Triage – decision or process?

Triage - a sophisticated decision

Complex decision not algorithm

There seems to be an entire industry springing up out there in NHS and Social services around the concept of Triage.   With the noble intent of improving speed and ease of access to services for those that need them most urgently, it’s execution often achieves anything but!

The idea of having a “front door” response to a request for help, stemming back from the Crimean battlefields, makes perfect sense.  Single points of access for a public who are often confused about who and what can help them, are a great idea!  So what is the problem?

As with most good ideas, this one fails when it is turned into a process (algorithm) and mechanised to within an inch of its life.  Many of the single points of access I come across are grindingly laborious processes, staffed by under-qualified practitioners who are overwhelmed by demand, making poor decisions and, consequently, mis-directing people.  In my view, this can be traced predominantly to misunderstanding the nature of the triage decision.  It is seen as binary, resulting in a “yes/no”, “include/exclude”, “accept/reject” outcome.  This, in turn, necessitates “access”, “eligibility” and “prioritisation” criteria that are rigidly and “fairly” applied.  The effect is depersonalised, inaccurate conclusions.

Triage is a complex person-centred decision about risk that must be made by a highly skilled and competent practitioner precisely because it cannot be reduced to an algorithm. It needs sophisticated reasoning through of:

  • the root of the person’s request for help,
  • the factors that will predispose them to and protect them from the precipitation of harm/impact, and
  • the factors that will perpetuate or worsen their current harm/impact.

Then it requires an in-depth knowledge of evidence-base, local services and resources to help  direct people to the most likely source of help in as timely a way as possible.  Effective Referral Conversations