Letters

Impact of NHS Direct on demand for immediate care

Target communities show poor awareness of NHS Direct

Service has not decreased attendance at one paediatric A and E department

Target communities show poor awareness of NHS Direct

EDITORMunro et al found that NHS Direct had no discernible effect on the use of emergency ambulances or accident and emergency departments in the first year of operation, leading to a suggestion that this service may not prove cost effective.¹ The study is limited by an assumption that the population studied had complete awareness of the service. Six months after the introduction of East Midlands NHS Direct we had anecdotal evidence to suggest that many patients attending our accident and emergency department were unaware of the telephone advisory service.

Consequently we undertook a survey of 300 consecutive ambulatory patients (or their parents) who referred themselves to the accident and emergency department and had not contacted NHS Direct. We wanted to find out whether they were aware of the service. Altogether 266 (89%) questionnaires were completed, with 166 (62%) patients claiming to have had no previous awareness of NHS Direct. Furthermore, of the 100 patients who were aware of the service, only 36 were aware of the telephone charge while 51 thought that calls were taken by doctors. Only eight "aware" patients, however, said that they would distrust advice given by a nurse, a finding that supports a study by O'Cathain et al.²

The survey also determined which sections of the community were unaware of NHS Direct. Patients aged over 65 (all 9), patients from ethnic minorities (41/59; 69%), patients from predominantly less affluent postcodes (101/129; 78%), and young men (20/28; 71%) were overrepresented. The survey also found that 240 (90%) patients claimed to have access to a telephone and that 56 (21%) might have been redirected away from our department by NHS Direct.

In the light of these findings we would say that NHS Direct has failed to market its existence to those members of the community who frequently access urgent health care. The results of NHS Direct impact studies have consequently been confounded by this oversight. Whether a proper national publicity campaign can improve the impact of this beleaguered service remains to be seen.

John McInerney, specialist registrar. 
emergmedlri{at}hotmail.com

Shekhar Chillala, specialist registrar. 
Colin Read, specialist registrar. 
Adrian Evans, consultant. 
Accident and Emergency Department, Leicester Royal Infirmary, Leicester LE1 5WW

Service has not decreased attendance at one paediatric A and E department

EDITOROur experience in a paediatric accident and emergency department supports the data showing that NHS Direct has had little or no impact on attendance rates in primary care.¹ We audited the attendance at Sunderland Royal Hospital's paediatric accident and emergency department before and after NHS Direct started operating. Admissions increased from 844 to 860.

The paper from Sheffield did not look at the impact on the number of telephone calls to the accident and emergency department for medical advice.¹ This is a large and often forgotten workload. We received 453 calls before NHS Direct began and 576 after, a 27% increase. Fourteen calls to the department were redirected there from NHS Direct.

We controlled for the time of year and the population. The annual attendance at the accident and emergency department did not increase over the two years of the audit. It would have been better if we could have done a crossover trial in the same population with and without NHS Direct. This criticism could also be made of the Sheffield work. Such a trial, however, would mean the temporary withdrawal of a popular public service.²

Our service does not provide documentation, computerised protocols, or staff training for the telephone advice given. It had been planned that all calls would be redirected to NHS Direct. This would have provided equity and safety for patients and staff. It has not been possible, however, to divert calls to NHS Direct because of the unexpectedly high volume of calls that it has received.

NHS Direct has not decreased the attendance at our paediatric accident and emergency department and has coincided with an increase in the number of telephone calls to our informal service. This decreases the time for patient contact. The situation needs further research and consideration if NHS Direct is to be a success.

G R Lawson, consultant paediatrician. 
J C Furness, paediatric specialist registrar. 
J.C.Furness{at}ncl.ac.uk Department Paediatrics, Sunderland Royal Hospital, Sunderland SR4 7TP

S Santosh, senior house officer in paediatric accident and emergency. 
Alder Hey Children's Hospital, Liverpool L12 2AP

S Armstrong, senior house officer in paediatric surgery. 
Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP

We thank the paediatric accident and emergency nursing and medical staff and audit department for their help.