Examination of Witnesses (Questions 80-97)
MR NIGEL CRISP AND MR PAUL JENKINS
WEDNESDAY 6 FEBRUARY 2002
80. I note what the Report says about those contracts and I was delighted to see that that was in place. If I can switch tack now and refer you, again, to Figure 5, just to ask you, what peak-flow management you have in place? This is relating to the remarks that my colleague Mr Williams asked.
(Mr Jenkins) We have a range of things. First of all, we have a routine programme of looking to forecast the amount of traffic that will come into NHS Direct and doing our best to roster staff accurately against that we are in the process of investing in a more sophisticated computer-based capacity forecasting and rostering system that will make that a lot more sensitive and allow us to mull round the variations in calls. The system that I described earlier about being able to route calls to the next available person will also be very powerful in busy times, just being able to shave off the marginal seconds here and there in terms of making the best use of staff. The other things we would been looking to do, which are now a lot easier that we are all operating on one support system, is we are can do some very detailed analysis of our processes and look, particularly where they are supported by IT, to see if you, for instance, gave a drop down menu instead of having to get the nurse to type something, would that shave 30 seconds off the call. The beauty about this is if you multiply that across millions of calls then you have large savings in efficiency.
81. Specifically, you will know, that the electricity web predicts its surge times, its peak times very much in line with television schedules. I wonder if have you noticed any particular surge after Casualty.
(Mr Jenkins) Yes. Not necessarily after Casualty.
Mr Gardiner: Hypochondriac times.
Chairman: Or after PAC hearings!
(Mr Jenkins) Anecdotally during the World Cup there was a noticeable surge of calls after particular games had finished or before they started.
82. Right. Trying to make the same point a bit more seriously, can you tell us what profiling has been done to predict with real specificity the peak times that you anticipate?
(Mr Jenkins) There are two things. In a very general way there is quite an established pattern of demand. The evenings during the week, the weekends of the week and the mornings of the rest of the weekend days are our busiest times. On bank holidays we are usually one or two times busier than we are on a normal day. This new more sophisticated system for forecasting and rostering will allow us to take that down from hours to minutes. The other thing that has a big influence on demand is illness. We invested in a programme of tracking symptoms, like flu-like symptoms, that will have an impact on our demand but will also have an impact on the rest of the NHS. We feed NHS Direct's data about flu symptoms as one of the variety of indicators that help the rest of the NHS decide what pressures there will be during the winter. This winter we were very accurately able to understand what sort of Christmas period we were going to have two or three weeks beforehand in terms of the way that that flu indicator was going.
Mr Gardiner: Thank you very much.
83. Like other members of the committee can I congratulate you on the way this has been implemented. I hope people throughout the NHS and indeed other public services can introduce this because it has obviously been extremely efficient. Like everyone else can I put my comments now in that context. I am a little bit concerned that the NHS Direct, as I understand from this Report, emerged out of the Chief Medical Officer's Report into emergency services as a way of alleviating pressure on emergency services but that that clear role has become much more profuse. I wonder if you would comment on the workshop that the NAO organises, this is paragraph 1.32 on page 9, of NHS Direct staff. One of the things they found was that this workshop, the people who work in the service, found the objectives lack clarity and measurability and leave some uncertainty about the role of NHS Direct. They make explicit reference to NHS Direct and a wider NHS, and so on, could you say something about that?
(Mr Crisp) Let me make one comment. This is an exact reflection of the fact there are a lot of possibilities here and we are starting to explore a number of different issues. This NAO Report very accurately reflects the fact that we are now at a point where we need to make a number of significant strategic decisions about where we go from now, having established the basic service.
(Mr Jenkins) Two things, one very direct follow-on from that workshop was a programme of work which we have nearly completed to develop a more comprehensive performance, measurement and management framework within NHS Direct, which was an attempt to understand responsibilities at different levels of the organisation but also the varying things that NHS are responsible for, like clinical safety, access, impact on the rest of the NHS fitted together so that both staff and the senior management of the service had a clearer idea of how things fitted together. The other point I would echo is that this is very much the time to say these are the priorities for NHS Direct, certainly in terms of what is delivered consistently as a national service. I think it is noticeable that instead of NHS announcements being made as an announcement in NHS Direct they are now imbedded in wider strategy documents, like the one that was published last October round reforming emergency care, saying how will NHS Direct play a role in our attempts to reform wider access to emergency care or as part of a wider strategy or the provision of the GP out-of-hours services. That is exactly right, not to see NHS Direct as an end in itself, but to see it as an agent for wider change within the Health Service.
84. Thank you for that. On paragraph 3.17 on page 23 there is a whole lists of local initiatives NHS Direct sites have undertaken. I wonder if I can go through each one, I will skip the patient waiting list, because I have a bee in my bonnet about that, and I will go on to number two, which is, "reminding patients about out-patient clinic appointments in the North West", which is an area I represent. That is a great idea. We know that that it is a big problem if people do not turn up for operations and appointments. Is that really something that NHS Direct should be doing?
(Mr Jenkins) It is going back to saying that if you have a call centre infrastructure there are lots of things you are can deliver from that infrastructure. If you recognise the profile of our demand we have to equip our call centres to deal with the Sunday morning surge of calls, which means on Tuesday mornings there are a significant number of spare desks and spare computers that can be used to deliver some of these other services. Instead of hospitals having to set up their own call centres, their own facilities, there is already an infrastructure and expertise to deliver that kind of service.
85. Another one, "Working with social services to provide robust support to child protection initiatives". Can you tell me something about that?
(Mr Jenkins) Again, there are a there number of services that we have done working with social services, again using the infrastructure that is available to us. One thing to highlight as well is on a national level we have been working with the setting up of the new Care Direct service which is designed to provide a range of information and advice to older people round the spectrum of issues that concern that population. Instead of re-inventing the wheel those calls are initially routed to NHS Direct call centres, answered as Care Direct but by NHS Direct staff with the appropriate training. I think there are two benefits to the wider public good there, one, is we are making good use of existing infrastructure but, secondly, an opportunity to actually create a seamless way into health and social care problems. As we all know for older people in particular health and social issues are often confused.
86. These are all very good things. My concern is that the Permanent Secretary, Mr Crisp, is going to start saying, we are great, we have this giant switchboard for the NHS, and your service is going to lose the focus of its original function because obviously the Permanent Secretary will be looking for efficiency savings. Perhaps I can ask both of you whether you think that is a risk. Mr Jenkins first.
(Mr Jenkins) I think the answer to it is that we have to have a very clear remit about what we provide as a core service, people contacting NHS Direct. I think, as we have tried to say today, that is about people who contact us on the 0845 number, the integration, the GP service link with ambulances and other emergency care services. We must not do anything else that compromises the quality or efficiency of that core service if there is the infrastructure and expertise available to do other things, particularly things you may want to do in one place and not do in another place. They are not so much a priority as long as we have some clear rules of how that is organised and clear ways of managing poor service. I think that is going to be a good investment for the NHS.
(Mr Crisp) Can I make two points. These are questions, as you can imagine, that within the management process we also ask. Firstly, the point here about getting absolutely clear what the strategy is right at this point. We need to have a core business and let us be clear how else we are using it. Then the question I have asked about NHS Direct is how big can it get? What is the scalability? What size can we grow it? It is already the largest such service in the world, having grown from nothing to 120,000 calls a week. We have now got a strategy for expansion which allows us to see how much their capacity we think we can handle within our current infrastructure. We are having some decisions about what that is so when we look at the bigger strategy picture, if there is some spare capacity here, we can decide what we should use it for.
87. You are not going to allow Mr Jenkins' excellent operation to be turned into a giant switch-board for hospitals reminding people about operations and so on?
(Mr Crisp) We need to have value-added services. Which are the things that will work? I think this out-of-hours issue and the very clear evidence that is coming through that it is reducing GPs' workload is a very important benefit to the NHS. Let's get a cost-benefit approach here. This takes us back to some of the earlier discussion about the waiting times, the points the Chairman introduced, let's not let these standards slip by turning ourselves into something different that we cannot do.
88. A related issue, obviously if there is a confusion within the rest of the Health Service about the role of NHS Direct, that might impair good relations between NHS Direct and local services. One of the disappointing things in the Report, I am looking here at paragraph 3.5, page 19, is where it says: "NHS Direct has to date only reached its desired state of integrated service delivery with a few health care providers in a few locations." In other words, the integration with local health care providers is not quite as it should be. Do you see that as a problem that you are working on?
(Mr Jenkins) I would see it as a problem if it continued to be the case. I think as the new kid on the block it is very hard, especially when you are a service like NHS Direct that sits in the middle of virtually everything, to make contacts and build relationships with every other part of the system within a short period of time. I am now confident that that relationship is getting much more well-established and people are seeing NHS Direct as an established bit of the furniture and understanding what it can offer. It is something we continue to need to work on.
89. Are you going to hit your March 2002 target of integrating with providers of out-of-hours services covering ten million people?
(Mr Jenkins) Yes.
90. You have only got a month. Is that the beginning of March or the end of March?
(Mr Jenkins) Those plans are in hand. It may be that some of them, because of the timing of Easter this year, happen just the other side of Easter which is on the cusp of March and April, but yes, in essence.
91. What about the integration with emergency services which, as I said at the beginning, was the original inspiration for this.
(Mr Jenkins) We already handle advice calls to a significant number of hospitals and some of these schemes have been evaluated and it suggests that it saves two whole-time equivalent nurses in those A&E departments, who are now seeing patients rather than answering the phone. We are keen to encourage that service in particular to become, if not the norm, the case in a large number of hospitals. One of the other ways that we are looking to integrate is through the decision support computer system that has been purchased for NHS Direct, which is already being piloted in a number of face-to-face settings. If the principle of this (which is that it helps you make safe, consistent clinical decisions) works in telephone advice, it could equally work elsewhere. We have a commitment to pilot the system in 25 A&E departments. We also have pilots in walk-in centres and in one primary care trust in GPs' surgeries. NHS Direct can integrate with emergency services not only by doing their work but also by exporting some of its techniques and approaches to other settings where they are likely to have benefit.
92. If I can in the last couple of minutes available to me pick up on something that Mr Gibb was asking about which was about the rotation of staff through NHS Direct working in the local NHS. You said that it was a good idea and the sort of thing you tried to encourage. It is not something you require, is it, yet? Is there a danger that people who just work on the phone and do not go into hospitals regularly will lose their clinical experience or lose their hands-on feel for health issues?
(Mr Jenkins) I do not think we feel that in any absolute sense. There is no evidence that those who have worked on the phones for two or three years in some of the more well-established sites are any worse than peoplewe are talking in all cases here about people who have got a significant amount of previous experience of working in a range of settings. One of the things we also find about the call centres is that they are quite a powerful school in a way. You are bringing together nurses from a very wide range of backgrounds, mental health nurses, A&E nurses, primary care nurses, people who in the normal course of work would not interact with each other. I think they have a great opportunity to learn from each other. If you go into one of our call centres you will see a lot of informal consultation about particular calls between people from different nursing disciplines.
93. One of the thingsit may have changedthat nurses said to me a couple of years ago was that the NHS in general has not been a terribly good family-friendly employer, to use the jargon. Mothers who want to work part time have not always found it easy to come back as a nurse. Are you setting an example to the rest of NHS about being a family-friendly employer?
(Mr Jenkins) I would hope so. There are things that we are uniquely able to offer because we are able to offer work at all times of the day and night and can mould that around people's particular circumstances. So I think there are a lot of people who work for us who choose particular types of shifts because that fits into family commitments. One constraint on the service which we have to be up front up about is that because our demand is very skewed towards the out-of-hours period, we do need a lot of staff to work at the weekends and evening periods. You cannot compromise on that because that is when the callers and the public need us.
(Mr Crisp) I think NHS Direct exemplifies quite a lot of things about how we need to change the NHS. The use of technology, the flexibility, the getting directly to people, and the notion that people will ring you back seem to be very important points. On this other point about flexibility of bringing staff in, in fact, there are a number of people working in NHS Direct centres who would not be able to work in other sorts of centres in the NHS as nurses and bring their experience to play. There are a lot of lessons that we can learn about how you do something like this and make really quite substantial change.
94. Thank you very much. There are a few questions coming from Members. The 0845 number is charged at local rates. Does the NHS receive any income from this number? If yes, how much? If not, why not?
(Mr Jenkins) We do not. Because an 0845 number is a way of balancing between local call charges and trunk call charges, we have to pay a premium to use that number, although because of our volumes at a considerable discount to other users.
95. Thank you for that. In the brief provided to us helpfully by the C&AG, it tells us: "Early experience has shown that integration of NHS Direct with providers of GP services outside normal working hours is already yielding reductions in workload for GPs. There have, however, been some teething problems in achieving integrated working, including the incompatibility of information technology". What is being done to remedy this? What is the timescale? In other parts of the public services this has been a serious problem such as the Police, I am told.
(Mr Jenkins) Effectively, the problem has been cracked in that for the range of site integrations rolled out this autumn we now have a standard way of communicating between our decision support system and the IT systems that GP out-of hours providers use. There are still some small issues about ironing that out, but in essence that is a question of fixing rather than new development.
96. If, as we know, there is a message read to you, how will this work when NHS Direct calls are brought together with 999 calls? You do not want to delay people with a message.
(Mr Jenkins) If we are taking a call that has come in on 999 there is an exemption of the confidentiality message or any other kind of message; they will get straight through.
97. Arising from Mr Williams' example of the man living alone who calls at 11.30 and is given advice and dies the next morning, I do not understand how the information gets back. If you are given wrong advice by a GP, if you go to your GP with a lump and he says it is nothing, immediately the family starts realising there is something wrong. I do not see how you correlate this information. You mention that you get all the information back from the information service. This chap is not going to complain. Unless families actually complain that the advice was wrong, how do you know about it?
(Mr Jenkins) If anybodyfamily, GPpicks up that the person has been in contact with NHS Direct (without any implication that the advice was wrong or right) and raises that with them, we will track that down and will treat that as a potential adverse event.
(Mr Crisp) In that particular case maybe one would never know that he had rung NHS Direct, which is no doubt why he chose it.
Chairman: I just wanted to thank you and perhaps, as we are being broadcast, we should ourselves publicise the number of this excellent service0845 4647. Certainly, as I have said, I have personally found them very helpful indeed. May I thank you for the way you have given your evidence. We expect that from the Permanent Secretary However, I hope I speak for my Committee when I say, Mr Jenkins, how particularly impressive we have found your performance. You are knowledgeable, competent, articulate and open with us. That is very impressive. Perhaps it comes from being in charge of the project for five years and perhaps the rest of Whitehall will take note. Thank you very much.