Friday, 30 April 2021

Should GPs turn off their online systems to control demand?

There has been a huge amount of comment in recent discussions about GPs being overwhelmed by the current level of demand. Many have proposed turning off their online systems to hold back the wave. This is problematic for many reasons but has highlighted many deep misunderstandings about total triage and online tools.

The right answer isn't that they should turn off online access, but to test whether or not doing so makes any difference. Or, better, they should design effective triage processes to ensure their limited capacity is used to treat the patients that most need their help without driving all the doctors into burnout.

How did GPs control demand before online systems?

In the world before online total triage solutions were common and before the pandemic changed everything, GPs were used to limiting access as a way of controlling their workload. 

The majority ran systems where the only way to get an appointment was to phone the practice between 8am and 9am. Then, even if you got through to reception, you would often be lucky to find an appointment slot free, especially if you wanted an urgent one. Some GPs offered open access clinics for urgent cases, but those require the patient to turn up in person in a narrow time slot and then wait a potentially extended period of time in a crowded waiting room.

There are problems with the traditional approach. One is that many patients can't get through on the phone because the lines are too busy. We don't know how many requests are lost to the system that way because almost nobody even tries to measure them. Another is that turning up in person for a long, unpredictable wait is often not possible for the patient so this discourages them from going to the clinic at all. Yet another is that the allocation of requests to same day slots is, in effect, unrelated to the patients' need as it depends more on the luck of the draw during the early morning phone lottery than it does on the urgency or severity of their condition.

On the upside, these approaches do allow GPs to limit the demand they see (though partially by making it entirely invisible).

Does turning off online tools work?

The big change from moving significant volumes onto online triage systems is that the capacity of the phone lines is irrelevant: online demand can't be blocked by switchboard capacity. It is far easier to make an online request than it is to make 30 attempts to get connected to reception by phone in the early morning rush. 

So GPs see more of the actual demand. Especially if the online systems are open 24 hours a day and at weekends. Many commentators have speculated that this greatly increases demand. They argue that making it easy for patients to contact the GP must increase demand (and some economists say this is exactly what theory would predict). But few bring data to the argument. 

Not looking at the data risks two serious errors. 

The first is to blame online tools for the increase in demand. The current debate has been triggered because many GPs are unusually busy right now. But many of those GPs have been online for a year and the excess demand has only materialised in the last month or two. The only thing being online has done is to make visible actual demand that would otherwise be lost to the morning phone lottery. It isn't the use of online tools that have caused the demand leap. If demand is going up now, the cause is something else.

The second error is the assumption that limiting the time online systems are open makes any difference to the overall weekly demand. This seems to feel right to many GPs used to limiting demand by limiting appointment slots or rejecting requests that can't get through in the morning phone rush. But we have good data on how patterns of online demand change when systems are turned off. Some smart GPs have run tests of how much demand they get with 24hr systems compared to systems only open in the working day. 

Everyone who has properly tested closing their online system has found that the major effect is not to lower demand but to redistribute it to the times when the system is open. Some, but certainly not all, have found that there is a small reduction in total weekly demand. And, for some, that might be a good outcome (though see what this implies below). 

Absolutely nobody–and this is my most important message here–should be shutting down online access without having done a proper trial to see what the result is. Closing down your online system in the vain hope that it will reduce demand and make your life easier is futile.

In short, limiting access to online systems might help, but no GP should do it unless they know it will, and that requires a controlled experiment collecting good data.

What does limiting access achieve for patients?

The rarely asked question about all schemes to control GP demand is what are the implications for patients? This question is obviously relevant to any debate on online triage tools but it is also relevant to every GP who uses the phone lottery to limit incoming requests or who denies the possibility of appointment bookings when the current slots are all filled.

There are two levels of problem with the traditional "phone the GP between 8am and 9am to get an appointment" model. 

The first is that many patients never even get through to the switchboard. We don't know how many because few GPs have set up their phone systems to monitor that statistic. This has the useful benefit of limiting the demand that reaches the practice. It also has the "benefit" that the unmet need never appears on any report.

The second level, where the patient gets through on the phone but can't get an appointment because all the slots are full, has a similar effect, though the numbers are more likely to be visible somewhere.

If your only concern is to manage the workload, then these methods are fine. The same–apparent–logic applies to limiting the opening hours of an online system (though, as I said above, it is a great deal less clear whether managing access online actually works as effectively as a busy switchboard).

But, if your concern is to actually help the patients who most need your attention, then all attempts to limit incoming requests are very bad. The morning phone lottery at best limits access randomly and, at worst, limits it to the patients with the fastest redial fingers who are, needless to say, not the ones with the greatest medical needs. Limiting appointment slots by a "first come, first served" process has a similar effect. 

The big difference with online triage tools is not that they create more demand; it is that the practice knows what the real demand is. There are no busy switchboards with online demand to arbitrarily reject the request because the patient can't get through. And closing the online system out of hours has a far smaller effect on incoming demand than a busy switchboard (patients quickly learn when the online system is open and make their requests then).

Bizarrely, one of the most common objections to using online systems at all is that they might bias access to particular groups. But compared to the traditional system that randomly rejects patients with slow redial fingers, this is a pretty weak objection (also, for well designed online tools that patients choose to use, the phone lines are far less congested and access for those who don't want to go online gets better). 

There are real tradeoffs to consider when GPs reject online tools. I think they don't increase the underlying level of demand (much of my data says so, but more providers need to release their data to independent researchers to show this is true in general). But they do make that demand more visible. If the response is to reject online tools because they don't arbitrarily limit visible demand, then practices must recognise the cost to patients of the traditional process. The arbitrary selection of requests, unrelated to need. The frustration to patients of the morning phone lottery. And the safety implications of random request prioritisation. GPs sometimes complain that they are overwhelmed by too many trivial, unimportant, non-urgent requests, but it is hard to see how the traditional process solves that when it rejects requests at random not by triage based on need.

And this brings us to a possible solution: effective triage.

If demand is overwhelming then triage is a better solution than limiting access

GPs and primary care researchers sometimes have a strong antipathy to triage (online or otherwise). Helen Salisbury (a GP and researcher) made this argument in a recent BMJ column called Triage is for disasters, not everyday general practice. She argued that, while the idea might be appropriate for front-line military hospitals where there just isn't the capacity to save every wounded soldier, it was completely inappropriate for GPs. But her argument contains several problems.

In a front line military hospital a wide range of injured soldiers arrive. Some have injuries that won't kill them soon and can be treated later; some might die whatever the medics do; some will survive if they are treated immediately. Triage is the sorting process that identifies which is which and allows the medics to focus their limited capacity where it will have the biggest benefit. GPs don't have decisions of the same magnitude, but they do have to see patients with a wide range of needs and should focus their attention where it can do the most good.

Salisbury argues that GPs should see everybody (and should probably do so face to face f-to-f). The implication is that GPs have the capacity to do this and that a one-size-fits-all f-to-f is the best response for every patient. But the whole point of GPs unhappiness with online tools is that they don't have the capacity. We don't seem to live in the world she describes.

She also makes an argument–and one that many researchers seem to agree with–that GP triage actually takes more time than just seeing everyone. This suggests some very deep misunderstandings about what triage is supposed to do or, possibly, how GPs need to do it. The military analogy should make this clear. If sorting the wounded took more time than treating them, triage would be killing more soldiers than not triaging. But triage was invented to save lives by sorting quickly so medical effort could do the most good with the limited resources available. If GPs are taking more time overall with a triage process than without one, then, whatever they are doing, it isn't triage

I don't want to pretend that a good triage process is easy. It isn't, especially when GPs are trained to be one-club golfers who only ever handle patients using short f-to-f meetings. But a disciplined process, especially an online one where the patient request can be assessed rapidly and asynchronously, can be fast and effective. The point is to sort the patients by urgency and need. And to use a flexible range of responses many of which are faster than bringing the patient in for an f-to-f. Even better, if a notable proportion of the requests are the trivial sort that GPs complain overwhelm their capacity, they can be dealt with instantly by a simple, pre-written, short message. 

One of the huge benefits of an effective triage process is that it can do a better job of managing demand than a process that involves limiting access. The urgent serious cases can rise to the top of the queue and get an appropriate amount of GP time; the trivial ones can be dealt with by short standard responses; the middling concerns can be dealt with quickly by message, saving the patient and GP the time taken by an f-to-f appointment. 

If the practice finds it is overwhelmed by demand, it can respond by altering the thresholds for each type of response. Why this is widely considered a worse way to handle demand than a system that arbitrarily denies patients–some of whom might have a serious or urgent need–the ability to make a request at all is something of a mystery.

Some experts object to this because many patients won't get an f-to-f response. They argue that patients mostly want an f-to-f response and will be unhappy if they don't get one. Or that f-to-f is vastly safer than alternatives. Martin Marshall recently made this argument in The Guardian and other places. There are two overwhelming objections to this argument. First, GPs don't have the capacity to do f-to-f appointments for all their current demand (that was, after all, how the whole debate about them being overwhelmed by online demand started). And randomly limiting patient access to even make a request can hardly be safer than triaging requests. Secondly, his claim about what patients want is just wrong. I know this because I have the data. AskmyGP is an online triage tool that has handles most of the incoming requests for several hundred GP practices (70% online, 30% by phone). For every request the patient is asked what sort of response they prefer (f-to-f, message, phone call, video call…). Before covid took off only about one in three requested an f-to-f.

In short, an effective triage process can direct limited GP time to those who need it and can also adjust to prevent that demand causing GP burnout.


There are several key themes here:

  • Online tools don't create extra demand, though they may make changes in demand more visible

  • Limiting access to online tools might sometimes work, but you need to look at the evidence for your practice rather than making knee-jerk decisions

  • Traditional methods of "demand management" have serious and often ignored issues

  • Online tools alongside efficient triage processes offer a better, safer route to manage GP capacity and avoid burnout

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