Digital triage in GP: enhancing access to care or increasing inequalities?

In recent times, general practice has had to respond to rising volume and increasing complexity of need, with each full-time GP now responsible for an average of 2,257 patients – 320 more than in 2015. Practices are having to rethink how patients access care, with one of these innovations being ‘digital triage’ – online tools that assess patients and direct them to the most appropriate care.

The Covid-19 pandemic accelerated this change, with national guidance recommending a digitally enabled ‘total triage’ system, which meant that all patient requests were screened remotely before being triaged to an appropriate pathway or consultation style. The government has also pledged to make a shift from analogue to digital one of the core elements of the NHS agenda in the 10 Year Health Plan. ‘Digital triage’ aims to streamline patient access in order to improve efficiency in GP practices, but there are concerns that it could widen health inequalities by adding barriers to accessing care.

During my GP training, I worked in two practices that have taken very different approaches to appointment access.

The first practice I worked in used a ‘clinician triage appointment system’. Patients either submitted an ‘e-consult’ form online, or if they were unable to do so, reception staff would complete a shorter version over the phone on their behalf. These requests would then be triaged by a doctor. From a clinical perspective, this model had advantages, as GPs could manage their workload more efficiently – for example, by arranging blood tests or investigations prior to a consultation. They could also respond to minor queries via text, or triage the patient to a more appropriate service such as community pharmacy.

However, it was frustrating for patients, as the forms were long and often asked irrelevant questions, such as whether a toddler smoked. Additionally, the online form was difficult to access for those with poor digital literacy, lack of internet access or language barriers. Despite exemptions, such as dyslexia, the need for an interpreter or lack of IT access, some patients were repeatedly asked to fill in the form anyway. This anecdotal feedback is reflected in a survey undertaken in Islington, which found that e-consult was hard to use for those lacking digital confidence, took too long to complete and was less suitable for certain patient groups.

The second practice operates an ‘on the day’ appointment policy, whereby patients either call up from 8am to make an appointment or book online from midnight. There is no clinician triage and it is first come, first served. For patients who are able to get through and book an appointment, it is simple and relatively quick. But some patients are unable to get through at all, spending days repeatedly phoning and finding all the appointments taken. Others were booked in to see a GP when their issue may have been better addressed by the admin team, a pharmacist or the social prescriber. Without any triage, limited appointments were not used in the most effective manner.

Neither system worked perfectly. The e-consult model improved efficiency for some but created barriers for others. In the first-come, first-served system, access was technically open, but the lack of triage meant inefficient use of appointments and more difficulty accessing care if you were unable to call at 8am.

What I learnt from this is that there is no one-size-fits-all solution, and there is no single model that will work for every community. When triage is implemented appropriately, it can ensure that patients get the right care at the right time with the right member of the multi-disciplinary team. But if systems are rigid and inflexible, they risk widening the very inequalities they aim to fix.

‘Blended’ triage systems, offering a mix of digital, phone and in-person options, may provide a more equitable and flexible way forward. This might mean simpler and more user-friendly triage tools, such as ones which ask more relevant questions and are easier to complete. Additionally, there should be clearer separation of admin queries from clinical ones, as these do not need a GP appointment and should be easy to divert. Finally, there should be a robust safety net and a consistent approach to exemptions for those who struggle with online forms, so that these patients are not marginalised by the triage system and it does not further entrench inequalities.

Although some practices are moving in this direction, there is unequal uptake of blended triage approaches. This variation is partly due to general practices operating as independent contractors, with uptake depending on practice priorities or leadership. Additionally, different triage tools (such as e-consult or PATCHES) add to the disjointed approach, making it difficult to implement a standardised system.

Digital triage certainly has a role to play in the future of general practice. But to truly enhance access, it must be inclusive. That means listening to patient experience, learning from this, and then building flexible systems that work for everyone. We must also ensure that national policy supports practices with the investment, infrastructure and guidance needed to implement blended approaches effectively. In an increasingly overstretched system, we cannot afford inefficiency, but we also cannot afford to widen inequalities by leaving people behind.