Dear Ambulance Staff: Six 111 Myths and Misconceptions

Dear frontline ambulance colleagues,

After 12 years of responding to 999 calls and subsequently watching from the sidelines as family and friends continue to do so, I am only too aware of the ever increasing pressures and the ongoing erosion of the ambulance clinicians' lot. Poor staff support from within ambulance organisations and the lack of comprehension from government (most recently exemplified by Jeremy Hunt's 'ambulance driver' comment) continues to frustrate me as I'm sure it does you.

I'm grateful for the opportunity the Broken Paramedic web presence gives me, allowing me to keep in touch with the mindset of many of my fellow clinicians on various issues that bubble up in the mainstream media. Thank you for contributing. For the most part, this level of interaction helps me to consider perspectives I might otherwise not have considered, which in turn informs many of the conversations I have with journalists who occasionally contact me for advice and PR-free clarification (not that this relationship moderated the misguided vitriol of certain Mail Online journalists, but lesson learned).

However, when it comes to certain issues, I can't help but notice that there's a degree of misinformation and prejudice which colours some of your responses.

For example, a comment received in regard to my recent employment as a 111 clinical advisor was as follows:

"...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... Personally I don't know how some of you sleep well at nights having passed the absolute dross you do to us."

Ouch.

In defence of this unnecessarily personal attack, from my own frontline experience I recall how angry I would get when yet another fatigue-inducing shift seemed to have been made all the worse by needless, time-wasting call-outs. I would frequently demonise what was then NHS Direct and also my own service's dispatch staff. Today, it's the medical advice line, NHS 111, which is perceived by many to be a root cause of unbridled ambulance service demand. Discontent under pressure breeds interdepartmental animosity, it seems.

As I've mentioned previously, last year I took up a post as clinical advisor at Hertfordshire's 111 service, a decision I took both out of professional curiosity and financial necessity. I can report the last six months has been a largely positive experience; I once again have the opportunity to directly help those in need and to make more constructive use of my knowledge and experience. Furthermore, it has given me a fantastic vantage point to see the difficulties facing healthcare provision - and they are manifold.

As such, I would like to take the opportunity to address some of your concerns and criticisms in the hope that you consider my viewpoint that NHS 111 is not quite the misguided, incompetent debacle some would like to paint it as. To this end, I have put together a few key facts and 'mythbusters' that might help the likes of Anonymous Angry Commenter above.

One caveat is that my experiences are exclusively based on my time at Herts Urgent Care in Hertfordshire and it should be noted that not all 111 providers have the same resources or working practices. Indeed, Herts Urgent Care tends to perform better than most in the national figures and I do not currently have access to the information to explain any disparity. Further, I don't have the number-crunching resources of the Office for National Statistics and all figures cited have been pruned from sources linked at the foot of this article.


1. The NHS Pathways assessment software is risk averse and sends ambulances needlessly.

The software is risk averse, but not needlessly so. Here's why:

While the vast majority of 111 calls are from individuals with minor ailments or other non-urgent needs, on occasion 111 callers are not always aware of - or prepared to accept - that they may be dealing with a life-threatening condition. As a result, it is not uncommon that people call 111 when they should be dialling 999 or attending an emergency treatment centre. Ideally, every member of public would be able to identify the onset of a stroke, heart attack, severe breathing problem or other potentially major problem, but ambulance staff of all people will know that is simply not the case. As such, Pathways is designed to rule out the presence of any 'red flag' symptoms as quickly as possible so the caller can move on to a more symptom-specific assessment.

It's fair to say that over the phone, this is a potential minefield. The inability to see the patient means that the call-taker is reliant on the information given by the caller. There are a multitude of reasons why this is sub-optimal, and that is the key limitation of telephone triage. While there is of course room for improvement, there is no way to make such a system fool-proof. No call-taker, clinical or not, is going to be able to guarantee they can be 100% accurate in separating indigestion from infarction, stroke from Bell's palsy, or hypoxia from hyperventilation. Not without a physical examination to rule things out.

So sometimes an ambulance gets sent when - even though its recognised that the worst case scenario is unlikely - it would be unprofessional, unethical and dangerous to do otherwise. We cannot not diagnose over the phone, even if every call was dealt with by a clinician.


2. Call handlers are prompted to ask ridiculous and irrelevant questions.

Some of the questions call handlers are prompted to ask during the assessment process can seem inappropriate or unrelated to the presenting problem, such as asking the caller who has been speaking freely during the initial conversation if they are fighting desperately for every breath, or having to ask the mother of a feverish baby if the child has been to a West African country affected by the Ebola outbreak in the last 4 weeks.

However, even though in the vast majority of cases the answer would seem to be an obvious no, imagine the outcry in the rare cases where those factors were in play but no attempt to identify them was made. For the record, both the above-mentioned breathing question and a further question regarding skin temperature are intended to catch signs of sepsis.

3. Calls to 111 are initially dealt with by non-clinical staff.

Mostly true. 111 Health Advisors, a.k.a. call handlers, are largely non-clinical (although there is the occasional clinician in training). They undergo 2 weeks of classroom work which gives them a grounding in identifying more common life-threatening signs and symptoms, but are strictly required to stay within the framework of questions as set out by the Pathways algorithm. Further training is ongoing during their employment and their growing experience should not be discounted either.

Furthermore, the call centre is always staffed by a mix of health advisors and clinical advisors (nurses, paramedics, midwives and other allied healthcare professionals). They work closely together and any call which Pathways wants to send an ambulance response can be checked with a clinician. Once past the initial [module 0] questions - and even during these questions in some cases - any potential ambulance response is verified by a clinician. In many of these cases, the clinician will advise the health advisor to transfer the call to a clinical advisor for 'further probing'. Health advisors cannot deviate from the Pathways outcome (known as a 'disposition'), but clinical advisors can override this, and frequently do when an appropriate alternative is available.

Clinical staff do help out with calls when demand is high and on the one occasion I've taken a call from a paramedic who assumed I was a health advisor, I found him to be quite condescending and rude. He was so abrupt, he didn't give me an opportunity to explain my role or qualifications. Nonetheless, after he terminated the call I did my best to address his request for an immediate GP callback at the scene of a peri-arrest patient with a DNAR. Sadly he went on to make his decision without the GP's (or my) clinical input and I fear he might have made a different choice had he taken the time to engage with me rather than bark down the phone.

Respect costs nothing, even in difficult circumstances, whether you're talking to a health advisor or a clinician.

4. NHS 111 would be more effective if all calls were handled from the outset by clinicians.

There are a number of reasons why this would not necessarily be the case. Notwithstanding the challenges of telephone triage as mentioned in Point 1, the sheer scale of this proposal in the face of the current demand makes the idea impractical.

Last year (2015), nationwide 111 dealt with nearly 1.1 million calls every month. The majority of those calls are for minor ailments, non-urgent problems or other enquiries ('I can't get through to my doctor for an appointment', 'my child has a runny nose', 'can I take paracetamol and ibuprofen?', 'I need a repeat prescription' etc.). It would be a monumental waste of tax payers' money to have qualified healthcare professionals deal with these issues. It makes as much sense as insisting GPs man their own receptions.

Even if it was financially justifiable, the current challenges within the NHS means we hardly have an excess of healthcare professionals to make an all-clinician telephone triage service viable.

To put this line of thought into context by comparing the current climate with that of 111's predecessor NHS Direct, which did favour clinicians as an initial point-of-contact, here's some stats to compare.

• In 2006/7, NHS Direct's busiest day (23rd December) saw 25,000 calls. An average day in 2015 saw 35,000 calls dealt with by NHS 111. 
• In 2006/7, NHS Direct answered 68% of all calls received within 60 seconds. In 2015, NHS 111 achieved 91.4%. 
• In 2006/7, NHS Direct referred 32% of all cases to 'emergency and urgent' services. In 2015, NHS 111's figure was 19% (11% ambulance, 8% emergency treatment centre). 

5. Ambulances are sent even if the caller has refused one.

Within the Pathways process, this is not true. Any 'disposition' [the recommended course of action arrived at by the assessment process] offered by a health advisor can be refused by the caller, at which point the call will be passed over to a clinical advisor.

At this point, the judgement of the clinician takes precedence over the Pathways disposition. Of course no ambulance is going to be sent without good cause and if there is an appropriate alternative treatment pathway, that would be explored - and in many cases it enables us to work with the caller to arrive at an informed and safe decision. However, in certain circumstances, healthcare professionals have a duty of care and may be required to act in the patient's best interests in spite of their preference. We would only do so if there was no other option, and would ensure that ambulance dispatch was informed of the situation.

These circumstances are relatively rare, but with increasing challenges faced by community mental health, patients discharged prematurely without appropriate home support, and other underfunded and buckling systems, it's a sad truth that the ambulance service is the only option in certain circumstances, lest the system abandons these people entirely.

6. Abandoning NHS 111 altogether and leaving the public to decide on the most appropriate treatment pathway would relieve pressure on 999 and other services.

This is hard to prove without actually doing it, but it seems very unlikely. With GP services facing a national crisis, A&Es already overburdened and ambulance service utility spiraling out of control, I would imagine a significant proportion of people who currently rely on 111 and out-of-hours GP services would simply call 999 or attend A&E out of desperation.

I believe some ambulance personnel are suffering from confirmation bias. Every ambulance attendance generated by 111 which turns out not to be as it initially appeared is held up as an example of failure, whereas the thousands of calls which might otherwise have resulted in a 999 call are never seen by ambulance staff.

As stated before, telephone triage is limited, sometimes there is no option but to have a clinician on scene to rule out things which may (or may not) require immediate attention. I'm genuinely sorry that this often means engaging ambulance clinicians who might otherwise be attending more obviously life-threatening situations, but that is a problem created by a lack of ambulance service resources and a growing population of elderly, infirm and vulnerable people, exacerbated by a broader failure of government to provide appropriate support and prevention measures.

Millions of people rely on the service provided by NHS 111 and for most, it is effective and useful. It is something of a Pandora's First Aid Box. Now the system exists and the box has been opened, it is nigh on impossible to put everything back, even if we wanted to. I believe to remove the facility altogether would increase pressure on other services, not protect them. It would be better for ambulance and 111 services to work together to improve the relationship between them.

In conclusion

I accept that NHS 111 is an imperfect system and that it does contribute to the pressure which impacts of the daily experiences of 999 crews. But I hope you will see that there are valid reasons for the calls generated. If there were enough ambulances to shoulder the demand, it wouldn't be an issue.

For what it's worth, I certainly hope to participate in making the process more effective, but even if there was a way to guarantee every ambulance referral was appropriate to the skillset of an emergency ambulance crew (which there really isn't), I suspect it would make little difference to the intolerably high utilisation rates under which crews toil.

The truth is that the general public will always seek the quickest route to solving their problem and healthcare organisations will always try to provide this on the lowest possible budget. There is a lack of high-level foresight in the utilisation of ambulance crews; the powers that be seem to work on the principle that replacing is more acceptable than protecting when it comes to the workforce. The beancounters think an ambulance crew not dealing with an attendance is one that is wasting money. This is compounded by the current ideologically-led efficiency savings suffered by ambulance services and by the competitive market model which 111 providers have to adhere to, creating all sorts of limitations (underbidding leading to cost-cutting measures, private provider need for profit, unwillingness to work openly with potential competitors).

The accessibility and convenience of NHS 111 and 999 services means that initial contact with primary healthcare has never been easier. Along with a growing and aging population, I believe this is the cause of the rise in demand. Like ambulance services, NHS 111 cannot deny the public treatment if there is any possibility that it may be appropriate. Making that determination is the key factor here – what  an individual wants and what they need are not necessarily the same thing. And making that decision over the phone is even trickier than doing it on scene.

Ultimately, 111 and 999 are on the same side and should find ways of working more closely together to deliver the right care to the people who need it. There's little to be gained from animosity.

Of course, if even after taking all this into account, you feel you need to continue scapegoating 111, then I can't stop you. I've been there – sometimes you just need someone or something to kick. But at least you'll hopefully now be doing it from a more informed position.

Sources:
Gov.uk: Connecting Health and Home: NHS Direct Annual Report 2006/07
NHS England: Ambulance Quality Indicators Data 2015-16
NHS England: NHS 111 Minimum Data Set 2015-16