The impact of the NHS 111 debacle continues to ripple through the health service. In many areas of the country the system remains suspended or heavily reliant on support from other over stretched services, including out of hours GP care.
Reports of poor quality call advice continue to surface with alarming regularity, while emergency care departments and many other areas of the NHS are still experiencing increased workload since the system suffered widespread collapse during its launch at Easter.
Like many other health initiatives, NHS 111 was a victim of policy by pronouncement and became a must-do for commissioners, regardless of local need or circumstance. The timing of NHS 111 could not have been worse, going live at the same time as the biggest ever NHS reorganisation resulting from the the Health and Social Care Act.
The timescale was far too short – NHS 111 was procured by Primary Care Trusts in a mad rush in their last year of existence, while they were downsizing and organising their demise. This predictably led to shortcomings in the procurement process. Yet the responsibility for NHS 111 has fallen onto fledgling CCGs, who did not procure the service, adding considerable pressure as they start to find their feet.
NHS 111 was designed as a stand-alone call handling service, artificially disconnected from those that provide urgent care, such as GP out-of-hours services. This leads to fragmented care with a lack of accountability for failings in call handling, or call dispositions that may have adverse consequences on all other elements of urgent care provision, including inappropriate A&E attendances.
NHS 111 serves as a graphic example of the problems of opening the NHS to greater competition. Commissioners were forced to competitively tender for 111 when it may have been more appropriate for it to be provided by current effective local providers. In some instances, tendering has undermined and destabilised local GP OOH services. As a result, many sites are now run by external organisations with no local accountability.
The BMA was given written assurances by ministers that all successful contract bids would be financially viable and monitored appropriately. Yet within six months NHS Direct pulled out of its responsibilities because its contract were not financially sound while reports have proliferated, not least in a recent Dispatches investigation, that questionable practices are emerging amongst some providers.
The Government has failed to keep its promises. This is a worrying development given that its policies will lead to more contracts being out-sourced to private providers in years to come.
Playing down problems
It became clear early on that the implementation date of April 2013 was unrealistic. The BMA and others repeatedly warned the Government and civil servants of the dangers of a hasty launch and argued for a delay. In spite of such warnings, the launch date was not postponed. Even after the launch, it was glaringly obvious to GPs and patients who had tried to access the service that NHS 111 was an abject failure in many areas.
Despite this undeniable reality, the Government continued to publicly play down these failings. It is unfortunate that it took the announcement of NHS Direct’s withdrawal from the NHS 111 service for Government to finally acknowledge that NHS 111 was manifestly failing the needs of patients.
There is a common theme that runs through all of these mistakes: a hasty political timeframe, with a failure to properly integrate a new service with the support of local clinicians.
Sharing financial responsibility
There are a series of steps ministers, civil servants and commissioners can take to correct this central failing and avoid history repeating itself.
Urgent care services should always be coordinated for local populations, given the interdependence of all elements of the system. 111 call handling should be integrated with all providers, from GP services and walk-in centres, to A&E minor units and urgent social care.
Call-handling must not be commissioned as a separate service, and the requirement for competitive tendering should be abandoned in favour of local provision as a preferred model.
Within this integrated framework, all urgent care providers should have shared financial and professional responsibility, and aligned incentives that are properly monitored externally.
Ministers have a responsibility to learn from the significant failings of the past and to look afresh at the system, rather than perpetuate an ideologically-flawed and fragmented approach. In doing so, it could finally honour its commitment, introduced as part of the Health and Social Care Act 2012, to a fully-integrated NHS.
Dr Chaand Nagpaul is the chair of the GPC and a GP in Stanmore, Middlesex.