Bookmarkers beware: Bookmarks to pages other than the home page may not work after we change servers in April Editor's Choice | This Week in BMJ | Press releases BMJ No 7126 Volume 316 Education and debate Saturday 17 January 1998 The New NHS: commentaries on the white paper NHS Direct: managing demand David Pencheon The second 50 years of the NHS will see a very different relation between the service and the public it serves. One of the four key themes of the white paper is the introduction of NHS Direct, a 24 hour nurse led helpline. After piloting it will cover the whole country by 2000, as proposed in the chief medical officer's report on emergency services in the community.(1) However, NHS Direct is not solely about telephone advice lines. It should also herald a fundamental shift in the NHS where more public participation in health care can happen closer to home and where more care can be delivered without face to face contact. It may well be the most important development this white paper has to offer. NHS Direct has profound implications for the shape and purpose of the developing health service in general and primary health care in particular (especially if the gateway to the NHS moves from the surgery to the sitting room). A publicly led NHS may soon complement a primary care led NHS, where NHS Direct could help enable much more graduated access to the right care at the right time in the right way by the right person. It is important to shape this public involvement such that public health is promoted, balancing the public's demands with professionally defined needs. The public is increasingly demanding convenience, quality, and explicitness and is less impressed by professional hierarchies (witness the increase in drop in health centres at London railway stations, nurse practitioners, and litigation). Far from being a threat we should perceive this evolution as part of the solution to managing ever increasing demand. Increasing expectations should be balanced with an increasing willingness and obligation to share responsibility for the decisions taken and the care offered. Access to interactive sources of information, be they telephone help lines or the world wide web clearly empowers the (potential) patient. Equally, it should also strengthen the role and influence of the health service to take its beneficence into the home - if the opportunity is seized thoughtfully. Telephone help lines are an important first step along this path. We can now buy a mortgage and check a bank account over the telephone. We can access the internet (where health is one of the most common subjects) over the telephone. We also use it to request appointments with our family doctor; but to do anything different - like seek advice without seeking an appointment - has proved difficult. The potential to seek and give advice over the telephone, and triage accordingly, has really been grasped only by ambulance services and, more recently, by general practitioner cooperatives (many of whom have coped with increased contacts by reducing the number that are face to face). In North America, health maintenance organisations have long seen the value of a telephone service (highly integrated with good self care manuals) as part of a convenient and cost effective primary care service.(2) The directness can work both ways. As well as the potential for NHS Direct to facilitate diagnosis, treatment, and administration by providing easier access into the NHS, it also has the potential to look out into the community - for example, with better monitoring of frail members of the community. As society changes, the role of a less paternalistic NHS must be to provide opportunities for people to play a greater part in decision making. Instead of simply requesting, and waiting for, a general practice appointment, an outpatient appointment, or being seen in the accident and emergency department, individuals should be able to use NHS Direct for meaningful access to care, where good care often starts with simple advice. This care can range from advice on which part of their self care manual to consult (and, if necessary, phone back) to the immediate sending of an emergency ambulance. The perennial fear is that increasing access increases demand. This may not be so.(3) Managing demand by cutting supply may be effective for some services but it is hardly ideal in primary care. A better way of managing demand is to offer a more graduated access to health care, where patients are as aware of the risks and costs of health care as they are of the benefits, with incentives to match. This needs to acknowledge that most health care is administered without (or with minimal) professional intervention. The NHS needs to support and improve this by empowering self care, in order to spend its limited resources on services which it is uniquely placed to provide. The three pilot sites should be studied carefully for the benefits, risks, and resource requirements. This assessment should pay particular attention to the effect NHS Direct has on the NHS as a complete system, not just as a isolated bolt on. As in all communications technology it should concentrate on communications, not technology. Perhaps most important, there is a real risk that many people may be disempowered by NHS Direct. Its development needs to address this crucial issue. Expectations and rights must be translated into responsibilities and participation. Only then will the second 50 years of the NHS contribute as much to the health of the public as the first 50. NHS Direct can be an important part of this process. Institute of Public Health, University of Cambridge, Cambridge CB2 2SR David Pencheon, consultant in public health medicine email: pencheond@rdd-phru.cam.ac.uk References 1 Chief Medical Officer. Developing emergency services in the community. London: Department of Health, 1997. 2 Sabin J E. "Mind the gap": reflections of an American health maintenance organisation doctor on the new NHS. BMJ 1992;305:514-6. 3 Flood A B, Wennberg J E, Nease, R F, Fowler F J, Ding J, Hynes LM. The importance of patient preference in the decision to screen for prostate cancer. Prostate Patient Outcomes Research Team. J Gen Intern Med 1996;11:342-9. Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline