In the five years since its launch in March 1998, NHS Direct in England and Wales has established itself as the world’s largest provider of telephone healthcare advice. NHS Direct now handles over half a million telephone calls and NHS Direct Online half a million on-line transactions every month.1 Consistently 30–40% of calls to the telephone service are about children.
- NHS Direct
Statistics from Altmetric.com
From the Government’s perspective, NHS Direct is intended to symbolise the changing relationship between the NHS and patients, supporting patients in becoming better informed and more able to exercise choices over their own health and health care. This is a matter of economics as well as philosophy because a public empowered in this way is more likely to be fully engaged with the Health Service, to have better health outcomes, and require less expensive health provision in the long term. At least that’s the theory.2
If it symbolises burgeoning public expectation on the one hand, NHS Direct is also being used as an instrument of change on the other. For example, in taking over out-of-hours contacts in primary care,3 in the integration of emergency services,4 and in legitimising telephone consultation and triage and the decision support systems that underpin it. Different sectors of the organisation have also been used as test beds for a range of projects and enhancements to the service. This entrepreneurial diversity has characterised NHS Direct from the outset,5 but the organisation has grown so rapidly that all this activity has left the Department of Health hastily erecting strategic goal posts for the future, to restrain NHS Direct from hurtling off in all directions at once.
CAGING THE GOLEM
As a result, the organisational structure of NHS Direct will change during 2004, with the introduction of a single national provider (perhaps a Special Health Authority) and commissioning undertaken by consortia of Primary Care Trusts (PCTs) to whom budgets for local developments will ultimately be devolved.1 Judging from experience of PCTs to date, this is not a recipe for bringing either sweetness or light to the proceedings; key elements of control will probably remain in the centre but it will be another important reason for paediatricians to engage with commissioners. However, the immediate aims of this are more prosaic and will mean that staff are employed by a single national body rather than a range of host organisations, and that a phase of consolidation and convergence takes place.
Individual call centres will be fully nationally networked so that calls can be distributed to wherever there is capacity on the system. The practicalities of establishing virtual call centres are considerable and require a new “Intelligent Telecoms Network” and national databases both for routing callers and for holding local information to which nurse advisers can refer. These systems are expected to be operative by mid 2004.1 Call centres will presumably remain the units of day to day operation and will be the points of contact with local communities. Bringing leadership and coordination to the management of the network will be essential and the risk is that local information will not be shared and interpreted consistently. Just how all this will be implemented remains to be seen.
There is significant variability between present sites in terms of the number of calls handled per full-time equivalent nurse,5 the lack of use of algorithms during triage,6 the frequency of alterations to the dispositions recommended by the clinical decision support software,6 and referral rates to A&E departments for symptomatic calls (national average 11.2% with a range of approximately 6–17% across all 22 sites in England and Wales).6 These variations are unlikely to be eliminated simply by wiring everything together; they need to be understood much more thoroughly before the virtual curtain descends because they suggest the possibilities of significant operational and training problems on the one hand, and unacceptable ambiguities in the current decision support software solution on the other.
By the end of 2006 NHS Direct will be a single point of access for out-of-hours care, and it is expected that it will then be capable of handling 16 million calls each year.1 It will also have to cope with significant peaks in demand, far greater than anything it has experienced so far. More nurses will need to be employed (numbers have not been announced) but strategies have been developed to minimise this requirement and to enable nursing staff to concentrate on the “core business” of telephone consultation. Information will be provided by other routes such as NHS Direct On-line and NHS Direct Digital Television; calls will be prioritised initially by non-clinical call handlers using specific computerised protocols and directed to the most appropriate part of the service (including the ambulance service); those patients who are identified as being very likely to require a face-to-face consultation could be fast tracked by call handlers to GP out-of-hours services or to A&E services. There could also be specific options to fast track certain paediatric calls, but the likely consequences must be thought through first with paediatricians and then carefully monitored.
THE MULTICHANNEL EXPERIENCE
Maximum use is to be made of new technologies such as digital television (DTV).7 The overall objective is the delivery across England of an “NHS Direct branded health and healthcare information service” on DTV from 2004.8 Intriguing is the potential to deliver the concept of a “personal health space that could provide secure access to patient records and on-line transactions”.1 Transactional services already tested in a preliminary way7 include talking to and seeing an NHS Direct nurse during consultation, a system for booking an appointment with a GP through the TV, an SMS text messaging reminder service for children’s vaccination dates, and a call-back service to ask for further information from a local service. These innovations will not be part of the initial remit8 but they do give an insight into what is coming, and a meaning to the multichannel terms in which NHS Direct is now being described.1,8
BACK TO THE FUTURE
Many of the issues previously raised about children in NHS Direct9 have been acknowledged by the organisation, but there is still much to be done to transform good intentions into genuine solutions. More focused priorities in the new structure may accelerate progress. Only 1% of NHS Direct nursing staff have a background in paediatrics10 and yet professional background and experience determines the formulation of the mental image of the patient that seems fundamental to the process of telephone consultation in practice.11 Work on telemedicine links has been put on hold, and it is not clear whether current clinical decision support software can compensate for a lack of clinical experience and knowledge, particularly in recognising important but subtle paediatric cues. Further clarification is badly needed.12 National standards for training in paediatrics relevant to NHS Direct and related organisations are required. The competencies necessary to manage paediatric consultations should be accredited, renewable, and externally validated. If this happens, NHS Direct could work considerably better for children and young people, and paediatricians would be more inclined to endorse it.
PRIORITIES AND OUTCOMES
Reports about NHS Direct have serially failed to analyse the adequacy or appropriateness with which children are served by the organisation,1,5,13,14 and the Central Project Team do not routinely collect information by the age of the caller or patient. Although there is a national mechanism for obtaining advice from relevant external agencies, the actual arrangements and the impact they have had, are much more threadbare than implied in official statements and reports.1,5,10,13 Better communication and more transparency are required. The teams involved in the maintenance and development of clinical systems and the entrainment of best evidence or consensus need to be developed more imaginatively and resourced more comprehensively. The highest priority of all, however, should be given to the acquisition of detailed clinical outcome measures and methods to feed these data into a process of continual evaluation and development of clinical systems. This is in sharp contrast to the data currently, and perhaps necessarily, produced which better describe the attributes of a commercial call centre operation than an important clinical service. These are changes that could gather pace as the new organisation becomes unshackled from direct political control.
NHS Direct (NHSD) and children; some core requirements
Uniform methodology and content across UK in all clinical pathways
Dedicated clinical content for children across NHSD and related services
Nationally validated evidence base/best consensus for assessment, dispositions, and advice
Clinically important outcome measures for children monitored and evaluated
Use of outcome measures in refining clinical service for children
Nationally validated training package to achieve paediatric competencies
Consistency and openness in evaluating adverse events involving children and young people
Local circumstances and provider arrangements matched to a child’s specific medical needs when referral route selected
Clear lines of communication with local child protection agencies and an understanding of how local networks function to protect children and young people
Prompt, effective, secure communication between NHSD and secondary level services about referrals and outcomes
THE FATE OF CHILDREN—FRICASSEE OR RAGOUT?15
In terms of innovation and overcoming the sheer practicalities of building a complex new organisation, NHS Direct has been a remarkable success. Equally significant is the potential that the organisation has in the future. The devil for NHS Direct and its related services lies in the detail and in the consequences of its actions. Nowhere is this more true than in its capacity to deal with children appropriately. The first module of the Children’s National Service Framework (NSF)16 and the accompanying consultation document17 eloquently establish a philosophy of service to children. It would be logical if the full NSF for Children contained proposals to raise the profile of children in NHS Direct and suggested a range of specific standards for meeting their needs. Many of these could be cost neutral or reinforce decisions already taken in principle but not yet implemented, and so stand a chance of escaping the final ministerial red pen. The startling indifference to children in recent national reports about NHS Direct1,5,13 is unacceptable and shows how far there is still to travel, virtual reality or not.
Review history and Supplementary material
Suggested Core Requirements for Appropriate Service Provision for Children and Young People by NHS Direct
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