NHS Direct now covers the whole of England. In the current year, the service will deal with approximately 5 million calls. By 2004, this is expected to rise to nearly 20 million.
In addition to being the first port of call for patients who are unsure about where to turn for help, NHS Direct provides a first-line service for 15 GP co-ops' out-of-hours service, and in time it is anticipated that the vast majority of out-of-hours calls will be routed through NHS Direct.
However, according to NHS Direct: a new gateway to healthcare,1 53% of all calls required referral to medical care, some urgently (see Table 1, below), and more than three-quarters of these were referred to their GP.
Table 1: Endpoint recommendations by NHS Direct
|Endpoint||Proportion of patients|
|Transferred to 999||3%|
|Accident and emergency||9%|
|GP immediate (within 4 hours)||16%|
|GP urgent (between 4 and 24 hours)||14%|
|GP routine (more than 24 hours)||11%|
|Other non-GP NHS advisor||10%|
|Source: NHS Direct daily information returns, 1 July to 8 October 2000|
Who is responsible for following up patients given advice by NHS Direct?
This issue was addressed in Health Service Circular HSC 1999/235 entitled NHS Direct and Primary Care – Liability Issues. The circular identifies three situations:
- Where patients use NHS Direct of their own accord
- Where a GP recommends NHS Direct to his or her patients as an additional service
- Where a GP or GP co-op or other out-of-hours grouping of GPs, enters into a formal agreement with NHS Direct to receive and process out-of-hours calls on their behalf.
1. Where patients use NHS Direct of their own accord and the GP is not involved
In this situation, NHS Direct is entirely responsible for the advice given to the patient. As the GP has no knowledge of the patient contact, he clearly cannot be held liable for anything that goes wrong as a result.
2. Where a GP recommends NHS Direct as an additional service
GPs may promote the use of NHS Direct to their patients in a number of ways:
- By displaying posters in their surgeries
- By including the NHS Direct telephone number on an out-of-hours recorded message
- By publishing the number in practice leaflets.
In essence, this last situation is no different from the first – the GP may have made the patient aware of the existence of NHS Direct, but unless told will be unaware that the patient has used the service, and consequently cannot be held liable for harm flowing from negligent NHS Direct advice.
However, the circular does exhort GPs:
' to take reasonable steps, as with other services which they recommend to patients, to notify the providing organisation [NHS Direct] of any problem which may come to their attention with the quality of advice or service their patients receive from NHS Direct.'
GPs promoting the use of NHS Direct through an out-of-hours recorded message are advised in the circular to use the model reproduced in Figure 1 (below).
|Figure 1: Standard answerphone message for GPs promoting NHS Direct|
"The surgery is closed. You have a choice. If you wish to speak to an emergency doctor, please phone [insert out-of-hours provider's number]. However, if you require information or advice, NHS Direct, a 24-hour, nurse-led advice line, is available on 0845 4647."
3. Where GPs refer callers directly to NHS Direct for advice and information and may arrange with NHS Direct to handle all out-of-hours calls
This situation requires an explicit agreement between the parties to include what is expected of both NHS Direct and the referring GP, or whoever may be standing in for the GP, to ensure that the service provided to patients is of a reasonable quality.
If, in the opinion of the NHS Direct nurse, the patient needs assessment by a doctor, the patient will normally be expected to contact the GP him/herself. NHS Direct may, if the patient is apparently too ill or otherwise unable to call the GP, do so for him or her.
This situation is different in some respects from the first two situations. Under their terms of service, GP principals are responsible for providing a 24-hour service to their patients, whether or not care is delivered personally.
Where care is delegated to another, including NHS Direct, the GP is responsible and could be held to account at a disciplinary panel for advice given by NHS Direct, or an administrative glitch that meant that, for one reason or another, an inadequate level of care has been delivered.
However, given the policy drive towards using NHS Direct for receiving all out-of-hours calls, there is likely to be pressure to amend the terms of service so that the GP is not responsible for any failures of NHS Direct.
In relation to claims in civil negligence, the GP will not be vicariously liable for negligent advice given by NHS Direct or any injury resulting from administrative failure within NHS Direct.
But once the GP has been contacted about the patient, whether by the patient personally, someone on behalf of the patient, or NHS Direct itself, the onus is on the GP to ensure that he or she is in a position to make a sound clinical judgment and act appropriately thereafter. In other words, the situation would be the same as if the doctor had been contacted directly by the patient in the first place.
Following up faxed messages from NHS Direct
GPs may also be advised about patient contacts with NHS Direct by fax. The Medical Protection Society (MPS) has been asked on a number of occasions to advise on when exactly the GP becomes responsible for the provision of follow-up if NHS Direct faxes through a message in the middle of the night.
If the fax is to a manned GP co-op, responsibility will transfer upon receipt of the fax as there is somebody on the spot to read it, make sense of it and take appropriate action.
But if the fax is sent to an unmanned GP surgery, responsibility cannot reasonably be assumed to transfer until the surgery is open and there is someone available to act on it.
Many claims and complaints arise from communication failures. Surprisingly, perhaps, to date communication failures between NHS Direct and GPs do not appear to have featured in cases referred to the MPS.
This is testimony to the working relationship established by the 15 GP co-ops (referred to earlier) and NHS Direct. Clear understanding of responsibilities is essential if that situation is to continue.
- NHS Direct: A New Gateway to Healthcare. Produced by NHS Direct, March 2001. Available from NHS Direct (tel 0845 4647).