The last decade has seen a plethora of change in the delivery of out of hours urgent care. Patient experience is varied and staff competency is mixed, leading to a handful of high profile disasters.
A wide range of provision exists across the country that has left patients and GPs confused. Where should our patients go to receive urgent care? What is the difference between a minor injuries unit, minor illness centre, out of hours centre, a walk-in centre, Darzi clinic or indeed an emergency department?
To try and challenge the national trend in emergency department attendances of 8% year on year, NHS County Durham and NHS Darlington conducted an extensive stakeholder consultation to develop a county wide urgent care strategy. All urgent care providers outside emergency departments were rebadged as urgent care centres.
The consultation also identified the need for a ‘single point of access’, an easily accessed phone number which directed patients to the most appropriate care.
Our single point of access commenced in October 2009 and NHS 111 is it’s evolved sister. But it is far from just being a number. The aim is to meet a patient’s’ health need, by the right person, within an appropriate timeframe, in the most cost efficient manner possible.
The urgent care pathway requires a whole system approach. This had to span from the timely answering of calls, the rapid triaging out of life threatening conditions, the immediate dispatch of an ambulance when required, to identifying the clinical need a patient had and which health professional was best placed to meet that patient’s need.
But who answers these calls? Non-clinical call handlers do. They use a set of symptom-prompted computer tools called NHS Pathways, which have been developed in agreement with all the major medical colleges in the UK. As they answer in excess of 3,000 calls per week, having these calls answered by clinicians would not be possible or financially viable.
Patients seem, perhaps rightly so, to be becoming more consumer-orientated. How sure can we be that NHS 111 meets the patients’ need without creating unnecessary demand? Our preliminary research suggests patients do follow the advice given and do not then seek further medical advice. Patients are very satisfied with the service provided by the call takers.
It is early days in the pilot but trends in comparison to neighbouring PCO’s look promising. Both emergency department referrals from 111 and 999 ambulances deployed are declining and GPs are not seeing an upsurge in workload. But of course it is finally capturing the urgent care data that will be absolute gold dust for future commissioners.
No system is perfect and there are some real ongoing challenges. How should NHS 111 be commissioned when a whole-system, often regional approach is required? NHS 111 is only as powerful as the directory of services which can then be offered, and links to social care remain elusive. Cost efficiency savings may only be maximised if alternative care is decommissioned. Clinicians can be hostile to the idea of non-clinical call handlers.
But the Department of Health has restated its commitment to NHS 111, and on the back of the national pilot sites, a second wave of adopters has been allocated. The DH has also stated there will be national coverage in England by April 2013.
So what has NHS 111 ever done for us? It’s providing the basis for an easily accessed, appropriate, safe, reproducible and equitable urgent care for our patients – and that feels pretty good.
Dr Katherine Noble is a National Clinical Advisor to NHS 111 by the Department of Health and a GPSI in Emergency and Urgent care in Brandon, County Durham.