Impact of NHS Direct on demand for immediate care: observational study
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7254.150 (Published 15 July 2000) Cite this as: BMJ 2000;321:150
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Editor - The recent study by Munro et al 1 found that NHS Direct had
no discernible effect on the use of emergency ambulances or accident &
emergency departments after the first year, leading to a suggestion that
this service may not prove cost effective. However this study is limited
by an assumption that the population studied had complete awareness of the
service. Indeed six months after the introduction of East Midlands NHS
Direct, we had anecdotal evidence to suggest that many patients attending
our accident & emergency department were unaware of the telephone-
advisory service.
Consequently we undertook a NHS Direct 'awareness' survey of 300
consecutive ambulatory patients (or their parents), who self-referred to
the accident & emergency department, and who had not contacted NHS
Direct. 266 (88%) questionnaires were completed with 166 (62%) patients
claiming to have had no previous awareness of NHS Direct. Furthermore of
the 100 patients who were aware of the service only 36% were aware of the
telephone charge whilst 51% of patients thought that calls were taken by
doctors. Only 8% of 'aware' patients however said they would distrust
advice given by a nurse, a finding that supports the study by O'Cathain et
al 2.
The survey also determined which sections of the community were unaware of
NHS Direct. Patients over 65 years of age (100%), patients from ethnic
minorities (70%), patients from predominantly less affluent post-codes
(78%), and young men (71%) were over-represented. The survey also
revealed that 90% of patients claim to have access to a telephone and that
21% of patients may have been potentially redirected away from our
department by NHS Direct.
In light of these findings it is our assertion that NHS Direct has failed
to market its existence to those members of the community who frequently
access urgent health care. Consequently the results of NHS Direct
'impact' studies to date are confounded by this oversight. Whether a
proper national publicity campaign can improve the impact of this
beleaguered service, remains to be seen.
1. Munro J, Nicholl J, O'Cathain A, Knowles E. Impact of NHS Direct
on demand for immediate care: observational study. BMJ 2000; 321:150-3
2. O'Cathain A, Munro J, Nicholl J, Knowles E. How helpful is NHS
Direct? Postal survey of callers. BMJ 2000; 320:1035
John McInerney
Specialist Registrar
Shekhar Chillala
Specialist Registrar
Colin Read
Specialist Registrar
Adrian Evans
Consultant
Accident & Emergency department, The Leicester Royal Infirmary,
Leicester LE1 5WW
Competing interests: No competing interests
Dear Editor
In his eletter response to our study of the impact of NHS Direct on
demand for immediate care, Dr Harper suggests that the results "come from
a department closely involved in the scheme, and therefore not entirely
free from conflicts of interest".
This suggestion is entirely unfounded. The research team's
relationship to NHS Direct extends only to evaluating it, and
communicating the findings as clearly and fairly as we are able. We have
no vested interest in the service's success or failure. I would
characterise our attitude to NHS Direct as one of "sympathetic
scepticism".
James Munro
Competing interests: No competing interests
Dear Sir,
In the recent article on the impact of the NHS Direct telephone
advice service on demand for immediate care (1) I was disappointed to see
that for nearly 70 000 calls, there was no impact on either attendances to
accident and emergency departments or ambulance services. The only
significant change was a marginal fall in the number of out of hour GP
consultations. Both in this study and in one into the patient satisfaction
with the service (2) approximately two thirds of the patients were advised
to contact either their GP or emergency services. The patients in this
latter study did report feeling reassured by the advice they received. The
articles have also come from a department closely involved in the scheme,
and therefore not entirely free from conflicts of interest in the
presentation of their findings.
The NHS direct was established to provide easy access to experienced
medical advice, with the aim of reducing unnecessary workload, in
particular for the emergency services. There has been significant
political backing for the project, as well as a large financial
investment. Given the findings, it seems a shame that the investment on
the project was not used to improve the current pre-existing services,
whereby patients can get advice and reassurance from medical staff who
would (ideally) have access to patient records. Whether or not there would
be a niche for a telephone advice service from the private sector is
another issue.
The authors state, on the one hand, that the service does not simply
represent an “extra step” for people to access medical services. On the
other, they state that the service “had little impact on the demand for
urgent health care.” Maybe things will change with time, but for the time
being the evidence seems to suggest that the NHS Direct is just another
step.
Yours faithfully,
Dr Adam Harper MBBS MRCP
1. Munroe J, Nicholl J, O’Cathain A, Knowles E. Impact of NHS Direct
on demand for immediate care: observational study. BMJ 2000;321:150-153
2. O’Cathain A, Munroe JF, Nicholl JP, , Knowles E. How helpful is
NHS Direct? Postal survey of callers. BMJ 2000; 320;1035
Competing interests - none.
Competing interests: No competing interests
Impact of NHS Direct on demand for immediate care.
Dear Sir - In their responses to the paper by Munro et al (1), who
found that NHS Direct had no significant impact on the use of ambulance
services and A&E departments, McInerney et al (2) and Lawson et al (3)
addressed two important
points: do the patients know about NHS Direct; and does NHS Direct make
any difference to the use of emergency services anyway? At the moment,
the answer to both questions sadly seems to be "No".
We are studying consultations with our out-of-hours GP co-operative
(Bridgwater Out-of-hours and Night Emergency Service: BONES), comparing
the outcomes for two groups of patients who have called our service: those
who have previously contacted NHS Direct about their problem, and those
who have not.
Preliminary results show that, of the 1153 consultations with BONES over
four weeks in October, in 1005 cases (87%) the patients said they had not
tried NHS Direct. We had a similar number of contacts over the same
period in
1997, before NHS Direct became operational, so even if NHS Direct is
preventing a small upward trend in out-of-hours calls (1), the fact
remains that the majority of patients do not use NHS Direct.
But would it make any difference to the outcome if they did? The purpose
of NHS Direct is to deal effectively with problems that can be dealt with
on the telephone, and pass on to the emergency services those problems
which are
likely to need some kind of intervention. Therefore, those who call NHS
Direct and then consult the emergency services should end up needing more
face-to-face consultations, on-the-spot treatment, visits and hospital
admissions, and fewer consultations by telephone alone.
On the contrary, we found that 53% of the problems that had already been
presented to NHS Direct could still be dealt with over the telephone by
BONES, compared with 47% of those which had not involved NHS Direct.
Furthermore, the NHS Direct callers ended up needing fewer treatments or
hospital admissions.
NHS Direct has the potential to alleviate some of the increasing demands
on primary care, both in- and out-of-hours, but if the government wants it
to be
useful it must be better marketed and must deal more effectively with the
problems presented to it.
Peter Aird, GP
Paul Hansford, GP
Richard O'Brien, GP:
Elizabeth Parfitt, research co-ordinator
Hilary Swindall, GP
East Quay Medical Centre, Bridgwater, Somerset TA6 5YB
(1) Munro J, Nicholl J, O'Cathain A, Knowles E. Impact of NHS Direct
on demand for immediate care: observational study. BMJ 2000;321:150-3.
(15 July.)
(2) McInerney J, Chillala S, Read C, Evans A. Target communities
show poor awareness of NHS Direct. BMJ 2000;321:1077. (28 October.)
(3) Lawson G, Furness J, Santosh S, Armstrong S. BMJ 2000;321:1077.
(28 October.)
Competing interests: No competing interests