Commission for Health Improvement

Commission for Health Improvement What CHI has found in: NHS Direct services sector report

  • 2 What CHI has found in: NHS Direct services Introduction from Dame Deidre Hine Context CHI’s findings Service user perspective
  • service user involvement Roles and responsibilities Ensuring clinical effectiveness
  • clinical information
  • risk management
  • performance information Staffing and education: addressing NHS Direct staffing needs The developing role of NHS Direct Appendices: 1: Clinical governance reviews 2: Assessing components of clinical governance Attainments by NHS Direct services 3: Performance measures Contents 10 12 12 13 13 14 16 19 20 21 22 What CHI has found in: NHS Direct services

3 What CHI has found in: NHS Direct services 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.

Introduction from Dame Deirdre Hine What CHI has found in: NHS Direct services

4 What CHI has found in: NHS Direct services The 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

5 What CHI has found in: NHS Direct services 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. Context What CHI has found in: NHS Direct services

6 What CHI has found in: NHS Direct services NHS 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 of 10% of the population have made calls to NHS Direct each year. This figure is expected to increase for at least the next three years. CHI is responsible for a programme of patient surveys in England. Our survey in 2003 of patients in England who use primary care services, found that 22% have contacted NHS 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 contact NHS Direct for a wide range of problems, ranging from emergencies and 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.

1 Developing NHS Direct. A strategy document for the next three years.

Department of Health (April 2003) 2 CHI national patient survey of primary care trust patients. (2003) 3 NHS Direct. A new gateway to healthcare. NHS Direct, Leeds (2001) What CHI has found in: NHS Direct services

7 What CHI has found in: NHS Direct services A 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: NHS Direct services

8 What CHI has found in: NHS Direct services CHI’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 three hours, and the target to have under 0.1% of calls getting through to an engaged tone4 . The success of NHS Direct means it will have to ensure it is setting 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.

4 Health intelligence unit. The performance frameworkservice delivery targets. What CHI has found in: NHS Direct services

9 What CHI has found in: NHS Direct services Good practice example: Good practice example: South Yorkshire and South Humber NHS Direct have taken a proactive 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. The Avon, Gloucestershire and Wiltshire NHS Direct site have worked hard within 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: NHS Direct services

10 What CHI has found in: NHS Direct services Good practice example: Although 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. Bedfordshire and Hertfordshire NHS Direct includes the views of ethnic 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

11 What CHI has found in: NHS Direct services Good practice example: Almost 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. The host trust for West Yorkshire NHS Direct is developing an innovative vision of 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: NHS Direct services

12 What CHI has found in: NHS Direct services Ensuring 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. CHI found that NHS Direct is good at collecting and reporting key performance indicator data, in line with the national performance frameworks, at conducting call audits5 , and at using both types of data to make improvements to services. However, there is potential for audit and information to be developed, analysed and used in more sophisticated ways, which would enable patient outcomes and 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 5 Sites are required to audit 2% of calls daily. This entails a trained call reviewer listening to random calls to ensure compliance with national call review standards, to report on individual profiles and to identify trends.

13 What CHI has found in: NHS Direct services CHI 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: NHS Direct services

14 What CHI has found in: NHS Direct services Staffing 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 away from other NHS services. NHS Direct has responded creatively to the challenges in staffing a 24 hour telephone help line.

It has worked to attract and retain nursing staff through the use of flexible working practices and a commitment to education, training and continuous professional development. This creativity and 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 qualifications and SCAN8 training. There are shut down days for training, where calls are diverted to other NHS Direct sites, and staff usually have protected time 6 NHS Direct Four Years On. March 2002. 7 NHS Direct. A new gateway to healthcare. NHS Direct, Leeds (2001) 8 Screening, care, advice, next steps.

What CHI has found in: NHS Direct services

15 What CHI has found in: NHS Direct services Good practice example: Good practice example: to 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.

Bedfordshire and Hertfordshire NHS Direct have a robust appraisal system. The 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. Hampshire and Isle of Wight NHS Direct held a successful annual staff away 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: NHS Direct services

16 What CHI has found in: NHS Direct services The 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

17 What CHI has found in: NHS Direct services Integration 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: NHS Direct services

19 What CHI has found in: NHS Direct services Appendix 1 What CHI has found in: NHS Direct services 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
  • staffing and staff management
  • clinical effectiveness 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.
  • clinical audit
  • education and training
  • use of information

20 What CHI has found in: NHS Direct services 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 Appendix 2 What CHI has found in: NHS Direct services

Attainments 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. 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.

21 What CHI has found in: NHS Direct services Patient & Public involvement Risk Management Clinical Audit Staffing and Staff Management Clinical Effectiveness Use of Information Education, Training and Continuous Personal and Professional Development I II III I II III I II III I II III I II III IV I II III I II III

  • 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. 22 What CHI has found in: NHS Direct services Appendix 3

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