NHS Direct, the nurse-led 24-hour advice and information helpline, should be available to all within two years. Three pilots were launched in March, and by the end of the year a second wave of pilots will cover 10 million people.

But it is unclear how the new service will fit with existing primary care and information services offering telephone advice.1 There has been little information about how the public might use it. This may hinder effective planning.

So far, the first three pilots have had limited local publicity, resulting in low uptake - an average of 25-60 calls a day over the service's first 10 weeks.2

As part of a scoping study for NHS Direct, the College of Health conducted a survey to find out the needs and views of potential users.3

A random sample of 965 households was taken covering the South Thames area and these were 'cold called' during March 1998. Trained interviewers called during the day and in the evenings, including weekends. Whoever answered the telephone, except for young children, was identified as a potential respondent.

Interviewers explained that NHS Direct was a 24-hour telephone advice line proposed by the government. Eight possible types of service were described, drawn from the specifications for NHS Direct and from some provided by North American call centres, such as a follow-up service. They were:

a 24-hour advice line staffed by doctors or nurses;

a follow-up service to check on the patient's progress after discharge from hospital;

information on the location of local health services;

information about diagnosed diseases;

information on self-help groups;

information about the NHS complaints procedure;

health and fitness information;

information about alternative treatments.

Closed and open-ended questions were used to ask respondents how these services should be provided, how they viewed the role of NHS Direct within the framework of primary healthcare services, and how the service should be funded.

The overall response rate was 55.5 per cent. Respondents' sex and age was noted, to prevent one group's views dominating the survey. Two-thirds of respondents and just under half those who refused to answer questions were women. Most respondents were aged 41-65 (38.5 per cent). The second- largest age group was 65-plus (27.3 per cent), followed closely by the 26-40 age group (24.9 per cent). The 16-25 age group was under-represented (8.4 per cent).

Nearly all respondents (88 per cent) had no previous experience of using a telephone helpline. And 86.7 per cent did not know about the existing Health Information Service in their area.

Most respondents said they would use NHS Direct. In particular, people with children under five, people who suffered from a long-term illness and those who had frail relatives living with them were highly likely to use the service (see table).

Respondents were asked to rank services they would like to see in order of preference. The three most popular were the 24-hour medical advice line, the follow-up service and information about local health services. The findings for the sub-groups were similar, with the 24-hour medical advice line and the 'follow-up' service as the top two. Parents of under- fives and carers of frail relatives put the information service about diagnosed conditions as their third choice.

When asked how and why they would use NHS Direct, the six most popular reasons mentioned, in order of popularity, were:

to get medical advice about minor ailments;

for medical advice if the GP was unavailable, for example out of hours;

for advice about the most appropriate use of primary healthcare services, such as whether to go to an accident and emergency department, request a GP home visit or wait until the next surgery;

to provide health information that the GP does not offer, such as where to find self-help groups;

for information that would make consultations with the GP more productive, such as treatment options or patients' rights; and

a possible way of getting a second opinion if they were unhappy with their GP.

Despite their enthusiasm, several people said if funding was at the expense of existing health services, they would be against NHS Direct. They viewed it as a back-up to primary care, not a replacement. Although NHS Direct is seen by the government as a free service, 87 per cent were willing to pay the price of a local telephone call for using it, and a further 5.8 per cent would 'possibly' pay.

When asked if NHS Direct would affect the way they used their GP, most said they preferred a face-to-face consultation with a doctor. As many people pointed out, helplines may have limited diagnostic capabilities because patients' descriptions are not always adequate. Nor will those staffing the lines have access to the patient's medical records.

Fears raised about how well NHS Direct will run in practice were:

whether it would be properly funded;

that the service would not be properly publicised;

the speed and ease with which users would get through to an operator, with several people saying urgent calls should be separated from the others;

the possibility of patients abusing the service.

This survey was conducted in South Thames, a region that lacks the experience of a pilot. Hence the views reflect those of people who have so far received little, if any, information about NHS Direct. The fact that people had to give their answers over the phone may have led to some groups being under-represented or unrepresented - for example, those with language differences, or homeless people.

Despite these limitations, the study shows much support for NHS Direct.

While the 24-hour medical advice line is the main component of NHS Direct, there is wide support for a range of other services. Information about local services was high on respondents' lists of priorities. For this to happen, NHS Direct will have to work closely with local health and social services. Excellent database facilities will be needed.

The fears raised by respondents reflect a lack of awareness about the planned service, and a degree of scepticism about the reasons for setting it up now. In particular, there was a concern that it might limit access to face-to-face consultations with a doctor.

To achieve its goals, NHS Direct needs to learn from the striking failure of the HIS to become known to the public. In fact, apart from the medical advice line and follow-up service, the other services described in the questionnaire are available from HIS providers on a freephone number.

Sufficient market research must be built into the pilots to ensure that publicity gets through to the public, and is informative and unambiguous.