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At the heart of general practice since 1960

Local intelligence is the key to 111’s future

GPs and the organisations they set up should run 111, argues the co-founder of Harmoni

‘Call 111 when it's less urgent than 999' - what could be simpler?

I've been asking around at our local postgraduate centre (yes, we still have one!) about 111. I am greeted either by a blank look or a grimace suggesting strong and primeval disapproval. There's a 111 pilot about to start in a neighbouring borough and the rumours are flying: ‘It's just a re-badged NHS Direct… It means more work for us… Why on earth do we need it? It must cost a fortune when we don't have any money.'

I work 400 metres from the local ambulance station and it's easy to tell when things are kicking off. Another clue is the morning email announcing that our local hospital is closed to acute admissions after a busy night, and would we kindly send patients to another hospital seven miles further away (a long way in London).

As a seasoned (old) ‘unscheduled care provider' (GP) I'm trying to understand this new spin of the wheel.

I co-founded Harmoni 15 years ago, back in the days when starting co-ops was all the rage and you had to have a funny name. I've worked with the company ever since, and we have endured and embraced the changes.

We've expanded to survive, and took on and ran NHS Direct in West London when it first started.

We can talk intelligently about unscheduled, scheduled and urgent care and, like all species working in and with the NHS, we have adapted to keep up.

I hate to say it but, back in the 90s when I was on call just one night or weekend in four, patients knew what to do. If you were very ill you dialled 999, and if you were just plain old ill you called me. Statistically, I got out of my bed once a week and we just about survived. And my patients did too. Then banks started opening at odd times, you could go shopping on Sundays and things changed.

Another early pioneer in the co-op movement, Mark Reynolds called it the ‘triage gap', where the level of illness in the community did not change but the amount of calls expanded exponentially.

This was the beginning of the beginning of the end of personal care. The response to rising demand has been an ever increasing number of organisations handling it: OOH, WIC, NHSD, UCC, PCC, UTC, A&E. The acronyms have multiplied and patients don't know where to go.

Well, they know in my patch. They go to A&E.

A&E has more brand awareness than M&S and when somebody said that all comers must be seen and treated in four hours, the bills started clocking up.

Now 111 is going to be the solution to all these problems! One free call, no ring-backs and everybody will know what the NHS can do for you, whatever the time and wherever you live.

And that's the trick. The talk is about the software and clinical assessment done by non clinicians when the key to making this happen for patients is the ‘directory of services'. Built into the system is the local intelligence to match the needs of the patient to the resources available.

If you want to survive in this pluralistic health service, you need to make sure your DOS entry is up to date, and does what it says it does. A blocked catheter at 1pm is a different problem to the same at 1am, but the need to change it is no less pressing.

But what if somebody else was in charge of 111? It could be a regional ambulance trust, or your local acute trust, or even your local council – rumour has it they are interested in this ‘any willing provider' contract).

We all need ‘footfall' to justify our existence and much as we whinge about how busy we are and how under-resourced our practices are, in truth if we were to become less popular and patients found alternative ways of treating themselves, there might be a radical look at the way primary care is organised.

111 will make us busier but it will also cement our role in the great scheme of things. If another non-GP organisation was running 111, alternative providers could scoop up those nice easy patients with acute problems – leaving us with the thorny hard-to-please patients with the long-term intractable conditions.

General practice should be the default first port of call for everything except emergencies. If GPs and the organisations that they set up run 111, common sense medicine will survive.

Dr David Lloyd is a GP in Harrow and co-founder of Harmoni

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