How helpful is NHS Direct? Postal survey of callers

It has long been BMJ policy not to publish or post any information
about patients
without their written consent--or the consent of relatives in the case of
those
not able to give consent. This policy, which is explained in detail in our
advice
to contributors and a series of articles on consent, is based on two
premises:
firstly, patients expect that nothing from their interaction with doctors
will be
released to third parties without their consent; secondly, it is
impossible to
guarantee anonymity.

Richard Smith
Editor, BMJ

Editor,

O'Cathain et al (1) report that most respondents found NHS
Direct advice helpful and reassuring. However mothers of a number of young
children recently admitted to our paediatric department have received
advice from NHS
Direct which in retrospect was concerning and inadequate. We report one
such case here.

The mother of a six-month-old boy telephoned NHS Direct for advice over
three consecutive days. He had been unwell with vomiting and increasing
lethargy over this period. She was interviewed and as he was still
drinking copious fluids and frequently wetting nappies she was reassured
on each
occasion. He was subsequently admitted with severe diabetic ketoacidosis.

Although diabetes is rare in infants, we know that lethargy is a highly
significant, although non-specific symptom (2). Reassuring information,
such as the history of adequate fluid intake and urine output should not
be taken
in isolation.Monitoring and audit of NHS Direct is essential particularly
considering that the evidence for the efficacy of telephone triage in this
population is lacking (3). Recent studies provide some evidence of
efficacy by the
"Absence of major adverse events"; but are these events being reported?

We attempted to give feedback on this case. The NHS Direct website has no
facility for clinicians to feedback. Use of the NHS Direct telephone line
to give feedback led to a succession of telephone calls culminating in the
suggestion that we write to NHS Direct care of Quarry House in Leeds.
Users are rightly able to provide feedback via the NHS Direct website and
telephone but attempting to give feedback as clinicians was time-consuming
arduous and unsatisfactory. We strongly recommend that a system for
clinician feedback be provided and made readily accessible.

Kate Farrer

Specialist Registrar

Neonatal Intensive Care Unit,
Guy's Hospital,
London SE1 9RT

Peter Rye

Consultant, Paediatric Intensive Care

Linda Murdoch

Director, Paediatric Intensive Care

Murray Bain

Consultant Paediatrician

Darryl Hampson-Evans

Consultant Anaesthetist

St. George's Hospital,
Tooting,
London SW 19 0QT

1. O'Cathain A, Munro JF, Nicholl JP, Knowles E. How helpful is NHS
Direct? Postal survey of callers. BMJ 2000;320:1035. (15th April)

2. Hewson PH, Humphries SM, Roberton DM, McNamar JM, Robison MJ.
Markers of serious illness in infants less than six months old presenting
to a children's hospital. Arch Dis Child 1990;65:750-756.

3. McClellan N. NHS Direct: here and now. Arch Dis Child 1999;81:376-
377

Editorial comment
The mother of the baby whose case is reported here has given her signed consent to publication.

Editor - An interesting question but with very little actual
substance in the article that we wondered how the findings would further
either science, patient care or NHS service provision.

26% were advised self-treatment and 14% found the advice helpful as it
avoided contacting a service but neither of these figures throws any light
onto the important questions of how the interaction with the NHS direct
altered the service demand on other services or whether it resulted in
better patient care. To estimate this we need a denominator which could
have been simply obtained from a simple question in the questionnaire of
"what would you have done if NHS direct wasn't available?".

Hypothetically, if 100% had said they would have gone to the GP or other
services then NHS
direct would have saved a significant work load (26%) to other services
but if 100% had said they would not have gone to anyone anyway (as, say,
they perceived the complaint to be minor enough to only warrant telephone
advice) then NHS direct would have done the great service of pointing 76%
in right direction (assuming these referrals would translate into better
patient care). Without this denominator of how many patients would have
otherwise resorted to other services the data in the study are of only
superficial
interest.

Quoting a varied response rate (of 65%-81%) without any attempt to explain
it is of limited value to a clinician or scientist or even for the purpose
of further hypothesis creation. Florin and Rosen's editorial(2)
highlighted
some interesting observational data that the authors could have explored
to further the debate constructively.

Keeping in with the style of BMJ when we asked the question "What do we
know already" and "What does this study add" we could only come up with
the (commonsense answer) that people like a reassuring voice at the end of
of a phoneline. The time is now right for a more detailed study where
outcomes
that are valuable to patients, care-providers and health planners are
studied rather that 'soft' easily obtainable outcome measures.

Dr A Coomarasamy

Research Fellow in Obstetrics

Birmingham Women's Hospital,
Edgbaston B15 2TG

Dr John Ayuk

Senior House Officer in Medicine

Queen Elizabeth Hospital,
Edgbaston B15 2TH

1 How helpful is NHS Direct? Postal survey of callers

A O'Cathain,J F Munro,J P Nicholl,E Knowles BMJ. 320:1035

2 Evaluating NHS Direct. Early findings raise questions about
expanding the service (editorial) BMJ 1999 Aug 21;319(7208):521