Editorials

NHS Direct

Evaluate, integrate, or bust...

General practice p 1054

The gradual introduction of NHS Direct, the 24 hour health telephone helpline due to be a national service by the year 2000, is a small but important symbol of the modern NHS.¹ It has been designed to respond to the fastest growing influences on service industries: consumerism and technology.² NHS Direct aims initially to do for the health service what cash machines have done for banking: to offer a more accessible, convenient, and interactive gateway. Its longer term aim should be to help the NHS change its predominant ethos from paternalism to partnership.³

This method of delivering services is not particular to health care. Telephone services in other sectors have been one of the fastest growth areas in employment in the United Kingdom. However, the speed of planned growth of NHS Direct (pilots launched March 1998, more bids invited May 1998 and announced in July 1998, 19 million people (40% of England's population) to be covered by April 1999) might suggest that fulfilling political promises precedes rigorous evaluation. A more likely interpretation is that the research is aimed at clarifying not if NHS Direct develops but how. At this rate of expansion, the learning needs to be rapid and responsive.

Those charged with developing and evaluating NHS Direct need to address five key issues. Firstly, to ensure that NHS Direct is both safe and effective, evaluation should establish the best process (how are the calls answered, which decision support software works best?) and the best content (on which guidelines should the advice be based?) for the service. Until recently the evidence on the safety and effectiveness of telephone consultations services has been mixed. More robust evidence is now emerging, as in the study by Lattimer et al in this week's issue (p 1054).⁴ This shows no increase in the rate of adverse outcomes (such as death) in people managed by a nurse telephone consultation service with decision support software when compared with those managed by doctors in the traditional manner. As the authors acknowledge, the promising results of this research probably depend on the setting, the method of training of the nurses, and the particular decision support software.

The second challenge is to ensure that a national service develops national standards. Do we perpetuate the natural experiment of pilot sites developing the service differently for too long, or do we stifle creativity by imposing uniformity too early? Too much individual autonomy for too long in the development stage may cause the same problems for NHS Direct as it has done for general practice computing systems.

The third challenge is to develop NHS Direct as an integral part of the NHS with a coordinating function for accessing health (and health related) services. The gateway to the NHS is changing rapidly with the development, and likely convergence of, general practitioner cooperatives, primary care groups, health information services, nurse telephone consultation services, and NHS Direct. A strength of the NHS is its potential to provide a seamless service, promoting collaboration within and between sectors while avoiding duplication. It would be ironic, wasteful, and confusing if NHS Direct developed independently of services provided by general practitioner cooperatives. Outside the NHS there must be an equally seamless integration with social services and other welfare agencies. Fortunately the recently announced second wave of NHS Direct pilot sites has a strong flavour of integration. The collaborating agencies include ambulance trusts, community trusts, cooperatives, health information services, health authorities, voluntary agencies, and research units, many of them working closely with social services.

Fourthly, a service that promotes access using technology will always risk helping those parts of the population who least need help. The service needs to be equally accessible to those without English as a first language, mentally ill people, and carers.

Lastly, NHS Direct has the potential to be much more than just a telephone help lineyet there is a risk that it will not be allowed to develop that potential. It should be the beginning of a range of systems that provide convenient, reliable, and interactive gateways to health and other welfare services. In reverse, NHS Direct offers the NHS the possibility of catering more directly for the special needs of particular individuals and groups and of promoting health rather than just responding to need. Self care in general, and support for self care (in the form of services such as NHS Direct), are extensions of the NHS, not substitutes. Moreover, fears that giving people alternative means of access increases demand inappropriately are largely unfounded. ^{5 6} More than just advice and telephone consultations can be offered. Managing chronic disease, dispensing prescriptions, and booking hospital appointments could all be possible. Why should booking an appointment to see the doctor around the corner be more complex than booking a plane to see the family around the world?⁷ The same analogy applies to professionals. Just as people can check their personal financial information from almost any bank machine around the world, so clinicians should be able to have rapid access to up to date accurate medical information via a simple interface. As NHS Direct may become Welfare Direct for the public, an analogous service could provide Knowledge Direct for the professional.

On the evidence available, we should keep developing and evaluating the "prompt, accessible and seamless" service that the government proposes.¹ More than any other health system in the world, the NHS is well placed to develop direct services as part of a fair gateway to collaborative welfare. With adequate support, evaluation, and integration, services such as NHS Direct can keep the founding principles of the NHS relevant for the next 50 years.