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Shifting demand

When Pulse revealed in 2017 that NHS England were mooting the idea that patients would need a referral to enter A&E departments, the PR machine went into overdrive, almost going as far as to accuse us of lying (until we produced a recording).

Three years on, and this suggestion is becoming a reality. A number of areas will be piloting a system that would direct patients to NHS 111 before attending A&E. In theory, there is some merit – on the face of it, it should reduce A&E attendance. But I don’t think this is how it will play in reality.

First, patients wouldn’t be stopped from going straight to A&E in certain cases – and rightly so. But I suspect that the small percentage of patients who currently misuse A&E will be the ones who find out how to exploit these loopholes.

This scheme could potentially actually increase A&E attendance

Second, I personally believe that the vast majority of people go to A&E in good faith, feeling it is their best option – and these are the people this scheme is aimed at. But I don’t see 111 as being the panacea to this. Without a significant increase in clinically trained people taking calls (which removes them from other parts of the service), this scheme could potentially actually increase A&E attendance as risk-averse call handlers follow the algorithm.

Finally – and perhaps most importantly – how will this affect GP practices and out-of-hours services? Yes, I understand that an individual A&E attendance is more costly than a GP attendance. But that doesn’t change the fact there is no capacity in general practice – routine or out-of-hours – and this scheme has the potential to drive more people there because they can’t get into A&E or they want a referral.

Of course we need to increase capacity across the NHS. But just as importantly, we need to reduce patient demand. This isn’t easy – it requires public health campaigns and patient education and it may not be politically popular. But this scheme simply moves the demand from one overstretched service to another.

Jaimie Kaffash is editor of Pulse. Follow him on Twitter @jkaffash or email him at

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