Elsevier

Social Science & Medicine

Volume 61, Issue 8, October 2005, Pages 1761-1771
Social Science & Medicine

Does NHS Direct empower patients?

https://doi.org/10.1016/j.socscimed.2005.03.028Get rights and content

Abstract

NHS Direct is a 24 h telephone helpline established in England and Wales, UK to offer advice and information for people about health, illness and the National Health Service (NHS) so that they are better able to care for themselves and their families. In 2001/2002 we undertook in-depth home interviews with 60 users of the service in two NHS Direct sites in England. In this paper we consider the extent to which NHS Direct facilitates patient empowerment in terms of helping people to be in control of their health and health care interactions. Our research suggests that NHS Direct facilitates patient empowerment by enabling patients to self care and to access health advice and services. It is also seen to offer the prerequisites for empowerment perceived to be lacking in the wider NHS, including time, respect, listening, support, and information. The service also functions by offering an alternative contact point for people seeking to avoid being labelled ‘time wasters’ by other busy health care providers. In the context of a wider health service which appears to problematise individuals’ ability to make decisions about the appropriateness of seeking health care, NHS Direct legitimises help-seeking actions. Empowerment in the context of NHS Direct has been associated with self care as a way of reducing ‘unnecessary’ demand on health services. However, health professional and patient perspectives on what is considered necessary demand differ, and in certain contexts, patient empowerment may involve service use as well as self care. Further, our data reveal the context-dependent nature of a concept like empowerment. For example, when people are ill, in pain, or anxious about a loved one, they may value being cared for more than being empowered. Our research suggests that, in addition to its other functions, NHS Direct is also valued as contributing to a sense of being cared for.

Introduction

NHS Direct is a 24 h telephone helpline established to offer “easier and faster advice and information for people about health, illness and the National Health Service so that they are better able to care for themselves and their families” (Department of Health, 1997). It began in three pilot sites in England in 1998 and by 2002 had expanded to 23 sites covering the population of England and Wales, with a similar service ‘NHS24’ in Scotland. The general public can telephone the service for health information or advice. They speak to a call handler, who may be able to deal with their request or who may pass the caller to a health information advisor or a nurse advisor. Nurses use computerised decision support software to triage callers to emergency care, primary care or self care as necessary. In addition, the service triages calls on behalf of some general practice out-of-hours services such as general practice cooperatives.

NHS Direct is based on research evidence from international experience of telephone triage. For example, general practitioners triaging patients by telephone in their out-of-hours services in Denmark (Christensen & Olesen, 1998), and nurses using telephone triage in an after-hours paediatric service in the United States (Poole, Schmitt, Carruth, Peterson-Smith, & Slusarski, 1993), and a province-wide helpline in Canada (Robb, 1996). Nurse telephone triage has been shown to be safe, capable of reducing general practitioner workload out-of-hours (Lattimer et al., 1998), and has been received favourably by patients (Poole et al., 1993). However, NHS Direct is an innovative service because it has been established on a national basis, is available 24 h a day, and deals with all health problems across all age groups. Thus it has generated international interest as similar services develop around the world, including Australia (Turner et al., 2002) and New Zealand (St George & Cullen, 2001).

This innovative service was one of a number of services, including walk-in centres and minor injury units, introduced to deal with increasing demand on traditional NHS services such as general practice and accident and emergency departments. Access to general practitioners outside normal working hours was seen as particularly problematic, and recommendations were made for more graduated access to the health care system through a single point of entry such as NHS Direct (Rogers, Entwistle, & Pencheon, 1998). Thus an aim of NHS Direct when first established was to help over-stretched health services by dealing with some of the people who did not need to contact or use those services (Calman, 1997). There has been minor success to date in meeting this aim in that it has halted the upward trend in demand for out-of-hours general practice while having no effect on attendances to accident and emergency services (Munro, Nicholl, O’Cathain, & Knowles, 2000). A further aim was to help people to manage problems at home or know where to turn for appropriate care (NHS Direct, 2001). There is evidence that this occurs, with 23% of callers finding the advice helpful because they learnt to deal with their problem themselves and 35% because it helped them to contact the right service (O’Cathain et al., 2000).

Patient empowerment has been a common theme associated with NHS Direct. Providers of NHS Direct have described the service as a response to the desire for increased patient empowerment, having the specific objectives of helping people manage problems at home, reducing unnecessary demands on other services, and allowing professionals to enable patients to be partners in self care (NHS Direct, 2001). A commentator on the policy has heralded the service as “a fundamental shift in the NHS where more public participation in health care can happen closer to home”, where access to interactive sources of information would empower patients, and noting that there was a need for the NHS to empower self care given the limited resources available to it (Pencheon, 1998, p. 215). In interviews conducted when NHS Direct was first established, a range of health service professionals sensed the opportunity for NHS Direct to empower callers to undertake self care, whereas others felt threatened by the risk of creating a population which would seek professional advice for the most minor of problems (Munro, Nicholl, O’Cathain, Knowles, & Morgan, 2001, p. 55). Thus patient empowerment has been variously implicated in both aiding and threatening demand management, but with a focus on the empowered individual caring for themselves rather than making unnecessary demands on services.

Given that patient empowerment was part of the intention of and policy commentary around NHS Direct we might ask whether this new service does indeed empower patients. The Economic and Social Research Council and the Medical Research Council, as part of the Innovative Health Technologies programme, funded empirical research to explore empowerment in NHS Direct from the perspective of the patient. Here we begin by examining the ways in which the concept of empowerment has been used before going on to describe how we conducted the research, and then presenting our findings. Finally, we discuss the implications of these findings for NHS Direct itself and for the notions of patient empowerment in health care more broadly.

Patient empowerment is a commonly used term within health care, but there is little consensus regarding its definition (Johnson Roberts, 1999). The meaning of empowerment more generally is far from clear (Mitcheson & Cowley, 2003), appears across a diverse literature (Rodwell, 1996), and changes depending on the context in which it is used (Kuokkanen & Leino-Kilpi, 2000). If we are to consider whether NHS Direct empowers patients, then we must first consider different definitions, and identify those relevant to NHS Direct.

Empowerment can be considered in the contexts of critical social theory, organisational theory, and social psychology theory (Kuokkanen & Leino-Kilpi, 2000). In critical social theory, empowerment refers to people uniting to achieve common goals and may involve citizen power and the emancipation of oppressed groups. Although patients might in some circumstances be considered as an oppressed group, this is not relevant to NHS Direct where the focus is on individuals rather than groups. In organisational theory, empowerment refers to delegation of power so that employees assume responsibility and act in line with the organisation's goals. This is relevant to the nurse advisors in NHS Direct rather than callers to the service. Social psychology theory, therefore, with its focus on individual development, and where empowerment refers to individuals gaining control over their own lives (Kuokkanen & Leino-Kilpi, 2000), is relevant to our study of NHS Direct.

Within this literature, empowerment has been defined by its absence, for example in terms of helplessness, paternalism and dependency, as well as more actively, as a feeling of having greater control over one's life (Anderson, 1996). This issue of control is a common theme within the patient empowerment literature, where the patient takes charge of their own health and their interactions with health care professionals (Johnson Roberts, 1999). Empowerment in this sense might manifest itself through individuals undertaking self care, gaining access to the services they want, and challenging health professionals (Johnson Roberts, 1999). Patients are considered as active agents (Salmon & Hall, 2003) who are free to make choices (Rodwell, 1996). Further, the concepts of responsibility and accountability are associated with freedom to make choices (Rodwell, 1996). People cannot be given empowerment, but health professionals can work with people in empowering ways (Starkey, 2003) and enable patients by making things possible (Mitcheson & Cowley, 2003; Rodwell, 1996). This entails a redistribution of power between patients and health professionals, with patients participating in decision-making about their own care (Paterson, 2001; Mitcheson & Cowley, 2003). The necessary conditions for such participation include health professionals showing respect and empathy, giving information, educating, spending time with, listening to, and offering emotional support to patients (Mitcheson & Cowley, 2003; Paterson, 2001; Rodwell, 1996; Starkey, 2003). Patients also need material resources to participate in decision-making about their individual health care in terms of money to spend on child care and travel when they attend appointments with health professionals (Paterson, 2001).

In all the above, empowerment has positive associations, and is considered to be something to be strived for. However, these positive associations can obscure the ways in which power operates (Anderson, 1996; Grace, 1991; Petersen & Lupton, 1996), and the way in which health professionals have an agenda which they wish people to follow (Grace, 1991; Johnson Roberts, 1999). Much of the discourse of the new public health seeks to shift responsibility to the population themselves (Anderson, 1996; Petersen & Lupton, 1996), and self care, a central tenet of the discourse of empowerment through NHS Direct, can be viewed as a way of managing demand (Chapple & Rogers, 1999) and simply being a cheaper option than reliance on health care (Rodwell, 1996).

In the context of patient interactions with health professionals, empowerment can disguise paternalism or even justify it (Paterson, 2001). Interventions aimed at empowering patients can result in professionals controlling the nature of interactions in health care (Mitcheson & Cowley, 2003) and can more accurately be regarded as disempowering if patients feel the burden of responsibility rather than experiencing enhanced control (Salmon & Hall, 2003). Additionally, an emphasis on self care can overlook the barriers to effective health care which people face (Chapple & Rogers, 1999). For example, patients may feel disempowered through previous experiences or lack of social support networks (Houston & Pickering, 2000); illness may make people less able to meet their own needs (Anderson, 1996) or participate in decisions about their health care (Salmon & Hall, 2003); and the focus on the individual ignores structural issues such as poverty, or institutional constraints (Anderson, 1996). Finally, there can be conflict between the caring and empowerment roles of health professionals (Rodwell, 1996) and between the notion of self reliance and the dignity of dependency which can be seen as one of the defining characteristics of humanity (Sennett, 2003). This highlights the rather narrow focus of empowerment in NHS Direct on self care, which is assumed to be good for patients by allowing them self efficacy, and good for the health service by reducing demand, but lacks acknowledgement of the problematic nature of empowerment.

Section snippets

Methods

The research was undertaken in two NHS Direct sites in England, one in London providing a service to a diverse ethnic population, and one covering a mixture of urban and rural areas. Ethics committee approval was gained for both sites. The methods included observation in the two sites, involving one of the authors (JG) making day-long visits to each site and training as a call-handler in one site; in-depth interviews with 33 NHS Direct staff chosen purposively to include a range of nurse

The interviewees

JG undertook 53 caller interviews, some of which were undertaken jointly with the caller and patient, resulting in interviews with 60 NHS Direct users. Joint interviews were not part of the study design but were undertaken in seven cases because the patient as well as the caller was present when the interviewer arrived and responded positively to negotiations around joint participation in the interview. In the sample, approximately a third of calls were from each sampling time period.

NHS Direct—facilitating empowerment?

Whilst it is not possible for NHS Direct to ‘give empowerment’ to patients, it can enable their access to effective care, and establish a relationship which is experienced as empowering. The ways in which these occurred, or not, in interviewees’ accounts of their interactions with NHS Direct are presented below.

Enabling or authorising?

NHS Direct not only enabled people to self care, access services and challenge health professionals, but also authorised their actions and legitimised their concerns.

If you’ve gone through NHS Direct they can authorise you to turn up at the out-of-hours centre […] you can’t just turn up [..] so that it would sort of justify my visit if I phoned [...] That gave me the authority to go the next morning and say “I’ve been through to NHS Direct” so there wasn’t a scene with the receptionist saying

The problem of equating low service use with empowerment

As described earlier, there was a hope when NHS Direct was first established that it would empower people to self care and thereby make less use of busy health services. However, it may not be possible to label an individual as empowered or not by the extent to which they use services. Health professionals and patients can make different judgements about the necessity of contact with a service. Some newly recruited NHS Direct call handlers for example expressed surprise that people called the

The importance of caring

Interviewees did not necessarily react positively, in their interactions with the NHS in general, to potential manifestations of empowerment. Some experienced the message that it was their responsibility to look after themselves and their family as burdensome, while others reluctantly took on an assertive role because they felt let down by the health service. In these circumstances ‘being active’ felt forced upon them; they were seeking advice, information, and access to services which they

Discussion

We have shown the range of ways in which NHS Direct can facilitate patient empowerment by enabling people to self care, and to access health services. However, NHS Direct also authorises them to take one or other course of action as they grapple with the challenge of determining when their health problems are serious enough not to be seen to be wasting the time of busy health professionals. Thus NHS Direct can be used to legitimise contact with health services in a context of the delegitimation

Acknowledgements

Many thanks to everyone in the NHS Direct sites who worked so hard to help us with this project, and the service users who gave us their time and views during the interviews.

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