BMJ 2013;348:f7659 doi: 10.1136/bmj.f7659 (Published 2 January 2014)
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Feature
FEATURE The battle for NHS 111: who should run it now? It all sounded so simple: a new phone number for urgent medical advice. But from its implementation the idea began to unravel. Gareth Iacobucci examines what’s next for 111 Gareth Iacobucci BMJ
General practitioners are on a collision course with senior civil servants over plans to give patients who dial the government’s 111 medical triage helpline the right to demand contact from a GP at their registered practice, an investigation by the BMJ has found. Email correspondence between senior figures at NHS England obtained by the BMJ show a desire to insert new clauses into GPs’ contracts, which would allow notice of breach of contract to be served to GPs who failed to see or speak to patients who have been diverted from 111 call centres. NHS England is also considering a plan to allow patients to book appointments with their GP directly through 111, as part of a drive to ease the pressure on hospital emergency departments.
But GP leaders said that plans to alter their contracts would be strongly resisted, as any such changes would overburden an already overstretched primary care system and undermine practices’ own triage mechanisms by effectively allowing remote lay call handlers to dictate to clinicians whether patients should be seen.
The investigation also shows that millions of pounds will be spent correcting the mismanagement of the service to date, after the litany of problems since its launch across England in April 2013. Against this backdrop, further tensions have emerged over the future running of the 111 service, with GP out of hours cooperatives fearing a land grab from ambulance trusts as plans are drawn up to redesign the service.
Ambulance trusts currently run 111 services for most people in England (figure⇓). But GP out of hours cooperatives have said they were better placed to operate the service, as the majority of calls are for queries most suited to being dealt with in primary care.
Warnings went unheeded
The BMJ’s findings come at a crucial juncture for the telephone triage service, which when it was launched faced problems with staff shortages, delays in callers receiving treatment, and ambulances being summoned unnecessarily.1 The launch was dogged by controversy after ministers pushed for it to be rolled out nationally from 1 April 2013, despite repeated warnings from the BMA that not all areas of the country were ready.2 For personal use only: See rights and reprints http://www.bmj.com/permissions
Described as a simple first point of access for patients seeking non-emergency medical advice (box), 111 was designed to handle calls previously made to local GP out of hours services and the old 0845 NHS Direct helpline, but with less clinical input in initial assessments, as it used lay call handlers working from a computerised clinical assessment system. Call handlers then redirected patients to other parts of the system if necessary, such as their GP or an emergency department. After these initial problems NHS England has been redrawing the national specification for the service to incorporate recommendations from its national review of urgent and emergency care, led by the NHS’s medical director, Bruce Keogh. The review has proposed reforming 111 by making it easier for patients to talk directly to a doctor or a nurse and by allowing patients to book an appointment directly with their general practice.3
Email correspondence disclosed to the BMJ under freedom of information legislation shows that NHS England officials have discussed the possibility of altering GPs’ contracts to ensure that they can be compelled to see or speak to patients sent to them from 111, to try to reduce pressure on emergency departments.
In one discussion NHS England’s chief operating officer and deputy chief executive, Barbara Hakin, relays reports that some patients had been advised by 111 to contact their GP, only to be told by practice receptionists that no appointments were available.
The email, dated 20 July, reads, “We want to put something in the contract that makes it clear that if a 111 caller (or any other health adviser) says [the patient] need[s] contact with GP in specific time, that GP will be in breach of contract if a GP doesn’t fulfil that though of course it could be by phone.”
A spokesperson for NHS England said that GPs were “required to care for patients as necessary” as part of their contractual terms. The spokesperson added, “We are working with the BMA to consider a joint statement which ensures practices make sure they meet this obligation. This is vital if a patient has been triaged through the clinical algorithm and the practice can respond with appropriate and timely clinical response.”
Hakin told the BMJ that NHS England was examining the issue closely but said that no decision had yet been reached on possible changes. She said, “Do patients get access to a clinician
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BMJ 2013;348:f7659 doi: 10.1136/bmj.f7659 (Published 2 January 2014)
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FEATURE
Original purpose of NHS 111 When David Cameron announced the concept of NHS 111 in 2011, the public was told: • If you think you might need emergency help, call 999. For all other urgent health care needs there is 111 • If you need to see a GP urgently, the NHS 111 service will make sure this happens • If you need to see a nurse or need an urgent home visit in the middle of the night, NHS 111 will organise that • NHS 111 content will be available online, enabling people to access health information and a directory of local services and to check their symptoms, as well as being able to connect directly to a 111 call adviser to assess the help they need
as quickly as they need? I wouldn’t want to second guess that, but we really are looking at that.
“111 should give people advice to be in the right place. Therefore, if we have people turning up in A&E [accident and emergency departments] when it’s not the right place, then 111 absolutely should help to prevent that.” But the BMA’s General Practitioners Committee said that it would strongly resist any moves that would force GPs to make contact with a patient referred through 111, without the patient being assessed by the practice first. Peter Holden, the committee’s lead negotiator on 111 and a GP in Derbyshire, told the BMJ that NHS England had “tried it on” during this year’s negotiations on the GP contract but said that GPs would not accept such proposals. “We said quite clearly there’s no way we are going to be told that we are obligated [to see patients sent via 111]. What we do is re-triage and decide what we’re going to do. But we are not going to have some lay operative working a computer programme telling us how to practise medicine. We’re not having it. End of.”
Holden said that such a move would see patients using 111 to “queue jump” practices’ waiting lists, causing surges in demand that would put huge pressure on already overstretched practices. “That was always one of the tensions with 111. If they [patients] ring me and say they’ve contacted 111, I say, ‘You will be triaged [by the practice] the same as anyone else.’ We’re already seeing 60 to 70 patients a day. We cannot do any more safely. We are absolutely saturated.” Holden said he believed that GPs were being targeted as ministers were desperate to avoid negative headlines about overstretched emergency departments, after ongoing problems with capacity this year.4 “The only headline that [David] Cameron cares about is accident and emergency,” he said.
The pressure on 111 to ease the strain was brought into even sharper focus by a study of 111 pilot sites by the University of Sheffield, published in November 2013.5 This found that in the period of the pilot from 2009 to 2011 the 111 service led to an increase in ambulances being dispatched and in patients’ attendances at emergency departments. NHS England acknowledged that there were initial problems but insisted that by summer 2013 there was no evidence that the service was still having an adverse effect on emergency department attendances.
NHS Direct admitted it was underfunded In an email obtained by the BMJ John McIvor, NHS England’s national responsible officer for 111, briefed Hakin on the situation in the summer of 2013. The email, dated 29 July, said that there was “no evidence that NHS 111 was causing lots of inappropriate ambulance journeys . . . or an increase in A&E attendances.” For personal use only: See rights and reprints http://www.bmj.com/permissions
He said, “Around 72% of ambulances dispatched through NHS 111 end up conveying a patient to hospital. This is the same as the number dispatched through 999, suggesting that dispatches through 111 are generally appropriate.” Hakin told the BMJ, “When some of these services came on stream they weren’t properly staffed and weren’t working very well . . . So we did see some increase in A&E attendances and ambulances called out. But it was very shortlived.”
These difficulties may have been overcome, but yet more problems arose when NHS Direct, which secured contracts to operate the new helpline in around a third of the country, withdrew from all its contracts in July, just months into its tenure, after admitting that it lacked the appropriate funding to operate the services safely.6
As a result, more than a third of 111 contracts (valued at more than £150m [€180m; $245m] in total) are having to be retendered, a process that NHS England said must be carried out in 2015. Clinical commissioning groups (CCGs), which will have to oversee this costly process, estimate that re-procuring one contract alone in the West Midlands would cost £500 000.7 As NHS Direct had 11 contracts with the NHS, this implies that millions could be spent across England correcting the mistakes made in the initial tendering process. Sources close to the process told the BMJ they believed that NHS Direct undervalued the cost of running 111 services by up to £30m and had launched some services with just 25% of the recommended staffing levels. In many areas GP out of hours providers had to be temporarily reinstated to handle the volume of calls. “We know the attitude of NHS Direct was, ‘We’ll go in and win it and then ask for some more money,’” said one source who wished to remain anonymous.
NHS Direct denied the claim. “We did not underbid in any of our contracts and bid in line with the requirements that were being put out,” a spokesperson said.
Cost savings negated by need to re-procure As part of its investigation the BMJ obtained details of the financial terms offered for 27 of the 46 111 contracts currently in operation. Sixteen areas refused on the grounds of commercial confidentiality, while the remaining three areas were unable to provide data.
Across the 27 areas that did provide data, commissioners awarded contracts worth more than £320m to service providers. This sum included £150m for contracts that began in April 2013 and that will have to be re-tendered in 2015. Most of this figure is accounted for by the NHS Direct contracts in the West Midlands (£93m) and the North West (£50.3m), both of which had huge difficulties when the service launched in April. In these areas CCGs told the BMJ that they had only paid NHS Direct for work it was able to fulfil. Subscribe: http://www.bmj.com/subscribe
BMJ 2013;348:f7659 doi: 10.1136/bmj.f7659 (Published 2 January 2014)
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Critics point out that the cost savings anticipated from awarding the contract to the lowest bidder will now be more than negated by the need to re-procure the contracts. “The savings made by giving the contract(s) to NHS Direct in the first place have been dwarfed by the costs incurred in putting right the mess,” said Bob Morley, chairman of the Birmingham Local Medical Committee, who witnessed at first hand what he described as “horrendous” problems in the West Midlands. “The whole thing has just been an utter disaster and a complete illustration of the sort of things that are going wrong in the NHS now.” The costs of re-tendering will add to the extra £15m the government has invested to ensure that the 111 service keeps working this winter, as part of Jeremy Hunt’s £500m rescue package for emergency care.8 Part of this will fund an extension of the original NHS Direct 0845 service in areas where 111 was not fit to operate. Holden estimated that the collapse of 111 may cost the taxpayer as much as £30m. “A lot of it went into keeping NHS Direct alive. It’s cost everybody in this country 50p each, and it’s hazarded people’s lives. It’s unacceptable, particularly as they were told by experts that this is what will happen. But they chose not to listen to the experts, as they thought we were just bloody minded trade unionists. We’ve proved we were honest brokers.” Holden said that the BMA was pushing NHS England not to force CCGs to tender contracts on the open market in 2015.
“Nobody would dream of doing a bid for A&E, so why are you dreaming of doing the first link in the chain? We are absolutely determined on this one. There are certain things you can’t put out to tender, and 111 is one of them if you want a decent service. The CCGs need to understand that the cheapest will not be the best.” NHS England said that it was still looking at its future approach but admitted that big mistakes had been made and vowed that the failings of the initial procurement process would not be repeated.
Hakin said, “We were putting in place completely new services, and sadly a number of providers promised us that they could deliver a service and then they failed to do so. That scenario won’t happen again. “We all learnt a lot of lessons about how careful you have to be that the provider can deliver the sort of services your patients need. We have put in enormous safeguards to ensure we have rigorous assessment, including external assurance that the providers have got enough staff and the right infrastructure to deliver.”
Stopgap arrangements As a stopgap to the new procurements NHS England has drafted in “step-in” service providers to run NHS Direct contracts on a temporary basis until 2015.
Most of these are NHS ambulance trusts, cementing their status as the biggest service providers of 111 in England. The BMJ’s analysis found that ambulance trusts currently provide the service to almost 34 million people—some 61% of the population. The next biggest providers are GP led cooperatives, so called social enterprises, which provide 111 to almost 13 million people. The private company Harmoni provides 111 services to a further seven and a half million people, while just over a million people are not yet covered by a 111 service. For personal use only: See rights and reprints http://www.bmj.com/permissions
GP led cooperatives—not for profit organisations that chiefly provide GP out of hours care—told the BMJ that they were concerned about a “land grab” from ambulance trusts, with clinical input from primary care being marginalised. They warned that this could hamper efforts to create an integrated system of care for patients.
But ambulance trusts, including established and aspiring foundation trusts, view 111 as an opportunity to expand their provision of services beyond traditional 999 emergency callouts and believe that they have the scale and experience to operate the service successfully. To allow time to devise a new specification NHS England ordered clinical commissioning groups not to re-tender any contracts until 2015. Hakin said that the pause did not mean that GP led organisations had been sidelined, but she said that ambulance providers had often proved best equipped to operate the contracts safely while a new specification was devised. “In essence, what we had was an urgent situation about patient care, and it was absolutely essential to identify what the best course of action was,” she said. “In many instances the organisations which were big enough to take on the volumes of calls that we were talking about were the ambulance trusts.”
But Holden said that he was concerned that ambulance trusts were being enlisted as the cheap option and said that the system should be redesigned so that experienced clinicians carry out initial triaging. “Triage is extremely complicated. It is a doctor-type decision. I’m concerned the government thinks the answer is to ‘dumb it down’ with paramedics,” he warned. The BMA is not a lone voice on this front. A report from the parliamentary health select committee, which concluded that 111 had been introduced prematurely and without enough evidence, recommended that greater involvement of clinicians in remote triage and assessment should be considered.9
Hakin acknowledged that the current national service specification for 111 “could be better” and said that NHS England was reviewing whether patients should have access to a clinician earlier in the process, whether call handlers should reduce the number of questions in the clinical algorithm, and whether 111 staff should have access to patients’ GP records. It seems the message that clinical input is vital has been heard, but whether the money is there to fund it is another matter.
The Health Committee’s inquiry heard that the maximum price initially set by commissioners to invest in 111 contracts ranged from £7 to £8 a call. “In retrospect, this price was too low and the resulting lack of resources in the new service contributed significantly to the service problems that arose at launch,” it said.10
This led to NHS Direct—which was initially running 111 services in 11 regions of England—relinquishing all its contacts after admitting that it could not afford to operate the service on the contractual terms it had accepted. Subsequently, call handling staff transferred to step-in providers through Transfer of Undertakings (Protection of Employment) (TUPE) Regulations.
A damning report by the accountancy firm Deloitte, which examined NHS Direct’s 111 contracts in the West Midlands and the North West, highlighted that the average handling time for calls was 220% greater than NHS Direct had originally estimated for its call handlers and 200% greater than it had estimated for its clinical advisers. “It is questionable as to whether the average handling times assumption in the NHS Direct commercial model is achievable,” the report concluded.11 Subscribe: http://www.bmj.com/subscribe
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Cooperatives sidelined CCGs contacted by the BMJ refused to disclose whether additional funding had now been invested in the contracts, citing commercial confidentiality. But some, including across the West Midlands, said that they had switched to a “standard form of the NHS contract” to make contract monitoring more uniform. Commissioners in the North West also said that NHS Direct was paid only 30% of the original contract values for 2013-14, as it only delivered “approximately 30% of the original aggregate contracted activity for the three North West contracts.” Mark Reynolds, GP and chairman of Urgent Health UK, a representative body for GP led cooperatives that run urgent care services, and medical director of the cooperative Integrated Care 24, which holds three 111 contracts, said that Urgent Health UK was concerned that decisions were being made on financial rather than clinical grounds. “I think the commissioners are desperate to pass it [111] to an organisation that has got a very solid financial basis [and] large numbers of staff and can absorb it to an extent—and appear to be less risky than a not for profit organisation,” he said. “Urgent Health UK’s concern has been that in some areas the price [of contracts] has been very low, and that makes it very difficult to deliver a service with adequate capacity.”
Of the 11 contracts previously held by NHS Direct (now 13, because of a three way split in the West Midlands), seven have been awarded to ambulance trusts on a step-in basis, three have gone to GP out of hours cooperatives, two have gone to Harmoni, and one (Cornwall) has yet to be awarded.
The largest 111 contract in England, initially held by NHS Direct but now taken over until 2015 by the West Midlands Ambulance Trust, is funded at £93m for the whole of the West Midlands. After NHS Direct’s withdrawal this contract now excludes Staffordshire, which has instead selected the out of hours provider Staffordshire Doctors Urgent Care to run its 111 service, and South Worcestershire, which has chosen Harmoni. The West Midlands was one of the worst affected areas when the 111 service launched in April, with inadequate staffing levels leading to serious concerns over patient safety. In the midst of this, two local GP out of hours providers, Birmingham & District General Practitioner Emergency Rooms (Badger) and Primecare, stepped in to handle calls. But despite their assistance during the turbulent launch, the organisations were overlooked to become the step-in provider in favour of the ambulance trust. Fay Wilson, chief executive and group medical director at Badger, which is a social enterprise, said she believed that her group had been sidelined for political reasons, because it spoke out about patient safety issues when the service was encountering problems. “We have been passed over in terms of providing the service in an integrated way. I think it’s an opportunity lost. I’m sure it’s been done for political reasons with a small ‘p.’ I just feel very disappointed. I think we were seen as troublemakers for rocking the boat, but we were actually quite restrained [in our criticism].”
Wilson said that NHS Direct had struggled to run Birmingham’s 111 service because of capacity problems, a lack of staff training, a lack of familiarity with systems among senior management, and “a lack of senior clinicians that could make decisions.” She said that the service had improved since but questioned whether the ambulance trust could offer enough clinical input.
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“It has improved, but the problems haven’t gone away,” said Wilson. “Our ambulance service doesn’t really have many high level clinicians because they have a big structure of paramedics, but I’m not sure they have any higher level clinicians to back them up.”
Ambulance trusts’ “land grab” With 111 at a crossroads while policy makers decide on its future, the BMJ’s analysis shows wide disparity in the current configuration of services.
A total of 17 of the 46 areas were able to provide a breakdown of the cost per patient for the 111 service. Contract values tended to reflect geographical differences, with the highest in Staffordshire (£16.21), Dorset (£12.92), and Bath and North East Somerset (£12.90) and the lowest across North Central London (£0.13).
Many contracts given to ambulance trusts cover several counties. For instance, the South East Coast Ambulance Service operates a £28.7m contract providing a 111 service across the whole of Surrey, Sussex, and Kent. But at the other end of the scale two of the smallest contracts, in Leicestershire (£1.2m) and Northamptonshire (£1.3m), are run by the GP led social enterprise Derbyshire Health United. Some areas have combined 111 and GP out of hours services into a single contract to bring about greater integration of services. Derbyshire Health United secured a combined 111 and out of hours contract priced at £58.2m (£2.34 per patient), while Somerset has also tendered for a similar combined contract.12
The Sheffield study found support for this type of integrated model: “Stakeholders felt that the success of NHS 111 depended on integration with more services, with direct links between NHS 111 and services such as community nursing, dental care and primary care in hours to ensure that callers to NHS 111 were dealt with within a single call,” it said.13 An academic “lessons learnt” review of 111, due to be published shortly by the University of Warwick, will echo these recommendations, in addition to proposing more integrated services covering smaller geographic areas. Holden, who is also a member of Derbyshire Health United, said that its model of an integrated urgent care system led by GPs was the best way to manage patients appropriately and avoid unnecessary admissions to hospital.
“Not all 111 is bad. DHU works because they also run out of hours [services], the community hospital, and district nursing. Nothing medical moves that isn’t under its control, and that’s why it works,” he explained. But despite acknowledging that local integrated services were effective, commissioners believe there is a need for financial stability against a backdrop of upheaval. Jonathan Leach, clinical lead for 111 in the West Midlands, echoed Hakin’s view that ambulance trusts were the safest option to keep the service afloat in the short term.
“We neither had the time nor the capacity to be able to go out to procurement again [so soon after launch],” he said. “We’ve got a number of organisations who would be interested in 111 services, but it is a regional service. And in terms of risk to patients, primarily—and also in terms of the finances—the best strategic fit as a step-in is the ambulance service.” He added, “We need to remember that the ambulance service already is an organisation which uses NHS pathways and have a huge track record.” Subscribe: http://www.bmj.com/subscribe
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Leach and Hakin emphasised that the arrangements were temporary and would allow time for a proper assessment before new procurements were carried out.
For their part, ambulance trusts said that they would collaborate with GPs and out of hours organisations to ensure a “slick service.”
But Reynolds said that GP led social enterprises were concerned about powerful ambulance trusts being in pole position to win future tenders, excluding primary care from shaping the service.
Phil Collins, head of 111 for the West Midlands Ambulance Service, told the BMJ that it was keen to take opportunities to provide more services but insisted that it would collaborate with GP out of hours providers.
“We will absolutely be talking to everybody who has a role to play,” said Hakin. “It doesn’t necessarily mean that out of hours providers will want to or be best placed to take on 111 services. But that intimate relationship between [111 and out of hours services] is absolutely critical.”
“Our power base as a group of organisations is much weaker than that of anyone else who has been in the game,” he said.
Reynolds said that the politics around the introduction of 111 had been “ferocious.” He said that perceptions of the competence of GP out of hours providers may have been unfairly tainted by “political rhetoric” that included pointed criticism from the health secretary.14 “I am concerned that the understanding isn’t there of the good quality service provided, particularly by the not for profit sector,” he said. “I can understand if a judgment is based on reality and what’s best for the patients, but if it’s a judgment based on prejudice or misinformation then that’s a shame and a missed opportunity.”
Reynolds said that qualitative evidence collected by Urgent Health UK indicated that 111 services with a high level of input from primary care were achieving better outcomes and greater satisfaction among patients than services with less clinical input from GPs. “We are convinced that a primary care input into the coaching and the training [of call handlers] can lead to a lower percentage of acute outcomes from the pathways algorithms,” he said. Like the West Midlands, the North West encountered major problems when its 111 service was launched with NHS Direct as the provider, and it was forced to turn to GP out of hours service providers to pick up the slack. But, as with the West Midlands service, the regional ambulance service has been selected to be the step-in replacement.
A spokeswoman for NHS England’s North West Area Team said that the decision had been taken because the ambulance service had already been supporting the service during an initial pilot and during the interim period at the end of March after the launch problems. “The priority was to ensure that the interim arrangements remained sustainable. A decision was taken at a national level to approach ambulance services and explore whether they would be suitable stability partners to take on the proportion of the calls that were being managed by NHS Direct,” the spokeswoman said. John Hughes, chairman of the Association of Local Medical Committees of Greater Manchester and a GP in the city, who experienced the chaos caused when 111 was launched, said that although things had settled down, he was unconvinced by the current service model.
“Ambulance services feel their paramedics and paramedic call takers can take the place of doctors and nurses in making decisions,” he said. “The difficulty of that is when they do dispatch paramedics to go and see someone, they won’t make a decision on the spot and often end up phoning the out of hours service or phoning the GP. So the GP ends up as the default anyway.” For personal use only: See rights and reprints http://www.bmj.com/permissions
A spokeswoman for the North West Ambulance Service said that it had “a proven track record with working closely with other healthcare agencies as part of its role as an emergency healthcare provider and will continue to do so with regard to 111.”
“We think [111] aligns with our organisation’s vision for providing high quality care and working in partnership,” he said. “Certainly we would hope to respond to any tender that comes out in due course.” “It is important to deliver the safe service that’s required for patients, [while] the commissioners are stepping back and reflecting and trying to make the right decision. But through this period we need to be well engaged with our out of hours providers in the area. We need to be delivering what for the patient becomes a slick service.”
Linking with emergency departments The College of Emergency Medicine, which has been actively feeding information into the Keogh review, would certainly welcome a slicker service, having criticised 111 in its initial phase for increasing pressure on already overstretched emergency departments.15
But while other organisations are focusing on how 111 links with primary care, Taj Hassan, the college’s vice president, said that services could be improved by linking more closely with emergency departments. “The urgent [and] emergency care system is extraordinarily stressed for a whole variety of reasons, and what you need is each part of this system to work consistently,” he said.
“I think part of the Keogh review should involve the service providers in 111 working more closely with emergency departments, so that there is a feedback loop to ensure the right types of patient have been referred in by 111 [and] are actually being fed into an emergency department system.”
Hassan said that it did not matter who operated the service but added that ambulance trusts “generally have a good track record of managing large caseloads of this type of activity.”
The college’s attitude of neutrality over who runs the services differs strongly from that of the GP cooperatives, which think that they are best placed to operate 111 services. But despite his worries over a land grab by ambulance trusts Reynolds thinks that the cooperatives’ message is being heard. “We see a huge qualitative importance in having expert primary care input into 111 services,” he said. “That’s operational as well as clinical. “We’ve had a very constructive dialogue. The details of how 111 is being run are being rethought, and we do believe that the messages coming from primary care have been listened to. But he warned, “The proof of the listening is in the next phase of the new specifications and the local commissioning and whether the lessons will truly have been learnt.” Competing interests: None declared. 1
Limb M. NHS 111 has poor quality advice, slow response times, and inappropriate delays, complainants say. BMJ 2013;346:f3382.
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NHS 111: what happened when July 2010—Coalition government’s white paper Equity and Excellence: Liberating the NHS (BMJ 2010;341:c3796, doi:10.1136/bmj.c3796) outlines plan to develop “a coherent 24/7 urgent care service in every area of England” October 2011—Prime Minister David Cameron and the health secretary, Andrew Lansley, announce that each area of England will have an NHS “111” service, a new number to call for all non-emergency NHS care and advice, by April 2013 (http://bit.ly/1esJO4h) February 2012—BMA and ambulance services call on government to delay rollout of 111, to allow adequate time to evaluate pilots and carry out local procurements for the service (BMJ 2012;344:e1204, doi:10.1136/bmj.e1204). Laurence Buckman, chairman of BMA’s General Practitioners Committee, said, “GPs are happy to work with NHS 111 to iron out any problems, but they need time in order to do that” March 2013—BMA renews call for national launch of 111 to be delayed until system is “fully safe for the public,” amid growing reports of chaos ahead of planned rollout (BMJ 2013;346:f2077, doi:10.1136/bmj.f2077) April 2013—Ministers press ahead with national rollout of 111. On launch, service is beset by problems, including staff shortages, treatment delays, and ambulances being summoned unnecessarily (BMJ 2013;346:f2394, doi:10.1136/bmj.f2394) July 2013—MPs conclude that 111 has failed to relieve pressure on hospital emergency departments in England since introduction and needs to be remodelled to give greater priority to early clinical assessment (BMJ 2013;347:f4717, doi:10.1136/bmj.f4717). Stephen Dorrell, chairman of health select committee, said, “It is vital to ensure that the needs of patients who don’t need to be at A&E are properly met elsewhere so that those who do need to be there receive prompt and high quality care” July 2013—NHS Direct withdraws from all its contracts to run NHS 111 services in England, claiming that the contracts were not financially sustainable (BMJ 2013;347:f4837, doi:10.1136/bmj.f4837) November 2013—NHS England’s review of urgent and emergency care, led by medical director Bruce Keogh, proposes enhancing 111 so patients can talk directly to a doctor, nurse, or health professional or book an appointment with their GP if needed (BMJ 2013;347:f6828, doi:10. 1136/bmj.f6828) 2
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Buckman L. NHS 111—CCG applications for implementation extensions. 17 Sep 2012. http://bma.org.uk/-/media/Files/PDFs/Working%20for%20change/Negotiating%20for% 20the%20profession/General%20Practitioners/NHS%20111/ nhslettertonickhall17september2012.pdf. Iacobucci G. NHS medical director proposes two tier emergency service. BMJ 2013;347:f6828. Limb M. Rescue boards are set up in England to deal with “significant deterioration” in A&E departments. BMJ 2013;346:f3065. Kmietowicz Z. NHS 111 led to more ambulance dispatches, finds study. BMJ 2013;347:f6811. Torjesen I. NHS Direct backs out of contracts to run NHS 111 because of poor funding. BMJ 2013;347:f4837. West Midlands NHS. 111 Update for CCG Governing Body. 11 Sep 2013. www. coventryrugbyccg.nhs.uk/mf.ashx?ID=e5dab949-d829-49b0-ba29-94ac22d2529d. Gould M. £500m fund for emergency services will not fix longstanding problems, say doctors. BMJ 2013;347:f5017. Iacobucci G. Reliance of 111 on non-clinical staff has increased pressure on emergency departments, MPs say. BMJ 2013;347:f4717.
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House of Commons Health Committee. Experience to date of the transition from NHS Direct to the NHS 111 service. www.publications.parliament.uk/pa/cm201314/cmselect/ cmhealth/171/171vw25.htm. Deloitte LLP. NHS Direct 111 “go live” review. 24 Apr 2013. www.nhsdirect.nhs.uk/en/ CorporateInformation/~/media/Files/BoardPapers/June2013/Item11-NHSDirectGoLive111.ashx. NHS South West Commissioning Support Unit. Invitation to tender for primary care out of hours and NHS 111 service. https://www.supply2health.nhs.uk/0AC/Lists/ Advertisements/DispForm.aspx?ID=7. Turner et al. Impact of the urgent care telephone service NHS 111 pilot sites: a controlled before and after study. BMJ Open 2013;3:e003451. Kmietowicz Z. BMA calls for meeting after health secretary blames GPs for pressure on emergency services. BMJ 2013;346:f2729. Iacobucci G. Roll-out of 111 telephone hotline causes hospitals severe problems. BMJ 2013;346:f2394.
Cite this as: BMJ 2014;348:f7659 © BMJ Publishing Group Ltd 2013
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Figure
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FEATURE The battle for NHS 111: who should run it now? It all sounded so simple: a new phone number for urgent medical advice. But from its implementation the idea began to unravel. Gareth Iacobucci examines what’s next for 111 Gareth Iacobucci BMJ
General practitioners are on a collision course with senior civil servants over plans to give patients who dial the government’s 111 medical triage helpline the right to demand contact from a GP at their registered practice, an investigation by the BMJ has found. Email correspondence between senior figures at NHS England obtained by the BMJ show a desire to insert new clauses into GPs’ contracts, which would allow notice of breach of contract to be served to GPs who failed to see or speak to patients who have been diverted from 111 call centres. NHS England is also considering a plan to allow patients to book appointments with their GP directly through 111, as part of a drive to ease the pressure on hospital emergency departments.
But GP leaders said that plans to alter their contracts would be strongly resisted, as any such changes would overburden an already overstretched primary care system and undermine practices’ own triage mechanisms by effectively allowing remote lay call handlers to dictate to clinicians whether patients should be seen.
The investigation also shows that millions of pounds will be spent correcting the mismanagement of the service to date, after the litany of problems since its launch across England in April 2013. Against this backdrop, further tensions have emerged over the future running of the 111 service, with GP out of hours cooperatives fearing a land grab from ambulance trusts as plans are drawn up to redesign the service.
Ambulance trusts currently run 111 services for most people in England (figure⇓). But GP out of hours cooperatives have said they were better placed to operate the service, as the majority of calls are for queries most suited to being dealt with in primary care.
Warnings went unheeded
The BMJ’s findings come at a crucial juncture for the telephone triage service, which when it was launched faced problems with staff shortages, delays in callers receiving treatment, and ambulances being summoned unnecessarily.1 The launch was dogged by controversy after ministers pushed for it to be rolled out nationally from 1 April 2013, despite repeated warnings from the BMA that not all areas of the country were ready.2 For personal use only: See rights and reprints http://www.bmj.com/permissions
Described as a simple first point of access for patients seeking non-emergency medical advice (box), 111 was designed to handle calls previously made to local GP out of hours services and the old 0845 NHS Direct helpline, but with less clinical input in initial assessments, as it used lay call handlers working from a computerised clinical assessment system. Call handlers then redirected patients to other parts of the system if necessary, such as their GP or an emergency department. After these initial problems NHS England has been redrawing the national specification for the service to incorporate recommendations from its national review of urgent and emergency care, led by the NHS’s medical director, Bruce Keogh. The review has proposed reforming 111 by making it easier for patients to talk directly to a doctor or a nurse and by allowing patients to book an appointment directly with their general practice.3
Email correspondence disclosed to the BMJ under freedom of information legislation shows that NHS England officials have discussed the possibility of altering GPs’ contracts to ensure that they can be compelled to see or speak to patients sent to them from 111, to try to reduce pressure on emergency departments.
In one discussion NHS England’s chief operating officer and deputy chief executive, Barbara Hakin, relays reports that some patients had been advised by 111 to contact their GP, only to be told by practice receptionists that no appointments were available.
The email, dated 20 July, reads, “We want to put something in the contract that makes it clear that if a 111 caller (or any other health adviser) says [the patient] need[s] contact with GP in specific time, that GP will be in breach of contract if a GP doesn’t fulfil that though of course it could be by phone.”
A spokesperson for NHS England said that GPs were “required to care for patients as necessary” as part of their contractual terms. The spokesperson added, “We are working with the BMA to consider a joint statement which ensures practices make sure they meet this obligation. This is vital if a patient has been triaged through the clinical algorithm and the practice can respond with appropriate and timely clinical response.”
Hakin told the BMJ that NHS England was examining the issue closely but said that no decision had yet been reached on possible changes. She said, “Do patients get access to a clinician
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BMJ 2013;348:f7659 doi: 10.1136/bmj.f7659 (Published 2 January 2014)
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Original purpose of NHS 111 When David Cameron announced the concept of NHS 111 in 2011, the public was told: • If you think you might need emergency help, call 999. For all other urgent health care needs there is 111 • If you need to see a GP urgently, the NHS 111 service will make sure this happens • If you need to see a nurse or need an urgent home visit in the middle of the night, NHS 111 will organise that • NHS 111 content will be available online, enabling people to access health information and a directory of local services and to check their symptoms, as well as being able to connect directly to a 111 call adviser to assess the help they need
as quickly as they need? I wouldn’t want to second guess that, but we really are looking at that.
“111 should give people advice to be in the right place. Therefore, if we have people turning up in A&E [accident and emergency departments] when it’s not the right place, then 111 absolutely should help to prevent that.” But the BMA’s General Practitioners Committee said that it would strongly resist any moves that would force GPs to make contact with a patient referred through 111, without the patient being assessed by the practice first. Peter Holden, the committee’s lead negotiator on 111 and a GP in Derbyshire, told the BMJ that NHS England had “tried it on” during this year’s negotiations on the GP contract but said that GPs would not accept such proposals. “We said quite clearly there’s no way we are going to be told that we are obligated [to see patients sent via 111]. What we do is re-triage and decide what we’re going to do. But we are not going to have some lay operative working a computer programme telling us how to practise medicine. We’re not having it. End of.”
Holden said that such a move would see patients using 111 to “queue jump” practices’ waiting lists, causing surges in demand that would put huge pressure on already overstretched practices. “That was always one of the tensions with 111. If they [patients] ring me and say they’ve contacted 111, I say, ‘You will be triaged [by the practice] the same as anyone else.’ We’re already seeing 60 to 70 patients a day. We cannot do any more safely. We are absolutely saturated.” Holden said he believed that GPs were being targeted as ministers were desperate to avoid negative headlines about overstretched emergency departments, after ongoing problems with capacity this year.4 “The only headline that [David] Cameron cares about is accident and emergency,” he said.
The pressure on 111 to ease the strain was brought into even sharper focus by a study of 111 pilot sites by the University of Sheffield, published in November 2013.5 This found that in the period of the pilot from 2009 to 2011 the 111 service led to an increase in ambulances being dispatched and in patients’ attendances at emergency departments. NHS England acknowledged that there were initial problems but insisted that by summer 2013 there was no evidence that the service was still having an adverse effect on emergency department attendances.
NHS Direct admitted it was underfunded In an email obtained by the BMJ John McIvor, NHS England’s national responsible officer for 111, briefed Hakin on the situation in the summer of 2013. The email, dated 29 July, said that there was “no evidence that NHS 111 was causing lots of inappropriate ambulance journeys . . . or an increase in A&E attendances.” For personal use only: See rights and reprints http://www.bmj.com/permissions
He said, “Around 72% of ambulances dispatched through NHS 111 end up conveying a patient to hospital. This is the same as the number dispatched through 999, suggesting that dispatches through 111 are generally appropriate.” Hakin told the BMJ, “When some of these services came on stream they weren’t properly staffed and weren’t working very well . . . So we did see some increase in A&E attendances and ambulances called out. But it was very shortlived.”
These difficulties may have been overcome, but yet more problems arose when NHS Direct, which secured contracts to operate the new helpline in around a third of the country, withdrew from all its contracts in July, just months into its tenure, after admitting that it lacked the appropriate funding to operate the services safely.6
As a result, more than a third of 111 contracts (valued at more than £150m [€180m; $245m] in total) are having to be retendered, a process that NHS England said must be carried out in 2015. Clinical commissioning groups (CCGs), which will have to oversee this costly process, estimate that re-procuring one contract alone in the West Midlands would cost £500 000.7 As NHS Direct had 11 contracts with the NHS, this implies that millions could be spent across England correcting the mistakes made in the initial tendering process. Sources close to the process told the BMJ they believed that NHS Direct undervalued the cost of running 111 services by up to £30m and had launched some services with just 25% of the recommended staffing levels. In many areas GP out of hours providers had to be temporarily reinstated to handle the volume of calls. “We know the attitude of NHS Direct was, ‘We’ll go in and win it and then ask for some more money,’” said one source who wished to remain anonymous.
NHS Direct denied the claim. “We did not underbid in any of our contracts and bid in line with the requirements that were being put out,” a spokesperson said.
Cost savings negated by need to re-procure As part of its investigation the BMJ obtained details of the financial terms offered for 27 of the 46 111 contracts currently in operation. Sixteen areas refused on the grounds of commercial confidentiality, while the remaining three areas were unable to provide data.
Across the 27 areas that did provide data, commissioners awarded contracts worth more than £320m to service providers. This sum included £150m for contracts that began in April 2013 and that will have to be re-tendered in 2015. Most of this figure is accounted for by the NHS Direct contracts in the West Midlands (£93m) and the North West (£50.3m), both of which had huge difficulties when the service launched in April. In these areas CCGs told the BMJ that they had only paid NHS Direct for work it was able to fulfil. Subscribe: http://www.bmj.com/subscribe
BMJ 2013;348:f7659 doi: 10.1136/bmj.f7659 (Published 2 January 2014)
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Critics point out that the cost savings anticipated from awarding the contract to the lowest bidder will now be more than negated by the need to re-procure the contracts. “The savings made by giving the contract(s) to NHS Direct in the first place have been dwarfed by the costs incurred in putting right the mess,” said Bob Morley, chairman of the Birmingham Local Medical Committee, who witnessed at first hand what he described as “horrendous” problems in the West Midlands. “The whole thing has just been an utter disaster and a complete illustration of the sort of things that are going wrong in the NHS now.” The costs of re-tendering will add to the extra £15m the government has invested to ensure that the 111 service keeps working this winter, as part of Jeremy Hunt’s £500m rescue package for emergency care.8 Part of this will fund an extension of the original NHS Direct 0845 service in areas where 111 was not fit to operate. Holden estimated that the collapse of 111 may cost the taxpayer as much as £30m. “A lot of it went into keeping NHS Direct alive. It’s cost everybody in this country 50p each, and it’s hazarded people’s lives. It’s unacceptable, particularly as they were told by experts that this is what will happen. But they chose not to listen to the experts, as they thought we were just bloody minded trade unionists. We’ve proved we were honest brokers.” Holden said that the BMA was pushing NHS England not to force CCGs to tender contracts on the open market in 2015.
“Nobody would dream of doing a bid for A&E, so why are you dreaming of doing the first link in the chain? We are absolutely determined on this one. There are certain things you can’t put out to tender, and 111 is one of them if you want a decent service. The CCGs need to understand that the cheapest will not be the best.” NHS England said that it was still looking at its future approach but admitted that big mistakes had been made and vowed that the failings of the initial procurement process would not be repeated.
Hakin said, “We were putting in place completely new services, and sadly a number of providers promised us that they could deliver a service and then they failed to do so. That scenario won’t happen again. “We all learnt a lot of lessons about how careful you have to be that the provider can deliver the sort of services your patients need. We have put in enormous safeguards to ensure we have rigorous assessment, including external assurance that the providers have got enough staff and the right infrastructure to deliver.”
Stopgap arrangements As a stopgap to the new procurements NHS England has drafted in “step-in” service providers to run NHS Direct contracts on a temporary basis until 2015.
Most of these are NHS ambulance trusts, cementing their status as the biggest service providers of 111 in England. The BMJ’s analysis found that ambulance trusts currently provide the service to almost 34 million people—some 61% of the population. The next biggest providers are GP led cooperatives, so called social enterprises, which provide 111 to almost 13 million people. The private company Harmoni provides 111 services to a further seven and a half million people, while just over a million people are not yet covered by a 111 service. For personal use only: See rights and reprints http://www.bmj.com/permissions
GP led cooperatives—not for profit organisations that chiefly provide GP out of hours care—told the BMJ that they were concerned about a “land grab” from ambulance trusts, with clinical input from primary care being marginalised. They warned that this could hamper efforts to create an integrated system of care for patients.
But ambulance trusts, including established and aspiring foundation trusts, view 111 as an opportunity to expand their provision of services beyond traditional 999 emergency callouts and believe that they have the scale and experience to operate the service successfully. To allow time to devise a new specification NHS England ordered clinical commissioning groups not to re-tender any contracts until 2015. Hakin said that the pause did not mean that GP led organisations had been sidelined, but she said that ambulance providers had often proved best equipped to operate the contracts safely while a new specification was devised. “In essence, what we had was an urgent situation about patient care, and it was absolutely essential to identify what the best course of action was,” she said. “In many instances the organisations which were big enough to take on the volumes of calls that we were talking about were the ambulance trusts.”
But Holden said that he was concerned that ambulance trusts were being enlisted as the cheap option and said that the system should be redesigned so that experienced clinicians carry out initial triaging. “Triage is extremely complicated. It is a doctor-type decision. I’m concerned the government thinks the answer is to ‘dumb it down’ with paramedics,” he warned. The BMA is not a lone voice on this front. A report from the parliamentary health select committee, which concluded that 111 had been introduced prematurely and without enough evidence, recommended that greater involvement of clinicians in remote triage and assessment should be considered.9
Hakin acknowledged that the current national service specification for 111 “could be better” and said that NHS England was reviewing whether patients should have access to a clinician earlier in the process, whether call handlers should reduce the number of questions in the clinical algorithm, and whether 111 staff should have access to patients’ GP records. It seems the message that clinical input is vital has been heard, but whether the money is there to fund it is another matter.
The Health Committee’s inquiry heard that the maximum price initially set by commissioners to invest in 111 contracts ranged from £7 to £8 a call. “In retrospect, this price was too low and the resulting lack of resources in the new service contributed significantly to the service problems that arose at launch,” it said.10
This led to NHS Direct—which was initially running 111 services in 11 regions of England—relinquishing all its contacts after admitting that it could not afford to operate the service on the contractual terms it had accepted. Subsequently, call handling staff transferred to step-in providers through Transfer of Undertakings (Protection of Employment) (TUPE) Regulations.
A damning report by the accountancy firm Deloitte, which examined NHS Direct’s 111 contracts in the West Midlands and the North West, highlighted that the average handling time for calls was 220% greater than NHS Direct had originally estimated for its call handlers and 200% greater than it had estimated for its clinical advisers. “It is questionable as to whether the average handling times assumption in the NHS Direct commercial model is achievable,” the report concluded.11 Subscribe: http://www.bmj.com/subscribe
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Cooperatives sidelined CCGs contacted by the BMJ refused to disclose whether additional funding had now been invested in the contracts, citing commercial confidentiality. But some, including across the West Midlands, said that they had switched to a “standard form of the NHS contract” to make contract monitoring more uniform. Commissioners in the North West also said that NHS Direct was paid only 30% of the original contract values for 2013-14, as it only delivered “approximately 30% of the original aggregate contracted activity for the three North West contracts.” Mark Reynolds, GP and chairman of Urgent Health UK, a representative body for GP led cooperatives that run urgent care services, and medical director of the cooperative Integrated Care 24, which holds three 111 contracts, said that Urgent Health UK was concerned that decisions were being made on financial rather than clinical grounds. “I think the commissioners are desperate to pass it [111] to an organisation that has got a very solid financial basis [and] large numbers of staff and can absorb it to an extent—and appear to be less risky than a not for profit organisation,” he said. “Urgent Health UK’s concern has been that in some areas the price [of contracts] has been very low, and that makes it very difficult to deliver a service with adequate capacity.”
Of the 11 contracts previously held by NHS Direct (now 13, because of a three way split in the West Midlands), seven have been awarded to ambulance trusts on a step-in basis, three have gone to GP out of hours cooperatives, two have gone to Harmoni, and one (Cornwall) has yet to be awarded.
The largest 111 contract in England, initially held by NHS Direct but now taken over until 2015 by the West Midlands Ambulance Trust, is funded at £93m for the whole of the West Midlands. After NHS Direct’s withdrawal this contract now excludes Staffordshire, which has instead selected the out of hours provider Staffordshire Doctors Urgent Care to run its 111 service, and South Worcestershire, which has chosen Harmoni. The West Midlands was one of the worst affected areas when the 111 service launched in April, with inadequate staffing levels leading to serious concerns over patient safety. In the midst of this, two local GP out of hours providers, Birmingham & District General Practitioner Emergency Rooms (Badger) and Primecare, stepped in to handle calls. But despite their assistance during the turbulent launch, the organisations were overlooked to become the step-in provider in favour of the ambulance trust. Fay Wilson, chief executive and group medical director at Badger, which is a social enterprise, said she believed that her group had been sidelined for political reasons, because it spoke out about patient safety issues when the service was encountering problems. “We have been passed over in terms of providing the service in an integrated way. I think it’s an opportunity lost. I’m sure it’s been done for political reasons with a small ‘p.’ I just feel very disappointed. I think we were seen as troublemakers for rocking the boat, but we were actually quite restrained [in our criticism].”
Wilson said that NHS Direct had struggled to run Birmingham’s 111 service because of capacity problems, a lack of staff training, a lack of familiarity with systems among senior management, and “a lack of senior clinicians that could make decisions.” She said that the service had improved since but questioned whether the ambulance trust could offer enough clinical input.
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“It has improved, but the problems haven’t gone away,” said Wilson. “Our ambulance service doesn’t really have many high level clinicians because they have a big structure of paramedics, but I’m not sure they have any higher level clinicians to back them up.”
Ambulance trusts’ “land grab” With 111 at a crossroads while policy makers decide on its future, the BMJ’s analysis shows wide disparity in the current configuration of services.
A total of 17 of the 46 areas were able to provide a breakdown of the cost per patient for the 111 service. Contract values tended to reflect geographical differences, with the highest in Staffordshire (£16.21), Dorset (£12.92), and Bath and North East Somerset (£12.90) and the lowest across North Central London (£0.13).
Many contracts given to ambulance trusts cover several counties. For instance, the South East Coast Ambulance Service operates a £28.7m contract providing a 111 service across the whole of Surrey, Sussex, and Kent. But at the other end of the scale two of the smallest contracts, in Leicestershire (£1.2m) and Northamptonshire (£1.3m), are run by the GP led social enterprise Derbyshire Health United. Some areas have combined 111 and GP out of hours services into a single contract to bring about greater integration of services. Derbyshire Health United secured a combined 111 and out of hours contract priced at £58.2m (£2.34 per patient), while Somerset has also tendered for a similar combined contract.12
The Sheffield study found support for this type of integrated model: “Stakeholders felt that the success of NHS 111 depended on integration with more services, with direct links between NHS 111 and services such as community nursing, dental care and primary care in hours to ensure that callers to NHS 111 were dealt with within a single call,” it said.13 An academic “lessons learnt” review of 111, due to be published shortly by the University of Warwick, will echo these recommendations, in addition to proposing more integrated services covering smaller geographic areas. Holden, who is also a member of Derbyshire Health United, said that its model of an integrated urgent care system led by GPs was the best way to manage patients appropriately and avoid unnecessary admissions to hospital.
“Not all 111 is bad. DHU works because they also run out of hours [services], the community hospital, and district nursing. Nothing medical moves that isn’t under its control, and that’s why it works,” he explained. But despite acknowledging that local integrated services were effective, commissioners believe there is a need for financial stability against a backdrop of upheaval. Jonathan Leach, clinical lead for 111 in the West Midlands, echoed Hakin’s view that ambulance trusts were the safest option to keep the service afloat in the short term.
“We neither had the time nor the capacity to be able to go out to procurement again [so soon after launch],” he said. “We’ve got a number of organisations who would be interested in 111 services, but it is a regional service. And in terms of risk to patients, primarily—and also in terms of the finances—the best strategic fit as a step-in is the ambulance service.” He added, “We need to remember that the ambulance service already is an organisation which uses NHS pathways and have a huge track record.” Subscribe: http://www.bmj.com/subscribe
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Leach and Hakin emphasised that the arrangements were temporary and would allow time for a proper assessment before new procurements were carried out.
For their part, ambulance trusts said that they would collaborate with GPs and out of hours organisations to ensure a “slick service.”
But Reynolds said that GP led social enterprises were concerned about powerful ambulance trusts being in pole position to win future tenders, excluding primary care from shaping the service.
Phil Collins, head of 111 for the West Midlands Ambulance Service, told the BMJ that it was keen to take opportunities to provide more services but insisted that it would collaborate with GP out of hours providers.
“We will absolutely be talking to everybody who has a role to play,” said Hakin. “It doesn’t necessarily mean that out of hours providers will want to or be best placed to take on 111 services. But that intimate relationship between [111 and out of hours services] is absolutely critical.”
“Our power base as a group of organisations is much weaker than that of anyone else who has been in the game,” he said.
Reynolds said that the politics around the introduction of 111 had been “ferocious.” He said that perceptions of the competence of GP out of hours providers may have been unfairly tainted by “political rhetoric” that included pointed criticism from the health secretary.14 “I am concerned that the understanding isn’t there of the good quality service provided, particularly by the not for profit sector,” he said. “I can understand if a judgment is based on reality and what’s best for the patients, but if it’s a judgment based on prejudice or misinformation then that’s a shame and a missed opportunity.”
Reynolds said that qualitative evidence collected by Urgent Health UK indicated that 111 services with a high level of input from primary care were achieving better outcomes and greater satisfaction among patients than services with less clinical input from GPs. “We are convinced that a primary care input into the coaching and the training [of call handlers] can lead to a lower percentage of acute outcomes from the pathways algorithms,” he said. Like the West Midlands, the North West encountered major problems when its 111 service was launched with NHS Direct as the provider, and it was forced to turn to GP out of hours service providers to pick up the slack. But, as with the West Midlands service, the regional ambulance service has been selected to be the step-in replacement.
A spokeswoman for NHS England’s North West Area Team said that the decision had been taken because the ambulance service had already been supporting the service during an initial pilot and during the interim period at the end of March after the launch problems. “The priority was to ensure that the interim arrangements remained sustainable. A decision was taken at a national level to approach ambulance services and explore whether they would be suitable stability partners to take on the proportion of the calls that were being managed by NHS Direct,” the spokeswoman said. John Hughes, chairman of the Association of Local Medical Committees of Greater Manchester and a GP in the city, who experienced the chaos caused when 111 was launched, said that although things had settled down, he was unconvinced by the current service model.
“Ambulance services feel their paramedics and paramedic call takers can take the place of doctors and nurses in making decisions,” he said. “The difficulty of that is when they do dispatch paramedics to go and see someone, they won’t make a decision on the spot and often end up phoning the out of hours service or phoning the GP. So the GP ends up as the default anyway.” For personal use only: See rights and reprints http://www.bmj.com/permissions
A spokeswoman for the North West Ambulance Service said that it had “a proven track record with working closely with other healthcare agencies as part of its role as an emergency healthcare provider and will continue to do so with regard to 111.”
“We think [111] aligns with our organisation’s vision for providing high quality care and working in partnership,” he said. “Certainly we would hope to respond to any tender that comes out in due course.” “It is important to deliver the safe service that’s required for patients, [while] the commissioners are stepping back and reflecting and trying to make the right decision. But through this period we need to be well engaged with our out of hours providers in the area. We need to be delivering what for the patient becomes a slick service.”
Linking with emergency departments The College of Emergency Medicine, which has been actively feeding information into the Keogh review, would certainly welcome a slicker service, having criticised 111 in its initial phase for increasing pressure on already overstretched emergency departments.15
But while other organisations are focusing on how 111 links with primary care, Taj Hassan, the college’s vice president, said that services could be improved by linking more closely with emergency departments. “The urgent [and] emergency care system is extraordinarily stressed for a whole variety of reasons, and what you need is each part of this system to work consistently,” he said.
“I think part of the Keogh review should involve the service providers in 111 working more closely with emergency departments, so that there is a feedback loop to ensure the right types of patient have been referred in by 111 [and] are actually being fed into an emergency department system.”
Hassan said that it did not matter who operated the service but added that ambulance trusts “generally have a good track record of managing large caseloads of this type of activity.”
The college’s attitude of neutrality over who runs the services differs strongly from that of the GP cooperatives, which think that they are best placed to operate 111 services. But despite his worries over a land grab by ambulance trusts Reynolds thinks that the cooperatives’ message is being heard. “We see a huge qualitative importance in having expert primary care input into 111 services,” he said. “That’s operational as well as clinical. “We’ve had a very constructive dialogue. The details of how 111 is being run are being rethought, and we do believe that the messages coming from primary care have been listened to. But he warned, “The proof of the listening is in the next phase of the new specifications and the local commissioning and whether the lessons will truly have been learnt.” Competing interests: None declared. 1
Limb M. NHS 111 has poor quality advice, slow response times, and inappropriate delays, complainants say. BMJ 2013;346:f3382.
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NHS 111: what happened when July 2010—Coalition government’s white paper Equity and Excellence: Liberating the NHS (BMJ 2010;341:c3796, doi:10.1136/bmj.c3796) outlines plan to develop “a coherent 24/7 urgent care service in every area of England” October 2011—Prime Minister David Cameron and the health secretary, Andrew Lansley, announce that each area of England will have an NHS “111” service, a new number to call for all non-emergency NHS care and advice, by April 2013 (http://bit.ly/1esJO4h) February 2012—BMA and ambulance services call on government to delay rollout of 111, to allow adequate time to evaluate pilots and carry out local procurements for the service (BMJ 2012;344:e1204, doi:10.1136/bmj.e1204). Laurence Buckman, chairman of BMA’s General Practitioners Committee, said, “GPs are happy to work with NHS 111 to iron out any problems, but they need time in order to do that” March 2013—BMA renews call for national launch of 111 to be delayed until system is “fully safe for the public,” amid growing reports of chaos ahead of planned rollout (BMJ 2013;346:f2077, doi:10.1136/bmj.f2077) April 2013—Ministers press ahead with national rollout of 111. On launch, service is beset by problems, including staff shortages, treatment delays, and ambulances being summoned unnecessarily (BMJ 2013;346:f2394, doi:10.1136/bmj.f2394) July 2013—MPs conclude that 111 has failed to relieve pressure on hospital emergency departments in England since introduction and needs to be remodelled to give greater priority to early clinical assessment (BMJ 2013;347:f4717, doi:10.1136/bmj.f4717). Stephen Dorrell, chairman of health select committee, said, “It is vital to ensure that the needs of patients who don’t need to be at A&E are properly met elsewhere so that those who do need to be there receive prompt and high quality care” July 2013—NHS Direct withdraws from all its contracts to run NHS 111 services in England, claiming that the contracts were not financially sustainable (BMJ 2013;347:f4837, doi:10.1136/bmj.f4837) November 2013—NHS England’s review of urgent and emergency care, led by medical director Bruce Keogh, proposes enhancing 111 so patients can talk directly to a doctor, nurse, or health professional or book an appointment with their GP if needed (BMJ 2013;347:f6828, doi:10. 1136/bmj.f6828) 2
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Buckman L. NHS 111—CCG applications for implementation extensions. 17 Sep 2012. http://bma.org.uk/-/media/Files/PDFs/Working%20for%20change/Negotiating%20for% 20the%20profession/General%20Practitioners/NHS%20111/ nhslettertonickhall17september2012.pdf. Iacobucci G. NHS medical director proposes two tier emergency service. BMJ 2013;347:f6828. Limb M. Rescue boards are set up in England to deal with “significant deterioration” in A&E departments. BMJ 2013;346:f3065. Kmietowicz Z. NHS 111 led to more ambulance dispatches, finds study. BMJ 2013;347:f6811. Torjesen I. NHS Direct backs out of contracts to run NHS 111 because of poor funding. BMJ 2013;347:f4837. West Midlands NHS. 111 Update for CCG Governing Body. 11 Sep 2013. www. coventryrugbyccg.nhs.uk/mf.ashx?ID=e5dab949-d829-49b0-ba29-94ac22d2529d. Gould M. £500m fund for emergency services will not fix longstanding problems, say doctors. BMJ 2013;347:f5017. Iacobucci G. Reliance of 111 on non-clinical staff has increased pressure on emergency departments, MPs say. BMJ 2013;347:f4717.
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House of Commons Health Committee. Experience to date of the transition from NHS Direct to the NHS 111 service. www.publications.parliament.uk/pa/cm201314/cmselect/ cmhealth/171/171vw25.htm. Deloitte LLP. NHS Direct 111 “go live” review. 24 Apr 2013. www.nhsdirect.nhs.uk/en/ CorporateInformation/~/media/Files/BoardPapers/June2013/Item11-NHSDirectGoLive111.ashx. NHS South West Commissioning Support Unit. Invitation to tender for primary care out of hours and NHS 111 service. https://www.supply2health.nhs.uk/0AC/Lists/ Advertisements/DispForm.aspx?ID=7. Turner et al. Impact of the urgent care telephone service NHS 111 pilot sites: a controlled before and after study. BMJ Open 2013;3:e003451. Kmietowicz Z. BMA calls for meeting after health secretary blames GPs for pressure on emergency services. BMJ 2013;346:f2729. Iacobucci G. Roll-out of 111 telephone hotline causes hospitals severe problems. BMJ 2013;346:f2394.
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BMJ 2013;348:f7659 doi: 10.1136/bmj.f7659 (Published 2 January 2014)
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FEATURE
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