Warwickshire LINk organized a seminar on March 16th to discuss Warwickshire Healthline, a new telephone service that will provide a single point of contact for people in need of healthcare. The service has been in development for some time, it is already in use by GPs and other clinicians, and it is soon to be opened to the public.
The seminar was advertised as a “development session”, and its goals included:
- Evaluating the script that call handlers will use when answering a call
- Helping to develop the customer satisfaction tool that the provider will use to evaluate the service
These goals could not be met because the service provider’s senior representative did not attend. Even so, and despite a late start caused by inadequate directions to the venue, the seminar was very interesting. About ten people attended.
There was an introduction by someone from NHS Warwickshire, the primary care trust that has commissioned the service. She seemed to think that the Healthline had been in development for eighteen months. (In fact a decision to create a single point of access had already been made three years ago, having been announced in the March 2008 paper: A Healthy Future for Warwickshire, and I would imagine its origins must have been somewhat before that.)
A clinician who works with the service provider, South East Health Limited, was their only representative. She had not had time to prepare a presentation, but she was able to share some of her experiences. South East Health is a private sector provider of out-of-hours services and other primary care services, created and run by a large group of GPs.
The seminar’s organizers claimed that they had not been given access to the service model and specification, and this information was not available for the seminar. However, the service model and specification are in fact publicly documented as reported to a public meeting of the NHS Warwickshire Board in August 2010: Single Point of Access (Procurement of Warwickshire Healthline)
What is it for?
Without access to the specification, there was some confusion about what Warwickshire Healthline (WHL) is actually for.
A new 111 service for non-emergencies is being piloted by the Department of Health in some areas, but Warwickshire is not one of the pilot areas and WHL is not the same thing. In the pilot, 111 is integrated with the 999 emergency service. When 111 becomes a national service, WHL might or might not become Warwickshire’s 111 service (although its telephone number, 03000 247 111, suggests that may be the intention).
NHS Direct (0845 4647) is to be replaced by 111, but that does not mean that 111 will have a single national provider like NHS Direct. (According to the public document, NHS Direct chose not to bid to provide the WHL service, partly because of some mysterious concern they had about the service specification, but none of this was made known in the seminar.)
The question of what WHL is for was never fully and clearly answered. It certainly acts as a directory enquiries service, holding a database of contact numbers and putting calls through. It also acts like a telephone triage service, determining the clinical nature of each case and identifying an appropriate provider.
There were some other suggestions about what it might be for, but there was even less clarity around these, and they were not specifically confirmed.
WHL might hold information about service availability in its database, so that it only directs each call to a service that can actually take the case on. But it was not clear how WHL would obtain this information on availability and ensure it is always reliable, and it was not clear how or whether WHL would manage waiting lists.
WHL might take clinical responsibility for making an appropriate referral, perhaps acting like a bed bureau. This would mean that, for example, once a GP had contacted WHL and passed on all the relevant information, he or she could forget about the case, confident that WHL would take it from there.
WHL might handle the entire referral process to each clinical service, resulting in widespread cost savings, but it was not clear how this would really work and there was no indication that it had ever been planned for.
WHL might be a “one-stop shop” for all healthcare matters, or it might only be for urgent needs.
WHL might be able to make appointments with GPs, or it might not.
It was stated that WHL includes out-of-area services in its database, but not third sector or private healthcare services. However, it is not clear that these statements can be relied on, because there was no specific mention of agreements with neighbouring NHS trusts to take WHL referrals, and it seems absurd that NHS contracts with third sector or private sector providers would be ignored.
WHL is currently being used by GPs and other clinicians to access acute and community services, though it was said to be receiving few calls and there was said to be “work to do” to get clinicians to use it more. It was not made clear what form this work would take.
The clinician who works for WHL had used the service herself with mixed results. WHL had been able to locate a service for the patient, but it had not handled the referral entirely satisfactorily, and further telephone contact had been needed to sort things out.
A leaflet advertising the service to clinicians mentions that it includes social care services, but it was remarked at the meeting that social care is not yet in WHL’s directory of services.
The trial continues while unspecified “technical issues” delay WHL’s public launch until May.
The call centre
There was criticism of the choice of service provider, with concern about job losses in Warwickshire as the call centre in Kent takes work that could have been done locally, and about regional differences in accent causing confusion. However, it was pointed out that the decision had been made long ago so that there is nothing to be gained from criticising it now.
Call handlers will use the national NHS Pathways system to determine how to handle each call. No one present at the seminar knew a great deal about NHS Pathways. In particular, it was not clear whether or how it adapts to local circumstances in Warwickshire. Also, at first glance it appears to be geared towards assessing undiagnosed symptoms, which might not be typical of the non-emergency callers WHL is aimed at.
The call handlers are not clinically trained, but some clinicians will be available in the call centre at all times.
It was claimed that NHS Warwickshire has been promised a dedicated team of its own call handlers, even though this seems to make no sense for the service provider. For example, it would mean that if there was a disaster somewhere else in the country, any call handlers in the Warwickshire team who happened to be idle could not be reassigned to help out.
It was pointed out that as the service will be making clinical judgements, and that as no system for making clinical judgements is 100% perfect, some mistakes will inevitably be made, and a proportion of those will end up in the news or in the courts. The impression given in the seminar was that NHS Warwickshire and WHL had not thought of this, but I find that hard to believe.
The seminar ended with a brainstorming exercise to determine the top ten indicators of customer satisfaction. Apparently these are to form the basis of a customer satisfaction survey.
Several participants were concerned that the service would be easy for the public to use — for example, that it would answer calls quickly, employ interpreters if necessary, be free from jargon, and that callers would feel listened to. Others were more concerned about clinical matters, like the accuracy and coverage of the directory of services database, and the outcomes that callers experience.
Peculiarly, the clinician who works for WHL conducted this session. From all the suggestions put forward, she picked the final ten, ensuring that no outcomes were picked. Indeed, at one point she went back to the flip chart where she had written all the suggestions and crossed out the word “outcome”. As a result, the final ten were all process measures.
My conclusion was that the LINk is right to get involved in WHL, even at this late stage of its development. There is a worrying lack of clarity about what WHL is for and how it will achieve whatever it is that it is meant to achieve.
It is also worrying that the service provider’s website does not mention any similar services to this. It might be that aspects of WHL will prove difficult for them while they build up experience, and that might have an impact on clinical outcomes. This could account for the “technical issues” delaying the launch.
The leaflet for clinicians mentions features of WHL that were never mentioned in the seminar:
…alternative care pathways for patients with urgent healthcare needs who otherwise might have been sent to A&E unnecessarily.
And on another page:
…alternatives to [hospital] admission.
These features match the statement of financial implications in the publicly documented specification:
…supporting the planned reduction in avoidable hospital admissions.
It might well be, for all I know, that Warwickshire’s clinicians do seek hospital admissions for their patients unnecessarily, but if that is so, then contracting with a call centre in Kent seems an odd way for NHS Warwickshire to make the point. It also seems possible that this financial goal of reducing hospital admissions might have been the mysterious concern that caused NHS Direct not to bid, because it might have scary legal implications for the service provider.
Many aspects of WHL are like this, with only partial information available, the real purpose not clearly defined, and the outcomes for patients in doubt. This seminar was the first time that I have been involved with a PCT’s work, and if this is the way they typically behave, I can appreciate the case for abolishing them. However, I get the impression that Warwickshire LINk plans to follow up this seminar with further action, and it might be that one day all will be made clear.