NHS Direct and nurses—opportunity or monotony?

Abstract

NHS Direct, the 24-hour telephone helpline providing information and advice about health problems, is available throughout England and Wales. It was envisaged as a nurse-led service presenting a new opportunity for the nursing profession. Free text comments from a postal survey of NHS Direct nurses revealed that a large proportion of nurses were happy with working in NHS Direct, and that it presented some nurses with the opportunity of a new and challenging role. However, a minority found the work monotonous and felt that NHS Direct is likely to face the challenge of staff retention.

Introduction

NHS Direct is a 24-hour telephone helpline established to offer “easier and faster advice and information for people about health, illness and the National Health Service so that they are better able to care for themselves and their families” (Department of Health, 1997). It began in three pilot sites in England in 1998 and rapidly expanded to 23 sites covering the population of England and Wales in 2001, with a Scottish version under development. The general public telephone the service for information or advice, and nurse advisors use computerised decision support software to triage callers to emergency care, primary care or self-care as necessary. NHS Direct is developing by expanding the range of services to which it relates, for example, the addition of pharmacy as a formal triage option, and strengthening relationships with other health services, for example, by triaging calls on behalf of general practice out-of-hours services (Department of Health, 1999).

Telephone triage services have been established in many countries; for example, general practitioners triage patients in their out-of-hours services in Denmark (Christensen and Olesen, 1998). Telephone triage is more commonly carried out by nurses than by doctors; examples include an out-of-hours service in primary care in the United Kingdom (Lattimer et al., 1998), an ophthalmic accident and emergency service in the United Kingdom (Marsden, 2000), an after-hours paediatric service in the United States (Poole et al., 1993), health maintenance organisations in the United States (Geraci and Geraci, 1994), and a province-wide helpline in Canada (Robb, 1996). However, in a global context, NHS Direct is innovative because it has been established on a national basis, is available 24 hours a day, and deals with all health problems in all age groups.

Nurse telephone triage has been shown to be safe and effective in terms of reducing general practitioner workload (Lattimer et al., 1998), and has been received favourably by patients (Poole et al., 1993). These findings have been confirmed for NHS Direct in that it has halted the upward trend in demand for out-of-hours general practice (Munro et al., 2000), it has reduced the number of telephone calls for advice being dealt with by accident and emergency clinical staff (Jones and Playforth, 2001) although it has had no effect on attendances to accident and emergency services (Munro et al., 2000), and callers find the advice helpful and reassuring (O’Cathain et al., 2000). Other empirical research on NHS Direct has shown that emergency ambulance calls generated by NHS Direct have similar triage categories on arrival in accident and emergency departments as self-generated calls (Gaffney et al., 2001), and that collaboration between health professionals is an important aspect of this new service (Rosen and Pearce, 2000). However, there are many more aspects of this new service to explore such as the appropriateness of advice given by nurse advisors, the delivery and organisation of the service, and its impact on the nursing profession.

The organisation of NHS Direct resembles that of commercial call centres, where employees sit at computer terminals, wearing headsets, and take calls from the general public regarding a range of issues. Over the last 10 years there has been a significant growth in commercial call centres for banking and insurance in Europe, America and Australia. This has led researchers to explore whether this new work practice offers employees new opportunities for skill development and career progression, or a highly routinised and de-valued area of work (Belt et al., 2000; Taylor and Bain, 1999; Knights and McCabe, 1998). The positive image of call centre employment is that it is highly skilled knowledge-intensive work. Indeed, employees themselves have recognised the skills needed in taking calls and the opportunities for women to move into managerial roles which was not necessarily available in their previous workplaces (Belt et al., 2000). However, criticism of call centres includes labels of “customer service sweatshops” and “sweatshops of the 21st century”, resulting in high staff turnover (Taylor and Bain, 1999). Research has identified specific problems such as workers’ desire to have breaks from taking calls due to the repetitiveness of the job, the emphasis on monitoring of calls, the need for more flexible family friendly working hours, and the flat organisational structure leaving little opportunity for promotion (Belt et al., 2000).

From the start, NHS Direct was envisaged as a nurse-led service, and health ministers suggested that this “new career direction” for nurses would encourage those who had left the profession to return (Dobson, 1999). It was seen as an important service development for nurses in a time of nurse shortages and disillusionment amongst nurses in the United Kingdom (Seccombe and Smith, 1997). However, in the light of evidence that new roles in nursing do not necessarily lead to job satisfaction (Collins et al., 2000) and the problems highlighted around call centre working (Belt et al., 2000), we felt that it was important to study the views of nurses adopting this new role in NHS Direct in the United Kingdom.