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Why NHS Direct is more than a call centre

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Nurses at NHS Direct do not have a hands-on role but, as Louise Hunt finds, they do need critical nursing skills.

For many nurses, the idea of swapping bedsides for headsets is somehow akin to early retirement. This is one of several misunderstandings about their work that NHS Direct (NHSD) nurses are keen to dispel.

‘I don’t feel any less of a nurse. It’s a very big misconception that you come into the service to be put out to grass and that it’s an easy option. It’s not easier, just different,’ asserts

Carol Tandridge, nurse adviser for NHS Direct Kent, Surrey and Sussex.

There are 1,200 nurses working for NHS Direct, which became a national service in 2000 after a two-year pilot. Its purpose is to unclog primary care services and A&E units by preventing inappropriate referrals through 24-hour access to health information and advice via three channels – telephone, internet and digital television. There are nine regional centres that host 28 call centres.

NHS Direct takes around eight million calls a year that are screened by call handlers who identify whether patients need a clinical assessment by a nurse adviser. These nurses develop far more skills than people might think, according to Helen Young, NHS Direct executive clinical director and chief nurse.

‘The external sector often voices concerns that nurses might get de-skilled [working for NHS Direct]. But, actually, it is quite the opposite because you are developing and using a broader range of knowledge all the time,’ says Ms Young, who worked as a nurse director in acute trusts before joining the organisation. She spends one day a month in a call centre to keep in touch with nurse advisers’ work and says she finds she uses more of her clinical knowledge on the phones than she did in a ward environment.

‘The main difference is to go through clinical assessments without seeing people. Suddenly, you have got the verbal clues without being able to match these to the visual ones – and that is difficult to say the least,’ she says.

From a career point of view, she believes it is one of the best jobs to develop the broad range of knowledge and skills needed to excel at triage and, rather than being a career cul-de-sac, working for NHS Direct could be a springboard into new nursing roles, particularly those in the community.

‘Nurses’ ability to triage is fine-tuned and I think that is a skill-set for the future as healthcare moves more towards treating people in their own homes. NHS Direct nurses have an understanding of all the community and social supports available and a wide general knowledge,’ she says.

For many nurses it is this challenge and the opportunity to consolidate years of experience that convinces them to make the leap. Treena Beard, who is now east region director for children’s services, initially joined NHSD as a nurse adviser, having worked in critical care settings in the UK and as a midwife in Australia.

She says she was attracted to the service because it was an opportunity to use all her skills in a new field. ‘Working for NHS Direct is an opportunity for any nurse who would like to diversify and suits someone who is calm and confident,’ says Ms Beard.

‘Because you don’t have direct contact with the patient, you have to develop acute critical thinking skills, which I found very challenging and rewarding.’

Flexibility is another draw. Nurses can work from 15 hours a week to full time. ‘Often, nurses have childcare or other work commitments and you can pretty much pick your hours,’ says Ms Young.

Having to do without direct contact with patients is an undeniable consideration for those who move to the service but nurses say this can be countered by other elements to the job.

‘Nurses sometimes say they miss the patient contact – I know I do,’ admits Ms Young. ‘They also comment on not being able to provide a complete episode of care; for the majority of calls you don’t hear back from the patients.’

But Julie Stott, who joined as a nurse adviser in 2004 and has since been promoted to a regional mental health lead, says: ‘I didn’t have concerns about the role not being hands-on.

There is a big role to play in health education and allowing people to self-manage. That very much interested me and wasn’t part of my previous role.’

In fact, as a nurse adviser, she found that she was able to give patients more attention during telephone assessments. ‘There were no interruptions to the care journey, nobody coming in and out of doors – I could really focus on patient care,’ she says.

NHS Direct admits it cannot offer nurses anything like the number of roles in mainstream NHS settings but it is working on expanding its options for career development. This has been prompted by a staff survey, published last December, which found that 57% of staff disagreed that there was career progression for those who wanted it.

‘We totally took that comment on board and we are responding to it through developments. We want to make NHS Direct a place for nurses to stay through their whole career if they wish,’ says Ms Young.

Currently, nurse advisers start at band six. They can also become supervisors and regional directors of nursing or, if they have relevant experience, take up posts as regional leads for children’s services or mental health. In these roles, nurses develop referral pathways and support nurse advisers on issues specific to those fields.

However, when there are no opportunities for nurses to progress upwards the organisation does encourage its staff to become involved in other aspects of work, such as secondments to auditing and research. Ms Young says: ‘As nurses we are used to a ward-based career structure. Here there is a different structure with fewer leadership roles. The opportunities are there, otherwise I wouldn’t have got to the position I am in. I feel well supported and encouraged to go further and explore my own training opportunities.’

This summer NHS Direct is starting a pilot in conjunction with NHS 24 (the equivalent of NHSD in Scotland) with the intention of developing an entry-level nurse adviser post. It will test two cohorts – those straight from qualifying and those with six months’ experience. ‘I would love to take nurses directly from qualifying. There is so much that NHS Direct has to offer but we are doing the pilot to ensure we keep patients safe and get the best model,’ says Ms Young.

It also wants to expand its opportunities for rotations in A&E units and primary care walk-in centres for those who wish to keep up with traditional nursing skills.
NHS Direct itself has been through a turbulent period of restructuring that has impacted on morale, admits Ms Young. Smaller call centres have been closed and consolidated, having been deemed technically unviable, and in some areas callers were experiencing waits stretching up to three hours for non-emergency call backs, when they should have been handled within 20 minutes.

‘Inevitably we lost some people who didn’t want to transfer and it has been painful because of the change. But I think most people now would say we have turned a corner,’ she says.

Future opportunities are likely to emerge if NHS Direct is awarded foundation trust status later this year. Some new services being considered are case manager roles for long-term conditions, such as diabetes. ‘The social care sector, supporting social workers and carers, is another domain we would like to explore,’ adds Ms Young.

It is a move that is rejuvenating enthusiasm among its staff. Ms Stott says: ‘Moving to foundation trust status will involve more local consultation about how we respond to what people want. For example, I am going to external meetings with mental health service users who want more one-to-one contact. Maybe this is something that NHS Direct is perfectly placed to do?’

The organisation is also fighting back against widely held criticism that patients usually end up seeing a doctor anyway. A tracking exercise looking at what patients do after using its services is indicating that more than half of its users are now self-managing and less than a quarter end up visiting a GP or A&E. ‘This year we are working towards a rate of 60%
self-management,’ says Ms Young. ‘But there will always be a proportion that we will need to refer.’

She adds that NHS Direct nurses have a role to play as ambassadors through every intervention. ‘What is consistent is the public love for NHS Direct. Every time it looks like we will get axed the public rallies to support us, which gives us political backing and that only lasts as long as we give a safe and responsive service.’

‘It’s nonsense to say that you don’t need to be a nurse to do the job’

As regional mental health lead for NHSD Yorkshire and Humber directorate, Mark Barker’s role is to provide specialist advice and training to his nurse adviser colleagues on mental health problems.

‘NHS Direct doesn’t have specialist mental health nurse advisers but I work closely with the [general] nurse advisers to provide training to enable them to manage calls more effectively,’ he says. His remit also includes developing referral pathways for people with learning disabilities.

Mark joined the service in 2000 on a 12-month secondment from a post as a community mental health coordinator.

‘The role came at the right time for me. I had been working as a clinician for 20 years. I was comfortable but wasn’t being stretched. This role has exposed me to a range of quite challenging experiences. It has helped me to develop broad political networking skills, along with personal training and leadership, which were blind spots in my previous role.’

For anyone who thinks that working for NHS Direct is a step away from nursing, he has this message:

‘Come and see what the nurses do. One of the criticisms that is levelled at us is that you don’t need to be a nurse to do the job but that is nonsense. We do need critical thinkers and nurses do work autonomously.’

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