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Independents' Day

Three-quarters of NHS 111 referrals to general practice are inappropriate

Exclusive Only one in four NHS 111 GP referrals is clinically appropriate, a Pulse survey has suggested, with GPs warning that some referrals are ‘harmful’ and an ‘insult to professional integrity’.

GPs said they had known of call handlers citing suspicions of ebola because the patient had visited Barbados, which the call handler thought was in west Africa, ambulances being sent out for a heavy painful period and 80-year old patients being asked if they were pregnant.

It comes ahead of today’s LMCs Conference, which will debate whether GP leaders think the service should be scrapped.

The survey of 592 GPs found that at least 70% of respondents felt that the majority of referrals were inappropriate, with many GPs backing claims by the BMA that patients with colds are being told by call handlers to book a GP appointment immediately.

A mid-point analysis showed that, in all, an average of 73% of referrals were deemed as clinically appropriate by GP respondents.

It comes as the BMA has called for a radical overhaul of the system, urging the Government to carry a serious and urgent analysis of the effect of NHS 111 on the wider health service ‘to determine where it may be working inefficiently and to ensure that it is cost effective’.

GPs have criticised the urgent phone helpline for being operated by non-medically trained call handlers and have accused the computer algorithm – and the call handlers – for being overly cautious and risk-averse.

Mounting concern over the system prompted NHS England’s national director of commissioning operations Dame Barbara Hakin to write to all NHS 111 commissioners this year, calling on them to ensure there is a GP presence, or on-call advice, during peak hours.

GPs have criticised the whole basis of the system, and said that it is removing resources from more appropriate areas.

Dr Chris Kenyon, a GP in Oxford, said: ‘I despise NHS 111 with every fibre of my being. It is the creator of anxiety and totally useless clinical activity which removes resources from what really needs to be done. It is expensive, harmful and a major insult to professional integrity.’

Dr Stephen Tomkinson, GP in Manchester, said had read a transcript of an encounter of one of his patients who had diarrhoea and vomiting during the ebola epidemic.

He said: ‘The 111 algorithm asked “has the patient returned from West Africa recently?”, to which the call handler typed in “Yes - Barbados” and the patient was then advised to attend her local A&E department asap!’

Dr Bharat Nanavati, another GP in Manchester, said that a young woman with heavy painful vaginal bleeding for 30 minutes was told to see an emergency treatment centre within an hour. He added: ‘I have no doubt that the young lady was seeking no more than telephone advice and refused the utterly stupid recommendations of the NHS 111.’

Another GP, Dr Mario Carl Wildenauer, out-of-hours GP in Oxfordshire, said that an over 80 year old male patient, with a deep voice, was asked whether he was pregnant.

However, Dr Joe McGilligan, a GP in Redhill, Surrey, said that the service does provide a ‘safety net’.

He added: ‘There is no perfect solution but this is at least now joined up between 999 and out-of-hours services.’

The BMA said it had heard of examples of minor ailments such as colds and sore thumbs being referred to GPs from call handlers.

It believes that a Government analysis of NHS 111 should ensure that there is a programme in place to boost the number of expertly trained clinicians answering calls from patients.

GPC lead on NHS 111 Dr Charlotte Jones told Pulse: ‘NHS 111 is delivering a significant number of calls. We are aware of the views surrounding 111 and know that improvements need to be made.

‘These include putting in place stronger clinically trained staff to support call handlers and improving algorithm training.’

NHS 111 has been plagued by worries and criticism since it started operating.

When NHS 111 was rolled out in April 2013, NHS England stressed that non-medically trained call handlers would be able to rely on NHS Pathways, which would direct patients to certain services based on a computer algorithm.

But months later Pulse revealed that GPs had lost confidence in the ability of the NHS 111 service to triage patients, with only 8% saying they believe the urgent care phoneline was safe for patients.

Later that year, NHS Direct - the largest provider - pulled out of contracts after concluding that it was unable to provide the services to an adequate level.

Results in full

What percentage of NHS 111 calls referred to you do you perceive as clinically appropriate?

0-20%: 243 (41%)

21%-40%: 174 (29%)

41%-60%: 77 (13%)

61%-80%: 25 (4%)

81%-100%: 11 (2%)

Don’t know: 62 (11%)

The survey launched on 9 February 2015, collating responses using the SurveyMonkey tool. The 37 questions covered a wide range of GP topics, to avoid selection bias on one issue. The survey was advertised to readers via our website and email newsletter, with a prize draw for a Samsung HD TV as an incentive to complete the survey. Some 592 GP partners answered these questions.

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Readers' comments (17)

  • I really don't understand this......
    4% think 61-89% inappropriate and 2% think 81-100% inappropriate.
    In my mind this means that 6% of GPs think that more than 60% of 111 referrals inappropriate.
    Where do you get your figures from?

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  • And....

    "A mid-point analysis showed that, in all, an average of 73% of referrals were deemed as clinically appropriate by GP respondents."

    Appropriate or inappropriate??????

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  • Hi thanks for pointing this out - it has been changed

  • Sad once again GP's showing they have no interest in anything done outside their own service. This was a Survey Monkey to Doctors - Therefore hear-say. No real figures and LMC are going to base their judgement on this? Please not over three quarters of GP's said it was less than 40% or they didn't know.

    NHS Direct had the same problem - lack of professionalism fro GP's I am very sad to say.

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  • My title should read Retired NHS Manager

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  • Misleading surveys and articles like this are really unhelpful.

    1. To state the obvious, to determine how many referrals are 'inappropriate', you would have to audit a bunch of referrals and get someone to count how many were appropriate or not. The survey here asks some GPs how many they 'feel' are appropriate. Without them having reference to any statistics or audit from their practice. Essentially asking them to pluck a figure from the air.

    2. The headline 'three quarters of referrals are inappropriate' is baseless. It was a 'midpoint analysis' (so done before the survey was finished - presumably since it gave a bigger number for the headline). And once again, no-one has even counted how many referrals were appropriate or not.

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  • Sadly Joe in Redhill area it should provide a safety net, but it ridicules itself by insisting that GPs see a sorethroat within 2 hours - which of course is a nonsense. Also because there are no clinicians on duty so there is a lengthy algorithym that staff have to go through - hence stupid and inappropriate questions for patients to answer - it is so cumbersome it is no longer preventing attendance at A nd E because patients who have used it would never do so again. A prime example of this was a patient called 111 to get details of emergency dentist and after the call handler had started to run through the algorithym the patient hung up and went to A and E - Without clinical present 24/7 it can never be what it was set up to be

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  • Bob Hodges

    I have personally seen the 111 software attempt to send an ambulance to a patient with nothing more than a cold sore, on TWO separate occasions. One was for a 14 year old boy who's mother was told that he was having a stroke. Ambulances are routinely sent to ladies with heavy periods and occasionally with UTIs.

    In OOH I spend so much of my time speaking to ambulance staff at patients' home (sent at the behest of 111) as to beggar belief.

    The stupidity of NHS111 knows NO bounds in our area, but I get the impressions from my OOH work that the NHS111 service provided by the Ambulance trust (SWAFT) in Devon might actually be miles better than the service provided to us by CareUK in it might be a curate's egg type of thing.

    But in the end, this was all another Islington Solution to a problem that we never actually had in Gloucestershire. Out old OOH triage system was superb and is sorely missed.

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  • Chris Kenyon

    In response to John Dale & Iain Marshall I stand by my comments while of course understanding completely that they are the results of my own experience. Of course I have not done an analysis of the total numbers, how could I have done? It's disingenuous of John to suggest that these comments are borne of "lack of professionalism" - in my case the sentiment is entirely the opposite.

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  • Why would they not send it? They do not have the risk or clinical acumen to say no, stay at home you will be fine.

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  • NHS 111 - google is scarily more cost effective. Even

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