The Scottish Government

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INTERIM CONCLUSIONS ON THE SPECIFIC REVIEW REMIT

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. Even now one tiny (and therefore statistically invalid) survey that 3 community groups in Tayside have kindly carried out for us at very short notice underlines that. But the people of Scotland have been repeatedly told that they can expect a first class service as a result of the introduction of NHS 24 and that is what they rightly expect. So it is in everyone's interest to put right the relatively few things that have gone so badly wrong. That responsibility lies with senior management. Much of the fall-out has unfortunately landed on front-line staff.

While we consider individually the 5 issues in our remit they are all, of course, invariably and inevitably interlinked.

General Responsiveness

General access to the services that NHS 24 provides is fundamental. Patients and callers need prompt, appropriate access. That access is always important but it is particularly important in remote and rural areas where local services (eg A&E and Ambulance) may be thin on the ground.

In December 2004 and January 2005, the aggregate core service calls into NHS 24 amounted to 305,000. December and January are recognised as the busiest months in any year - by some margin. But the original business case, the prerequisite for NHS 24 to go ahead, was based on a design that catered for an annual volume of 2.5 million calls. NHS 24's subsequent estimate of the annual volume was 2 million. The recent figures for December and January extrapolated as they stand, would give an anticipated annual volume of 1.8 million but of course December and January would not be a realistic basis for an annual total.

So, even with the deluge of seasonal calls, even with the considerable challenges following the GP/GMS contract, it was not the overall volume, not the average monthly volume that caused the problems, but the weekend and public holiday peaks within those monthly figures. There ought to have been closer monitoring of demand, day by day - even hour by hour. Perhaps not surprisingly the marked increase in volumes following the new contract, beginning with GP surgeries closing on Saturday mornings, brought some long-standing NHS 24 weaknesses to the fore.

That challenge is now being faced within NHS 24 - looking at productivity, best use of people, and examining yet again improving staff retention. We applaud those efforts and we shall continue to liaise with the new Chief Executive between now and the final report.

Any examination of general responsiveness takes us back to the fundamental issues of capacity and resource. The overall design capacity ought to be sufficient, at least for the present NHS 24 volumes. There has been consideration of building a fourth large centre in central Scotland. Even at this early stage of the review we have to question whether one further major nurse recruitment campaign would be successful. But something has to be done and we are interested in one line that the new Chief Executive and his team are pursuing. That recognises that the organisation needs between 70 to 90 more nurses but that it would be unwise to look to one particular area for the necessary recruitment. So, instead of building one large centre, NHS 24 will explore, with Health Boards and the Scottish Ambulance Service, how to address its resource and service interface issues by developing an alternative service model - not unlike the proposal for the Highlands and Islands Boards which offers the opportunity for more flexibility which could in turn be progressively developed. Preliminary research suggests that recruitment, at modest levels and on a part-time basis, could be successful particularly if staffing rosters can be managed (within reason) to complement those of NHS partners - where individual staff might contribute to more than one service. The added attractions there include alleviation of remote and rural difficulties by ensuring that the outcomes of NHS 24 calls are compatible with local service configuration and also the ability to allow, to some extent, local Health Board solutions for local problems. (It is not in any way a suggestion that every Health Board can expect to have its own 'mini-NHS 24'; the original concept of national out-of-hours cover with national standards, etc, remains very important.) However, there is a caveat. One of our criticisms of the first phase of NHS 24's development is that the technique used was essentially "design and build". We feel strongly that there must be an agreed design, a small pilot and proper evaluation - all to avoid the danger of going, albeit in a more modest way, down the same "locate to recruit" road instead of ensuring a sound and sustainable service delivery capacity. We recommend that the NHS 24 team continues, as a matter of urgency, to examine the feasibility of several "mini-centres" with specific Health Boards and with SEHD, having particular regard to the necessary staffing resources required.

Before the final report we shall be reviewing whether the technology and telephony systems etc are being used to their maximum capacity.

It is axiomatic that the longer NHS 24 staff are on the phone to one caller, the less calls they can handle overall. Since first going live in 2002, high among the (admittedly very small) number of complaints from the public has been the length of time it takes to get to the reason for the call. Similar complaints arise from what callers regard as unnecessary, sometimes duplicated, questions if the call is passed to a nurse adviser. Again, efforts to reduce the total call time to an acceptable and safe minimum have not been successful in the past. Of course there is a need for personal details, confidentiality and not least clinical safety, but it is paradoxical that the original design required call durations to shorten quite significantly after a few months in post. Management has struggled to achieve that reduction. With safety always paramount, senior management needs to ensure that the length of time taken to get to the caller's reason for phoning NHS 24 should be reduced to the levels that the original design plan, approved by clinicians, suggested.

We know that, under the direction of the new Chief Executive, NHS 24 is re-examining various areas of productivity and that call handling is included. We recommend that this work is taken to a conclusion as soon as possible.

We also recommend that SEHD seconds a senior project manager (someone with experience of the NHS in Scotland) to help NHS 24 find the improvements it needs and is currently pursuing and to play an important part in examining the case for 2 or 3 'mini-centres' across Scotland with implications in particular for remote and rural areas.

Call-Back

Call-back has been used in the NHS for many years; it was standard practice within GP out-of-hours co-ops. But call-back usually happened within a very short time. Used in that controlled way it is a reasonable form of prioritisation. The way that NHS 24 has increasingly used call-back has resulted, however unintended, in some glossing over of the fact that it did not have the staff resources, in the right place at the right time, to do the job in a properly planned manner. And the on-going use of call-back as a routine procedure meant that NHS 24 could continue to avoid facing up to major underlying chronic problems; to continue to convince itself that recruitment problems could eventually be resolved by carrying on with remedies that had been tried a number of times already without the required results. It meant that it could continue to duck the horrendous management problem of trying to cope with more than 300 staff shift rosters - a problem that management itself had created.

Immediate and on-going action must be taken to reduce the use of call-back as an integral part of the service process. Call-back, and the consequences of call-back, carry risk and we are not convinced that that risk has been adequately assessed and managed. That needs to be examined urgently and professionally so that the public at large can again have confidence in the service. Call-back is also expensive in terms of senior frontline resources and de-motivating for staff. It puts added pressure on call handlers. Call-back, used reactively and extensively on a regular basis, is a symptom of management failure. It is as likely to exacerbate as it is to resolve the underlying problems.

Remote and Rural

There always have been and there always will be more challenges in responding to health care issues in remote and rural areas than in the rest of the country for reasons that everyone accepts, not least the people who live there. But public services must be tailored wherever possible to extend the principle of "equity" as far as is practicable. That is why the concept of NHS 24 ought to be an ideal means of achieving an equal level of service access across the country.

So it is regrettable that the opportunity for a pilot exercise on the "hub and satellite" idea was not taken 3 years ago. In the short term we would expect to see closer collaboration between the Health Boards and NHS 24 - real NHS team working, led by Health Boards, with the interest of the local community first and foremost. A proposal to site telephone triage services, Scottish Ambulance Service resources and NHS Highland and the 3 Island Boards' out-of-hours dispatch centre is currently being developed in Inverness to ensure service delivery coordination for the benefit of patients. We recommend that other Health Boards with remote and rural issues should confer with NHS Highland and NHS 24 along the way to assess to what extent that model has the potential to create the linkages that most Boards need for their particular remote and rural requirements.

(We mention in the chapter on 'General Responsiveness' above a further possible initiative that could well be very relevant to the improvement of service access in remote and rural areas.)

Over the next 4 months, we shall consider whether the 3 current options available to a nurse adviser (self-care advice, refer to out-of-hours services or Accident & Emergency department) could be extended by increasing the flexibility of algorithms to cover other parts of the NHS - and possibly some of the very many voluntary health organisations.

'Seamless Patient Journey'

One of the main attractions of NHS 24 is that it is "one telephone call" (sic) away from many NHS services - particularly valuable to the public during out-of-hours periods. For that to be fully efficient there must, first of all, be easy access to NHS 24 itself and we comment on some of that in the chapter on "General Responsiveness." Beyond that the major changes of the last 18 months or so (the dissolution of NHS Trusts, the new contract for GPs) have produced a different type of relationship between Health Boards and NHS 24. From 2002 NHS 24 has tended to be the dominant partner and to some extent that was unavoidable because of national access, national standards, substantial technology investment and roll-out. Now the relationship needs to change back. All Health Boards assumed responsibility for patient care out-of-hours by 31 December 2004 but of course they have the wider responsibility for whatever patient care is required by those within each Health Board area. Particularly in remote and rural areas, Health Boards need to be in the lead on what their particular healthcare obligations require. Of course there has to be a partnership relationship but, as with the Scottish Ambulance Service, NHS 24 is essentially an important NHS service partner.

In 2002, NHS 24 promised real, meaningful partnership working - perhaps beyond the realistic. But now it is for Health Boards to ensure that the partnership delivers best value to the end user.

We recommend that, particularly over the next 12 months or so, Health Boards take the lead in co-operating and collaborating in a meaningful, realistic and holistic manner and we recommend that senior managers across NHSScotland are reminded of their responsibilities and accountabilities in that respect.

Staff and Staffing Issues

By the time the first NHS 24 contact centre opened in Grampian in May 2002, it was becoming clear that predictions about the supply of nurses available and willing to join were flawed. We understand that the Project Board, in consultation with senior clinicians, had been advised of the risks around recruitment - and nurse grading - but had decided to press on. Conversely, the capacity of that first centre had, to some extent, been determined by the estimate of available nursing resources. With hindsight, the capacity was possibly too low for the demands which would fall on it. Those factors together would mean that almost as soon as the doors of the West Contact Centre opened the overflow of calls that Grampian could not handle was being diverted to Clydebank. That meant additional pressure there as, among other things, staff tried to get to grips with a virtual national local knowledge database. So retention difficulties arose there with all the related consequences. The relentless drive to set up the third contact centre (at South Queensferry) so that the entire technological roll-out was completed on schedule meant that many staff - often still grappling with new IT and telephony - were left short of technical support when technical colleagues moved on to the East.

More recently, problems of difficult access for callers and call-back have exacerbated the difficulties of frontline staff who generally want to do a good job and who take pride in giving good service. The frustration increases when, as a result of NHS 24 management's attempts to prioritise calls, it then asks for help from local Health Board services who can only suggest transferring calls back to local services where GPs have to be brought in to provide triage. We have been impressed by the general commitment and dedication front line staff have shown to individual patients and the community in such difficult circumstances.

Over the next 4 months, we shall be looking in depth at the quality of the algorithms used to support clinical decision, competencies, training, professional development and internal communications.

We note with interest the recently expressed appreciation of staff in all 3 Centres and at Headquarters, of the "open and frank" approach adopted since the arrival of the new Chief Executive. We recommend that senior management finds time to meet more often with front-line staff, to talk with them and, importantly, to listen to them.

We also recommend that a further staff survey be completed by August of this year.

We further recommend that senior management, working with the partnership forum and in consultation with front-line staff, re-examines shift rosters with a view to producing a more practicable process.

Managing expectations

We refer earlier in the report to the tendency to publicise what NHS 24 could do; how it was to be "the gateway to the NHS in Scotland". A lot of that was both desirable and necessary but it was perhaps overdone at times - leading to some confusion and misunderstanding on the part of the public at large and to expectations that it would be difficult to meet at the best of times. As we have indicated the technological and telephonic facilities within NHS 24 offer huge potential in due course. But somehow we have to seek the cooperation of the people of Scotland, at least for a while. There is evidence that callers are phoning in for general advice at peak times. They have never been told why that can cause difficulties for the caller with a real problem - not least the caller who cannot get through. There is not an easy solution. No-one who needs the help of the NHS must ever hesitate to call - at any time. That applies most of all to calls concerning the elderly and the very young. But if people who want very general advice, and who have no immediate problem whatsoever, could call outwith the peak periods, particularly avoiding Saturday mornings and through the weekends, that would help significantly.

There are many unavoidable reasons for call volumes, and related peaks, rising to where they are now but there is a widely held view that part of the volume problem relates to the intensive "sales and marketing" campaigns mounted by NHS 24. In normal circumstances that would be sensible given the potential for more "call centre" type services within the NHS but at this point in time we recommend that the Board of NHS 24 focuses primarily and essentially on the current problems which impact on satisfactory frontline service delivery.

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