The Scottish Government

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EXECUTIVE SUMMARY

Following criticism of some aspects of the operational performance of NHS 24 an independent review team was asked by the Minister for Health and Community Care to examine the issues. The remit and the members of the review team are on the previous page.

Despite recent and often very justified criticism, the general level of service from NHS 24 remains high. "Customer" satisfaction, though it has taken a sharp fall over the last 6 months or so, has also generally been high. The people of Scotland have been repeatedly told that they can expect a first class service following the introduction of NHS 24. The potential for a first class service is undoubtedly still there but several parts of the service need to be improved markedly - and quickly.

This is an interim report after some 9 weeks of the team coming together. This report does a lot of looking back in order to look forward: to find out what challenges have arisen, how those were dealt with, what challenges remain and how these challenges might be met. Many, if not most, of the report's conclusions are based on hindsight but in some instances we have to question the judgement and foresight of decisions when those were actually made. A final report will be delivered to Ministers by 30 September 2005.

We examine the history of the service from a Ministerial "statement of intent" in March 1999 through to the formal establishment of NHS 24 as a Special Health Board. We look at the progress of NHS 24 from the design and implementation of 3 large contact (call) centres through to nurse-led advice and triage given to just over one million callers in the year to December 2004. We recognise the priorities in the early stages - design, construction and fitting out of each individual contact centre - and we note some of the unintended consequences of judgements and decisions legitimately made in the context of that part of the programme (how there was no time for a proper pilot exercise, almost no time to evaluate the first centre - and certainly no time to consider any major changes along the way). We note that an opportunity for a pilot exercise to deal with the peculiar problems of remote and rural populations was effectively put to one side and how, in general, identified risks tended to more about risks to the design implementation phase rather than to subsequent service delivery.

We pay tribute to the NHS 24 Board for delivering the network of modern, sophisticated contact centres that should bring real benefits to the people of Scotland, but we express some concern at the level of non-executive input at times. We can appreciate why there might have been a low-level input in the first 2 years or so when the executive team clearly demonstrated impressive leadership but we think that the executive leadership over the 2 years or so up to the end of 2004 has been less impressive and, with hindsight, we think that non-executive leadership at the highest level was necessary to re-focus the executive team. We found little evidence of that leadership.We question, again with hindsight, the role of the centre (the Scottish Executive Health Department - SEHD). Hindsight suggests that some sort of "programme manager" within SEHD would have been useful and advisable - to keep the Department generally informed, to facilitate balanced consultation among Health Boards and NHS 24 and generally to keep a long-term eye on the ultimate service delivery to patients and callers. That leads us to consider the "link" role of SEHD officials who "monitor" all Health Boards and Special Health Boards. What do they report back - either at regular intervals or for the specific purposes of a Health Board's annual accountability review? We shall look further at this between now and September.

We comment on the impact of the new General Medical Services contract which came into force in April 2004 - the general content and possible implications of which had been fairly clear to Health Boards for some 9 months before that. Some 3,500 out of 4,000 GPs in Scotland would repay a part of their remuneration to SEHD in order to exercise their legitimate, contractual right to opt out of 24-hour patient care. That would present specific challenges for Health Boards and for NHS 24. Many Health Boards would rely heavily on the quality of service that NHS 24 had promised in the past and was still promising. Many GPs were prepared to offer their services back to Health Boards in out-of-hours periods but even then we wonder how NHS 24 could have continued to offer such fulsome reassurance given all the changes going on and the potential for risk around them. In the event, most Health Boards would struggle to find local solutions over the 2004 festive season when, belatedly, NHS 24 signalled that it might struggle to give the level of support previously promised.

We then turn to the specific issues within our remit. We make the obvious point that all 5 issues (ability to respond promptly and effectively, the use of call-back, remote and rural problems and a "seamless patient journey", together with staff and staffing questions) are not isolated but closely interwoven. We feel that the relationship between NHS 24 and Health Boards, perhaps understandably over the last 2 years, has tended to be dominated by NHS 24. We think that relationship has to change. While co-operative and collaborative partnership working is clearly to be encouraged, we feel that the lead role must be played by Health Boards who have the overall responsibility for patient care. (We also think that NHS 24 will need considerable help and support from Health Boards, at least in the short term).

We examine the issues of capacity, demand and supply, of the length of call times and other "productivity" issues. NHS 24 is looking at the possible need to open new centres and it is premature for us to reach any conclusions on this. We would doubt, however, the wisdom of building another large centre - on the obvious grounds of long-established recruitment issues. We note that NHS 24 is examining the case for several "mini-centres" across Scotland. Those may well provide a solution, particularly with separate and modest nursing recruitment targets. But we think that SEHD will want to be well satisfied that going down this route would be good value for money and would be sustainable in the long-term and not just a short-term remedy. We think that the examination of this option should not colour what is currently going on around such issues as more productive use of resources, optimum use of the technology and telephony systems within the contact centres etc.Call-back has been used in the NHS for many years. It was standard practice within GP out-of-hours co-ops. But the actual call back usually happened within a very short time. We see call-back used as a permanent, routine process (particularly with delays in making the return call) as a symptom of management failure.

We acknowledge the problems, in all walks of life and across many services, that face people who live in remote and rural areas. NHS 24, consistently reaching the high standards of which it is capable, ought to be an ideal means of "equal access". We refer to a lost opportunity, some 3 years ago, when a small pilot exercise might have indicated the way ahead and we note ongoing work to establish a "hub and satellite" type of operation in Inverness to provide some common services for Highlands and the 3 Island Boards. We again think there is scope for better collaboration and co-operation to produce holistic solutions within remote and rural areas.

There are real problems around staff and staffing issues. Most of the fall-out caused by at times ineffective management has landed on the heads of front-line staff. We have generally been very impressed by the commitment and dedication of the front-line staff who often do their best to deal with problems not of their making. Communications appear to have been poor or confused. What appears to be an extreme "family friendly" culture has left NHS 24 management with more than 300 shift rosters to manage. Senior managers need to engage more in consulting staff - and, more importantly, in listening to staff.

We note in the report that since the arrival of the new Chief Executive in February 2005 an internal review has already begun. We welcome that and we shall be watching with interest how that develops in the months ahead as well as monitoring progress on the main recommendations in this report.

Finally, in this interim report, we pose the difficult question of how to "manage down" expectations that have been continuously revved up by NHS 24.

Owen Clarke CBE

Chairman of the Independent Review Team

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