We all know there are significant issues with the way that the NHS responds to urgent healthcare needs, from failings of NHS 111 to surging patient numbers at A&E. But how can we solve these problems?
The theory for urgent health care provision is simple. First, assess what an individual person or patient needs, and then meet that need with the required care within an appropriate timescale. Sounds easy.
But even assessing what a patient needs is problematic. Every day, tens of thousands of people across the country feel that for some reason or other they need to see a healthcare professional that day. Indeed, some will have a genuinely urgent health-related problem that requires the input of hospital based specialists. However, the vast majority of people will not. So, it makes sense that some form of assessment of need is undertaken before an individual attends A&E.
In short, there are deficiencies throughout the whole of out-of-hospital care
Currently, this is NHS 111, which patients are advised to phone ‘when it isn’t an emergency’. However, the tragic case of baby William Mead highlights deficiencies with the sensitivity of the software used by 111, and questions the ability of non-clinicians to handle those calls.
So, few would argue that 111 is currently a great system. But would I scrap it? The short answer is no. Because what would the alternative be?
The alternative options
There have been suggestions that calls should be taken by a clinician, perhaps by experienced nurses. Where are those nurses going to come from? The likelihood is that they would be recruited from A&E departments and GP practices, as was the case when the predecessor of 111, NHS Direct, employed clinicians to take calls. The net effect of that would be to take clinicians away from front line services and heap more pressure on A&E and GP practices. Secondly, a significant number of calls to 111 are not urgent. Some are related to lost or forgotten medication, some are dental, some are general enquiries about NHS services. It would be a complete waste of a nurse’s time to be taking those calls.
The alternative advice to patients is to call their GP practice, if it’s open.
GP practices are currently under huge pressure. GPs are leaving the profession in their droves, either retiring early or seeking less stressful ways to earn a living. Newly qualified doctors are not choosing general practice as a career, and practices are closing all over the country. All of this is mainly due to chronic underfunding and significant increases in workload. It’s therefore not surprising that patients have difficulty getting through on the phone, and when they do they are often told that there are no appointments available that day, and to call NHS 111 if they are concerned.
Most urgent care patients are still managed by GP practices. However, until practices are adequately resourced, or alternative urgent care arrangements are put in place within their own community, then calls to NHS 111 will continue to increase, as will patients making their own decision to attend A&E.
The third option that patients are being advised to consider is to seek advice from their community pharmacy. Sadly, recent decisions to reduce funding to pharmacies will lead to closures, especially in areas of high deprivation. Again, this will inevitably increase pressures elsewhere within the NHS, with the default position being a trip to A&E.
And GP out-of-hours organisations are now finding it increasingly difficult to attract GPs to work for them covering evenings and weekends. In short, there are deficiencies throughout the whole of what is called ‘out-of-hospital care’.
So, if patients don’t trust NHS 111, can’t get an appointment at their GP practice, their local pharmacy has closed, and their out of hours organisation can’t see them until 3am because they too are short of doctors, then what else is a patient to do but pitch up at A&E?
A possible solution
I think we need to work with what we’ve got. I would continue with non-clinicians taking NHS 111 calls, and I would continue with some form of protocol or decision-making support tool to guide the call takers in how to best manage a particular case. Where I feel NHS 111 is lacking at present, is in the fact that regional call centres are too big, too remote, and often lack direct clinical support to the call taker. There is a real disconnect between the NHS 111 service and ’front end’ service provision. This is because NHS 111 has been centralised into huge regional call centres and is just too big to be able to be locally sensitive to patient need.
NHS 111 needs to be integrated within other urgent care services and localised, with clinicians being available to offer direct advice to the call taker. There needs to be a balance between ’local’ urgent care services and these large scale remote NHS 111 call centres. The balance between economies of scale and local sensitivity and quality has been lost with these massive procurements. There needs to be geographically and speciality appropriate layers of provision and support with integrated call handling and clinical service provision.
We need to re-create small call-taking centres, integrated with front line provision, i.e. co-located, so that local clinicians can directly support the call takers and the call takers are fully aware of local services.
Big may be cheaper on a cost per NHS 111 call basis but it doesn’t necessarily deliver what’s needed in terms of patient experience and quality outcomes. The cost savings of a localised, integrated model are downstream in terms of the call taker being in a better position to make the right decision.
Clinicians working in urgent care, whether it is NHS 111, GP out-of-hours organisations, ambulance services or A&E departments, also need access to detailed medical records. This has been called for now for over 10 years, and a solution still seems a long way off.
As I see it, there are two possible solutions to NHS 111. Firstly, accept the current situation and build bigger and bigger A&E departments. Secondly, make NHS 111 more locally sensitive, with direct clinical support, as well as properly resourcing primary care so that it has the capacity to respond to patients who feel that they are unwell. I’d vote for the latter.
Dr Mark Spencer is co-chair of NHS Alliance and GP in Fleetwood