NHS Direct: an evolving concept

Although the use of telephone health advice services is not new, a report by the Chief Medical Officer on emergency health services in 1996 was the first to suggest a national freephone NHS advice line. Such a service, it was envisaged, would integrate current service provision, encourage self-care at home where appropriate and foster appropriate use of the 'traditional' sources of emergency care: accident and emergency departments, general practitioners and '999' ambulance services. Despite the paucity of information regarding the safety and effectiveness of nurse-run telephone helplines and triage/decision support systems, The New NHS white paper announced that NHS Direct would be a central element of the government's strategy to achieve a responsive and dependable service.3 It was envisaged that NHS Direct would provide 'easier and faster advice and information for people about health, illness and the NHS' and also ultimately 'access to an integrated system of care that is quick and reliable'.

The three NHS Direct pilot sites have been running for more than a year, and with the second-wave sites launched in April 1999, over 19 million people in England can now access the scheme (see figure 1). Although the evaluation of the pilot sites is not due to be completed until the end of 1999 the government has deemed NHS Direct a phenomenal success. The roll-out of the scheme across England has been speeded up, and plans for NHS Direct Scotland and NHS Direct Wales are being developed for implementation in 2000. The scope of the service is also being extended in some areas beyond the core telephone help line, with many of the second-wave schemes providing direct links to other services. Some will also include the distribution of self-care guides for common ailments, and access via the internet to accredited information about diseases and self-help groups.1 More recently, the government has also provided money to pilot fast-access walk-in centres, as a supplement to NHS Direct and general medical practice services.

Figure 1
figure 1

NHS Direct coverage

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Early experiences

There are various reasons for thinking that NHS Direct may have either a major or a minimal effect on the way people access dental care and the organisation of dental services. On the one hand, access to care — particularly outside normal surgery hours — is a major cause of dissatisfaction among dental patients, and there is much confusion in the public's mind about the registration system and how to access NHS dentistry.4 If there is a genuine unmet need for dental care or information about dental services then it is likely that NHS Direct will become a major focus of these demands. On the other hand, if NHS Direct is perceived by the public as largely an extension of the 'traditional' sources of emergency medical care, then current patterns of dental care provision may co-exist relatively unchanged alongside the new advice lines.

To date the evaluation of the first-wave pilots of NHS Direct — in Milton Keynes, Lancashire and Northumbria — has focused on those services where the greatest impact might be expected: ambulance services, A & E departments and GP co-ops.5 Preliminary data revealed no changes in overall levels of demand which could be attributed to NHS Direct. There was also no discernible effect on demand for less serious conditions. Overall it is estimated that, in these three schemes, approximately 3% of calls were for dental problems.6

The initial evidence from the first-wave pilot sites therefore suggests that any impact of NHS Direct on dental services is not likely to be immediate. However, at the time of the surveys NHS Direct call volumes were relatively low but steadily increasing. The first report concedes that it is too soon to judge reliably how other services might be affected in the long-term.5 The findings also indicated high levels of satisfaction among callers, that the service was largely seen as an out-of-hours service and there was no evidence of adverse clinical events. On a less positive note NHS Direct appears to be under-used by older people, possibly reflecting that older people generally either do not like getting health advice over the telephone, or that they are more familiar with other sources of advice.

Implications for dentists and dental patients

Assuming that NHS Direct expands as planned, and that many more people with dental problems will call their local NHS Direct number, what are the implications? Of the various roles of NHS Direct, the referral of callers to the appropriate service when needed is perhaps the most important. It presumes the development of call-handling protocols and triage systems based upon clear definitions of what constitutes a dental emergency. At present many out-of-hours dental services sift their calls to a limited extent or purport to be for 'emergencies only', but only occasionally is this based on any explicit (ie written) definition. Formal triage, based on structured questions to identify clearly defined categories of problem, is a long way from what currently happens in most out-of-hours dental services.

Firstly then, the formal triage of callers — possibly by non-dentists aided by computer-based decision support systems — will require more explicit and locally agreed definitions of which dental problems require different types of care or advice. Such 'graduated access'7 might include advice on self-care until surgeries re-open for less severe conditions; advice to contact a dentist urgently; advice to contact a dentist within the next 24 hours; or advice to attend the local accident and emergency department for treatment of oro-facial injuries, bleeding or swelling. One approach is simply to adopt the questions and diagnosis algorithms for dental callers which are already a part of the decision support software. Many of the NHS Direct schemes employ software developed in the United States, with mixed success and with varying degrees of adaptation to UK and local professional norms.

Without confidence in agreed and tested triage protocols which are used by welltrained staff, dentists will be reluctant to delegate important decisions about their patients.

Crucially the nurses or other staff carrying out the triage will need to have sufficient experience or training in oral health and the organisation of dental services to use the information appropriately. At present this is certainly not the case: while NHS Direct nurses are appointed for their wide experience of medical problems, their knowledge or experience of dental conditions is probably very limited. Without confidence in agreed and tested triage protocols which are used by well-trained staff, dentists will be reluctant to delegate important decisions about their patients.

The second major challenge for dentists is what information should be given to callers with different types of dental problems.8 Whereas calls for many medical problems may result in advice to 'contact your GP', in most areas as much as half of the population cannot be said to have 'their own dentist'. A recent telephone survey of UK health authorities found that there were no formal out-of-hours dental care arrangements for as many as 5 million (unregistered) people at weekends (25 authorities) and 19 million (82 authorities) on weekday nights.9 For patients not registered with a dentist there may therefore be no clear advice on how they can get to see a dentist urgently, or the advice will vary substantially for callers in different places and at different times of the week. At present information regarding the availability of dental care out-of-hours is often not available from a single local source. If NHS Direct becomes a popular source of information about the NHS it will merely serve to highlight the fragmentary or non-existent availability of NHS dental services in many areas; in effect, for many unregistered patients it may become not so much a pathway to care as a dead end.

NHS Direct may also generate wider awareness among NHS-registered patients of their dentists' responsibilities to make out-of-hours care arrangements. Moreover, for callers judged not to be in immediate or urgent need, forms of advice will also need to be locally agreed which enable self-care and encourage appropriate attendance should the problem worsen.

It has been said that NHS Direct aims to do for health services what cash machines have done for banking.10 Such a revolutionary and positive vision of NHS Direct has relied on various assumptions — and some evidence — regarding the safety, effectiveness and acceptability of telephone advice for medical problems. Most of these assumptions have simply not been explored in relation to emergency dental patients or callers. For example, is it only a minority of dental callers who have a genuine and urgent need to see a dentist as soon as possible? Conversely, would the majority of out-of-hours dental callers in fact be satisfied (and effectively treated) by clear and appropriate telephone advice on self-care plus a reliable appointment the following day?

I have pointed to two challenges for dentists but others have raised more general issues, such as how to develop national standards for an ostensibly national service.10 Given the perceived need to reduce dental attendances in inappropriate settings, and to screen out those 'trivial' problems where self-care would be effective, the potential for NHS Direct to improve the effectiveness and efficiency of dental care seems considerable. This, and the continuing importance of access to dental services in political debate and public opinion, makes it paramount that dentists are aware of NHS Direct and contribute positively to its development.

Unlike medical GPs, for many of whom NHS Direct is a natural extension of the shift to out-of-hours co-operatives, most dentists are less familiar with the concepts and practices which are central to NHS Direct. The fragmentary nature of existing out-of-hours dental services, the relative lack of experience with formal triage, and the registration system arguably give dentists a more awkward starting point. However, NHS Direct is here to stay, and dentists need to decide whether to use it merely as a well-advertised and sophisticated call-handling system for existing services, or to help harness its full potential — as a universally accessible gateway to a more integrated primary care and health information service.