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Independents' Day

Ministers must admit 111 has failed and look at the system afresh

111 providers must share financial and professional responsibility with other urgent care services, Dr Chaand Nagpaul writes, and we must abandon competitive tendering in favour of local provision

The impact of the NHS 111 debacle continues to ripple through the health service. In many areas of the country the system remains suspended or heavily reliant on support from other over stretched services, including out of hours GP care.

Reports of poor quality call advice continue to surface with alarming regularity, while emergency care departments and many other areas of the NHS are still experiencing increased workload since the system suffered widespread collapse during its launch at Easter.

Like many other health initiatives, NHS 111 was a victim of policy by pronouncement and became a must-do for commissioners, regardless of local need or circumstance. The timing of NHS 111 could not have been worse, going live at the same time as the biggest ever NHS reorganisation resulting from the  the Health and Social Care Act.

The timescale was far too short - NHS 111 was procured by Primary Care Trusts in a mad rush in their last year of existence, while they were downsizing and organising their demise. This predictably led to shortcomings in the procurement process. Yet the responsibility for NHS 111 has fallen onto fledgling CCGs, who did not procure the service, adding considerable pressure as they start to find their feet.

Losing accountability

NHS 111 was designed as a stand-alone call handling service, artificially disconnected from those that provide urgent care, such as GP out-of-hours services. This leads to fragmented care with a lack of accountability for failings in call handling, or call dispositions that may have adverse consequences on all other elements of urgent care provision, including inappropriate A&E attendances.

NHS 111 serves as a graphic example of the problems of opening the NHS to greater competition. Commissioners were forced to competitively tender for 111 when it may have been more appropriate for it to be provided by current effective local providers.  In some instances, tendering has undermined and destabilised local GP OOH services. As a result, many sites are now run by external organisations with no local accountability.

The BMA was given written assurances by ministers that all successful contract bids would be financially viable and monitored appropriately. Yet within six months NHS Direct pulled out of its responsibilities because its contract were not financially sound while reports have proliferated, not least in a recent Dispatches investigation, that questionable practices are emerging amongst some providers.

The Government has failed to keep its promises. This is a worrying development given that its policies will lead to more contracts being out-sourced to private providers in years to come.

Playing down problems

It became clear early on that the implementation date of April 2013 was unrealistic. The BMA and others repeatedly warned the Government and civil servants of the dangers of a hasty launch and argued for a delay. In spite of such warnings, the launch date was not postponed. Even after the launch, it was glaringly obvious to GPs and patients who had tried to access the service that NHS 111 was an abject failure in many areas.

Despite this undeniable reality, the Government continued to publicly play down these failings. It is unfortunate that it took the announcement of NHS Direct’s withdrawal from the NHS 111 service for Government to finally acknowledge that NHS 111 was manifestly failing the needs of patients.

There is a common theme that runs through all of these mistakes: a hasty political timeframe, with a failure to properly integrate a new service with the support of local clinicians.

Sharing financial responsibility

There are a series of steps ministers, civil servants and commissioners can take to correct this central failing and avoid history repeating itself.

Urgent care services should always be coordinated for local populations, given the interdependence of all elements of the system. 111 call handling should be integrated with all providers, from GP services and walk-in centres, to A&E minor units and urgent social care.

Call-handling must not be commissioned as a separate service, and the requirement for competitive tendering should be abandoned in favour of local provision as a preferred model.

Within this integrated framework, all urgent care providers should have shared financial and professional responsibility, and aligned incentives that are properly monitored externally.

Ministers have a responsibility to learn from the significant failings of the past and to look afresh at the system, rather than perpetuate an ideologically-flawed and fragmented approach. In doing so, it could finally honour its commitment, introduced as part of the Health and Social Care Act 2012, to a fully-integrated NHS.

Dr Chaand Nagpaul is the chair of the GPC and a GP in Stanmore, Middlesex.

Readers' comments (8)

  • Excellent diagnosis.
    Spot on prescription.
    Will Jeremy Hunt take his medicine?
    Regrettably you can pretty much bet that he will not!
    Will he ask for a second opinion?
    Not likely, very sadly the only opinion he ever seems to take any notice of is his own.

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  • No, Mr Hunt will listen to the same old advisors from the various large consultancy firms who continue to pursue their very own agenda. Nothing ever changes

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  • DoH (yes, that's the best way to describe it) still fantasises that a telephone algorithm can solve everything. It works OK for people with trauma (999 triage), but most patients need a good listening to, preferably from someone they know (which is why unqualified GP receptionists get triage right most of the time).
    NHS Direct was a failure - the twice that I've reviewed its effectiveness (an urban situation, and a rural one), over 70% of calls to NHS Direct had to be passed on to another health provider in other words extra steps and extra cost for no improvement in patient care. NHS Direct then covered up for its failure by arguing that its marketing hadn't been good enough - and 111 was born. How fitting that it is NHS DIrect that had to pull out.
    Taking the other aspect - national and external providers - we already saw how universally unhelpful the ISTCs were, imposed on local commissioners by the same wonks at DoH, making a hole in the local budget.
    GP OOH should be properly funded and should be the true decision of local commissioners. Patients do deserve the best, but the best is often the cheapest.

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  • Abdul QADRI

    Dr Chaand Nagpaul, NHS has been bombarded with too many changes by successive Governments. These changes have been made just to please innocent voters. Why do you need all these outside unregulated so called medical advisors to run out of hours service. Those of us who have worked as single handed practitioners since the beginning of 1980's didn't have any problem whatsoever to provide such a service. Patient knew who they were talking to and that in itself was reassuring to them. At the time, I used to take my own calls at night and my patients would rarely disturb me for non urgent or irrelevant problems during night time. I didn't mind at all to take my own calls as I was young , vibrant and full of energy to make my contribution in the over all care of my patients. After say the age of 50 years one can understand the difficulties you can face to cover the patient care during out of hours. Nowadays it is not a big deal as most of the practices are in partnerships of two or more doctors. They can easily provide a cover on rota basis like everybody else in the secondary sector. There will be no confusion and all the patients records will be under one umbrella and trust me our patients will appreciate that. Come on in your early 30's to 50's you have got be part of this care and will have more satisfaction of having chosen to be a primary care Doctor or in old terminology Family Doctor. I am sure all this debate GP representatives and the Govt is waste of time and will achieve nothing except some emergence of another out of hours service like magic 111?
    I am sure that my colleagues might say : yes yet another observation from an old retired GP who is out of touch with the current challengues. I disagree with that as after working for 32 years as a GP , there hasn't been a single occasion when I had to face any disciplinary body like Family practitioner heads, Pct's or GMC and that itself is an example of self governance.

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  • Buy the service on the cheap. Unqualified and seriously under trained staff. Algorithms instead of brains and experience. 111 was never going anywhere except the scrap heap. Sadly, I don't expect lessons will be learnt.

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  • Perhaps they could extrapolate this result to the rest of the reforms which can only be disasterous for the NHS.

    The public cannot be fooled for ever, that these changes are 'improvements'.

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  • >The public cannot be fooled for ever, that these changes are 'improvements'.

    I wish this were true.

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  • nhs 111 is an absolute farce.

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