Beacon Medical Group are one of the pioneer practices when it comes to the Total Triage model of care using an online consultation solution. Following the initial model that was co-created with eConsult and another practice, Beacon Medical Group developed their own Total Triage model, and have been using this since November 2019. In the Total Triage model of care, all requests to the practice come via an online consultation where possible. This allows the practice to manage the demands of their patients through one, information-rich channel. Total Triage is now being highlighted by NHS England as a blueprint for online consultation models.
Beacon Medical Group, based in Plymouth and part of Devon Clinical Commissioning Group, first formed after the merger of several practices in 2015. With a 43,000 patient list size across six sites, Beacon became the largest GP provider in the South West of England. By early 2019, the practice realised they needed support to review their model of care and existing processes, due to several compounding reasons. As patient demand and clinical work increased, the phone lines became unmanageable and wait times for routine appointments were exceeding 5 weeks, causing frustration and negativity amongst both patients and staff. Within the space of two weeks, they lost vital resources when three GPs were absent for a period of time due to sickness, causing the practice further strain to meet both pre-booked and new patient demand. The practice knew they needed to reduce waits, increase resiliency and make changes to how services were accessed.
Around the same time, Devon Sustainability and Transformation Partnership and the Clinical Commissioning Group became one of five NHS England-funded Digital Accelerators. The aim was to drive uptake of online consultation usage in Primary Care and to support the creation of a change capable workforce. Prior to the involvement of the Devon Digital Accelerator (DDA), Beacon Medical Group had planned to use eConsult on a trial basis to see how it could be used to support the practice. A few weeks later, with support from the DDA, Beacon identified how they could introduce an new access model and roll eConsult out further as an existing and approved online consultation provider that would enable the practice to add an alternative access route into the surgery for patients. Crucially, patients using eConsult as a route to contact the surgery would support the practice to be able to internally manage the demands of their own patients and staff.
Collaboration and hard work to develop a blueprint
Devon Digital Accelerator Programme Manager, Sian Bunce and Beacon’s Improved Access Project Manager, Joseph Nicholson, alongside Beacon’s Operations team and lead GPs were instrumental in getting to this point. Together they worked closely with NHS colleagues and several other organisations UXC group over the past year. Their goal was to fulfil one of the DDA’s ambitions: to provide shared learning and collaborative planning relating to digital transformation (online consultation) to GP practices across Devon. Several members of eConsult’s team were also involved in discussions with the practice and DDA, feeding into product development of the online consultation platform. Shared learning is at the heart of the DDA, so experiences and support from eConsult’s key clinical and operation teams, as well as, other eConsult practices were key to shaping how Beacon developed their process to use eConsult as the primary entry point for all their patient queries. In particular, Brownlow Medical Group in Liverpool, a similarly sized practice facing the same concerns were able to bring learnings and insights.
“It’s been complex with a huge amount of learning about how best to implement technology combined with new models of care. It’s something that we are still refining and monitoring six months later.”Joseph Nicholson, Improved Access Project Manager for Beacon Medical Group
The practice worked hard before launch to map out and document possible patient journey flows and to identify patients who may be best helped through existing access routes. Each staff member was provided with their own booklet containing these process flows, to ensure a consistent patient experience but also to ensure that each member felt comfortable knowing what to do next. Patient Advisors, who were the main contact point with requests from the patient population, were also provided with bespoke protocols built into the clinical system that supported them to guide patients down the appropriate flow.
These flows now help the Patient Advisors know when it is or is not appropriate to suggest that a patient try eConsult. For example, if the parent of a child aged under 6 months old called the practice, the protocol would not prompt the Patient Advisor to suggest that they use eConsult as the platform is not suitable for a child of this age. The practice also decided to segment their patients based on long term conditions. Those with a significant need for GPs, such as cancer and palliative care patients, are not encouraged to use eConsult when they phone in. Additionally, these patients are currently booked in with GPs only.
Implementation of a new model of care supported by online consultations
By November 2019 Beacon Medical Group was ready to implement this new access model, enhanced by the use of eConsult, and it became known as ‘Total Triage’. The model allows clinicians to decide which patients need an appointment in the surgery and which could be dealt with remotely. It works better than a pure traditional phone-based only triage because online consultation allows the practice to manage a portion of work asynchronously and efficiently. Use of eConsult supported Beacon’s change requirements because it allowed for a greater amount of clinical information to be provided on each eConsultation received by the practice. Importantly, this was information provided by the patient in their own time and following a consistent structure that adapted based on inputted clinical information. Key red-flag questions embedded into every symptom or condition questionnaire identify and immediately navigate away patients reporting serious symptoms to the appropriate care, to ensure each eConsult submitted is suitable for a primary care response by the end of the next working day. Detailed scripts with suggested wording for explaining the system to patients and suggestions for how to respond to common questions formed a large part of the practice’s training in preparation for this change.
Through Beacon’s collaboration with and support from the DDA, great effort was taken to bring patients with them on this change journey, including before implementing this new model. Beacon’s patient participation group expressed reservation when first introduced to the concept of online consultations and that this may become the preferred method of contacting the practice for queries. However, once they had an opportunity to test the online consultation interface and had experienced the 24/7 access to an improved journey with quick response times, it soon became popular within their patient population.
“On just day two of implementation, I was very impressed with the calm and professional environment in which the PA’s were operating and dealing with patients both on the phone and those processing the eConsult requests. The focus on the telephone call situation on the screen was very noticeable, with a great desire throughout the team to ensure waiting was kept to a minimum by a team effort.”Chris Boote, Chair of Beacon Medical Group Plympton PPG
To start, use of eConsult was gently pushed and easy entry routes were highlighted to patients (such as submitting administrative requests or sick notes). The DDA also provided financial and logistical support with patient communications and advertising through letters and texts to patients as well as on social media. As well as increased advertising of the new eConsult service through posters and updated telephone messaging, Beacon’s website was also redesigned to encourage use of eConsult as the main access point to the practice. Patients were not mandated to use the service but rather were reminded about the service with every physical and virtual interaction with the practice.
“This [Total Triage] model, using eConsult, allowed us to move from a 5-6 week wait to a ‘same or next day’ service where patients were either offered an appointment, called for more information, sent an SMS or emailed by a GP or member of our urgent care team.”Joseph Nicholson, Lead – Improved Access Project Manager
The practice has, over the last 6 months, primarily focused on refining and improving patient workflow and response times, as well as monitoring capacity. Although they have experienced a busier than normal winter, there is a sense that phone calls have reduced, and patient access has improved – including for those who are unable to contact the practice online. Online consultations are generally quicker to resolve and open up more options for clinicians in terms of how to respond (text, one-way email, phone call, video consultation or inviting the patient in for a face to face consultation). Having a full patient history upfront has reduced the need for face to face appointments and improved the quality and efficiency of those that are required.
Clinicians feel supported in making safe and impactful decisions that are in the best interests of their patients. Since the implementation of Total Triage, eConsult has on average contributed to 36% of clinical triage work the practice manages, with the remainder coming from patient phone calls or from other members of the practice’s multidisciplinary team. The practice is focused on making sure that the cases are going to the right staff member.
The impact of COVID-19
In the wake of the COVID-19 pandemic that started in March 2020, many practices across the UK were encouraged to move to a ‘Total Triage’ model; only essential face to face appointments, protective equipment for practice staff to reduce the risk of transmission, a heavy emphasis on online, telephone and video consultations to support patients remotely and a strong encouragement from the NHS for practices to start to triage patients first to be able to cope with demands. Practices without online or video consultations were entered into a rapid procurement and national webinars hosted to explain the Total Triage model that few practices were familiar with.
At this point, Beacon’s Total Triage model delivered on its promise of increasing resiliency to continue to meet patient demand. As the number of staff available to answer the practice telephone lines reduced due to self-isolation and sickness, Beacon was able to direct patients to use eConsult instead, allowing continued access to their services. eConsult usage at Beacon, who by then had six months of experience with Total Triage, increased from just over 1000 eConsults a week to over 1400 a week at the start of the COVID-19 crisis. At this time, it made up around two thirds of the practice’s triage requests. eConsult has continued to make up around half of demand, despite a decrease in patients numbers contacting the surgery, giving clinicians an opportunity to remotely close two thirds of patient demand. With members of the GP and urgent care teams also in isolation, the practice enabled them to work remotely and further decreased the number of in surgery appointments carried out. This was done safely due to the greater amount of clinical information being received in the first instance in each eConsult submitted by patients.
The GP consultation face to face appointment conversion rate decreased from 30% to 15% on average, reducing the overall demand on clinical team members and freeing them up to see sick patients face to face, where safe and appropriate. Where patients chose to complete an eConsult, having the patient history upfront, including COVID-19 screening questions that were built into the eConsult platform, allowed clinicians to make informed judgement calls and an ability to consider key risk factors associated with COVID-19. The Total Triage model was designed to work as a hub and spoke model, this and greater patient information for over half of triage allowed Beacon to redistribute clinical work across their six sites to create distinct ‘hot and cold sites’ as well as an isolated administration site. Processing of eConsults has occurred across Beacon’s sites, or from the homes of its staff, allowing socially isolating staff to continue working.
“As the COVID-19 pandemic has become a reality, we have not needed to significantly alter our access model or cancel routine appointments with our GPs and urgent care team.”Joseph Nicholson, Lead – Improved Access Project Manager
During COVID-19, Beacon has seen an increase in the number of eConsults received as patients have taken to this new way of approaching the practice. During March 2020, 6,055 eConsults were received by the practice, compared to the 4,500 submitted in November when they moved to this new model of care. eConsult allows all patients to stay in contact with the surgery team, avoid telephone queues and the need to come in for a high proportion of their issues. Increased use of eConsult during this period has also enabled phone lines to remain open for those unable to contact the practice by any other route.
Previous experience of both Total Triage and eConsult has enabled Beacon to maintain ‘business as usual’ elements of practice work. The practice has been contacting patients that are known to have long term conditions at home and inviting them to submit a review through eConsult. Not only does this allow the practice to keep monitoring and caring for patients whilst minimising footfall into the practice, it has also allowed them to keep collecting Quality Outcomes Framework (QOF) data. With fewer COVID-19 queries reaching GPs, thanks to sign-posting to NHS 111 and COVID-19 screening questions on the eConsult platform, the practice has been able to use their time to respond to non-urgent patient queries, especially evident when the phone service was not running.
The next step for the practice is the introduction of more formal video consultation follow-ups, using another third-party supplier, within the surgery to allow clinicians to “see” more patients without potentially exposing staff to COVID-19. They hope that this pandemic offers patients an opportunity to use eConsult to continue addressing their health concerns. In the long term, Beacon hopes to identify how they can continue to use eConsult to support the practice and what may be required for online consultation to become the ‘normal’ access route for the practice. This will include exploring data around efficiencies that have been introduced through the Total Triage model and the implementation of eConsult. The impact on other local health services will also continue to be monitored, for example, potential effects on the rate of A&E attendances that relate to Beacon patients.
Policy implications highlighted
Several policy implications were discussed and highlighted during the process of writing this case study that we would like to highlight:
- Further training for clinicians on adopting and adapting to new technologies and best practice on online consultation and how to work digitally.
- Centralised support for practices to adopt existing best practices and understand how to adapt this to their specific practice and patients.
- Funding support for communicating the benefits of online consultation for patients in a system/provider agnostic way.
- Support on collecting and analysing data to be able to evaluate the impact of change processes for busy practice staff.
- The need for clinical systems to adapt interfaces to better suit high throughput triage practices and on the day monitoring of capacity/demand.
Case study written by:
- Irene Reguilon, Marketing Manager, eConsult Health Ltd
- Joseph Nicholson, Improved Access Project Manager, Beacon Medical Group
- Sian Bunce, Devon Digital Accelerator Programme Manager, Devon Sustainability and Transformation Partnership
- Jim Roberts, Digital Marketing Specialist, eConsult Health Ltd
- Arvind Madan, Executive Director of Partnerships, eConsult Health Ltd
When the COVID-19 pandemic started, Beacon’s Total Triage model delivered on its promise of increasing resiliency to continue to meet patient demand. As the number of staff available to answer the practice telephone lines reduced due to self-isolation and sickness, Beacon was able to direct patients to use eConsult instead, allowing continued access to their services.