Exploring two-step and one-step urgent care telephone triage: a UK-based semi-structured interview study

Complexity and delays

England-based participants shared their experiences of navigating a complex pathway, often involving several complicated steps. These were experienced as being time-consuming and that care was unnecessarily delayed. Although they expected and understood the need to speak with a non-clinician when calling the NHS 111 service they described delays in the process, including needing to wait for an additional callback from a clinician and needing to repeat information about their health problem in at least two different telephone calls. Some patients questioned why this was necessary:

'I knew I just needed to get her antibiotics into her … knowing that I had to wait for another phone call and repeat it all again before anything would be done was a little bit frustrating … I'm not gonna lie, it is a bit of a pain repeating the whole, like, the whole thing over and over. … I don't know if that middle step [clinician triage] is totally necessary from, like, a patient point of view because I'm assuming the 111 caller’s [call takers], I don't know, are they just as qualified to make that call to say, “Oh yeah, a GP needs to speak to you.” So is it totally necessary and efficient for that middle phone call?' (Mother of child aged 3 years, F, England, aged 25–34 years, White Irish, triaged to OOH GP callback; P12)

Patients’ frustrations in relation to delays in two-step triage were compounded when they additionally experienced poor integration between services. For example, a patient who was referred in secondary triage to the emergency ambulance service described receiving a call from the emergency service, who referred her back to the initial triage at NHS 111 for a problem that subsequently required hospital admission. She expressed frustration and potential for clinical safety issues to arise from such delays:

'So, had I been another hour messing about and 111 hadn’t got back to me or they hadn’t have realised that there was a big problem here ... and had it had been a different nurse, it could have been a different … So, it’s just, it was thanks to the nurse going, “This is ridiculous, the only other thing I can do is refer to the doctor and I’m gonna put it as urgent as I can.”' (Patient, F, England, aged 25–34 years, White British, referred to emergency ambulance service; P11)

Navigating urgent care triage appeared to be a more complex process for patients in England, with patients expressing their frustration and concerns about receiving timely care owing to delays caused by needing to speak to different call takers and needing to describe symptoms repeatedly.

Communication barriers and facilitators

Patients described rigidity in communication during triage, particularly non-clinician triage. They described it as repetitive and scripted or algorithmic, simply needing to provide ‘yes’ or ‘no’ answers and feeling unable to ask questions. In the quote below, the patient describes a lack of human touch in NHS 111 primary triage:

'It’s all very synthetic and … I suppose it’s talking to a computer basically … rather than a human, you know? ... There wasn’t a lot of human touch. It was just tap, tap, tap. Now, next question. Tap, tap, tap.' (Patient, male [M], England, aged 75–84 years, White British, triaged to routine GP appointment; P24)

Patients did not feel the rigidity of triage communication served any purpose in helping or supporting them. Clinician triage, however, was described as more natural, even when they acknowledged the use of scripted triage questions:

'I mean, she, she may, she may have a set of questions that she has to ask … But she did it in a friendly manner, that it, it just felt like two people having a conversation.' (Patient, M, England, aged 55–64 years, White British, triaged to routine GP appointment; P22)

This highlights the acceptability of digital triage being used during the telephone call, when it is not perceived to interfere with the natural flow of communication. Communication that was ‘reassuring’ was important to participants, particularly where self-care was being advised by the clinician; this was evident across both triage models:

'So she [triage nurse] was very good, she said, “You need to write it down.” And then she gave me advice to put her head on a hot-water bottle and see if that would help ease her a bit, you know, it’s just, like, common sense really, but I didn’t think of it at the time … she’s very good, very reassuring, and that’s what I just needed at that time in the morning.' (Mother of child aged 5 years, F, NI, aged 35–44 years, White British, routine GP appointment; P25)

Reassurance and empathy provided by the clinician helped in the patient’s decision to stay at home, rather than seeking further care, which they felt they may have done otherwise:

'The nurse that phoned me back ... again, she was ever so thorough, she went through all different things with me to check on him. And she ultimately said, "Look if, if you really feel anxious I would go, just for you to put your mind at ease," she said, "I think he needs to be monitored. And if any other symptoms arise then, you know go to A&E." … Which ultimately I didn’t do ‘cause I thought, "You know what she’s right, perhaps it was me being a bit anxious." But she did calm me down a lot by kind of, reassuring me ... that you know, it wasn’t as bad as probably I thought it was.' (Patient, F, England, aged 35–44 years, White British, triaged to self-care; P1)

Patients shared their appreciation for unhurried communication, being listened to, and having space to explain their symptoms during ‘natural’ conversations with a clinician, which contrasted with the rigidity that occurred with non-clinician triage. Below, a patient describes their positive interaction with a triage nurse:

'You need someone to sit back and take time to listen … And that’s what, that’s what she did … She left it, she left the empty spaces that I could freely fill … you know, with relevant or non-relevant information, you know. And I think that’s how a nurse should be … a nurse or a doctor. They should do that. Because it’s not always what you say. It’s, it’s the information in between that can give clues on what’s going on.' (Patient, M, England, aged 55–64 years, White British, triaged to routine GP appointment; P22)

Patients described difficulty in communicating their symptoms or feeling anxious, particularly when they felt the professional was under pressure and could not allocate enough time to listen or appeared not to take the problem seriously. Not being rushed was the antithesis of the rigidity sometimes experienced.

Influence of the patient’s confidence

Many factors fed into the dynamic between patient and professional, including the patient’s confidence about the care they felt they needed, which was affected by support from family members, and fear of exposure to COVID-19 in subsequent in-person care. These factors influenced shared decision making and agreement of the triage decision.

Some patients described seeking validation and reassurance from a professional to help them make a judgement on the level of care that was required. They described a sense of being giving permission to access other services. For example, one patient reported a conversation with a paramedic conducting triage helped to confirm that care was needed, and that they would not be wasting the GP’s time:

'Well, his advice was to see my GP straightaway and I, you know, as soon as the GP, as soon as I was able to call in the morning I, you know, I did that … And, and I mentioned the call that I’d had with the paramedic. And I think that probably just helped the GP understand that, you know, I needed some help and, and that I was following advice and, and not just, you know, wasting their time.' (Patient, M, England, aged 45–54 years, White British, routine GP appointment; P6)

Another patient described feeling that the nurse helped to confirm the need to go into hospital:

'She, kind of, confirmed my suspicions, I thought we should go to hospital.' (Patient, F, England, aged 25–34 years, White British, triaged to emergency service; P11)

Participants needed to feel that their potential use of the health service had been validated by a healthcare professional. In contrast, others took agency and asserted their view on the level of care required. This was particularly evident for participants who were more familiar with their health problem, had family support, or owing to previous experiences of a long-term condition:

'You know, if you haven’t, if you’ve been fortunate not to, you haven’t needed doctors and not to have been exposed to, you know, hospitals and things you mightn’t have the same … confidence, I suppose, in expressing yourself and knowing what these symptoms might be. I’m not saying I’m medically trained or anything like that, but, you know, my mum has had issues over the years.' (Daughter calling about mother aged ≥75 years, F, NI, aged 45–54 years, White British, OOH GP callback; P20)

'Well yes because we finally got the outcome that I wanted ... for my husband. And I suppose in one way it gave me a choice, at least I could voice my opinion.' (Partner of male patient, F, England, aged 65–74 years, White British, triaged to emergency service; P3)

Considering Oben’s framework, which describes patient experience to be 'informed by a complex combination of the patient’s personal life, as well as their own and their family’s experiences within the health-care system at all levels of care',²⁶ the two quotes above demonstrate that prior experience shapes the patient experience: for participant 21, their confidence related to a knowledge of a long-term health condition; while participant 3 asserted the care she felt was needed, this participant was a retired nurse and likely drew on this experience.

Evidently a range of different factors, including family support, knowledge, assertiveness, or need for validation influenced how patients communicated with call takers. These sometimes influenced the triage outcome (priority and type of referral) recommended at the end of triage.