In response to the article by Stewart et al1 on a review of calls to NHS Direct related to attendance in the paediatric emergency department, we think it would be helpful to set some of the findings in context.

When NHS Direct was first set up it was anticipated that, in such a high profile service—the first national nurse telephone clinical assessment service in the world—there would be a significant degree of risk aversion. The paper relates to circumstances in late 2002 and early 2003. The situation today is very different, so care needs to be taken in extrapolating the study’s conclusions to the present day. NHS Direct now works as a single virtual contact centre with calls being routed throughout England; the study relates to patients calling a single NHS Direct site. NHS Direct has made considerable changes to the decision support software (10 new clinical versions have been released since the study) and to the training and culture of the organisation.

One of the key drivers for these changes has been the need to reduce urgent referrals while maintaining our excellent clinical safety record. This we have done, and advice to callers supporting home care for those aged under 16 years has increased from 15% for the study site in 2002/3 to >26% nationally in 2005/6. Emergency and acute referrals have continued to fall overall.2

We recognise that there is further progress to be made in this area, and are committed to continue to work with partners to ensure alignment with current best practice, new guidance and learning from feedback, complaints and incidents.

Telephone clinical assessment, especially of children, nevertheless needs constant careful development and the UK needs to reduce infant mortality to bring it into line with other European countries. To achieve this, and bearing in mind the comments of the author and Laird3 with respect to the difficulties of assessing sick children over the telephone, it is likely that a number of children who ultimately turn out to have a self-limiting illness or injuries will need to be assessed in a face-to-face setting in order to identify, in a timely manner, others who are significantly unwell.

During the past 2 years, NHS Direct has introduced major upgrades to IT and telephony systems which will facilitate two-way data exchange. NHS Direct would welcome the opportunity to work with colleagues on the ongoing development and audit of the outcome of referrals such as those reviewed in this study.