Internationally, there has been mounting interest in call centres and their use of modern telecommunications and information technology for the purpose of medical triage.1 These initiatives originated mostly in the United States in response to the need to reduce escalating healthcare costs.2 However, they became widespread in the early 1990s as part of a broader strategy by many US healthcare organisations to implement demand-management strategies focused on improving consumer health knowledge and preventing unnecessary use of expensive health resources such as emergency departments.3

These services, staffed largely by registered nurses, often acted as a gatekeeper for access to emergency healthcare services and provided telephone triage, recommending appropriate levels of care supplemented by advice on self-care and information about provider availability. In countries with largely public healthcare systems, such as the United Kingdom and Canada, gatekeeper functions are performed mostly within existing primary care services. Thus, potential indirect benefits such as improvement in service access and availability (especially after-hours) have made telephone triage a rational and popular policy initiative. The largest whole-of-population approach to date has been NHS Direct in the United Kingdom. This service began in 1997 and currently 65% of the population of England has 24-hour access.1,4 In the United States 100 million people are estimated to have access to telephone triage, while in Ontario, Canada, the Ministry of Health and Long-Term Care has instituted a similar approach for a population of more than 10 million people. In 1996, the Department of Health in Western Australia (DoHWA) began negotiations with relevant stakeholders which culminated in the official launch of HealthDirect at the end of May 1999. This triage and health information service is provided by McKesson, a specialist in the delivery of health call centre services on behalf of the DoHWA. It operates from a dedicated call centre with 33 full-time-equivalent (FTE) operational staff (48 nurses) and is available to the whole of the State, 24 hours a day, seven days a week. Here, we document the activity of this centre over the first two years.

Telephone triage is performed by nurses registered to practise in Western Australia. Recruitment is followed by several weeks of intensive training. Once nurses are taking calls it takes a further three to six months to build skills to a level commensurate with the expected triage standard performance criteria (Box 1) and key performance indicators (Box 2). During training and throughout the probationary period, nurses are provided with information about their individual performance related to these performance indicators. Monitoring and feedback continue throughout employment, focusing on the positives while identifying areas for improvement.

Access to the triage service is by an extensively advertised, freecall 1800 number. The nurse asks for the caller's name and contact number, although the service accommodates the 6.4% of callers who wish to remain anonymous. After registering the caller, the nurse obtains sufficient history to assign a "primary symptom" from which the most appropriate clinical guideline is selected from the call centre Centramax decision-support software (proprietary software written in the US, but modified by a DoHWA-appointed group of Western Australian general practitioners to reflect Australian terminology and medical practice). After a series of responses to guideline-prompted questions, a disposition (one of 26 codified management recommendations; see Box 3) is reached and the caller advised to seek the recommended level of care. At their discretion nurses may override to a higher level, but there is no provision to downgrade dispositions.

HealthDirect was instigated by DoHWA to provide symptomatic callers with advice on when and where they should seek medical attention. The numbers of calls (an average of 95 per 1000 for the 1.67 million WA population) is similar to that documented in other countries.7,8 The annual call centre budget of $4.5 million (including all programs) is less than $2.51 per capita and represents about 0.2% of the State health budget. This translates to about $20 per triage call. It must be stressed that HealthDirect advises most symptomatic callers to attend a healthcare provider, albeit in differing time frames. A homecare disposition was deliberately omitted initially in the interests of introducing a new service with maximum possible safety, but has now been included in some guidelines on the advice of the local medical review panel. In any case, there is evidence from a recent 72-hour call-back study conducted by Curtin University of Technology in WA (yet to be released) that a substantial number of callers given lower dispositions are satisfied with the telephone advice provided and do not attend a medical service. Therefore, the greater use of a homecare disposition could potentially reduce general practitioner consultations for minor complaints without compromising patient wellbeing. Although we have records of several patients, including seven with documented meningococcal infections who were offered and took advice to attend hospital immediately, there are insufficient data to rigorously address the issue of efficacy, or to benchmark performance against other forms of medical assessment.

At present, there are only two specific outcomes supported by data. Firstly, the service appears to be popular. This accords with the experience of others,5,9,10 including in Australia, where research has "demonstrated enormous community support [for] emergency department telephone advice"11 which is "rated highly by the community and the compliance is strong".12 Secondly, telephone advice calls directed to the Perth metropolitan hospital emergency departments are now, to all intents and purposes, non-existent. Given that 50 000 emergency department attendances equate to 24 hours of non-stop telephone advice,11,12 HealthDirect has relieved emergency departments of a considerable burden.

Currently, a 12-month independent evaluation of HealthDirect is being undertaken by Curtin University of Technology WA on behalf of DoHWA and the Commonwealth Department of Health and Aged Care. The results will also form part of a national after-hours primary medical care "trial", with similar studies being conducted in four other States. The main focus will be to determine the effectiveness of telephone triage as a demand- management and referral tool for the more efficient use of health services, particularly after-hour services. The approved study plan is comprehensive and employs several methods to gauge consumer compliance and satisfaction with advice given, health-provider acceptability with referrals, quality of clinical advice, impact on services, as well as financial aspects. The study will also measure the impact of HealthDirect on emergency department workload and ascertain the appropriateness of referrals.

Although overseas data document that call centre nurses with GP backup do not increase mortality, morbidity, admission to hospital or emergency department attendance,7 as well as significantly reduce after-hours telephone calls to GPs,8 there is justified uncertainty about the role of telephone triage centres. Opinions include those which regard the service as no more than a "de facto general practice"13 or express the opinion that "a multinational or offshore managed care organisation" would be "in a very good position to slowly set up a monopoly by opening their own health centres and directing after hours, and in-hours patients . . . to their own facilities".14 Others argue that the impact of telephone triage on health services is unknown and assert that the high cost of such ventures would be better directed elsewhere. It bears repeating that only further research will provide sufficient data to decide these issues. Regardless, it is not the aim of telephone triage to diminish the role of general practitioners. Experience has shown that almost three-quarters of calls occur after normal practice hours, and indeed HealthDirect consistently receives calls every few days from one or more of the six Perth GP after-hours cooperative clinics advising they are unable to accept further referrals.

Over the next 12 months, given the policy direction articulated by both State and Federal governments, it is likely that an increasing proportion of the Australian population will have access to telephone-based triage and health information services. Further, the use of call centre infrastructure to provide services focused on improving access and outcomes for the mentally ill and those with chronic medical conditions is also likely to be trialled. Information documenting demand will be complemented by data measuring the ability of this type of service to favourably influence human behaviour and medical outcomes. It remains to be seen whether the inclusion of interactive options such as cardiac telemetry and spirometry is likely to prove beneficial and cost effective. Attractive as they may seem, novel inventions must transcend novelty.

4: Call patterns over the 24 months