THE PARTICULAR PROBLEMS AND CHALLENGES FOR NHS 24
General Responsiveness
NHS 24 provides 2 services to the public.
· There is a 24-hour nurse consultation service where callers can have their symptoms assessed by experienced nurses, be advised of the most appropriate response and, if necessary, have appointments arranged for them, either at an out-of-hours primary care centre or at an accident and emergency or minor injuries unit, a home visit by an out-of-hours (OOH) service provider - usually a GP but occasionally a nurse practitioner.
· There is also a health information service which answers questions about general health issues.
It is important to note that NHS 24, in out-of-hours periods (in practice generally from 6.00 pm to 8.00 am Monday to Thursday and from 6.00 pm on Friday through to 8.00 am on Monday plus all public holidays) is primarily intended for people who feel they need urgent medical advice and who feel that that advice cannot wait until the GP surgery re-opens.It is equally important that anyone who thinks that an emergency ambulance needs to be called should dial 999.
The health information service, as distinct from the nurse-led consultation, is there to answer fairly general questions about medical conditions, NHS services, health promotion, disease prevention etc. This service was intended to relieve some of the pressure on GP surgeries and so NHS 24 expected most of the health information calls to come in during normal surgery hours (8.00 am-6.30 pm Monday to Friday).
When an urgent call goes through to NHS 24 it is answered by a call handler who asks the caller for a few important personal details, and also asks for a telephone number, the name of the patient's GP and the reason for the call. That information is necessary for the setting up of a patient record within NHS 24's computer system. If the call handler concludes, even at that early stage, that this could be an emergency then the call can be transferred immediately to the 999 emergency ambulance service. In most other cases the call is passed to a nurse adviser. When a call is passed to a nurse adviser, the nurse confirms the personal details for security and confidentiality reasons and then asks a series of questions designed to allow the nurse to decide on the most appropriate response for the caller. That response might range from immediately transferring the call to the 999 emergency ambulance service to reassuring the caller that the symptoms do not appear to be serious and can be managed within the home, at least until the local GP surgery re-opens. If no nurse adviser is immediately available, arrangements will be made for one to call back within a certain period - which should be explained in detail to the caller.
When callers get through to NHS 24 straight away, and a nurse adviser is immediately available, then the standard of service is usually very high and generally well appreciated by the caller. Problems can arise when the caller finds it difficult to get through to the NHS 24 number because it is busy. There can also be frustration at the length of time spent on giving, and repeating, those personal details - particularly when the caller is anxious to get an immediate response. The most frustrating experience of all is when it takes much longer for a nurse adviser to call a patient back than intended or promised.
The specific processes followed by call handlers and nurse advisers have been designed to give assurance about the quality and the clinical safety for the caller, but they can come over to the caller at times as being somewhat stereotyped and over-long. Although the service is generally of a high standard, there are times - particularly during high volumes of calls - when the service can fall significantly short of what is intended.
Calls Not Answered Within a Reasonable Time
NHS 24 sets a target of picking up 90% of incoming calls within 30 seconds. In normal "office" hours, when demand is not high, it generally achieves or comes close to that. But at busier times, over weekends for example, a caller may have to wait much longer to be connected. At particularly busy times the caller will receive a pre-recorded message to that effect and the person trying to get through will be told to try again later. That can be extremely frustrating, even a little frightening, if the caller is particularly anxious. And it can cause additional problems where the call is from a remote part of Scotland where geography and distance may well mean that time is of the essence if further services are required.
Given that general access to the services that NHS 24 provides is fundamental, and that patients and callers need prompt and appropriate access, why is it that there have been major problems, occasionally serious problems, at times? There are a number of reasons including:
? call volumes that are difficult to manage at peak times, particularly over weekends and public holidays;
? failure to inform the public of some necessary restrictions of calls that are not really urgent;
? shortage of nurses available to cover certain shifts at peak times;
? failure to balance clinical service requirements with exploiting commercial telephony and technology in the 3 NHS 24 contact centres;
? an assumption by management in the past that "call-back" is an integral and acceptable part of day-to-day work;
? the almost pre-determined time taken to reach a decision on the most appropriate advice/assistance for the caller even when the appropriate decision could be made much earlier;
? reluctance to allow consideration of some degree of discretion to experienced call-handlers;
? an over-cautious approach to the use of the clinical software;
· unsuccessful attempts at joined-up, effective, partnership working across the health economy have also meant some problems in the hand-over of patients as they move between NHS 24 and its NHS partners.
These issues will be explored in depth later in this report. What is important is that any review of the whole process of handling calls should be comprehensive and holistic. Tinkering round the edges, which has been attempted at regular intervals in the past, will be likely to merely delude management and staff that the problem as a whole has been resolved. There is no one magic key.