Examination of Witnesses (Questions 60-79)
MR NIGEL CRISP AND MR PAUL JENKINS
WEDNESDAY 6 FEBRUARY 2002
60. You knew how many calls were being aborted, did you?
(Mr Jenkins) We could see an increase. We asked callers about this in the caller survey and we used other inferences and we talked to the data registrars office and got agreement to change the message so that it was shorter.
61. Right. Figure 3, I am always dubious about going to these charts because I never know whether I understand them or not, so if I have the wrong end of the stick please tell me. On this particular chart it shows in one of the call centres there was two per cent of calls abandoned after 30 seconds and at the far end of the graph 10 per cent of the calls were abandoned after 30 seconds. Why is there such a discrepancy between the sites?
(Mr Jenkins) Again, I think one of the reasons that counts here is there have been at various times some significant variations of the business of sites. Certainly one of the ones on the far right is a site with a very heavy volume of GP out-of-hours calls which do present a lot of the same thing, which, of course, is some of those issues. One of the things we are doing in the service is we can do clever things with the telephone system of NHS Direct where it begins to start routing calls round the country. It looks not just in one call centre but right across the nation for who is available to take a call. Effectively when we have introduced that we should eliminate both the discrepancy and also the problem.
62. You have basically answered the question I was going to ask. If you live in a certain part of the country do you go to a specific call centre or is it a sort of scheme where if one call centre is busy then it is transferred to another call centre?
(Mr Jenkins) At the moment we have set the service up on the basis you get routed to a local call centre. We are to able to move calls round the country to compensate for different levels of business, to some extent, at the moment. The plan is that we begin to start routing the calls round the country more systematically so that we can improve access.
63. The point Mr Williams made, where one centre is very busy and another is not, the centre where they are not so busy
(Mr Jenkins) That will drive some very big improvements in productivity because you do not have nurses frantic in one part of the country where others are relatively less busy.
64. It is a bit like the television licence call centre centres, when you phone you are all over the place.
(Mr Jenkins) The important thing we have to get right is that the nurse has access to the local information that allows them to refer people to the right services and understand. Clearly somebody giving advice about where to send a patient who needs help at one particular level in West London is very different from somebody in Cornwall. We have put a lot of investment in developing those information systems that allow you to get those choices right wherever. What we have found is that patients do not mind where they are answered, as long as we sort their problem out they are quite happy being answered wherever the call lands.
65. We are told that you have cut the message from 40 seconds down to 30 seconds and this was introduced from the end of December, so we are only into it. It is working, is it, not so many people are putting the phone down now?
(Mr Jenkins) It is probably a bit early to look at the information, but certainly anecdotally there has been less negative reaction to the message.
66. Fine. I am very impressed with the Report, as everyone else seems to be, I am also very sceptical about the whole thing, I am becoming more and more conservative with a small `c' as I get older. The old idea of being able to phone your doctor up still appeals to me rather than talking to somebody who you do not know, if at the end of day you get the right advice that is the important thing. Paragraph 3.9 on page 21 talks about the partnership with the out-of-hours GP service. "Over time, callers start to call NHS Direct when they find their calls are diverted there anyway", I think that is what happened to me, "it is not clear what happens to callers who ring off when they find their call is diverted who want to speak only to their GP". That is a bit like me, really, if I cannot get through to my GP, which is impossible these days anyway even during the day to be honestI am being facetiouswhat happens then, can you follow that up?
(Mr Jenkins) Except for a small number of doctors who still do their own out-of-hours arrangements your chances of speaking to your own GP out of surgery hours is minimal. NHS Direct is merely saying that instead of talking to another doctor you are talking to a nurse first.
67. What about the person who demands a visit? By rights you can, can you not, no doctor can refuse to come out to you, is that right?
(Mr Jenkins) Nor do we try and stop that. When people put a lot of pressure on us we will put the call through. One of the things the doctors like about the nurses handling this is they are very good at talking to patients, persuading patients to do what they are advising to do and reassuring them that that is the right course of action. It is not arbitrary, we are talking about process of negotiation.
68. Okay. The last bullet point, again, I was interested in, says "The NHS Direct exemplar programme will reflects the fact that integration works much more efficiently when there is a direct electronic transfer of calls from the out-of-hours and NHS Direct, and callers referred to a GP by NHS Direct do not have to go through a second consultation to confirm NHS Direct's advice." People do not want to have to go through the same information twice, has this been prevented? I have a feeling when I did it I did have to go through the information twice.
(Mr Jenkins) As we have now set up what we call the exemplar programme, which is the latest round of integration, there are direct electronic links between NHS Direct and the GP out-of-hours organisation. If a patient is then put through the GP out-of-hours provider has all of the demographic details plus all of the information of what the NHS Direct nurse said to that patient.
69. Being Devil's Advocate about questioning, I find it difficult to come to terms with somebody over the telephone telling me what to do without being able to examine me. I have seen the day when you would do that, where you would ring a doctor up and they would say, "No, we are not going to give you that, you have to come into the surgery." Do you think that is the right way to go about things? Do you think this way of actually moving is medically correct?
(Mr Crisp) I wonder if Mr Jenkins can talk you through a bit of an algorithm, what the nurse does when she talks to you. It may not be a physical examination but it starts to answer some of the questions.
(Mr Jenkins) The whole system is predicated really on talking a patient through the symptoms they have and ruling out the things that might be the sign of something more serious. If it is not possible to rule it out over the phone then they need a face-to-face examination and consultation. You are working through an algorithm that rules out all of the serious consequences of some symptoms first and then gets to the point where it is actually appropriate and safe to give self-care and self-care advice. I think I would argue that our safety record demonstrates that that is an appropriate way of operating but it is based on if there is an issue of doubt and if a physical examination is necessary to establish some advice then you must ask the patient to go and see a doctor.
70. It does not surprise me at all that advice will vary from one nurse to another nurse to a caller, because even though you have certain symptoms how you describe those symptoms can be different even though the symptoms are the same and therefore it does not surprise me that the advice can be different and varied. Again, that worries me.
(Mr Jenkins) That is why we need nurses doing this job and not just lay people at one level. If the answers were crystal clear the computer system could decide this for itself. The reason why we have nurses is they are able to interpret clearly what patients say about their symptoms and they relate that to the advice that is in the computer system.
71. I was also quite, I would not say worried, but I was very suspicious about a thing Mr Gibb mentioned as well, the mystery calls that were done by a Health Which. I thought that it was very cheeky and very rude to do something like that, as well as wasting the nurses' time. I do not believe, as the Chairman did, that you can give a symptom over a telephone when you do not have those symptoms and, therefore, I do not think you can get an accurate response. If are you not feeling ill how can you say that you are. How accurate is the information that they got? When you do your mystery calling those people will not be ill, they will be false symptoms, how can you be sure that you are getting valid advice?
(Mr Jenkins) Perhaps what you will not get is some of the nuances of somebody who is anxious and worried about a problem in a genuine sense. For our mystery shopper survey we construct clinical scenarios and we do brief the people very clearly about what the implications of those symptoms are and how they might feel and what they might answer if they are given supplementary questions by the nurse. We feel for our own purposes it is done in the right way, it is a valid tool, not the only tool. One of the best ways of evaluating the quality of what we do is actually listening to real calls, which we have a programme of doing.
Mr Steinberg: Right.
72. Unlike Mr Steinberg I do not think I am getting more conservative as I grow older, either with a small `c' or large `C'. I just want to say I think it is an excellent report. Clearly it has been a great job of work setting it up and congratulations for that. I am delighted that it was a Labour government initiative. My remarks where they are critical should be set in that context. What I would like to refer you to is paragraphs 2.38 and 2.39, where it says, "NHS Direct has produced guidelines for sites on raising awareness amongst ethnic minority communities." In the following 2.39 it says, Nine sites out of the 22 had not undertaken any initiative at the time of the survey in June 2001. I would like to know how many of those nine sites still have not followed those guidelines?
(Mr Jenkins) That is not information I have at my fingertips. We can let you have that. What I would say is that we have communication staff at the centre of NHS Direct and in each site and reaching these harder to reach groups will be the main focus of what we ask them to do in the coming year and, I think, beyond. It will be an area we will continue
73. I hope it will not be beyond. My next question to you is, what is the deadline by which you will have had all of the sites implement those guidelines?
(Mr Jenkins) That must be in the course of this year.
74. By December of this year all sites will have rolled out those guidelines in full?
(Mr Jenkins) That is right.
75. Thank you very much. Can you tell me what mapping has taken place in relation to the ethnicity of the local communities that each of the sites serve and what the proportion of the calls received has been?
(Mr Jenkins) There are two things that we are about to do here, first of all we have successfully piloted in one site in London a routine programme of ethnic monitoring of callers, which will be rolled out to all sites. This is not just for ethnic minority groups, we are also looking at a whole range of things. Now we have everyone operating on one call system and have comparable data we will be looking to do some systematic work about mapping, patterns of usage on wards or smaller units of geography so that we can look at things like social deprivation, areas where there is a large ethnic minority population and look at why patterns of usage may be different in different places.
76. What you are saying to me is that no mapping work so far has been carried out?
(Mr Jenkins) Not on those criteria because we have not had the basis for that information. We have clearly looked at bigger divisions, age and other criteria.
77. I am simply focussing on ethnicity here.
(Mr Jenkins) That is information we will have this year and this mapping will happen.
78. That mapping will happen by December this year?
(Mr Jenkins) Yes, indeed.
79. If I can take you over the page now to section 2.41, where the Report says, "Estimates suggest that over 600,000 people prefer to receive medical advice in Asian languages alone." Just taking that figure of Asian languages, as a percentage of the population of England I think that works at out at about 1.5 per cent. The other figures that you have there, "only about 1,000 times during 2000-01 out of a total of 3.5 million calls", people did use the interpreters' facilities. I think you will find that that is 0.0285 per cent. If you take one as a percentage of the other then you are looking at only reaching 1.9 per cent of your target population of 600,000. I think that is a pretty appalling statistic and it shows exactly why the mapping needs to be done, the monitoring needs to be done and the roll out of those programmes needs to be done by December this year, would you agree?
(Mr Jenkins) Yes, I would agree that we need to reach more of those communities. Can I add a further point, we clearly can look at a number of the different media that we deliver NHS Direct through. We already have audio content on the NHS Direct website in a range of languages and we are looking to considerably expand that content again during the course of this year.
1 Note by witness: At the latest review of local communications activity, 22 January 2002, five of the nine sites had implemented the guidelines on raising awareness amongst ethnic minority communities. The remaining sites have plans in place to implement the guidelines fully this year. We have an ongoing commitment to review progress. In order to ensure sites implement these guidelines, we request monthly communications activity plans from the sites and also conduct fortnightly teleconferences with the communication leads in order to monitor progress. Back