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Rapid Responses: Rapid Responses published:
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NHS Direct can help Accident and Emergency departments
- Mike Sadler (17 November 2000)
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NHS Direct growing pains
- Kevin Mckenna (20 November 2000)
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Mike Sadler, Medical Director NHS Direct Hampshire and Isle of Wight
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Editor McInerney et al found low awareness of NHS Direct in attenders at their Accident and Emergency (A&E) department, and wondered whether ‘a proper national publicity campaign’ would help.1 November 20 sees the start of such a national campaign to mark the service becoming available throughout England. It would be worth repeating the Leicester study after this has taken place. Replicating the study in other sites seems a useful way to assess population awareness. We intend to perform a similar study in A&E Departments in Hampshire, where NHS Direct has been established for 19 months. It is unfortunate that Lawson et al have been unable to divert telephone calls for clinical advice from their A&E Department to NHS Direct.2 Such a scheme has been in place in Portsmouth for over a year now, and more recently was extended to Southampton. As Lawson noted, call diversion to NHS Direct offers significant advantages in service quality, 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 evaluations3, Lawson and colleagues comment on 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 GP or attend Accident and Emergency, and yet are advised about self-care, potentially saving a visit. However, it is evident that other callers would not otherwise have accessed health care 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. However, 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 evaluation, increased access to healthcare information and advice, and demand on existing services being the others. Dr Mike Sadler
Mr Mike Howell
Mr Chris Cahill
Queen Alexandra Hospital, Southwick Hill Road, Cosham, Portsmouth PO6 3LY 1. McInerney J, Chillala S, Read C, Evans A. Target communities show poor awareness of NHS Direct. BMJ 2000;321:1077 2. Lawson G, Furness J, Santosh S, Armstrong S. Service has not decreased attendance at one paediatric A and E department. BMJ 2000;321:1077 3. 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 4. Hannay D. The symptom iceberg. London: Routledge and Kegan Paul, 1979 |
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Kevin Mckenna, GP and Medical director of NHS Direct Northeast Bondgate Practice Alnwick
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Editor- The comments by Munro1 and your correspondents2 pertaining to the early days of NHS Direct confirm work undertaken locally about the marketing of the service in its embryonic days. ‘If you did not know about it you did not use it’ was the message. However, the data referred to related to a time when call volumes were very small and impact understandably miniscule1. The service is still at the 'toddler' stage of development and because the shape of the service is still so variable it has been impossible to obtain a ‘whole service’ view of the impact upon the NHS. There remain 3 different structures to NHS Direct pending the adoption of the nationally procured NHS Clinical Assessment System(CAS) in 2001, It is apparent that the majority of the clinicians in the NHS are still unaware of the enormous potential for the CAS developed by NHS Direct, to alter the way medicine in this country will be delivered. Those involved have come to understand the differences in decision support logic and the profound changes that come from its application to historical models of care. To those not involved, the issues remain outside their day to day experience so the whole concept of its first application(NHS Direct), seems a costly irrelevance. Herein lies a real challenge for NHS Direct to broaden understanding and awareness. It is regrettable that so many of our professional leaders have remained focussed on the politics of NHS Direct rather than gaining a true understanding of the clinical issues and potential involved in the development of the clinical assessment tools of NHS Direct. Sometimes their lack of vision has been a cause for considerable concern. NHS Direct Northeast has been in an integrated pilot with NDUC (the out of hours provider in Northumberland and North Durham) to assess the impact of NHS Direct since July 1999. Comparative data for two of the biggest areas of the co-op and their adjacent A/E departments for the month of September have just been validated and are as shown below. Without wishing to draw conclusions from the figures, they do need to be considered, if only to stimulate interest in the clinical community of what this ‘toddler’ might aspire to as it grows up. Some of the figures may appear startling but are in keeping with those of the other large integrated sites in Nottingham and West London.
Combined divisions of GP Co-op (out of hours only) contacts
Sept 1999 Sept 2000 Change
Phone advice 1048 712 -32%
Centre visits 899 842 -6.3%
Home Visits 749 656 -12.4%
Combined local
A/E's (24hr) 6397 6153 -3.8%
NHS Direct
North East
call volume 10122 17559 +73.50%
Is NHS Direct locally reducing overall workload? It is far too soon for such a conclusion. It is however, reshaping the patterns of care provision in the area most significantly. Single month snapshots do not describe trends but these figures are in keeping with our month on month pattern of activity. What is evident is that the huge growth in NHS Direct activity does not appear to be driving up overall demand in our local NHS. Domestic visiting rates for the co-op as a whole (12.13%) are about half the national levels reported by the National Association of GP Co- operatives and these are achieved using algorithms designed by our partner Community Health Councils. Patient satisfaction when surveyed, is always well in excess of 90% yet many are no longer seeing doctors following the intervention. There are many teething problems, but these would be anticipated in something so new and different. However, the integrated partnership approach is working. The advent of the NHS Clinical Assessment System(CAS) will enable the long overdue restructuring of acute care provision as described in the recently published out of hours services review review3. NHS Direct will continue to pilot its development. The evolution of A/E into the integrated ‘Acute Care Department’ will only be possible with this system at the core of development. Is NHS Direct a ‘beleaguered service’? No, but a future support for those who might be so described is certainly a possibility. This year’s figures are starting to catch the eye but the service is still in its infancy. Next years are going to be more interesting and by then the number of clinicians as well as patients who understand the system will have grown too. Growing pains can be anticipated by us all, but NHS Direct and the NHS CAS it is developing will produce significant changes in patient activity within the next twelve months. The school reports will get much more interesting as adolescence approaches! Dr K McKenna
1.Munro J, Nicholl j, O’Cathain A Knowles E. Impact of NHS Direct on demand for immediate care: observational study BMJ2000;321 150—3(15 July) 2. BMJ Letters BMJ 2000 No 7268 (28 Oct )
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