Models of AH PMC are in flux in a number of developed countries. In Australia there is increasing concern that lack of AH care is resulting in an increase in care substitution with more GP-like presentations occurring in emergency departments [1
]. While it remains unclear whether this is true, it has resulted in a renewed impetus to develop viable models for providing high quality AH PMC.
Telephone triage and advice services form one common model or feature of care in the provision of AH PMC. Most frequently these services are embedded in other AH services such as general practitioner (GP) cooperatives in the UK, HMOs in the US and the county-based service arrangements now operating in Denmark [2
]. In addition, a small number of standalone services have been established. NHS Direct, the national AH telephone triage service system in the UK, based on nurses using proprietary health call centre software is the most important of these. An outcome of the recent review of AH services in the UK is that NHS Direct has become the point of first contact for people accessing AH services in the UK. It is now also better integrated with other AH service providers, and not just GPs, and operates with improved functionality [3
A recent structured review of AH PMC care was however only able to identify a small number of high quality studies evaluating the various impacts of these telephone triage services [4
]. Central to these impacts is their effect on service utilisation, given that high levels of service utilisation pose the greatest challenge to the viability of AH PMC services. The review concluded that the growth in telephone triage and adviceservices usually, but not always, reduced immediatemedical workload through the substitution of telephone callsfor in-person consultations. Considering embedded services first, a randomised control trial (RCT) from the UK compared a nursetelephone consultation service integrated within a GP co-operative with the usual practiceof that co-operative [5
]. There was 69% reduction in telephone advicefroma GP, 38% reduction in patient attendanceatprimary care centres and 23% reduction in home visits.
The implementationof a telephone-based nurse triage service in a HMO, in the US (where GPs do not act as gatekeepers to medical care) led to 15% decrease in hospitalemergency department services and 11% decrease in out-patient physicianservices [6
]. AH telephoneaccess to physicians in an inner city, adult, general medicine clinic again in the US, had no impact on hospitalisations or ED visits, as demonstrated by an RCT. Uptakeof the service thoughwas low [7
In 1992 in Denmark, locally organised GP AH serviceswere replaced with centrally organised services that includedtelephone triage and advice services. Christensen found that the numberof consultations in doctors' surgeries was relativelyunchanged, but home visits were much reduced from46 to 18% [8
]. Hansen, in the county of Funen, three yearsafter the change reported similar results [9
Considering standalone services, a before/after study following the introduction of NHS Direct in the UK found a small, but significant change in use of GP co-operatives but no change in use of ED and ambulance services [11
]. NHS Direct also had no impact on the number of general practice consultations for influenza-like illness and other respiratory infections during a winter epidemic[12
]. A pilot national telephone advice service (Healthline) in Christchurch, New Zealand though had little effect on overall ED numbers but decreased the workload for ED nursing staff charged with answering advice calls [10
This article considers a recent initiative of the Australian Government – the After Hours Primary Medical Care Trials (AHPMCTs) and its impact on service utilisation and service mix. The goals of the AHPMCTs were to improve the quality of service delivery as well as consumer acceptability, consumer access (including affordability) and equity, appropriateness of service mix, provider satisfaction with regard to their impact on service mix as well as service use more generally [13
The aim of this paper is to determine in four of the five AHPMCTs where telephone triage was the only service innovation, whether telephone triage reduced immediate AH PMC service utilisation and altered AH service mix towards GP clinic use (and away from GP home visits, ED visits and ambulance use). Two of these four AHPMCTs were standalone services and the two others, embedded services. It is therefore possible to compare the effects of telephone triage in standalone and embedded services on service utilisation and service mix. The study covers not just GP care – GP clinic care and GP home visits – but also ED, ambulance and professional medical advice by telephone. Service utilisation analysis is considered at a whole population level – rather than at an agency level – which surprisingly, is uncommon in previous studies of AH PMC care [8
]. In these ways the article adds to the growing knowledge base on the effects of telephone triage on AH PMC services.
Telephone triage services used by the four study AHPMCTs differed in form and function within the individual AHPMCT as follows.
These were call centres where nurses, using proprietary health call centre software, which were aimed at providing more accessible advice and promoting more appropriate AH PMC service use.
1. A stand-alone Statewide call centre (studied in both metro and non-metro areas);
2. A stand-alone Regional call centre (studied in both inner metropolitan and rural satellite areas);
These triage and advice systems did not use proprietary health call centre software. The aims of the services in which they were embedded were also different. These were to manage demand so as to support the GP workforce in terms of recruitment and retention. They consisted of
3 A GP-based telephone triage and advice service (without guidelines or software) in a pre-existing Deputising service;
4 Local triage and advice service using hospital nurses with locally developed, paper-based protocols to support AH services in GP own-practice arrangements in a small rural community;
The AHPMCTs commenced operation in late 1999-mid 2000. Their organisational settings and regional contexts are summarised in Table .
Local context and services of individual trials