Triage – decision or process?

Triage - a sophisticated decision
Complex, professional decision
not a binary judgement or neat algorithm

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, with the intention of … well, that’s the million dollar question. What is the intention of these “triage points”?

I am assuming it is to get the right people to the right place at the right time to maximise the effectiveness of any intervention, minimise unhelpful waiting and reduce the number of high risk people being missed. However, in my experience it is not working.

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.

Organisations seem to be in 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 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.

A highly complex, person-centred decision about risk that must be made by an experienced, level-headed practitioner 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 what is perceived as a high risk by some is not even noticed by others. You only have to read the statistic that up to 70% of 999 calls to ambulance services are not medical emergencies to recognise that my “urgent” isn’t always high risk!

The nature of the decision is also critical. Many people treat it as a binary “yes/no”, “in/out”, accept/reject”, “urgent/routine” decision which then requires “access”, “eligibility” or “prioritisation” criteria that are rigidly and “fairly” applied by anyone making this decision. 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. 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.

The mode of access is also critical. Most services/specialties use written referrals and most triage decisions are based on written information. Sadly this often leads to an exaggeration of symptoms or problems by the referrer to ensure their referral is “accepted”.

Anxious people do not make good decisions and services do not reassure worried referrers by telling them not to worry or they don’t need services. If they don’t believe we understand why they are worried, the resultant feelings of helplessness can quickly escalate to frustration and even anger, generating a very high volume of complaints about services, significant waste of resources and true reputational damage.  

A referral is almost always an expression of anxiety so triage is most effective when it is utilised to contain their anxiety through a kind, empathetic conversation which, in most cases, calms people them down enough to be able to think. It means a conversation that seeks to understand the person’s concern or perception of risk, not looking for evidence that they person they fits a set of service thresholds or criteria. It requires that they are not unnecessarily alarmed when they are at low risk of harm (as this simply creates incongruous anxiety and creates more demand on services) but also know that, when they are high risk they will be able to get into services quickly and be taken seriously.  This is not rocket science but is truly is transformative when triage becomes a conversations that results in a collaborative decision. The 3 options being: Support self-help and reassure, admit for routine assessment, admit for urgent assessment/intervention.

So, what does this mean in practice? Services that have had most success:

  1. Change the word referral to “request for help” or “request for assistance” ensuring you have an active partner at this point.
  2. Scrap written referrals of all kinds – paper and electronic – especially the ones with tick box fields
  3. Scrap all eligibility criteria based on disease, disorder, severity and complexity and stop using the pejorative words like eligible/ineligible, appropriate/inappropriate.
  4. Change the mode to voice, video or drop-in so a proper, empathetic conversation can take place
  5. Encourage 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 or conflict.
  6. Have 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 ensures your less experienced staff get to learn these skills too. Effective Referral Conversations
  7. Record 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.

The unintended consequences?

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.