title: Implementing telephone triage in general practice: a process evaluation of a cluster randomised controlled trial.
abstract: BACKGROUND
  Telephone triage represents one strategy to manage demand for face-to-face GP appointments in primary care. However, limited evidence exists of the challenges GP practices face in implementing telephone triage. We conducted a qualitative process evaluation alongside a UK-based cluster randomised trial (ESTEEM) which compared the impact of GP-led and nurse-led telephone triage with usual care on primary care workload, cost, patient experience, and safety for patients requesting a same-day GP consultation. The aim of the process study was to provide insights into the observed effects of the ESTEEM trial from the perspectives of staff and patients, and to specify the circumstances under which triage is likely to be successfully implemented. Here we report perspectives of staff.
  
  
  METHODS
  The intervention comprised implementation of either GP-led or nurse-led telephone triage for a period of 2-3 months. A qualitative evaluation was conducted using staff interviews recruited from eight general practices (4 GP triage, 4 Nurse triage) in the UK, implementing triage as part of the ESTEEM trial. Qualitative interviews were undertaken with 44 staff members in GP triage and nurse triage practices (16 GPs, 8 nurses, 7 practice managers, 13 administrative staff).
  
  
  RESULTS
  Staff reported diverse experiences and perceptions regarding the implementation of telephone triage, its effects on workload, and on the benefits of triage. Such diversity were explained by the different ways triage was organised, the staffing models used to support triage, how the introduction of triage was communicated across practice staff, and by how staff roles were reconfigured as a result of implementing triage.
  
  
  CONCLUSIONS
  The findings from the process evaluation offer insight into the range of ways GP practices participating in ESTEEM implemented telephone triage, and the circumstances under which telephone triage can be successfully implemented beyond the context of a clinical trial. Staff experiences and perceptions of telephone triage are shaped by the way practices communicate with staff, prepare for and sustain the changes required to implement triage effectively, as well as by existing practice culture, and staff and patient behaviour arising in response to the changes made.
  
  
  BACKGROUND
  Current Controlled Trials ISRCTN20687662. Registered 28 May 2009.
authors.affiliation: School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK. jamie.murdoch@uea.ac.uk.
authors.forename: Jamie
authors.initials: J
authors.lastname: Murdoch
authors.affiliation: School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK. Anna.Varley@uea.ac.uk.
authors.forename: Anna
authors.initials: A
authors.lastname: Varley
authors.affiliation: Primary Care Research Group, University of Exeter Medical School, Exeter, UK. E.Fletcher@exeter.ac.uk.
authors.forename: Emily
authors.initials: E
authors.lastname: Fletcher
authors.affiliation: Institute of Health Service Research, University of Exeter Medical School, Exeter, UK. N.Britten@exeter.ac.uk.
authors.forename: Nicky
authors.initials: N
authors.lastname: Britten
authors.affiliation: Institute of Health Service Research, University of Exeter Medical School, Exeter, UK. linnieprice@live.co.uk.
authors.forename: Linnie
authors.initials: L
authors.lastname: Price
authors.affiliation: Primary Care Research Group, University of Exeter Medical School, Exeter, UK. R.Calitri@exeter.ac.uk.
authors.forename: Raff
authors.initials: R
authors.lastname: Calitri
authors.affiliation: Institute of Health Service Research, University of Exeter Medical School, Exeter, UK. C.Green@exeter.ac.uk.
authors.forename: Colin
authors.initials: C
authors.lastname: Green
authors.affiliation: School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK. V.Lattimer@uea.ac.uk.
authors.forename: Valerie
authors.initials: V
authors.lastname: Lattimer
authors.affiliation: Primary Care Research Group, University of Exeter Medical School, Exeter, UK. S.H.Richards@exeter.ac.uk.
authors.forename: Suzanne H
authors.initials: SH
authors.lastname: Richards
authors.affiliation: Institute of Health Service Research, University of Exeter Medical School, Exeter, UK. D.A.Richards@exeter.ac.uk.
authors.forename: David A
authors.initials: DA
authors.lastname: Richards
authors.affiliation: Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK. c.salisbury@bristol.ac.uk.
authors.forename: Chris
authors.initials: C
authors.lastname: Salisbury
authors.affiliation: Primary Care Research Group, University of Exeter Medical School, Exeter, UK. R.Taylor@exeter.ac.uk.
authors.forename: Rod S
authors.initials: RS
authors.lastname: Taylor
authors.affiliation: Primary Care Research Group, University of Exeter Medical School, Exeter, UK. john.campbell@exeter.ac.uk.
authors.forename: John L
authors.initials: JL
authors.lastname: Campbell
mesh_terms: D058006:General Practice / Q000458:organization & administration*; D006801:Humans; D024802:Nurse's Role; D015279:Organizational Culture; D017064:Process Assessment, Health Care; D013689:Telephone; D014218:Triage / Q000458:organization & administration*