Many of you supported the idea of a simple triage system and some supported
NHS Direct. Amongst the critics was the common comment that NHD Direct "just
referred patients on for treatment by GPS or A&E Departments" and evinced
surprise at my support for NHSD. I think we need to look at this
historically. Rob Cocks referred to Jeremy Dales work in the early 90s on
Primary Care patients in A&E . I was lucky enough to work with Rob and
colleagues when they were developing the nurse triage system for telephone
advice offered by nurse practitioners. This system has subsequently been
developed further to provide one of the scripts supporting NHS Direct, along
with two other sysyems developed in the USA, which have been adapted for the
UK. None of these systems are perfect as they have had to verge towards
caution . However, I do believe that this is the way ahead. Public education
through advertising etc. has had little effect. Telephone advice will
gradually inform the enquiring public - often the frequent users of the
system - if it is used correctly. Over this last holiday it was easy to
blame each other yet we were running a "Health Gold" system for region at
Essex Ambulance Service, collating emergency activity for health and social
services. The pattern of various workloads were monitored closely and the
heavy increase was matched over A&E, Ambulance Service, GPCo-ops,
Healthcall, Social Services and NHS Direct. Up to 200% increase in calls was
received by some co-ops and 100% by NHS Direct. These figures were matched
in other areas of the country, and aggravated by a shortage of ITU beds..
NHS Direct was not always able to answer all calls quickly , any more than
other services. Both the co-ops and NHSD had to put a holding message on
their tapes for short periods. NHSD also piloted the transfer of carefully
selected 999 calls (from category C) to reduce the load on the ambulance
service. Although 20% were found to need A&E services, most had their own
transport and were willing to attend under their own steam wheas the other
80% received telephone advice or  were asked to contact their family doctor
at a later time. Of the 1,000 NHS D calls at the peak period, over 40%
accepted telephone advice. Yes, many were referred to their GPs at a later
time and a few were directed to A&E and GP Co-ops, but the system is in
place and is being honed into being a useful adjunct to our emergency health
provision. We have just started to include Social Services Direct into our
system which was busy over Christmas too, and in April will include a fourth
disposition, to visit the pharmacist. The local and national  pharmaceutical
societies are working closely with us on this. I still see it as the way
ahead and, in conjunction with the co-ops, could provide an emergency
medical practitioner service to offer a fifth disposition.
Thank you all for your replies, both to the list and to me personally
Yours Judith Fisher
-----Original Message-----
From: Robbie Coull <[log in to unmask]>
To: [log in to unmask] <[log in to unmask]>
Date: 03 January 2000 19:36
Subject: Re: NHS Direct triage


>Judith,
>
>I think a national system of nurse telephone triage is a good thing,
however
>I have anxieties about NHS direct as it is as present which make me very
>nervous.
>
>1.  GPs (and A+E) feel left out of the loop in many ways and this is going
>to make acceptance of the system difficult.  GPs are asking who will get
>sued if NHS direct makes a mess of their patient's call?
>
>2.  Lack of sufficient operators at peak times.  No telephone system will
>ever be successful if they are engaged!  Health care is not a customer
>support line, and the public will rapidly (and irreversibly) lose faith in
a
>system that they cannot contact.  They already, rightly or wrongly, hate
>deputising services for this reason, whereas they like A+E and the
ambulance
>service because they are seen as easily contactable.
>
>3.  A lot of people (myself included) have anxieties about the triage
system
>used - triage systems are controversial anyway, but NHS direct seems
>universally to be seen as poor.
>
>I have not seen the algorithms you use, but the website ones are not very
>encouraging.  They appear to lack a logical and consistent approach (such
as
>asking low discriminator questions before high discriminator ones, or
giving
>different advice depending on where in the algorithm you are).
>
>Can you elaborate on who wrote the algorithms and how they were assessed
>clinically.  Did you look at other systems in use (eg: A+E, ambulance,
>foreign)?
>
>NHS direct needs to overcome these problems if it is to be successful in
the
>long run.  It won't take many deaths from poor triage or delays in
answering
>before NHS direct falls into real disrepute with the public, so you need to
>sort these things out rapidly.
>
>What do you think NHS direct can do to overcome these problems?
>--
>
>
>> From: "Dr J. M. Fisher" <[log in to unmask]>
>> Reply-To: [log in to unmask]
>> Date: Mon, 3 Jan 2000 08:21:57 -0000
>> To: <[log in to unmask]>
>> Subject: Re: What is a primary care problem?
>>
>> Dear Friends and Tim in particular
>> It will not suprose you that I support your (AWWs and mine too)  ideas
for
>> an Emergency Care Practitioner and abolition of the 24 hour GP contract
but
>> wonder how you see the present infrastructure of hospitals supporting
thhhis
>> increased work load. Most A&E Departments are complaining about
overcrowding
>> already. You could consider retaing the system of triage used by NHS
Dirct
>> to send patients to an out of hospital Emergency Care Practitoner, based
on
>> existing community facilites, retaining hospital referral for those who
>> really need hospital facilites.  NHS Direct already has the commuication
>> networks to work closely  with GP Out of Hours Services, often triaging
>> calls for them to reduce the GP workload. This could extend into
providing
>> the contracts for the doctors and sharing premises, as well as sharpening
>> the referral to hospital algorithms. The present busy period has
highlighted
>> the fact that all services were stretched to the limit,  and a review is
>> imperative.
>> Happy new year. Comments welcomed
>>
>> Judith.Fisher FRCGP FFAEM
>> (Medical Director Essex Ambulance Service NHS Trust and Essex NHS
>> Direct )
>
>





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