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Independents' Day

Leaked report casts doubts over NHS Direct’s ‘overall viability’ in wake of NHS 111 failings

Exclusive An explosive secret report has raised questions over the future viability of NHS Direct after revealing a catalogue of failures during its rollout of NHS 111.

The 86-page confidential review by consultancy firm Deloitte, obtained by Pulse, was commissioned by NHS Direct, NHS England and the Trust Development Authority and reported on 19 April. It details a series of problems during the rollout by NHS Direct, which provides the NHS 111 service to just over a third of England’s population in 11 different areas.

The Deloitte report acknowleges that if there were to be changes to the organisation’s NHS 111 contracts in the North West and West Midlands – where many of the soft launches of the service were abandoned and remain suspended – it would ‘impact the overall viability of NHS Direct nationally’.

NHS Direct told Pulse it is now in discussions with NHS England and CCGs over the contracts and admitted it was unable to confirm at this stage whether it would remain viable if the contracts were removed. A spokesperson said that NHS Direct’s chair ‘broadly agreed’ with the main findings of the review and announced the organisation had begun disciplinary procedures as a result of the report.

The Deloitte report lists a series of shocking details around NHS Direct’s delivery of NHS 111, including:

- NHS Direct was granted a Key Performance Indicator ‘holiday’ in the first quarter of its operations and will not incur contractual penalties for the problems with the launch of the service

- The NHS Direct board did not heed warnings from key staff ahead of the soft launch

However the most significant parts of the report concern the wider future of NHS Direct.

It concludes that NHS Direct was unable to deliver its shared goals in the North West and the West Midlands at the agreed price, saying: ‘It is clear from our analysis… that it is simply not possible for NHS Direct to recover to a position where it can deliver originally contracted volumes within the current commercial parameters without incurring significant additional cost.’

It adds that there has been ‘considerable concern among the commissioners we spoke to in the West Midlands and North West and there is a clear sense of urgency around the decisions that will need to be made regarding the future of these two contracts’.

‘There is also a recognition that interventions on these contracts would impact the overall viability of NHS Direct nationally.’

The report also says that a recovery plan for NHS Direct in the two regions was estimated to cost ‘in excess’ of £9m. NHS Direct told Pulse this figure was not correct and only an ‘early informal illustration provided to commissioners’, but added that the organisation was ‘now projecting that it will make a deficit in 2013/14 as a result of the operation of its NHS 111 contracts.

‘The [NHS Direct] trust has agreed to a plan with NHS Trust Development Authority to maintain the provision of safe and stable 111 services already mobilised despite the financial deficit that this will entail. The trust is in ongoing discussions with NHS England and its local commissioners of the NHS 111 services, and until these are complete it is not possible to predict the likely financial outturn for the year.’ 

Pulse reported in March that NHS 111 services had been suspended in much of the North West and West Midlands, but the Deloitte report casts more light on the specific failures in the regions.

It says the NHS 111 services run by NHS Direct did not have enough trained staff, calls were taking  more than twice as long as predicted and assurances given to commissioners pre-rollout were ‘less than robust’.

The service was returned to out-of-hours providers after 70% of calls were abandoned in the North West on the first day, with only 13.5% were answered within 60 seconds. In the West Midlands, 37% of calls were abandoned and 49% of calls answered within 60 seconds.

The Deloitte report claims the NHS Direct board had ‘succumbed to optimism bias’ and that it did not pay heed to warnings from key staff. Some call handlers were unable to work due to problems validating their ‘smart cards’ while others had not been fully certified as being ready to handle calls themselves.

The ‘preceptorship’ process, whereby call handlers are observed on live calls by a ‘buddy’ to ensure they are competent, resulted in a ‘bottleneck’ during recruitment, the report says, adding: ‘This situation led to staff being on the roster, working shifts, that had not been fully preceptored (ie could not handle calls by themselves)’.

The report highlights failures in governance of the 111 programme and concludes: ‘In hindsight, it is hard to understand how the significance of these concerns, which were articulated in project management meetings, RAG [red, amber, green] reports and in email correspondence with colleagues, was not appreciated in time to allow remediation to be effected in a timely fashion and in any event before the “Go Live” decisions were taken.’

In a long statement to Pulse, NHS Direct said it accepted that ‘at launch its 111 services fell short of the standards that patients should expect’.

‘The board profoundly regrets the impact that this had on the quality of services that patients received in the immediate period following launch and the effect on other parts of the NHS,’ a spokesperson said.

‘NHS Direct, working very closely with commissioners and NHS England, acted immediately to stabilise the service for patients, with patient safety paramount.’

‘As a result of the actions taken performance stabilised quickly, and improved from the very poor service levels seen in the first few days after launch.’

However NHS Direct rejected the report’s criticism of call centre staff certification, insisting that ‘the quality of staff training and sign-off for handling calls solo was of high quality and was not compromised, despite the pressure to increase staffing’.

A spokesperson for NHS England, which had previously refused to release the Deloitte report, said it was taking the review ‘extremely seriously’.

‘We are working closely with the NHS Trust Development Authority to identify an approach and response,’ she said. ‘Meanwhile it is our absolute priority to ensure patients get a high quality, safe service and we are working with NHS Direct and local commissioners of the 111 service to find a way forward.’

Dr Richard Vautrey, GPC deputy chair, said: ‘The report demonstrates how flawed the whole procurement system was and why we were right to raise concerns about the system. One of the concerns we had was that CCGs were in a development phase and weren’t able to really play a leading part.’

Please note: After publication of this story, NHS Direct informed Pulse that this was not the final draft of the report, and the final version clarified that the reference to not heeding warnings from key staff ahead of the soft launch referred to Executive Board members and not to Non-Executive members. The review found that the Non-Executive members did exercise challenge but that no significant concerns regarding the organisation’s ability to deliver 111 services were raised by senior executives at Board sessions.

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Readers' comments (14)

  • What a total waste of tax payers’ money is it not time to close down 111 and return to the NHS Direct Nurse led Triage service, but delivered at a local level rather than national. NHS Direct delivered at a local level would meet the needs of a local population just like it did when it first started in 1999. The public deserve better

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  • "The ‘preceptorship’ process, whereby call handlers are observed on live calls by a ‘buddy’ to ensure they are competent, resulted in a ‘bottleneck’ during recruitment"

    There's a natural in-built bottleneck within the NHS Pathways license requirements- that staff have to undertake a minimum of 200 calls a month to stay accredited. Therefore any provider will have had to schedule their call handling recruitment very carefully to avoid staff being recruited too far in advance of being able to take that many calls in a live environment. NHSD may well have undercooked the staff required at launch, but the very design of Pathways prohibits services from building up a bank of staff to pull in as required.

    Also fair to say that in our area (not provided by NHSD), call lengths at start were significantly over the estimated call times provided by DH. I would have thought this was fairly commonplace and reflects more on the information provided centrally, although as NHSD were providers of a number of the initial pilot sites, they should have shared call handling data at launch with other areas rather than the total lengths when handlers / clinicians were more practiced, which I assume (although don't know) may be what happened.

    Certainly NHSD in the NW and West Mids were the most public failures for 111 launches, but they were by no means the only ones to have significant issues at launch.

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  • Vinci Ho

    We have two types of 111, NHS direct 111 and non NHS direct 111?
    While the former is now labelled as 'the bad guy' according to this report , does that mean 111 will become perfect as long as it is run by the other guys?Eh?
    (sorry , old demented me can be sometimes naive!)

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  • Re anonymous 3:53- NHS direct did publish call length data from pilots.All longer than the procurement specification.
    The issue appears to have been that for the service to appear VFM the apparent call length for the likely volume of calls was altered- there are calculations "Erlang C" that gives you number of staff to answer the calls within a set time frame, which is basically dependent on the call length. Double the call length double the staff- and it appears the "optomism" was to make the call length fit the budget and expect reality to change.

    I personally would call anything that expects an alteration from scientifically evaluated reality a type of insanity....................

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  • So, according to Jeremy Hunt, a senior NHS manager should be held personally accountable for this mess.

    Remind me who the senior most official in NHS might be? Oh, it's you Mr Hunt.

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  • "NHS Direct a failure"; next week another devastating expose': "Bears evacuate boewls in arboreal locations!"

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  • I am a tax payer

    Can I have clarity please, I read above:
    NHS Direct was granted a Key Performance Indicator ‘holiday’ in the first quarter of its operations and will not incur contractual penalties for the problems with the launch of the service

    Are NHS DIrect being paid in the first quarter for the 24 hours or so of utter shambles they delivered in the West Midlands, who is picking up the bill for the organsiations having to suddenly rebuyild capacity and take on the work again?

    We have a right to a clear answer, and for the answer to be given to our Patient Groups

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  • I suggest you ask that question to Jeremy Hunt. NHS111 was not originally (i say this as we have now inherited this by default, even if we didn't want to) commissioned by the CCG

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  • NHS Direct worked extremely well and safely for 14 years, however, 'the powers that be' deemed it was too expensive at £24 a call! As usual governments not looking further than the next election decided they needed to save money and bring the cost of the calls down. In this case Labour! Hail the beginning of the 111 service. The plan.. for calls to be dealt with a top heavy proportion of non-clinical call handlers. Thereby passing less calls through to drastically reduced numbers of experienced senior nurses.
    With NHSD the majority of these calls were given advice about how to manage symptoms at home with specific worsening instructions, so the caller was in no doubt about what to do should their condition change.
    So now we have the 111 service being managed by over 40 different organisations both NHS and private organisations, where once we had one national organisation managing we now have over 40! Non clinical staff have high dispositions due to lack of knowledge and as we know face to face consultations cost a lot more than £24!
    Shortsighted governments that don't look at the bigger picture and unqualified ideas that in this case has cost the country dear. It is not NHSD at fault here!

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  • and Ann Macintosh needs to know that most part time women doctors work more than 40 hours a week, we just get paid part time , because the full timers are workload superheroes.Really have to stop listening to radio 4.

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