NHS Direct putting the E into e-Health

Thursday 31 January 2002

The Board Room, Moorfields Eye Hospital, City Road, London, EC1V 2CD

Unfortunately our invited speaker, Dr Nick Robinson, Medical Director, NHS Direct West London couldn’t be at the meeting. Self reliant and informed as ever, members present took the subject themselves and, based on an introduction by Simon Midlane (Senior Manager at Redbridge and Waltham Forest Informatics Service) and Stephen Elgar (Director of Health Informatics at Harrow PCT), on how NHS Direct worked on their patch, they launched into the evening’s subject.

NHS Direct North East London: Nurse delivered telephone advice to the public is linked to the Ambulance service. Nurses use a new national system which allows client records to be created as the Nurse is guided through a series of questions for the caller, underpinned by decision support algorithms embedded within the system. Although all NHS Direct Centres use the same software (AXA), client records are not shared between centres and there is no link from the NHS number Tracing service.

Calls are local for the most part but can be 'switched' to and from other centres when a centre is too busy. Mobile call routing also means that many callers are not local. Decision support is nationally consistent (overseen by a national Clinical group) but the callers records can be fragmented across different centres and some callers will have multiple records within one centre.

The outcome of most calls is advice for self-management with self-referral to A&E departments and to GPs as an alternative. If the caller consents, a summary of the call can be Faxed to the GP.

NHS Direct West London; is run by a GP Out-of-Hours co-operative (GPs have grouped together so that individual practices don’t have to provide evening / night / weekend visits). This had meant that collaboration with GPs is stronger. As well as faxing a note of a patient contact, an XML-based message can be sent to GP applications as an email (un-encrypted at present) which can then be viewable (free text) within the to GP application just as Pathology results are handled.

Plans are under also under development to set up a web-based area for the public, linked to NHS-OnLine (self advice system), to allow the individual to provide a narrative that would then be available to the NHS Direct Nurse. This could hold anything but there is discussion of providing a series of 'tick boxes' to allow a client to make a consent statement for their prospective information exchange. There is also discussion of how Care Direct services can be developed in conjunction with NHS Direct to receive emergency call services from clients’ homes and potentially to monitor particular conditions.

Once significant components of the health and social records is available in browsable form over NHSnet (e.g. Care Plan for Mental Health patient and Single Assessment Process for Elderly clients), it is expected that the NHS Direct Nurse can call this up and that this information can inform dialogue with the client.

Nu Care; at Northwick Park Hospital, one of the many innovative projects to remodel A&E services is now live, based on:

GPs working in the evenings and at weekends in the department – GPs have a more general training and a greater range of clinical experience than the A&E team and, it is often said that, many patients attending A&E would be better treated by GPs
An integration of NHS Direct services with the A&E portal
Emphasis on making services and information available to patients so that they can manage themselves or receive services other than medical.

As discussion widened, the following were included:

NHS Direct and OnLine fit within this Governments interest in improving accessibility of Public Services (set against a perception of services as being slow, difficult to access and comparing badly with other sectors and the commercial world).

Both Direct and OnLine can be seen in terms of a models of participation of citizens in making choices about services they receive, of empowerment and active engagement in choices.
They can be criticised as being dramatic initiatives and as a diversion of funds and distraction from the long-term work of improving quality and consistency of NHS provision and resulting health outcome. Has Direct and OnLine increased or decreased pressure on GPs and A&E?
Also do they play on anxieties of the worried well? Are they relevant to building and maintaining health and quality of life? Are they another part of a Sickness rather than a Health service?
Great opportunities for innovative service redefinition will follow for NHS Direct and its successors as the clinical and social care Electronic Records begins to become usual rather than exceptional. Anxieties on the management of Members expressed concern on management of confidentiality and of the exercise of the citizens’ / clients’ / patients’ right of consent as interoperability, and openness of systems becomes more significant.

Some members thought that a key development is the individual managing their own information and rules of exchange - an internet-based record, for the most part, owned by the citizen. Such as approach can be compared to the present fragmented and often chaotic and inaccurate institutionally owned and managed record.