Evaluating NHS Direct
BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7201.5 (Published 03 July 1999) Cite this as: BMJ 1999;319:5
All rapid responses
EDITOR-Florin and Rosen are right to be wary of the extension of NHS
Direct prior to comprehensive evaluation . However, while sharing their
concerns, we believe NHS Direct can make a positive contribution to
primary health care.
A key feature of the service is uniform, easy access. NHS Direct may
be particularly appropriate for those for whom access to health care is
difficult. Several pilot sites, including ours, offer immediate
interpreting in almost any language. Moreover, particular groups, such as
young people, recent refugees, homeless people may find NHS Direct
valuable as a means of receiving confidential and anonymous information
and advice.
NHS Direct could make a contribution to addressing the needs of
disadvantaged groups and reducing inequalities in access to health care
but much wider debate is needed on practical ways to realise this
potential. In South East London, we are making links with young people's
sexual health services and hostels for homeless people to make health
advice readily available and encourage uptake of mainstream services.
NHS Direct can also play an important role in locally based
strategies for managing demand, if it is developed and evaluated as part
of the local system of immediate access services . Through the twin aims
of encouraging appropriate self care and routing callers to the most
appropriate service, NHS Direct can be central to an integrated system
which provides graduated access to care . This system can include
alternatives such as: self care; self care supported by medication
obtained from a pharmacist; a nurse consultation face to face or by phone
in general practice, a walk in centre or NHS Direct. These may be
appropriate responses to needs which do not, in the first instance,
require a medical response.
There is concern that NHS Direct may increase GP workload. Assessing
the impact of NHS Direct on the immediate access system is complex.
Overall demand may increase if previously unmet needs are addressed but
could reduce if self care is encouraged. Demand may also shift within the
system. It is too soon to estimate the net effects but it is important to
keep the impact on general practice in perspective. The maximum capacity
at NHS Direct South East London, of about 3,500 calls a week, is
equivalent to an average of 8 patients per week for each of 416 GPs.
Currently, about a third of local callers are advised to contact their GP.
Lynda Jessopp, Project Manager
Lambeth, Southwark and Lewisham Out of Hours Project,
Department of General Practice and Primary Care,
Guy's, Kings and St. Thomas' School of Medicine,
Weston Education Centre,
Cutcombe Road,
London SE5 9PJ.
1 Florin D and Rosen R. Evaluating NHS Direct. BMJ 1999; 319:5-
6.
2 Harrison A. The London Health Care System. King's Fund, 1997.
3 Pencheon D. Matching demand and supply fairly and efficiently. BMJ
1998; 316:1665-7.
Competing interests: No competing interests
Dear Sir,
Evaluation of NHS direct
Observations in the review about the limitations of the material
published to date were well made. Because the sites are still being
established it will probably be another year before meaningful data can be
produced for analysis.
The variability in the advice currently given by the different sites
is inevitable given that there are three totally different NHS direct
triage systems. There are certain key ingredients needed for consistency
of outcome and demand management which are not present in all of the
current systems in use. These features for NHS Direct must be included in
the national specification given to suppliers.
Studying the consistent outcomes produced over fifteen years in the
USA by the system used in Hampshire and Newcastle3 gives confidence that a
correctly designed tool properly applied, does manage demand. It also
produces consistency in clinical standards and delivers 24hour access to
services at levels that are appropriate and not demand led.
Will NHS Direct do the same? By next year we will have the answer. Until
then, because of so many variables, we can only speculate. Until our site
has its full staff complement and is taking over 150,000 calls per annum
interim evaluation, while interesting, is of very limited value.
The authors suggestions that NHS Direct must develop strong
relationships with GP co-operatives and Primary Care in general are
welcome, but their assertion that current models of clinical triage4
without decision support systems are safe, is wrong. Unless aided by a
correctly designed support programme, telephone triage by doctors1 or
nurses2 is inconsistent and will drive up both risk and utilisation.
NHS Direct can bring together health professionals in a way never
before possible. The partnership between our site and the GP co-ops in
Northumberland and Durham is doing just that. For the first time a co-
ordinated out of hours service exists involving GPs, Social Services,
Dentistry, Health Information, Drug information, District Nursing etc.
Far from 'cutting across' services, the system brings together and is
being shaped by all the partners.
If we are to have a needs driven service which is affordable and in
harmony with what the population is seeking, tools are required that are
new to us all. NHS Direct is one of those tools. It is being evaluated,
but so is our professional ability to cope with the changing world about
us. Let us hope both are up to scratch.
Dr Kevin McKenna MB BS MRCGP
Medical Director NHS Direct Northumbria
1. Providing out of hours Primary Care in Northumberland, an
evaluation of the development, operations and impact of the Northumberland
out of hours co-operative
April 1999 NPCRDC University of Manchester
Hallam and Henthorne
2. Pediatric telephone triage protocols: standardized decision making
or a false sense of security?
Wachter DA et al
Ann Emerg Med. 1999 Apr;33(4):388-94.
PMID: 10092715; UI: 99194512
3. Personal Health Advisor
Access Health UK
4.Wuerz R, et al.
Inconsistency of emergency department triage. Emergency Department
Operations Research Working Group.
Ann Emerg Med. 1998 Oct;32(4):431-5.
PMID: 9774926; UI: 9844805
Competing interests: No competing interests
The editorial of 3 July 1999 makes an interesting reading. Florin and
Rosen raised concerns about expanding the NHS Direct service, against the
background of shortage of nurses in the NHS. We would like to add that NHS
Direct would indeed, help to ease the problem of recruitment and retention
of nurses, at least in the short term. In our experience, we estimate that
the introduction of Essex Ambulance NHS Direct service in February this
year has saved our department the equivalent of employing a doctor or
emergency nurse practitioner for 28 hours a week (unpublished report). At
the moment all advice calls go to Essex Ambulance NHS Direct as patients
either call the service directly or their calls are redirected to NHS
direct service. Prior to its introduction, we audited the advice calls
answered in the department, which showed we received on average 80 calls a
day each lasting on average 3 minutes (1-25 mins.), giving a saving of 240
minutes (4 hours) per day. In real terms, this is equivalent to saving an
extra half-day shift of a doctor or nurse per day or employing extra staff
to work 28 hours a week.
The audit also shows that the commonest reason for telephone advice
was due to guardian or parental concerns about children. This might in
part explain why older people are under represented in this editorial.
Furthermore, the editorial highlighted differences in pieces of
advice given to dummy calls to three different NHS Direct services. This
is not surprising as advice from each site is given according to local
computer aided guidelines. It is hoped that with time a common national
computer aided guidelines would be developed, especially with the
formation of the National Institute for Clinical Excellence (NICE). What
is important at this stage is that the service is safe and effective. The
safety and effectiveness of a nurse – led computer–aided telephone advice
service has long been established1-2.
Finally, the fact that a certain proportion of patients are still
referred to A&E departments and General Practitioners is not in our
view, a reason for delaying expansion of the scheme. NHS Direct is not
just a telephone triage system, but also deals with some minor medical and
social problems without referral to anyone else3-4. There is no doubt that
as the service evolves with increases in public trust and awareness of its
availability, the potential of NHS Direct would be fully maximized. (406
words).
Yours Sincerely,
Okechukwu O. Jibuike
Specialist Registrar
Accident and Emergency Medicine
East Glamorgan General Hospital
Tel: 01443 216113
Formerly,
Staff Grade Accident & Emergency Medicine
Basildon Hospital
Nethermayne, Basildon, Essex.
Miss Barbara Baird
Consultant Accident and Emergency
Basildon Hospital
Nethermayne, Basildon
Essex SS16 5NL
Tel 01268 593406
Mr Michael Imana
Clinical Director and Consultant
Accident & Emergency
Basildon Hospital
Nethermayne, Basildon
Essex SS16 5NL.
Tel 01268 593488
1) Turnbull J, Smith H, Moore M, Bond H, Glaspe A (1998) The South
Wiltshire Out of Hours Project (SWOOP) Group ‘Safety and effectiveness of
nurse telephone consultation in out of hours primary care: randomized
controlled trial. Br Med J Vol 317 October 1998 Pp 1054-1059.
2) Pencheon D (1998) ‘NHS Direct – Evaluate, Integrate, or Burst…’.
Br Med J Vol 317 October 1998.
3) Lake L (1998) ‘Hello, NHS Direct. How can I Help?’ 3M A& E
Focus Magazine No. 2 Winter 1998.
4) Essex Ambulance Service (1998) ‘NHS Direct Goes Live’. NHS Direct
News Letter Issue 2.
5)Florin D, Rosen R (199) "Evaluating NHS Direct" Br Med J 319 Jult
1999, Pp 5-6.
Competing interests: No competing interests
Dear Sir
I read with interest the recent leader on NHS Direct (1).
What seems to have been forgotten within the current strategy is the
central role of the GP service. The NHS has functioned until now based
primarily on the patients' entry into the service via the GP, at the base
of a 'pyramid' of care.
If there is a perceived need by management and clinicians to enhance
this phase of care for patients it would seem logical, for many different
reasons, to build on the pre-existing structure rather than to set about
building another pyramid.
It has been demonstrated that telephone triage can be an effective
method of management for patients after telephoning their GP's
surgery(2,3,4).
Improved telephone access to GP surgeries is desired by both patients and
professionals working in surgeries. The main barrier to providing this is
the actual process of obtaining access (5).
In our practice we have tried to gain, (a relatively small amount) of
funding, to set up a nurse telephone triage service in house to improve
telephone access. Apart from the benefits to ourselves and our patients,
we are keen to carry out research into the cost effectiveness of such a
system. However there has been little support from 'higher authorities' in
achieving this. Investigating or piloting other possible models has been
stifled by one track approach of NHS Direct.
When faced with something they cannot understand GP's instinctively
return to their knowledge of the consultation. The conclusion must be that
in the case of NHS Direct there is either a hidden agenda or possible
early signs of a state of confusion.
Yours faithfully
Dr Mark Vorster BSc, MB. BS. (Lon), FRCS (Eng), DRCOG, MRCGP
The Surgery
Station Road
Knebworth
Herts SG3 6AP
1 Florin D, Rosen R, Evaluating NHS Direct, BMJ 7201, pp5-6 July 3
1999.
Competing interests: No competing interests
Florin's article on assessing the impact of NHS Direct in a number of
pilot sites indicates considerable variability in advice offered...
perhaps not unusual for anyone in the medical profession. However, I
fully agree with their conclusion that advice is probably best left to
those who know the patient best.
Considerable sums of money are being diverted by the present
government to pet projects aimed at increasing demand at a time when
demand cannot be met. The increased funds being made available for health
care initiatives are founded on political rather than practical principles
and as such should be subject to public debate and also assessment by the
new organisations created to determine best practice.
As a busy and dedicated GP I am continuously frustrated in my
attempts to win investment in my practice, despite a list that has grown
by over 100% in three years - 1.5 doctors cater for 5000 patients and can
still provide continuity of care and same day appointments. We have one of
the lowest per capita prescribing costs in East Sussex -saving this
Government well over 250000 pounds a year - only to learn that 20million
is being made available to provide 20 walk-in surgeries.
As GPs we must be aware that we are being affected by the effects of
marketing by both the government and by Insurance Companies who wish to
promote increased uptake of services in the NHS Direct and in private
medical surgeries... for every 100 people who read such adverts, only a
small percentage will respond privately.. the remainder will believe that
it is an invitation to attend their NHS GP for reassurance. Consultation
rates have already risen to 5 per year per patient in my practice and are
likely to rise further year on year while this government pursues its
irresponsible attitude to what it calls "public opinion" but without
actually asking the public its opinion.
As a profession we should insist on analysis by either the National
Audit Office or the National Institute for Clinical Excellence before any
more of our taxes are squandered by the current Government.
Nigel Higson MA BM BCh DRCOG
GP, Brighton and Hove
Competing interests: No competing interests
Further research is needed
D. Floren and R. Rosen high lighted the pilot project of the NHS
direct, a telephone triage scheme introduced by the government in part to
tackle the problem of increasing demands on primary and emergency care in
the NHS. The service is manned by nurses who advise patients about the
most appropriate form of care.
The authors expressed anxiety about the Government's plans to
expand the service without any evidence that the service is effective at
reducing demands on primary and emergency services. In fact, the authors
felt the service may paradoxically increase the demands on the NHS. We
work in Lancashire,which is one of the regions piloting the NHS direct
scheme, and have recently encountered a case that
highlights this point.
A 28-year-old gentleman suffered chest pain while at home. He did not feel
that the chest pain was severe enough to present either to his GP or to
casualty. The pain persisted and his partner persuaded him to ring the NHS
Direct Line. The nurse advised him to attend the nearest casualty
department. He was referred by the casualty officer to the medical SHO.
The medical SHO felt that his history was suggestive of angina, his ECG
showed a partial RBBB and his troponin I was markedly raised. He was
admitted to the
CCU with a provisional diagnosis of unstable angina and was started on iv
heparin, GTN as well as aspirin and anti-anginals. He was reviewed the
next day by a consultant cardiologist who felt any cardiac disease
unlikely. However in view of his age and the difficulty in making a firm
diagnosis a coronary angiogram was performed. His coronary arteries were
normal, as was his LV cineangiogram.
He is now asymptomatic and has been discharged from our care. The raised
troponin I was a false positive result, which is well recognised with this
test.
This case highlights how the NHS direct line rather than reducing the
demands on the NHS may paradoxically increase the demands on NHS resources
from minor self-limiting symptoms. In this case, no organic disease was
identified and the patient would not have come to the attention of the
medical profession through the usual channels. Further research into the
NHS Direct is needed prior to the scheme
being extended nationally.
R. KHIANI SPR in cardiology.
V.SURESH Research Registrar in cardiology.
N. NAQVI. Consultant Cardiologist.
Competing interests: No competing interests