Evaluate the Impact of the National Health Services Direct, It’s Success Rate and the Changes it has Made in UK Health Care Practices and Procedures
-
Anne Cook
Abstract
NHS Direct was set up to as part of the NHS Modernization Plan – launched in 1998; the objective of NHS Direct was to offer 24-hour medical information to the general public. This was done through the use of a telephone in service, a website on the Internet, interactive touch screen kiosks and interactive digital television. NHS Direct operates across the whole of England and its digital television and website are available across a wider area.
Growth and change have been ongoing, with the introduction of providing services to other departments within the NHS framework and ongoing expansion. In the main, the general public is satisfied with NHS Direct services. They have formed partnerships with other NHS departments to reduce the workload in areas such as Accident and Emergency – these initiatives have had a mixed success ratio.
The Business Plan for 2006 onwards was focused on further expansion and growth of NHS Direct. However, on April 3
rd
, 2006, the Ministry of Health announced that the NHS overall had a budget deficit of 50 million pounds and made public that NHS Direct would be forced to reduce their workforce by one third. Overall NHS Direct had met their targets, all be it at a high cost due to the requirement for advanced technology to support and run the systems needed.
The focus of NHS Direct Management will now be on restructuring and downsizing with a reduced workforce. The staff turnover has always been high at 30% and the staff morale in difficult times will be a problem that needs addressing in order to retain experienced staff.
The overall conclusion is that the NHS as a whole will have to reconsider its ability to provide free medical to all based on current funding. The funding to NHS has increased over the last decade.
Regardless of the increase in funding, the system was not monitored in a way that identified an growing deficit, now resulting in NHS Direct and other departments having to downsize, in this case not due to their own inefficiency but the overall financial crisis in the whole NHS system. By using change agents the process of going from being a growth division to one that is reducing needs to be well managed to focus on the positive contributions they can make to the health of the general public and by closing or redirecting the services that they are not handling competently and/or cost efficiently.
1.
Table of Content
Brief Introduction to Change Management
Force Field Analysis – NHS, Direct, April 2006
Table 2 – Force Field Analysis
2.
Introduction
The National Health Service (NHS) is the largest employer in the UK and has a diverse workforce with many different professional groups (Smith, 2000). The researcher believes that there is accelerating pace of change within the NHS, as they need to keep a step up and embrace further growth in the public sector. In recent journals there are many problems related to the NHS Direct, which the researcher feels an investigation should be undertaken to identify the problems. A political editor said;
“The report doubted whether the target of 90 per cent of callers speaking to a nurse within five minutes would be met. It said NHS Direct was changing the target waiting time to 20 minutes” (Waugh, 2002).
NHS Direct is the National Health Service’s 24-hour information, advice and guidance service available by telephone, the Internet, interactive touch screen kiosks and interactive digital television. NHS Direct operates across the whole of England and its digital television and website are available across a wider area.
NHS Direct is a Special Health Authority and employs approximately 4000 staff and handles around 600,000 telephone calls and one million visits to the website each month.
The NHS Direct website gives patients the same information as their doctors, in clear and jargon-free language, which helps them to make informed choices about their healthcare.
At the time the HNS Direct website was set up the then Health Minister, Rose Winterton, stated ‘We are working to provide a modern, flexible NHS that fits around patients’ needs and meets their expectations. We know that patients would like more information to support them in making decisions about their healthcare. This is an important step in providing patients with the resources they need to make informed choices’
The NHS is implementing a 10 year modernization program – the NHS Modernization Board is advising the Secretary of State on implementing the plan.
Due to the vast nature of the NHS, this study will specifically look at NHS Direct and analyze the changes that have occurred, and the affect on stakeholders, both within the NHS and their external customers.
3.
Literature Review
Brief Introduction to Change Management
Over the last 20 years the impact of change has been greater than ever before, as the pace of change is now so fast that, for organizations to sustain business growth and operate successfully they must be able to adapt with the frequent changes in markets and competition. Therefore businesses must respond very quickly if they are to survive. Clarke, (1994) Today, change is not the exception but a steady ongoing process that organisation strive on to keep a crucial part of competitive edge.
[1]
Burns (2000, p148) states:
“What worked in the past will not work in the future, and organizations, like society at large, will have to change in unprecedented ways if they are to survive.”
Managing change is a broad area to concentrate on, as change affects organizations in general and people in many different ways. The NHS has made changes to their provision of health care, which gave rise to the NHS Direct in the first place; however, the current financial crisis shows that initiatives in health care to date have not been adequate or appropriate. The one area that has not changed is the demand and scope of the services to be provided – they are providing medical for all, regardless of the persons ability to pay. Certain members of the public have opted for private health care insurance but this is not the norm. In addition, the population is aging and increasingly more seniors need long tern, high care that puts pressure on available resources.
“It is easy to change the things that nobody cares about. It becomes difficult when you start to change the things that people do care about—or when they start to care about the things that you are changing.”
[2]
(Lorenzi and Riley 1994)
The NHS is important to the vast majority of the population; it is considered a right to have medical care available to all, regardless of their financial contributions. Most people do not carry private health care insurance. The Ministry of Health has repeatedly changed the NHS to maintain this service, with differing levels of success in recent years. The current situation shows serious financial deficits, a shortage of qualified staff and dissatisfaction with the service.
We live at a time when organizations are continually changing and success is now determined by how well the changes are implemented and whether the desired gains can be achieved. (Collins, 1998)
The rate of change is increasing in almost all organizations. The pressure is intense as the world focuses the time and attention on understanding the forces driving the changing environment and expands or applies the information systems needed to support the changed environment.
The phrase
change management
in reference to the comments of
[3]
Peter Drucker is as to
‘whether one can manage change at all or merely lead or facilitate its occurrence within an organisation’
.
Change management is the process by which an organisation gets to its future state, however creating change starts with creating a vision and then empowering individuals to act as change agents to attain that vision.
In today’s rapidly changing, competitive environment, the ability to change efficiently, can distinguish the winners from the losers. Many health-related organizations find themselves unable to adapt due to the independence of technologic change.
NHS Direct has been in a period of change due to their growth since inception. In 1998, the change was positive, bringing on and implementing new technology, growing call centres and providing an expanding service to the general public as well as reducing the workload in some other sectors within the NHS. However, this additional service within the NHS has involved high costs for technological infrastructure, software and implementation, as well as on going maintenance and extended the service without huge reductions to the demands on other sectors of health care.
NHS DIRECT
Purpose of the NHS Direct
The NHS is a 24-hour health help line that handles around 100,000 calls every week across its 22 sites. Since the launch of the first wave of NHS Direct sites in March 1998, the service has expanded to cover the whole of England. In addition, it has developed a range of multi-channel services, including NHS Direct Online, Information Points using touch screen kiosks, NHS Direct in Vision (new digital TV pilot projects) and the Self-Help Guide (formerly the NHS Direct Healthcare Guide).
NHS Direct has also expanded, working with frontline staff and managers to devise new with out-of-hours services to succeed in their aims and objectives providing consistent access to high quality, integrated care.
Ref
[4]
http://www.nhsdirect.nhs.uk/
– a new gateway to healthcare
The NHS Plan – A Plan for Investment, a Plan for Reform
, July 2000
4.
Research Objectives
Introduction of the NHS direct has made a big departure to the existing practice and presents a major challenge in the management of change in the public sector.
The aim of this report is to analyze the role of the NHS Direct through the use of the Internet and the impact on the Medical services. The following areas will be evaluated:
- Investigate the purpose of NHS Direct.
- Research the NHS Direct history and its operations.
- Identify the NHS Direct objectives and the success to date
- Investigate the Impact on all stakeholders, including Medical Services and the general public
- Evaluate the role of NHS Direct Website in helping NHS Direct meet its objectives.
- The challenges the change has imposed on NHS Managers and the affect on their change management approach
5.
Research Methodology
A literary review will be undertaken to study the NHS Direct and the elements listed in the research objectives.
A range of sources will be utilised including e-journals and journals, newspapers, books and the Internet.
The success of the change management will be measured by the success of NHS Direct and its ability to meet predefined goals and objectives, referred to as Key Performance Indicators. The KPIs include the changes being introduced and new services that have grown since inception of the service.
The NHS Direct website will be evaluated as to how user friendly it is, what content it provides, and its acceptability from the user community.
6.
Research Findings
Investigate the purpose of NHS Direct.
NHS Direct is a response to the desire for increased patient empowerment. It is also
recognition that the NHS is a complex, multi-layered system that can be confusing for the non-health professional. NHS Direct enables people to make decisions about their own or their family’s health by providing expert advice and up to the minute information. The service can also act as a 24-hour signpost, directing people to the most appropriate level of care.
NHS Direct was launched in 1998, initially at three pilot sites, to provide “easier and faster advice and information for people about health, illness and the NHS so they are better able to care for themselves and their families”.
The success of NHS Direct in achieving this aim rests largely on the premise that it should be accessible to all sectors of the population regardless of race, age, gender, preferred language choice, income, sensory impairment, disability, social positioning or cultural background/preference. Ref NHS Direct website, a new gateway to healthcare
http://www.nhsdirect.nhs.uk/
Objectives of NHS Direct – Specific objectives set for the service included:
- To provide for the public a confidential, reliable and consistent source of professional advice on healthcare 24 hours a day so that they can manage many of their problems at home or know where to turn to for appropriate care.
- To provide simple and speedy access to a comprehensive and up to date range of health and health related information.
- To improve quality, increase cost-effectiveness and reduce unnecessary demand on other NHS services by providing more appropriate response to the needs of the public.
- To allow professionals to develop their role in enabling patients to be partners in self-care, and help them focus on those patients for whom their skills are most needed.
The Ministry of Health’s mission to modernize the NHS is not confined to hospitals. The roll-out of NHS Direct, a nurse-led telephone help line, and the introduction of walk-in primary care centres indicate that the same philosophy is being applied to GP services. The common theme in these initiatives is the desire to improve access and convenience within the NHS, a theme that is emerging as the defining element of New Labour’s approach to health policy.
The modernization of the NHS, which included the introduction of NHS Direct was a major change designed to streamline the interface between the general public and the NHS. As the NHS Direct service grew, it came under criticized for severing the personal link between patients and their GP. Some patients preferred the face-to-face interaction with their doctor when a health problem arose, even though the situation did not require medical procedure or physical intervention and was competently handled by a call to NHS Direct.
Ref Coulson –Thomas, C and Coe, T (1991), The
Flat organisation
. British Institute of Management: London. They stated that
Change is an ever-present feature of organizational life, though many would argue that the pace and magnitude of change have increased significantly in recent years. The Institute of Management, formerly the British Institute of Management, which regularly carries out surveys of its members, has certainly found this to be true. In 1991, the institute reported that 90 per cent of organizations in its survey were becoming ‘slimmer and flatter’.
Such change will bring resistance – there are 4 bases for resistance to change, identified as follows by Leigh, A (1988) Effective Change. IPM
Cultural – When change seems at odds with accepted values and norms: “the way we do things around here”.
Social – When change threatens to disrupt relationships or break up valued groups.
Organizational – When change affects formal, hierarchical status and threatens the individual’s power and influence.
Psychological – When change is seen to be counter to the individual’s vested interest, when loss outweighs gain.
NHS Direct could have created resistance in all the above areas.
Cultural – for many senior citizens, for example, prefer to talk face to face with their medical personnel and those less computer literate people would not be inclined to use the web site as a source of information. There is a trust relationship between many doctors and patients who have worked together on the individual’s health needs for many years.
Social – NHS Direct has been criticized for severing the ties between doctor and patient and recommending patient care options that differ to those ‘normally’ followed by the patient under his/her GP.
Organizational – an article on the BBC, 30 August 2001 ref
http://news.bbc.co.uk/1/hi/health/1516701.stm
shows a concern regarding the changes to the organizational structure. ‘
NHS Direct blamed for rise in 999 calls’
‘There has been a 30% rise in 999 calls since last year. The introduction of the NHS Direct help line has been blamed for a leap in the number of 999 calls made to an ambulance service.
The Isle of Wight Healthcare NHS Trust is failing to meet government-set response targets of answering 75% of life-threatening calls within eight minutes.
The trust says its efforts are being hampered by a 30% rise in call-outs since NHS Direct was made available to islanders.
NHS Direct denies it is advising people to call out ambulances without good reason.
‘
The facts are denied by the manager of NHS Direct, he believes the increase in calls were correctly recommended by NHS Direct and that hey are being used as a scapegoat for the inability of the ambulance services to meet their target for responding to calls.
The Times on line, quotes the NHS chief, Dec 08, 2005, in the article titled, ‘Turbulence is the Price of a Better Service’ – “When you are introducing change you will inevitably have some degree of turbulence,”
Psychological
–
The Emergency Medical Journal, C J Morrell, et al wrote a report entitled
‘
The Impact of NHS Direct on Other Services; The Characteristics and Origins of Its Nurses.
It states ‘the introduction of any new health service can clearly have
an impact on other services in two distinct ways: firstly, by
altering the pattern of patient demand for existing services;
and secondly, if it competes for the same resources, by affecting
the ability of existing services to supply care.’
This was commissioned in response to increasing criticism that the service was taking qualified nurses away from the profession. The article went on to point out that a number of the nursing staff working for NHS Direct actually have disabilities or personal reasons for not being able or willing to do active nursing duties and have been encouraged back into the work force by NHS Direct – they would otherwise have remained outside of their profession al together.
Research the NHS Direct history and its operations.
NHS Direct was one of the new services that were introduced in 1999/2000 to improve and reform the NHS healthcare making it a modern, efficient and patient led health service giving patients more choice and better access to their own healthcare.
The service provides access to confidential health advice and information, 24 hours a day, in a range of easy and convenient ways – the NHS Direct telephone service, NHS Direct Online website and the NHS Direct Interactive service on digital satellite TV service. As well as helping patients improve their health and looking after themselves, NHS Direct helps patients access the right health care service for their needs.
The value of the use of technology was reported by
[5]
Carr (1996) who agrees that, when properly used, information technology is a powerful tool for increasing speed, quality, and flexibility, and for creating new, different, and effective process operations. “It enables businesses to maximize their return on investment and deliver breakthroughs in competitive advantage.” But in practice, “many organizations have been sending millions of dollars down the drain by applying sophisticated information technology to automatic existing processes. The consequences? Making the same mistakes faster.”
The costs and changing structure of the NHS Direct in the past and concerns regarding the accounting were tabled by the National Audit Office in Feb 2006 ref
http://www.nao.org.uk/pn/05-06/0506484.htm
‘
Established in 1999, until April 2004 NHS Direct was centrally managed by the Department of Health but the service was delivered at a local level by 22 NHS Trusts. When NHS Direct became a Special Health Authority in April 2004, it had to put in place new accounting
systems and procedures. While these systems were being established the host Trusts which had previously funded and managed the service continued to be responsible for providing accounting and payroll services under service level agreements. Since NHS Direct had not implemented a centralized ledger or payroll system and the payroll providers and records were dispersed across the country, there was an absence of central management control over the processing of payroll.
Work by NHS Direct and the NAO has indicated that in the region of £1.6m of payroll expenditure in 2004-05 may be inaccurate.
According to today’s report, NHS Direct has also been unable to provide evidenced comparative income and expenditure figures for previous years. NHS Direct has estimated total income and expenditure of £121 million for the previous year based on returns provided by the host Trusts to the Department of Health together with an estimate of central departmental costs, but has been unable to provide sufficient evidence to support these figures.’
Identify the NHS Direct objectives and the success to date
Objectives are stated as Key Performance Indicators (KPIs) and divided into sections – Patient, Staff and Organisation, Stakeholders & Financial. The table below summarizes the KPIs for the sections, as stated in the Executive Report for July 2005, tabled in Sept 2005. This provides a recent snapshot of NHS Directs adherence to KPIs and provides actuals for previous month and year allowing comparisons for improvement over the period. As the department is in a growth phase, these KPIs include measurements of change management as well as maintenance and adherence to standards and processes and procedures.
The section for Financial KPIs does not include any metrics, therefore it is assumed they were not discussed or agreed prior to the tabling of the report.
The following table has been extracted from the Executive Scorecard, a method used to measure adherence to targets.
Patients KPIs
Overall, patients reported being satisfied with the service received, however, the department did not achieve its objectives against the majority of KPIs
- The number of complaints were up from 2004, although lower than reported in June
- Number of complaints responded to within 20 days was 39% below target and 37% worse than in June
- Serious adverse incidents exceeded the target and has shown an improvement over prior year and month figures
- The number of web visits and calls answered were lower. This is likely to be due to the fact that this was summer and not due to any shortcoming on the service.
- The number of abandoned calls is above target, although improved over the period
- The assessment of calls, all types, have met target and are significantly improved over the period.
The National Audit Office paper ‘NHS Direct in England, published in 2002 stated ‘
NHS Direct’s project team has balanced the need to publicize the service and its capacity to meet demand. It has already met its target for 60% of the population to be aware of NHS Direct by March 2002. Public satisfaction with NHS Direct is consistently very high at over 90%. Very few callers received the engaged signal when telephoning, but in Sept 2001 only 64% of callers were able to speak to a nurse adviser within 5 minutes compared with the current target of 90%.
’
Staff & Organisation KPIs
Schedule adherence appears to be a problem, with the target not being met by 2 key staff members by 9 & 18%.
The cause for concern is within the rolling year turnover rate for staff. This is exceptionally high at 39% and this should be further investigated to find out the root cause.
The BBC article ‘Call Centres: An Ideal Calling’ an NHS Direct employee commented ‘However, with a staff turnover of some 30%, it looks as though the call handlers are not enjoying the fruits of this telecommunications boom.
‘Jonathan, who works at a major call centre in northern England, has seen this staggering turnover at first hand. “Two-thirds of the people who join us don’t make it past their second month. Most [of the others] leave within a year,” he says.
Companies have been accused of taking a cavalier attitude to happiness of their staff, preferring to hire agency workers rather than investing time and money in a full-time workforce.’
Stakeholder KPIs
The departments reached the majority of stakeholder KPIs – stakeholders are other departments within the NHS and therefore this indicates that the NHS Direct should have a successful relationship within the NHS as a whole.
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G |
% Patients satisfied with service |
99% |
95% |
98% |
99% |
|
R |
Number of complaints (per 10,000 calls) |
0.84 |
0.5 |
1.01 |
0.49 |
|
R |
Number of complaints responded to within 20 days |
56% |
95% |
93% |
– |
|
G |
Serious adverse incidents (per 10,000 calls) |
0.16 |
0.24 |
0.34 |
0.25 |
|
A |
Number of web visits |
963.3k |
1040.9k |
1013.0k |
662.6k |
|
A |
Number of calls answered |
570.01k |
591.3k |
553.5k |
526.3k |
|
A |
Abandonment rate |
7% |
5% |
10% |
13% |
|
A |
% calls answered within 60 seconds |
76% |
95% |
71% |
57% |
|
G |
% urgent calls commencing clinical assessment in 20 minutes |
97% |
95% |
97% |
50% |
|
A |
% non-urgent calls commencing clinical assessment in 60 minutes |
97% |
95% |
97% |
50% |
|
G |
% of HI calls assessed within 3 hours |
91% |
90% |
91% |
90% |
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G |
Overall ICT availability |
99.97% |
99.00% |
99.99% |
99.99% |
|
R |
Schedule Adherence: Nurse Advisor |
61% |
80% |
61% |
57% |
|
A |
Schedule Adherence: Health Advisor |
72% |
80% |
70% |
66% |
|
A |
Calls per available hour |
7.7 |
8.8 |
8.7 |
7.5 |
|
G |
Short term sickness |
6% |
6% |
5% |
5% |
|
R |
Rolling year turnover rate for staff |
39% |
25% |
39% |
30% |
|
A |
% of funded staff in establishment |
90% |
100% |
91% |
93% |
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