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Analysis: NHS 111 debacle piles pressure on GPs

As the new urgent care number struggles to handle calls and practices are swamped with lengthy patient reports, Jaimie Kaffash looks at what went wrong – and the prospects of a solution

Easter weekend 2013 is not a period that the NHS will look back on fondly. In the run-up to the biggest reconfiguration in its 65-year history, the health news agenda was dominated by one topic – the disastrous rollout of its new three-digit urgent care number.

A leaked report of NHS 111 performance from 26 March to 1 April – obtained and published online by Pulse – revealed call abandonment rates in some cases of more than 40%. Patients in 30 different areas of the country waited for more than an hour for a call-back from a clinician. One area reported a wait of 11 hours.

In the worst-affected regions, out-of-hours providers were forced to take back control of call triaging, and practices complained they had to wade through mountains of paperwork.

NHS England insists it remains determined to complete the national rollout of NHS 111 by June, but GP commissioners and the GPC are warning pushing ahead would be a grave error.

Dr Peter Holden, GPC negotiator and a GP in Matlock, Derbyshire, says: ‘It is broken beyond repair in its current form. They have got to return to an integrated system. That will take time. June is hopelessly optimistic.’

NHS England says it is constantly reviewing the service and that it has added another ‘assurance step’ before any new NHS 111 sites launch, with a group of senior managers from NHS England reviewing whether they are able to deliver a ‘quality service before they go forward’.

‘It is broken beyond repair in its current form. They have got to return to an integrated system. That will take time. June is hopelessly optimistic.’

Dr Peter Holden, GPC negotiator

But out-of-hours experts argue the design of the service is flawed, with non- medically trained call handlers using a computer algorithm to triage patients.

Dr Michael Rooney, chief executive of Mastercall Services, which provides an out-of-hours service for Manchester, Stockport and Trafford, says: ‘Computer algorithms have to be risk averse. They are almost certainly not going to perform as well as a medically trained individual, who can listen to the tone of a patient’s voice and other clues.’

He predicts the system will run into major problems when support from out-of-hours providers is switched off and NHS 111 becomes fully operational.

He says: ‘There is a massive potential for an increase in demand. First, the 111 system is heavily advertised and that could see a change in patient behaviour to increase the number of callers.

‘Secondly, one of the successes of the out-of-hours co-operatives is they have been very good at telephone triage.

‘It may be that the burden will be taken by the ambulance service and [it will result in] many more home visits by out-of-hours providers, which could destabilise the whole system.’

Dr Ken Megson, medical secretary of Gateshead and South Tyneside LMC, agrees: ‘Because it is a non-clinical triage, it will certainly increase face-to-face consultations and use extra resources.’

GPs are also finding that the new system is piling more work on them. Dr Peter Goodall, a GP in Southampton, says: ‘We’ve noticed a significant increase in people asking for emergency appointments. I’m in a small practice so we know our patients well and we can often intervene on the phone.

‘But the 111 system is increasing patient expectations. They often say: “I was told to make an emergency appointment”. One parent phoned because of her daughter’s threadworms. NHS 111 said “go to A&E”, A&E said “go to your GP in the morning”.’  

Nine-page reports

Practices are also having to wade through irrelevant reports for each patient who calls NHS 111, says Dr Holden.

‘You get nine-page reports with a series of negative answers to triage questions, instead of what we were promised, which was a proper clinical summary,’ he says.

‘I am beginning to think that NHS 111 is about shifting a percentage away from A&E and onto GPs. If they resource it, we might be able to think about it. But they are not resourcing it.’

One practice IT manager, who did not wish to be named but is in an area where the rollout has been relatively smooth, says her surgery receives an average of three to four contacts for every patient who calls 111 – equating to around 100 emails every Monday morning.

Some practices have had to adopt a duty doctor system to cope with the number of requests they have to act on and ensure they do not miss anything important.

Dr Michihiro Tomonaga, a GP in Warrington, says: ‘The office manager checks at least once an hour as there is no other way of knowing whether there is a report or not. Once they come in, she will print it and give it to the duty doctor who will have to deal with it.

‘It is a long, complicated report with about 10 lines to do on each case. The local GP lead has told us there is no obligation for us to act on it. But our concern is if we are given information that we don’t act upon, I am not sure about our clinical accountability for that.’

‘It may be that the burden will be taken by the ambulance service and [it will result in] many more home visits by out-of-hours providers, which could destabilise the whole system.’

Dr Michael Rooney, chief executive of Mastercall Services

The project has also lost the support of CCG leaders. NHS Clinical Commissioners called on NHS England last month to delay the rollout, warning delays and abandoned phone calls have put patients at risk.

An uncertain future

NHS Direct has been paid £8.4m to continue providing its telephone helpline until June for patients in areas which have so far been unable to roll out NHS 111.

But after this it is unclear what support, if any, will be available – NHS England refuses to say if this stopgap funding will be extended beyond June.

The unwieldy summaries produced by NHS 111 are at least due to be reviewed. LMC leaders first raised concerns about the ‘cluttered’ reports last year and were told back in February that a revised template for the summaries would be issued as part of the next release of the NHS Pathways tool in the summer. NHS England again, though, is unable to give a precise date for the upgrade.

Tricia Hamilton, chief nurse at NHS Direct, which runs NHS 111 in 12 regions, says it is taking action to improve performance – ‘reviewing forecasts against capacity, bringing in additional frontline staff and strengthening our existing on-site operational and clinical management such as clinical floor walkers to ensure we continue to deliver a safe service.’

But Dr Holden fears NHS 111 will continue to struggle and could fall over again in busy periods this month.

‘We are concerned that we will see the same problems over the May bank holiday,’ he says. ‘NHS 111 is not sorted.’

Readers' comments (6)

  • The lack of GP input into the call centre is having a detrimental effect and more calls are going to the GP OOH services with a necessity to speak to a GP. This means that the expected savings in the OOH service is not going to be realised if the OOH service has to retain this triage component.

    Cohesion of the Urgent Care system in each area is not robust enough to cope with whatever the inefficient call centre sends out under the poor risk management electronic triage tool

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  • I gather that in North Kent some patients have been advised to attend hospitals in South Essex. This is because Harmoni's computer software calculates the distance from the patient's home to the nearest suitable hospital as the crow flies, ignoring intervening expanses of water. I supsect that similar problems are being experienced by patients living near the Severn, Humber & Mersey estuaries.

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  • Chaos.
    An elderly patient fell of the bed. Called ambulance
    Was assessed and tel the surgery to report the fall.
    Then ambulance called 111 to handle call.
    111 called Harmoni to take over.
    Harmoni assessed pt over tel and arranged a visit.
    We had a few pages of reports
    Took hours to sort out this situation.
    Has commen sense gone out if the window?
    This is all to avoid pt attending A&E
    This has huge cost implications.

    I

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  • A mother rang and told 111 that she thought her child had tonsiliitis; 10 minutes later a blue light ambulance appeared!! Waste of money! Why could the NHS not build on the strengths of the existing OOH service?

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  • The concept of triage was a military one and relates to the need of an overwhelmed health service to prioritise cases - as inevitably occurs during battles.

    However the central concept of triage was that it MUST be performed by the most senior, most experienced military surgeon available. Only he/she would have the necessary skills to make the quick decisions required. (Average call length for 111 interactions now 18 mins - what in god's name do they talk about?) Thus, NHS 111 breaks the first rule of triage, that's why it doesn't work.

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  • blue light ambulance sent to a 20 year old with toothache (jaw pain may be cardiac). blue light ambulance sent to somebody with neck pain for 20years (couldnt touch chin to chest on questioning, so could have been meningitis!)

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