Examination of Witnesses (Questions 1-19)
MR NIGEL CRISP AND MR PAUL JENKINS
WEDNESDAY 6 FEBRUARY 2002
1. Good afternoon and welcome to the Public Accounts Committee. Welcome back, Mr Crisp. You are going to reply to our questions on NHS Direct. Could you introduce your colleague?
(Mr Crisp) Yes, Mr Paul Jenkins, who is the national project manager for NHS Direct. In the light of your annual report, he has been the national project manager for the last four years and this is an extremely successful project that he has managed.
2. Perhaps I could start by looking at your overall objectives. If you turn to page four of the Comptroller and Auditor General's Report, you will see paragraph 19 there and it lays out the need for more strategic management and clearer objectives. I wanted to ask you what your key priorities for the future development of the service are. In relation to that, perhaps I can refer you to page 23? If you look at page 23, you will see there is a check list there of various things that might be done in paragraph 3.17. Could you tell us a bit about your ideas for the future?
(Mr Crisp) As you appreciate, NHS Direct was set up to provide information and advice and has been piloting various approaches for the future. The one big issue which is in the list here is the link with the out of hours GP service, so that people will ring one telephone number to get access to the GP out of hours service but also to NHS Direct. That has already been piloted very successfully and has reduced GP workload. What you also have is a list of other processes and other ideas here. Another one which is on this list which has also been piloted in a number of areas is the linkage with the 999 calls. With 999 calls, we can make sure we draw off into other services people who may not need an emergency ambulance to take them to hospital. You will also see there the one about validation of in-patient lists. We are working with NHS Direct about providing information on consultant waiting lists.
3. Do you want to say a word about integrating your online services with other services?
(Mr Jenkins) We launched the website as a stand alone health information resource in December 1999 which complements the telephone service in terms of access to approved websites and self-care information. We took that a stage further this November when we launched the first interactive service on the website which allows patients to mail into us very specific health information queries that they cannot find information about on the main website. The direction of travel will be to look at a range of things, maybe into the areas of clinical advice that we could make available through the website as well as through the telephone service, recognising that some people might find that medium more accessible than having to discuss particular problems over the phone.
4. Are we conceivably going to get some sort of chat room in the future or are we going to get members of the public able to access the algorithms so that they can go through the symptoms themselves?
(Mr Jenkins) It is probably somewhere between the two. We already have some very simple algorithms on the website which allow people to look at problems themselves and decide whether to seek help or not. What we may be able to do is develop a more sophisticated version of that, closer to what nurses use, but in a real time consultation with the nurse, allowing the nurse to check the validity of what a patient is coming back with, and perhaps to pass out a picture of a rash or other information that helps a patient decide what the problem might be.
5. Mr Crisp, I know that NHS Direct takes a very small proportion of the total number of nurses but there is a fear, is there not, that it may be creaming off some good staff. Would you say a word about that and what you are doing to minimise this risk?
(Mr Crisp) The total number of nurses is 1,150 whole time equivalent, which is a very small proportion. Something of the order of six per cent at this stage are people who could not work in an ordinary nursing environment and it provides a lot of opportunity for people who cannot do lifting or whatever and also part time opportunities. It is bringing people into nursing who might otherwise be leaving the profession. The point you are no doubt wanting to get at that is also in this report is that as NHS Direct developed we have not had a really strategic HR strategy to make sure that it fitted in with minimising any potential impact.
6. Could I refer you to page 12, paragraph 2.10, which deals with the time it takes you to get to speak to a nurse. If you look at paragraph 2.10, it seems to be a pretty impressive record. I tested this myself last night. I rang up NHS Direct at seven minutes past seven. My call was answered at 12 minutes past seven by a very polite lady. I briefly described my symptoms. I put the phone down at 7.15 and she said a nurse would ring back. I waited an hour and a quarter for a nurse to ring me back. I know it was in the evening, but we look at things like this in reports and they seem to proclaim a wonderful picture. She did ask me what my name was, what I did and how I found out about NHS Direct. I said I was doing a parliamentary inquiry the next day on it. Maybe that is why it took an hour and a quarter for them to ring me back. When she did ring me back, it was immensely impressive and I thought the way the questions were asked was far less discursive than talking to one's own GP. The advice she gave was very good and useful so I congratulate you. My wife rang you last year and she was told that she was going to be called back by the dentistry equivalent and they never rang back. It is purely anecdotal but do you want to say a word about how you are coming to grips with this problem?
(Mr Crisp) We record these timings through the system. The figures here are impressive, given that what we are doing is not providing a simple service over the phone. This is a more complex service than most. We also try and measure patient satisfaction and there are very impressive records of patient satisfaction, despite some people waiting longer than we would want. On some of the following pages it shows the number of calls taken by a nurse. This autumn, we are now able to make comparisons between sites because we are using the same kit. We have also been learning as we have gone how you try and target your staff to anticipated workloads, but it is quite fluctuating. We are getting a better grip on that.
(Mr Jenkins) It has been one of the banes of my job that very often your friends and acquaintances can come back with their very direct experience of using the service, which is a very positive thing. Our call handlers are trained so if you have been presenting with symptoms which were of considerable concern your call will be prioritised. If you had been presenting with symptoms of a classic, life threatening condition, you would not have even spoken to the nurse; you would have been patched straight through to an ambulance. We would also prioritise around young children or people with threatening conditions. We are putting a lot of effort into expanding capacity in the service so that we can deal with some of the challenges in terms of increased demand but also to improve our responsiveness. One of the things we will increasingly be able to do is if a particular site is busy move your call to another part of the country to ensure that you get a quicker answer. They will be able to access the same information as your local site. We have also introduced standard decision support system. We are much more able to benchmark processes and shorten transaction times so that we can handle more calls and get to callers quicker.
7. Her advice to me was to go away and take a paracetamol, which is the usual advice given by the NHS. Can I refer you to page 16, paragraph 2.32, and the difficulty that you are having in accessing some social groups such as young people and those over 65? Tell us a bit about what you are trying to do to increase take-up amongst these groups.
(Mr Jenkins) Inevitably in the first three years of setting up the service our focus has been on building up overall awareness of the service. We do regular tracking of awareness of the service which suggests that over 60 per cent of people when prompted are aware of NHS Direct and just under 30 per cent have spontaneous awareness. We are aware that that awareness is lower in certain sections of society and we are now able to bring in very tailored initiatives to improve awareness in those groups. That can operate nationally. In the next month or so we will be starting a specific campaign targeted at young people and later in the year a specific campaign targeted at older people. There is also an ongoing process at a local level where people go out to talk for instance to older people's lunch clubs, engage with religious communities and talk to schools. It is something that we take very seriously. We recognise that we are in an acceptable position now but in two or three years' time when the service has grown to its wider take-up we must have even awareness and take-up of the service in all sections of society.
8. Could I refer you to page 21, paragraph 3.10? That is this problem with GPs out of hours. What are you doing to ensure that these problems will not recur?
(Mr Crisp) There have effectively been teething problems within those schemes.
(Mr Jenkins) One of the things that NHS Direct has been quite good at doing is that, although we have 22 locally based providers that together form the national service, we have a good tradition of passing on experience from one provider to another so that we ensure that those who are starting new schemes of integration with a GP out of hours are advised by people who have been through the experience. We make improvements to IT systems and other processes that take account of what we have learned. We get the planning of staff and capacity right more quickly than in some of the earlier schemes. What we are now building on is much greater confidence from GP out of hours providers and NHS Direct has a positive impact on their workload. We are operating in a better climate in terms of working with our partners in that sector.
9. One problem that worries me is that NHS Direct takes on more and more workload. If you ring your GP out of hours, you are put through to him automatically and then, as we see in paragraph 3.11, that would become more and more within working hours. It is a very valuable service to people where they can ring their GP and talk to someone they know. We have already seen in recent years the virtual elimination of GPs being prepared to go out through the night so if you ring your GP at night you are put on to a locum. Are we going to have a system within four or five years whereby if you try and ring your GP you are not going to get through and you will be put through to somebody you have never met before, who no doubt is very competent but you just do not know them?
(Mr Crisp) I do not think we have yet a clear position on what the access route to GP services will be in four or five years' time. You have the pilots referred to here; you have also the people who are working in primary care collaborative, which is about developing access to GP services. They are establishing some of their own telephone services within the individual primary care sites. What is most important is that there is the partnership between NHS Direct and local GP premises so that we can get people to the right place. In some cases, that may mean that the GPs are dealing with the calls themselves; in other cases, it may mean that NHS Direct are the most appropriate people to deal with them.
10. That is interesting but you have not given me reassurance that people are going to continue to have the right to ring up their GP and talk to him or her.
(Mr Jenkins) When the schemes of out of hours integration start, there are a significant number of patients who, perhaps because they do not know that the arrangements have changed or whatever, are a bit bemused. They say they would like to talk to their doctor. When they say that, we will pass them straight through to the doctor's service. Two years down the road in the more established schemes, that question never arises and patients are quite comfortable. Their expectation is they will talk to a nurse. If we take patients and listen to their experiences, we do not have a problem. If we try and force a change that goes against what people want, then we get into difficulty.
11. What NHS services do you think are going to be most affected by NHS Direct in three or four years' time? After all, this is now costing £99 million. Could that be spent better elsewhere on providing more hip operations or whatever? In that context, how do you see this developing and how is it going to affect the rest of the NHS?
(Mr Crisp) It is complementary to the rest of the NHS. This report brings out the fact that effectively you can put together a cost analysis which suggests about half its costs are met by providing a different sort of service. I think it will be affecting the service quite significantly. I have been in contact with Surrey Ambulance Service where they now have a scheme whereby doctors referring patients to local hospitals go through the Surrey Ambulance system, which is linked in with NHS Direct and as a result people are not only able to equalise pressure between hospitals where patients are referred, but also a number of patients end up being offered some different sort of treatment, rather than admission to hospital. This is part of how we communicate and manage the NHS in a lot of different ways. You have talked about the examples of where we provide access to GP services. It is going to be quite widespread as a very significant way of getting information to patients and helping them to find the right bit of the service.
12. My wife is a GP, just to declare an interest. We are told that in the White Paper that set up NHS Direct the aim was to provide easier and faster advice and information for people about health, illness and the NHS so that they are better able to care for themselves and their families. Is that still the aim of NHS Direct?
(Mr Crisp) That is the essential aim, yes.
13. How do you measure whether you are getting better and whether you are enabling people to care for themselves and their families better?
(Mr Crisp) There is quite a developed programme of asking people what they think. There is a significant amount of talking to patients about what they feel about the advice they are getting. You have also seen some of the evaluation studies that are taking place about whether or not, as a result of people ringing NHS Direct, they have decided to do something different from what they would have done beforehand.
(Mr Jenkins) In some of the academic evaluations of NHS Direct, quite substantial caller surveys have probed about "has NHS Direct helped you to deal with a problem of this kind better as a result of the advice we have given?" We scored around 80 per cent in patient satisfaction.
14. I fully appreciate that patients are satisfied and that is good news. I wonder to what extent the patients saying they have changed what they otherwise would have done is realistic in the sense that, had they gone to the GP and had the advice given by NHS Direct been that they need another form of help, whether that would not have happened had they gone to the GP anyway. I wonder how you can measure whether NHS Direct has changed something that would have happened anyway?
(Mr Jenkins) Yes, that might be true in some cases but we have allowed patients to do that from the comfort of their own home. We have that response to them available 24 hours a day, seven days a week when they perhaps could not contact their own GP. We have been perhaps able to give them time and reassurance that having to wait for the answer would have avoided.
15. They would not necessarily have had to wait for the answer if they had rung their GP. If you ring a GP in the middle of the day, you can sometimes get through. Equally, if you ring them at night, you may get through to a locum service which could give you advice perhaps as quickly as NHS Direct.
(Mr Jenkins) In some cases that is true. The reason why so many people have used this service is a very strong indication that people do not perceive they are able to get those answers in the way you suggest. In some cases, people are getting a different answer from NHS Direct than they would have got from other options.
16. You said NHS Direct has given a different answer from what they would have got from other options?
(Mr Jenkins) Sometimes people are nervous or anxious about bothering the doctor. They leave a problem longer and a lot of our life saving stories are often people who were leaving a problem but get worried and give NHS Direct a ring and are rushed to hospital or the GP is called very quickly. This is a service available around the clock and there is no stigma of being foolish if the problem turns out to be nothing. I think it is an important addition to what the NHS does.
17. How many agency staff do we currently have in the NHS working in A&E departments, on average?
(Mr Crisp) I do not know.
18. Is it in tens, hundreds, thousands, tens of thousands?
(Mr Crisp) There are of the order of 270 A&E departments. During the course of an average weekend, I would guess it would be more than 1,000.
19. Roughly the number of nurses working for NHS Direct?
(Mr Crisp) Potentially, but I am giving you a pretty rough estimate.