Letters

Impact of NHS Direct on demand for immediate care

NHS Direct must be better marketed and deal with problems more effectively

Meaningful review is still outstanding

NHS Direct can help accident and emergency departments

NHS Direct must be better marketed and deal with problems more effectively

EDITORIn their responses to the paper by Munro et al,¹ who found that NHS Direct had no appreciable impact on the use of ambulance services and accident and emergency departments, McInerney et al² and Lawson et al³ addressed two important points: do the patients know about NHS Direct; and does NHS Direct make any difference to the use of emergency services anyway? At the moment, the answer to both questions seems to be "no."

We are studying consultations with our out of hours general practitioners' cooperative (Bridgwater Out-of-hours and Night Emergency Service, BONES), comparing the outcomes for two groups of patients who have called our service: those who have previously contacted NHS Direct about their problem and those who have not.

Preliminary results show that, of the 1153 consultations with BONES over four weeks in October, in 1005 cases (87%) the patients said they had not tried NHS Direct. We had a similar number of contacts over the same period in 1997, before NHS Direct became operational. Even if NHS Direct is preventing a small upward trend in calls out of hours,¹ the fact therefore remains that most patients do not use NHS Direct.

But would it make any difference to the outcome if they did? The purpose of NHS Direct is to deal effectively with problems that can be dealt with on the telephone, and pass on to the emergency services those problems that are likely to need some kind of intervention. Therefore, those who call NHS Direct and then consult the emergency services should end up needing more face to face consultations, on the spot treatment, visits, and hospital admissions, and fewer consultations by telephone alone. On the contrary, we found that 53% of the problems that had already been presented to NHS Direct could still be dealt with over the telephone by BONES, compared with 47% of those that had not involved NHS Direct.

Furthermore, the NHS Direct callers ended up needing fewer treatments or admissions to hospital. NHS Direct has the potential to alleviate some of the increasing demands on primary care, both in and out of hours, but if the government wants it to be useful it must be better marketed and must deal more effectively with the problems presented to it.

Peter Aird, general practitioner. 
Paul Hansford, general practitioner. 
Richard O'Brien, general practitioner. 
RichardAOB{at}aol.com

Elizabeth Parfitt, research co-ordinator. 
Hilary Swindall, general practitioner. 
East Quay Medical Centre, Bridgwater, Somerset TA6 5YB

Meaningful review is still outstanding

EDITORThe comments by Munro et al and the responses by McInerney et al and Lawson et al relate to a time when the volume of calls to NHS Direct and their impact were very small. ^{1 2-3} Today three different structures to NHS Direct remain, pending the adoption of the NHS clinical assessment system this year. A meaningful review of a whole service, therefore, is still a way off.

Clinicians participating in NHS Direct see the profound changes that can come from the application of decision support logic to historical models of care. To others it remains outside their experience, and its first application (NHS Direct) seems a costly irrelevance. The vision of our professional leaders has remained focused on the politics of NHS Direct rather than its clinical potential.

The north east site has piloted integrated care out of hours since July 1999. Recent comparative data for two large areas of the integrated cooperative (Northern Doctors Urgent Care) and adjacent accident and emergency departments are shown in the table. The brief is to improve patient access and appropriate direction, but it is reassuring that NHS Direct apparently does not accelerate acute demand as the volume of calls grows.

Domestic visiting rates for the cooperative (12.1%) are half the rates before integration. For every two patients referred to a higher level of care, three are directed to a lower level of intervention.⁴ Patient satisfaction is over 90%, yet 72% are diverted from their original intention and many no longer see doctors. All this, while the service is still in its infancy.

The NHS clinical assessment system piloted by NHS Direct will produce important changes in the behaviour of patients and clinicians over time and outcome studies of a high quality will be needed. The partnership experiment is working, and integrated acute care departments behind the triage platform will be piloted next year. Many teething troubles and a long way in a short time for the NHS certainly, but "a beleaguered service"? I don't think so.

K McKenna, medical director, NHS Direct Northeast. 
Bondgate Practice, Alnwick, Northumberland NE66 2NL mmck{at}globalnet.co.uk

NHS Direct can help accident and emergency departments

EDITORMcInerney et al found low awareness of NHS Direct in patients attending their accident and emergency department, and wondered whether a proper national publicity campaign would help.¹ Such a national campaign started on 20 November to mark the service becoming available throughout England. It would be worth repeating their study after the campaign. Replicating the study in other sites seems a useful way to assess awareness among the population. We intend to perform a similar study in accident and emergency departments in Hampshire, where NHS Direct has been established for 19 months.

Lawson et al have been unable to divert telephone calls for clinical advice from their accident and emergency department to NHS Direct.² Such a scheme has been in place in Portsmouth for over a year now and was recently extended to Southampton. As Lawson et al noted, call diversion to NHS Direct offers significant advantages in quality of service, including staff trained specifically in telephone advice, computerised protocols, and improved documentation. It can also increase time for direct patient contact. In Portsmouth we estimate that the removal of the need to respond to telephone calls has freed up the equivalent of two whole time equivalent senior nurses, enabling them to improve the quality of service to patients requiring face to face advice.

Along with other published evaluations,³ Lawson et al comment on the lack of impact of NHS Direct on numbers attending established healthcare services. Such evaluations oversimplify the objectives of the service. NHS Direct was set up to improve access to healthcare services, which it has achieved, with over 3 million callers to the service already. Many callers indicate a prior intention to call their general practitioner or attend accident and emergency wards, and yet they are advised about self care, potentially saving a visit. It is, however, evident that other callers would not otherwise have accessed healthcare services. Some of these patients, who would normally fall "below the water level" of the "iceberg of illness,"⁴ are advised to seek further clinical advice and will thus move into the system. The net numerical effect of these flows on existing services may be neutral. But those accessing services should be doing so more appropriately. Evaluations of NHS Direct must tackle this challenge of measuring appropriateness. This is the third side of the triangle of evaluationincreased access to healthcare information and advice, and demand on existing services being the others.

Mike Sadler, medical director. 
NHS Direct Hampshire and Isle of Wight, Winchester SO22 5DH mike.sadler{at}hants-iow.nhsdirect.nhs.uk

Mike Howell, consultant in accident and emergency. 
Chris Cahill, associate clinical director, accident and emergency. 
Queen Alexandra Hospital, Portsmouth PO6 3LY