Triage – decision or process?

Triage - a sophisticated decision

Complex decision not algorithm

   Triage – what goes wrong?

The idea of having a “front door” response to any request for help or need, stemming back to Crimean battlefields, makes perfect sense. Single points of access also make sense to a public who are often confused about who and what will help.

There is now an entire industry springing up out there in NHS and Local Authority services around the concept of Triage.

When most good ideas fail it is normally because they are turned into processes and algorithms and mechanised to within an inch of their lives. They end up taking more resources and becoming yet another hoop to jump through for the public, often with no measurable benefit to them or to services. “Access” to services is now at risk of being controlled with a fist of steel which is often defeating the point.

Services seem to be a double-bind of keeping the “worried well” out of services but being fearful someone will get missed! The result is an extremely high conversion rate in most services from referral to treatment, especially as their “efficiency” is often measured by a key performance indicator called rtt (referral-to-treatment!!)

Triage is a decision, not a process.

It is a complex, person-centred decision about risk that must be made by an experience, highly skilledpractitioner capable of making a reasoned and balanced decision about foreseeable harm.  It cannot be reduced to an algorithm or standardised precisely because it entirely individualised and involves supporting people to think and, when necessary, access help in as timely a way as possible.

We cannot reassure people who are anxious by telling them not to worry if they don’t believe we understand why they worried. Anxious people do not make good decisions, so containing their anxiety through a kind, empathetic conversation will, in most cases calm them down enough to be able to think. It means the conversation must change to understanding the person’s concern, not looking for evidence that the person they are referring fits a set of service thresholds or criteria. It requires that they are not unnecessarily alarmed when they is low risk of harm as this simply creates incongruous anxiety and creates more demand on services.  Not rocket science but it really is transformative when applied to referral conversations.

The nature of the decision is also critical. Many people treat it as a binary “yes/no”, “in/out” decision which then requires “access”, “eligibility” or “prioritisation” criteria that are rigidly and “fairly” applied. The assumption underpinning criteria is that the right people will get quick and easy access to the services they need!  The effect is often a very poor experience and results in many people being “turned away” with little or no help. The resultant feelings of helplessness which quickly escalate to frustration and even anger, generating a very high volume of complaints about services, significant waste of resources and true reputational damage.  Generally, the most able and articulate people then get services through coercion, at the expense of those who are less resilient, less articulate and more in need of help.  Sadly, the evidence is the demand for services goes up when criteria are applied as they create a sense of entitlement and so equity of access becomes impossible to achieve.

So, what does this mean in practice? You need to change the conversation by:

  1. Changing the word referral to “request for help” or “request for assistance” ensuring you have an active partner at this point.
  2. Scrapping written referrals of all kinds – paper and electronic – especially the ones with tick box fields
  3. Scrapping all eligibility criteria based on disease, disorder, severity and complexity and stop using the pejorative words “appropriate” and “inappropriate”.
  4. Changing the mode to voice, video or drop-in so a proper, empathetic conversation can take place
  5. Encouraging worried people to talk directly to services and not go via other gatekeepers, like GPs. This avoids things getting lost in translation and prolonged worry turning into frustration and conflict.
  6. Having experienced practitioners at the front door – with in-depth knowledge of evidence-base, local services and resources. This reassures both the public and the service but, also ensuring your less experienced staff get to learn these skills too. Effective Referral Conversations
  7. Recording decisions in ways that represents the outcome of the co-productive conversation with the requester – avoiding the toxic words “accept” or “reject/decline”.

The Results?

The evidence from services that have started to work in this way is that it takes a while for concerned people to trust services to listen and some get quite cross that they are being asked to engage in a conversation rather than just tick a box.  However, quite quickly, relationships start to detox and collaborative decisions are made that reduce the need to convert most referrals into assessment and treatment.

The number of requests will not go down and you do not want them to. You don’t want to hide need, but the conversion rate from request to assessment will go down dramatically and the satisfaction with and reputation of your services will grow exponentially.

Watch out for the impact this then has if services around you are not working in this way and are not accessible.  The public will start turning to you as the only service they can talk to.  So, this can only really have sustained impact if the entire system starts working like this.