Telephone Triage: Look Who’s Talking

Dr Toni Hazell

GP in Tottenham

Dr Toni Hazell qualified from St. Mary’s Hospital Medical School and did her Vocational Training Scheme at Northwick Park Hospital.

She is a GP in Tottenham and was instrumental in her practice’s move to full telephone triage 7 years before everyone else started doing it!

Toni has a strong academic background and works for the Royal College of GPs as an eLearning fellow. She also writes continuous professional development programmes for a variety of organisations, is an appraiser and sits on the Local Medical Committee for Haringey East.

When not at work, she is kept busy by her two young children; in the occasional moment of spare time, her hobbies include running and playing the piano.

Dr Toni Hazell

GP in Tottenham

Back in 2013, our practice took a bold decision. Faced with a mismatch between supply and demand, we started triaging every request for a GP appointment. Anyone wanting to see a GP in person would speak to one on the phone first. I still remember my fears that the system would collapse by mid-morning on the first day, but on the whole it was a success. Patients liked being able to talk to us on the phone, we could signpost them to the most appropriate professional, and tests could be done before an appointment so that the patient needed to come in only once.

Fast-forward 7 years and telephone triage is now the done thing for everyone, important for reducing footfall in the context of COVID-19. Tips and tricks for effective, safe triage are being shared widely, and I doubt that things will ever go back to how they were. With better text and video technology, phone triage is great for many, especially those who work. We must, however, be careful that no one gets left behind and put thought into some of the people who might, such as those who don’t have access to a mobile phone, don’t speak English, are frail, are deaf, are homeless or are vulnerable in some other way.

But what about vulnerabilities that are to do with the subject, not the patient? Talking about sexual health, mental health, contraception or the need for a termination is hard enough face to face and often worse over the phone. What if the GP calls when you’re on the bus or at work? Teenagers are worried about confidentiality within the confines of a consultation room; how much worse is it when Mum might overhear from the kitchen? And how embarrassing is it for some people to have to tell the receptionist what they are calling about?

As doctors, we need to gatekeep without discouraging those with sensitive problems. It’s useful for reception to get a brief idea of what the problem is so I can work out the order in which to call people back – it’s never great to get to the last call on your list and find that they are vomiting blood or have central crushing chest pain when I’ve spent the last hour talking to people with ingrowing toenails. But it can’t be compulsory; every day I have some calls where the clinical details just say “personal”, and that’s fine. Most of those will be about sensitive subjects, although occasionally someone is embarrassed about their ear wax or eczema.

A downside of phone triage is that you don’t know who is in the room with the patient. Face to face, I often ask the patient’s parent or partner to leave the room while we talk (how many teenagers will be open about their sex life or smoking habits in front of Mum?), but when they’re at home I don’t know who is around. Could the patient’s controlling or abusive partner be in the room with them or listening through paper-thin walls? Closed questions with a yes/no answer are useful here. Are you on your own? Can anyone else hear you? If you feel unsafe and want to be seen face to face, just say “yes”. It’s important not to make assumptions about the patient’s situation. If I jump in with “Lovely news, congratulations!” when a woman tells me she is pregnant, that makes it much harder for her to say that she wants a termination – something that she may already be feeling sad and guilty about. “How do you feel about that?” is a great question to ask when a woman discloses her pregnancy to a health or care professional, as it leaves the door open for an honest discussion about feelings and worries.

Decisions about who to see face to face are difficult at this time. There is a need to reduce footfall, maybe more over the coming months of the second wave, and there is a temptation to see only those who absolutely need it. You can’t lay a hand on someone’s belly virtually, nor can you look in an ear or do a gynaecological examination. Taking this view of face to face only when there is no alternative isn’t a great thing for those with mental health problems, either. Yes, depression can be discussed on the phone – no physical examination is needed – but it isn’t nearly as good. All the non-verbal cues are lost, and the therapeutic effect of the ‘doctor as drug’ that you get from a good consultation is difficult, maybe impossible to achieve on the phone. When possible, I try to lower my threshold for a face-to-face appointment if I think there are significant mental health issues. If I’m thinking about prescribing antidepressants for the first time, or if a patient with mental health problems has had several phone calls without improvement, it’s probably time to see them face to face – even if it is through a mask.

Medicine is an art, not a science, and that doesn’t change in pandemic times. That elusive quality, the GP ‘spidey sense’, should be our final arbiter, along with the insomnia test. If your antennae are twitching or you think you won’t sleep tonight if you haven’t seen the patient, they need to come in.

Good luck to all those walking the triage tightrope.