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PRIMARY CARE: Val Lattimer, Joanne Turnbull, Abigail Burgess, Heidi Surridge, Karen Gerard, Judith Lathlean, Helen Smith, and Steve George Effect of introduction of integrated out of hours care in England: observational study BMJ 2005; 331: 81-84 [Abstract] [Full text]

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Advice rates?

David Lloyd   (8 July 2005)

NHS Direct and integrated out of hours care

Mike A Sadler   (14 July 2005)

Advice rates? 8 July 2005
David Lloyd, GP The Ridgeway Surgery HA2 7DU Send response to journal: Re: Advice rates?	Could I ask if the advice only rates apply to the entire NHSD work stream or only the exemplar stream? 17% for exemplar 07 seems incredibly low. Competing interests: Director Harmoni GP Coop Integrated with NHS Direct in West London
NHS Direct and integrated out of hours care 14 July 2005
Mike A Sadler, Medical Director NHS Direct Special Health Authority, 207, Old St, London EC1V 9PS Send response to journal: Re: NHS Direct and integrated out of hours care	NHS Direct has actively contributed to and supported the evaluation of the exemplar programme undertaken by Lattimer and colleagues1. The evaluation commenced in April 2002, and finished over a year ago, and we have learnt much from this work as it has progressed. We are pleased that it is now being shared more widely, but think it important to set its findings in the current context. NHS Direct started as a pilot project in 1998, in effect the first entirely new service introduced by the NHS since its inception. Extremely popular with the public from Day 1, and with safety established by numerous external assessments2 3, it has attracted criticism from NHS partners around clinical and operational performance, and insufficient integration with existing services. Some of this criticism has been valid, but we believe considerable progress has been made since the service became a single national organisation in April 2004. Onward referral to emergency and urgent health services is a key parameter for both commissioners and urgent care providers. Continual staff and system development, based on accumulated experience from 29 million calls, internal and external feedback, and new research evidence, has allowed clinical safety to be maintained whilst reducing some elements of risk aversion inevitable in a high profile new service. The proportion of emergency and urgent endpoints (999, A&E and GP <2hrs) has fallen by over 20% in the last 12 months. A further step reduction is anticipated with the roll-out of the latest version of the clinical decision support software this summer. Operational performance has been improved by better staffing levels, and development of technology and infrastructure to share call loads more evenly across the service. The latter is not yet fully implemented, and we accept that further improvement is necessary, but the service has for several months now consistently achieved the 95% national target for urgent clinical assessment to be commenced within 20 minutes. There has also been a significant improvement in call answering standards, which for our clinical integration schemes are now close to the OOH Review requirements. Models of single integration with GP out of hours services are less relevant to the needs of the health service now than when the Review Body report was published in 2000. The new GP contract, emergency care networks, and the recent Ambulance Services Review, all point to the need to develop integrated unscheduled care services on a 24 hour basis. Key to this will be consistent, high quality telephone clinical assessment, the development of common prioritisation and assessment systems, and clear pathways for referral to the most appropriate service. NHS Direct has the experience, infrastructure and commitment to be a major contributor, and will continue to drive clinical and operational performance improvement to optimise such contribution. Dr Mike Sadler Medical Director, NHS Direct Special Health Authority 207 Old St, London EC1V 9PS mike.sadler@nhsdirect.nhs.uk 1 Lattimer V, Turnbull J, Burgess A, Surridge H, Gerard K, Lathlean J et al. Effect of introduction of integrated out of hours care in England: observational study. BMJ 2005;331:81-4 2 The Comptroller and Auditor General. NHS Direct in England. London: Stationery Office, 2002. 3 Munro J, Nicholl J, O’Cathain A, Knowles E, Morgan A. Evaluation of NHS Direct first wave sites: final report of the phase 1 research. Sheffield: Medical Care Research Unit, 2001 Competing interests: None declared