NHS Direct may be placing patients in danger by failing to recognise emergencies, according to the Consumers' Association magazine Health Which?
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Researchers had concerns over calls to NHS Direct about repeat prescriptions |
The survey involved three researchers each making 10 calls to different NHS Direct centres and each giving a different medical scenario. A panel of experts, consisting of three general medical practitioners, a nursing professor and a pharmacist, then assessed tape recordings of the calls.
One researcher adopted the guise of a 55-year-old man with worsening angina. He said that he was away from home and was running out of his glyceryl trinitrate spray because he was using it more frequently. On six occasions his query was not passed to a nurse but was dealt with by a call handler. In only two cases did nurses go further than deal with the need for a repeat prescription. And only once was the researcher asked enough to discover whether the condition was becoming worse. He was then given appropriate advice.
The expert panel said that the nurses should have asked enough questions to discover that the "patient" had already had one heart attack and that his angina attacks were becoming more frequent. They should then have referred him urgently to his GP.
The panel decided that the other two researchers, who presented less serious scenarios, had on the whole received adequate advice, although there was inconsistency in the detail and the nurses sometimes followed their computer protocols in a mechanistic way without really engaging.
In only three of the 30 calls were the "patients" asked the name and address of their GP, and these GPs were not contacted by NHS Direct.
The study also found that the advice given varied across England because NHS Direct workers used different computer guides according to where they were based.
As part of the study, the researchers also visited NHS Direct walk-in centres and consulted the NHS Direct Online website and the 'NHS Direct healthcare guide' book. The panel found that the service provided through these alternative sources of NHS Direct advice could also be improved.
Commenting on the survey, the principal researcher (Ms Sally Williams) said that NHS Direct should take a close look at the way it dealt with calls about repeat prescriptions to make sure that potential emergencies did not slip through the net.
A Department of Health spokeswoman said that the way calls about repeat prescriptions were handled would be reviewed in the light of the report. But she suggested that the investigation had major flaws, including an inadequate sample size. NHS Direct had advised more than three million callers, with a high level of caller satisfaction, she said, and it had often proved a lifesaver.
According to Dr Steve George, director of the University of Southampton health care research unit, who helped develop guidance for NHS Direct nurses, the study was poorly designed and the report is sensationalist in its writing. He said that subjecting a group of people to simulated patients over the telephone would always result in variations. The research was trying to compare NHS Direct with "a mythical gold standard that doesn't exist".
The Health Which? findings conflict with those of a team led by Dr George early in the development of NHS Direct. In a three-year randomised controlled trial of a nurse-run service, the team found it to be at least as safe and effective for patients as a normal GP out-of-hours service, with no increase in deaths and fewer emergency hospital admissions (BMJ, October 17, 1998, p1054). It also improved patients' access to out-of-hours care and greatly cut the number of visits patients had to make to surgeries.