Intended for healthcare professionals


NHS Direct audited

BMJ 2002; 324 doi: (Published 09 March 2002) Cite this as: BMJ 2002;324:558

Customer satisfaction, but at what price?

  1. Steve George (pluto{at}, reader in public health
  1. University of Southampton Health Care Research Unit, Southampton General Hospital, Southampton SO16 6YD

    NHS Direct—“the gateway to the NHS.” An all singing, all dancing mega-service that will give you health advice and information when you ask for it; make sure that you receive the urgent care you need but did not realise you did; stop you demanding care you did not need by encouraging you to undertake self care, or by diverting you to a more appropriate source of care if you cannot manage by yourself; find you a dentist or a pharmacy open outside shop hours; and will soon be able to book you your appointment with your general practitioner, remind you of your hospital appointment, and… the list goes on. NHS Direct, the telephone health advice and information line is nearly four years old.1 How is it performing?

    Three NHS Direct pilot sites were launched in March 1998 and the service now covers all of England. While not the first telephone health service in the world, it promised something more than triage of emergency calls.14 Initially set up to provide clinical advice, health information, and referral to other NHS services via the telephone, it is now set to become the hub of out of hours care.5 In January the National Audit Office, an independent body that scrutinises public spending on behalf of parliament, published its report on NHS Direct in England.6

    NHS Direct is presented in a positive light, but not all is rosy. In addition to difficulty with meeting call handling targets there has been no visible effect on demand for NHS services overall.7 The hoped for reduction in demand for other services might be achieved by the proposed integration of NHS Direct with existing out of hours general practice cooperatives and ambulance services.5 Where such integration has taken place demand for general practice consultation has fallen, especially for telephone consultation.8

    Despite shortcomings, customer satisfaction with NHS Direct is high9—that is, among those who use it. Sadly, the evidence indicates that they are the same people who use existing health services. It is underused by older people, ethnic minorities, and other disadvantaged groups. Rather than reach people who are currently failed by the health system NHS Direct may have discovered previously unexpressed demand among the worried and well middle classes.

    What of NHS Direct online? The internet version of the telephone service makes only a brief appearance in the report, but its use is clearly limited to those with access to the internet and money to pay for it.

    When callers reach a nurse the advice they get may vary—usually on the side of caution. This is predictable, but has inevitable consequences. The predictive value of a diagnostic test depends on the prevalence of the condition being tested for. The rarity of serious disease among callers to NHS Direct must mean that its computer based decision support system, however good, has a low predictive value for serious illness. For every caller with a serious condition detected by NHS Direct, many more with self limiting conditions will be directed into the health system. Consistently to err on the side of safety might seem logical, but the effect of doing so is to fill a health system with people who do not need to be there.10

    Finally, is it worth the money? The report suggests that half of the £90m annual cost of NHS Direct has been offset by encouraging more appropriate use of NHS services. Cost savings are calculated according to other health service contacts avoided. These are determined on the basis of callers' stated future actions rather than on actual data. The savings are therefore speculative and in any case a maximum estimate.

    Is £45m, the theoretical additional cost of NHS Direct, worth it for a system that eventually might work as a coordinator of access to health care? It seems unlikely that NHS Direct will do anything to address health inequality, and it may even serve to widen existing differences. Ask yourself. If you had £45m a year to spend on improving health, empowering the socially disadvantaged, and reducing health inequality what would you spend it on?


    • SG was a member of the operational board of the Hampshire NHS Direct second wave pilot, and the Health Care Research Unit received funds to undertake an evaluation of the pilot and to train nurses to undertake telephone consultation.


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