NHS Direct has handled 5 million calls since its launch in 1998, and surveys show overwhelming user satisfaction. But has its impact lived up to expectations, asks Seamus Ward
You do not often hear that a 125-year-old invention is going to transform the NHS, but this is a claim that has been made for Alexander Graham Bell’s humble electro-magnetic telephone.
The phone, combined with some ultra-modern computer technology, forms the basis of NHS Direct, the nurse-led helpline that is now three years old and covers the whole of England and Wales.
NHS Direct’s aims include helping patients receive the most appropriate care and improving quality and increasing efficiency by reducing unnecessary demands on other services.
But has it made a difference? Politicians, academics and clinicians say the signs are encouraging. NHS Direct, launched in March 1998, has now handled 5 million calls, and surveys consistently show more than 90 per cent of users are satisfied with the service.
NHS Direct Online, launched in December 1999, is also providing information and advice to thousands of Internet users every month.
But researchers are coy about the helpline’s impact. Much of the evidence of NHS Direct’s effectiveness comes from research carried out by Sheffield University’s school of health and related research (SCHARR), which has produced two reports on the three first-wave sites - Northumberland, Milton Keynes and Lancashire.
The best these reports have to say about its effect on other services is that it has not added to the workload of casualty departments and ambulances and may have arrested the increase in demand for out-of-hours primary care.
Dr James Munro, clinical senior lecturer in the medical care research unit at SCHARR, says the impact on other services has been patchy. ‘I am pretty sure it has had a negligible impact on demand for A&E and ambulance services and it has probably had only a small impact on out-of-hours care, ’ he says.
‘As lots of people have pointed out, including ourselves, at a time when the calls going to NHS Direct are fewer than those to out-of-hours or A&E, it can’t expect to have an impact. As the call volume increases it could have a greater impact, but we can’t say whether it will increase or reduce demand. ‘
Clinicians in NHS Direct are more upbeat. ‘We have found a significant reduction in the demand for out-of-hours care. I think That is because a lot of patients who can manage with self-care have been taken out of the system, ’ says Dr Kevin McKenna, medical director of NHS Direct Northeast.
‘A Northumberland community health council survey found a net reduction in demand for A&E, but the question is whether it is a net reduction of people who would not have gone to A&E anyway, or a general net reduction.
‘I do not know the answer but it looks as if we are not adding to the workload and we might be reducing it. I would like to see more outcome work before saying that is certain. ‘
Dr Mike Sadler, medical director of NHS Direct Hampshire and Isle of Wight, says: ‘We take all the phone calls for clinical advice for the two main A&E departments in our area. In Portsmouth that has saved two whole-time equivalent staff nurses a day.
Southampton has been running a shorter time but we expect similar results. The diversion of inappropriate calls from A&E to us means they have more time in frontline care. We also do it better. In a busy A&E department you are not really trained to give telephone advice. ‘
The quality of advice given by NHS Direct has come in for criticism. GPs have complained of extra workload because of inappropriate referrals.
An investigation by Health Which? last August criticised the listening skills of NHS Direct nurses who missed important symptoms because they were too concerned with following prompts on their computer screens.
The Department of Health says a study of 1,000 referrals to A&E departments in the West Midlands indicated that 92 per cent were appropriate.
And though he admits it ‘is not terribly strong evidence’, Dr Munro says the high customersatisfaction ratings suggest they are being given appropriate advice.
‘We do not have any direct evidence for this, but it is likely since such a large proportion of callers are satisfied. If patients are wrongly told to stay at home, they will not tick the satisfied box - likewise if they are sent to A&E and told they have wasted their time, ’ he says.
He adds that doctors are being simplistic if they complain of increased workload due to inappropriately referred patients. These doctors only know the patients referred to them by NHS Direct - they do not know how many the helpline has diverted to other routes of care.
Dr Sadler says that evaluation of appropriateness will be a key factor in proving the success of NHS Direct. ‘Accessibility is proven because we have had so many callers; impact on numbers is broadly neutral, but we must get indicators of appropriateness. To date, evaluation has not dealt with this and I think it is one of the key tests of the service, ’ he says.
Evaluation of NHS Direct’s impact has been complicated by the signing last November of a partnership agreement between the DoH and Axa Assistance.
The seven-year deal, worth£68m, is for a new clinical-decision support system for NHS Direct.
However, research into the helpline’s effectiveness was conducted on the first-wave schemes, none of which used the Axa system. Dr Munro says further research is needed.
‘We would not expect the new software to change things like the pattern of users, case mix and the times that people call. But some things will change, ’ he says. ‘The pattern of advice and referral decisions may change and we are planning some research, looking at the impact of different types of software on the decisions nurses make. We shall be looking at consistency of advice in the new system and comparing it to previous systems. ‘
Not every site has received the new system, known as the NHS Nurse Clinical Assessment System. It has not been installed in Hampshire, for example, but Dr Sadler says there is no problem with the rollout.
‘There are 22 sites and pilots of the system in walk-in centres, so it clearly was not going to happen simultaneously. We haven’t got any major problems with our existing system and we are happy to have an ordered roll-out.
‘Overall, it will probably take about 12 months, which is about one site every two weeks. That is what you need to install it and train the nurses, ’ he says.
Indeed, the system has many advantages. The NHS will receive up to 20 per cent of all overseas sales of the system, which could amount to£10m over the seven-year contract.
The DoH also claims it will save£50m in running costs by March 2004. ‘It seems to offer shorter triage times, and because it is an NHS-owned system it is much more responsive, ’ adds Mr Sadler. ‘If we find an algorithm that does not reflect current evidence we can update it quickly. ‘
Nurses are supportive of NHS Direct. Karen Jennings, Unison’s head of nursing, says NHS Direct is seen as part of the wider ‘professionalising’ of nursing.
‘When it first started there were some concerns about the employment situation because the same terms and conditions were not being guaranteed, but that has been overcome now. In fact, most nurses in NHS Direct are in the G grade so they are on a pretty reasonable salary for that position, ’ says Ms Jennings.
Unison is aware of some problems with the service. ‘There are always going to be teething problems in any new service. Most occur due to shortage of staff, or when patients are kept waiting.
‘There are also some concerns about mental health issues. Most of the nurses working for NHS Direct are from a general background and if someone with a mental health problem calls there is a lack of expertise to deal with it. I believe NHS Direct is trying to address it. ‘
Another problem is the lack of older people and people from ethnic minorities using the service.
The average NHS Direct user is a young woman calling out of hours, probably because she is worried about her child.
‘We need to know more about why older people are not using NHS Direct to the extent we would expect, ’ says Dr Munro.
‘Maybe It is because older people are unhappy using the phone, but they use it for out-of-hours primary care. Maybe It is not clear what NHS Direct is for. ‘
Early publicity targeted parents of small children, so older people may feel the service is not for them, he adds. ‘Perhaps older people know what to do when something is wrong. They have wellestablished routes into healthcare and long experience of their own problems so they need less advice than others. ‘
Integration of NHS Direct with local services will be another challenge. The Northumberland site is already integrated with a large GP out-of-hours co-operative. It is based in the same building as the GP co-op and has been handling the co-op’s calls since July 1999. But so far only a few sites have achieved this.
NHS Direct wants more than 20 per cent of the population to be covered by an integrated site by April 2002 and the whole country by 2004.
Kevin McKenna says that this is crucial to NHS Direct’s future success. ‘As a free-standing helpline, NHS Direct would have had no future, ’ he says.
‘Like all helplines, unless it is publicised constantly it will gradually fade from the public’s mind.
Integrated, it is a tool to bring services together and direct patients to the most appropriate form of care. ‘
NHS Direct: who’s on the end of the line NHS Direct covers the whole of England and Wales, operating through 22 call centres in England and one in Wales. A Scottish service, NHS 24, should be completed in 2003.
The service handled 375,000 calls both in December 2000 and in January 2001, at least one-third more calls than in previous months.
NHS Direct handled about 5,000 calls on the national helpline for the retention of organs issue.
In January 2001, NHS Direct Online took more than 900,000 hits each week.
The age and sex profile of callers hardly changes month-on-month. Female patients make about six of every 10 calls. Most of the female patients are young adults. Demand peaks at about 9pm on weekdays and 11am and 6pm at weekends.
NHS Direct employs about 1,000 whole-time equivalent nurses. Over 60 per cent of NHS Direct staff are part-time, allowing them to work in other parts of the NHS.
The latest caller satisfaction survey shows that 96 per cent are either satisfied or very satisfied with the service.
Between 20 and 30 per cent of NHS Direct calls are health information calls and do not require consultation with a nurse.
According to NHS Direct’s daily information returns for 1 July to 8 October 2000,3 per cent of patients were transferred to 999,9 per cent to A&E,16 per cent told to see a GP immediately (within four hours),14 per cent told to see a GP urgently (between four hours and 24 hours) and 11 per cent to see a GP in over 24 hours;31 per cent were advised on self-care.
NHS Direct tunes into digital TV In about six months’time, patients will not only be able to get information from NHS Direct by phone and Internet, but also by using digital TV.
The Department of Health has contracted Communicopia Productions to produce a pilot interactive channel that will be available initially to NTL digital interactive and Yes TV customers.
Gavin McWhirter, Communicopia’s manager of interactive accounts, says the channel will be easy to use. ‘People will be able to go into the service at a number of different points, ‘he says. ‘One will be a series of questions and answers to narrow down the problem and we will do that in a number of graphical and pictorial ways. The questions will be similar to those on the NHS Direct website. The patient will be given three types of advice - ring 999, phone NHS Direct because the staff need to talk to you further and the third will be advice on self-care. ‘
The company hopes to develop the service further. ‘Say a patient has a verruca. We could explain what a verruca is, show some examples and list the forms of treatment. We could offer suggestions from alternative practitioners. The ultimate position might be a video from the world’s leading verruca specialist on how to deal with it and maybe some patients talking about their experiences. ‘
More than just a one-way information line NHS Direct is not just a service where patients can call in for help. The service’s nurses could also call patients to remind them to take their medication, for example, or to check on side-effects. The helpline could also be used to improve patients’experience of the NHS.
The latter is the aim of a project in north-west England which is using NHS Direct to eradicate the need for some surgery patients to go to hospital for a pre-admission assessment and increase the number of patients receiving assessments.
‘Not every patient coming in for surgery gets a pre-admission assessment at the moment, but we are trying to provide a larger proportion with such an assessment, ‘says Joanne Ellis, booked-admissions project manager at Bolton Hospitals trust. ‘The people we are focusing on are people with less complex medical histories coming in for minor operations. We want to give them a pre-assessment in their own homes at a time convenient to them. ‘The scheme, which is part of the national booked-admissions project, will operate initially for a year, though local primary care groups will continue funding if evaluation is positive.
Patients who have consented to be contacted by NHS Direct are asked a number of questions that can lead to three outcomes. ‘The first is that it appears the patient is fine to undergo the booked surgery and they are advised to come in at the appointed time, ‘says Ms Ellis. ‘Under the second option, the patient needs to come back to the hospital, possibly for more tests. This may be because the patients tell the nurse something about their past medical history that has not previously been picked up.
‘The third option is that the patient does not appear to be suitable for the surgery - for example, if they are booked as a day case and they do not have the right support at home. ‘The initiative may also help reduce the number of non-attendees and cancellations. ‘If, for example, a patient were to say that they feel flu symptoms coming on and it was still three weeks before their operation, the NHS Direct nurse could ask for permission to get a colleague to ring them back and advise them on self-care, ‘she adds.