For HTN Now we held a webinar on the topic of harnessing data for total triage in primary care with an expert panel, including Ananya Datta, associate director of primary care digital delivery at South East London ICB; Asad Ashraf, GP and digital clinical lead at North East London ICB; and Devin Gray, GP and clinical lead for digital first programme at Wandsworth GP Federation.
Panellists shared details on current uses of data for total triage, discussing key successes, challenges, learnings, and best practice.
Starting out with the introductions, Ananya talked about her role in digital service delivery in South East London. “I mostly work in primary care transformation and GP IT, but we also support community pharmacy and some of the adult social care programming,” she explained. A current key ambition for the region’s primary care is around ensuring ease of access for patients, improving total triage and supporting the modern general practice vision.
Devin shared that as well as being a GP in a practice in South West London, she is also clinical lead for digital transformation at Wandsworth GP Federation, which supports 38 practices in Wandsworth. “That covers all aspects of digital really, including more recently automation and AI. In the last three years we’ve seen a transition from almost no practices using a triage model, to now two-thirds using total triage, and most of the remaining practices using a hybrid model or some other form of triage.” That has been an “extraordinary transformation”, she reflected, “and we’re now predominantly using Accurx with one PCN using eConsult”.
With a range of responsibilities spanning his positions as a GP, PCN clinical director and digital transformation clinical lead, Asad said: “I’m coming at this from a partner perspective, where we’ve been operating a hybrid model since before COVID, slowly building into what will eventually be a total triage model in the next three months in line with the October contractual change.” At the moment, the ICB primarily uses Accurx and eConsult, he went on, “which are all funded by the ICB, and we’ve also done a lot of QI projects with regard to harnessing data to improve access”.
Journeys to date
In South East London the journey started after COVID, according to Ananya. “We heard from GPs that we had too many tools to use, so we were looking at that, as well as streamlining the process to help navigate the patient journey. We ended up having one tool funded by our ICB, but there are still some practices that use different tools.” The move to total triage has also been motivated by the upcoming contractual changes, she said, “and one ambition is to make it so if a person is sending a request at six pm, the local pharmacy would be able to handle it, as many community pharmacies are open until eight thirty in the evening”.
There has been “great success” to date in a number of practices, Ananya told us, particularly in Greenwich borough, where they have started getting a better understanding of those who need continuity of care and those who have low acuity so can be triaged to other areas. “When the request comes from the patient’s end, teams then have a better understanding of the patient, and have their data, which makes it easier to direct patients to the right care. Those more complex patients might be sent to a GP, whilst low acuity patients might be triaged directly to MSK, for self-care, as well as community pharmacy, which is becoming a more integral part of primary care.”
Feedback has been “quite positive”, Ananya said, “and one of our GPs provided feedback saying that whereas before he’d work until 8.30pm after finishing his day, now he’s able to go home at six, or six thirty, instead”.
“We took advantage at a time when the rule book had already been ripped up,” Devin said of Wandsworth. “We were mid-pandemic, rolling out the vaccine, and essentially already operating a total triage model, although that was telephone-first.” In hindsight, the pandemic made it “a lot easier” to make the change, she reflected, as the normal processes had already been altered.
The decision was made to make the transition in mid-January, and it was live by the end of January, Devin shared. “It worked really well until the political shift over the summer where patients were encouraged that if they wanted a face-t0-face appointment they should just ask for one. There was a lot of misinformation and confusion at that time, which undermined the triage system, so for about a year and a half we ended up using almost a parallel system.” Whilst still trying to encourage as many requests as possible through the Accurx form, patients could still ring and ask for an appointment, she continued, “and it was becoming a two-tier system which was inequitable”.
The second time around, the team spent longer on planning, Devin said, “so that was three months of figuring out what we wanted total triage to look like, before we went live in November 2023”. Describing outcome data as “quite dramatic”, she noted that the improvements seen initially have been sustained. “Now, however you come to the practice it’s all processed using the same form, and we have a dedicated hub team that manages all of our requests.”
Asad echoed the fact that COVID had instigated “a lot of change” at practice level. “Overnight we had to move to a telephone-only model, and patients didn’t like it.” Undertaking a large-scale patient engagement survey, analysing data and list size highlighted that surrounding practices had all moved to total triage and seen a reduction in list sizes by ten percent on average. “We canvassed patients to find out what the motivation was for movement – we’re inner city London, so our local practice is a five minute walk one way, and there’s another a five minute walk the other way, so it’s not like there’s a big need to change.”
For many of those patients approached, the reason given was that they didn’t like having to use total triage, Asad told us. “We eventually went over to a hybrid system, where we’ve said that ideally for anything routine, patients should be filling in an online consultation. Our receptionists were trained, and we were signposting to our online consultation or helping patients who couldn’t do it on the phone.” His team is now looking to move to a position whereby routine appointments can be offered online without having to triage to a certain extent, he added, “and we’ve done a pilot with Hero Health to allow our website to be used to book non-GP appointments online”.
This approach gives patients the autonomy to decide that they need to see someone, and who they need to see, Asad said. “We’re working through the nuances of that, because there are negatives and we do want to safeguard our appointments, so we’ve put the caveat in that you can’t book more than one appointment in advance, unless you put an online consultation in.” The hybrid system should be introduced next month, he noted. “We’re undergoing another patient and clinician engagement survey, and we’re hoping that by making that change we’ll be able to safeguard the clinician’s satisfaction, but also make sure that patients are dealt with at an appropriate time”.
Measuring satisfaction levels for patients and staff
When implementing any kind of triage system, it’s important to know what problem you’re trying to solve in order to effectively measure success and determine what your outcome measures are, said Devin. “I do think data dashboards are useful to keep an eye on, but you need to also look out for unintended consequences, because if you’re just looking at what you think the success metrics are, you might miss some of the unintended consequences such as patient satisfaction.”
Although patients could submit feedback on their experience by filling out the form when submitting a request, that didn’t capture what happened next in their journey or their experience after that point, Devin noted. “We made a Google form which asked exactly the questions we wanted to gather a range of qualitative and quantitative feedback, and sent that out by email to all patients that had booked an appointment in the last couple of months.” Out of 2,000 patients, 200 responded, she continued, “and it was 80 percent positive, with the remaining 20 percent being constructive feedback such as missing being able to see the appointments and booking in – I think with booking links you can achieve that”.
Looking at Edenbridge Apex data has helped gain an understanding of appointment availability, according to Devin, “and since moving to total triage our average has gone from 15 days to four or five”. Continuity is another important element that can often be overlooked, she considered, “but again, because the form allows patients to write in their preferred clinician, we’ve seen our continuity almost double in terms of patients being seen by their named GP”. Things like dashboards available through Accurx and looking at the breakdown of medical versus admin requests are also key, “and when we looked into why a practice was getting 20 percent more triage requests than normal, it turned out they were getting two-and-a-half times the number of repeat prescription requests through their Accurx form because their patients had no idea that they should be using the NHS App”.
In South East London, work has also been done with Accurx, who reached out to all practices that had gone live with them and received 197 responses, Ananya told us. “That included both total triage and non-total triage practices, 93 percent of whom said the solution had significantly improved their ability to manage their workload, and 70 percent of total triage practices found it has improved their overall work satisfaction.” The ICB also captured data around improvements suggested by users, working with Accurx to improve the tool accordingly.
“Nine months post-implementation we rolled out a survey similar to what Devin mentioned, via a portal on our web page, and also by sending to practices to share with their population,” Ananya went on. “We got 9,000 responses, which is huge in terms of overall feedback, and 70 percent of respondents said they found it easy to use, although patients found they were repeating information again and again when completing forms.”
Asad talked about work with NHS adoption, running clinics to help people download and use the app. “What we found was that our submissions were totally online, our receptionists weren’t having to do it, and now 60 percent of booking submissions are made via the NHS App. Even in our telephony programme we send out links to the NHS App to help submit an Accurx online consultation.” Whilst all of this means improvements are continuing, there’s still a need to ensure that those who can’t use these tools are supported, he added, “and we make sure they can still ring in and have our reception team help them”. Although assumptions were that the over 60’s demographic would be most resistant to the change, they tend to be the demographic who most want online consultations.
“We also use Edenbridge Apex, which is vital for us, as well as EMIS and TPP data,” Asad said. “We’ve worked with other entities to make sure our searches are on point, so we look at it completely from a data point of view, but the patient engagement is important too – Devin and Ananya have spoken on a lot of the same things that we’ve done.” The online consultation model and the triage model don’t fix access if you don’t “fix your system behind the scenes”, he continued, “looking at your appointment book, your processes, your signposting, are all really big things”. Asad also echoed Devin’s point about the importance of continuity, noting: “We’ve got certain pathways in place to support that, and the fundamental point is both patients and clinicians need to understand the pathways, because if they don’t, that’s when your processes fail.”
Overcoming challenges
On challenges around digital inclusion, Devin said: “You’re not expecting everyone to be able to submit a request online, but if you are getting those people who can do that to do it, then you’re freeing up both phone and physical capacity to support those who can’t. We’re still working on that, and there’s still a narrative out there about GPs moving online and people being left behind – we haven’t done a good enough job selling total triage to our community.”
Another thing to consider is language, Devin noted, “so that might mean using a tool that sits in front of the triage form and offers translation, or looking at other digital tools to meet those needs”. Those needs might be different depending on the setting or demographic, she continued, “and I know of an example of a practice in Wandsworth that had heard of a tool being used to great benefit for other practices and decided to switch it on for themselves and then didn’t see any benefit”. They hadn’t done any of the work behind the scenes to understand what their existing processes were or how it would integrate, and “there was this expectation that if you turned it on the magic would just happen, when that’s not how it works – you’ve got to put a lot of the work in to see how you can really make use of that tool”.
Ananya also reflected on overcoming digital inclusion, stating: “Digital inclusion doesn’t mean we have to enable everybody using digital, but we have to ensure everybody gets the same service as part of the clinical care they need.” Work to improve reception flow is ongoing, she said, “meaning if someone calls the practice, the receptionist or a care coordinator can fill out the form for them, other people can submit Accurx requests on behalf of the patient”. South East London is running practice-level promotions to invite patients to use the NHS App, with teams who go out and help them through it, which Ananya describes as “a slow but steady process of bringing people on board”. Teams are also visiting local colleges to educate the younger population on the app, in the hopes of them passing their learning along to elderly relatives.
The role of emerging technologies
The panel moved on to tackle the role of emerging technologies, with Asad highlighting the importance of GPs and GP partners understanding that when using tools such as automated triage, they are the data controllers. “You’ve got a legal responsibility, and when you’re not going through the normal NHS procurement process, all the clinical and information governance sits with the practices. For that reason, I’d always recommend being hesitant when procuring and having a clinical safety officer, or your CCIO, digital transformation lead or data protection officer involved.”
Noting that many suppliers are looking to use automation and AI in their digital solutions, including in triage, Asad said: “Just like online consultations, it’s not going to solve your access issue, and although I’m a big advocate of adopting AI and automation in tools, it’s not in my opinion quite ready to be used in triage yet.”
“I agree with that position,” said Devin. “There isn’t a single practice in Wandsworth that is using an AI triage system, and we have a constant debate about how much clinician capacity you put towards the triage. Quite a few practices are not using clinicians for their triage; they’re using receptionists that they’ve trained, but we’ve audited and compared the number of appointments booked or saved with receptionists doing it versus duty GPs, and we were saving more than a clinic’s worth of appointment through using the GP.”
That’s because a lot of low-level requests were being resolved without an appointment, Devin explained, “and where the real capacity gets saved is in the fit note requests where all the information is there, or where there are prescription issues – AI can’t do all of that for you”. Whilst AI can be useful for signposting or saving receptionist time by automating the process of delivering the booking link or getting patients booked in, “it’s not going to replace that”, she considered.
Suppliers are developing smart navigation to offer nudges whilst a patient is filling out the form, offering advice where they might be better served by visiting a pharmacy, for example, Devin noted. “For me, that’s a more intuitive next step use of AI in triage.”
“Primary care is very nuanced, and it isn’t linear in its process. Whereas things like generative AI can help when you have a defined problem and solution, primary care doesn’t work that way,” Asad shared. “A patient’s journey has so many different variables that a clinician needs to consider. Maybe in the future when we move to something like agentic AI we could potentially re-look at these tools, but I agree it doesn’t help with the triage element.”
Picking up on Devin’s example of the receptionist versus clinician triaging, Asad said that his team has also tried both, finding similar results in that GP triaging saves “a lot more” capacity. “We ended up saving four percent more appointments, because the GP will not only do the lower-hanging fruit consultations, but as a partner, I’d look at the access because I’m ultimately responsible. So, I will notice things like if a patient’s already got an appointment in two days time, that reception wouldn’t necessarily look at.”
Looking ahead
Ananya told us about plans for the future, including looking into options around nudging to inform people about other options available to them. “We’re also looking at the neighbourhood approach and whether we could add that to their directory of services, and at working with the NHS App team to see if the NHS App could be used to start triage before it even gets to the GP.” That would mean having a repository or single patient record where when a patient is submitting, it processes the request alongside their health and care data to direct them to the right care. “We’re very keen to see how that goes,” she added.
“I think it’s important to get the balance right between moving forward with automation and AI, and getting the basics right,” said Devin. “I’m not convinced we’ve got the equity of access piece right in most of our areas, so for me there’s that groundwork that still needs to be done before looking at next steps.” There is definitely more scope for automation, she added, “but the tools are changing so quickly that we need to be sure we’re keeping up with our own risk management”. Wandsworth is trying to gain a better understanding of the legal responsibilities around clinical risk management and things to have in place prior to looking at adopting new tech, she added.
Preparing for the move to total triage in July/August time, Asad shared how the focus at the moment is on ensuring patients are fully informed and involved in the process. “As a PCN, we try to take advantage of things that offer economies of scale,” he said, “we already have EMIS integrated to support interoperability, and triage is definitely one of those things we think can be done at scale.” Each practice is piloting a different automated tool such as document management, lab automation, and registrations, “to try and get a case study in place before we look at doing that procurement at scale’, he added. “The vision for total triage is same-day access, which we do for our PCN already, and extended access, and how we can expand on that to help with the access issue to allow practices to move to total triage.”
We’d like to thank our panellists for joining us and sharing their insights on this topic.
