Do callers to NHS Direct follow the advice to attend an accident and emergency department?

OBJECTIVES: To provide an objective assessment on callers' compliance with NHS Direct advice to attend an accident and emergency (A&E) department. METHODS: A representative three week period in May 2000 was investigated. During this period there were no health scares, major health campaigns, or bank holidays that may have affected the call rate. NHS Direct callers who were advised to attend A&E were identified. Data from the four A&E departments for the same three week period and two additional days were searched and matched to NHS Direct data by surname, date of birth, and post code. This process created three groups: (1) callers triaged to A&E who attended, (2) callers triaged to A&E who did not attend, (3) callers with different triage outcome who attended A&E. The age, sex, relationship of caller, time of call, and distance to nearest A&E were compared for groups (1) and (2). RESULTS: Just less than two third of callers triaged to A&E attended with the same presenting complaint. There were no statistically significant differences between group (1) and (2) in terms of age, sex, relationship of caller, time of call, and distance to A&E. A small number of callers (2.4%) were identified as being given other advice and attending A&E for the same presenting complaint. This group took significantly longer to attend A&E than group (1) (chi(2) =139.01, df=7, p<0.001). CONCLUSIONS: Assessing levels of compliance is difficult. These findings suggest that NHS Direct may have comparatively high levels of compliance compared with other similar services. However, using the single triage outcome as the means of identifying the advice given may oversimplify the range of possible advice given. The delay in attending A&E for the group of callers who were given other advice may indicate they had tried other actions. Further larger studies are needed to assess the appropriateness of referrals through investigation of clinical outcomes.

"Your ears become your eyes": managing the absence of visibility in NHS Direct.

AIMS: To identify and describe nurses' perceptions of interactional practices they use to manage the absence of visual cues in telephone consultations with callers at an NHS Direct site. BACKGROUND: A routine activity in telephone consultations is visualizing the patient and the situation from which the call is made, that is, "building a picture of the patient". Little is known about interactional practices between nurse and caller that contribute to shaping a conception of the caller, or other activities that nurses do to manage the absence of visibility in the consultation. METHODS: Qualitative analysis of semi-structured interviews conducted with nurses new to NHS Direct telephone consultations, the first immediately prior to the NHS Direct site's opening, and the second 6 months later. FINDINGS: The activity of visualizing patients and their environment is closely linked to interactional practices carried out between nurse and caller. Nurses described a range of interactional activities that they perceive help callers to describe with more precision what the nurse cannot see. Nurses also tailor interaction to a nonvisual environment in order to manage the more emotional aspects of telephone consultations, such as delivering information, advice, reassurance, and building trust and rapport. CONCLUSION: Nurses developed skills to manage interaction with callers in order to compensate for the absence of visibility. Skills were based on their professional backgrounds and experience and developed in an ad hoc way. Further research could examine the efficacy of these strategies, and be a prerequisite to adding them to training programmes.

A qualitative study of older people's views of out-of-hours services.

BACKGROUND: Out-of-hours primary care services continues to change with the growth of general practitioner (GP) co-operatives and the more recent development of NHS Direct. While older people are more likely to have increased needs for such services, evidence suggests that they are reluctant users of GP out-of-hours services. AIM: To explore older people's experiences and perceptions of different models of general practice out-of-hours services. DESIGN OF STUDY: Focus group methodology, with qualitative data analysis undertaken using a grounded theory (Framework) approach. SETTING: Thirty people aged between 65 and 81 years old from community groups based in south east London. METHOD: Four focus groups were held, each with between five and 12 participants. Each focus group session lasted 90 minutes and was audiotape-recorded with the permission of the participants. The tapes were transcribed verbatim. RESULTS: Two related themes were identified. First, attitudes to health and healthcare professionals with reference to the use of health services prior to the establishment of the NHS, a stoical attitude towards health, and not wanting to make excessive demands on health services. Second, the experience of out-of-hours care and the perceived barriers to its use, including the use of the telephone and travelling at night. Participants preferred contact with a familiar doctor and were distrustful of telephone advice, particularly from nurses. CONCLUSIONS: Older people appear reluctant to make use of out-of-hours services and are critical of the trend away from out-of-hours care being delivered by a familiar GP. With increasing numbers of older people in the population it is important to consider steps to address their reluctance to use out-of-hours and telephone advice services, particularly those based around less personal models of care.

NHS Direct: review of activity data for the first year of operation at one site.

BACKGROUND: NHS Direct was set up in 1998 and now covers all of England. One site in South East London, which went live in April 1999, has been studied to gain an insight into how NHS Direct is used and by whom. METHODS: Routine data from TAS was obtained from NHS Direct in South East London for its first year of operation. RESULTS: Data were collected on 56540 calls. Almost one-quarter of calls were for 0- to 5-year-olds. The service was busiest between 9 a.m. and 2 p.m. and again between 6 p.m. and 9 p.m. The majority of calls (68 per cent) were received during the out-of-hours period. Most calls to the service (56 per cent) are categorized with no urgency level, with 37 per cent of callers given advice on how to look after the problem themselves. Over the millennium celebration period the call volume tripled. However, calls tended to be less urgent, with more being from the older age groups. CONCLUSION: NHS Direct is an important service to parents of young children and can provide advice about when contact with another service is necessary to those who traditionally worry about this.

Patient-perceived benefits of and barriers to using out-of-hours primary care centres.

BACKGROUND: The rapid growth of GP co-operatives has encouraged the development of primary care centres, but little is known about patients' views and experiences of these new forms of out-of-hours service delivery. OBJECTIVES: This study was designed to understand patients' views, expectations and experiences of attending an out-of-hours primary care centre which was part of an inner London GP co-operative. METHODS: Systematic samples of patients using the out-of-hours service received semi-structured interviews covering the decision to contact the service, expectations and experience of the service and, if relevant, the experience of travelling to the primary care centre. Interviews were conducted by telephone between 7 and 10 days after patient contact. RESULTS: Interviews were completed with 55.4% (72/130) of sampled patients who were primary care centre attenders, 50.0% (47/94) of those receiving telephone advice and 45.3% (53/117) of those receiving a home visit. Most attenders of the primary care centre said that they were satisfied with the consultation (90.0%, 65) and were able to get all the help they needed (83%, 60). The speed of being seen and the opportunity of having a face-to-face consultation were key benefits identified. For some, this outweighed difficulties experienced in attending the centre, including arranging transport, caring for other children, managing several children on the journey and travelling while ill. The main barriers patients identified for not wanting to attend the primary care centre included feeling too ill to travel, having other dependants to care for or lacking transportation. CONCLUSIONS: While primary care centres offer patients speedy access to face-to-face consultations, there are a range of obstacles which are encountered. Those who are socially disadvantaged appear likely to experience greatest difficulty, raising concerns about equity in access to services. Out-of-hours services may need to give consideration to patient transport and a more flexible approach to visiting at home if such inequities are to be avoided.

Concerns and confidence of general practitioners in providing telephone consultations.

BACKGROUND: In recent years the number of telephone consultations provided out of hours has increased. However, most general practitioners (GPs) have received little training in this area despite the specific skills needed to compensate for lack of visual information. Moreover, there has been no research exploring GPs' concerns and training needs in telephone consulting. AIM: To assess GPs' concerns and levels of confidence in providing telephone consultations in order to inform the development of a new training course. METHOD: Prior to attending the course, GPs were surveyed by interview or self-completion questionnaire to explore their confidence in providing telephone consultations. RESULTS: Thirty-eight GPs participated, and the sample was highly skewed towards females. The average age of participants was 42 years, 5 years less than the mean for GPs in the area. Low levels of confidence were reported by GPs in providing telephone consultations out of hours. A number of characteristics were common to telephone consultations described as difficult. The most important were lack of visual clues and lack of information about the patient, both of these were heightened in the out-of-hours period. Organizational factors leading to reduced confidence levels were also identified. CONCLUSIONS: This study demonstrates low levels of confidence among GPs conducting telephone consultations, and highlights contributing factors. Although it is not clear how far these results can be generalized, they demonstrate the need to consider telephone consulting skills training in the context of new out-of-hours arrangements. The results have been used to develop a two-day course.