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Frequently Asked Questions

Where did the idea of NHS Pathways come from?

An issue regarding the access to urgent and emergency healthcare was identified by a group of NHS clinicians. NHS Pathways was developed by the group with extensive experience of both urgent and emergency care provision, and clinical decision support tools. Because there are three main routes to access urgent care by telephone – a patient can dial 999, NHS Direct or GP out of hours – each of those settings uses a different clinical tools to identify the severity of any given patients symptoms. It means patients go through different assessment processes depending on the number they called and may have to repeat information while their call is being transferred. Each of the services also maintains their own directory for local care services.

NHS Pathways sets out to create a clinical assessment tool that would provide consistent clinical assessment in any telephone access setting, built upon the very latest clinical evidence, and linked to a single directory. This would cut down duplication of directory maintenance, and enable consistent assessment and easy transfer of patients to a relevant service, without repeating all the details again.

How do you ensure that the questions within NHS Pathways will be used to successfully diagnose particular illnesses?

NHS Pathways does not diagnose illnesses; it uses the presence and features of symptoms to progressively exclude conditions during the phone assessment.

As the phone assessment progresses, if a point is reached where a condition cannot be excluded, the caller is referred to the appropriate level and location of care. An appropriate timeframe is also advised for that consultation.

How does NHS Pathways compare with comparable ambulance triage systems?

NHS Pathways uses a solely symptom-based approach to call assessment. This is in contrast to other ambulance triage systems which are designed to support triage up to the point where a vehicle is dispatched.

NHS Pathways is designed to give a complete triage, which may end with a primary care referral or home care advice via the locally held and populated directory of services. It must also dispatch emergency ambulances in a timely manner, but this is only one aspect of its function.

How can the data within NHS Pathways be used to monitor the clinical performance of the service and those using the system? 

The data collected within NHS Pathways enables services using the system to monitor every aspect of the calls they receive. Services can even see how specific questions are handled by call handlers, in terms of the answer given and how long it took for that answer to be reached. This information and such things as call length can be aggregated by team, trainer, shift. Services can then clearly pinpoint any clinical or operational issues and target the appropriate training to improve individual and service performance.

Reports are often very difficult to access within IT systems, is NHS Pathways any different? 

Recognising this difficulty, the development team ensured that there was complete flexibility to enable reporting on any aspect of the system. As a result, NHS Pathways has an inbuilt reporting suite that presents information in a standard 'dashboard' format. It is possible to report any specific measure against any other measure, so additional reports are easily configured but all of the important ones are immediately available to the user organisation.

Are there any national reports that look at the effects of using NHS Pathways and the Directory of Services from a patient's point of view?

At present there are no national reports from a patients' perspective on NHS Pathways and the Directory of Services. The North East Ambulance Service, one of the first organisations to use the system, conducted surveys involving patients who called 999 and were directed to primary care. Patient satisfaction rates of over 90% were returned from those not offered an ambulance dispatch in response to a 999 call. Comments indicated that 'satisfaction' came from the patient receiving the appropriate level of care.

NHS Blackpool have also conducted a series of patient satisfaction surveys, the results show that NHS Pathways has not had any adverse effects on patients' urgent and emergency care experience. In many cases it has enhanced it, as patients have been able to get advice over the telephone or go to a service close to where they live.

How often is NHS Pathways reviewed and updated?

Routinely, system updating and a release of new content takes place.  Each release contains material resulting from requests for change, new evidence or national protocols and guidelines.  Some pathways, e.g. those relating to a snake bite, may be rarely used and attract little comment from users. To ensure it accurately reflects current best practice, all content, regardless of pattern of use, is subject to a rolling review cycle, with release of reviewed content included in the scheduled bi-annual releases.

What happens if an urgent problem is identified with the clinical content, how quickly is it fixed?

There is a formal process for users to notify the NHS Pathways clinical authoring team of any clinical issue that may have arisen. The issue is immediately logged and considered by the clinicians in the team and any associated risk is assessed. The severity of the associated risk dictates the immediacy of the response. If a serious risk was to be identified, an immediate workaround would be recommended to users while the relevant clinicians and developers corrected the problem. Once corrected and approved by the National Clinical Governance Group there would be a new release of corrected content. As new releases have training implications, the timing of any new release would always be determined in discussion with users.

How are changes within NHS Pathways agreed and acted upon?

All changes and upgrades to the system are governed and overseen by an independent National Clinical Governance Group. This group is chaired by the Royal College of General Practitioners (RCGP), and has representation from those Royal Colleges and professional bodies which have an interest in urgent and emergency care.

What training do call handlers receive to ensure they can use NHS Pathways safely and provide an effective and safe service to callers?

Any call handler using NHS Pathways to answer calls undertakes a 60 hour training programme. This includes a pre-course learning pack which provides an introduction to the system and key areas of anatomy, physiology and medical terminology, classroom tuition, written and practical assessments. All call handlers must achieve a pass mark of 70%.

All call handlers receive a minimum of four weeks of supervised use on the live system followed by another assessment. This includes a clinical audit of calls taken and direct feedback to the individual.

Additional training may also be given by the organisation on use of telephony, call control and local processes and procedures for call referral under different circumstances, such as child protection, vulnerable adult, frequent caller or patient with special notes.

Has the safety of NHS Pathways been evaluated?

NHS Pathways has been independently evaluated, on behalf of the Department of Health, by the Universities of Sheffield, Southampton and Swansea. The evaluation found NHS Pathways to be 'at least as safe and effective' as comparable systems.

Read the full evaluation report

Unlike other triage systems, used in out-of-hours or NHS Direct, systems that are able to dispatch and prioritise ambulances need to have a government licence, and must go through much greater scrutiny before such a licence is issued.  NHS Pathways is only the third such system to receive this license.

How has clinical safety been assured?

Clinical Safety has been a key part of the development process for NHS Pathways. Every clinical question and every piece of care advice is, where possible, linked individually to at least three pieces of evidence, if available (preferably UK, if possible) and dated within the last five years, where possible. All evidence is graded for quality so if anyone approaches with a change request or alternative suggestion, we can compare the evidence underpinning and select an approach based on the highest quality evidence available.

A robust and comprehensive clinical governance process for the authoring of material, and for any changes means there is a required quorum for decisions to change, and also a full audit trail of any change made, by whom, when and the rationale agreed for the change. Once a new release of the clinical content is agreed, a process of logic checking and clinical integrity checking ensures the absolute safety of the proposed release.

All flows in the initial version of NHS Pathways was peer reviewed by groups made up of symptom based specialist and generalist representatives of the Royal Colleges and professional bodies.

How does the Directory of Services link with NHS Pathways?

As an assessment is being carried out using NHS Pathways it collects certain data items related to:

  • patient's age and gender
  • patient's location at the time of the call  
  • the clinical indicators about the presenting symptom/symptoms
  • the time and day of call.

For example:

A female adult in Torbay on a Tuesday morning calls with symptoms indicators X, Y, Z.

These symptom indicators are linked to the questions within the NHS Pathways clinical content. Positive answers to those questions trigger the indicator flags.

This information is then sent to the Directory of Services and it looks for a match to that information, and then presents details of each service that has matched this combination of requirements.

Is the Directory of Services the same as the one used by Choose and Book?

No, the NHS Pathways Directory of Services is another directory that is designed and owned by the NHS. It stores different data to Choose and Book in a pre-defined format.

There are other directories available on the market why do we have to use the NHS Pathways Directory of Services?

NHS Pathways and the Directory of Services are fully integrated – no other service has this. All other directories are reliant on a user physically searching a directory manually to find out what is the correct service. NHS Pathways and the Directory of Services are completely seamless and enable both direct matching of the patient to a service that can definitely meet their need. It also captures data for commissioners on demand.

Can non-clinical services (e.g. social care) be made available in the Directory of Services?

Yes, any service that a patient can be referred into can be made available on the Directory of Services. However, the NHS Pathways automatic search only matches on clinical criteria.

As a commissioner, do I need to add all the primary care services to the Directory of Services or can I leave some off?

As a commissioner you can decide which services are made available via the Directory of Services. Due to clinical governance risks, only certain services can be made available directly to NHS Pathways call handlers. Other services which are available for direct clinician search can be added with local agreement.

Are there any primary care services that could or should not be added to the Directory of Services?

No, all available primary care services can be added to Directory of Services. Due to clinical governance risks, only certain services can be made available directly to NHS Pathways call handlers. Other services which are available for direct clinician search can be added with local agreement. To assist in this, a number of profile templates have been developed and tested, based on national contracts and experience.

Is the Directory of Services populated and updated in real time or is there a delay?

A service's notes and capacity status are updated in real time. The clinical population of data is done and validated 'offline' before being made available in the live environment, once approved. Similarly clinical updates follow a procedure of validation before use in live.

Who is responsible for keeping the Directory of Services up-to-date?

It is the responsibility of the local service commissioners, providers and the local Directory of Services manager in each area to populate and keep it up-to-date.

Does the Directory of Services give users more than one option so that providers do not get overcrowded?

The Directory of Services will list all services that match a patient's needs.

Can cross-border services be recommended to a patient?

Yes, the directory does not recognise borders. Services which meet the specific needs of a patient are primarily returned in a priority order set by the commissioners, followed by in the distance from the patient, with the nearest being presented first. The priority will need to be appropriate and agreed at a local level between commissioners and providers.

If the patient needs to be seen within the next six hours, will the system show what will be available then and not just what is available at the time of the call?

Yes, the system allows for services which are scheduled to open within the required timeframe as well as services which are currently open.

Can the Directory of Services be used to book a patient into an urgent care centre?

If there is a technical link between the referring service system and the booking system at the receiving service the patient can be booked into an urgent care centre. If not a phone call would be made to book the appointment.

Where can I find out more about NHS 111?

Information about NHS 111 can be found on the Department of Health website and NHS Choices.