-face appointments or home visits are intercepted by a clinician (usually a nurse) who may address the problem or allocate ‘appropriately’, potentially overriding the patient's original choice of provider and mode of consultation. In such scenarios it is not surprising if telephone calls increase re-consultation rates and may not always be acceptable to the patient.1,10 Similarly, incoming e-mails and text messages are sorted into prescription requests, appointments, and clinical queries and then forwarded to the ‘appropriate’ member of the team.6 From the patients' perspective the ‘dragon at the door’ reputation of receptionists may be being replaced by the ‘triage genie’, ensuring that the doctor remains hard to reach. Real choice of when, where and how a patient is treated,8 requires breaking the link between ‘telephone’ and ‘triage’ — exemplified by Bunn et al1 who observed that the ‘terms were used interchangeably’ — and inviting patients to select the mode of consultation appropriate to their presenting problem and personal preference. Reassuringly, early experience does not suggest that this will ‘flood’ the service with additional work,1,3,6,11,12 but trials incorporating patient preference will be needed to examine the overall effect on workload.

Patients and clinicians should be free to choose and mutually agree the mode of consultation most suited to the task and personal circumstances. Email consultations may be ideal for seeking health information and text messages may economically communicate progress with an understood condition. People with asthma may choose the convenience of a telephone review when their asthma is controlled, but a face-to-face consultation for the assessment of a problem. Preferences may not always coincide, and clinicians must be free to arrange a timely face-to-face consultation if it is clear that an e-mail interaction is inadequate, or if a series of remote consultations fail to resolve an issue. This approach will relieve the unhelpful pressure on a triaging clinician to reduce the number of face-to-face consultations when telephone calls are used to deal with excess demand. Remote consultations are not a panacea for lack of appointments.

The telephone imposes psychological distance and both patients and clinicians may be concerned that they lack the verbal and auditory skills to explain and understand a complex clinical situation in the absence of non-verbal clues.13 E-mail relies on literacy skills as even verbal clues are lost: for some people this may limit its suitability to relatively simple requests for test results, repeat prescriptions or information.6 The practical approach of using previously prepared ‘cut and paste’ messages in reply to e-mail requests for information may lead to an unintended impersonal feel to responses. ‘Texting’ has a language of its own, potentially incomprehensible to the uninitiated, providing a further challenge to successful communication. Systems that impose the type of consultation, or limit face-to-face access to those sufficiently articulate to negotiate telephone triage, risk compromising equality of access.11

In traditional UK primary care, both clinician and patient may have prior understanding of a problem and trust each others' assessment and advice, potentially facilitating remote consultation.14,15 It is less clear how a relationship is maintained if face-to-face meetings are rare, or how trust is built in remote consultations between an unknown patient and advisor. Conversely, the choice of impersonal communication styles, such as ‘texting’ and e-mail, potentially offers patients wishing to ask sensitive questions a less embarrassing option than a face-to-face conversation hampered by avoidance of eye contact.

Despite the policy drive to increase use of these alternative modes of consultation, there are unresolved issues about their official status. For example, UK certification for sickness benefit requires a doctor to sign to say that they, or a colleague, have ‘seen’ a patient. The UK General Medical Services contract sets targets for regularly reviewing people with a range of chronic diseases, but it is not always clear whether the choice of a telephone or e-mail review is acceptable. The lack of reimbursement in some healthcare systems for remote consultations similarly discourages clinicians from offering patients the choice.

The different status accorded to telephone consultations may be reflected in the way appointments are made. It is unusual for receptionists to ask a patient the nature of a face-to-face consultation, yet telephone appointments may be annotated with the reason for the requested consultation, a practice inherited from an era when telephone calls were described as ‘messages’. Patients e-mailing a clinician may not be comfortable with sorting arrangements that involve their message being read by someone other than the intended recipient.7

As the ‘gateway to the NHS’ primary care could lead the development of professional training by including remote communication skills teaching within both undergraduate and postgraduate courses. Computer algorithms have been developed to support telephone advice, an approach that may discourage patient-centred primary care consultations. Safety and security are generic issues that apply to all consultations, but procedures will require adaptation for remote consulting.3,16 The need to ensure that face-to-face or telephone conversations are not overheard is understood: maintaining confidentiality with video, texts and e-communication is similarly important. Software designed to transfer e-mail and text consultations into patient records could facilitate record-keeping and audit trails.

Thinking beyond triage and offering genuine choice of mode of consultation has the potential to improve access and is an aspect of the choice agenda which is potentially deliverable and may enhance primary care services. Defining the official status of remote consultations, ensuring that professionals have appropriate consultation skills, and that safety and security issues are understood and implemented are important first steps.

  • © British Journal of General Practice, 2005.

REFERENCES

  1. ↵
    1. Bunn F,
    2. Byrne G,
    3. Kendall S
    (2005) The effects of telephone consultation and triage on health care use and patient satisfaction: a systematic review. Br J Gen Pract 55:956–961, 000.
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Pinnock H,
    2. Bawden R,
    3. Proctor S,
    4. et al.
    (2003) Accessibility, acceptability and effectiveness of telephone reviews for asthma in primary care: randomised controlled trial. BMJ 326:477–479.
    OpenUrlAbstract/FREE Full Text
  3. ↵
    1. Car J,
    2. Sheikh A
    (2003) Telephone consultations. BMJ 326:966–9691.
    OpenUrlFREE Full Text
  4. ↵
    1. Neville RG,
    2. Greene AC,
    3. McLeod J,
    4. et al.
    (2002) Mobile phone text messaging can help young people manage asthma. BMJ 325:600.
    OpenUrlFREE Full Text
  5. ↵
    1. Car J,
    2. Sheikh A
    (2004) Email consultations in health care: 1 — scope and effectiveness. BMJ 329:435–438.
    OpenUrlFREE Full Text
  6. ↵
    1. Neville RG
    (2004) E-mail consultations in general practice. Br J Gen Pract 54:546.
    OpenUrlFREE Full Text
  7. ↵
    1. Sittig D,
    2. King S,
    3. Hazlehurst B
    (2001) A survey of patient-provider e-mail communication: what do patients think? Int J Med Informatics 45:71–80.
    OpenUrl
  8. ↵
    1. Department of Health
    (2003) Building on the best: choice, responsiveness and equity in the NHS (Department of Health, London).
  9. ↵
    1. Committee on Quality Health Care in America, Institute of Medicine
    (2001) Crossing the quality chasm: a new health system for the 21st century (National Academy Press, Washington, DC).
  10. ↵
    1. Richards DA,
    2. Meakins J,
    3. Godfrey L,
    4. et al.
    (2004) Survey of the impact of nurse telephone triage on general practice activity. Br J Gen Pract 54:207–210.
    OpenUrlAbstract/FREE Full Text
  11. ↵
    1. Chapman JL,
    2. Zechel A,
    3. Cater Y,
    4. et al.
    (2004) Systematic review of recent innovations in service provision to improve access to primary care. Br J Gen Pract 54:374–381.
    OpenUrlPubMed
  12. ↵
    1. Leong SL,
    2. Gingrich D,
    3. Lewis PR,
    4. et al.
    (2005) Enhancing doctor-patient communication using email: a pilot study. J Am Board Fam Pract 18:180–188.
    OpenUrlAbstract/FREE Full Text
  13. ↵
    1. Foster J,
    2. Jessop L,
    3. Dale J
    (1999) Concerns and confidence of general practitioners in providing telephone consultations. Br J Gen Pract 49:111–113.
    OpenUrlAbstract/FREE Full Text
  14. ↵
    1. Tarrant C,
    2. Stokes T,
    3. Baker R
    (2003) Factors associated with patient's trust in their own general practitioner: a cross sectional survey. Br J Gen Pract 53:798–800.
    OpenUrlAbstract/FREE Full Text
  15. ↵
    1. Maynard A,
    2. Bloor K
    (2003) Trust, performance management and the new GP contract. Br J Gen Pract 53:754–755.
    OpenUrlFREE Full Text
  16. ↵
    1. Car J,
    2. Sheikh A
    (2004) Email consultations in health care: 2 — acceptability and safe application. BMJ 329:439–442.
    OpenUrlFREE Full Text
Back to top
Previous ArticleNext Article

In this issue

British Journal of General Practice: 55 (521)
British Journal of General Practice
Vol. 55, Issue 521
December 2005
  • Table of Contents
  • Index by author
Download PDF
Article Alerts
Or,
sign in or create an account with your email address
Email Article

Thank you for recommending British Journal of General Practice.

NOTE: We only request your email address so that the person to whom you are recommending the page knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Triage and remote consultations: moving beyond the rhetoric of access and choice
(Your Name) has forwarded a page to you from British Journal of General Practice
(Your Name) thought you would like to see this page from British Journal of General Practice.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Triage and remote consultations: moving beyond the rhetoric of access and choice
Hilary Pinnock, Gaylor Hoskins, Ron Neville, Aziz Sheikh
British Journal of General Practice 2005; 55 (521): 910-911.

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Triage and remote consultations: moving beyond the rhetoric of access and choice
Hilary Pinnock, Gaylor Hoskins, Ron Neville, Aziz Sheikh
British Journal of General Practice 2005; 55 (521): 910-911.
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
  • Mendeley logo Mendeley

Jump to section

  • Top
  • Article
    • REFERENCES
  • Info
  • eLetters
  • PDF

More in this TOC Section

  • Long COVID in children and young people: uncertainty and contradictions
  • Overcoming barriers to autistic health care: towards autism-friendly practices
  • Childhood eczema: paths to optimisation of management
Show more Editorials

Related Articles

Cited By...

Intended for Healthcare Professionals

BJGP Life

BJGP Open

 

@BJGPjournal's Likes on Twitter

 
 

British Journal of General Practice

NAVIGATE

  • Home
  • Current Issue
  • All Issues
  • Online First
  • Authors & reviewers

RCGP

  • BJGP for RCGP members
  • BJGP Open
  • RCGP eLearning
  • InnovAiT Journal
  • Jobs and careers

MY ACCOUNT

  • RCGP members' login
  • Subscriber login
  • Activate subscription
  • Terms and conditions

NEWS AND UPDATES

  • About BJGP
  • Alerts
  • RSS feeds
  • Facebook
  • Twitter

AUTHORS & REVIEWERS

  • Submit an article
  • Writing for BJGP: research
  • Writing for BJGP: other sections
  • BJGP editorial process & policies
  • BJGP ethical guidelines
  • Peer review for BJGP

CUSTOMER SERVICES

  • Advertising
  • Contact subscription agent
  • Copyright
  • Librarian information

CONTRIBUTE

  • BJGP Life
  • eLetters
  • Feedback

CONTACT US

BJGP Journal Office
RCGP
30 Euston Square
London NW1 2FB
Tel: +44 (0)20 3188 7400
Email: journal@rcgp.org.uk

British Journal of General Practice is an editorially-independent publication of the Royal College of General Practitioners
© 2022 British Journal of General Practice

Print ISSN: 0960-1643
Online ISSN: 1478-5242