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Are NHS 24 and NHS Direct a waste of money?

Yes- argues Dr John Havard, as too many patients end up seeing their GP anyway. No- says Dr Brian Gaffney, the evidence is growing showing these services save the NHS money

When we stopped providing 24hr care there was general discontent with the OOH services that replaced us but they were at least local. Unlike NHS Direct which - in essence – gives patients 24hr access to an unknown health professional operating nationally.

I'd argue that beefing up primary care would have been a more effective way forward although not as politically popular.

When we used to advise patients over the phone we were able to offer early appointments or other follow up arrangements that were lost with the changes- although that's not to say a change wasn't needed.

GPs had retired in their droves up til 2004 but it was public demand and expectation that was at the root of the problem. This should have been tackled nationally with some discussion about patient responsibilities as well as rights.

The threat of litigation combined with out of hours exponential demand had fundamental change as an inevitable consequence.

NHS Direct is better known as ‘NHS Redirect' among some of us because of the frustrating perception that it generates - rather than eases - our work.

We should be wary of this impression - simply because we don't know how many contact NHS Direct and don't go on to seek our help - but we do know that the default position is ‘see your GP'.

A GP consulation costs around £30 and I believe it's slightly more for an NHS Direct consultation. So either NHS pays £30 to see the organ grinder or more than double that to see NHS Direct and the organ grinder.

It is widely accepted that triage is best done by the most experienced health professional possible.

GPs should be at the centre of triage because we are used to handling risk and making sensible follow up arrangements. There is also a good chance that we will know the patient at the other end of the phone and can competently and appropriately reassure them - don't forget that nearly 90% of our work involves just 10% of our patients.

I advocate a rather radical idea- GPs taking on OOH telephone triage. Of course this would have to be properly funded but I predict it would save huge amounts of money in unscheduled care costs.

Dr John Havard is a GP in Saxmundham, Suffolk

A patient's sitting in your surgery saying "I phoned NHS Direct and they told me to come and see you" as if you didn't have enough to do! At times like this, it's easy to assume all NHS Direct does is refer patients to their GP, but that's simply not true.

NHS Direct is an integral part of the NHS. Last year 5 million patients phoned us and the same number used our web services. To put it into context, around 50 patients from an average practice population in England will call NHS Direct each month. Over 60 per cent of patients who call us will be given self-care advice for their problem, which means they can treat themselves at home - we GPs never actually hear from or see these patients. We know that almost half of patients given self-care advice would have gone to their GP and a quarter would have gone to A&E if they had not sought advice from NHS Direct.

The evidence is that patients will use alternatives to visiting their GP - including local pharmacies, their family and friends, the internet, and NHS Direct web and telephone services - when these are accessible and trusted. The results of analysis with our commissioner (East of England SHA) shows that in 2008 we saved the NHS £162m in efficiency savings. This includes £106m through reduced demand on emergency care (including A&E and 999), and in the order of £56 million in other primary care. Our analysis shows that 1.7 million GP consultations were avoided through the use of NHS Direct's core service. This frees up GPs time and practice resources so GPs can deal with those patients who really need them.

You may be interested in the results of a pilot we conducted with a GP practice in North West England, where we provided in-hour nurse triage to help them manage requests for appointments. Over the nine month pilot, we reduced demand for same-day appointments to one third of all calls. Out of the calls we triaged, one third of patients were happy with self-care advice or using their pharmacy (equivalent saving of 4,000 appointments per year). The rest were either given a routine appointment and a small number were advised to call 999 or go to A&E. This showed the potential to help GPs manage their time and resources better, including meeting the 48 hour access target.

I'm under no illusion about the challenge I took on when I accepted the role of NHS Direct's Director of Public Health. GPs in particular have not seen the benefits that NHS Direct can bring to their patients' care, and to their practice. I want GPs to see that we do not want to replace GP care but we are increasingly a cost effective partner in primary care. Amongst my responsibilities, I will be talking to as many medical professionals as possible, especially GPs. It is ongoing engagement that will help us to build lasting relationships that I am confident will benefit GPs and their patients.

I am keen to discuss your views and experiences of NHS Direct and would encourage you to contact me. Email:

Dr Brian Gaffney is director of public health at NHS Direct and works part-time as a GP in Northern Ireland

Other GP views on NHS Direct

In Leeds we have a large out of hours service covering Leeds, Bradford and Wakefield which is manned by GPs. For many years the GPs have triaged patient enquiries and now see patients in the local centres as well as visiting them at home after NHS Direct have triaged them from protocols followed mainly by ex nurses. I presume similar arrangements exist all over the country.

I always thought this was a ridiculous waste of money on a second tier of triage by people who could not take medical decisions and always had to refer the patient on. GPs in the OOH services are now seeing patients referred to them by NHSD and are therefore having to take the history a second time. As GPs, we all know how inefficient this is and how it can lead to unnecessary consultations as well as occasional serious delays.

I do not know the costs of running the NHSD service but I am sure that if this money was spent on improving the service from GP OOH centres and also the extended hours provision in practices, it would lead to improved medical decisions, reduced referrals to A&E and a better service for patients, who would not have to give a history twice.

Dr Martin Islip is a GP in Leeds

Since its' inception NHS 24's role here in Scotland was to offer health advice and direct patients to appropriate NHS services. But is this happening?

Its staff are both clinical and non clinical and use a diagnostic algorithm to triage calls. The diagnostic algorithm is a useful tool for prioritising calls and identifying patients for referral to emergency services and as a guide to the clinical presentations but can be overruled.

But this is where I'd like to see the clinical experience of NHS 24 staff used more, overriding the algorithm when appropriate and taking responsibility for decision making rather than referring to medical staff to assess. After all some of the clinical staff are on the same pay banding as a ward sister.

There is a clinical supervisor on for NHS 24 who can be contacted by staff to get authorisation to override the suggested outcome so a second opinion is always available.

I would like to see the clinical staff quantifying patients' complaints rather than just reporting them. For example a patient answers "yes" to being short of breath but is speaking in full sentences on the phone or the patient with a cough who answers yes to chest pain but this only occurs when coughing. Without assessing the whole clinical scenario and using knowledge and experience of medical conditions and their presentations and also accessing previous consultations I believe triaging of calls can't be effective.

In my experience I see patients who are directed for assessment without appropriate advice being offered in the first instance. The patient with abdominal pain for 30 minutes with no analgesia taken, the child with a fever and patients with symptoms of gastroenteritis- all should receive initial advice.

Is NHS24 cost effective given the high referral rates for assessment? Could we see an automated initial response in the future, press 1 for an emergency, 2 for …etc. Will we have more access to patients G.P. notes other than Emergency Care Summary?

Why are the GP consultation rates so high? Prior to NHS 24 access to GPs out of hours was emergency only but we have encouraged patients to use this service- many of whom use it like their own GP. We have downgraded the role of the doctor and created a generation of doctor dependence. Ease of access allows patients to opt in when it suits, for example "I just wanted to get checked out prior to going on holiday tomorrow". The changes within family dynamics where the experience of the extended family circle was utilised previously, the worried well, patients seeking a second opinion, patients who can't get appointments with their G.P. are but a few reasons.

So what can be done? We should be empowering patients to make decisions in managing their symptoms before seeking a medical opinion. The NHS 24 website has useful patient information resources but should we be utilising text messaging to send advice for initial management?

Dr Terry McIntyre is a GP in Glasgow.

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