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.]