An unhelpful helpline

Recently in A&E I saw a young vetinary nurse who had been looking after a sick dog overnight. The vet she was working with had mentioned that the dog might have rabies, and the nurse was worried that she might have caught it. What should she do?

Sensibly, rather than rushing straight into hospital she phoned NHS Direct, the government help-line for health problems. But predictably they told her to rush straight to A&E. Had she spoken to her mum or perhaps an elderly relative, she might have been told: ‘Rabies? Sounds a bit unlikely to me dear. It’s not been seen in Britain for years….’ Instead she came to A&E, where, after a two-hour wait, she saw me – who said exactly that. She then phoned the vet, who said the dog had a rare muscle disorder, not rabies. She left feeling very embarrassed, apologising for having wasted my time.

Research published in the British Medical Journal in October 2004 raised doubts about the NHS Direct service (1). Patients phoning a GP surgery for advice were randomly selected to speak to either a practice nurse or to NHS Direct. NHS Direct staff were significantly more likely to refer patients to see a doctor. Also, the treatment of patients who went through the practice nurse route was cheaper, both in terms of time and money. This echoes previous studies, which show that NHS Direct has a very high rate of referring patients to visit their GP or A&E. One study, using trained actors pretending to be patients, showed that NHS direct referred 82 per cent of callers to a hospital or a GP (2).

My experience is that NHS Direct is used mainly by the worried well, people who know that they don’t really need to see a doctor but who want a bit of reassurance. Unfortunately, this is the one thing NHS Direct is not equipped to offer. To justify its existence, it has to put safety first. No one will pull the service up for sending people to hospital unnecessarily – but if it misses a serious diagnosis, there will be big trouble.

For example, I have seen several young patients with chest pains who were referred to A&E by NHS Direct. They don’t have a terrible, crushing pain, or else they would have gone straight to hospital. Because it’s simply a niggling pain about which they are worried, they phone NHS Direct for reassurance. Then they are put through the computer question system and, surprise surprise, it is impossible to rule out a heart attack or pulmonary embolus over the phone – so they end up being sent to hospital.

The problem is that any system that is designed never to miss anything serious will inevitably pick up lots of ‘false positives’. As one commentator put it: ‘Consistently to err on the side of safety might seem logical, but the effect of doing so is to fill a health system with people who do not need to be there.’ (3) We already have over-long queues at A&E – why not spend money on treating patients who are ill enough to turn up by their own volition rather than attempting to generate more business?

My grandmother was referred to A&E in the middle of the night when she phoned NHS Direct about her painful leg. ‘It could be a DVT – lie very still in bed, we’ll phone you an ambulance’, she was told. Gran was sure her final hour had come. But the ambulance crew who arrived to pick her up shook their heads in disbelief; sure enough, after a six-hour wait in her local casualty she was diagnosed with a sprained calf muscle and sent home with some painkillers.

The government is proud of NHS Direct, which is used by half a million people a year and has high levels of patient satisfaction. But if someone is sympathetic and polite, of course patients will feel satisfied. This doesn’t mean they are receiving appropriate treatment. It is frustrating that in a health system strapped for cash, where there are constant delays in the treatment of patients with serious illnesses, ‘patient satisfaction’ should be enough to secure further funding for an expensive service – especially when the evidence suggests that the service generates more work, not less.

‘NHS Direct is helping people take more responsibility for their own health and empowering them to become proactive partners in their own healthcare’, said health minister Gisela Stuart as she opened the online section of NHS Direct in March 2000. I think the opposite is true. NHS Direct is part of a culture that increases people’s awareness and anxiety about their health, and induces a sense of vulnerability.

The phrase ‘I just wanted to get it checked out’ is heard more commonly than ever in A&E. Sometimes one seems to spend a whole shift reassuring people about minor ailments, rather than looking after those with acute illnesses or injuries. Where in the past people would have sought sensible opinions from friends or neighbours, or, God forbid, taken an aspirin and gone to bed, today we are encouraged to phone a stranger for advice.

Dr Liz Frayn is a surgical trainee in southwest England.

(1) ‘NHS Direct versus general practice based triage for same day appointments in primary care’, Richards et al, BMJ 2004;329:774

(2) ‘An observational study comparing quality of care in walk-in centres with general practice and NHS Direct using standardised patients’, Grant et al, BMJ 2002;324:1556

(3) ‘Editorial: NHS Direct audited’, S George, BMJ 2002;324:558