Commission for Health Improvement What CHI has found in: NHS Direct services sector report
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Commission for Health Improvement What CHI has found in: NHS Direct services sector report
Contents
Introduction from Dame Deidre Hine 3
Context 5
CHI’s findings 8
Service user perspective 8
• service user involvement 9
Roles and responsibilities 10
Ensuring clinical effectiveness 12
• clinical information 12
• risk management 13
• performance information 13
Staffing and education: addressing NHS Direct staffing needs 14
The developing role of NHS Direct 16
Appendices:
1: Clinical governance reviews 19
2: Assessing components of clinical governance 20
Attainments by NHS Direct services 21
3: Performance measures 22
What CHI has found in:
NHS Direct services 2Introduction from Dame Deirdre Hine
NHS Direct’s telephone help line service was first piloted in March 1998 and,
following a positive reception, was launched in England in November 2000 and in
Wales six months later. It provides health information and advice 24 hours a day,
365 days a year. NHS Direct is often the first port of call for somebody who is
concerned that they or a member of their family may need medical help, but is
uncertain which part of the health service will be best able to help them. Nurse
advisers direct callers to their GP, their local accident and emergency department,
their pharmacist or they provide basic health advice, such as how to manage a
cold or flu.
The Commission for Health Improvement (CHI) is committed to promoting
improvement in the quality of patient care. One way we hope to achieve this is
by sharing what we have learnt. This report has been produced to share what we
have learnt about NHS Direct services. It gives our view of how well NHS Direct
services are meeting the needs of the service users and the public and responding
to the challenges they face. It is based on the findings of our clinical governance
reviews of NHS Direct sites conducted between July 2002 and October 2003. CHI
has reviewed, or is in the process of reviewing, 20 of the 24 NHS Direct sites in
England and Wales including NHS Direct online.
So what does it tell us? NHS Direct has complex management arrangements,
including strategic direction from the Department of Health and the Welsh Assembly
Government, and a host trust that employs the staff, provides basic management
functions and oversees implementation of national policies. This report raises a
number of issues which occurred in our local reports, such as the lack of clarity
around the responsibilities of each of the parties and the difference between their
local and national roles and the need to raise the awareness of their services.
A great deal of good practice was also evident during the reviews, some of which
is illustrated by examples throughout the report. At the same time, NHS Direct
in England is in the process of a major organisational change towards a single
national provider that will provide services commissioned by local primary care
trusts. The future organisation of NHS Direct in Wales is still under consideration.
Lessons learnt from CHI’s clinical governance reviews may help to inform how this
new structure could work most effectively.
What CHI has found in:
3 NHS Direct servicesThe public profile of NHS Direct is not as high as it could be; it generally receives
media attention only on the rare occasions when things go wrong or it fails
to meet one of its targets. Our findings indicate that this does not give an
accurate picture; it is a successful service that is valued by the public and that
staff are proud to work for. In the short time NHS Direct has been running it has
made a big impact and the future investment in the service indicates the ongoing
commitment to it. We have found that many of the issues facing the service have
been given careful consideration and have been responded to in various positive
and successful ways.
NHS Direct is not perfect, however, and we hope that the issues outlined in this
report will allow sites to celebrate their achievements to date and focus attention
on further improvements in care.
Dame Deirdre Hine
What CHI has found in:
NHS Direct services 4Context
NHS Direct is a 24 hour nurse led telephone help line covering England and
Wales. Its two main functions are to provide healthcare advice and health
information. It aims to provide fast and easy access to advice and information
for people about their health, illness and the NHS so they are better able to care
for themselves, their families or friends. A call to NHS Direct can often be the
starting point of the patient treatment process.
This report presents the Commission for Health Improvement’s (CHI) view on how
effectively NHS Direct provides its services. It is based on the inspections (known
as clinical governance reviews) carried out by CHI. To date, CHI has carried out,
or is in the process of carrying out, clinical governance reviews of 20 of the 24
NHS Direct sites including NHS Direct online, across England and Wales. The
clinical governance review for NHS Direct Wales is due to be published shortly.
A brief description of clinical governance reviews is provided in Appendix 1.
Assessment scores used in clinical governance reviews are shown in Appendix 2.
As a result of the inspections CHI has been able to obtain a large amount of
evidence about what is happening in NHS Direct services. The aim of this report is
to support improvements in NHS Direct services and, specifically, so that NHS Direct
can make use of lessons learnt in planning and implementing any organisational
change. Using the information and evidence we have obtained we have attempted
to highlight practical examples of what works well, but we have not shied away
from stating where improvements are needed.
We hope this report will be of interest to the public, many of whom use the
services provided by NHS Direct. In addition, this report should be of interest to
trust boards, NHS organisations, including those that will be commissioning NHS
Direct services, policy leads and the management and staff of NHS Direct services.
What CHI has found in:
5 NHS Direct servicesNHS Direct was piloted in March 1998. From November 2000 some NHS Direct
sites started operating in England, and NHS Direct in Wales was launched in June
2001. It now handles over half a million telephone calls and NHS Direct online
receives half a million transactions every month1. Since it was founded an average
1
Developing NHS Direct. of 10% of the population have made calls to NHS Direct each year. This figure is
A strategy document for the
next three years. Department expected to increase for at least the next three years. CHI is responsible for a
of Health (April 2003)
programme of patient surveys in England. Our survey in 2003 of patients in
2
CHI national patient survey
of primary care trust patients.
England who use primary care services, found that 22% have contacted NHS
www.chi.gov.uk (2003) Direct, either for themselves or on someone else’s behalf, in the last 12 months2.
NHS Direct employ call handlers, who field incoming calls, nurse advisors and health
information advisors. Most calls occur outside the working hours of GP surgeries,
and calls about children under five make up around a quarter of all calls3. People
3
NHS Direct. A new gateway
to healthcare. NHS Direct,
contact NHS Direct for a wide range of problems, ranging from emergencies and
Leeds (2001) minor injuries to health advice.
There are 24 NHS Direct sites, including NHS Direct online covering all of England
and Wales. The call centre sites in England cover an average of 2.5million people
with the largest site covering 4.1million3. Each NHS Direct site belongs to one of
four network groups. The network groups provide technical back up and cover
during busy periods or staff training days.
NHS Direct Wales provides services for all of Wales and is hosted by Swansea
NHS Trust. Wales elected to join one of the four English network groups, who
provide technical support when necessary. However, Wales does not routinely
export calls at times of increased capacity because the other sites in their
network are unable to provide a bilingual service in English and Welsh. The Welsh
Assembly Government sets the strategic direction for NHS Direct Wales and there
are some differences in the performance framework.
What CHI has found in:
NHS Direct services 6A central management team, at the Department of Health, directs NHS Direct
services in England, and oversees the procurement and implementation of the
necessary IT and telecommunications infrastructure. They also support the day to
day management of NHS Direct services, by engaging with the host trusts. Each
NHS Direct site has a host trust that employs staff at the NHS Direct site, and
carries out basic management functions such as payroll. The host trusts also help
oversee the implementation of national policy at a local level.
The performance frameworks, both in England and Wales, help support the
implementation and development of NHS Direct services. The frameworks contain
information on how implementation and development will be monitored and
managed, and the vision and objectives for the service. They also outline the
responsibilities and expectations of individuals, the site, host trust, network group,
the Welsh Assembly Government and the central management team within the
Department of Health.
The frameworks also include performance measures and service targets, which
differ slightly between England and Wales. Continuous quality improvement is
integral to the framework in both England and Wales, and NHS Direct is
encouraged to continually monitor services and improve performance.
NHS Direct, in England, is about to embark upon major organisational changes.
From April 2004 a dedicated NHS Direct provider will be established with
responsibility for the delivery of services. Primary care trusts (PCTs) will be
commissioning services from NHS Direct sites, with the aim of making delivery
more accountable and responsive to local priorities. A national commissioning
board will be established along with a national tariff for services and national
performance standards. In addition, a key development priority for NHS Direct
in England is the integration with GP out of hours services1. In Wales plans for
out of hours services are under consideration and core services will continue to
be commissioned by Health Commission Wales.
What CHI has found in:
7 NHS Direct servicesCHI’s findings
The service user’s perspective: using NHS Direct
NHS Direct services are highly valued. Users feel they are dealt with in a professional
manner and that staff respect their dignity and privacy. The services are described as
helpful and reassuring and receive very few complaints. Although there are examples
of good practice in raising awareness of NHS Direct services there is more that could be
done. NHS Direct faces a challenge in trying to engage the public as it is not a face
to face service, but they recognise the importance of understanding service users’
needs and need to find ways to tackle this challenge. NHS Direct services are becoming
increasingly popular and the volume of demand is growing.
Patient feedback about English NHS Direct services in CHI’s 2003 patient survey
was impressive. Of the respondents that had used NHS Direct in England, 90%
were either ‘completely satisfied’, or ‘satisfied to some extent’, with the way their
call was dealt with2. During the clinical governance reviews of NHS Direct sites,
CHI heard many positive comments from service users who praised the way staff
handled their calls. CHI has observed that call handlers generally speak to callers in
a professional, polite and courteous manner. Staff training programmes for NHS
Direct staff reflect the emphasis placed on customer care and effective
communication.
CHI was impressed with the way call handlers respect the dignity and confidentiality
of service users. Sites are implementing the national confidentiality policy and
training staff in accordance with this, and confidentiality is actively maintained
across sites. Members of the public, service users and voluntary organisations said
they value the helpline and advice offered by the service. They also found the
advice given to be helpful and reassuring.
The national performance frameworks for England and Wales set targets for NHS
Direct services, which relate to the primary objectives for the service. These targets
are set out in Appendix 3. Sites are having problems meeting the target to answer
90% of telephone calls within 30 seconds and triaging 90% of symptomatic calls
within 20 minutes. They are also having problems meeting the target to have a call
abandonment rate of less than 5% (based on data for the year 2002). However, sites
are meeting the target to action or assess 90% of health information calls within
4
Health intelligence unit. three hours, and the target to have under 0.1% of calls getting through to an
The performance engaged tone4. The success of NHS Direct means it will have to ensure it is setting
frameworkservice delivery
targets. www.nhsdirect.nhs.uk appropriate targets for performance, and ensure that sites are meeting these.
CHI’s 2003 survey of primary care patients in England shows that 72% of those
surveyed had heard of NHS Direct2. There has been some good practice in raising
awareness of NHS Direct services, particularly among ethnic minority groups, young
people and people aged over 55, who tend to be infrequent users of NHS Direct.
However, some stakeholders feel that more could be done to increase awareness
of NHS Direct services and help improve equal access.
What CHI has found in:
NHS Direct services 8Good practice South Yorkshire and South Humber NHS Direct have taken a proactive
example: approach to reach young people and raise awareness of services available to
the wider community. Staff have used a number of venues including youth
clubs, schools and county shows to promote the services offered by the site.
There are many examples of good initiatives to improve access for marginalised
groups, including those with special needs and mental health problems. Steps to
ensure access for those from ethnic minorities are particularly noteworthy. All
NHS Direct sites have access to an interpreting service for callers who may require
information in languages other than English. Nationally produced fact sheets
about NHS Direct in over 20 languages are also supplied to GP surgeries and
social services offices in England.
NHS Direct provides a text phone system that can be used by deaf people. CHI
also found examples of work being undertaken to help improve access for service
users aged over 55 or those with learning disabilities.
Good practice The Avon, Gloucestershire and Wiltshire NHS Direct site have worked hard within
example: the local community to improve access to services. It has mapped services across
three counties for inclusion in a local database and has been involved in the
development of the Avon mental health services directory. It has also developed
protocols with local mental health service managers for addressing crisis referrals.
Service user involvement
NHS Direct acknowledges that it is difficult to engage the public in a service that
is not delivered face to face, but recognises that it is still important to understand
the needs of service users. NHS Direct services, and other health services, need
ways of obtaining the views of users, and of the wider public, and of taking them
into account when planning services. The central management team provide
strategic direction on patient and public involvement in England, while the Welsh
Assembly Government provides the same function in Wales. Implementation of
the strategy at a local level is variable. Some NHS Direct sites make good use of
structures and individuals working in patient and public involvement at their host
trust, while other sites have service user representation on their own committees
and groups, or lead individuals for patient and public involvement distinct from
the host trust. Many sites allocate specific resources to support patient and public
involvement work. It will be important, therefore, for NHS Direct to consider how
national guidance can be most effectively implemented at a local level under the
new organisational arrangements.
What CHI has found in:
9 NHS Direct servicesAlthough the quality of this work can vary, there are some good examples such as
using public reference groups, user forums, local partnership forums and focus
groups and holding days targeting specific patient and public groups.
Good practice Bedfordshire and Hertfordshire NHS Direct includes the views of ethnic
example: minorities, marginalised and vulnerable groups through initiatives such as an
equality and diversity group, ethnic minority focus groups and NHS Direct
information points in areas of social deprivation.
Generally sites receive very few complaints, and there is evidence that information
about complaints is regularly collected, analysed and acted upon to improve services.
Staff also receive complaint handling training and there are systems in place to deal
with complaints, that arise out of the national guidance. Sites also make significant
efforts to obtain feedback on their services by carrying out regular user satisfaction
and mystery shopper surveys. The results of these lead to changes to practice.
Roles and responsibilities
We have already outlined the complex management arrangements for NHS Direct
sites, combining strategic direction and performance management at a national
level, with local accountability through host trusts. This situation creates confusion
and a lack of clarity over roles and responsibilities. There needs to be some
refinement around how NHS Direct works on a local level and there are good
early signs of joint working with health partners.
CHI has consistently found a lack of clarity about the responsibilities and
accountabilities of NHS Direct sites, their host trusts and the Department of
Health’s central management team or the Welsh Assembly Government. This leads
to confusion between sites and host trusts about where responsibility for strategic
direction lies (with the host trust, the site, or the central management team/
Welsh Assembly Government) and can confuse lines of communication over
developments in policy, practice and performance.
Across all the components of clinical governance CHI has found variation
around strategic planning, policy formation and reporting structures across sites.
What CHI has found in:
NHS Direct services 10Almost half of the sites inspected have adopted, or fed into the strategies,
policies and committees of their host trust. Around a third of sites have developed
their own strategies, policies and committees, drawing on the national strategy
in order to respond locally. This illustrates the inconsistent approach, which needs
to be addressed.
There is also variation in how well host trusts and NHS Direct sites have integrated
with each other. Some host trusts are seen to be failing to provide sufficient
support in terms of local leadership and strategic direction. In some instances
host trusts could benefit from better integration of clinical governance and closer
working with NHS Direct sites.
There are, however, some examples of good formal and informal links with host
trusts in some components of clinical governance. For example, in education and
training, which helps create a supportive environment for staff, providing good
feedback and educational opportunities.
Good practice The host trust for West Yorkshire NHS Direct is developing an innovative vision of
example: where its services fit in with the rest of the local health community. Developing
the trust’s new call centre as a single point of contact for emergency, patient
transport, NHS Direct and out of hours services is part of that vision.
The Department of Health wants NHS Direct in England to integrate locally with
the wider NHS. One of the challenges of this new organisational structure will be
the effectiveness with which a national provider can integrate at a local level.
Despite variation in the degree of integration between NHS Direct sites and host
trusts, CHI found evidence of good relationships with other partner organisations
in the local health community. There are examples of initiatives such as
emergency care partnership groups, joint planning for children’s services, out of
hours planning with GP services and joint training programmes. However, further
work is still needed to persuade all healthcare professionals of the value of the
service; as in some instances the development and integration of NHS Direct is
not seen as a priority area. This was evident in the views of staff at some host
trusts, and is confirmed by the lack of close joint working between host trusts
and NHS Direct sites in around half of the sites reviewed.
What CHI has found in:
11 NHS Direct servicesEnsuring clinical effectiveness
Callers to NHS Direct want to know they will be receiving safe, high quality and
reliable advice provided in an appropriate manner and in a timely way. Using
performance and clinical information effectively is essential to achieving this.
5
Sites are required to audit CHI found that NHS Direct is good at collecting and reporting key performance
2% of calls daily. This entails
a trained call reviewer indicator data, in line with the national performance frameworks, at conducting
listening to random calls to call audits5, and at using both types of data to make improvements to services.
ensure compliance with
national call review However, there is potential for audit and information to be developed, analysed
standards, to report on and used in more sophisticated ways, which would enable patient outcomes and
individual profiles and to
identify trends. pathways to be better understood, developed and used, particularly at a local level.
Clinical information
When somebody telephones NHS Direct they will be asked a series of questions,
to which they will give a yes/no answer. Staff use these structured, evidence
based question frameworks (known as algorithms) to aid decision making and
ensure they give accurate and appropriate advice. The question frameworks form
the basis of the clinical service provided to patients who call NHS Direct. They are
developed by the clinical assessment system (CAS) governance group, part of the
central management team, which is responsible for making any necessary changes
to them. CHI found implementation of national guidance around algorithms to
be good, and that sites mostly follow the set processes for changing questions.
CHI also found that NHS Direct has systems in place to ensure staff have access
to an up to date evidence base to inform clinical practice.
Changes to the questions can be suggested at a local level through change request
forms that get fed back to the clinical assessment system governance group, but some
sites commented that the implementation of changes can be slow. In some instances,
CHI found evidence of staff choosing not to use algorithms without following the
formal reporting procedures. The central management team should carefully consider
the level to which this is happening and the potential risks that could result from it.
Some sites have a tendency to see implementation of national guidance around
algorithms as the only element of clinical effectiveness. In line with this, local
clinical effectiveness was found to focus on the algorithm review processes that
feed into the clinical assessment system governance group. There is potential for
sites to work more with other local health organisations on specific effectiveness
issues, for example through participating in external specialist interest groups and
working with the local health community on the development of care pathways.
Call audits5 are actively carried out at many sites and have led to improvements in
services, such as changes to documentation standards and changes to the greeting
at the beginning of the call to reduce the number of callers who hang up.
What CHI has found in:
NHS Direct services 12CHI found a tendency for NHS Direct to interpret call audits as the main form of
clinical audit. Call audits are a useful tool for assessing individual performance
but are not sufficient for improving clinical services.
A number of sites have undertaken clinical audits at a local level, in areas such
as mental health call referral and child protection, but these are not widespread.
There are also some good examples of audits undertaken with partners in around a
third of all sites reviewed, looking at, for example Accident and Emergency (A&E)
referrals. However, training to enable staff to undertake audit is variable across sites.
Risk management
CHI found that sites adhere to standards for reporting serious adverse events, but
that there is variance in relation to monitoring risk in clinical practice. There was
little evidence of trend analysis of adverse incidents, although this may be because
few incidents occur. The existence of site risk registers was found to be patchy.
At many sites staff are aware of what NHS Direct deems a near miss or an adverse
incident, but at others more could be done to improve staff awareness. Staff
understanding of risk was found to centre on algorithm use. Some clinical
performance indicators have recently been developed, for which reporting is in
place. Concepts of risk, risk reporting and monitoring, should be captured and
developed through analysis of the new clinical performance indicators. These
clinical performance indicators include multiple algorithm use (where one or
more algorithms are completed) and symptomatic sorting (where calls are sorted
in various categories such as 999, A&E, dental and pharmacist).
Performance information
Key performance indicator data is collected at all sites, in line with the national
performance frameworks, and is fed back to the central management team on a
daily basis, or on a montly basis to the Welsh Assembly Government. However,
some sites are making more use of this data than others. Some sites benchmark
their performance by analysing their own data alongside national comparative
data provided by the central management team. However, analysis rarely goes
beyond the scope of the national performance framework, and there is potential
for improvements across a number of sites.
The key indicators against which NHS Direct measures performance tend to focus on
capacity issues, rather than the effectiveness of the service. However, some clinical
performance indicators have recently been developed, for which reporting is in place.
These include indicators focusing on call sorting by category (health information,
symptomatic or other), non algorithm use (sorted by referral to another service or
not) and altered dispositions (the number of calls that have used one or more
algorithm). While these address issues relating to the effectiveness of the service
they do not emphasise patient outcomes.
What CHI has found in:
13 NHS Direct servicesStaffing and education: addressing NHS Direct staffing needs
Staff enjoy working for NHS Direct, are committed to providing a good quality
service and morale is generally high. Staff are well supported by management,
and there are good education and training prospects. CHI found that on the
whole staff enjoy working for NHS Direct and the sites provide opportunities
for flexible working. NHS Direct is a fast growing service and this provides some
continuing capacity challenges in the recruitment and retention of staff, which
the service will need to tackle.
CHI found NHS Direct staff are committed to providing good quality services and
are generally supported by management. There are many examples of good systems
for the management of NHS Direct staff, which are often supported by the continual
quality improvement framework. Many NHS Direct sites also adopt an open and
approachable management culture.
NHS Direct recruits nurses from a wide range of backgrounds to handle clinical calls6.
At its inception there was concern that NHS Direct would take too many nurses
6
NHS Direct Four Years On.
away from other NHS services. NHS Direct has responded creatively to the challenges
March 2002. in staffing a 24 hour telephone help line. It has worked to attract and retain
www.nhsdirect.nhs.uk
nursing staff through the use of flexible working practices and a commitment to
7
NHS Direct. A new gateway
to healthcare. NHS Direct,
education, training and continuous professional development. This creativity and
Leeds (2001) flexibility is reflected by over 60% of NHS Direct staff working part time7.
There are many examples of good recruitment processes. Assessment centres help
the applicant understand what the job entails at the recruitment stage and this
has resulted in reduced turnover of nurses at some sites. Some sites are continually
reviewing flexible recruitment, in particular joint posts with partner and host
organisations, such as rotational posts with ambulance trusts and NHS walk in
centres. However, some sites are experiencing persistent problems recruiting and
retaining staff.
Proactive approaches have been used to tackle the high sickness rates at some
sites. For example, supervised return to work programmes, actively seeking staff
views on the issues surrounding sickness rates and improved ill health assessments
have all been employed.
Opportunities for internal and external training are good and funding is available
to staff at all levels for personal development. Examples include: the use of
competency based induction; work based training; training in handling callers
with mental health problems and child protection issues; study for professional
8
Screening, care, advice,
qualifications and SCAN8 training. There are shut down days for training, where
next steps. calls are diverted to other NHS Direct sites, and staff usually have protected time
What CHI has found in:
NHS Direct services 14to undertake training. CHI found many instances of joint education and training,
such as shared training opportunities with the host and partner trusts, clinical
placements, modular programmes at local universities, links with social services
and national vocational qualification (NVQ) training at local colleges. However,
some sites have problems balancing the educational needs of staff with the
operational demands of the services. This means that workload pressures and
unusual working patterns prevent some staff from accessing training. In some
cases there is also a lack of awareness of training opportunities available to staff.
Systems for appraisal, personal development planning and clinical supervision are
in place but the quality of these are variable across sites, as is the assessment of
training needs and systematic methods for monitoring training. Training and
personal development plans should be renewed on a regular basis, fed back to
training coordinators and linked to organisational objectives. However, in practice
this does not always happen.
Good practice Bedfordshire and Hertfordshire NHS Direct have a robust appraisal system. The
example: appraisal system has clear links to both education and training needs and to
individual performance management.
In general, staff report that they feel supported by their peers and enjoy working for
NHS Direct. Staff at all levels are committed to providing a good quality service and
staff morale is generally high. Most sites place a high value on staff views, and
actively use staff surveys, away days and consultation committees to obtain feedback.
Changes are often made as a result, such as introducing family friendly policies.
Many staff said they felt valued and that their views and needs are considered.
In many cases, CHI found good systems for debriefing and counselling following
difficult calls.
However, some sites identified problems with communication which is sometimes
attributed to having a largely part time workforce and, in one instance, attributed
to a management culture that was perceived to be top down. Some sites need to
consider more structured ways of involving staff in clinical debates.
Good practice Hampshire and Isle of Wight NHS Direct held a successful annual staff away
example: day where staff were given the opportunity to give feedback. Their comments
were analysed and action was taken where possible and as a result staff felt
they had been genuinely listened to and involved in decision making.
What CHI has found in:
15 NHS Direct servicesThe developing role of NHS Direct
The Department of Health plan is for the NHS Direct number to become the single
point of access for out of hours care in England by the end of 2006, enabling easy
and fast access to emergency care networks1. In time it is envisaged that NHS
Direct will become the means by which patients are able to get in touch with any
part of the NHS. As part of this it is expected that use of NHS Direct will increase
rapidly over the next three years.
At the same time, NHS Direct in England is in the process of a major organisational
change towards becoming a single national provider that will provide services
commissioned at a local level by PCTs. This new emphasis is an attempt to address
the challenges faced by a national organisation with a local presence, and is
important in terms of devolving services to the front line. Lessons learnt from
CHI’s clinical governance reviews should help inform how this new structure could
work most effectively.
There is an obvious need for clarity about the roles and responsibilities of the
central management team, the local sites and commissioning bodies. In the
process of developing these roles, careful thought will need to be given to
balancing the desires of commissioners for local service developments and the
desire to maintain consistency in the service.
CHI found numerous examples of good partnership working with host trusts,
other local healthcare providers and educational bodies across all areas of clinical
governance, from education and training, to audit to out of hours planning.
If NHS Direct is to strengthen its effectiveness in the local health community,
partnership working will need to continue to develop and improve. The continuous
quality improvement element of the performance framework is a good foundation
to help NHS Direct achieve this aspiration.
What CHI has found in:
NHS Direct services 16Integration with GP out of hours services has emerged, from the Department of
Health, as a key development priority for NHS Direct in England. Alongside this,
strong operational and clinical leadership has been identified as being of critical
importance; maintaining and strengthening existing relationships with PCTs will be
fundamental to working towards this aim. It may require some effort on the part
of NHS Direct in terms of increasing awareness of the potential of their services.
Future arrangements for out of hours care in Wales are under consideration.
When considering these future arrangements, there is a need for Wales to ensure
clarity around responsibilities and accountabilities at a local and national level.
Many sites already provide opportunities for joint working, through job sharing,
rotational posts with A&E departments or PCTs, and links with pharmacists and
dentists. CHI encourages NHS Direct to develop these schemes further.
Integral to establishing whether NHS Direct is providing clinically effective services is
the need to develop performance indicators that focus on patient outcomes. These
would enable the service to assess what happens to patients after they have received
care or information from NHS Direct, and may help in the integration of NHS Direct
in the local health community. They may also enable the service to better assess
patient satisfaction with the care and information they receive from NHS Direct.
NHS Direct is a relatively new service successfully providing a new type of healthcare.
Many NHS Direct sites have recently undergone a major review of their clinical
governance arrangements. CHI found that many of the issues facing the service
have been given careful consideration and have been responded to in various
positive, and successful ways. There remains, however, a lack of clarity about
national and local roles and responsibilities and this needs addressing. NHS Direct
should also ensure that good work in clinical governance is continued and
improved, including managing the risks involved in the way in which algorithms
are generated and managed. The planned restructure provides an excellent
opportunity for NHS Direct to embrace the findings of CHI’s inspections of their
sites and use them to further enhance the unique and vital care they provide.
What CHI has found in:
17 NHS Direct servicesAppendix 1
Clinical governance reviews
CHI began undertaking clinical governance reviews of NHS Direct services in
mid 2002. This is part of the rolling programme to assess clinical governance
arrangements in NHS organisations in England and Wales, which has completed in
excess of 300 reviews. To date CHI has published 19 reports on NHS Direct services.
One review is in progress and four sites have yet to be scheduled. Many NHS Direct
sites have been reviewed in conjunction with their host trust, but some have been
reviewed independently. The present report draws on findings from the completed
clinical governance reviews and the Welsh CGR which is currently underway.
CHI defines clinical governance as:
The framework through which NHS organisations and their staff are
accountable for the quality of patient care.
Clinical governance reviews of NHS Direct services use the same process as in
other healthcare sectors. The tools we employ are also similar although adapted
to reflect the special circumstances of NHS Direct services.
These reviews describe and assess the seven components of clinical governance
which are assessed on a one to four scale:
• patient, service user, carer and public involvement
• risk management • clinical audit
• staffing and staff management • education and training
• clinical effectiveness • use of information
In addition, reviews describe the patient experience and the organisations’ strategic
capacity to deliver clinical governance, but these are not given numerical assessments.
The assessment system and a summary of the attainments by NHS Direct services
are included in Appendix 2.
During the reviews, evidence is gathered through documents, stakeholder interviews,
and further interviews and observations during a site visit. This involves a peer
review process, for which CHI seconds a team of people most of whom work in
the NHS. A review team typically has six to eight members depending on the size
and complexity of the organisation and will include a doctor, a nurse, an NHS
manager, a representative of the professions allied to medicine and a lay reviewer.
The team is managed by a review manager who is a CHI employee.
What CHI has found in:
19 NHS Direct servicesAppendix 2
Assessing components of clinical governance
On the basis of the evidence collected, CHI’s reviewers assess each component of
clinical governance against a four point scale:
I little or no progress at strategic and planning levels or at operational level
II worthwhile progress and developments at strategic and planning levels but not
at operational level
or:
worthwhile progress and development at operational level but not at strategic
and planning levels
or:
worthwhile progress and development at strategic and planning levels and at
operational level but not across the whole organisation
III good strategic grasp and substantial implementation. Alignment of activity
and development across the strategic and planning levels and operational level
of the organisation
IV excellence – coordinated activity and development across the organisation and
with partner organisations in the local health community that is demonstrably
leading to improvement. Clarity about the next stage of clinical governance
What CHI has found in:
NHS Direct services 20Attainments by NHS Direct services
The table below illustrates the spread of development in each of the elements of
clinical governance. Each indicates one trust attaining that level for the component.
Patient & Public I
involvement II
III
Risk I
Management II
III
Clinical Audit I
II
III
Staffing and I
Staff II
Management III
Education, I
Training and
Continuous Personal II
and Professional III
Development IV
Clinical I
Effectiveness II
III
Use of I
Information II
III
The scores above are the results of the inspections that CHI has carried out in England only.
The Welsh scores are not included because the inspection has not been published yet.
Three NHS Direct sites were not assessed, as they were pilot sites for the CHI methodology for
clinical governance reviews of NHS Direct.
It is worth noting that level IV has been attained on very few occasions in over 2,000 assessments
of different kinds of trusts.
What CHI has found in:
21 NHS Direct servicesAppendix 3
Performance measures and service targets for NHS Direct
in England and Wales
These are set and monitored by the central management team at the Department
of Health and the Welsh Assembly Government.
Targets
• 90% percent of telephone calls will be answered within 30 seconds
(following the message).
• 90% percent of symptomatic calls will be triaged within 20 minutes.
• 90% percent of health information calls will be actioned or assessed within 3 hours.
• Under 5% abandonment rate (after 30 seconds and following the message).
• Under 0.1% of all calls will receive the engaged tone.
• Maintain at least 95% of callers satisfied or very satisfied within the
telephone service.
Additional targets in England
• 90% percent of online enquiries will be responded to within 5 days of receipt.
• Maintain at least 65% awareness of the telephone service.
What CHI has found in:
NHS Direct services 22Commision for Health Improvement Finsbury Tower 103-105 Bunhill Row London EC1Y 8TG Telephone 020 7448 9200 Text phone 020 7448 9292 www.chi.nhs.uk
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