Update: NHS Direct won 111 contracts covering 32% of England, but eventually decided they were uneconomical. It closed in 2014.
A mother is worried about her son being unable to keep down water or food. A nurse tells her to feed him small amounts of water every five minutes to prevent dehydration, and send her partner to a chemist to get rehydration solution and a thermometer. In another call immediately afterwards, the same nurse reassures another mother that a child’s attack of diarrhoea is normal – but that it might carry on for up to a week. Then she has to convince a man who wants an ambulance for his son, who is suffering from stomach pains, to instead take a taxi to a nearby accident and emergency unit.
The callers, who gave permission for a third party to listen to their calls, are scattered around England, but the nurse is sitting in front of computer in an NHS Direct office in Milton Keynes. While speaking calmly to the callers, she flicks between pages of decision support software that helps her make a diagnosis, offer advice and locate nearby NHS services. It does not provide her with a script, and it takes skill on her part to calmly gather information from callers who are often upset then tell them what they need to do.
Stuart Toulson, NHS Direct’s divisional director of nursing, says the nurses are paid salaries equivalent to a hospital sister, but tend to last only three or four years in what is a mentally draining job. In the middle of this weekday afternoon the volume of calls is low, and nurses take most immediately from the operators who decide their urgency. But in busy periods – such as Friday nights, Saturday and Sunday mornings – the nursing staff call people back depending on urgency, and as many as 1,000 patients could be waiting.
NHS Direct’s main number, 0845 4647, is taking fewer calls than in the past: from 5.1m in 2009-10 – the year of pandemic flu – to 4.7m in 2010-11, with 200,000 fewer expected this financial year. It exceeded 6m a few years ago.
“People think of NHS Direct as the 0845 service,” says Nick Chapman, its chief executive, and it still provides 80% of the organisation’s income. But 0845 4647 is part of patchwork of non-emergency NHS telephone services, which the government plans to replace across England with one number – 111 – by April 2013. NHS Direct’s 0845 number will disappear, along with complaints about its cost to the caller, which are higher than 01, 02 or 03 numbers.
NHS Direct hopes to provide the 111 non-emergency service across many parts of the country in 2013, but it does not have a guarantee, putting it in a similar boat to much of the health service in England. “We have to earn that right through locally commissioned 111 services,” says Chapman. “We don’t yet know when those competitions will be held, under what circumstances, or the size of the patches. That I’m sure will pan out over the next 12 to 18 months.”
However, it is already running the 111 pilot in Luton, where its staff can provide advice, make GP appointments or dispatch an emergency ambulance (elsewhere it has to transfer callers to their local ambulance service, which will then make its own assessment). “The idea is, you have one assessment, which leads to whatever outcome is appropriate for you,” says Chapman.
It is also involved in pilots in Nottingham and Lincolnshire – in the latter case providing an out-of-hours service – and is providing some services to the 111 pilot in Durham and Darlington, which is led by the North East ambulance service. It also provides an out-of-hours service in West Yorkshire, which Chapman says is effectively a 111 service by another number.
The organisation, which is seeking foundation trust status, is diversifying, such as through providing other telephone services. It already contacts ‘category C’ callers to most of England’s ambulance services – those whose symptoms do not justify an emergency ambulance, such as the father told to take his son to A&E by taxi.
But it is expanding faster online. NHS Direct has provided web advice for several years, it now has 38 health and symptom checkers, and will soon be offer some of these through applications for iPhone and Android. And for more than two years, it has allowed web users to provide some details online, receiving advice from an operator reading words off a computer screen, then if it is appropriate request a call from a nurse. Web users answer the same questions as if they were calling the 0845 number.
The organisation, which Chapman says is going “web first” – for the first time there were more online than phone users on some days last Christmas – is also piloting patient decision aids, which will be primarily available online. A phone service will also be available for those without internet access.
These will help patients with already diagnosed conditions to decide what course of treatment they want to take, such as whether to undergo surgery. The system does not tell the patient what to do, but asks questions, displays videos from health professionals and patients, and at the end provides something they can print and discuss with their own doctors.
“There’s a massive opportunity in terms of giving patients good information to help them make good decisions, shared decision with their clinicians,” says Chapman.
He says the organisation has also made itself more efficient. The cost of the 0845 service fell from £140m in 2008-09 to £123m in 2010-11, through reduced management, overhead and IT costs, and improving productivity.
For example, the organisation has about 100 nurses working from home, with access to the same computer software as those in an office. Some, who work on a part-time basis to boost capacity when needed, don’t wait for a manager to call to ask them to take calls – they ask if they can do so when they see demand spiking. Stuart Toulson says this suits some home workers well, as they can organise work around their other commitments, but earn some money if they find themselves with spare time.
The organisation uses shifts made of 30 minute blocks to maximise flexibility, and uses staff provided by private sector firm Conduit to handle initial assessment calls, along with other services including the Choose & Book and GP and dental out of hours services for some parts of the country – although not the core nurse advice service.
As the incumbent provider since 1998, it would seem likely that NHS Direct will continue to provide medical telephone advice services to most of the country in two years’ time. It is clearly keen to do so, and its focus on quality and efficiency through the use of technology might have been designed as a case study for the NHS’s Quality, Innovation, Productivity and Prevention agenda.
“We can do in an hour what it could take a district nurse in a car a day,” says Chapman. It is a tough – if relatively well paid – job for the nurses on the phone, but telephone and internet advice looks like an essential part of a more efficient NHS.
Nick Chapman will be speaking at the Guardian’s Public Sector IT Leadership Forum on 8 June. The event will provide a rare opportunity to influence the debate at the boardroom level of public authorities. If you are interested in attending, please contact [email protected].
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