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NHS Direct: the early years

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VOL: 98, ISSUE: 19, PAGE NO: 39

Sandra Nolan, BA, RGN, is education and professional development coordinator, NHS Direct North West Coast

In January the Audit Commission acknowledged that NHS Direct has relieved other patient services in the NHS (National Audit Office, 2002). This marked a sea change for the service, which was conceived by the Conservative Party, delivered by the Labour government and has been contentious from the outset.

In January the Audit Commission acknowledged that NHS Direct has relieved other patient services in the NHS (National Audit Office, 2002). This marked a sea change for the service, which was conceived by the Conservative Party, delivered by the Labour government and has been contentious from the outset.

The New NHS: Modern, Dependable (Department of Health, 1997) called for the provision of 'quality patient care, whenever and wherever needed', laying the foundations for the development of NHS Direct. The idea was promoted by the Information for Health strategy (DoH, 1998), which called for 'fast and convenient public access to information and care through online information services and telemedicine'. In line with this aim, NHS Direct enables nurses to carry out clinical consultations and assessments over the telephone, supported by computer-based clinical decision support systems. These are designed to ensure the safety of callers by providing consistent advice and a clinical record of the consultation.

The complexity of the role and the broad range of questions and crises nurses employed by NHS Direct may have to deal with means that they are expected to have a good understanding of at least two clinical specialties and a minimum of five years' nursing experience.

Telephone services
Before the establishment of NHS Direct, a range of local services were offered in many areas, but this was done in a fragmented and informal way. Some nurses gave informal advice over the telephone through general practices, A&E departments and community nursing services to patients who had been discharged or had questions about their illness or aspects of their treatment.

Most telephone advice was given without evidence-based support and was not recorded. The need to record such conversations was highlighted by a pilot postoperative telephone service run in Burnley between October 1996 and March 1997 (Heseltine and Edlington, 1998). It found that although a questionnaire was used in providing the service, the data could be misinterpreted because of variations in the way it was written down. NHS Direct uses the latest telecommunications technology, which enables all calls to be recorded and provides uniformity of gathered and interpreted information.

Computerisation
NHS Direct deals with a huge volume of calls: in December last year it took more than 500,000. Comprehensive record-keeping is therefore essential, as is a robust evidence base to support the advice and guidance given. Callers describe a wide range of conditions and presenting symptoms, and the advice they receive should not depend on which nurse takes the call or what part of the country the patient is in.

A clinical assessment system manages enquiries from anywhere in England and Wales. Nurses enter source data, such as presenting symptoms and medical history, and the computer analyses the symptoms, suggests diagnoses and recommends an appropriate course of action. Crucially, the nurse can accept or reject its recommendations.

Nurses are selected on the basis of their extensive clinical experience, because the ultimate decision on what to advise the patient rests with them.

A nurse-led service
With the establishment of NHS Direct as a nurse-led service, the government showed its support for nurses as autonomous practitioners. This may have been for financial or strategic reasons, but its efforts to ensure that patients receive appropriate care for specific problems is laudable.

The UKCC backed government recognition that the nurses, midwives and health visitors employed by NHS Direct enjoyed the confidence of the public and possessed the skills, ability and knowledge to deal with the range and complexity of the calls they receive (UKCC, 1999). This rubber-stamped what the RCN had pre-empted when it issued Nurse Telephone Consultation Services: Information and good practice in 1998. In doing so the RCN and UKCC formalised what had previously been an informal and fragmented practice.

Growing pains
Nurse advisers at NHS Direct will continue to develop their roles and responsibilities. The main component of this lifelong-learning pathway is clinical supervision, which has been an invaluable tool in supporting nurses as they develop professionally and clinically. Peer-group meetings, with a thorough infrastructure for 'live' clinical supervision, followed by critical analysis of consultations have empowered nurses to share knowledge, ideas and concerns.

This enables nurse advisers to identify their learning needs, which can be met through study, clinical placements, research and discussions with colleagues.

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