It’s been said that NHS 111 ‘will improve patient safety’. But what might prevent it doing so?
NHS 111 is a great concept: not many could argue with the principle of simplifying access to an assessment of whether urgent care is required and sign-posting or referring the patient to the most appropriate service. It is working pretty well in some places. Where it is, it has not made the news.
This may be a heresy for some but NHS 111 is, in reality, only a complex development of what primary care out of hours (OOH) organisations have been doing for years. The good ones have done the following well, for a long time, in increasingly difficult circumstances: coping with huge surges in demand, seeing and treating the sick, giving self-care or telephone based care for the mildly unwell, and referring to community services, to their own GP practice, mental health, A&E or 999 as clinically appropriate.
Call-handlers have for many years and arranged 999 for immediately life-threatening conditions safely prioritised , and sent the clearly injured to A&E without recourse to a clinician.
Why then has even the ‘soft launch’ of NHS 111 been so difficult, if not a risky failure, in some areas, whilst it has gone OK elsewhere?
Three key challenges
What is different in the delivery of NHS 111 across much of the country, is that organisations not used to the full scope and variation of urgent primary care are being asked to provide it – and provide it now. They may not fully appreciate the challenges, of which there are three key issues.
The first challenge is the increased reliance on trained lay people to perform the initial assessment using complex clinical algorithms. The interpretation of a patient`s answers using pathways gives scope for variation. If call-handlers are not well trained and supported there will be a negative impact on the health care economy, in particularly 999 ambulance services and A&E as recently reported in the media.
The second challenge is the directory of service (DoS), to which outcomes are intimately and electronically linked. If the DoS is set-up incorrectly the patient will be directed to the wrong service.
The third challenge is the time taken on each call by the call handlers and the clinicians supporting them. Instead of the two- to three-minute calls that most OOH providers are used to, NHS 111 needs six to eight minutes per call on average.
If these challenges are not understood and managed they will conspire to produce a poor service. Organisations not used to providing good high volume ‘urgent’ or ‘on demand’ assessment and care will struggle to get to grips with the rota flexibility and extreme variation in capacity required to make sure callers get through quickly irrespective of time of day or day of week, or during a bank holiday weekend.
If there is no tradition of providing treatment or dealing with the full gamut of illness, practice communications and all the other challenges faced in urgent phone-based and face-to-face care, then it is inevitable that mistakes and problems will occur. The importance of special patient notes, first-rate demographic details and fast transmission of patient details to the front line will not be ingrained in the culture and may never be fully appreciated. And if primary care culture and knowledge is not shared with call-handlers and nurses using NHS pathways, too many calls will be interpreted as being urgent.
Commissioners have a lot to learn from the way NHS 111 has been procured and delivered, or not, in the early weeks and months. They should have a hard look at where it is going well, reasonably, and poorly. They should look at the track record of organisations and delve deeper than professionally-presented bid documentation. There must be openness, honesty, and a willingness to enforce big changes if the fully-publicised hard launch is to succeed.
NHS 111 will be much better where it is provided by, or with the close participation of, an organisation with a solid track record of high quality out-of-hours care. In those circumstances – and, given that it is a 24/7 service – it should do what it says on its tin.
Conflict of interest: Dr Reynolds works in an organisation that provides NHS 111
Dr Mark Reynolds MBE is the chair of Urgent Health UK and a sessional GP in Maidstone, Kent. He was formerly a chair of the National Association of GP Co-operatives.