Plain English Summary
Background and study aims
Patients often ring their surgeries asking for same-day consultations. Not all such patients want or need to see a doctor or nurse face-to- face on each occasion. Some people, such as those who work during the day or have caring responsibilities, may find it easier to get prompt advice over the phone, rather than having to visit the practice in person. This system of assessing how best to meet patients' needs is called 'telephone triage'. Our study looks at how telephone triage systems led by doctors and nurses work. We are particularly interested in how these systems affect patients' experiences, safety and health, as well as practices' workloads and costs. There is already some evidence illustrating the advantages and disadvantages of GP and nurse-led triage. However, much of this evidence is based on small samples. There has also not been a thorough comparison between GP and nurse led triage. Therefore, there is a real need for a large trial that directly compares these models of telephone triage for patients that are seeking a same day appointment.
Who can participate?
Any patient that calls the practice and asks to see a GP on the day of the call is eligible for the trial. Patients will be entered into the trial providing they are not too unwell and providing there is no language barrier.
What does the study involve?
Forty two GP surgeries across England have agreed to participate in the trial. They will be separated into three groups. One group will implement a GP triage model, with only GPs calling patients who have requested a same day appointment. A second group will implement a nurse triage model, with only nurses calling patients who have requested a same day appointment. The third and final group will 'carry on as usual' and form our usual care or control group. Patients who call up asking for a same day appointment will be asked by a clinician whether a researcher can have a look at their medical notes to see if they needed any further help or advice after their first contact. About four weeks after the same day appointment request has been made, patients will be sent a questionnaire asking for their feedback on their experience of care. The questionnaire will also ask patients how their health condition is currently and will also ask them to report their age, gender and ethnicity.
What are the possible benefits and risks of participating?
There should be some relatively immediate benefits to those patients who belong to a GP surgery that is in one of the triage groups - they may receive faster access to a clinician than they would do usually. The outcomes of the trial may make an important contribution to the way that same day appointments are managed in general practice. There may be future benefits to patients through the provision of better access to clinical care. There are unlikely to be any risks in taking part in this research.
Where is the study run from?
The ESTEEM study has been set up by the University of Exeter Medical School, The University of Bristol, The University of Warwick, and the University of East Anglia.
When is the study starting and how long is it expected to run for?
The main ESTEEM trial will start patient recruitment in April 2011 and will be completed by December 2012. All follow up work will be completed by the end of March 2013.
Who is funding the study?
The NIHR Health Technology Assessment Programme - HTA (UK).
Who is the main contact?
Prof John Campbell
Prof John Campbell
St Luke's Campus
Department of Primary Care
University of Exeter Medical School
University of Exeter
+44 (0)1392 722740
The effectiveness and cost effectiveness of telephone triage of patients requesting same day consultations in general practice: a cluster randomised controlled pilot study comparing nurse-led and GP-led management systems
The aim of this trial is to assess the clinical and cost-effectiveness of nurse-led computer-supported telephone triage and GP-led telephone triage, compared to usual care for patients requesting same day consultations in general practice. The specific research objectives of this pilot study are as follows:
1. To confirm the ability of practices as sufficient to implement the GP-led and nurse-led triage systems
2. To confirm the proposed recruitment of practices
3. To assess the level of clustering of outcomes
4. To check data collection systems
5. To identify potential difficulties in implementing the triage systems
More details can be found at http://www.nets.nihr.ac.uk/projects/hta/085315
Protocol can be found at http://www.nets.nihr.ac.uk/__data/assets/pdf_file/0005/52997/PRO-08-53-15.pdf
Devon and Torbay Research Ethics Committee, 07/09/2009, ref: 09/H0202/53
Multicentre cluster randomised controlled pilot study
Primary study design
Secondary study design
Cluster randomised trial
Patient information sheet
Not available in web format, please use the contact details below to request a patient information sheet
Triage systems in GP practice
Three interventions will be compared:
General Practitioner-led Telephone Triage:
We will use the Stour Access System to deliver GP-telephone triage as designed in 2000 by a 4-partner teaching practice in Christchurch, Dorset. The Stour Access System aims to improve patient access to healthcare and give GPs control over their working day. A core element of the intervention is the use of the GP to undertake triage (as opposed to other non-medical members of the clinical team). While the Stour Access System as used elsewhere involves triaging of all appointment requests, we will be limiting the system only to those requesting same day consultations.
Nurse-led computer-supported telephone triage:
Plain Healthcare's Odyssey TeleAssess system (formerly 'TAS') will be used to deliver telephone nurse triage. Odyssey TeleAssess provides computerised interactive decision support software for nurse telephone triage. The stated aim of this triage system is to 'provide rapid, safe assessment and advice for primary care through decision support software'.
Practices will be asked to continue with their standard consultation management systems for handling same day consultation requests.
The duration of the interventions will be 2 weeks. Follow-up data will be collected 4 weeks after the patients' index consultation (via postal questionnaires). A second mail out will be sent to non-respondents 2 weeks later. Further follow-up information will be collected 12 weeks after the index consultation (via patient note review). A one week observation study with brief interviews with practice staff will also be undertaken.
Primary outcome measures
Number of healthcare contacts taking place in the 4 week period following the index same day consultation request. The 'number of contacts' will include the initial clinical assessment contact, and will thus include the triage contact in the two intervention conditions. The total number of contacts per 1000 patients requesting same day consultations in each of the trial conditions will be derived from numbers of GP, practice nurse, GP out of hours, A&E, and (although they may not impact significantly on GP workload) NHS Walk In Centre attendances. Data collection, capturing information on timing (am/pm), and type (face to face, telephone, home visit, GP out-of-hours, A&E and WIC attendance) of primary care contacts in all trial practices will take place as part of a note review occurring at least 12 weeks after the index consultation request with data extracted from the primary care medical record.
Secondary outcome measures
1. Descriptive study of patient flow. We will describe the management and interim and final disposition of patients in the working day in which they request a same-day consultation up to the point of final contact within that working day for each of the trial conditions.
2. Primary care NHS resource use. We will capture NHS primary care resource use by monitoring the number of contacts resulting for patients in the three trial conditions as for primary outcome. To derive estimates of cost for each consultation type in 'same day' and 'follow up' phases we will also collect detailed information on the duration of primary care contacts in all trial practices. We intend to use a direct measure of the start and end of all participant consultations in each of the participating practices for each consultation type, and to do this for both 'same day' and 'follow up' periods separately since these represent very different types of clinician interaction. Timing data will be extracted from the electronic record at the time of note review. Non-attendance rates for allocated appointments in the month following the same day request will be described and compared between trial conditions using data extracted at practice record review.
3. Patient reported outcomes, collected by postal questionnaire 4 weeks following the request for a same day consultation:
3.1. Patient experience of care: We propose to use a modification of the new national GP patient survey instrument (NGPPS) for the purposes of monitoring patient experiences of care in this study. Areas addressed in NGPPS are highly pertinent to ESTEEM and include:
3.1.1. Getting through on the phone
3.1.2. Seeing a doctor
3.1.3. Waiting times
3.1.4. Opening hours
3.1.5. Experience of GP care
3.1.6. Experience of nurse care
3.1.7. Overall satisfaction
3.2. Safety: deaths within 7 days of same day consultation request (from practice records), and attendance at A&E within 4 weeks and number and length of stay of emergency hospital admissions within 7 days of index consultation (from primary care records examined 12 weeks after same day consultation request)
3.3. Health status: we will use the 36-item Short-Form questionnaire, one of the most widely used measures of generic health status in clinical studies producing eight dimension scores (spanning social functioning, mental wellbeing and physical health) and two summary scores for physical and mental health
Overall trial start date
Overall trial end date
Participant inclusion criteria
All consecutive patients making telephone requests for same day consultations will potentially be included. All patients aged less than 12 and greater than or equal to 16 years requesting a same day consultation will be included in respect of the primary outcome measure.
Target number of participants
1,200 (400 patients in each of the three trial arms)
Participant exclusion criteria
We do not propose to include young people aged between 12 and 16 years in this study since this will involve receipt of a postal survey along with written consent to review notes to the young persons address - a process which we believe may inadvertently lead to a breach of confidentiality should third parties open or have access to the young person's mail. Parents/guardians of children aged less than 12 years will be invited to provide consent on behalf of the child. Adults greater than 16 years will be included.
Recruitment start date
Recruitment end date
Countries of recruitment
Trial participating centre
University of Exeter
Devon Primary Care Trust (UK)
Research Management & Governance Unit
Public Health Directorate
+44 (0)1392 267785
NIHR Health Technology Assessment Programme - HTA (UK)
Funding Body Type
Funding Body Subtype
Results and Publications
Publication and dissemination plan
Not provided at time of registration
Intention to publish date
Participant level data
Not provided at time of registration
Results - basic reporting
2013 protocol in: http://www.ncbi.nlm.nih.gov/pubmed/23286331
2014 results in: http://www.ncbi.nlm.nih.gov/pubmed/25098487
2015 results in: http://www.ncbi.nlm.nih.gov/pubmed/25690266
2015 results in: http://www.ncbi.nlm.nih.gov/pubmed/25986572
Campbell JL, Britten N, Green C, Holt TA, Lattimer V, Richards SH, Richards DA, Salisbury C, Taylor RS, Fletcher E, The effectiveness and cost-effectiveness of telephone triage of patients requesting same day consultations in general practice: study protocol for a cluster randomised controlled trial comparing nurse-led and GP-led management systems (ESTEEM)., Trials, 2013, 14, 4, doi: 10.1186/1745-6215-14-4.
Campbell JL, Fletcher E, Britten N, Green C, Holt TA, Lattimer V, Richards DA, Richards SH, Salisbury C, Calitri R, Bowyer V, Chaplin K, Kandiyali R, Murdoch J, Roscoe J, Varley A, Warren FC, Taylor RS, Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis., Lancet, 2014, doi: 10.1016/S0140-6736(14)61058-8.
Campbell JL, Fletcher E, Britten N, Green C, Holt T, Lattimer V, Richards DA, Richards SH, Salisbury C, Taylor RS, Calitri R, Bowyer V, Chaplin K, Kandiyali R, Murdoch J, Price L, Roscoe J, Varley A, Warren FC, The clinical effectiveness and cost-effectiveness of telephone triage for managing same-day consultation requests in general practice: a cluster randomised controlled trial comparing general practitioner-led and nurse-led management systems with usual care (the ESTEEM trial), Health Technol Assess, 2015, 19, 13, 1-212, doi: 10.3310/hta19130.
Warren FC, Calitri R, Fletcher E, Varley A, Holt TA, Lattimer V, Richards D, Richards S, Salisbury C, Taylor RS, Campbell JL, Exploring demographic and lifestyle associations with patient experience following telephone triage by a primary care doctor or nurse: secondary analyses from a cluster randomised controlled trial, BMJ Qual Saf, 2015 , doi: 10.1136/bmjqs-2015-003937.