Impact of the National Health Services Direc

Published Date: 25 Jan 2018

Evaluate the Impact of the National Health Services Direct, It’s Success Rate and the Changes it has Made in UK Health Care Practices and Procedures

• Anne Cook

 

Abstract

NHS Direct was set up to as part of the NHS Modernization Plan - launched in 1998; the objective of NHS Direct was to offer 24-hour medical information to the general public. This was done through the use of a telephone in service, a website on the Internet, interactive touch screen kiosks and interactive digital television. NHS Direct operates across the whole of England and its digital television and website are available across a wider area.

Growth and change have been ongoing, with the introduction of providing services to other departments within the NHS framework and ongoing expansion. In the main, the general public is satisfied with NHS Direct services. They have formed partnerships with other NHS departments to reduce the workload in areas such as Accident and Emergency - these initiatives have had a mixed success ratio.

The Business Plan for 2006 onwards was focused on further expansion and growth of NHS Direct. However, on April 3^rd, 2006, the Ministry of Health announced that the NHS overall had a budget deficit of 50 million pounds and made public that NHS Direct would be forced to reduce their workforce by one third. Overall NHS Direct had met their targets, all be it at a high cost due to the requirement for advanced technology to support and run the systems needed.

The focus of NHS Direct Management will now be on restructuring and downsizing with a reduced workforce. The staff turnover has always been high at 30% and the staff morale in difficult times will be a problem that needs addressing in order to retain experienced staff.

The overall conclusion is that the NHS as a whole will have to reconsider its ability to provide free medical to all based on current funding. The funding to NHS has increased over the last decade.

Regardless of the increase in funding, the system was not monitored in a way that identified an growing deficit, now resulting in NHS Direct and other departments having to downsize, in this case not due to their own inefficiency but the overall financial crisis in the whole NHS system. By using change agents the process of going from being a growth division to one that is reducing needs to be well managed to focus on the positive contributions they can make to the health of the general public and by closing or redirecting the services that they are not handling competently and/or cost efficiently.

1. Table of Content

Abstract

1. Table of Content

2. Introduction

3. Literature Review

Brief Introduction to Change Management

NHS DIRECT

4. Research Objectives

5. Research Methodology

6. Research Findings

SWOT Analysis

Table 1 – SWOT Analysis

Force Field Analysis – NHS, Direct, April 2006

Table 2 – Force Field Analysis

 

2. Introduction

The National Health Service (NHS) is the largest employer in the UK and has a diverse workforce with many different professional groups (Smith, 2000). The researcher believes that there is accelerating pace of change within the NHS, as they need to keep a step up and embrace further growth in the public sector. In recent journals there are many problems related to the NHS Direct, which the researcher feels an investigation should be undertaken to identify the problems. A political editor said;

“The report doubted whether the target of 90 per cent of callers speaking to a nurse within five minutes would be met. It said NHS Direct was changing the target waiting time to 20 minutes” (Waugh, 2002).

NHS Direct is the National Health Service’s 24-hour information, advice and guidance service available by telephone, the Internet, interactive touch screen kiosks and interactive digital television. NHS Direct operates across the whole of England and its digital television and website are available across a wider area.

NHS Direct is a Special Health Authority and employs approximately 4000 staff and handles around 600,000 telephone calls and one million visits to the website each month.

The NHS Direct website gives patients the same information as their doctors, in clear and jargon-free language, which helps them to make informed choices about their healthcare.

At the time the HNS Direct website was set up the then Health Minister, Rose Winterton, stated ‘We are working to provide a modern, flexible NHS that fits around patients' needs and meets their expectations. We know that patients would like more information to support them in making decisions about their healthcare. This is an important step in providing patients with the resources they need to make informed choices’

The NHS is implementing a 10 year modernization program – the NHS Modernization Board is advising the Secretary of State on implementing the plan.

Due to the vast nature of the NHS, this study will specifically look at NHS Direct and analyze the changes that have occurred, and the affect on stakeholders, both within the NHS and their external customers.

3. Literature Review

Brief Introduction to Change Management

Over the last 20 years the impact of change has been greater than ever before, as the pace of change is now so fast that, for organizations to sustain business growth and operate successfully they must be able to adapt with the frequent changes in markets and competition. Therefore businesses must respond very quickly if they are to survive. Clarke, (1994) Today, change is not the exception but a steady ongoing process that organisation strive on to keep a crucial part of competitive edge.

^[1]Burns (2000, p148) states:

“What worked in the past will not work in the future, and organizations, like society at large, will have to change in unprecedented ways if they are to survive.”

Managing change is a broad area to concentrate on, as change affects organizations in general and people in many different ways. The NHS has made changes to their provision of health care, which gave rise to the NHS Direct in the first place; however, the current financial crisis shows that initiatives in health care to date have not been adequate or appropriate. The one area that has not changed is the demand and scope of the services to be provided – they are providing medical for all, regardless of the persons ability to pay. Certain members of the public have opted for private health care insurance but this is not the norm. In addition, the population is aging and increasingly more seniors need long tern, high care that puts pressure on available resources.

“It is easy to change the things that nobody cares about. It becomes difficult when you start to change the things that people do care about—or when they start to care about the things that you are changing.” ^[2](Lorenzi and Riley 1994)

The NHS is important to the vast majority of the population; it is considered a right to have medical care available to all, regardless of their financial contributions. Most people do not carry private health care insurance. The Ministry of Health has repeatedly changed the NHS to maintain this service, with differing levels of success in recent years. The current situation shows serious financial deficits, a shortage of qualified staff and dissatisfaction with the service.

We live at a time when organizations are continually changing and success is now determined by how well the changes are implemented and whether the desired gains can be achieved. (Collins, 1998)

The rate of change is increasing in almost all organizations. The pressure is intense as the world focuses the time and attention on understanding the forces driving the changing environment and expands or applies the information systems needed to support the changed environment.

The phrase change management in reference to the comments of ^[3]Peter Drucker is as to ‘whether one can manage change at all or merely lead or facilitate its occurrence within an organisation’.

Change management is the process by which an organisation gets to its future state, however creating change starts with creating a vision and then empowering individuals to act as change agents to attain that vision.

In today's rapidly changing, competitive environment, the ability to change efficiently, can distinguish the winners from the losers. Many health-related organizations find themselves unable to adapt due to the independence of technologic change.

NHS Direct has been in a period of change due to their growth since inception. In 1998, the change was positive, bringing on and implementing new technology, growing call centres and providing an expanding service to the general public as well as reducing the workload in some other sectors within the NHS. However, this additional service within the NHS has involved high costs for technological infrastructure, software and implementation, as well as on going maintenance and extended the service without huge reductions to the demands on other sectors of health care.

NHS DIRECT

Purpose of the NHS Direct

The NHS is a 24-hour health help line that handles around 100,000 calls every week across its 22 sites. Since the launch of the first wave of NHS Direct sites in March 1998, the service has expanded to cover the whole of England. In addition, it has developed a range of multi-channel services, including NHS Direct Online, Information Points using touch screen kiosks, NHS Direct in Vision (new digital TV pilot projects) and the Self-Help Guide (formerly the NHS Direct Healthcare Guide).

NHS Direct has also expanded, working with frontline staff and managers to devise new with out-of-hours services to succeed in their aims and objectives providing consistent access to high quality, integrated care.

Ref ^[4]http://www.nhsdirect.nhs.uk/ – a new gateway to healthcare

The NHS Plan – A Plan for Investment, a Plan for Reform, July 2000

4. Research Objectives

Introduction of the NHS direct has made a big departure to the existing practice and presents a major challenge in the management of change in the public sector.

The aim of this report is to analyze the role of the NHS Direct through the use of the Internet and the impact on the Medical services. The following areas will be evaluated:

• Investigate the purpose of NHS Direct.
• Research the NHS Direct history and its operations.
• Identify the NHS Direct objectives and the success to date
• Investigate the Impact on all stakeholders, including Medical Services and the general public
• Evaluate the role of NHS Direct Website in helping NHS Direct meet its objectives.
• The challenges the change has imposed on NHS Managers and the affect on their change management approach

5. Research Methodology

A literary review will be undertaken to study the NHS Direct and the elements listed in the research objectives.

A range of sources will be utilised including e-journals and journals, newspapers, books and the Internet.

The success of the change management will be measured by the success of NHS Direct and its ability to meet predefined goals and objectives, referred to as Key Performance Indicators. The KPIs include the changes being introduced and new services that have grown since inception of the service.

The NHS Direct website will be evaluated as to how user friendly it is, what content it provides, and its acceptability from the user community.

6. Research Findings

Investigate the purpose of NHS Direct.

NHS Direct is a response to the desire for increased patient empowerment. It is also

recognition that the NHS is a complex, multi-layered system that can be confusing for the non-health professional. NHS Direct enables people to make decisions about their own or their family’s health by providing expert advice and up to the minute information. The service can also act as a 24-hour signpost, directing people to the most appropriate level of care.

NHS Direct was launched in 1998, initially at three pilot sites, to provide “easier and faster advice and information for people about health, illness and the NHS so they are better able to care for themselves and their families”.

The success of NHS Direct in achieving this aim rests largely on the premise that it should be accessible to all sectors of the population regardless of race, age, gender, preferred language choice, income, sensory impairment, disability, social positioning or cultural background/preference. Ref NHS Direct website, a new gateway to healthcare http://www.nhsdirect.nhs.uk/

Objectives of NHS Direct - Specific objectives set for the service included:

• To provide for the public a confidential, reliable and consistent source of professional advice on healthcare 24 hours a day so that they can manage many of their problems at home or know where to turn to for appropriate care.
• To provide simple and speedy access to a comprehensive and up to date range of health and health related information.
• To improve quality, increase cost-effectiveness and reduce unnecessary demand on other NHS services by providing more appropriate response to the needs of the public.
• To allow professionals to develop their role in enabling patients to be partners in self-care, and help them focus on those patients for whom their skills are most needed.

The Ministry of Health’s mission to modernize the NHS is not confined to hospitals. The roll-out of NHS Direct, a nurse-led telephone help line, and the introduction of walk-in primary care centres indicate that the same philosophy is being applied to GP services. The common theme in these initiatives is the desire to improve access and convenience within the NHS, a theme that is emerging as the defining element of New Labour's approach to health policy.

The modernization of the NHS, which included the introduction of NHS Direct was a major change designed to streamline the interface between the general public and the NHS. As the NHS Direct service grew, it came under criticized for severing the personal link between patients and their GP. Some patients preferred the face-to-face interaction with their doctor when a health problem arose, even though the situation did not require medical procedure or physical intervention and was competently handled by a call to NHS Direct.

Ref Coulson –Thomas, C and Coe, T (1991), The Flat organisation. British Institute of Management: London. They stated that Change is an ever-present feature of organizational life, though many would argue that the pace and magnitude of change have increased significantly in recent years. The Institute of Management, formerly the British Institute of Management, which regularly carries out surveys of its members, has certainly found this to be true. In 1991, the institute reported that 90 per cent of organizations in its survey were becoming ‘slimmer and flatter’.

Such change will bring resistance – there are 4 bases for resistance to change, identified as follows by Leigh, A (1988) Effective Change. IPM

Cultural – When change seems at odds with accepted values and norms: “the way we do things around here”.

Social – When change threatens to disrupt relationships or break up valued groups.

Organizational – When change affects formal, hierarchical status and threatens the individual’s power and influence.

Psychological – When change is seen to be counter to the individual’s vested interest, when loss outweighs gain.

NHS Direct could have created resistance in all the above areas.

Cultural – for many senior citizens, for example, prefer to talk face to face with their medical personnel and those less computer literate people would not be inclined to use the web site as a source of information. There is a trust relationship between many doctors and patients who have worked together on the individual’s health needs for many years.

Social – NHS Direct has been criticized for severing the ties between doctor and patient and recommending patient care options that differ to those ‘normally’ followed by the patient under his/her GP.

Organizational – an article on the BBC, 30 August 2001 ref http://news.bbc.co.uk/1/hi/health/1516701.stm shows a concern regarding the changes to the organizational structure. ‘NHS Direct blamed for rise in 999 calls’

‘There has been a 30% rise in 999 calls since last year. The introduction of the NHS Direct help line has been blamed for a leap in the number of 999 calls made to an ambulance service.

The Isle of Wight Healthcare NHS Trust is failing to meet government-set response targets of answering 75% of life-threatening calls within eight minutes.

The trust says its efforts are being hampered by a 30% rise in call-outs since NHS Direct was made available to islanders.

NHS Direct denies it is advising people to call out ambulances without good reason. ‘

The facts are denied by the manager of NHS Direct, he believes the increase in calls were correctly recommended by NHS Direct and that hey are being used as a scapegoat for the inability of the ambulance services to meet their target for responding to calls.

The Times on line, quotes the NHS chief, Dec 08, 2005, in the article titled, ‘Turbulence is the Price of a Better Service’ - “When you are introducing change you will inevitably have some degree of turbulence,”

Psychological – The Emergency Medical Journal, C J Morrell, et al wrote a report entitled ‘The Impact of NHS Direct on Other Services; The Characteristics and Origins of Its Nurses. It states ‘the introduction of any new health service can clearly have an impact on other services in two distinct ways: firstly, by altering the pattern of patient demand for existing services; and secondly, if it competes for the same resources, by affecting the ability of existing services to supply care.’

This was commissioned in response to increasing criticism that the service was taking qualified nurses away from the profession. The article went on to point out that a number of the nursing staff working for NHS Direct actually have disabilities or personal reasons for not being able or willing to do active nursing duties and have been encouraged back into the work force by NHS Direct – they would otherwise have remained outside of their profession al together.

Research the NHS Direct history and its operations.

NHS Direct was one of the new services that were introduced in 1999/2000 to improve and reform the NHS healthcare making it a modern, efficient and patient led health service giving patients more choice and better access to their own healthcare.

The service provides access to confidential health advice and information, 24 hours a day, in a range of easy and convenient ways – the NHS Direct telephone service, NHS Direct Online website and the NHS Direct Interactive service on digital satellite TV service. As well as helping patients improve their health and looking after themselves, NHS Direct helps patients access the right health care service for their needs.

The value of the use of technology was reported by ^[5]Carr (1996) who agrees that, when properly used, information technology is a powerful tool for increasing speed, quality, and flexibility, and for creating new, different, and effective process operations. “It enables businesses to maximize their return on investment and deliver breakthroughs in competitive advantage.” But in practice, “many organizations have been sending millions of dollars down the drain by applying sophisticated information technology to automatic existing processes. The consequences? Making the same mistakes faster.”

The costs and changing structure of the NHS Direct in the past and concerns regarding the accounting were tabled by the National Audit Office in Feb 2006 ref http://www.nao.org.uk/pn/05-06/0506484.htm

‘Established in 1999, until April 2004 NHS Direct was centrally managed by the Department of Health but the service was delivered at a local level by 22 NHS Trusts. When NHS Direct became a Special Health Authority in April 2004, it had to put in place new accounting systems and procedures. While these systems were being established the host Trusts which had previously funded and managed the service continued to be responsible for providing accounting and payroll services under service level agreements. Since NHS Direct had not implemented a centralized ledger or payroll system and the payroll providers and records were dispersed across the country, there was an absence of central management control over the processing of payroll.

Work by NHS Direct and the NAO has indicated that in the region of £1.6m of payroll expenditure in 2004-05 may be inaccurate.

According to today’s report, NHS Direct has also been unable to provide evidenced comparative income and expenditure figures for previous years. NHS Direct has estimated total income and expenditure of £121 million for the previous year based on returns provided by the host Trusts to the Department of Health together with an estimate of central departmental costs, but has been unable to provide sufficient evidence to support these figures.’

Identify the NHS Direct objectives and the success to date

Objectives are stated as Key Performance Indicators (KPIs) and divided into sections – Patient, Staff and Organisation, Stakeholders & Financial. The table below summarizes the KPIs for the sections, as stated in the Executive Report for July 2005, tabled in Sept 2005. This provides a recent snapshot of NHS Directs adherence to KPIs and provides actuals for previous month and year allowing comparisons for improvement over the period. As the department is in a growth phase, these KPIs include measurements of change management as well as maintenance and adherence to standards and processes and procedures.

The section for Financial KPIs does not include any metrics, therefore it is assumed they were not discussed or agreed prior to the tabling of the report.

The following table has been extracted from the Executive Scorecard, a method used to measure adherence to targets.

Patients KPIs

Overall, patients reported being satisfied with the service received, however, the department did not achieve its objectives against the majority of KPIs

• The number of complaints were up from 2004, although lower than reported in June
• Number of complaints responded to within 20 days was 39% below target and 37% worse than in June
• Serious adverse incidents exceeded the target and has shown an improvement over prior year and month figures
• The number of web visits and calls answered were lower. This is likely to be due to the fact that this was summer and not due to any shortcoming on the service.
• The number of abandoned calls is above target, although improved over the period
• The assessment of calls, all types, have met target and are significantly improved over the period.

The National Audit Office paper ‘NHS Direct in England, published in 2002 stated ‘NHS Direct’s project team has balanced the need to publicize the service and its capacity to meet demand. It has already met its target for 60% of the population to be aware of NHS Direct by March 2002. Public satisfaction with NHS Direct is consistently very high at over 90%. Very few callers received the engaged signal when telephoning, but in Sept 2001 only 64% of callers were able to speak to a nurse adviser within 5 minutes compared with the current target of 90%. ’

Staff & Organisation KPIs

Schedule adherence appears to be a problem, with the target not being met by 2 key staff members by 9 & 18%.

The cause for concern is within the rolling year turnover rate for staff. This is exceptionally high at 39% and this should be further investigated to find out the root cause.

The BBC article ‘Call Centres: An Ideal Calling’ an NHS Direct employee commented ‘However, with a staff turnover of some 30%, it looks as though the call handlers are not enjoying the fruits of this telecommunications boom.

 

‘Jonathan, who works at a major call centre in northern England, has seen this staggering turnover at first hand. "Two-thirds of the people who join us don't make it past their second month. Most [of the others] leave within a year," he says.

Companies have been accused of taking a cavalier attitude to happiness of their staff, preferring to hire agency workers rather than investing time and money in a full-time workforce.’

Stakeholder KPIs

The departments reached the majority of stakeholder KPIs – stakeholders are other departments within the NHS and therefore this indicates that the NHS Direct should have a successful relationship within the NHS as a whole.

	July 2005 Executive Scorecard
	Patient KPIs (Key Performance Indicators)
		Actual		Actual	Actual
Rating		Jun-05	Target	Prev mth	Last Year
G	% Patients satisfied with service	99%	95%	98%	99%
R	Number of complaints (per 10,000 calls)	0.84	0.5	1.01	0.49
R	Number of complaints responded to within 20 days	56%	95%	93%	-
G	Serious adverse incidents (per 10,000 calls)	0.16	0.24	0.34	0.25
A	Number of web visits	963.3k	1040.9k	1013.0k	662.6k
A	Number of calls answered	570.01k	591.3k	553.5k	526.3k
A	Abandonment rate	7%	5%	10%	13%
A	% calls answered within 60 seconds	76%	95%	71%	57%
G	% urgent calls commencing clinical assessment in 20 minutes	97%	95%	97%	50%
A	% non-urgent calls commencing clinical assessment in 60 minutes	97%	95%	97%	50%
G	% of HI calls assessed within 3 hours	91%	90%	91%	90%
	Staff & Organisation
G	Overall ICT availability	99.97%	99.00%	99.99%	99.99%
R	Schedule Adherence: Nurse Advisor	61%	80%	61%	57%
A	Schedule Adherence: Health Advisor	72%	80%	70%	66%
A	Calls per available hour	7.7	8.8	8.7	7.5
G	Short term sickness	6%	6%	5%	5%
R	Rolling year turnover rate for staff	39%	25%	39%	30%
A	% of funded staff in establishment	90%	100%	91%	93%
	Stakeholders KPI
G	% Emergency & Urgent Referrals	32.80%	<34.1%	34.60%	40.30%
G	% completed within NHS Direct	30%	>29%	33%	35%
R	Number of Cabal calls	322	3982	238	-
G	CaBal call length in seconds	199	<360	300	-
G	OOH calls answered	99.0k	95.2k	95.7k	79.4k
	Rating Legend
	R - Performance has not reached target and difference is greater than 15%
	A - Performance has not reached target but is within 15% of target
	G - Performance has reached target
	Note
	No Financial KPIs included, targets state these have not been set

The NHS Directs Business Plan 2005-2206 executive summary reported ‘NHS Direct’s performance is improving but we believe that for it to reach the growth and performance targets required by the Department of Health we need to increase the numbers of staff answering calls. We calculate that we would need an additional 700 full time equivalent staff, a mix of call handlers and nurse advisers’

The announcements on April 3^rd, 2006 to cut 1/3 of the workforce at NHS Direct will have major impacts on their ability to meet target levels and are likely to reduce the service. This will result in restructuring and need strong change management skills and expertise from management to ensure that the service that remains continues to be viable and provide a good service, although the breadth of the service itself will certainly be reduced.

The Times newspaper reported on April 03, 2006, ‘We must rethink NHS, plead senior doctors’

Plans have been drawn up to cut jobs at the telephone advice organisation NHS Direct by a third, it was reported last night. Its board has been asked to consider scrapping almost 1,250 of 3,746 jobs, replacing nurses with unqualified staff and closing eight call centres. The proposed cuts would bring job losses in the health service to more than 5,800 in the past month.

According to a report in the Telegraph, the job cuts are some of the highest within the NHS, taking 4^th place by volume behind The University Hospital of North Staffordshire, County Durham and Darlington and the Royal Free Hospital, North London.

The job losses are part of an overall plan to reduce the 20 mill pound deficit in the NHS funding – this will result in NHS Direct going from the flagship of the NHS to only offering a limited service to the public and resulting in pressure being moved back to the GPs and outpatient services if patients are unable to be adequately served by the Direct service. The high ongoing investment in technology is likely to be reduced – this will have a direct affect on the service. In addition, upgrades and future expansion will be minimal as they are costly.

There does not appear to be any link between the level of success of NHS Direct and the decision to cut a third of its work force. It was close to making targets and was considered a valued service by the public. The reduction in funding that will result in the job losses is outside the control of NHS Direct and is part of the overall budget deficit suffered by the NHS. The statement that untrained staff should replace nurses to reduce costs is cause for concern. Untrained call handlers with no prior medical experience should not provide medical advice.

^[6]Pettigrew (1985) argues that changes within an organization take place in response both to business and economic events and to processes of management perception, choice and action.

In July 2002, the House of Commons Public Account Committee, stated ‘NHS Direct is a "potential victim of its own success"

NHS Direct is in danger of becoming a victim of its own success and trying to do too many things at once, warns a report from the House of Commons Public Accounts Committee.

In a report published this week the committee of MPs says the Department of Health should set clear objectives within a medium term development plan, with appropriate measures of the scheme’s success, such as patient satisfaction.

The plan should include a clear statement of priorities and a timetable for integrating NHS Direct with other parts of the NHS.

NHS Direct, it says, has proved popular with the public and has a good safety record, and very few adverse incidents have occurred—only 29 reported cases in the three years to June 2001, equivalent to less than one in every 220 000 calls.

However, callers are currently waiting too long to speak to a nurse, with the service failing to meet its own target of 90% of callers who need to speak to a nurse getting through to one in five minutes. Also, the NHS Direct sites vary in the number of calls handled per full-time nurse.

In April 2003 the BBC reported ‘NHS Direct 'to double in size' and stated ‘Ministers are hoping that the number of calls to its NHS Direct telephone advice line will double by 2006.

Currently, NHS Direct deals with half a million calls a month It hopes that the service will free up capacity in other overstretched parts of the NHS.’

Ref http://news.bbc.co.uk/2/hi/health/2950071.stm

This is in sharp contrast to the current status as reported in The Telegraph on April 3rd 2006 – ref http://www.telegraph.co.uk/opinion/main.jhtml?xml=/opinion/2006/04/03/dl0302.xml ‘The NHS needs surgery’

Surely the fiction cannot be sustained any longer. The Government has increased annual healthcare spending by 80 per cent since 1999; we now spend more than the European average; and yet the NHS still does not work. Indeed, it is now in serious financial difficulties.

The latest casualty of the system is, in fact, one of the trendy innovations introduced to give the impression of modernization and reform. NHS Direct - the telephone medical advice service hailed by the Prime Minister at its launch as "a symbol of modern healthcare" - has drawn up plans to lay off a third of its workforce, so straitened are its finances. If implemented, this plan would add 1,250 to the 4,450 NHS job losses already announced in the past month.

The fate of NHS Direct explains much of what is wrong with the Government's "reform" programme. In outline, the principle is admirable: connecting patients directly to professionals using modern technology. The same principle lies behind the new funding system for acute care, launched today, called "payments by results", which will automatically allocate money for treatments according to patients' choice of provider.

The overall success or regression of the NHS, including NHS Direct, will need to be addressed as a result of the funding cuts. One article cited other departments also suffering from a reduction in funding as the trusts within their area had a deficit, not the division itself. Therefore, the NHS does not apply the same principles as does the private sector where successful departments who are within their own budget and providing a good service generally results in self sufficiency in income and the ability to control one’s own future spending so long as it is cost effective and produces profits.

The conclusion has to be a total overall of the NHS and its aims and funding are required. They have a responsibility to provide medical services to all, regardless of the individuals’ ability to pay. Their funding is limited by the UK government budget and this has not worked in the past and has to be analyzed to ensure the future budget spend is appropriate. Alternatively, the health care system in the UK has to look at its capabilities to be the sole provider of health care for all. The additional spend by the Ministry of Health overall has not resulted in sustainability over the last 8 years, initiatives started 8 years back, which cannot have made a return on investment in that time, are now to be downsized and the services reduced.

Investigate the Impact on Medical Services.

The information below was taken from the National Audit Offices report ‘NHS Direct in England, Jan 2002. It must be noted that this information was tabled when NHS Direct was in effect for 3 years.

The North East site is integrated with 6 GP co-operatives covering 28% of the local population. 5 of the 6 co-operatives allows NHS Direct nurses to take the consultation to the stage where they make the decision whether to involve the GP, without getting a second opinion from the co-operative.

Impact - Figures for 2000-1 show a fall of 18% in the number of calls received by the cop-operatives compared with 1999-2000.

In Gateshead a GP co-operative integrated with the local NHS Direct site in Oct 200, but withdrew from the arrangement 2 weeks later because of dissatisfaction with the level of service provided by the site.

Impact – Unsuccessful integration. Reasons for this were cited as

• The decision to integrate coincided with the start of the busiest period of the year for NHS Direct, exacerbated by staff shortages.
• The 2 parties differed on their interpretation of the service standards contained in the service level agreement

NHS Direct Hampshire site also experienced initial problems integrating with the GP co-operative on the Isle of Wight, in this instance the differences were later resolved. In Gateshead, the trial continued for a short period, 2 weeks is not long enough to make a decision to withdraw from using NHS Direct and there is no sign of consultation to resolve the problems encountered.

One NHS Direct site takes calls on behalf of a GP group practice. Callers who wish to see a doctor immediately, but where no same day service is available, are referred to NHS Direct.

Impact – a reduction 36% drop in home visits compared with the same period in the previous year. This is a significant reduction that freed up doctors, a resource that is always in short supply.

Telephone callers to Rochdale Healthcare Trust Accident and Emergency Department who had not previously been seen at the hospital were given the option of contacting NHS Direct instead.

Impact – Of those that required health advice 72% were redirected to an end-point other that A&E. As NHS Direct has met targets for negative incidents, this is a high reduction in demand on the A&E services for the area that are always under extreme pressure. There is no data as to how the calls we rectified and which alternative departments were used to take up the 72% of calls or if the majority actually were helped by NHS Direct and did not need additional medical services to resolve their medical call.

The A&E at Queen Alexander Hospital, estimates that transferring calls to the local NHS Direct site has saved the equivalent of 2 full time equivalent staff posts over the course of 24 hours who can be released for face-to-face consultation instead of having to answer the phone.

J Jones and M J Playforth, Sept 2000 tabled the report ‘The effect of the introduction of NHS Direct on requests for telephone advice from an A&E Department’.

The excerpt refers to the Pontefract Infirmary, West Yorkshire

‘Results—the number of advice calls responded to within the department fell by 72.6% (84 in October 1998, 23 in October 1999). The number of calls redirected to NHS Direct was 242. The total number of calls to the hospital seeking advice thus increased by 315%.

Conclusion—the introduction of NHS Direct has allowed for a mechanism to be put in place reducing the number of calls for advice being dealt with by the A&E department clinical staff with a concomitant time saving. At the same time the number of calls for advice made by the public to the hospital has dramatically increased.’

NHS Direct was accused of taking qualified nurses, mainly from A&E department – themselves understaffed, and creating a greater skills shortage within the nursing profession. A study of the source of nurses working for NHS Direct, looking to see if there was a negative outflow of nursing staff from A&E departments reported ‘of the 81 accident and emergency departments or minor injury units which supplied nurses to NHS Direct, 64 supplied only a single nurse, 10 supplied two nurses, five supplied three nurses, one supplied four, and one supplied seven.’

In addition, it was found that many NHS Direct nursing staff had decided to work for them specifically as they offered part time working hours and would not have re-entered the medical workforce for a permanent full time post.

 

In the British Medical Journal, JamesMunro, clinical senior lecturer ref http://emj.bmjjournals.com/cgi/content/full/19/4/337 did a short observational study on the impact of NHS Direct on demand for Immediate Care, after 1 year from start up of the services.

Objectives: To quantify the impact of NHS Direct on the use of accident and emergency, ambulance, and general practitioner cooperative services.

• Results: NHS Direct received about 68500 calls from a population of 1.3million in its first year of operation, of which 72% were out of hours and 22% about a child aged under 5years. Changes in trends in use of accident and emergency departments and ambulance services after introduction of NHS Direct were small and non-significant. Changes in trends in use of general practitioner cooperatives were also small but significant, from an increase of 2.0% a month before introduction of NHS Direct to 0.8% afterwards (relative change 2.9% (95% confidence interval 4.2% to 1.5%)). This reduction in trend was significant both for calls handled by telephone advice alone and for those resulting in direct contact with a doctor. In contrast, the six control cooperatives showed no evidence of change in trend; an increase of 0.8% a month before NHS Direct and 0.9% after (relative change 0.1% (0.9% to 1.1%)). Conclusion: In its first year NHS Direct did not reduce the pressure on NHS immediate care services, although it may have restrained increasing demand on one important partgeneral practitioners' out of hour’s services.

Evaluate the role of NHS Direct Technology Based Services

NHS Direct Website

The Good Web Guide evaluated the NHS Direct web site and produced the following evaluation ref http://www.thegoodwebguide.co.uk/index.php?rid=1771

‘NHS Direct is a 24-hour telephone help line led by National Health Service nurses that offers information and advice to patients and the general public. Its aim is to sift through the 100,000+ health related sites on the Internet and recommend those that offer good quality information to the general public. It is an excellent service, and impressively simple to use and understand. Although conservative and conventional in its approach to treatments, it is comforting that the information has NHS approval or backing, and the editorial offers plenty of preventative health advice as well as instructions for what to do when someone has already fallen ill. The homepage is very easy to navigate. Pages on the site are kept short, so it's easy to use if you have a small screen. The Top 5 Topics lists the highest hitting pages every hour –this is an excellent service’.

The website promotes and follows the guidelines of the NHS Direct to make health information readily accessible to the public.

The web site is easy to use, and has a simple, straightforward format, making it easy to navigate under headings

• Find out about illnesses, operations, tests and treatments
• Get advice on common health problems from the self-help
• Find your nearest doctor, dentists, optician and pharmacists

Some of the medical content has come under criticism as being too complex for certain conditions, e.g. diabetes.

The web site makes medical information and has contacts in the local area readily available to those who have internet availability and the required skills to use the internet. It is a valuable component of NHS Direct. It compliments the other facilities of telephone calls, interactive kiosks and digital television to keep the public informed of matters relating to their health.

Kiosks

Similar information to that found on the website is available via touch screen kiosks spread throughout the UK. An evaluation of the NHS Direct kiosks was carried out by Ray Jones ref http://www.plymouth.ac.uk/assets/HSC/abstract%202002%20-%20Jan%2016%20evaluation%20of%20NHS%20Direct%20kiosks.pdf

In order to improve equity of access to NHS Direct information, they installed touch screen kiosks in 136 locations between Sept 2000 and Oct 2001 with similar information to the website.

The study showed that

• The average number of episodes of usage per day was 12, with a maximum of 49, per day. One in 5 had less than 4 episodes per day.
• Users state that 2/3 would use it again, 4 out of 5 users would pay to use it and 40% would make a special trip t use it.
• ¾ of the respondents found some useful information and 95% thought the kiosk easy to use.
• Location of the kiosks is key to their success and increased usage.

Kiosks placed in accessible places do increase accessibility to information for younger people who would not otherwise seek it and for older people who do not have access to the internet or interactive TV.

Professor David Nicholas led a study in 2003 for NHS Direct on the location of kiosks and his research found ‘the most used kiosks were at docks at which 173 page views a day were recorded. Out of 16 different sites the kiosks showing the lowest usage were screens in Community Voluntary Service organizations, Citizens Advice Bureau and youth centres.

The study concludes that the surprising results can, “in part be attributed to the number of people passing through each location,” but also accepts that this might not be the only factor. Anonymity and privacy might also be important.

There were also differences in the time that users spent on the screens. In terms of page viewing time, the page on losing weight was viewed for the longest time, followed by the page on itchy rashes and adult chest pains. These three pages were each viewed for longer than half a minute.

These findings undermine theories that kiosks need to be in health environments to maximize their use and value.

Clearly more research is needed to ensure that kiosks are optimally positioned, and that the information available is clear and relevant according to the location and user requirements, in order to make best use of this method of health information delivery.

Satellite Television

On Dec 16^th, 2004 NHS Direct Interactive was launched and available to digital television subscribers.

The report on BBC quoted the Health Secretary John Reid

"For the first time ever, people will be able to access NHS accredited information through their television sets.

"Some seven and a half million households have digital satellite TV, so this will be one of the biggest digital television interactive services in the world, dramatically increasing access to health information and advice through people's televisions."

He added: "The public have told us they want easy access to high quality information so they can make their own choices about their health and healthcare."

Initial reports stated that £5 million per year will be invested for the next three years in NHS Direct Interactive, which will cover the cost of running the service across all the main digital TV platforms. This amounts to roughly 10p per year for each person in the country (or about 20p per current digital TV viewer per year).

The internet, touch screen kiosks and interactive TV are different ditribution mediums for similar information; all aimed at broadening the spread and availability of health care information to the British public. Due to the methods of aquiring the information, the outlets reach different sectors of the community.

The kiosks provide anonymity to the user, who may not have internet access or skills. The internet user has the convenience of being able to call up medical information, book appointments, etc 24/7 from their own home, as do users of the interactive TV.

There are no overall costs readily available of the total cost of technology based services run by NHS Direct to date. However, the costs of technologically based services are expensive to implement and carry high overheads to maintain and upgrade.

Total costs for NHS Direct (NHS Direct Business Plan 2005-2006) show the following expenditure projections for the current accounting period (figures exclude capital charges)

Expenditure Projection 2005/6	Pounds Mill
Pay	96.5
Non-Pay	54.5
Reserves	14.6