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Crisis of confidence in NHS 111 as only 8% of GPs think triage is 'safe for patients'

Exclusive GPs have lost confidence in the ability of the NHS 111 service to triage patients, with only 8% saying they believe the urgent care phoneline is safe for patients.

In a major blow to the service, 71% of the 440 GPs surveyed by Pulse said that they did not have confidence that the triage at NHS 111 call centres was safe for patients.

The survey also found that confidence was little better among the 291 GPs in areas where NHS 111 has been rolled out, with only 12% saying they were confident the triage was safe for patients. Some 70% disagreed with the statement.

More than half of those in areas where the troubled service has been rolled out say that they have experienced a high workload since the helpline had been rolled out, mainly citing the long reports sent to practices after their patients call the phone line.

This survey comes as Pulse revealed last month that NHS England is considering a change to the triage process to include more clinically trained call handlers.

The computerised algorithm used by NHS 111 is operated by non-medically trained call handlers - with some clinical input if the caller doesn’t accept the call handler’s recommendation, or they have complex medical needs. But the phone line has been plagued with problems, and Pulse revealed in May that there had been 22 serious untoward incidents involving NHS 111 in the first six weeks of its soft launch.   

Many of the GPs surveyed said that the lack of medically qualified call handlers was their main concern with the phone line.

Dr Andrew Mimnagh, the urgent care and 111 implementation lead for South Sefton CCG, said: ‘It is deeply regrettable that the profession has a low level of confidence in this system of triage.

‘It is [also] deeply regrettable that the incident data reporting is so deficient, that I cannot disabuse them of that view.

‘It is a fact that our local clinical assurance group has had to put on the risk register that we cannot assure the safety of the 111 service in this region.’

Dr Bob Hodges, a GP in Gloucester, said: ‘It is a flawed concept and utterly nonsensical - triage by computer is dangerous and shifts and magnifies costs and risk for no benefit.’

Another GP said: ‘Only a third of calls made it through to the out-of-hours services in the first months. The average wait for 111 to pick up was 40 minutes. Workload for out-of-hours services is now more like normal so it is improving. They are still sending 999 ambulances for ridiculous problems, for example a heavy period.’

Another doctor commented: ‘Just reading their ridiculous communications makes my head throb.’

But NHS England defended the service, saying call handlers were ‘fully trained’.

A spokesperson said: ‘They use a clinical assessment system which enables them to assess a caller’s needs safely and effectively and direct them to the right local NHS service. All advice provided is supported by experienced nurses.

‘Using the clinical assessment system means a smaller proportion of calls need to be referred to a nurse. This means that NHS 111 nurses can focus on cases where their clinical skills are most needed rather than dealing with calls that don’t need their expertise. However, should a patient be assessed as needing to speak to a nurse, they will be put straight through to a nurse.’

What GPs think of NHS 111

 

Do you have confidence that the triage at NHS 111 call centres is safe for patients (total GPs)?

Yes - 8%

No - 71%

Don’t know - 20%

 

Do you have confidence that the triage at NHS 111 call centres is safe for patients (GPs in areas where NHS 111 has been rolled out)?

Yes - 12%

No - 70%

Don’t know - 18%

Have you noticed an increase in workload since the introduction of the NHS 111 service (GPs in areas where NHS 111 has been rolled out)?

Yes - 53%

No - 33%

Don’t know - 13%

 

Source: Pulse survey of 440 GPs

 

Readers' comments (14)

  • 111 is overly safe and far too risk averse, that's the issue.

    The thresholds for dispatching an ambulance or referring to ED are too high and there's no ability for local teams to alter the way that symptom discriminators point, other than by taking a risk by deviating away from the given classifications, e.g. in the two discriminators below, there is very little provided by NHS Pathways that describes the difference between a blunt injury requiring ED assessment and one suitable for primary care- if systems want to point the ED cases to a MIU, this has to be done relatively blind with an acknowledgement that although most of the cases can be managed safely within a community setting, there will be some that will require onward referral to ED, contravening the ethos of right care first time (and providing a poor patient experience).

    ankle or foot injury, blunt -> full ED assessment and management capability
    ankle or foot injury, blunt -> full Primary Care assessment and prescribing capability

    The Pathways team need to open up the underlying architecture and make it far more explicit as to the differences between discriminators, so that local systems can understand the balance of risk of flagging ED discriminators as suitable for management by other services and giving CCGs and their provider organisations the power to channel patient demand by reducing the numbers being sent to ED.

    At the national Pathways forum the week before last, one area announced that they have deliberately set a number of the ED discriminators to point towards MIU, but this seems to be a local response to an unsatisfactory triage process inherent within Pathways itself.

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  • (continued from previous post)

    Its the same on the ambulance side- c. 8% of our 111 calls result in an ambulance being dispatched, but c. 40-45% of these subsequently don't convey (which is the same percentage as non-conveyances made via 999). By virtue of them being managed by the crew on scene or being referred (usually) to primary care or another community based service by the crew, this would suggest that Pathways should have pointed the patient to another service in the first place, but when we've audited such calls, the call handler has managed the call correctly- its the underlying triage that has resulted in the dispatch.

    Locally we're working with our OOH and 111 provider to place medical intervention far earlier in the process, including possibly within the call centre itself, so that we can try and avoid unecessary referrals to ED or ambulance, but again, this is our local adaptation to the flaws within Pathways and really shouldn't be necessary.

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  • Don't forget GPs did all of this as well as the job for £6000 a year. Weren't we cheap and undervalued!

    I've retired early now and smile every day.

    Good luck

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  • Bob Hodges

    In response to anonymous 09:46.

    Your argument is actually a bit like discussing the melting point of chocolate when you're trying to make a teapot.

    NHS 111 using pathways software is a fundamentally WRONG concept. No amount of tweaking will make it right.

    NHS 111 is a good idea in so far as it could be a front door that signposts people to the appropriate service - a bit lit an 'NHS Operator'. It should NEVER do triage.

    In Gloucestershire we HAD a triage system that worked. Staffed by experienced local clinicians, it wasn't cheap but it was GOOD and SAFE. I resent the disruption and risk created by the imposition of NHS 111 - something no one asked us if we wanted. In the age of 'no more top-down reorganisations of the NHS' (Cameron 2009) it's the biggest 'Islington solution to a non-existent Gloucestershire problem' yet. Quite frankly, it makes Darzi centres look like a God send.

    As a GP commissioner, full time GP and OOH doctor, I will NEVER sign anything to accept responsibility for a system that includes NHS 111 using pathways software. I have absolutely no confidence in it and never will.

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  • Harry Longman

    Classic case of hubris I'm afraid among those who thought that a computer could do what a trained clinician could do. They ignored the warnings and have wasted £gazillions. Will heads roll?
    All they do now is talk about how many % of calls are answered within a minute - and that's fixed??? Well done Pulse for going deeper.

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  • Bob, I absolutely agree with you that 111 is sub par compared to areas that used GP triage for their out of hours (I posted the two anon comments and do so as I am a CCG employee and want to protect my anonymity).

    We also used GP Triage very successfully in our old out of hours model and if I could, I would move us back to that , but we were handed the 111 teapot and asked to use that, so we are trying to come up with ways that we can improve it locally until such time as we can do something different. That was the thrust of my posts.

    I have limited faith that the NHS England review of 111 implementation, the service spec etc that is forthcoming will suggest anything radical such as returning to previous models of care, so all we can focus on in the short term is improving the current model as much as possible while chipping away at the national position.

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  • Bob Hodges

    Fair enough - smash the system from within!!

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  • Does anyone honestly believe that it would be possible, let alone affordable, to deliver the NHS 111 service using a GP triage process?
    I don't think there are any arguments as to what would provide a better service. But as it is estimated that annually 111 will receive 12 to 15 million calls, that would need thousands of GPs to be working in call centres. NHS Direct struggled to employ enough nurses to cope with the 5 million calls that the 0845 service received. So the chances of employing sufficient GPs to provide a national service is zero.

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  • I worked for the old system prior to 111 and felt valued as a nurse.... not in the the 111 service and have now left. Say no more

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  • regarding the posting on 9th July at 9:18pm. The point is being missed, it's about clinical triage but not necessarily via a national call centre model. GP or nurse triage is what used to happen anyway in every area before 111 came along and happens now in those areas where 111 doesn't take the Out of hrs calls.
    The issue is how to deliver it adequately....done properly it wouldn't necessarily be a particularly expensive venture, unlike 111 as the model stands. NHS Direct took many calls due to lack of capacity, but if thought through properly I wonder whether local clinician triage as part of a 111 service could possibly work with the right technological input?.....I'm not technologically minded so forgive me if i'm wrong.

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