The rollout of NHS 111 is going on fine where the local implementation plan is actively managed and on course – in other words, where the providers are working with commissioners to ensure there are the right staffing levels and the right levels of training and so on are in place.
The decommissioning of the 0845 NHS Direct number will also result in an increased call volume to NHS 111 which needs to be anticipated and planned for. Where testing has shown that NHS 111 service is not yet ready – for example with appropriate levels of trained staff – it is only sensible that go-live is delayed with safe contingencies in place.
The whole of London is successfully covered by NHS 111 now, except for the one area in southeast London where the model is not in full operation, so it is unfair to call it ‘chaos’. Every area has a local NHS 111 clinical governance group led by a local GP that oversees the safe and effective development of NHS 111 in their area.
The staff training for NHS 111 is very robust – you can’t get anyone to answer the phone and carry out an assessment, you need appropriate numbers of properly trained staff.
Three things are happening at the same time. NHS 111 is being developed as the 0845 NHS Direct call volumes fall as it is decommissioned and front-end call-taking from GP out-of-hours services transfers to NHS 111. Pilot data from around the country shows that NHS 111 hasn’t increased A&E attendance, nor has it impacted on daytime general practice. The total call volume to GP out-of-hours services has reduced significantly, and the acuity of the case mix seen as a proportion increased as would be expected.
Data has shown that ambulance call out rates have gone up marginally; however, this now includes callers who would have been referred directly to the ambulance service by NHS Direct and GP out-of-hours services as these services merge with NHS 111 for call handling. When the NHS 111 service starts, the training of the staff means they are more risk averse than when they get experience.
But what is being found, especially in London, is that of those who are referred to the ambulance service, a high proportion of them – around 82% of red calls – are conveyed to hospital, suggesting that these are sick people that require this response anyway, meaning it is working. It is picking up what it should pick up. It is a learning curve for call handlers and as the service becomes more mature and they get used to doing it, then ambulance call outs become less.
It will not endanger patient safety – on the contrary, people that should be going to hospital early are being picked up by the ambulance service, and more importantly, getting there quickly, so there are no delays in ringing the patient back. With NHS 111 you get through and get advice on the phone, with the aim of patients getting the right care first time.
All local GP commissioners of NHS 111 services have chosen to use NHS Pathways. NHS Pathways is a suite of clinical content used by the call handlers and is designed to be clinically appropriate for the NHS, consistent and evidence based. It is governed by a group made up of representatives of the medical royal colleges. So it is not relying on an individual call handler or a clinician’s knowledge about local services but supports their decision making. NHS Pathways is designed so that non-clinicans can be trained appropriately to safely come out with the appropriate outcome to direct callers to the most appropriate level of care using a local directory of services determined by local commissioners.
It is too early to say whether NHS 111 is successful or not as it is only just being rolled out as the NHS Direct 0845 number is decommissioned. However, as a single point of contact with an easy-to-remember number for patients, it is a model that is safe using an evidence-based suite of clinical content and access to a local directory of services. It is an invaluable tool for commissioners to help design their services locally, as well as making better use of a nurse and GP workforce that is in short supply. The concept of NHS 111 offers opportunities.
Dr Agnelo Fernandes is the RCGP’s urgent care lead and a GP in Croydon.