Scottish Government

THE WAY FORWARD FOR NHS 24

The immediate priority for NHS 24 is simply to deliver a safe and acceptable service over the coming winter season. Nothing must be allowed to get in the way of that. The picture we sketch below is about 2006 and beyond; not short-term survival but planned, prolonged, sustained and sustainable improvement.

Earlier in this report we set out the reasons, as we see them, why NHS 24 cannot consistently deliver the high quality of service which it delivers most of the time. We now bring together our views on some of the ways that greater consistency might be achieved (and again we emphasise that some of this work is already being tackled by NHS 24). Most of the detail is, of course, contained elsewhere in this report; we have said all along that all of the issues highlighted in the Minister's remit and our responses are hugely inter-connected and interwoven.

For the avoidance of repetition we emphasise that consideration of any significant change will, of course, include the full process of risk assessment.

The Handling of Calls Received

We think the way that calls are managed needs to be changed in a number of ways:

• to acknowledge the changed role of NHS 24 itself in ways that will improve the quality of delivery and which might well increase personal job satisfaction;
• some further empowerment of experienced call-handlers to allow them to make appropriate decisions;
• recognition that algorithms should be useful discretionary tools for highly trained and experienced nurse advisers;
• technical operational management should be allowed to apply basic "call centre"-type practices and techniques where appropriate while observing, as always, clinical standards;
• triage should be shorter in length in some instances - and longer in others as appropriate;
• nurses advisers would benefit from further training in the technique of triage;
• urgent calls need to be identified and treated as such;
• where triage concludes that a medical appointment is needed those arrangements should by a call-handler and not by the nurse adviser;
• calls from remote and rural districts should be quickly identified and dealt with accordingly;
• every effort must be made to match the required resource with the predicted call volume - particularly over the peak but unpopular shifts;
• effective integration with social services across Scotland - whether centrally via SEHD or locally via Health Boards;
• consultation with the voluntary sector in Scotland on the most appropriate handling of some specific types of call.

Some Points on Demand at Certain Peak Times

We made the point earlier that NHS services in OOH periods (at night and over weekends) have always been available on an "emergency" or "urgent" basis. It is important that that remains the case and that non-urgent cases that can safely wait for the GP surgery to re-open do not obstruct calls that do need an earlier response. That is sometimes a difficult balance and the benefit of any doubt must always be with the caller.

There is a great deal of largely anecdotal but persuasive evidence that a fairly significant number of calls at peak weekend periods are not 'urgent' - ie they could safely await the re-opening of the surgery on the Monday morning. That is not a criticism of those who call and we recognise that it is not an easy message to get over in a caring and responsible manner. But it is not so much about imposing a restriction as correcting an impression misleadingly put out by NHS 24 (however well intentioned at the time); a message put out before the new world of 2004, when GPs still had the responsibility for out-of-hours care.

• we think it would be effective, at weekends and public holidays, to give some sort of automated message to that effect as soon as the call gets through;
• that message would be better understood, and probably more readily accepted, if Health Boards were to include something similar in more general information pieces that they are putting out to the public - as at least one Health Board has already done;
• a national communications strategy re-defining the role of NHS 24 and NHS Boards during out-of-hours should be co-ordinated by SEHD;
• in the continuing absence of NHS 24's own healthcare website we recommend that the public in Scotland should be provided with easy access to NHS Direct's website - which, we understand, is popular and well used down south (the website took just over one million hits last month);
• the point we make above about matching resources to generally quite predictable demand becomes even more important at peak times;
• NHS 24 ought to be well prepared to download calls to willing Health Boards, quite early in the process, when exceptional 'spikes' (which it would be quite uneconomic to staff up to) make that a reasonable and sensible thing to do.

Shortage of Nurses to Cover Shifts

• NHS 24 has a reputation for being a good employer. Being 'employee friendly' it has tended in the past to agree individual employee preferences for particular shifts. That has produced more than 300 different shifts to manage but that is not the main problem; the real problem is that this large number of shifts often does not afford cover for some of the busiest (and least popular) periods. The problems are considerable and not easy to resolve. We appreciate the restrictions on remuneration packages across the NHS generally and we note the need for the national negotiations to pay heed to this sector;
• the points made earlier about some limited empowerment of call-handlers and greater discretion to experienced nurse advisers seem very relevant here also;
• again, when all possible internal procedures have been exploited to the full, pre-planned, short-term assistance of Health Boards might come into play.

Failure to Maximise Technology, Telephony, etc, within Contact Centres

We have already covered this earlier in some detail.

• we believe NHS 24 already has plans to bring in experienced call centre managers for a trial period;
• that may, in turn, free up some of the time of very experienced nurses who could play an important part in the redesign of the way calls are handled clinically - by call handlers and by nurse advisers alike;
• that freed-up time could also allow those very senior and experienced nurses to support both call handlers and nurse advisers by providing real time training and feed-back;
• it seems possible to recognise a repeat call without going through all the preliminary detail again - but that still seems to happen at times and clearly irritates the caller.Time Taken to Reach a Conclusion on the Appropriate Response

We know that this is one of the most common complaints that callers make. The reaction is understandable when a caller is anxious - or if it has already taken some time to get through. It is also understandable when a nurse adviser is dealing with what might be a complex situation. But more generally:

• when a nurse adviser is quite clear on the action to be taken we see no reason why there should be further unnecessary dialogue.

Over-cautious Approach to the Use of Algorithms

• unnecessary adherence to a lengthy algorithm will not increase the nurse adviser's confidence; it might indeed encourage a degree of risk aversion.

Call-back

We have already given our clear views on the damage that sustained use of call-back as an integral part of the process of handling calls can do. We are equally clear that:

• call-back has to be reduced to a manageable basis;
• management must monitor and review call-back on a daily, not on an average weekly (or whatever) basis;
• management must recognise that it is actually managing 2 quite distinct contact centre delivery requirements - one covering Monday to Friday (pm) and another covering Friday evening through to Monday morning;
• everything that has been said about managing calls, managing volumes, different ways of using resources, empowerment, discretion - all the way through effective partnership working; all of these are relevant to controlling call-back;
• but all of these must be introduced if this overwhelming handicap - to callers and to staff - is to be reduced to the manageable.

No other remedial action is more essential to the future success of NHS 24. It has become embedded over 3 years. Recovery must be achieved in a significantly shorter time.The Seamless and Effective Handover of Patients

This is a hugely important aspect of patient care, but it does not seem unreasonable to suggest that in the past not too many patients moving from one part of the NHS to another would have immediately considered that they were fortunate that they were being looked after by that holistic organisation known as 'NHSScotland'.

We in the Review Team are delighted that all the current signs are of partnerships, keen to take on real, meaningful, partnership working within NHSScotland. Not just partnership working between neighbouring Health Boards but involving Primary Care, A&E services, the Ambulance Service, NHS 24. The future will surely extend that partnership working fully to embrace social services - and to include some of the huge potential of the organised voluntary sector.

Add the framework for primary care set out in the Kerr report and the scope for real improvement for patients going from one part of health and social services to another is immense. That opportunity must not be missed and the situation of NHS 24, perhaps a little paradoxically, certainly provides the opportunity to make a real - and recognisable - start.