NHS Direct versus general practice based triage for same day appointments in primary care: cluster randomised controlled trial

Abstract

Objective To assess the relative effects on consultation workload and costs of off-site triage by NHS Direct for patients requesting same day appointments compared with usual on-site nurse telephone triage in general practice. Design Cluster randomised controlled trial. Setting Three primary care sites in York, England. Participants 4703 patients: 2452 with practice based triage, 2251 with NHS Direct triage. All consecutive patients making requests for same day appointments during study weeks were eligible for the trial. Main outcome measures Type of consultation after request for same day appointment (telephone, appointment, or visit); time taken for consultation; service use during the month after same day contact; costs of same day, follow up, and emergency care. Results Patients in the NHS Direct group were less likely to have their call resolved by a nurse and were more likely to have an appointment with a general practitioner. Mean total time per patient in the NHS Direct group was 7.62 minutes longer than in the practice based group. Costs were greater in the NHS Direct group-£2.88 (£0.88 to £4.87) per patient triaged-as a result of the difference between the groups in proportions of patients at each final point contact after triage. Conclusions External management of requests for same day appointments by nurse telephone triage through NHS Direct is possible but comes at a higher cost than practice nurse delivered triage in primary care. If NHS Direct could achieve the same proportions of consultation types as practice based triage, costs would be comparable.

Effects of computerized decision support systems on nursing performance and patient outcomes: a systematic review

“…White and the study of triage of same day appointment requests, CDSS use had no effect on the number of practice based consultations, emergency department consultations, and out of hours consultations in the month following triage. 22 When CDSS was used for glucose regulation in ICU, there was no effect on the proportion of time blood glucose levels were within the target range (risk difference 0.01, 95% CI -0.13 -0.15, p = 0.85). 19 In summary, in one study CDSS use improved performance measures, 19 in another it was associated with poorer performance, 22 and no study found an impact of CDSS on patient outcomes.…”

“…Improved performance and patient outcomes were anticipated if the CDSS was effective. Targeted behaviours were anticoagulation management, 21 telephone triage of same day appointment requests, 22 and glucose regulation. 19 The studies by Richards et al 22 and Rood et al 19 assessed the impact of CDSS in terms of performance measures.…”

“…Targeted behaviours were anticoagulation management, 21 telephone triage of same day appointment requests, 22 and glucose regulation. 19 The studies by Richards et al 22 and Rood et al 19 assessed the impact of CDSS in terms of performance measures. Richards et al compared management of same day appointment requests by nurses using CDSS at NHS Direct (the telephone triage and advice service for England) with practice nurses using clinical protocols.…”

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

“…Seventeen studies reported impacts on their own service or other services, either from increased or reduced service use and or increased or reduced staff workload [68][69][70]86,95,98,99,[101][102][103]105,109,112,114,122,126,134 One study found that NHS Direct referred a higher proportion of patients to other services when compared with general practice. 134 A RCT by Lattimer et al 68 reported a 38% reduction in primary care appointments and a 23% reduction in home visits, whereas another study reported no change in primary care appointments but home visits reduced by 18%.…”

“…93,94 Costs Nine studies reported costs or cost savings. 75,79,86,101,[108][109][110][111][112]126 The most common method of calculating and reporting costs was to report costs saved from callers' change in subsequent health-care-seeking behaviour as a result of the call. 75,79,108,110 These were not consistently reported and were reported as average per patient savings, cost savings per call recommendation type, annual net savings and overall reduction, making comparison difficult.…”