Calling up a storm

A “disaster”.  A “disgrace”. “Extremely worrying”. “Significantly problematic”. A “total meltdown”. “Chaos threatening patient care”.

These are just some of the terms that critics have used to describe the troubled implementation of the NHS 111 telephone service for non-emergency medical issues, since it was formally launched on a national scale in April 2013.

Now with an election just around the corner – and Labour putting the NHS performance at the centre of its campaign to challenge the incumbent coalition – NHS 111 is still making headlines for poor performance.

As such, it is seen by many as one of the major failings of former health secretary Andrew Lansley’s plans to overhaul healthcare in England.

Muddled initiatives

The idea for a simple, three digit NHS helpline number was a Labour initiative. Towards the end of their time in office, ministers filed plans with Ofcom for a 111 number service to run alongside NHS Direct and 999.

At the time, the idea was to run pilots. However, after the coalition came to power, new health secretary Andrew Lansley unexpectedly announced a national roll-out in August 2010.  

In a move that initially caused considerable confusion, Lansley announced on a hospital visit that 111 would replace the 0845 number service run by NHS Direct. This left it unclear whether the 0845 number or NHS Direct itself would go.

However, the Department of Health eventually decided that it would replace the older advice service, and that it would be run regionally by any qualified provider, using the NHS Pathways and Director of Services software to enable call-centre staff to determine the most appropriate service for patients. 

Condemnation was rife from the offset, with critics voicing fears that call handlers would not provide a comparable level of support to NHS Direct, which was staffed by teams of trained NHS information handlers and healthcare professionals, particularly nurses.

The decision also became a political hotpoint for the ousted Labour party, with shadow health secretary Andy Burnham saying the decision to cut NHS Direct was “more evidence that Andrew Lansley is on a vindictive mission to break up the NHS.”

Despite this, NHS 111 services were established in different regions over the next few years by a mix of providers, including NHS Direct, until it found it couldn’t make the numbers add up, private health or IT companies, social enterprises, not-for-profit organisations run by GPs and ambulance trusts.

National roll-out was completed in April 2013, paving for the way for the closure of NHS Direct in March 2014. Since then, there have been periodic reports of problems, including high abandoned call volumes and long wait times.

There have also been persistent reports that the service has actually led to an increase in ambulance call-outs as non-clinical staff opt for an emergency response rather than recommend another option to patients.

Increased A&E referrals?

Leading the criticism has been the BMA, which has stated several times over the past two years that NHS 111 is in need of radical change.

Most recently, the organisation has taken the service to task on the increase in A&E referrals, claiming figures have increased by 200% since NHS 111 was introduced – although the BMA’s interpretation of data has been disputed by NHS England’s head of media Roger Davidson.

Issues with the quality of service have certainly compelled Dame Barbara Hakin, NHS England’s national director of commissioning operations, to write to NHS 111 providers to have GPs on hand at peak times to offer clinical advice.

Hakin also held out the possibility of GPs being joined by “other advanced practitioners” in the longer-term, effectively bringing NHS 111 closer to its predecessor NHS Direct.

The BMA welcomed the move but repeated its call for an overhaul of the system and for NHS 111 to become part of an urgent care pathway that includes GP out-of-hours providers and a range of unscheduled care services. 

“This is just a sticking plaster in the short-term, it's not addressing the root problem of the way NHS 111 is structured, as a standalone body,” said chair of the BMA GPs committee Chaand Nagpaul.

Speaking to EHI News BMA’s GPs committee lead for urgent care Charlotte Jones said a longer term solution involved greater collaboration between organisations. “This is not about getting rid of NHS 111,” she said. “It’s about working more closely with the service.”

According to Jones, who is also chair of the BMA’s GP committee for Wales, the BMA is doing just that.

“We are working with NHS 111 to improve the algorithm and how to make it more appropriate for patients,” she told EHI News, commenting that the current combination of computer software and non-healthcare staff “can’t replace clinical judgement.”

GP pilots

The Royal College of General Practitioners has repeatedly described the concept of NHS 111 as a “sound one” but has also raised multiple concerns about the way the service has been introduced, claiming shortly after its national roll-out that it offered a "patchwork quilt" of patient care.

The organisation – like the BMA – is keen to improve the service, however, and is working with NHS 111 on pilots involving the use of GPs, with early evidence suggesting that the addition of clinical support can cut the number of ambulance call-outs by two-thirds.

Agnelo Fernandes, urgent care lead for the RCGP, is helping to lead these GP pilots as chair of the steering group of the NHS 111 learning and development pilot projects.

He told EHI News: “What has come through from the pilots is that there is huge and important scope for clinical commissioning groups, NHS 111 and GP out of hours services to work closely together, especially at peak times, such as during and in the run up to national holidays, in the best interest of providing excellent patient care and alleviating pressures across the NHS.”

Fernandes also explained that there is a possibility of greater GP involvement in the future of NHS 111: “Moving forward, an economic evaluation would be helpful and for CCGs to liaise with local GPs, out of hours providers and NHS 111 providers to consider the most effective ways of using GP skills – and the overall benefit across local NHS economies of deploying GPs within NHS 111.” 

Improving the service

The concept of using healthcare professionals to support NHS 111 is not a new one, however, and one provider IC24 has experimented with using both clinician and non-clinician ‘floor walkers’ to support its call-handlers at its services in Great Yarmouth and Waveney and South Essex.

Speaking to EHI News, IC24’s managing director Lorraine Gray, a nurse by background, compared the use of call handlers to healthcare assistants in hospitals who need clinical support to help patients.

Training is also an essential part of creating a successful NHS 111 service said Gray: “It can be a scary environment for call handlers. So we have our training at a certain level – not just on NHS Pathways. We provide extra training on such things as life support, mental health and end-of-life care. We’re not just a call-handling service.”

This extra training seems to have paid off as when NHS 111 referrals to A&E services were increasingly significantly over the winter period, IC24 actually managed to reduce the number of referrals.

Another provider, Advanced Health and Care, which covers several areas with its Adastra 111 service, also backs the pragmatic use of healthcare professionals as part of NHS 111.

The company’s managing director Jim Chase told EHI News that one of the benefits of Adastra 111 is its ability to provide a sophisticated workflow management system, which gives complete control over how to queue calls, meaning a subset of calls can be created based on condition or priority.

“It’s possible to then direct appropriate calls direct to clinicians – who are trained to take a rounded view on a healthcare issue – by managing those queues.”

Improving on the current NHS Pathways system is also a goal for Advanced Health and Care, Chase said. “We are developing a decision support system based on Bayesian logic, which is more similar to how a clinical makes decision, rather than an algorithm.”

The future of NHS 111

It seems certain that NHS 111 will evolve with increased support from healthcare professionals and better training for its call handlers, although there must also be external support the BMA’s Charlotte Jones told EHI News.

“It’s not just up to NHS 111 to improve CCGs must make sure they are doing enough to support the service,” she said.

The next hurdle immediate hurdle the service it has to cross though is the general election on 7 May, although the result shouldn’t have a huge impact on the future of NHS 111 according to IC24’s Lorraine Gray.

“There are other agendas for the parties to focus on and there is no need to change completely,” she said. “We just need to focus on developing and improving.”

The BMA’s Jones also called for a unified focus ahead of the election: “NHS 111 should not be used as a political football. It’s not fair to play NHS services against each other when there are not enough resources to go around and it’s not right to raise patient expectations.”