The widely predicted NHS winter crisis has now come home to roost (yes, Jeremy, it is a crisis). This year is far worse than last. The last was worse than its forerunner.
We know some of the causes of this and mainstream and social media is full of graphs and statistics elaborating on them. Reduced beds, funding squeezed, reduced social services funding, increased demand, ageing population, increasing complexity, increased drug costs with a weaker pound, increasing treatments available etc. However, at the coal face there is an area of potential blame that it seems few are pointing an exhaustedly shaking finger at.
I am privileged to have a varied work life. I am a GP principal and, as part of that, I work in an urgent care centre both in and out of hours, as well as looking after intermediate care patients in a community hospital. I am also an emergency medicine (EM) doctor working in a busy A&E. I feel this gives me glimpses of parts of the system that I might not otherwise see.
Four years ago, against the advice of many, the NHS 111 number was launched. It was heralded as a triage system to trump (and I use that word advisedly) all others. On the ground, the effects in A&E were virtually instantaneous. We suddenly had more patients than we had before in our A&Es.
NHS 111 leads to over-referral to A&E and increased, unnecessary burden on our ambulance service with the consequent increase in ambulance waiting times
GPs also began to be barraged with unwanted, and unnecessarily long, reports every time one of our patients had used the number. Clifford Mann, former President of the Royal College of Emergency Medicine, reported to the health select committee that 442,000 extra patients seen in A&Es the previous year had come via NHS 111.
GPs, EM doctors and paramedics started rolling their eyes and shaking their heads as a reflex on hearing mention of those three little numbers. Times have moved on and we seem to have become used to the ever-present NHS 111, even including it in our safety netting advice to patients. If I’m honest, I quite like the simplicity of it in that setting.
However, I believe it is still causing huge problems, compounding the current winter pressures. NHS 111 leads to over-referral to A&E and increased, unnecessary burden on our ambulance service with the consequent increase in ambulance waiting times. I suspect this is particularly acutely felt where the NHS111 provider is not the ambulance service.
From a GP perspective, some recent cases that rang alarm bells included: the father of the ambulant child with intermittent abdominal pain who called 111 for advice – only to then have an ambulance dispatched (no significant diagnosis found); the patient in her thirties with torticollis who rang for advice regarding analgesia and was sent a paramedic (she laughed that she had enjoyed the entanox given to her initially though); and the woman in her forties with what she felt was a chest infection and so wanted to see a GP (she made the mistake of confessing to some chest pain when she coughed and you can guess the rest).
From an A&E perspective it in not uncommon to hear patients say they have ended up in A&E when all they wanted was some advice or to see a GP but were sent there by NHS 111. There is also, though, a completely unmeasured cohort of patients who say they haven’t bothered to ring 111 as they felt they would only be sent to A&E anyway.
The knock-on effects can be subtle. One paramedic colleague told me he has never phoned patients’ GPs so much in his career before. The reason is that, when a paramedic is with a patient they feel doesn’t need to be transferred, it can leave them feeling quite exposed and wanting to run the decision past someone, often leading them to call the patient’s own GP. Since NHS 111, he finds this situation happening more frequently.
This, inevitably, has a knock on effect to GP work load. I feel uneasy during these phone calls. I haven’t seen or spoken to the patient and I perceive the paramedics pressure not to transfer them. In addition, these phone calls come through as ‘urgent’ on my screen – often interrupting a surgery as a result. Having said that, I have been glad to be called on occasion. Once as I was able to tell the paramedic that the patient habitually played down their symptoms and they would definitely need further assessment – it transpired they were having an ACS.
What, however, is the alternative? It is going to be very difficult to roll back the clock on this one – particularly politically. There may be some further integration needed between NHS 111, ambulance services and A&Es which may help things.
I understand there is now a target of 30% clinical input into NHS 111 calls but I’m unclear on what level of clinician that is. In A&E triage of all patients arriving in Majors is now carried out by the most senior clinician – not the least. It would be utopian that this would be the same for NHS 111. The best person to triage may well, therefore, be a GP. However, there is a massive shortage of GPs doing the day job and, I suspect, being a 111 call supervisor is not a job a lot of GPs are going to be queueing up for.
Ultimately, whatever the answer is going to be, the first thing we need to do is keep talking about it rather than forgetting it wasn’t always there.
Dr Jim Wood is a GP principal in Devon, covering an urgent care centre and community hospital, and a middle grade EM doctor in an emergency department. He is also a community surgical GPwSI. You can follow him on Twitter @Drjimwood65