Evaluation of NHS Direct ‘‘referral’’ to community pharmacists

OBJECTIVES: To evaluate a pilot scheme of referrals from a nurse-led telephone helpline (NHS Direct) to community pharmacists. METHODS: A multi-method approach, including analysis of routine data from NHS Direct, postal surveys of NHS Direct callers, analysis of anonymised transcripts of calls, a postal survey of callers referred to pharmacists, and face-to-face interviews with NHS Direct nurses. SETTING: Essex, Barking and Havering. KEY FINDINGS: During the first three months of the pilot scheme, 6% (1,995/31,674) of NHS Direct calls triaged by nurses were logged as referred to pharmacists. This built on an existing foundation of informal referral to pharmacists of 4%. There was no measurable change in callers’ views of the helpfulness of advice, enablement, or caller satisfaction associated with the scheme. Conditions sent to pharmacists included skin rash, cough, sore throat, stomach pain, and vomiting and/or diarrhoea. 86% (54/63) of callers referred to pharmacists during the scheme felt the referral was very or quite appropriate and 75% (48/64) attempted to contact a pharmacist. In general, those who did so found the experience a positive one: 65% (31/48) spoke to the pharmacist, and 80% (28/35) of people expressing an opinion were satisfied with the advice offered, but the lack of privacy in the pharmacy was of some concern. Although routine data indicated high usage of the scheme, nurse referral of callers to pharmacists declined over time. Their initial enthusiasm diminished due to concerns about the appropriateness of guidelines, their lack of understanding of the rationale behind some referrals, and the lack of feedback about the appropriateness of their referrals. CONCLUSIONS: The evaluation of the pilot scheme has generated a range of recommendations for the wider national roll-out of the scheme, including revision of the guidelines and review of NHS Direct nurse training for referral to pharmacy. NHS Direct and pharmacists should consider how to strengthen the system of pharmacist feedback to NHS Direct

Impact of NHS Direct on demand for immediate care: observational study

OBJECTIVES: To quantify the impact of NHS Direct on the use of accident and emergency, ambulance, and general practitioner cooperative services. DESIGN: Observational study of trends in use of NHS Direct and other immediate care services over 24 months spanning introduction of NHS Direct. Setting Three areas in England in first wave of introduction of NHS Direct, and six nearby general practitioner cooperatives as controls. SUBJECTS: All contacts with these immediate care services. MAIN OUTCOME MEASURES: Changes in trends in use after introduction of NHS Direct. Results NHS Direct received about 68 500 calls from a population of 1.3 million in its first year of operation, of which 72% were out of hours and 22% about a child aged under 5 years. Changes in trends in use of accident and emergency departments and ambulance services after introduction of NHS Direct were small and non­significant. Changes in trends in use of general practitioner cooperatives were also small but significant, from an increase of 2.0% a month before introduction of NHS Direct to - 0.8% afterwards (relative change - 2.9% (95% confidence interval - 4.2% to - 1.5%)). This reduction in trend was significant both for calls handled by telephone advice alone and for those resulting in direct contact with a doctor. In contrast, the six control cooperatives showed no evidence of change in trend; an increase of 0.8% a month before NHS Direct and 0.9% after (relative change 0.1% ( - 0.9% to 1.1%)). CONCLUSION: In its first year NHS Direct did not reduce the pressure on NHS immediate care services, although it may have restrained increasing demand on one important part—general practitioners' out of hours services

Exploring the effect of changes to service provision on the use of unscheduled care in England: population surveys

Background Unscheduled care is defined here as when someone seeks treatment or advice for a health problem without arranging to do so more than a day in advance. Recent health policy initiatives in England have focused on introducing new services such as NHS Direct and walk in centres into the unscheduled care system. This study used population surveys to explore the effect of these new services on the use of traditional providers of unscheduled care, and to improve understanding of help seeking behaviour within the system of unscheduled care. Methods Cross-sectional population postal surveys were undertaken annually over the five year period 1998 to 2002 in two geographical areas in England. Each year questionnaires were sent to 5000 members of the general population in each area. Results The response rate was 69% (33,602/48,883). Over the five year period 16% (5223/33602) 95%CI (15.9 to 16.1) of respondents had an unscheduled episode in the previous four weeks and this remained stable over time (p = 0.170). There was an increased use of telephone help lines over the five years, reflecting the change in service provision (p = 0.008). However, there was no change in use of traditional services over this time period. Respondents were most likely to seek help from general practitioners (GPs), family and friends, and pharmacists, used by 9.0%, 7.2% and 6.3% respectively of the 5815 respondents in 2002. Most episodes involved contact with a single service only: 7.0% (2363/33,602) of the population had one contact and 2% (662/33602) had three or more contacts per episode. GPs were the most frequent point of first contact with services. Conclusion Introducing new services to the provision of unscheduled care did not affect the use of traditional services. A large majority of the population continued to turn to their GP for unscheduled health care

Signatures of the Pair-Coherent State

We explore in detail the possibility of generating a pair-coherent state in the non-degenerate parametric oscillator when decoherence is included. Such states are predicted in the transient regime in parametric oscillation where the pump mode is adiabatically eliminated. Two specific signatures are examined to indicate whether the state of interest has been generated, the Schrodinger cat state - like signatures, and the fidelity. Solutions in a transient regime reveal interference fringes which are indicative of the formation of a Schrodinger cat state. The fidelity indicates the purity of our prepared state compared to the ideal pair-coherent state.Comment: Figures hacked down to size for serve

Entangling photons using a charged quantum dot in a microcavity

We present two novel schemes to generate photon polarization entanglement via single electron spins confined in charged quantum dots inside microcavities. One scheme is via entangled remote electron spins followed by negatively-charged exciton emissions, and another scheme is via a single electron spin followed by the spin state measurement. Both schemes are based on giant circular birefringence and giant Faraday rotation induced by a single electron spin in a microcavity. Our schemes are deterministic and can generate an arbitrary amount of multi-photon entanglement. Following similar procedures, a scheme for a photon-spin quantum interface is proposed.Comment: 4 pages, 4 figure

Impact of NHS Direct on other services: the characteristics and origins of its nurses

OBJECTIVE:: To characterise the NHS Direct nurse workforce and estimate the impact of NHS Direct on the staffing of other NHS nursing specialties. METHOD: A postal survey of NHS Direct nurses in all 17 NHS Direct call centres operating in June 2000. RESULTS: The response rate was 74% (682 of 920). In the three months immediately before joining NHS Direct, 20% (134 of 682, 95% confidence intervals 17% to 23%) of respondents had not been working in the NHS. Of the 540 who came from NHS nursing posts, one fifth had come from an accident and emergency department or minor injury unit (110 of 540), and one in seven from practice nursing (75 of 540). One in ten (65 of 681) nurses said that previous illness, injury, or disability had been an important reason for deciding to join NHS Direct. Sixty two per cent (404 of 649) of nurses felt their job satisfaction and work environment had improved since joining NHS Direct. CONCLUSION: The NHS Direct nurse workforce currently constitutes a small proportion (about 0.5%) of all qualified nurses in the NHS, although it recruits relatively experienced and well qualified nurses more heavily from some specialties, such as accident and emergency nursing, than others. However, its overall impact on staffing in any one specialty is likely to be small. NHS Direct has succeeded in providing employment for some nurses who might otherwise be unable to continue in nursing because of disability

NHS Direct: consistency of triage outcomes

OBJECTIVES: To examine the consistency of triage outcomes by nurses using four types of computerised decision support software in NHS Direct. METHODS: 119 scenarios were constructed based on calls to ambulance services that had been assigned the lowest priority category by the emergency medical dispatch systems in use. These scenarios were presented to nurses working in four NHS Direct call centres using different computerised decision support software, including the NHS Clinical Assessment System. RESULTS: The overall level of agreement between the nurses using the four systems was “fair” rather than “moderate” or “good” (k=0.375, 95% CI: 0.34 to 0.41). For example, the proportion of calls triaged to accident and emergency departments varied from 22% (26 of 119) to 44% (53 of 119). Between 21% (25 of 119) and 31% (37 of 119) of these low priority ambulance calls were triaged back to the 999 ambulance service. No system had both high sensitivity and specificity for referral to accident and emergency services. CONCLUSIONS: There were large differences in outcome between nurses using different software systems to triage the same calls. If the variation is primarily attributable to the software then standardising on a single system will obviously eliminate this. As the calls were originally made to ambulance services and given the lowest priority, this study also suggests that if, in the future, ambulance services pass such calls to NHS Direct then at least a fifth of these may be passed back unless greater sensitivity in the selection of calls can be achieved

Quantum computation with optical coherent states

We show that quantum computation circuits using coherent states as the logical qubits can be constructed from simple linear networks, conditional photon measurements and "small" coherent superposition resource states

Attaining subclassical metrology in lossy systems with entangled coherent states

Quantum mechanics allows entanglement enhanced measurements to be performed, but loss remains an obstacle in constructing realistic quantum metrology schemes. However, recent work has revealed that entangled coherent states (ECSs) have the potential to perform robust subclassical measurements [J. Joo et al., Phys. Rev. Lett. 107, 083601 (2011)]. Up to now no read-out scheme has been devised that exploits this robust nature of ECSs, but we present here an experimentally accessible method of achieving precision close to the theoretical bound, even with loss.We show substantial improvements over unentangled classical states and highly entangled NOON states for a wide range of loss values, elevating quantum metrology to a realizable technology in the near future