Examination of Witnesses (Questions 40-59)
MR NIGEL CRISP AND MR PAUL JENKINS
WEDNESDAY 6 FEBRUARY 2002
(Mr Jenkins) Whenever a patient has been in recent contact with NHS Direct and an adverse event happens to them afterwards, that can be anything up to 24 hours after the advice.
41. What mechanism is there for ensuring that the quality of advice that has been given is good?
(Mr Jenkins) We use a decision support system. We have national review bodies that look at the clinical content of that system to ensure that it is in line with United Kingdom best practice and those groups have input from the relevant royal colleges.
42. What we are told is sites are required to report adverse events to NHS Direct national advisers. What mechanism is there to ensure that that information is (a) being correctly recorded and (b) that there is a follow up to ensure that something has not happened within, say, two, three or four hours? How is that done so that you can give us the reassurance you have tried to?
(Mr Jenkins) I do not think any clinical service can find out every consequence of its actions. We use all available networks. A lot of our services are connected to the ambulance service so they will provide information from the patient's GP, sometimes from a direct complaint raised by the patient themselves.
43. If Joe Bloggs, living alone with no family, phones at 11.30 at night and is given advice but dies at 6.30 the following morning, is there any way you would know of that?
(Mr Jenkins) If the ambulance service was called out or his doctor was called out or if there was a coroner's investigation after the event.
44. The NAO has looked at this. Are you satisfied that the situation is statistically sound?
(Dr Robertson) Yes. We have looked at the statistics and it is a good safety record. We would not want to say any more than is in the report which is that the system appears to be operating safely.
45. We are told there are certain social groups which do not make as much use of you as they might. It is interesting that although once young people find the availability of the service seem to use it more enthusiastically, the young and the old are two groups that seem less aware of the existence. They make up a big part of the population. Then we are told that in addition the ethnic minorities are less aware and that the less advantaged social groups are less aware. This suggests an epidemic of less awareness, does it not? What are you doing about it?
(Mr Jenkins) The levels of awareness are lower than for the general population but they are not massively lower. We are talking of 10 or 15 per cent. The profile of how awareness of the service has built up as a new health service is not unsurprising because it would follow the trend of adoption of many new things in society. We are now clearer about the groups that we are not reaching. We are doing some very specific marketing targeted at younger people and older people at the national level this year. Our sites continue a rolling programme of contacting voluntary groups and other local agencies to get the message over about the service. Particularly in respect of older people, the awareness and take-up of the service will significantly increase as we integrate with GP out of hours services. People who have an established relationship with their GP probably see that as a natural way of contacting help. They contact NHS Direct and they will then hopefully perceive NHS Direct as a way of dealing with a whole range of problems.
46. I am glad that you have this contract for 200 languages and for translation facilities to be provided. I realise how difficult it must be to determine where to locate what. If I had more time, I would ask you about that. Turning to paragraph 2.41 on page 18, it says there that interpreting facilities have been used sparingly to date, only about 1,000 times during 3.5 million calls. That means there has only been one caller every 3,500 that has needed interpretation, which suggests that you have a very specific communication problem here, far more difficult than getting to the young and the elderly. How are you going to overcome the problem of ethnic awareness of the service?
(Mr Jenkins) It is about communication. We are tackling a range of ways of communicating with the representatives of different ethnic minority communities. It is also about increasing training and awareness amongst our staff and adapting our service to the particular needs of those communities. What I would be arguing is that, while general awareness has grown quickly and the service is popular, we may have some barriers to overcome with some sections of society who are perhaps initially less happy with this method of accessing services. It is a process of two way communication, us communicating what the service can offer to them but also hearing and adapting our services to the requirements of those callers.
Alan Williams: I look forward to an update in a couple of years and I wish you well.
47. This is a great report. NHS Direct is a great idea. If you have food poisoning, it is nice to be told not to eat more food. I would not have known that. When I had food poisoning in my twenties, I had to sit in a disease ridden waiting room for an hour to be told that. How do you ensure that calls are not coming from abroad?
(Mr Jenkins) Because it is an 0845 number, the arrangements bar international calls.
48. What about e-mails from abroad?
(Mr Jenkins) We require some registration information. For instance, being able to give a United Kingdom post code, so we make it clear that we are only offering this service to residents of the United Kingdom.
49. What is the target time for calls being answered by the initial handler?
(Mr Jenkins) We do not set a specific target for that. We measure people's satisfaction with the front end of the service in terms of the number of people who abandon their call before getting through. The average performance is 30 seconds. We play a message at the beginning, when people get through to the service, explaining important information about confidentiality of their information. 30 seconds after that is the average performance.
50. I also did try this today but I abandoned my call because I thought I was not ill. You do not have a system on the phone that tells you that you are number 15 in the queue and your call will be ten more seconds?
(Mr Jenkins) We have not, largely because we take the view that particularly for people who are ill we probably do not want to put an awful lot of extraneous stuff on before people get through to the service. If we are especially busy, we will put a message on that explains this to callers and encourages them to stay on if they need urgent advice.
51. In paragraphs 2.15 and 2.21, you are proud that there are not these adverse events and things are going well. My worry is the inverse, that there might be a tendency to be over-cautious in order to avoid adverse events and therefore if that tendency continues the whole service becomes irrelevant. Do you think there are dangers of being over-cautious?
(Mr Jenkins) I would rather be over-cautious than under-cautious. We are very careful to keep the quality of our advice under review. The fact that we have a centralised decision support system means we can continue to review that and modify that. If we feel in any area that we are over referring to particular services or being particularly cautious on some issues, we can review the advice and modify that. Where we are integrated with GP services gives a very good window. If they are telling us that we are sending them a whole lot of inappropriate referrals, that is a prompt for us to look at the system we use and the quality of the training and performance of our nurses.
52. Is there a system of returning nurses back to the front line after they have been with you for a period so that they can refresh their experience?
(Mr Jenkins) We are finding that a lot of nurses will probably move through NHS Direct over a period of two to three years. This is not a job for life. It is natural to get the very interesting and different experience of giving advice on the phone and move on to other things. We also deliberately encourage clinical placements and rotational posts between NHS Direct and face to face settings in a number of sites. A significant group of our staff are part time and may well combine working within NHS Direct with working in a GP's surgery or in A&E at the same time. The principle of not just working on the phone we see as a positive virtue rather than a problem.
53. Paragraph 2.14 talks about a target time of completing calls within 20 minutes, 90 per cent, and all within 30 minutes. Is that not giving an incentive to rush calls?
(Mr Jenkins) No. That target was identified by the out of hours review team on the basis that the end of the call is the point at which you have definitively dealt with the issue of clinical risk. At the end of the assessment you know if the patient is sick and needs to be referred urgently or if the patient is able to look after themselves or whatever.
54. You do not think it will lead to an incentive to terminate calls earlier?
(Mr Jenkins) Like every target, it is the way it is implemented. A good call completed in 33 minutes is much better than a hastily completed call completed in 29. We will look at this target along with all sorts of other measures of how we perform.
55. Finally, a slightly flippant question about the Consumer Association mystery shopper. You have your own mystery shoppers, which is a good thing, but was this mystery shopper exercise authorised by you?
(Mr Jenkins) No. They did tell us that they were doing it, but we did not approve of the methodology.
56. I wonder if they ought to be doing this because it is taking up nurses' time for their own business purposes and they are not really ill. Why would you approve these things? Would you not condemn them for doing that?
(Mr Jenkins) Clearly anybody taking an independent assessment of what we do, in a sense, if it is not abused is, I think, a good thing because it is, in a sense, another way of getting confidence and issues out to the public. I think our concern about this was not the doing of the exercise but the lack of comparison, some of the methodology of assessing NHS Direct calls and some of the lack of comparison with other services. They made very absolute statements about NHS Direct against what would happen to you if you contacted your GP or contacted another service.
Mr Gibb: Thank you.
57. I am not too sure whether I have used the service or not. In the North-East, in Durham, we have been on this out-of-hours doctors' scheme for a long time now which when it was originally introduced I did not, frankly, approve of it, I thought the doctors were just skiving and I thought if you rang your doctor you should able to speak to your doctor. However, about 18 months ago I rang this service up, or about a year agoI am not sure if I got through to my out-of-hours doctor or whether I got through to the NHS Directand at the end of the day I got the pain killers, so it must have worked
(Mr Crisp) I wonder if it matters, actually, because these things need to be integrated?
58. I do not know how it works, but I should do because I am in the target group, 55 or 56 year olds, and will probably need it more in the future. However, I mentioned this to the Member for Carlisle and he was very complimentary. He had used it, he got a rash or something and he was told to put some cream on it. I did not go into anything further about where this rash was or where he had to put the cream, but apparently it worked, so that is pretty good. One of the things that actually I loathe, and I think Customs & Excise used it, was one of these services where you telephone somebody and then you get a recorded message where they tell you to press a button, then another button, then another button, this service does not do that, does it?
(Mr Jenkins) The only circumstances in which we do something like that is if there is a major health scare, if there is something in the news, and we told lots of people to telephone NHS Direct about that one issue then in terms of dealing with the increased volume of calls efficiently, for example, if you are calling about the infected health care worker at X hospital press one, if you are ringing for general advice press two. We, and ministers, both share your loathing of that.
59. Good, I am delighted about that. This was touched upon by another member in paragraph 2.8 on page 12, where we are told that originally the message was 40 seconds in length at the start of the call, therefore it does not surprise that a lot of people put the telephone down. That is a long time to listen to somebody withering on. What was the message originally saying?
(Mr Jenkins) The message was detailing all of the information that we are legally obliged to tell people about the uses to which the information they give NHS Direct will be put. This would be one of the cases where the spirit of the service, in terms of testing things and changing them, is very true. We got some significant feedback. We looked at the abandoned call figures.