EXECUTIVE SUMMARY
Following criticism of some aspects of the operational performance of NHS 24, particularly over the winter months of 2004-2005, 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. We produced an interim report which can be found on the Scottish Executive website:
www.scotland.gov.uk/Publications/2005/06/InterimReportNHS24
The executive summary of the interim report can be found in the annexes to this report.
NHS 24 is now an essential service provider partner within the NHS in Scotland. Following the introduction in 2004 of the General Medical Services contract, when GPs were given the right to opt out of responsibility for providing out-of-hours (OOH) patient care, it assumed a central role in the Scottish Executive's plans for providing OOH care throughout Scotland. But there have been, and remain, a number of problems and challenges.
Despite recent and often very justified criticism, the general level of service from NHS 24 has remained high and statistics for complaints and compliments support that view. But it has not always been consistent by any means and sometimes it has been very bad.
During the first 3 months of our review we concentrated largely on looking back at the problems and challenges that had arisen and we highlighted:
- the difficulties in recruitment and retention of nurses;
- the way calls were taken and subsequently handled;
- the particular problems for people in remote and rural areas;
- the relationships between NHS 24 and other NHS partners;
- staff and staffing issues;
- the impact on NHS 24 of the General Medical Services contract in 2003 and 2004;
- problems facing patients transferring from NHS 24 to other parts of the NHS in Scotland
- the risks and the many problems caused by the persistent and reactive use of call-back;
- the probability that NHS 24, in enthusiastically promoting its existence, had failed to explain to the public at large that during out-of-hours periods its main service was intended primarily for callers who felt they had an urgent need for help or advice.
Over the last 3 months we have explored all of those in depth. Our main conclusion is that: it is essentially the cumulative effect of most of the issues listed above that has at times rather overwhelmed NHS.
We recognise that managing successfully the challenges of this winter is the imperative priority for NHS 24. Nothing that is avoidable, unless it manifestly contributes to the handling of that priority, should be allowed to get in the way.
Once NHSScotland has got through whatever this winter brings, there should be a quite radical review and overhaul of the ways in which NHS 24 contributes to unscheduled care particularly out-of-hours. There are 2 main reasons for that; firstly, the actual role has changed fairly dramatically since the original design blueprint of 2001-2002; secondly, some of the operational processes and procedures in place since those early days have simply not stood up to some pressures that have certainly been significant but which were generally not unpredictable. The Board's failure to acknowledge some of those weak spots (to continue, for example, to believe that rising numbers of calls-back were simply an inexorable, and integral, consequence of increased call volumes) meant that there was no critical review of the process of performance delivery; no obvious consideration that if a process needs a specific level of human resource and that level, continuously, cannot be reached it is then necessary to review the process. That review - which has already begun - and any subsequent process changes will be significantly more challenging and more wide-ranging now than they would have been 3 years ago.
Call-back is by far the most problematic issue and that in turn causes difficulties in a number of different ways. It was not designed to be used other than as an exceptional, temporary, planned method of dealing with low-priority calls. In fact it was soon (as early as 2002) accepted as an integral part of the day-to-day service. In this report we explain the problems it can leave in its wake - first and foremost for anxious callers; for Health Boards arranging local out-of-hours clinical services; for nurses called away from dealing with live incoming calls to make return calls; for the contact centres themselves that were designed quintessentially to receive and not to make calls.
The only practical way to manage down call-back to the minimum is to change, always in consultation and always following rigorous assessment of risk, the ways in which the job is done. We make a number of suggestions and recommendations along those lines in this report. For NHS 24 these include:
- limited and monitored empowerment of experienced call-handlers;
- encouraging highly experienced qualified nurses and experienced call-handlers to break away from an almost pre-determined length of call time and to take the time appropriate for each call;
- encouraging experienced nurses to use the extensive clinical software as they themselves require on a call by call basis and not comprehensively as a matter of course;
- more efficient management in the technological and telephonic aspects of the operational handling of calls in all 3 contact centres;
- using the new volume predictive technology to ensure the best match possible of supply to demand;
- giving response priority to callers from remote and rural parts of Scotland.
We readily acknowledge that a number of those performance issues are already under scrutiny within NHS 24 but we believe that some of the internal transformation reviews need to be even more radical for the longer term - thinking that is not just logical but lateral.
Health Boards and the Scottish Executive Health Department (SEHD) also have important roles to play in the future of NHS 24 in the context of primary care particularly in out-of-hours periods and we explore those in some depth. We emphasise the need for real, meaningful, well co-ordinated partnership working among Health Boards, NHS 24 and the Scottish Ambulance Service - much more 'corporacy' within NHSScotland as a whole. We ourselves in our visits to Health Boards around the country have seen and heard clear commitment to that philosophy and ready recognition of how essential that is - particularly for the future of unscheduled primary care in Scotland. We see the need for SEHD to take a rather more active, at times perhaps proactive, overview role. We welcome the clear and positive but demanding messages that have been going out from the centre in recent months - particularly on responsibilities and accountabilities.
Finally, we tackle one difficult aspect of volume demand. There is a lot of, admittedly largely anecdotal, evidence that in publicising its presence in its early years, NHS 24 encouraged almost unlimited public expectations of the services that were available - at any time. We suggest that NHS services during the night and at weekends have historically been in place for emergencies or for cases that have had some degree of urgency and could not reasonably wait until the local GP surgery re-opened. We think that SEHD, with the support of NHS 24 and Health Boards, should agree on a carefully worded message to that effect. The original design plan for NHS 24 envisaged that it would have its own 'health online' website by the end of 2004. The continuing absence of such helpful on-line information is bound to increase calls to NHS 24 and one of our recommendations is that NHS 24 takes steps as soon as possible to allow easy access for the Scottish public to the highly regarded and highly used website of NHS Direct.
Independent Review Team
September 2005