NHS Direct reviews referrals and advice

Tags: AIM GPs NHS Direct Quality Social care

03 Nov 2008

NHS Direct is to review the clinical effectiveness of its referrals and the self-care advice provided to patients. A 12 week evaluation will aim to ensure these are “fit for purpose” in comparison with other patient pathways and that they are evidence-based.

The organisation will hold seven workshops across the country at which health and social care professionals will analyse the patient pathways experienced by people who call NHS Direct, based on the top ten reasons for people contacting the telephone helpline.

There have been persistent concerns from doctors that NHS Direct refers too many patients into other NHS services. Last year, the British Medical Association called for an inquiry into the service, arguing that because it referred two thirds of cases onto GPs or emergency services it was “putting a strain on the system.”

There have also been national and international concerns about the quality of advice given to patients by out of hours services.

The most recent review of urgent and emergency care services by the Healthcare Commission found they were working well against individual targets, but that the system as a whole was not working as well as it could. NHS Direct says the workshops will give professionals a chance to look at such issues.

Helen Young, NHS Direct clinical director, said: “The study will help us to ensure that the Department of Health targets for 2008/9 – 60% of calls completed within NHS Direct and fewer than 20% referred to an urgent pathway – are clinically safe and appropriate for the patient.”

The study will identify the most commonly used algorithms that contribute to the largest percentage of urgent, self-care and other outcomes within NHS Direct. A random sample of these calls will be anonymised and turned into case studies for discussion at the workshops, most of which will be held in the first week of December.

More information: NHS Direct is inviting GPs and other professionals to attend the workshops. For more information or to contribute to the debate contact helen.young@nhsdirect.nhs.uk

Lyn Whitfield

Reader's Comments

No surprise

david.royal@nhs.net

03 Nov 08 16:11

Well well "NHS-Oh I don't like the sound of that you better see a doctor-Direct" refers too many patients. What a shock. I am constantly astounded by the stream of patients directed to urgent GP appointments or A+E where all is needed is someone with a bit of clinical experience and acumen to tell them nothing is wrong. How many millions does this cost ? Never mind though it ticks the boxes of new-pathways, blue-sky thinking, pushing the envelope and patient empowerment so the politicians love it. Besides whatever is wrong with it is bound to be the fault of overpayed and lazy GPs.

find out about the service before dismissing it as no good.

03 Nov 08 21:11

Dear ???? Can I ask have you ever asked to be shown round one of the centres and spent some time with the front line staff who deal with the calls. If you have and you still hold the views you have posted on this forum, have you feedback your comments to the site you visited. NHS Direct welcomes feedback from other health care colleagues, and they review the comments and look at the call involved. What this article is talking about is a national clinical audit to look at our present practices and outcomes and to see if they were appropate or not. NHS Direct has learnt from comments and has changed their practices in line with best practices and Nice guidance’s. The part of the article “There have also been national and international concerns about the quality of advice given to patients by out of hours services.” When you use the hyperlink to look at the article is nothing to do with NHS Direct. In the section where it talks about “The most recent review of urgent and emergency care services by the Healthcare Commission they were working well against individual targets, but that the system as a whole was not working as well as it could.” It is talking about the sharing of data within the whole of the OOH service provider and GP’s not just NHS Direct. What is does say is that we share our triage data with our partners, but not all parts of the NHS has the ability to either see all the data or only want selected parts of the data. As yet the NHS a whole is not make use of the e-health environment and the advantages this can bring to the patients journey. I have to say the patients journey through NHS Direct and the OOH providers is far smother, when there is a data link in place and saves time and money for the patient and the NHS. Also the patient is also given self care advice to ensure that they feel able to care for themselves , or the patient while either accessing or waiting for the OOH service to contact them. I know NHS Direct bashing may be fun and satisfying for some , but as a whole the patients welcome NHS Direct been there when they need them 24/7 365 days of the year . There is no post code lottery and the triages/ information can be with the support of a translator where English is not the first langue of the caller/patient. NHS Direct is not just a “triage service”, this is what the core services is but they have other patient cantered care going on in partnership with other stakeholders. So before you run NHS Direct down can I ask you engage with your local site and find out more of what NHS Direct is.

Tough questions not "knocking"

04 Nov 08 12:11

Calls to NHS Direct increase, while A&E attendences also increase and demand for GP appointments increase.

What is happening?

1. The population (perceives) it is getting sicker

2. NHS Direct has unmasked and is serving a previously unrecognised need

3. NHS Direct has fulfilled the prime marketing directive of creating a demand which did not previously exist

We may never know for sure. However whenever a nurse, doctor, pharmacist etc walks into a pub and lets slip their profession they instantly 'discover' unmet demand for healthcare advice.

Meanwhile telephone assessment is perhaps the most difficult and riskiest task a GP faces (faced) out-of-hours - even when they know the patient personally.

At the root this I believe is a misunderstanding of triage. The following is axiomatic in combat zones and major disasters

>>The most skilled medic doesn't work treatment, he or she is assigned to triage.<<

http://chirontraining.blogspot.com/2006/11/triage.html

Counterintuitively (to politicians at least) the skill needed to identify serious illness without swamping downstream services with trivia actually increases when serious cases are rare amidst masses of worried well.

People are not 'knocking' NHS Direct, just asking the questions which should have been answered in small scale pilots before National roll-out.

Root - could this money be better spent elsewhere in the NHS?

Appropriateness and evidence

04 Nov 08 21:11

I seem to recall that the early research on NHS Direct (Sheffield University) indicated that the service might not be reducing the burden on other parts of the NHS, but was improving the appropriateness of the service to which people were directed. Surely this is the critical issue?

In the various discussions there doesn't seem to be any indication of the proportion of referrals on to GPs or emergency services that are actually inappropriate. It reminds me of some research on increasing ambulance call outs which the Ambulance service claimed was the result of GPs offloading responsibility. The figures didn't back this up at all.

We need some hard figures rather than unsubstantiated claims from vested interests.

No ignorance but experience

david.royal@nhs.net

05 Nov 08 08:11

No surprise in the reply - "of course if we frontline staff only understood what NHS direct did we would be full of praise and admiration". The problem is that we see the consequences of the service on a daily basis but are powerless to do anything about it. Out of hours and emergency triage are the MOST difficult and challenging areas of primary care and need the MOST experienced and qualified clinicians. Instead of this we have nurses and computer algorythmns with pre-determined questions and pathways and no ability for the nurse to use any intuitive or learned clinical skills. I have seen the centre in action and more importantly spoken to the nurses who are forced to work in this restricted and protocol led way and believe me they are not happy or satisfied clinicians. On a daily basis I see the result of quite ridiculous advice given - completely innapproriate directions to A+E departments or insistance on urgent GP appointments for sore throats or colds -"NHS direct said I might have pneumonia!" As always with the NHS this huge white elephant was introduced with no pilot or discussion with staff working in GP or A+E who have bourne the brunt of its midirected advice. After introduction the senior management have spent their time producing a constant stream of reports saying how successful it is. Now this "major review" what are the chances of anyone in DOH or god-forbid a politician saying "sorry we got this wrong"?