The Scottish Government

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BACKGROUND

Setting Up The Organisation

In March 1999 the Secretary of State for Scotland announced a £2.5 million investment in primary care to pilot the expansion of existing GP out-of-hours services to include 24-hour access for patients to health advice from nurses. NHS Direct Scotland (as it was described at that time) would be designed to:

• offer reassuring health advice to, for example, parents of young children or the elderly living alone who have worries about their health which may not be serious enough for a GP contact;
• build better links among GP OOH services, out-of-hours social work services, and other secondary care services; and
• provide a better, more appropriate response to 999 callers who do not require the immediate dispatch of an ambulance.

After intensive consultation with medical, nursing and other health related professionals a Project Board was set up by the SEHD. The Board was chaired by the then SEHD Director of Planning and Performance Management and comprised the Chief Medical Officer, Chief Nursing Officer, the SEHD Director of Finance and the then Director of Primary Care. That Board appointed a Chief Executive for the project and with the help of external consultants (general, hardware, software and telephony) the broad shape of how NHS Direct Scotland would look began to emerge. There was continuing consultation with senior clinicians.

In December 2000 the Scottish Health Minister announced that the new 24-hour telephone advice service for patients in Scotland would be called NHS 24. The new service was to be rolled out in pilot areas during 2001 and would offer guidance, health information and nurse-led triage over the phone. The Minister added "while the new service in Scotland is similar to NHS Direct in England - in that nurse triage will play a leading role in the service - we will be adopting a distinct approach in Scotland with a greater emphasis on integration into existing services. That will include GP out-of-hours services, ambulance services, and pharmacists".

On 6 April 2001 NHS 24 was established as a Special Health Board and adopted the design plan which was termed the 'blueprint'. The Project Board became the Management Board of NHS 24 under the Chairmanship of the SEHD Director of Finance until such time as the appointment of a Chairperson and Non-Executive members could be made. The project Chief Executive became the Chief Executive of the Special Health Board. The Chairperson was appointed in September 2001, with the Non-Executive members being appointed in December 2001.The Roll-Out of a Network of Contact Centres

Three contact centres were developed from scratch - one in the North (Aberdeen), one in the West (Clydebank) and one in the East (South Queensferry). The North Contact Centre came on line in May 2002, the West in November that year and the East in September 2003 just a few months behind the original schedule. Those centres would then progressively integrate technologically with GP out-of-hours services and subsequently with Health Boards across Scotland. That programme would continue until November 2004.

The cumulative direct costs of NHS 24 over the 4 years to 31 March 2005 were in the region of £110 million to £115 million. For the financial year to 31 March 2005 the revenue spend was £41.8 million and the capital spend was £0.8 million.

Some Unintended Consequences

The development of NHS 24 was a major and novel project for the NHS in Scotland. It was intended to be a flagship for the modernisation of public services in the 21st century. The concept of integration with GP OOH co-operatives when local GP surgeries were closed meant a complex, innovative, technological project. The mandate given to the project Chief Executive left him with a very tight timetable. There were good reasons for this but it would produce a few significant anomalies along the way.

Pilots

Early statements clearly mentioned pilots. There were to be none. It seems that the first centre (opened in May 2002) was initially to have been viewed as such but the tight timetable did not allow for assessment, review, lessons learned etc. Within weeks of going live in Aberdeen most of the NHS 24 executive team, with most of the technological support team, were on their way to Clydebank to concentrate on the second part of the 3 centre roll-out. Hindsight suggests that this was unfortunate because there were signs even then that some changes to the delivery design might have been useful. (This need to move on quickly would also in turn impact on the frontline staff in the North centre.)

Remote and Rural

At the very first formal Board meeting of NHS 24 in February 2002, a paper from the Chief Executive was considered which highlighted the likely challenges ahead if NHS 24 was to integrate with GP practices in remote and rural areas. Because of the number of small practices, and in certain areas lack of or no GP OOH co-operatives, the main integration model would have to be substantially adapted; that would take time and additional funding - and the roll-out deadline would be at risk. All the points made were reasonable in that context but the consequence was that a possible solution for remote and rural areas was effectively put on the back burner. That possible solution is only now, 3½ years later, about to be tested in Inverness on behalf of Highland and Islands Health Boards.

Risk Assessment

While risks were undoubtedly recognised, assessed and managed, the emphasis seems to have been much more on the risk to the roll-out timetable than on risks to the quality of ultimate service delivery. This would become much more pertinent as increasing call volumes led to the extended and problematic use of 'call-back'.

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