GPs working for Covid assessment service lacked training and support, finds review

A review of the NHS 111 response at the early stages of the Covid pandemic has identified an overreliance on phone services and a lack of support for clinicians.

Clinicians working for the Covid Clinical Assessment Service (CCAS), many of whom were GPs several years into retirement, reported receiving IT training but no clinical training, nor updates regarding the developing virus.

The review, carried out by the Healthcare Safety Investigations Branch also noted that relying solely on a phone-first model disabled continuity of care between vulnerable patients and their GP.

The NHS 111 service was also severely overwhelmed, with only around half of calls answered in March 2020, it noted.

The HSIB also criticised the NHS 111 set-up for failing to note patient co-morbidities sufficiently, and allow for patients to receive adequate enhanced advice should their symptoms deteriorate.

Suspected Covid patients with co-morbidities including diabetes would have likely benefited from face-to-face assessment to a greater extent, the report suggested.

‘Given the potential limitations of remote telephone assessments – where clinicians cannot necessarily make objective clinical findings or conduct a physical assessment – there may be a case for a lower threshold for face-to-face examinations in callers with comorbidities,’ it said.

The report said that while the NHS 111-first approach likely reduced pressure on other NHS services, ‘there is a risk that it disrupted continuity of care’.

‘This is particularly relevant given the decision that primary care providers were not to be involved in triaging patients with Covid-19 related symptoms.’

In response to the findings, HSIB recommended that NHS England ‘reviews the risks associated with increased use of telephone triage in response to national healthcare emergencies’.

More than 3,500 clinical staff were recruited to work in the CCAS, including retired GPs returning to work, nurses, pharmacists, dentists, allied health professionals and shielding GPs, the report noted.

‘Interviewees recruited to CCAS told the investigation that they were provided with IT training but received little in the way of clinical training. They established informal networks to try to share up to date information as knowledge of the virus improved,’ it added.

In addition to interviews with key stakeholders, including CCAS clinicians, the review focused on four case studies where patients died after initially being advised to self-care at home.

HSIB national investigator Amber Sargent said: ‘We recognise that the events in this report were from the earliest months of the pandemic and that systems had to be put in place at incredibly short notice – there were many unknowns as the NHS tackled a novel virus.

‘Our investigation has focused on how quickly the healthcare system identifies major risks, responds accordingly, and adapts as knowledge grows.

‘However, whilst we know there has been much learning and improvement since March 2020, the stories the families told us during the investigation were incredibly moving and emphasised the importance of future planning.

‘Anyone may need to access NHS 111 or other telephone triage when there is an emerging healthcare crisis. It is critical that services can be stood up within a short timeframe and that communication of messages and advice to the public is as clear as possible to help them get the crucial care and treatment they may need.’

Pulse warned in February 2020 that around 25% of calls to NHS 111 were being abandoned by patients unable to get through.