A year down the line

One year after the launch of the NHS Direct pilot scheme, health secretary Frank Dobson has declared it 'a great success' and is accelerating the programme so that 60 per cent of the country will have access by December.

But an independent evaluation of the first three sites, by Sheffield University, has shown that all are operating well below capacity.1 The report points out that while calls to the sites are rising, the overall number has been two-thirds lower than that envisaged by the government.

'While each site was asked to tender for a minimum volume of 75,000 calls per year, in fact only about 50,000 calls have been made in the first eight months to all sites combined, equivalent to a mean of 25,000 calls per site per year', it notes.

Nonetheless, health authorities have been told to submit proposals for a third wave of call centres by tomorrow, and hastily convened meetings to draw up plans are taking place up and down the country. The evaluation data is still only preliminary but the political decision has been made: NHS Direct is forging ahead.

The Department of Health has denied in a report (The Independent, February 27 1999) that NHS Direct will be used to filter all calls to GPs. But out-of-hours calls to GPs are going to be routed via NHS Direct in Northumberland.

Part of the rationale for introducing NHS Direct faster than originally planned is that it might ease winter pressures at the end of the year and help the service cope with any special problems encountered with the millennium computer bug. But so far there's no evidence that this sort of helpline will divert people from accident and emergency departments or from calling their GP. In fact, some fear it could lead to an upsurge in demand.

Sheffield University's evaluation says current figures show that NHS Direct has had no impact on demand for ambulance, A&E or GP co-operatives in its first five months of operation.1

James Munro, clinical lecturer in epidemiology at Sheffield's school of health and related research, and one of the report's authors, comments: 'Everybody accepts it's too soon to say anything about the impact on other services. It is entirely possible that as call volumes increase there may be a significant change in demand for other services and that could be an increase or decrease.'

When the health secretary made a statement on NHS Direct in the House of Commons in February he drew heavily on internal data - from the first- wave pilot sites - which showed that 80 per cent of callers were advised to do something different from what they had intended before ringing.2

Just 9 per cent of callers said they had originally planned to look after themselves at home, but after calling NHS Direct 38 per cent were advised to do just that. Twenty per cent of callers were directed to more urgent care, and 40 per cent to less urgent care than they would otherwise have sought.

Jeremy Dale, professor of primary care at Warwick University, believes this is rather flimsy evidence for pushing ahead with such speed. 'The data on people's intentions is rather dubious because it was just a question tacked on at the end of the phone call and there were no follow-up calls.'

In September 1998, 1,050 questionnaires were sent out to callers to all three sites as part of the Sheffield University evaluation. A total of 710 replies were received and 76 per cent described the service as 'very helpful' and a further 20 per cent as 'helpful'. But more than half the respondents felt the service had not been given enough publicity.

Overall, 57 per cent of calls related to female patients and 43 per cent to male patients. And two-thirds concerned people under 35. One in four calls related to a child of five or under. Use of the service by over 65s is lower than would be expected from their use of other health services, the report notes.

Overall, 71 per cent of calls are out of hours - between 6pm-8am, or at weekends - and this figure did not differ between sites. 'Current patterns of use suggest it is being seen as an out-of-hours service, with problems which might reach NHS Direct being taken elsewhere during the daytime,' authors comment.

One interesting finding by the Sheffield researchers was that when presented with the same set of test calls, there were considerable differences between the responses of the three sites when dealing with urgent calls. In Milton Keynes and Lancashire, patients with urgent problems were nearly always advised to visit their local A&E department, while in Northumbria such patients were just as likely to be advised to contact their GP immediately.

A second wave of pilots is just getting underway, and all 13 will be up and running by the end of April. Lessons have been learned from the first three schemes and the latest guidance suggests that call centres covering a population of more than

2 million will secure the most significant economies of scale. The Milton Keynes pilot, by contrast, covered just 185,000 people.

There is also a new emphasis on linking up with primary care. The latest pilot launch is run by the Harmoni GP co-op in Hillingdon, west London. But the majority of schemes are run by ambulance trusts, as is the case in Essex, one of the first second-wave pilots to be set up and which went live on 1 February.

Stephen Robinson, the NHS Direct project lead, says Essex Ambulance Service was able to put in a bid that was strong on collaboration and the 'nuts and bolts' of setting up a control centre. The service was also the only single NHS organisation that covered the whole of Essex.

'We have learned a great deal from the first three pilots and we decided to follow the Milton Keynes model of one central control centre, as opposed to the alternative 'hub and spoke' model where the nurses dealing with calls are based at more than one site. A key tenet is the importance of establishing links with other information and health providers.'

The centre has tapped in to the translation service Language Line, which means that NHS Direct can set up a three-way conferencing facility with access to more than 300 translators, who work off-site. This facility has already been used to help with calls from Chinese and Croatian callers.

'Another thing we learned was how vital it is to get local medical opinion on board. We identified consultants and GPs who could effectively sign off the computerised clinical algorithms that are used by the nurses to make decisions,' says Mr Robinson.

Mr Robinson believes it is feasible that NHS Direct could take on call- handling for the GP out-of-hours service and provide nurse triage for it. 'That is if the GP wanted that. Sometimes people will call and the recommendation will be 'see your GP immediately'. That call could go straight through to the GP call system and would not have to go through another triage.'

As with the other pilot sites, the number of calls the centre receives is gradually rising. After starting at a rate of 50 calls a day the Essex centre is now up to an average of 150 a day. 'To be honest, we didn't know what to expect, but the volume of calls is now going up faster than we anticipated,' adds Mr Robinson.

The centre is based at ambulance headquarters in Broomfield Hospital, Chelmsford, and now covers a total population of 1.6 million people, although that may be expanded in future.

When it is running at full capacity it will receive£1.3m a year. The centre now employs 15 nurses but is in the second phase of a recruitment campaign and will eventually employ 30 nurses and 10 call-handlers. 'On the issue of recruitment I think hospital managers were worried about us to begin with when we said we needed 30 nurses.

'But it has turned out that the impact on any one organisation has been minimal. The only potential difficulty was one GP practice where two of the practice nurses came over to us, but otherwise we have drawn staff from quite a wide area.'

Not all the posts are full-time, as the centre hopes to encourage applications from people like health visitors who could split their time between the call centre and working in the community.

Mr Robinson hopes that in future NHS Direct will become a more integrated part of the service. 'As things stand, it is a sort of overlayer to other NHS services - it isn't seeping down into the infrastructure.

'If someone needs a health visitor, NHS Direct can't arrange for one - it still has to be done by the GP. But in future I can see callers being referred to other services without having to go through a GP.'

One Essex GP who is not yet 'on board' the NHS Direct project is Dr Les Brann of the Laurels surgery in the village of Boreham near Chelmsford, a practice that has been using nurse triage for the past 30 years. 'We have a lot of experience with this, not that anyone has asked for our opinion. They call it a primary care-led service and then they impose NHS Direct on you.'

Dr Brann says he has a number of concerns about the new initiative. 'One fear is that NHS Direct is very protocol-driven and I think it could lead to the service being swamped.

'There are lots of people who want permission to go to the doctor, and if a nurse on the phone says 'see your GP' they'll come rushing to us as a matter of urgency, day or night.'

Dr Brann believes that nurse triage works well for his practice because the nurse taking the calls knows the patient and has immediate access to their notes and drug records. 'The key is local knowledge, but the way they are implementing NHS Direct you are not going to get that. A 24-hour service sounds great, but nobody has stopped to think through the effect on the service. Our gut feeling here is that it's going to be a problem.'

Dr Brann also has concerns about how the government may develop NHS Direct. 'Looking way ahead, they are talking about appointment systems being available on NHS Direct. So the nurse will say: 'I think you need to see a doctor within four hours and I see there's an appointment available with Dr so and so on Friday at 5pm.' This would be totally inappropriate. It's fine if it were one of our own nurses, but it's not OK to have that imposed from outside.'

Dr Paul Davis, vice-chair of the Royal College of General Practitioners and a GP in Redbridge, says this concern is shared by other doctors. 'From what I've seen of the computer programme which leads nurses to work down a given pathway, it tends to err towards the conservative safety-net approach and suggest a visit to a GP. And if a nurse has given that advice, it's difficult for me as a GP to overrule a colleague.

'Once it hits the headlines that you can pick up the phone any time, day or night, it is going to raise activity levels. People have got used to the idea of dialling out for a pizza. Now they'll be able to dial out for a doctor.'

Dr Davis adds: 'I know at the moment it is being centrally funded, but will that continue? And if there is an explosion in demand where will the money come from? In my area we pay doctors on the out-of-hours service£300 a shift, so it's not cost-effective to do work at night that could be done during the day. I like the idea of improved access, but I'm not sure this is the right way to go about it.'

But Royal College of Nursing assistant general secretary Tom Bolger, who oversaw the introduction of the college's membership helpline, RCN Direct, says nurses are more positive than doctors about the new service.

'NHS Direct may well attract extra calls from people who are worried but don't want to bother a doctor. But surely we're talking about providing an improved service to the public, and part of that is offering people reassurance. If it creates more demand, then ways have to be found of meeting that demand.'

On the question of launching the new service in the middle of a nursing recruitment crisis, Mr Bolger says he hopes to see greater efforts to attract work-injured nurses to NHS Direct.

'If they can bring back nurses who have left the service, either because of a disability or any other reason, then it need not have an adverse effect on staffing.

'As for the number of calls, I'm sure that will soon pick up. With the right publicity the public will definitely make use of it. People are getting used to being offered services over the phone. NHS Direct is an idea whose time has come.'