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Where did NHS Direct go wrong?

By Ian Cameron

When it launched NHS Direct in early 1998, the new Labour Government hailed the telephone hotline as an example of its commitment to an innovative NHS offering 'fast, convenient and flexible' access.

NHS Direct nurses would enable patients to look after themselves 'rather than having to attend a GP's surgery', former Health Secretary Alan Milburn announced.

Two years later, in celebration of achieving full coverage of England, Mr Milburn proclaimed NHS Direct's number would become 'as well known as 999'. He added: 'Before long it will become a single gateway into NHS services.'

The vision Mr Milburn laid down was for NHS Direct to become the single point of contact for out-of-hours calls, to handle category C ambulance calls and even to assess in-hours calls to GPs.

Fast forward six years and it is none of these things. And it is now consulting staff on plans to cut several hundred jobs and a dozen call centres to save £15 million. So where did it all go wrong?

There is no doubting the service is popular with patients. Its 0845 4647 number is called by more than 500,000 people a month, while a similar number access it over digital TV and 1.5 million over the internet. Satisfaction ratings are also consistently high.

But NHS Direct, which has a £151 million budget this year, is increasingly seen as too expensive by PCT commissioners. GPs have also seen no reduction in demand for their services.

Dr Helen Pelendrides, a GP in north London, says NHS Direct is 'an experiment that never worked ­ it was never a success from the beginning'. She adds: 'The inevitable response was ''Go to see your doctor'' and patients say there is no point ringing as they know what they will be told.'

The fact NHS Direct nurses are using computer algorithms to assess undiagnosed conditions means they will always be risk averse, says Dr Ron Singer, president of the Medical Practitioners Union and a GP in north London. He says: 'Nurses feel they can't use their clinical experience and nobody is going to take a risk over the phone, apart from a GP.'

Another fundamental problem, GPs say, is that NHS Direct is seen by patients as an additional service not an alternative.

Dr Mark Reynolds, a former member of the national advisory group on NHS Direct, says this problem stems from the Government's failure to involve clinicians at the planning stages. The service was originally to have been hosted by ambulance trusts, he says, but was changed to a nurse-led service.

This led to the risk-averse culture ­ demonstrated by the fact only 8 per cent of calls in Kent are completely resolved without referral ­ which has proven the achilles heel of NHS Direct.

Dr Reynolds, a GP in Maidstone, says: 'It's quite good at health information but not health care. Its safety function was its downfall.'

These flaws are the root cause of NHS Direct's failure to link with out-of-hours service providers.

When GPs passed their responsibility for 24-hour care to PCTs in 2004, NHS Direct was held up as the ideal organisation to triage out-of-hours calls for new providers.

But the Government also gave PCTs the option of commissioning alternative providers, as long as they could meet required quality standards.

In the last two years, the number of PCTs using NHS Direct's clinical assessment service has fallen from 29 per cent to 12 per cent. Dr Reynolds says NHS Direct did not have 'the right skill-mix, the right training or the right software' to do the job properly.

Dr Paul Hobday, medical director of On Call Care in Kent, estimates NHS Direct costs 10 times as much as its own triage system. He says: 'Government didn't pay enough attention to the experience of out-of-hours people.'

Kent PCTs eventually opted for another provider and Derbyshire's three PCTs are following suit because NHS Direct has been unable to cope with call volumes ­ forcing the out-of-hours providers to pick up the service at busy times.

Out-of-hours providers are clear about the way forward. Dr David Lloyd, medical director of Harmoni and a GP in Harrow, Middlesex, says NHS Direct should give advice, but stream any calls requiring triage to established deputising services.

He says: 'Calls for unscheduled care should be passed to people who can deal with it much quicker with the urgent call part put out to tender. That's going to happen more and more.'

This is something Dr Mike Sadler, national medical director of NHS Direct, admits is likely to happen: 'My prediction is that out-of-hours calls would be slightly lower. Maybe NHS Direct was too costly. Certainly some commissioners found it so.'

So what is the future for NHS Direct?

It plans to expand into chronic disease management, notably helping patients with medicines compliance.

But consensus among GPs is that despite its popularity NHS Direct has not been worth the millions spent on it.

Dr Laurence Buckman, GPC deputy chair, sums up the feelings of many when he says it should be scrapped.

'It's a shame because a lot of people have put a lot of time and effort into making it work. But it doesn't do anything the rest of the health service can't do and it never needed to be there,' he says.

icameron@cmpmedica.com

'If NHS Direct closed, patients would miss it'

Dr Mike Sadler, NHS Direct's national medical director, is adamant the service has been

a success, even though it has

not helped empty GPs' waiting rooms.

Dr Sadler, a former GP, says the failure of conventional techniques to stem the flow of patients to GPs and A&E demonstrates an advice line available 24-hours a day is necessary and valuable.

But he accepts that NHS Direct probably has been overcautious.

He says: 'That was always bound to be the case, it has always been inclined to be slightly risk averse.

'Even a GP would be slightly more risk averse without the sense of vision.'

NHS Direct is hitting its target for handling calls without referring on to other professionals ­ now resolving 38 per cent of all inquiries.

Call-back time targets ­ a contentious area ­ are also improving, with 97 per cent of highest-priority patients being called back in 20 minutes.

Dr Sadler says the service's adverse incident rate is one in every 40,000 to 50,000 calls ­ 'far lower than any other health care system'.

He adds: 'If it closed today patients would miss it and the

rest of the health service would notice pretty soon that demand would be thrust into other parts of the NHS.'

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