The Committee of Public Accounts has agreed to the following Report:
NHS DIRECT IN ENGLAND
INTRODUCTION AND LIST OF CONCLUSIONS AND RECOMMENDATIONS
1. NHS Direct provides healthcare information and advice to the public in England (and Wales) through a telephone helpline and an associated on-line service. The remit is to provide easier and faster health advice and information to the public. NHS Direct is already the world's largest provider of telephone healthcare advice, receiving 5.3 million calls in 2001-2002. The on-line service provides an e-mail health information enquiry service and web links to health information.
2. On the basis of a Report by the Comptroller and Auditor General, we looked at the implementation and delivery of NHS Direct, and the impact of NHS Direct on the public and on the NHS.
3. In the light of this examination, the Committee draws three overall conclusions.
- NHS Direct has quickly established itself as the world's largest provider of telephone healthcare advice, and is proving popular with the public. It has a good safety record, with very few recorded adverse events. Departments should consider what wider lessons they could learn from the successful introduction of this significant and innovative service on time.
- Current priorities are to complete the programme of integration with out-of-hours general practitioner services and establish closer links with ambulance services and accident and emergency departments. The Department now needs to set a clear strategic direction for the service in order to avoid it becoming a victim of its own success by trying to do too many things at once.
- Callers are currently waiting too long to speak to a nurse. NHS Direct expects that its capacity to handle calls will be improved greatly by forthcoming technological improvements in call routing and staff rostering, but it also needs to improve response times overall and review productivity levels at individual sites to cope with increasing demand.
4. Our more specific conclusions and recommendations are as follows.
(i) The Department of Health has not yet set clear longer term objectives for NHS Direct. While the immediate priorities are full integration with out-of-hours healthcare providers followed by the handling of 999 calls deemed non-urgent by ambulance services, there are a large number of other possible scenarios for future development of the service. The Department should set clear objectives within a medium-term development plan, with appropriate outcome measures on issues such as patient satisfaction. The plan should include a clear statement of the priorities and timetable for the integration of NHS Direct with other parts of the NHS.
(ii) NHS Direct does not yet have a human resources strategy that would allow it to take co-ordinated action to minimise the impact of its nurse recruitment on organisations elsewhere in the NHS. The Department of Health should move swiftly to finalise its strategy, in part to provide assurance to hard-pressed NHS trusts that the wider needs of the NHS are being taken into account.
(iii)Satisfaction with NHS Direct's service is high. Where general practitioner services out-of-hours have integrated with NHS Direct, patients are generally comfortable with speaking to NHS Direct. Nevertheless, many patients value being able to speak directly to their general practitioner, and NHS Direct are rightly committed to giving them that choice.
(iv) There are wide variations in the levels of productivity across sites: the number of calls handled per full-time equivalent nurse varied significantly in 2001-02. A minimum level of staffing is required to deal with unpredictable surges in demand, and the capacity of the network is being increased through the introduction of new computer call-routing software which will allow calls to be distributed more easily to sites with spare capacity. While this should allow sites to operate at optimum staffing levels, the Department of Health should also review the number of calls handled at each site to ensure that all are operating efficiently.
(v) Awareness of NHS Direct remains too low among some groups within the population, including ethnic minorities. Use of interpreting services indicates that NHS Direct is only reaching a tiny proportion of its potential non English-speaking callers. By the end of 2002 all NHS Direct sites should be aware of the patterns of ethnic minority habitation and social deprivation within their catchment areas, and have devised specific initiatives to encourage the use of the service by these groups.
(vi) Integration with providers of general practitioner services out-of-hours is a key priority for NHS Direct. It is learning the lessons of pilot projects and making progress in overcoming the initial technical problems experienced. NHS Direct now needs to maintain the momentum to ensure that it achieves full integration at current project sites and meets its timetable for future projects.
(vii) It is too soon to measure the impact of NHS Direct on the NHS as a whole. The evidence so far suggests that NHS Direct has the potential to save costs by re-directing callers to more appropriate forms of care. NHS Direct should take forward evaluation of the costs and benefits of the service, relative to possible alternative uses of these NHS resources.
IMPLEMENTING AND DELIVERING NHS DIRECT
5. NHS Direct's telephone and on-line healthcare information and advice services were implemented across England in less than three years, to the demanding timetables set by Ministers. This was a significant achievement given the innovative nature and scale of NHS Direct. The service has quickly established itself as the world's largest provider of telephone healthcare advice, and is proving popular with the public.
6. The tight timescales meant that implementing NHS Direct's telephone helpline service proceeded alongside piloting. There was little formal opportunity for lessons from pilot sites to be incorporated, although short lines of communication between the centre and sites allowed key lessons to be taken forward. While Ministers had taken the decision at the outset that NHS Direct was to be introduced across the country, the model of NHS Direct has been influenced by a continual process of piloting, learning from that experience, and modifying as implementation progressed.
7. The overall aim of NHS Direct is 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. More detailed objectives for the service have been slower to develop, as have measures of success. A more comprehensive performance measurement and management framework has since been developed, which attempts to clarify responsibilities at different levels of the organisation, and to determine how NHS Direct fits with the wider responsibilities of the NHS. NHS Direct also recognises that it needs to make a number of strategic decisions about future development of the service.
8. NHS Direct employs the full-time equivalent of 1,150 nurses, 80 per cent of which have been recruited from elsewhere in the NHS. There is a fear in other parts of the NHS that NHS Direct might be creaming off some of their key staff, particularly from accident and emergency departments. NHS Direct sites have taken a range of measures to minimise the impact of recruitment on other healthcare providers, including providing clinical placements and rotating staff, and encouraging staff to combine working part-time within NHS Direct with working in another part of the NHS. NHS Direct is currently developing a staffing strategy for the service.
9. The true cost of NHS Direct will reflect both: the cost of employing agency staff, where they are replacing nurses recruited by NHS Direct; and compensating factors such as the potential of NHS Direct to reduce demand on other NHS services, and reductions in agency costs through use of the NHS' own agency, NHS Professionals, run from NHS Direct sites.
THE IMPACT OF NHS DIRECT ON THE PUBLIC
10. NHS Direct impacts on the public in a number of different ways. We looked in particular at the quality of customer service provided, use of the service by minority groups and safety.
(a) Quality of service to customers
11. National surveys have consistently shown that over 90 per cent of callers are satisfied with the service they receive from NHS Direct. In addition, in areas where integration with general practitioner out-of-hours services is well established, patients are generally comfortable with speaking to NHS Direct. Nevertheless, there are a significant number of patients who would like to speak to their own doctor, rather than NHS Direct, when seeking advice outside normal working hours. NHS Direct acknowledges that it should respect patients' wish to speak to their own doctor if they would prefer.
12. However, NHS Direct is not achieving its internal target for 90 per cent of calls which require nurse advice to reach a nurse within five minutes (Figure 1), or an alternative NHS-wide target for 90 per cent of out-of-hours calls which require nurse advice to be completed within 20 minutes.
13. The umber of calls handled per full-time equivalent nurse also varied significantly across NHS Direct's sites in 2001-02 (Figure 2). Factors influencing this included how well established sites were, and the learning curve associated with their transfer to a new computer decision support system. There will always be some down-time at sites, as calls do not arrive in an even flow, and there are unpredictable surges in demand within more predictable peaks. But NHS Direct acknowledges that the variations in productivity are currently too wide.
14. Standardisation of computer software is allowing NHS Direct to make better comparison between sites, including benchmarking of processes so that ways of improving on the time taken to handle calls can be identified. NHS Direct is also investing in a more sophisticated computer-based capacity forecasting and staff rostering system, so that it is better able to match staffing requirements with demand. In addition, capacity is being increased by developing systems to move calls to another part of the country if one particular site is busy, which should allow for more efficient use of nursing staff.
(b) Use of the service by minority groups
15. Regular tracking suggests that over 60 per cent of people are aware of NHS Direct when prompted. However, some groupsyounger people, people over 65, ethnic minority groups, less advantaged social groups and people with disabilitiesare either less aware of NHS Direct or use it less, but have equal or greater need for the service. In setting up the service, NHS Direct has focused on building up overall awareness amongst the population, but is now bringing in more tailored initiatives to tackle lower levels of awareness in certain sections of society. There will shortly be a specific campaign targeted at younger people, and later in the year one for older people. In addition to these national campaigns, there is also an ongoing process at a local level where staff from NHS Direct sites go out to talk, for instance, to older people's luncheon clubs, engage with religious communities, and talk to schools.
16. NHS Direct offers a translation service in over 200 languages. However, interpreting facilities have been used sparingly to date - only about 1,000 times out of 3.5 million calls received in 2000-2001. This suggests that the service has reached only a tiny proportion of those people who would prefer, for example, to receive advice in Asian languages only.
17. NHS Direct has produced guidelines for its sites on raising awareness amongst ethnic minority groups, although at the time of a National Audit Office survey in June 2001 nine of the sites had not undertaken any initiatives to increase awareness amongst their ethnic minority populations. By January 2002, five of the nine sites had implemented the national guidelines and the remaining sites have plans in place to implement them fully during the course of the year. In addition, NHS Direct has piloted a routine programme of ethnic monitoring of callers in one site in London, which is to be rolled out nationally. And now that the service is operating on one computer system and has comparable data, NHS Direct is able to do some systematic work to map patterns of usage in wards or smaller units to look at factors such as social deprivation, ethnicity and patterns of usage.
(c) Safety of the service
18. NHS Direct has a good safety record, with 29 adverse events cases being reported in the three years to June 2001 - fewer than one for every 220,000 calls. Sites are required to report adverse events to NHS Direct's national advisers on nursing and medical issues. These advisers review the events, and recommend actions for individual sites and NHS Direct nationally. NHS Direct's nurses use a computer decision support system to assist them in providing advice to callers. National bodies review the clinical content of the system to ensure that it is in line with United Kingdom best practice. The relevant royal colleges input to this review.
19. NHS Direct uses the available networks to determine the consequences of its actions for callers. When adverse events are identified where the ambulance service or general practitioner is called out, where there has been a coroner's investigation after the event, or sometimes from a direct complaint from the patient themselves. However, NHS Direct, in common with other clinical services, cannot find out every consequence of its actions.
20. The advice provided by NHS Direct can vary from caller to caller, depending on how a caller describes the symptoms they are experiencing. The judgement of a skilled nurse therefore plays a vital role in interpreting clearly what patients say about their symptoms, and relating that to the guidance given by the computer decision. If there is any doubt, then the nurse should advise a caller to see a doctor.
THE IMPACT OF NHS DIRECT ON THE NHS
21. The NHS Plan envisages that NHS Direct will play a pivotal role in the provision of healthcare services to the public by 2004, especially through its function as the gatekeeper to out-of-hours care. NHS Direct is also introducing a range of additional initiatives at the local level. We looked in particular at: NHS Direct's integration with providers of GP services out of hours, and with emergency services; other services provided by NHS Direct; and at the impact on the NHS as a whole.
(a) Integration with general practitioner out-of-hours services
22. A review of out-of-hours services in England commissioned by the Department of Health recommended a model putting NHS Direct at the hub of out-of-hours care (Figure 3). NHS Direct would use its position as a national service with universal clinical standards to provide a gateway to other services, either by people calling it directly or by automatic call transfer from a general practice. The Government accepted this recommendation. As a first step towards implementation NHS Direct aimed to integrate with 22 general practitioner out-of-hours providers by March 2002, through a programme of exemplar initiatives located throughout the country. Together with a further 12 providers already integrated with NHS Direct, this covers 10 million people.
23. NHS Direct has experienced some teething problems in achieving integrated working with general practitioner out-of-hours providers, including difficulties with the incompatibility of technology. These have been tackled through the sharing of experience between sites, and the development of a standard way of communicating between NHS Direct's computer decision support system and the IT systems that providers use - although there were still some issues to be ironed out. The direct electronic links between NHS Direct and out-of-hours providers established for the exemplar sites mean that callers do not have to go through the same information twice as records of the advice given can be shared automatically.
24. By March 2002 access to out-of-hours care through NHS Direct covered seven million patients, and the Department intend to extend this coverage to 10 million patients over the following couple of months. The Department's target is for the whole country to have access to out-of-hours general practitioner care through NHS Direct by 2004.
Source: Independent Review of GP out-of-hours services in England (2000): Raising standards for patientsnew partnerships in out-of-hours care.
(b) Integration with emergency services
25. NHS Direct has strong historic links with emergency services, and the original trigger for the setting up of the service as it is today came from the Chief Medical Officer's review of emergency services. NHS Ambulance Trusts provide more than half of NHS Direct sites.
26. There is scope for calls to ambulance services that are not deemed emergencies by call-takers to be transferred to NHS Direct for advice or information. The Reforming Emergency Care strategy  highlighted this as a priority and suggests that the handling of 999 calls will be brought together with calls to NHS Direct by 2004. At least four NHS Direct sites are currently assessing such calls on behalf of ambulance services. The Department of Health has stated that, building on the experience of these pilots, NHS Direct could handle a proportion of less urgent ambulance calls, thereby providing those patients with a more appropriate response to their needs and freeing up ambulances to deal with more urgent cases.
27. NHS Direct is also taking steps to integrate with accident and emergency departments so far, at least 13 sites are taking calls on behalf of a range of such departments. Evaluation of such schemes suggests that transferring calls to NHS Direct can save the full-time equivalent of two nursing posts over a 24 hour period in a hospital's accident and emergency department, with these staff now seeing patients rather than answering the telephone. In addition, the Reforming Emergency Care strategy sets out plans to pilot a face-to-face version of NHS Direct's decision support software in 25 accident and emergency departments by March 2003. There are also currently pilots in walk-in centres and in one primary care trust in GPs' surgeries. NHS Direct can therefore integrate with emergency services not only by doing their work but also by exporting some of its techniques and approaches to other settings where they are likely to benefit.
(c) Other services provided by NHS Direct
28. At the local level NHS Direct sites carry out a range of other tasks on behalf of healthcare providers, such as validating in-patient waiting lists on behalf of acute hospitals, reminding patients about out-patient clinic appointments, and working with social services to provide robust support to child protection initiatives. There is a risk that these initiatives, while useful, could lead to NHS Direct losing its original focus.
29. The Department explained that, outside peak times, NHS Direct will have spare computer resources and expertise available. Instead of hospitals setting up their own call centres, it makes sense to use this infrastructure to deliver the additional services which local healthcare providers need. In addition, at the national level NHS Direct has been working with the new Care Direct service which is designed to provide a range of information and advice to older people. Instead of reinventing the wheel, those calls are initially routed to NHS Direct call centres, answered as Care Direct but by NHS Direct staff with the appropriate training. This has the benefit of making good use of existing infrastructure, and helps create a seamless way into health and social care advice. The Department acknowledge, however, that they need to have a very clear remit about what they provide as a call service, and a strategy for the use of any spare capacity.
(d) Impact of NHS Direct on the wider NHS
30. NHS Direct re-directs large numbers of callers away from the course of action they had originally intended, which has implications for workload elsewhere in the NHS. Analysis suggests that NHS Direct is offsetting around half its running costs by encouraging more appropriate use of NHS services. Research has also shown some possible reduction in demand for general practitioner services provided outside normal working hours. However, it will be some time before NHS Direct is achieving the sort of call volumes that will allow it to have a visible redistributive effect on the pattern of access across the NHS as a whole.
1 C&AG's Report, para 1; Official Report, 17 April, col. 1034W Back
2 C&AG's Report, NHS Direct in England (HC 505, Session 2001-02) Back
3 Q84; C&AG's Report, para 2 Back
4 C&AG's Report, paras 1, 11 Back
5 ibid, paras 3, 1.5 Back
6 Q29 Back
7 Q14; The new NHS - modern, dependable, Department of Health, 1997 Back
8 Q84; C&AG's Report, para 1.31 Back
9 Qs 5, 52; C&AG's Report, paras 1.25, 1.30 Back
10 Qs 17-26 Back
11 C&AG's Report, para 2.2 Back
12 Qs 9-10 Back
13 C&AG's Report, paras 2.10, 2.14 Back
14 C&AG's Report, para 2.12 Back
15 Qs 32, 37-38 Back
16 Qs 6, 32 Back
17 Q80 Back
18 Qs 6, 80 Back
19 Qs 7, 45; C&AG's Report, para 10 Back
20 Q7 Back
21 Qs 46, 79 Back
22 Q72 Back
23 Ref footnote to Q72, Ev 10 Back
24 Qs 75-78 Back
25 Q39; C&AG's Report, para 2.16 Back
26 Q42; C&AG's Report, paras 2.15, 2.17 Back
27 Q41 Back
28 Qs 42-43 Back
29 Qs 69-70 Back
30 C&AG's Report, para 3.1 Back
31 ibid, para 3.7 and Figure 8 Back
32 ibid, para 3.7 Back
33 ibid, para 3.10 Back
34 Qs 8, 96 Back
35 Q68 Back
36 Qs 90-91 Back
37 Q84; C&AG's Report, para 3.12 Back
38 Reforming Emergency Care - practical steps, Department of Health, 2001 Back
39 C&AG's Report, paras 3.13-3.14 Back
40 NHS Direct Four Years On, Department of Health, 2002 Back
41 C&AG's Report, para 3.13 Back
42 Q92 Back
43 C&AG's Report, para 3.17 Back
44 Q87 Back
45 Qs 2, 85-88 Back
46 Qs 1, 88; C&AG's Report, paras 3.3-3.4, 3.21 Back