The rationale for NHS Direct was never really about health: it was about engaging middle-class taxpayers with the service. Like the walk-in centres, also introduced by the Blair government, NHS Direct is a system of reassurance for the worried middle classes.
As a GP in an impoverished area of Birmingham once put it to me: "It's all very well that old ladies in sheltered accommodation can get their toenails cut, but if you are a busy, higher-rate taxpayer, you don't care. Then the taxpayers say: 'I never use the health service, so why can't I have a discount on my tax so I can pay it into my insurance?' And that's the end, once we have people opting out of the NHS."
So she supported the NHS Direct service and the walk-in centres. "I'd rather have the middle classes here [at the walk-in centre] and have them saying, 'Isn't the health service wonderful?' and have them paying their taxes so that, in due course, I can replace the leaking drain in my practice."
NHS Direct's 3,000 staff discovered they were to lose their jobs in late August when the Health Secretary, Andrew Lansley, carelessly let slip that the service was to close. What a way to find out that you are going to be replaced by a cut-price call centre - the NHS 111 system.
Slash and burn
Should we care if it closes? On the one hand, NHS Direct is an imperfect service and an expensive middle-class benefit. Like free university education, it is overwhelmingly used by the better-off. Studies have found the use of NHS Direct to be consistently lower among the elderly, the poor and ethnic minorities. The poor go to casualty; the middle classes pick up the phone.
Most GPs have never liked it - they think NHS Direct simply enables the worried well to duplicate their use of health services. But there is a snobbery, too: why should a nurse be allowed to give advice that a GP has had to do five years' training after medical school to give?
Yet NHS Direct also helps GPs. It facilitates the contracting out of out-of-hours services, which has been popular among family doctors. A study reported in the British Medical Journal showed that, in its first year of operation, 72 per cent of calls to NHS Direct were out of hours. I wonder where the government thinks people will turn once there is no acceptable out-of-hours NHS service. To the private sector?
I don't think Lansley would mind that. His decision to close NHS Direct was political, not pragmatic, as evidenced by the way he announced it less than a fortnight after the Department of Health claimed there would be a series of evaluations of the NHS 111 pilot scheme in the north-east. This closure is based on the slash-and-burn approach to public services, not on any assessment of user need. The government probably doesn't care if it loses middle-class support for the NHS; it plays into its wider ideological agenda.
NHS Direct has huge problems. Staff morale is poor and its costs have spiralled up to £25 per call. There is a high turnover of staff due to the mechanistic nature of the work and oppressive managerial oversight. More than one in ten staff is off sick at any one time and employees clock up 23 days' sick leave per year on average. Those figures represent astonishing management failures, which left NHS Direct vulnerable to political assault.
By chance, I used NHS Direct the day before its closure was announced. I'm not a regular user and there was a good online questionnaire that pretty much gave me the answers I needed. Still, a nice lady - let's call her Tina - rang me 20 minutes later. Tina was kind and patient but not exactly reassuring. She seemed to be having trouble with a computer system that couldn't accept that I had moved house in the past four years, trouble remembering which questions
I had just answered and trouble getting her basic facts straight. Had I actually been worried, I wouldn't have trusted her. But at least Tina was employed. Soon, she won't be, and she will probably struggle to find work elsewhere in this economic climate. There will be thousands more like her; NHS Direct attracted an overwhelmingly female staff, many of them working mothers, due to its flexible hours. It also provided employment for nurses who could not continue front-line work due to ill-health (could that account for some of that sick leave?). These staff, and not the managers, will ultimately pay the price for the closure of the service.
The chief executive of NHS Direct, Nick Chapman, has been smoothly sanguine about it, offering the risible defence that 111 would be an easier number for people to remember. Oh, and the new service will offer better value for money and "be a more seamless service". No wonder NHS Direct was open to attack, with that level of brave leadership at the top.
And the chair of NHS Direct? She is Joanne Shaw, appointed in January. She also happens to be chair of Datapharm, which - who would have guessed it? - "provides digital medicines information to the NHS, the pharmaceutical industry and the general public".
Datapharm may be a not-for-profit organisation but it is funded by 170 pharmaceutical companies. I'm sure they will be very interested in the advice given out by NHS 111. Incidentally, you can follow Shaw on Twitter at "EvolvingPatient", though there has scarcely been a tweet about the NHS Direct closure thus far, at least at the time of writing.
Silence can be golden. Presumably the chief executive will be OK, because he hasn't kicked up a fuss. And Shaw will be fine, too, with her portfolio of jobs (she is also a director of the British Board of Film Classification). But Tina? She probably won't have a job at all, and nor willthousands like her.