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Independents' Day

'Political pressure' behind decision to roll out NHS 111 prematurely, says official report

Local commissioners felt under political pressure to rollout NHS 111 on time and prioritised cost savings without properly testing to see if the service could be delivered at the lower price, an independent investigation commissioned by NHS England has found.

The review found the cost per call of over £20 for NHS Direct’s 0845 service was perceived as ‘too expensive’ and that commissioners responded to ‘strong pressure’ to find savings and that providing the service at the eventual figure of £7.50 to £8.50 per head of population was not tested sufficiently.

The post-mortem also found failings in the oversight of the project at NHS England, with the project not discussed in detail at board level in NHS England until March 2013, as the service caused major problems in some areas.

The review, led by independent advisor Peter Garland, also found that the results from a pilot evaluation written by academics from Sheffield University – which were ‘at best neutral’ – failed to trigger ‘any substantial debate or rethink of the programme’.

The report is the first to look in detail at the problems with the national rollout, following a report leaked to Pulse that looked specifically at problems with NHS Direct’s provision of services in the North West and the West Midlands.

It is the first of a series of reviews commissioned by NHS England, with subsequent reports looking at ‘the longer term resilience and sustainability of the NHS 111 service and whether the design and set up of NHS 111 are appropriate for the future the current make-up of NHS 111’.

It found that local commissioners were ‘reluctant’ to take up the Government’s offer – made in June 2012 following pressure from the BMA - to extend the deadline for rollout until after April 2013.

It said: ‘There may have been a perception that because this initiative was high on the political agenda and featured in the coalition agreement the imperative to meet the pre-announced timetable was very strong and that arguments for delay had to be similarly convincing. This may have led to reluctance to seek a deferred launch.’

The review said: ‘By the time the final report on the pilots was available in the autumn of 2012 the decision had been taken to roll out the programme nationally from April 2013 so there was little time available for amending the plans for NHS 111 implementation. But there is limited evidence that the evaluation triggered any substantial debate or rethink of the programme. There should have been a more formal re-evaluation and stocktake of the programme at this stage.’

It also found that, although at a national level cost cutting was not a major driver for NHS 111, locally it was used to drive down costs.

It said: ‘At local level, however, because of the wider financial position of the NHS, there was a strong pressure to find savings from this exercise. NHS Direct’s 0845 service with cost per call of over £20 was perceived as too expensive and the call centre component of GP out of hours services, estimated to be between 20% and 40% of total costs, was also seen as an area where savings could be made.’

There was evidence that the project could be delivered at the around £7.50 to £8.50 per head of population, which is the cost in all regions, the review said. However, it added: ‘Deliverability within this envelope needed to be tested and it was important that commissioners as well as providers had a good understanding of costs.’

The report criticised the absence of discussions at board level at NHS England. It said: ‘In view of the inherently high risk associated with introducing a programme of this scale and the concerns that were being expressed it is surprising that NHS 111 does not appear to have been extensively discussed above the level of its own programme board until the end of March 2013 when problems had already surfaced and the risks had materialised.

‘There is no record of papers on the subject going to the NHS England Board. NHS 111 does not feature on the main risk register.’

This review follows a series of damning reports around NHS 111. Pulse revealed that there were 22 serious untoward incidents connected with the project in the first month of the rollout, while NHS Direct – the biggest provider of 111 – has had to pull out of two regions.

A recent Pulse survey also revealed that only 8% of GPs think the triage service is safe.

Readers' comments (9)

  • Harry Longman

    I did my best to tell them. I first raised the alarm at a Nottingham pilot review in Jan 2011. I did so repeatedly thereafter. I was only one of many who told them so.
    Do you think they'll listen next time?

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  • Harry Longman

    Let's get this clear: the design to achieve a cost per call was doomed to failure. The true cost includes everything which flows from the call, and dispositions are the big one, not the call. Utter failure to think.

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  • It's interesting to note that the NHS direct costed £20 per head of population to just give telephone advice , compared to £3-4 per head of population as cost of OOH care by individual GP's pre 2004 contract. It's time BMA asked for change from capitation to a HRG tarrif for GP' s in the next contract.

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  • I would consider OOH cover for £20 a call!

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  • HSJ- please be advised that the DH issued PCTs with a guide range for cost per call of £8-£13. Certainly locally we agreed a cost per call that was above £10 as the decision was taken to focus on quality rather than lowest cost.

    Therefore to say that the pricing range was £7.50 to £8.50 is a little misleading and there was certainly no pressure applied from centre to achieve a price within this.

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  • Oops- meant Pulse, not HSJ- reading too many articles this morning...

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  • The fact that the information and research findings from the pilots was inconclusive and flawed is evidence enough that there needed to be a review? I still cannot understand why there was not more work on improving NHS Direct and amending the telephone numbers as well as the costs? This is before we even look at the very limited amount of clinical governance and patient safety measures - it's not just about costs.

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  • Interesting that our local hospital is currently being vilified by Keogh for having a disconnect between front line services and the Board. May we need a turn around team to manage NHS England!
    Locally we are pushing for a local 111 service that will help manage out local urgent care difficulties rather than exacerbate them.

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  • My interview with the Treasury OGC on 15/12/2011, our formal meetings in Feb 2012 and right up to March 2013 between GPC and 111 and my membership of the 111 inmplenetation Board during summer 2012 I repeatedly warned them of failure and told them theor highets risk areas but nobody would listen. Well Mr Hunt a well known TV programme will get you in 3 weeks time

    Peter Holden GPC 111 lead

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