By April 2013, all GP commissioners will have to be using a 111 number in their area. Dr Ruth Livingstone shares her experience of setting up a pilot 111 scheme.
Three years ago I was chairing a regional Darzi urgent care review meeting, when a GP colleague made a very valid point. We've been talking about educating patients about how to use urgent care for 25 years, he said. Why don't we just make it as easy as possible for people to get to the right place?
The meeting, which gathered GPs and consultants round the table to discuss the Darzi urgent care recommendations for our area, came to agree that a single telephone number patients could phone for anything other than 999 would overcome the complicated, fragmented structure of our local urgent care service.
Services available on one day of the week can be closed on another, for example, and patients can't be expected to navigate this.
We were not alone in our thinking. Of the 10 SHAs holding regional Darzi meetings, nine fed back a single urgent care number as a proposal. East Midlands was chosen as one of four Department of Health pilots.
How 111 works
When a patient phones 111, they speak to a trained, experienced 111 call adviser backed up by nurse support. Although the calls are handled by NHS Direct, the algorithm system they use is not the normal 0845 software but rather NHS Pathways, in which call advisers undergo six weeks' training.
Our original intention was to have operators from several providers but only NHS Direct could fulfil the training and skills required.
NHS Pathways has been around for some time and is used by some ambulance and out-of-hours services, which hold the system in high regard. It also has the backing of both the BMA and the royal colleges with an interest in urgent care.
After taking the patient's demographics such as age and name, the call adviser will then go through the big questions – shortness of breath, bleeding and so on.
If it is clear this should be a 999 call, the call adviser can dispatch an ambulance. The call doesn't have to be re-routed as the dispatch is made via computer and the same operator can continue to give advice while the ambulance is on its way.
If it is established a call isn't 999, the operator doesn't attempt to make a diagnosis, but instead makes an assessment of the skills and competencies required. For example, if a patient has abdominal pain, the operator will deem whether a clinician needs to examine them within two or 24 hours and signpost them to where they should go.
To facilitate the signposting, we've had to develop a directory of services, which has been a huge undertaking. Services mean different things in different counties and are open at different times. So a minor injury unit in Lincolnshire may provide different services to one in Nottinghamshire.
The closest geographic services to the patient's home show up on the call adviser's screen, with extra prioritisation according to which services the commissioners would prefer the patient to use. The call adviser can discuss the options with the patient and offer a range of choices.
First steps
After being approved as a pilot, we held a one-day conference and invited relevant stakeholders including the out-of-hours services, PCTs, LMCs and NHS Direct.
The pilot didn't require a hard-sell, however, as we only needed to cut A&E attendance by some 2% for the 111 service to cover its costs. Some GPs were worried they would see an increase in patients being sent to them, but this hasn't proved to be a real burden in practice. February figures show some 48% of calls were referred back to GPs.
The biggest effect has been on the type of patients being dealt with by the local out-of-hours service (NEMS). The service can't stop patients going to A&E, but patients are given a consistent message about where to go.
While the pilot funding paid for the software and training, the scheme has only worked because local out-of-hours providers came on board. In Nottinghamshire we have NEMS, a large long-standing GP out-of-hours provider, while in Lincolnshire out-of-hours cover is provided by the PCT, which employs a number of local GPs.
NEMS already sub-contracted its calls to NHS Direct so it wasn't such a big leap, but the change to NHS Pathways was still significant. Under the old model (using the 0845 software), the call would transfer quite quickly to NEMS and their own clinicians would decide whether the patient should be seen or have a GP call-back.
Soft launch
To get the service going, we needed to get calls coming in to 111 operators. Before going for a big local campaign advertising the number we decided to do a ‘soft launch' and have NEMS calls routed to 111. This was quite timely as the new coalition government had announced the 111 number would be rolled out nationally by April 2013.
There were lots of teething problems during this initial stage, such as operator errors and calls being cut off, but none of it was insurmountable or life threatening.
The pilot leadership team had daily telephone conferences to work through the problems and once we were on top of these, we did a large public launch with a publicity campaign encouraging patients to call 111.
We were keen to do this before Christmas to help with the seasonal peak in urgent care calls, but we were then hit by a mini flu epidemic and that we think really increased the calls to 111.
Our next stage will involve routing the calls to Lincolnshire out-of-hours service to 111 and persuading the ambulance trusts locally to switch to NHS Pathways.
The existing local ambulance system makes decisions on how quickly an ambulance needs to be sent to a patient even if that's some hours later, but their system can't access our directory.
New landscape
The organisation that has probably been most affected by the pilot is NEMS, which has seen a shift in the proportion of the number of people it has had to see, although it was not overwhelmed, despite a very busy Christmas. If the system was going to break, it would have done so then.
It's too early to say if this is changing what patients eventually do. The advisers can directly pass the call on to an out-of-hours service to book a slot, but in-hours patients have to contact their GP directly.
This has been a fantastic opportunity to change the way patients get access to urgent care, for the better. I am grateful for the hard work and co-operation of everyone involved in the project and I am really proud of what we have achieved.
Dr Ruth Livingstone: we can't expect patients to navigate our fragmented urgent care systems Dr Ruth Livingstone: we can't expect patients to navigate our fragmented urgent care systems
