NHS Direct

HL Deb 02 February 1999 vol 596 cc1436-45

4.16 p.m.

Baroness Hayman

My Lords, with the leave of the House I shall now repeat a Statement being made in another place by my right honourable friend the Secretary of State for Health. The Statement is as follows:

"Madam Speaker, I wish to make a Statement on the development of NHS Direct; the nurse-led 24-hour helpline.

"In March last year we launched three NHS Direct pilot schemes in Milton Keynes, Preston and Newcastle upon Tyne. Between them these pilot schemes covered over 1.5 million people. They have proved a great success. Up to the end of December they had taken over 60,000 calls. Independent research has revealed that 97 per cent. of users are satisfied with the service provided, which they find prompt, friendly and professional. It has been particularly popular with young mothers and around 40 per cent. of calls have been about children.

"Callers get through at first to a call handler who takes the callers' details and deals with any requests for basic information. Those callers who have a specific health problem are then put through to a nurse.

"The nurse listens to the caller, assesses the case, using what is called an expert computer based decision support system, and then recommends what action the caller should take. This can range from immediately summoning an emergency ambulance to advising them to visit their GP or their accident and emergency department, or advice on how to treat someone at home, or just offering simple reassurance.

"A detailed survey of the three pilots showed that for the latest quarter: 80 per cent. of callers were advised to do something different from what they had intended before they rang NHS Direct; only 9 per cent. of callers had intended to look after themselves at home, but after calling NHS Direct 38 per cent. were enabled to look after themselves at home; 20 per cent. of callers were directed to more urgent care and 40 per cent. to less urgent care; and 530 people were transferred to the 999 service.

"It rapidly became clear that the pilot schemes were a success. So last summer I authorised the extension of the scheme with 13 call centres to cover 40 per cent. of the country—20 million people—by April this year. The first of these opened last month covering 1.1 million people in the Black Country. Yesterday, a further scheme covering 1.6 million people opened in Essex. A further service covering Nottinghamshire opens next week and the first service in London opens in parts of West London early in March.

"The other areas to be covered by April are in the West Country, Manchester, West Yorkshire, Hull and East Yorkshire, Hampshire, North West Lancashire, Birmingham (as well as the Black Country), Lambeth, Southwark and Lewisham, Buckinghamshire, Northamptonshire and Oxford, Newcastle and the North East. Most of those services will be provided by the local ambulance trust but they usually involve the local GP co-operatives, other NHS trusts and voluntary bodies. In some cases local social services are involved as well.

"The success of NHS Direct springs partly from the use of modern technology, properly managed and staffed by top quality professionals with a sympathetic ear. It also depends on commanding the support of the NHS in each locality and in particular the professions involved in providing primary care. At my personal insistence there will be a major role for GP co-operatives in the delivery of this service in many parts of the country. I am pleased to be able to report that the west London call centre to be located in Southall will be run by a local GP co-operative.

"Our original intention was to extend NHS Direct to cover 60 per cent. of the country by April next year. However in view of its growing success and my concern to help the NHS cope with the special problems it is likely to encounter over the millennium period at the turn of the year, I have decided that this programme should be brought forward to aim to cover at least 60 per cent. of the country by the beginning of December this year. In some cases this will be achieved through extensions to the existing centres where the service is well established and in others through opening new centres.

"It is intended to cover South Yorkshire, Leicestershire, Derbyshire, Liverpool and parts of London, in all of which NHS Direct could be particularly valuable next winter. To do this we will be investing from the NHS Modernisation Fund an additional £10 million on top of the £44 million from the fund already committed to the NHS Direct in the coming financial year.

"NHS Direct is proving to be a modern, additional, convenient and dependable service for the people who turn to it. It is also proving to be a very popular and professionally satisfying service with the nurses who staff it. One centre recently received over 300 applications for 50 jobs. Nurses applying for jobs with NHS Direct have been coming from other parts of the NHS, from the private sector, and others are returning to nursing. With the support of the Royal College of Nursing and Unison I am very keen to encourage applications from experienced nurses who have left nursing because of, say, a back injury which left them unable to carry out routine nursing tasks. Working in NHS Direct could give them the opportunity to continue to put their hard-won professional skills and experience to good use for the benefit of patients.

"The new schemes should provide the basic NHS Direct advice and information service which has proved so successful in the three pilot areas—Newcastle, Preston and Milton Keynes. However, I should report that from July the Newcastle centre will be working with local doctors, A&E departments and other services to provide one gateway for out-of-hours services, providing a single number for patients to call. This idea shows the huge potential for using NHS Direct to develop new and better services for patients in a way that is also popular with the professionals involved. Building on the experience of this pilot I will be prepared to consider further pilots of this kind where NHS Direct has shown it can deliver the basic service and where there is joint commitment by both NHS Direct and the local doctors and other professionals involved to deliver services in this way.

"Arrangements are now being made to set performance standards for NHS Direct call centres drawing on careful evaluation of experience so far and on best practice in other sectors. We are also determined to use the capacity of a national network we are creating to provide the most dependable service. NHS Direct is a good example of the opportunities which new technology offers to help make the best possible use of the professional skill and knowledge of NHS staff—21st century technology in place for the beginning of the new century.

"I am pleased with the success of NHS Direct; delighted that it can be funded from the extra £21 billion we have found to invest in the health service, and glad to have been able to announce today that 60 per cent. of the country should have access to NHS Direct by December this year".

My Lords, that concludes the Statement.

4.24 p.m.

Earl Howe

My Lords, I shall be brief. First, I thank the Minister for repeating the Statement. From these Benches we believe that much of what it contains is positive and we give it a general welcome. I particularly welcome the fact that so many people availed themselves of the service plus the news that, against a background of fragile morale in the nursing profession, NHS Direct is attracting nurses out of retirement and that those who staff the service find it a professionally satisfying job. Long may that continue.

The debate of my noble friend Lord Rowallan in your Lordships' House last November on health service helplines enabled the Minister to apprise us of the background to the Government's thinking on NHS Direct and I do not intend therefore to go over the same ground again. However, the Statement gives rise to a few important questions.

One of my main concerns centres around the evaluation of the service. The Government took the decision last summer to proceed with the second wave of pilots and now we learn that the third stage of the programme is to be brought forward so as to commence later this year. That seems to be a rapid roll out. The Statement referred to a survey of the first stage pilot areas during the latest quarter. I was hoping to glean from that survey something in the nature of an evidence base on which a balanced judgment could be made in relation to the scheme's success. That is not what we have been given. It is one thing to discover that 80 per cent. of callers were advised to do something different from what they had intended to do before ringing up, but a more pertinent question might be: was the advice that they were given the right advice? Of the 530 people transferred to the 999 service, how many turned out to be genuine emergencies? Only with that sort of information and evaluation can a proper assessment be made of the cost-effectiveness of NHS Direct. It was therefore a little surprising to hear that Ministers have already felt able to judge the pilot schemes a success.

My other main concern relates to nurses. The key to success for NHS Direct is thorough and appropriate nurse training. Manning a helpline is a specialist skill. Can the Minister say anything about the training that nurses receive for NHS Direct? How rigidly is a nurse dependent on the computer-based protocol? Are the Government happy that the computer-based system can be relied on with confidence by nurses and patients? Also, can the Minister say what proportion of nurses appointed to NHS Direct come from other parts of the NHS? At a time of national nurse shortages there must be a worry if NHS Direct is sucking in trained nurses from areas that are already under considerable pressure.

I strongly agree with the need for NHS Direct to command support from the wider NHS in each locality and indeed from the professionals who deliver primary care—a point that I stressed in the debate last November. Perhaps I can ask about the procedural links between NHS Direct and GP practices. If an individual receives advice from the service, is the fact of that call, and the content of that advice given to the individual, automatically notified to the patient's GP?

I understand that in the pilot schemes a number of models have been running. I am aware of anxiety that, while local schemes with nurses based in GP surgeries allow more co-ordination with other primary care services, they are also thought to be less efficient and may be subject to regional variations in standards. On the other hand, national centres, which are viewed as more efficient and lead to more uniform standards, reduce co-ordination with local GPs. Have the Government come to any conclusion as to which scheme they prefer?

NHS Direct, as I said in our debate on the subject of helplines, is a service with considerable potential and we shall follow its development during the course of this year with close interest. We wish it well.

Lord Clement-Jones

My Lords, from these Benches I join the noble Earl in thanking the noble Baroness for repeating the Statement from the other place. We welcome regular updates about NHS Direct, the Government's commitment to bring forward the roll-out of the scheme and the commitment to provide additional resources to do so. However, it is clear that there are a number of concerns which should be expressed in relation to the development of NHS Direct. I have already expressed those concerns to the noble Baroness.

Above all, there is the question of the relationship of NHS Direct to the specialist voluntary sector helplines. Will NHS Direct work alongside those existing helplines? Will it make sure, in addition to its triage role, that optimum cross-referral to specialist services by NHS Direct takes place whether for mental health problems, cancer or asthma?

Furthermore, is the department addressing the question of the quality of service both for NHS Direct and for the voluntary sector? They must operate within the same quality framework. With the advent of NHS Direct, will the department consider some kind of kite-marking or accreditation, perhaps along the lines of the guidelines for good practice in telephone work, drawn up by The Telephone Helpline Association? Will they ensure that those helplines that are of sufficient quality will be able to enter into service-level agreements with NHS Direct to provide specialist information, support and advice on referral?

Do we yet know enough about NHS Direct's effect on primary care services? Will the service build on the primary care experience of general practitioners? Will it build on the extremely successful Wiltshire trial and the University of Southampton research which resulted in a 40 per cent. drop in patients' visits to surgeries, halved GP's out of hours workloads and cut hospital admissions and casualty visits?

Is NHS Direct currently developing draft national guidelines or protocols? Will second-phase pilots be working next year with draft national guidelines?

In a recent Statement, the former health Minister, Alan Milburn, indicated that a national telephone line might be the way of the future. However, the Statement seems to indicate that a single local line for GP surgeries and accidents and emergencies—NHS Direct itself—might be the way forward. Which way is preferred by the department?

When will software systems be rationalised? The first three pilots have used three different software systems.

Reflecting some of the comments by the noble Earl, what are the recruitment implications for NHS Direct? Some estimate that another 15,000 nurses will be needed to provide a full national service. In the face of a major recruitment crisis, with about 12,000 nursing vacancies, will there be enough experienced nurses available to start the service?

Finally, is the December 2000 deadline for the full coverage of the whole country still the department's target, or will it be earlier as a result of bringing forward implementation for 60 per cent. of the country? We welcome the implementation of NHS Direct, but it must not be an over-hasty implementation and it must take into account some of the considerations that we have put forward.

4.32 p.m.

Baroness Hayman

My Lords, I am grateful to the noble Earl and the noble Lord who, overall, have welcomed the announcement today of speedier implementation of national coverage by NHS Direct.

The noble Earl, Lord Howe, commented on the move towards national implementation before the results of the evaluation have been fully understood. There has always been a commitment to a national roll-out. The information that we have received so far has been so positive that we feel confident in speeding up the implementation of the next phase. Sheffield University is conducting a detailed evaluation which will give us some answers to the questions about protocols, national standards and forms of implementation. The first phase of that evaluation will be published soon.

In the developmental process it is important that we go ahead and make changes and carry out improvements to make sure that we have standardisation where appropriate as we move forward. We have clear indications that that is the right thing to do and that it is sensible to cover as much of the country as soon as possible.

I do not want to be drawn by the noble Lord, Lord Clement-Jones, on whether we will be able to bring forward the full coverage implementation date, but we are making considerable progress on the date that we have put in for the 60 per cent. coverage.

I was specifically asked about the training that those involved in providing the service receive. They receive specific and extensive training of six to eight weeks both in using the computer software available and the decision support systems. They also receive training in helpline skills, which is a separate issue. There is increasing evidence on how those skills are developed. We shall consolidate that for the national service.

The question about the quality of the service and the advice given has been raised. We have highly qualified nurses, operating expert clinical decision support systems which have been validated by local clinicians. As we move towards the national service, we shall develop national clinical standards for NHS Direct and national validation processes for the decision support systems. The nurses who give the advice also have on-line access to medical advice should they need something above and beyond their own skills or what is in the decision support mechanisms.

On the balance between national standardisation and local implementation, as with so much else in the NHS, we have to assure ourselves of the quality of the service provided throughout the country. However, we must not do that in so rigid a way that we take away any local sensitivity and the real benefit that knowledge of, for example, local voluntary organisations and local services can bring. That is not an impossible task, but we are moving towards a model with a number of centres rather than a single national centre. The phrase used by the Secretary of State is "horses for courses". There will be variety in the size and coverage of different schemes.

On the nurses who will perform the important role of giving advice, as I said in the Statement, some come from other parts of the NHS, but some are returning to nursing and others come from the private sector. We believe that there will not in any way be an issue of competition with other parts of the NHS. We see valuable opportunities for retaining staff who want a different form of work from that which they have had in the past; a form that provides flexible working opportunities for those who are thinking of returning to nursing, with specific training for this particular role.

As I said earlier, there are opportunities for those who have had to leave conventional nursing because of injury. That is not an insignificant pool of people. I believe that providing a wide range of opportunities for nursing is more likely to increase retention and return-to-work rates than diminish the pool of nurses available across the NHS.

I was specifically asked about the issue of GP notification when patients call NHS Direct. Yes, GPs will be notified, but only after the patient has given his or her permission. We have to recognise the confidentiality issues that may cause some people to prefer to call a telephone helpline in some circumstances.

The noble Lord, Lord Clement-Jones, asked about the inter-relationship with the specialist helplines that already exist in many areas of healthcare. In your Lordships' House we have discussed the specialist helplines in mental health and I know that the noble Lord is particularly interested in the services that BACUP (the British Association of Cancer United Patients) provides for patients with cancer. Perhaps I may repeat that it is certainly not intended that NHS Direct should take over the role of specialist helplines. We want to work with them and to work closely with voluntary sector agencies and their helplines to ensure co-operation and synergy between the two sets of services.

Rather than the two being in competition, I believe that the availability of a well-known central point for telephone inquiries will help to increase the use of specialist helplines, rather than diminish it. I believe that that will be true as long as we ensure that the protocols for referral to the specialist services are correct and that, wherever possible, the technology ensures that a patient does not have to put down the telephone and to call another number. Instead, we should "hotline" patients through to the appropriate specialist service. The Department of Health is conducting consultations with those from that sector, with the NHS Steering Group and with other telephone advice lines. This is to ensure that we work together to provide the most appropriate form of treatment, advice and help for those who call NHS Direct.

We are looking to have a single national telephone number to give people access to NHS Direct. As I said in the Statement, there are opportunities in particular localities to provide an out-of-hours service on a specific local number. As we roll out the service we shall have to work out the specific details.

4.41 p.m.

Baroness Gardner of Parkes

My Lords, I welcome the new NHS Direct. However, perhaps I may put a number of practical questions to the Minister. First, legal liability is now becoming a major issue in the health service. Who will be legally liable if a patient is given the wrong advice? How will we be able to differentiate between whether the patient was genuinely given the wrong advice or is fraudulently claiming to have been give the wrong advice?

Will the patients be identified? If you telephone an insurance company, you are given a warning that your call is being recorded. If you telephone a bank, you have to identify yourself in some way. What will patients have to do? How can we reconcile a patient having to identify himself with the position of a patient who wants to call anonymously, perhaps with regard to HIV? Has the Minister thought about that? If not, will the Government give some thought to it? I believe that one day such a case will go wrong, just as we hear about with regard to ambulance trusts, and it will be claimed that the patient died because the wrong advice was given. Will the general practice carry that responsibility or will the responsibility be carried centrally? Exactly where will that responsibility lie?

The Minister said that it is hoped to operate national clinical standards and that nurses will be able to call for expert advice if needed. How will a nurse know when she needs expert advice? Surely that will be extremely difficult to decide when talking to a patient over the telephone as opposed to actually seeing the patient. Perhaps that is an issue for training.

I note from the Minister's answers that NHS Direct is to be a 24-hour service. The Minister mentioned the possibility of a national number. Will it be an 0800 number or an 0345 number, which means the patients will be charged at local rates? Presumably, the number will be widely publicised, but will the Minister confirm that?

As I said, I am pleased to hear about NHS Direct. My final question is: how many human beings will be available to answer telephone lines at any one time? If the Minister, like me, has tried to telephone a phone-in line, she will know that trying to get through for a long time can be very frustrating. One has very little hope of getting through, but when one does one is often greeted by an answering machine saying that there is a queuing system. Will there be a queuing system for NHS Direct?

Baroness Hayman

My Lords, in the interests of publicising the number widely, perhaps I may tell your Lordships that it is 0845 4647. We hope that that number will become well known and well recognised.

The noble Baroness made a number of important points. She is right that the issue of legal liability affects the whole of the NHS. NHS Direct will be staffed by employees of NHS bodies with exactly the same legal liabilities as any other NHS staff. Situations analogous to that outlined by the noble Baroness can happen with ambulance trusts or general practitioners. Such cases have to be decided on the facts. Calls will be recorded, as will decisions under the decision support systems. In fact, there is a lot more back-up in terms of hard evidence of what has been done and advised than was the case in many of the paper records that were kept—or perhaps not kept—in the past.

The noble Baroness asked about how a nurse at the end of a telephone can tell whether she needs further professional advice. That is difficult. Giving advice over the telephone, rather than face to face, is a skill. Many of the expert and specialist helplines have had to come to terms with that. Against the disadvantage of not seeing a patient face to face must be set the fact that the decision support systems and the software are very impressive in terms of prompting people to ask the right questions and to give validated advice following the answers to those questions.

I cannot give the noble Baroness any information now about the number of people answering the telephones. Perhaps I may write to her on that point. However, I do not think that there have been problems with queuing systems so far. Matching supply and demand is difficult. We shall have to consider that matter carefully over the Christmas and New Year period this year because last year calls to the pilot centres were up by nearly 100 per cent. That in itself is evidence of how valuable they have been. A large proportion of callers had 'flu symptoms and a large proportion of them were advised to stay at home and self-treat. One can see that that presents opportunities. The pilot schemes had the capacity to deal with those calls without becoming overwhelmed, but we shall have to consider that issue carefully.

Baroness Pitkeathley

My Lords, does my noble friend agree that we should not overlook the part of the Statement referring to simple reassurance? I know from my own experience of running helplines for carers and people with disabilities that very often that is precisely what they need. Calls are not about emergencies or practicalities, but about the need for reassurance. We should constantly emphasise that fact.

Baroness Hayman

My Lords, my noble friend is absolutely right and speaks from detailed experience in this area. This is not merely, as it has sometimes simplistically been presented, a way of persuading people not to go to hospital. Indeed, if hospital is where they should be, many have found that the process has been speeded up. Frankly, nobody is better off for taking a sick child out and waiting for several hours (because they are not high priority) in an accident and emergency department when they could instead be receiving advice and reassurance in their own home, through the telephone, and thus better and more effective care for that child.

Lord Skelmersdale

My Lords, I find this a very exciting innovation and an extra avenue into primary care. NHS Direct consists of what I call in my own mind "telephonic triage nurses". I believe that that is basically a fair analogy. I note that in the trial areas NHS Direct has resulted in a 40 per cent. drop in visits to GP surgeries. However, I have one slight niggle. I hope that the noble Baroness will be able to give a commitment now that when patients telephone their own surgeries, they are not asked whether they have first telephoned NHS Direct, with the result that if they have not, they will be turned down for the surgery. It is very important that the Minister and her department should express this as an extra service within the NHS rather than a replacement service.

Baroness Hayman

My Lords, as regards any patients in the pilot areas ringing up their general practitioners asking for consultation, it is certainly not my understanding that they would be told that there was an additional and separate loop for them to go through; namely, ringing NHS Direct. That is not my understanding of what would or should happen. However, if I am wrong in that respect I shall write to the noble Lord when I have checked the position. As the noble Lord said, it is an additional service. It may well be a substitute in that people find it a more appropriate service, but that should be a matter of their choice because they have chosen to go there.

I very much welcome what the noble Lord said about the service. The only thing on which I would semantically niggle with him is the fact that, although it is triage in one sense, it is not the classic triage because the appropriate advice will be given. There are also opportunities for the future in that other things may be accessed through NHS Direct; as, indeed, ambulances are now being accessed for those who ring up with, perhaps, chest pains thinking that they can see it through until the morning. In such a situation the NHS Direct nurse would think "no", and send an ambulance immediately.