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GENERAL PRACTICE: James Munro, Jon Nicholl, Alicia O'Cathain, and Emma Knowles Impact of NHS Direct on demand for immediate care: observational study BMJ 2000; 321: 150-153 [Abstract] [Full text]

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Telephone advice lines - all just hot air

Adam Harper   (27 July 2000)

NHS Direct: Do Not forget the telephone calls to A&E

John Furness   (9 August 2000)

Re: Telephone advice lines - all just hot air

James Munro   (21 August 2000)

NHS Direct 'impact' studies are confounded by poor awareness of the service in target communities

John McInerney   (8 September 2000)

Impact of NHS Direct on demand for immediate care.

Richard O'Brien   (29 November 2000)

Telephone advice lines - all just hot air 27 July 2000
Adam Harper, SpR geriatrics Queen Alexandra Hospital, Portsmouth Send response to journal: Re: Telephone advice lines - all just hot air	Dear Sir, In the recent article on the impact of the NHS Direct telephone advice service on demand for immediate care (1) I was disappointed to see that for nearly 70 000 calls, there was no impact on either attendances to accident and emergency departments or ambulance services. The only significant change was a marginal fall in the number of out of hour GP consultations. Both in this study and in one into the patient satisfaction with the service (2) approximately two thirds of the patients were advised to contact either their GP or emergency services. The patients in this latter study did report feeling reassured by the advice they received. The articles have also come from a department closely involved in the scheme, and therefore not entirely free from conflicts of interest in the presentation of their findings. The NHS direct was established to provide easy access to experienced medical advice, with the aim of reducing unnecessary workload, in particular for the emergency services. There has been significant political backing for the project, as well as a large financial investment. Given the findings, it seems a shame that the investment on the project was not used to improve the current pre-existing services, whereby patients can get advice and reassurance from medical staff who would (ideally) have access to patient records. Whether or not there would be a niche for a telephone advice service from the private sector is another issue. The authors state, on the one hand, that the service does not simply represent an “extra step” for people to access medical services. On the other, they state that the service “had little impact on the demand for urgent health care.” Maybe things will change with time, but for the time being the evidence seems to suggest that the NHS Direct is just another step. Yours faithfully, Dr Adam Harper MBBS MRCP 1. Munroe J, Nicholl J, O’Cathain A, Knowles E. Impact of NHS Direct on demand for immediate care: observational study. BMJ 2000;321:150-153 2. O’Cathain A, Munroe JF, Nicholl JP, , Knowles E. How helpful is NHS Direct? Postal survey of callers. BMJ 2000; 320;1035 Competing interests - none.
NHS Direct: Do Not forget the telephone calls to A&E 9 August 2000
John Furness, Paediatric SpR Sunderland Royal Hospital Send response to journal: Re: NHS Direct: Do Not forget the telephone calls to A&E	Dear Editor Our experience 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 Paediatric A&E before and after NHS Direct. There was an increase in admissions from 844 to 860. The paper form Sheffield [1] did not look at the impact on the number of telephone calls to A&E for medical advice. This is a significant and often forgotten workload. We received 453 calls before NHS Direct and 576 after, a 27% increase. 14 (2%) calls to A&E were redirected from NHS Direct to A&E. We controlled for the time of year and the population. There was no increase in the annual attendance at A&E over the 2 year period of the audit. It would have been better if we could have done a cross-over trial for the same population with and without NHS Direct. This criticism could also be made of the Sheffield work [1]. We can see that this would be a problem, as it would involve 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. However it has not been possible 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 A&E and has coincided with an increase in the number of telephone calls to this informal service. This decreases the time for patient contact. We feel that the situation needs further careful research and consideration if NHS Direct is to be a success. Dr G.R.Lawson (Consultant) (Dr Lawson is Paediatric Advisor to North East Ambulance NHS trust, lead trust for NHS dorect North East) Dr J.C. Furness (SpR) Dr S. Santosh Dr. S Armstrong With thanks to Paediatric A&E nursing and medical staff and audit department Department Paediatrics, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP 1. Munro J, Nicholl J, O’Cathain A and Knowles E Impact of NHS Direct on demand for immediate care: observational study. BMJ 2000; 321:150-3 2. O’Cathain A Munro JF Nicholl JP and Knowles E How helpful is NHS Direct? Postal survey of callers. BMJ 2000; 320:1035
Re: Telephone advice lines - all just hot air 21 August 2000
James Munro, Consultant Senior Lecturer Medical Care Research Unit, University of Sheffield Send response to journal: Re: Re: Telephone advice lines - all just hot air	Dear Editor In his eletter response to our study of the impact of NHS Direct on demand for immediate care, Dr Harper suggests that the results "come from a department closely involved in the scheme, and therefore not entirely free from conflicts of interest". This suggestion is entirely unfounded. The research team's relationship to NHS Direct extends only to evaluating it, and communicating the findings as clearly and fairly as we are able. We have no vested interest in the service's success or failure. I would characterise our attitude to NHS Direct as one of "sympathetic scepticism". James Munro
NHS Direct 'impact' studies are confounded by poor awareness of the service in target communities 8 September 2000
John McInerney Send response to journal: Re: NHS Direct 'impact' studies are confounded by poor awareness of the service in target communities	Editor - The recent study by Munro et al 1 found that NHS Direct had no discernible effect on the use of emergency ambulances or accident & emergency departments after the first year, leading to a suggestion that this service may not prove cost effective. However this study is limited by an assumption that the population studied had complete awareness of the service. Indeed six months after the introduction of East Midlands NHS Direct, we had anecdotal evidence to suggest that many patients attending our accident & emergency department were unaware of the telephone- advisory service. Consequently we undertook a NHS Direct 'awareness' survey of 300 consecutive ambulatory patients (or their parents), who self-referred to the accident & emergency department, and who had not contacted NHS Direct. 266 (88%) 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 whilst 51% of patients thought that calls were taken by doctors. Only 8% of 'aware' patients however said they would distrust advice given by a nurse, a finding that supports the study by O'Cathain et al 2. The survey also determined which sections of the community were unaware of NHS Direct. Patients over 65 years of age (100%), patients from ethnic minorities (70%), patients from predominantly less affluent post-codes (78%), and young men (71%) were over-represented. The survey also revealed that 90% of patients claim to have access to a telephone and that 21% of patients may have been potentially redirected away from our department by NHS Direct. In light of these findings it is our assertion that NHS Direct has failed to market its existence to those members of the community who frequently access urgent health care. Consequently the results of NHS Direct 'impact' studies to date are confounded by this oversight. Whether a proper national publicity campaign can improve the impact of this beleaguered service, remains to be seen. 1. Munro J, Nicholl J, O'Cathain A, Knowles E. Impact of NHS Direct on demand for immediate care: observational study. BMJ 2000; 321:150-3 2. O'Cathain A, Munro J, Nicholl J, Knowles E. How helpful is NHS Direct? Postal survey of callers. BMJ 2000; 320:1035 John McInerney Specialist Registrar Shekhar Chillala Specialist Registrar Colin Read Specialist Registrar Adrian Evans Consultant Accident & Emergency department, The Leicester Royal Infirmary, Leicester LE1 5WW
Impact of NHS Direct on demand for immediate care. 29 November 2000
Richard O'Brien Send response to journal: Re: Impact of NHS Direct on demand for immediate care.	Dear Sir - In their responses to the paper by Munro et al (1), who found that NHS Direct had no significant impact on the use of ambulance services and A&E departments, McInerney et al (2) and Lawson et al (3) 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 sadly seems to be "No". We are studying consultations with our out-of-hours GP co-operative (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, so even if NHS Direct is preventing a small upward trend in out-of-hours calls (1), the fact remains that the majority of 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 which 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 which had not involved NHS Direct. Furthermore, the NHS Direct callers ended up needing fewer treatments or hospital admissions. 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, GP Paul Hansford, GP Richard O'Brien, GP: Elizabeth Parfitt, research co-ordinator Hilary Swindall, GP East Quay Medical Centre, Bridgwater, Somerset TA6 5YB (1) Munro J, Nicholl J, O'Cathain A, Knowles E. Impact of NHS Direct on demand for immediate care: observational study. BMJ 2000;321:150-3. (15 July.) (2) McInerney J, Chillala S, Read C, Evans A. Target communities show poor awareness of NHS Direct. BMJ 2000;321:1077. (28 October.) (3) Lawson G, Furness J, Santosh S, Armstrong S. BMJ 2000;321:1077. (28 October.)