Sunday, 6 December 2015

Does NHS 111 Work?


NHS 111 services sit in the eye of a nationwide healthcare storm.

Amidst a chaotic vortex of hospitals in special measures, funding and resource concerns, escalating demand, demoralised healthcare staff and belligerent health ministers, the public continues to need treatment - and it is to the 24/7 medical helpline to which they often turn.

As a paramedic who has recently taken up a position as a clinical advisor in Hertfordshire's 111 service (run by Herts Urgent Care), it has given me an opportunity to see first hand the efforts to mitigate the unprecedented pressure on wider NHS services.

Sadly, the impression given by recent press coverage paints a bleak picture of those efforts (Daily Mail: 'NHS 111 Whistleblower Speaks Out', Independent: 'Most people told to go to hospital after calling NHS 111 did not need emergency treatment'). I'd like to take this opportunity to offer an alternative, more informed viewpoint than the kind of fearmongering anecdotes which have been the focus of much mainstream media coverage.

I am all too aware of the intolerable workload faced by my colleagues delivering 999 emergency care and the related challenges faced by A&E departments. GP services are also in crisis as are other community-based services. So it is absolutely imperative that whatever can be done to alleviate the pressure of relentless demand on primary care services (that being the umbrella term for any 'first point of contact' to healthcare, including GP surgeries, A&E departments and ambulance services, amongst others) whilst maintaining the standard of patient care people expect from the NHS. This is no small task and is fraught with risk.

It is vital to recognise that 111 does not exist to replace any of those services. It cannot. It is a supporting service which should enable its users to get the right care in the right timeframe. However, primary care is a minefield for the uninitiated. To expect the layman to know the urgency of their need and which point of access would get them the care they require is a huge assumption.

Risk Aversity Versus Safe Practice

Sourced from the internet - unkind and incorrect
Much has been made of the scripted process of assessment, provided by NHS Pathways, and its use by the non-clinical health advisors who take the majority of initial 111 calls. While the health advisors do not generally have an extensive clinical grounding, I have found them to be knowledgeable and passionate about the service they are providing. It is evident that the experience of dealing with the healthcare-seeking public dozens of times in a single shift soon gives them insight and understanding of the vast majority of the calls they field.  Of course, as non-clinicians, they are required to stay strictly within the constraints of the Pathways assessment, with any complex or concerning issues being transferred through to a clinical advisor.

The point of the Pathways assessment itself is to attempt to leave no stone unturned when ruling out medical problems which are not appropriate to be dealt with over the phone. It's a robust system which formalises the process which any clinician would be instinctively doing the moment they laid eyes on their patient. Using the system, there is no reason why an experienced non-clinical health advisor cannot provide as safe and thorough an assessment over the phone as a clinician. For the most part, the limitations lay not with their ability or training, but with the obvious restrictions of being on the other end of the phone, unable to physically assess the patient.

In an ideal world, every member of public would know the difference between a sleeping patient and an unconscious one, or a minor wound and a potentially catastrophic one. But that is simply not the case, so before any attempt can be made to address the problem at hand, those risks need to be identified and ruled out.

It's fair to say that, prior to my training, I had my reservations about the idea of being able to make any kind of reliable assessment of an unwell patient without actually being in the same room as them. But my experience over the last few months has given me plenty of reason to be assured that the process works for the most part.

Room For Improvement

Having undertaken the health advisor training as a precursor to my clinical induction, I spent a number of shifts working in that role. I did experience a degree of frustration as I was required to switch my paramedic brain off, relying purely on Pathways to identify areas of clinical concern. Despite that, as I worked through the assessment with my caller, I would be mentally noting what information I would have sought and almost without fail, the Pathways assessment would cover it (and often far more besides). Indeed, as I progressed on to my clinical advisor role, I found that, with transferred calls requiring further clinical consideration, the brief handovers health advisors provided would often show they had a good grasp of the underlying clinical concerns, even if they couldn't qualify them.

That's not to say the system works perfectly every time. Of course it has its limitations and there is most certainly room for improvement (something which I hope to discuss in subsequent articles), but in my experience, the sheer volume of calls which are dealt with and result in a positive outcome unequivocally prove that NHS 111 provides a useful service and does much to protect the public and the interconnected primary care services.

There is of course pressure not to send ambulances inappropriately, just as there is clear guidance on the use of other primary care services, and this is something which any regular reader of this blog will know I feel strongly about. It is guidance which is entirely appropriate. The idea – as suggested in some media coverage - that patients are being wilfully denied ambulances when they need them is ridiculous and would be unethical.

I have dealt with a few cases where I know the ambulance crew despatched would probably be cursing me, and if I could call them to justify my decision, I would. But the limitations of telephone triage make it impossible as a clinician to take the risk based on the information provided by the caller.

But the number calls I've dealt with which have ended with the caller happy to deal with their problem at home who might otherwise have called an ambulance or taken themselves to A&E comprise the vast majority of my workload. Those kinds of calls vastly outweigh the occasional ones in which the need for immediate care cannot be completely ruled out I have no doubt that NHS 111 is a net positive both for professional healthcare services and for the general public.

The Real Problem is Lack of Education and Resources

Broadly speaking, I suspect any perceived pressure coming from NHS 111 arises from ever increasing public demand,  not inappropriate referrals. NHS 111 provides a wide and accessible safety net which may well be accurately highlighting that increase in demand. In its absence, I have little doubt that the increase in pressure on other services would be far greater.

I wish we had more ambulances so the occasional over-cautious referral didn't punish crews so much. I wish so many A&Es hadn't been closed and GP services weren't in such dire straits that I feel a twang of guilt every time I choose to err on the side of caution by sending the individual for assessment when my gut suggests it might not be necessary.

But I certainly don’t see the concept of NHS 111 as an appropriate target for attack by various media outlets and even some healthcare professionals. Without it, things would be far worse.

In any case, I'm glad there are employment alternatives for staff who have been fed through the front-line meatgrinder and  I won’t be compromising on my goal of endeavouring to provide the best and most appropriate care for every individual I deal with.

While the healthcare storm continues to rage around us and the NHS suffers the ongoing assault of the government’s misguided efficiency savings programme, I am grateful, despite the adverse conditions, to be able to provide clinical guidance and for the opportunity to work alongside health advisors and fellow clinicians who work hard to do the same.

The primary care sector and public should be grateful too - things would be worse without 111.


[Disclaimer: The views and opinions in this article are solely those of the author and are not representative of Herts Urgent Care or its partners.]

16 comments:

  1. Hmmm another well written article, however you don't mention the people that try and refuse an ambulance but still get one, or how pathways turns a three day history of dry thickly cough into a red two response

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  2. Having worked soley as a 111 Health Advisor, the questions are aimed at what is happening now at the time of the call, not how long it has been ongoing for. Also the patients description of how they are feeling and their willingness to answer yes to every question may well explain some of the call outs.

    To answer your first point however and patient that refuses a disposition or end point we would be advised to transfer through to a clinical college to discuss the situation further, and if they felt that an ambulance or other disposition was needed, then they would insist on it, and had the power to send out a vehicle regardless of the patients wishes under their duty of care.

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    1. What would be the stance if the patient refused an ambulance and you sent one any way, surely there is a problem with sharing their data without permission? I cannot make a referral without permission to share that data, so why can 111 get away with it?

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  3. Having worked soley as a 111 Health Advisor, the questions are aimed at what is happening now at the time of the call, not how long it has been ongoing for. Also the patients description of how they are feeling and their willingness to answer yes to every question may well explain some of the call outs.

    To answer your first point however and patient that refuses a disposition or end point we would be advised to transfer through to a clinical college to discuss the situation further, and if they felt that an ambulance or other disposition was needed, then they would insist on it, and had the power to send out a vehicle regardless of the patients wishes under their duty of care.

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    1. Their duty of care only goes so far as the patient wishes it to. If the patient has capacity, which we must assume they do. They have a complete right to deny an ambulance. It worrys me that you have just admitted ambulances are being sent to patients against their wishes. This reinforces my current concerns surrounding 111.

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  4. Would also be interesting to actually see how many of the so called life threatening ambulance attendances actually are, also is people's eagerness to say yes down to leading questions? My gripes are not with the clinicians or the call takers

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  5. It doesn't matter what triage system you use over the phone it has to be risk averse. For those who think there are no consequences to getting it wrong there is a doctor and nurse who have just been found guilty of manslaughter by gross negligence for not recognising a septic child early enough who may disagree with you. Something to think about next time we leave someone on-scene. As a paramedic I'm very careful about my assessment before I leave patients at home, but I've made mistakes and we all will at some time, be it paramedics, technicians, doctors or nurses.

    You can't blame patients for wanting to access healthcare, you have to provide the right pathway and sufficient resources that's all. There are no "inappropriate attenders" in the ED, they should all be assessed and triaged to the correct pathway the same as phone triage attempts to do. The calls do and will increase year on year whether 111 or NHS Re-Direct is there or not. If call rates are increasing for the ambulance service, there are only 2 things you can do about it, you can triage some out, but there's a limit to the number and the only other thing you can do is increase resources, yes ambulance resources and GP/community, hospital/ED/minors/urgent care.

    There are many varied reasons ambulance calls have increased, many not known but some of the known reasons being closure of A&E departments, patients unable to get a GP appointment, patients deteriorating because they have been misdiagnosed or discharged too early or received a poor service. It's not usually the minor illness and minor injury attenders who cause ambulance trolley queues at hospital, its lack of trolleys/beds.

    Yes I can't stand the workload, late finishes and above all the crap way I'm treated by managers, (and to the manager in EEAST who has decided to remove the paper PRF's to force staff to use the EPCR, we all know you are a complete twat but the job is hard and stressful enough as it is FFS without you making the job harder/longer and when the pile of electronic crap doesn't work and we get given a scrap of paper from the FRV).

    I moan about some patients the same as the rest of you, but I think we are looking at this from the wrong perspective. If all are patients were immediately life threatening we would burn out very quickly, let's not blame the patients. We require more care pathways, improved training, more paramedics and less twats.

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  6. 111 call handler - "Hello. How can I help you?"

    Caller - "Hi. I'm really, really sorry to bother you as I'm sure it's nothing but I'm a very fit and healthy 20 year old and I've been to the gym and lifted a few weights. I think I might have overdone it as I have now got a slight pain in the right side of my chest that.."

    111 call handler - "Woah, woah, woah. Stop right there. Did you say chest pain?"

    Caller - "Yes I did but it's to the right side and it hurts if I move or take a deep breath."

    111 call handler - "That's irrelevant. I have a flow chart here that I follow if you have chest pain. This could be a heart attack or even a pulmonorous embo thingy. You need an ambulance straight away."

    Caller - "No, no. Hang on. It's on the right side and even I know it can't be my heart. Not on that side anyway, unless I'm ambidextrous or whatever the phrase is. I only wanted a bit of advice about pain relief and stuff".

    111 call handler "Too late youngster. An ambulance has already been dispatched by me even though I have absolutely fuck all knowledge about medical matters".

    Caller - "But I don't need one and I really don't want one. I can make my own way to see the GP or hospital if you really think it necessary."

    111 call handler - "Nope. It's on it's way and there is not a single thing the proper professionals can do to stop me. Mwwahhahh".

    Caller - "But might this mean that a crew gets diverted from something like a road traffic accident?"

    111 call handler - "That's not my problem and to be honest, it's seen as a quick result for us. I can palm it off to someone else and I don't have to ask a Doctor to get involved because although they are in the same room as us, we don't like to ask them to do stuff for their £150/hour as they get grumpy and we're a little bit frightened of them".

    Caller - "Well this seems wrong and is putting a massive strain on an alredy creaking ambulance service".

    111 call handler - "That's not my problem chum (well unless my family need one). Have a good day and thank you for calling 111".

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    1. If you said the pain was brought on by movement you wouldn't get a red 2 you moron

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    2. I got sent on a red 2 for a 19yom with pain on movementhafter a night out drinking. It does happen!!

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  7. Wise words on your banner Matt.

    "Only call 999 in an emergency when someone's life is at risk or someone is seriously injured or critically ill".

    Unfortunately, the reality is that you and your colleagues will routinely pass calls to the ambulance service that are nowhere near that serious and you all know it.

    I think it's fair to say that 111 is despised by many of those in the ambulance service. You're so risk adverse, it's pathetic.

    Similar calls that came into the ambulance service would often result in an ambulance not even being sent but we can't retriage the crap that gets passed by your non-clinically trained call handlers who don't / aren't even allowed to consult with someone in the same room who should know what they are doing.
    One of these days someone from 111 is going to need an ambulance for themselves or one of their family and they won't get one.
    Why? Because they will all be committed to jobs with a large chunk of those being totally inappropriate 111 calls.

    Personally I don't know how some of you sleep well at nights having passed the absolute dross you do to us. I'd love to know how many 111 Red 2 calls actually result in that patient ever going to hospital. Probably very few in fact from my experience.

    If people think they are going to die or are very ill, they ring 999. If it is less serious, they try and do the "right thing" and try 111 who then simply pass it onto us.

    The best thing that could happen is to close 111 and plough that money back into the ambulance service and having a few more OOH GPs who actually try and see patients rather than also passing the buck to us.

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  8. I have randomly come across this blog on Twitter... And it's so nice to hear that perspective from a clinician. I am a call handler, who had the misfortune to work with the latest "whistle blower" and this recent press attack is completely untrue and devastating to the workers who put everything they have into providing the public with the right care. Iv seen so many sarcastic comments, like the one above about the chest pain... Which by the way if you TOLD the call handler the pain was brought on by movement you would NOT get a red 2. I follow the ambulances I send out and 95% of them take the patients to hospital. I have had parents call about their baby FIGHTING for breath (and yes I heard the attempt to breathe) because they didn't know what it meant for them to be sucking in their chest, and an elderly man saying his wife was unable to speak and had lost power in one arm. I have no doubt in my mind both of these patients would have been left at home overnight if 111 didn't exist because they "only wanted advice" and wrongly thought it could wait for the doctor to open the next day. Recently I had to instruct a foreign carer with CPR because she didn't know who to call. If patients give us stupid answers because they think they need to pretend things are worse than they really are, I'm not going to assume they are lying potentially risking their life. For every one person complaining, I get 100 thankyou's. That's enough to get me through a 12 hour night shift, and to be endlessly proud of the job I do no matter what money grabbing ex staff members or abysmal newspapers write about us.

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    1. Well said. I'm also a 111 call handler, though not at the call centre where the press has been focused on recently. The press and remarks from people who work for the ambulance service have really got myself down recently. I just try and remember those moments I know I have made a huge difference.

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  9. I work in Emergency Mecicine and we're often frustrated by the patients who are referred to us by 111. However, when I have followed up referrals that I've thought were inappropriate, it's often become clear that patients tell different stories to different services. I do wonder sometimes what we all did before 111 or similar services were available. Has the easy access to medical advice stopped us thinking for ourselves?

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  10. I would love a transcript of my daughters call to 111. No ambulance was sent to her, and she died 3 weeks later. How do I get a transcript ?

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  11. I would love a transcript of my daughters call to 111. She died soon after. No ambulance was sent to her. Anyone care to let me know how to get a transcript?

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