Shared learning database

NHS Direct
Published date:
February 2011

NHS Direct uses the computer-based technology of a clinical decision support system to provide 24 hour patient centred assessment, advice and information which responds to patient's needs. By making sure the technology is updated to reflect NICE guidance, we support people, staff and the wider NHS. Remote and virtual services can improve patient experiences, relieve pressure on traditional face-to-face services, empower people to access the right services at the right time and overcome barriers to implementing NICE guidance to the benefit of both patients and staff. By ensuring the clinical content of systems are updated against NICE guidance, in this example with symptoms of diarrhoea and vomiting due to gastroenteritis, all staff have the same supported evidence and information, consistent with patients accessing this information via the web thus resulting in consistency and appropriate care and information specific to their symptoms.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

Provide flexible quality services responding to people's needs. Develop more efficient innovative ways of delivering services to address increasing demand and economic constraints. Use technology to empower and support staff to deliver safe, valued health care services. Develop all clinical decision support systems utilising the same principles. Review and update clinical content of clinical decision support systems used to reflect all NICE guidance. Adhere to regulations by using NICE guidance within the context of services delivered. Input into NICE guideline consultation stages from the experience of an expert provider of telephone triage. Provide patient centred, up to date, relevant, consistent information, assessment and advice irrespective of channel of access to the service. Support patients by identifying those at greatest risk and use trained staff to ensure appropriate advice and/or referral to symptoms. Empower people to actively manage appropriate symptoms with self-care and do more for themselves. Support the wider NHS by empowering people to access the right services at the right time. Eg where NHS Direct prevents people from accessing urgent care inappropriately we can avoid unnecessary disruption of their lives, reduce avoidable stress and demand on heavily subscribed urgent and emergency care services. Create opportunities for people to benefit through remote and virtual services and free up resources for the wider NHS, improve patient experience and relieve pressure on traditional face-to-face services. Reduce inequalities in care by maximising the use of technology to enable 24 hour access to up-to-date, evidence based assessment, advice and referral. Use technology to overcome the barriers associated with implementation of NICE guidance and reduce the variables when adopting and adhering to them. Use technology to share knowledge and reduce time required to assimilate NICE guidance. Review and update the clinical content of the clinical decision support systems used within NHS Direct to reflect NICE CG84 - Management of acute diarrhoea and vomiting (D&V) due to gastroenteritis in children younger than 5 years . Using technology and consistent clinical content principles, create a Health and Symptom Checker on the topic of D&V, available through digital services to support a more efficient and innovative way of delivery services and to meet patient demand. Maintain NHS Direct's adherence to the NHS Litigation Authority Risk Management Standards and the CQC Essential Standards of Quality and Safety to take account of NICE guidance. Input into NICE at all stages of the CG84 development consultation to benefit from experts in this field and to share our experience as a unique provider of telephone triage. Provide up to date, relevant and consistent information, assessment and advice tailored to a patient's symptoms of D&V irrespective of the patient's access channel to the service. Ensure the assessment of the symptoms of D&V identifies those at greatest risk to enable trained staff to provide appropriate advice and/or referral tailored to the symptoms identified. Ensure that the clinical content supports people to manage appropriate symptoms with self-care and enables and empowers people to do more for themselves. Ensure the D&V algorithms and protocols direct appropriate cases to the most appropriate NHS services at the right time. Enable users who access via the web to seamlessly receive a call back from a nurse advisor, when symptoms necessitate. Use technology to remove variances and ensure the CG84 is adopted by all staff. Create and deliver training materials to support staff in understanding the changes to clinical systems because of the CG84. Reduce the time required off line for staff to assimilate the changes made into the clinical content.

Reasons for implementing your project

Prior to the publication of CG84 the Clinical Decision Support System (CDSS) supported clinical and non-clinical staff to provide advice and information related to symptoms of D&V during the dialogue of a telephone assessment/call. The CDSS consists of over 300 clinical algorithms and protocols based on symptoms not diagnosis. They are ordered steps through an assessment to an end point. which could be self care information or referral to an appropriate care provider. If the end point reached directs a caller to another service, appropriate information is given how to access the service and interim care advice given prior to reaching the service. The skills of the trained staff facilitate a decision to be reached. By using technology we help people take more control both in managing how to stay healthy and, when relevant, in managing illnesses and conditions. The process to ensure clinical content remains up to date and reflects the latest NICE Guidance is an essential part of the CDSS development and started within NHS Direct at the outset of the NICE consultation for CG84. Our Business Plan 2010/211 stated 'around 53% of the population now uses the internet every day, and 69% use it every week. Remotely delivered health services have a crucial contribution to play in addressing these challenges.' Prior to the release of CG84 patients with D&V symptoms received web-based advice, assessment and information from our Health and Symptom Checkers (HaSC). By applying consistent content principles across all channels we identified we could improve the HaSC for D&V. Now 38 HaSCs are available, accessed directly by the public via NHS digital services and also syndicated to third party digital services. These maximize the opportunity to provide remotely delivered health services and help address increasing demand and economic constraints.

How did you implement the project

National Lead became member of CG84 Development Group to contribute as expert in telephone triage and to benefit from specialist expert opinions. Early identification of the need to implement CG84 planned into work programme. Existing content reviewed by group of internal clinical advisors and gap analysis to assess if the questions, rationales, co-morbids, referral end points, interim care advice and self care reflected CG84. Feedback from governance processes such as users, complaints, IFNR considered. Changes made: Improved self care to be age specific. New questions re taking of any oral medicines. Updated rationales. Interim care advice to support callers to manage their symptoms whilst awaiting further assessment. Changes peer reviewed by users and clinicians. Clinical and uat testing. Changes clinically approved and operationally implementation. Training resources delivered to staff via 'train the trainer' to cover geographically spread. Release notes supported staff training. This approach reduced off line time required by front line staff to assimilate knowledge. Learning log identified learning and whether further knowledge required. Hyperlink and reference to CG84 highlighted for independent access if required. Barriers to implementation were associated with the time taken from identification of changes to implementation within the system. Design and build processes with third party external suppliers and testing can make the process lengthy and cost dictates that changes are combined together and implemented as a version release. However, all content is risk assessed against Guidance when published and if it was identified for clinical safety or operational performance reasons that an immediate change was required this would be implemented to a quicker but more costly process. For the case of CG84 clinical changes were improvements only and the current system remained clinical safe until the release could be implemented.

Key findings

Project documentation noted the objectives and these were monitored against milestones until the successful completion of the clinical developments. CDSS changes were implemented within the nurse assessment centres during June/July 10. Since that date to 6.2.11, nurses have supported 106,787 callers with D&V symptoms. 50% of these assessments resulted in self care advice. The dedicated D&V symptom related HaSC was launched to the public on 30 Nov 10. Since that date to 31.1.11 this has been accessed 80,929 times, supporting people to be informed about their own health needs. 303 of the users benefited from further support of a nurse advisor through the click to call back functionality linked seamlessly with the nurse assessment centres. Based on NHS Direct's standard tariffs, checking symptoms online costs as little as 13p per individual transaction- £454.87 less than an ambulance call-out or £110.87 less than having a patient visiting A&E. Similarly, a GP visit accounts to a cost of £32 and an NHS Direct telephone call £16. The online HaSC therefore eliminate unnecessary costs. Governance processes continue to feed into the on going development of the clinical content Best practice guidance from NICE and other professional bodies is also searched out for review by clinicians to identify if this impacts on the D&V clinical assessment, advice and information. As a key performance indicator, all algorithms and protocols are clinically reviewed every 12 months. Call review and performance monitoring of non clinical and clinical staff takes place to support practices and clinical sorting. Date analysis of key performance indicators and clinical sorting are monitored regularly to identify impact and feed into the development of the clinical content. Evaluation suggests, using technology and applying clinical content across all channels consistently does remove any variances in the successful implementation of NICE Guidance.

Key learning points

Using technology is an effective way to overcome the barriers associated with the implementation of NICE Guidance and remove the variables within an organisation. Technology can also reduce patient inequalities and improve access to advice, information and care in line with the most current NICE guidance. Working together as a group of clinicians to analyse the guidance and being involved early in the NICE development stages of consultation helps understanding, share knowledge, identify impact and reduces the time to assimilate NICE Guidance. Having a system which highlights NICE guidance development timeframes and allows planning to factor in the review of clinical content to reflect NICE guidance will have benefits for staff, health professional patients and carers

Contact details

Enid Povey
National Head of Clinical Content, Information and Knowledge Development
NHS Direct

Is the example industry-sponsored in any way?