NHS111 refutes ambulance dispatch claims

NHS111 today refuted suggestions that it refuses to send ambulances to patients who are seriously ill.

In a rebuttal of claims made in a national newspaper, the helpline service said it had an exemplary safety record while dealing with around 38,000 calls a day across the country.

And NHS England defended the service saying it “continues to provide an incredibly robust service in the face of huge demand”.

Both organisations spoke out after claims in the Daily Telegraph after an undercover reporter spent seven weeks working as a call handler at the South Central Ambulance Service’s (SCAS) NHS111 call centre at Bicester in Oxfordshire.

Among its claims, the paper said the service’s Pathways system – which prompts call handlers to ask patients questions about their symptoms before it reaches a decision on the best course of action – had posed more than 30 questions but denied a person an ambulance.

The paper further claimed call centre staff refused to dispatch emergency crews unless approved by a clinician.

Dr Ossie Rawstorne, NHS111 National Medical Advisor, denied the claims saying: “Call handlers are not expected to use their own judgement to determine if an ambulance is required. That would be inappropriate.

“They are guided by the system, called Pathways, in making this assessment.

“Pathways is a decision-making support tool for call handlers that has been safely developed by doctors representing all the Royal Colleges and experienced nurses and paramedics.

“Call handlers are trained to ‘early exit’ from the system and pass the call to a clinician for a further clinical assessment should they believe the call is complex, the caller refuses the disposition, or they are concerned for any reason.

“In this situation the clinician – a nurse or paramedic – will be able to over-ride the Pathways system.”

“We are encouraged to see this is exactly what happened regarding the call with a patient experiencing chest pains, allowing the clinician to provide additional expertise and assessment.”

Dr Rawstorne said that during April 2015 the SCAS call centre had dealt with more than 99,000 calls and had dispatched 7,329 ambulances – for around 9.3% of the call triaged – sending ambulances across Buckinghamshire, Berkshire, Hampshire, Oxfordshire, Bedfordshire and Luton.

“NHS111 continues to provide an incredibly robust service in the face of huge demand. Our call handlers nationally are dealing with around 38,000 calls a day – more than 92 per cent of these are answered within 60 seconds.

“Not only is the service meeting the increased demand from the public but is also doing an excellent job in terms of protecting both A&E and ambulance services from unnecessary attendances and call outs. Of the calls triaged, on average around the country just 11 per cent have ambulances dispatched and 7 per cent are recommended to A&E.”

Dr Rawstorne also pointed to the exemplary safety record of the NHS111 service in handling calls, explaining: “In 2014-15 there were 90 NHS111-related Serious Adverse Incidents, of which 70 were patient safety incidents (the others were related to technical failures). So as a rate of patient safety that is approximately 0.006 per 1,000 calls or about six per million calls. That is a very impressive record.”

The Telegraph report comes a day after the Care Quality Commission (CQC) published its pilot inspection reports on three NHS111 call centres run by the Isle of Wight Ambulance Service, the North West Ambulance Trust and Mallard House in Derbyshire.

Dr Rawstorne said: “All three CQC pilot inspection reports show the call centres are providing safe, effective, caring, responsive and well-led services. The public can be confident and reassured that they will get a prompt and effective response to their calls to NHS111 whenever they need it. And we welcome the CQC plan to assess all 111 services over the next 15 months.”

Regarding the newspapers claims of a patient with chest pains being denied an ambulance, Professor Keith Willett, Director for Acute Care, who is leading NHS England’s Urgent and Emergency Care Review which will also focus on the future role of NHS111, said: “On clinical grounds, after four weeks training, and three weeks of experience, this wannabe ‘doctor’ felt she was capable of diagnosing a heart attack better than a tiered set of questions designed by a consensus of senior clinicians, approved by the Royal Colleges, refined over many years, and reinforced by an experienced clinician who personally reviewed the history at the time.

“It was the refined system that said a 999 ambulance was an inappropriate response – that ambulance could better serve a critically ill or injured patient, especially important when we know we have fewer paramedics that we need.”

Professor Willett added: “On the training issues, clearly it is correct in any industry or profession to learn from events that have not gone well and explain how to avoid repetition. You would expect this as part of an open improvement process.”

Dr Ossie Rawstorne said: “The undercover reporter clearly acted appropriately in keeping with her training and raised their concern with a 111 clinician who has exercised their clinical judgement in this case.

“Our clinical staff have many years of experience in dealing with a wide range of medical conditions, from the minor to the acute and life-threatening. It is completely incorrect to assert that the patient must ‘prove’ that their symptoms are related to a particular cause.”

In another case the Pathways system prompted the undercover reporter to ask more than 30 questions before it offered a conclusion.

Dr Rawstorne refuted any claims that computer prompts “slowed down the service”, explaining:

“NHS 111 call handlers are required to answer all of the questions in the algorithms, it would be unsafe to allow them to skip any questions. However, not every question has to be asked verbatim.

“The doctors and nurses who built and work on Pathways do not include irrelevant questions. The system is built on their expert knowledge and vast experience, as well as best practice and the latest clinical evidence.

“Even if a condition is very minor and likely to require only self-care, it is important that questions are asked so as to exclude any more serious conditions. It would be clinically wrong and unsafe to make assumptions about a seemingly minor presenting symptom.

“NHS Pathways is constantly seeking to improve and regularly reviews and tests the system to ensure it fully supports patients and reflects the latest clinical evidence. There will always be a balance between asking enough questions to be sure that no significant symptom is missed and making the process as user friendly as possible.”

Dr Rawstone added: “Locally and nationally there is a system in place for staff to continually feedback examples of where the Pathways could be improved and, of course, when the outcome is less than expected.

“NHS 111 is a good service and already meets the needs and expectations of the vast majority of callers. Our last survey showed that 90 per cent of people were satisfied with it.

“We have an extensive programme of work underway to improve it even further especially in better meeting the needs of particular patient groups such as those with complex medical conditions and mental health needs. We are not complacent.”

Background Information:

  • NHS111 call handlers at the South Central Ambulance Service call centre at Bicester deal with 3,000 calls a day at a peak, and 1,350 on most days.
  • Ambulance dispatches by NHS111: in April 2015 in England there were 1,130,894 calls offered to NHS 111 of which 1,076,194 were answered, and 934,879 were triaged. Of those triaged calls, 93,390 (10.0%) ended with an ambulance dispatch. The total number of ambulance dispatches during 2014-15 was 1,124,474.
  • Since it was first trialled in August 2010, NHS111 has dealt with 25,494,846 calls. The average length of call since 111 started is 14min 32sec. 93.1% of all calls have been answered within 60 seconds.
  • In the past year NHS111 nationally has received more than 12 million calls and, as a result, offered treatment to over two million people who would otherwise have visited A&E, and another 600,000 who would have dialled 999 for an ambulance, reducing a significant amount of unnecessary pressure on our urgent care services.
  • The latest NHS 111 follow-up surveys, for the year ending September 2014, show that 30% of callers would have gone to A&E, and 17% would have contacted the 999 ambulance service, had NHS 111 not been available. Of actual NHS 111 calls over the same year, 8% were recommended to attend A&E, and 11% had an ambulance dispatch.
  • The differences mean that over 2 million people that year were directed away from A&E, and 600,000 were directed away from calling an ambulance.
  • 2 million directed away from A&E breaks down as: 177,000 per month; 41,000 per week; nearly 6,000 per day.
  • 600,000 calls to NHS111 that would otherwise have resulted in calls to 999 for an ambulance breaks down as: 50,000 per month, 12,000 per week, 1,600 per day.