Let's dump NHS 24 and set up a proper emergency service

Published on Wednesday 30 September 2009 20:51

NOT many documents issued by NHS Scotland are welcome (or even intelligible). Usually, they herald a ploy to cut costs and ration the service.

However, the consultation document of the Scottish Ambulance Service (SAS) on "Future Strategy" is an exception. With a little more courage from the SAS, it could lead to a decent emergency service for the people of Scotland; provided, of course, the health secretary has like courage to put NHS 24 back in its box. Money could be saved, too, for the present out-of-hours (OOH) arrangements are wasteful as well as defective.

In 2004, when doctors opted for office hours, patients were shuffled off into the remote benevolence of NHS 24. It hasn't worked. NHS 24 was conceived to let people talk to someone about their health over the phone at any time. As such, it was useful and welcome.

The trouble came when the then health secretary, Andy Kerr, caught on the hop by the Westminster government's capitulation to doctors' trade union the BMA, decided to tag cover for OOH on to NHS 24.

Thus was created a monster of a process, with too many arms, a disordered brain and three separate wings: local health boards, NHS 24 and the SAS.

To get help, sufferers have to wrestle with this grotesque creation. It has been a constant cause of suffering for many patients, and for some a fatal disaster.

After every disaster (mere suffering is ignored) successive health secretaries have promised improvement, but nothing much changes. This is no surprise, for the problem lies not with the application of the process, but with the process itself. It is too long, too remote, too convoluted, too confusing. There are, by my reckoning, between nine and 12 steps from making the first call to eventual examination and diagnosis. It is not fit for purpose.

For evidence, don't bandy statistics. Listen to the man who found blood on his pillow at two in the morning, or the wife whose husband had collapsed, or the parents of the teenager who was misdiagnosed and died, or the daughter who spent 20 minutes trying to explain what was really wrong with her mother. The list goes on.

Those with experience of the system have concluded it doesn't respond fast enough. So they have found short-cuts. Hence the SAS report, which says: "Over the past five years, demand for unplanned care services has increased. More frequently patients call 999 or attend A&E wards with symptoms and conditions that could be better treated at primary care level."

Cunning patients are not the only ones to have adapted. The ambulance service has seen the need and responded. Not long ago, ambulances were allowed only to take a patient to hospital. That has changed. Ambulance crews now carry out a whole range of procedures, including operating defibrillators, administering oxygen and other emergency procedures.

Such is the gathering expertise of paramedics that some doctors now summon an ambulance automatically if they are called out to an emergency during surgery hours. Ambulances have become the de facto emergency service.

This development should be encouraged and accelerated.

The SAS is headed in that direction, but it keeps ploughing into the old bog: the OOH process. Thus, the consultation document complains (ever so gently) that: "NHS 24 and OOH clinics receive a small but significant number of calls relating to potentially life-threatening conditions that would be better directed to 999."

And, because different tools are used by different agencies, "confusion can lead to increases in call transfers and delays for patients". No wonder.

Who knows whom to call in an emergency? What is an emergency anyway? Is it a heart attack or the pickled onion I ate with the chips?

The way ahead is clear: take NHS 24 out of the loop, for the SAS itself describes it as "a non-emergency telephone service".

Let the SAS develop into the Scottish Emergency Service and direct all emergency calls to a dedicated number: 999 will do for a start. Let the emergency service then decide what action is appropriate. Let doctors concentrate on "scheduled healthcare".

If this is done, we will know who to call if we run into what we think is a health emergency. Clarity will be assured, anxiety reduced, suffering relieved and lives saved.

It will save money, too. NHS 24 does not need 11 directors and a budget of 50 million a year to give advice over the phone. Many already find such help online. Who knows, a private company may well take it on for a fraction of what it costs now.