As an Emergency Medicine Consultant, I understand and feel the constant pressure on the front door of the hospital.
It is the ED Consultant’s responsibility to make sure all patients arriving in the department are safely seen, treated and either referred or discharged within a four-hour target.
This is a target that we, as a specialty vehemently agree with in order to deliver a safe and effective service. However, with increasing numbers of undifferentiated cases arriving, maintaining this target is becoming increasingly challenging.
In March this year, the NHS 111 service had a record number of calls, reaching over 1.5 million, over 33% more than March 2015. Of that rather large number of calls, 11% had ambulances dispatched, 8% were recommended to attend A&E with 63% recommended to primary care.
It is clear that NHS 111 is both responding to significant demand, and directing the majority to primary care and other options.
The service is commissioned locally by CCGs and the providers are commonly ambulance services or GP out-of-hours companies. Each provider follows national minimal standards and quality is monitored within the CCG with a local CG lead overseeing these standards. Currently, that clinical lead feeds up to a regional lead, who feeds up to the national lead for 111, overseeing serious incidents that develop and considering ways to improve the service.
In 2015, the then Deputy Chief Executive of NHS England, Dr Barbara Hakin, announced that NHS 111 would integrate with the out-of-hours providers to form an integrated urgent care model.
The intention is to deliver a more streamlined service and increase the chance of getting the patient to the right place, first time. However, for this to be achieved, a new specification would need to be developed, with an enhanced form of triage, a new workforce and with that, new commissioning standards and metrics to measure quality. Governance of this new model will eventually fall within the remit of the Urgent & Emergency Networks that are developing in each region.
Much of the criticism that surrounds 111 comes from the algorithm currently used by all providers: NHS Pathways. This is a computer system that requires significant training, but no previous clinical knowledge.
Every call must go through module zero, just like the 999 calls: is the patient breathing and conscious, or bleeding heavily? Then, unlike 999 calls, the caller needs to be spine-matched, if possible, to the correct NHS number prior to the symptoms being triaged. A symptom will generate a pathway for the call-handler to follow. This may trigger the need for advice from, or direct transfer to, a ‘clinician’, which is known as a warm transfer. Currently, clinicians are usually paramedics and nurses within the call centre.
Eventually, a disposition is reached which may lead to an appointment in the out-of-hours centre, a call back from a GP, or request for an ambulance.
The reliability of the dispositions is dependent on the local DOS (Directory of Service). The more advanced the DOS, the more accurate the disposition. If the DOS is poor, the ‘catch-all’ is often triggered. Invariably, the ED is the ‘catch-all’ for all 111 services. That often explains a number of inappropriate referrals.
However, with a new integrated service, it is hoped the system should improve significantly. However, it is up to local commissioners and robust procurement processes to produce a specification that will enhance the current model. Within this model, the most significant change is the development of the ‘clinical hub’.
The clinical hub is proposed to host a group of clinicians from various backgrounds: GPs, pharmacists, mental health nurses, dental nurses and even specialists. There is some debate as to which professional groups would offer most value.
It may be a physical hub, with these clinicians working within a call centre, or a virtual hub, with relevant clinicians being available at the end of a phone. A combination of the two seems more likely and would be most cost efficient.
Pathways will remain and is not likely to change in the near future. But with the development of a clinical hub and integration with the out-of-hours service, the future of 111 is one of change. Clearly staffing, recruitment and retention of staff within the hub will be one of the most significant challenges at a local level.
I am an optimist about the future of NHS 111. I encourage senior ED and GP colleagues to get involved. Stop being negative about 111 and stop the stereotype turning into a self fulfilling prophecy. Connecting through the regional Urgent & Emergency Network Board is vital and if possible, contact the local 111 CG lead for the service, give feedback and if possible, visit the call centre. The service provided to your ED will only be as good as the service commissioned through local procurement. In many regions, these specifications are currently being developed and input from in and out-of hours GPs and ED physicians is vital.
Dr James Ray is Emergency Medicine Consultant at Oxford University Hospital NHS Foundation Trust and Clinical Governance Lead for NHS 111 in Oxfordshire.
His main current interest is to improve the urgent care pathway by making it as accessible as possible without compromising safety and effectiveness to improve the patient experience. Also, to spread out the workload across services, encourage team working throughout providers and continue to develop the workforce needed for the ever increasing demand.
James is an advocate of all doctors and nurses, from all backgrounds, whether primary or secondary care, working together with the sole aim of providing the same goal, to put the patient first. Such idealism, he says, is the key to success of the National Health Service.