If It Ain’t Broke, Don’t Fix It – A Lesson From NHS Direct (Part 2/4)

Here’s part 2 of my NHS 111 extravaganza – check out part 1 here.

So why was it abolished? Primarily, a Department of Health report said that there was confusion around which NHS service to use and that one three digit number for triaging non-emergencies might help solve this. This I can completely understand. An ideal world would be I ring up 111 and I’m told exactly what I should do with this cough I’ve been having. That service should know what services are available in my area, have a good knowledge of clinical problems to send me to the correct service and, most of all, not result in me dying due to poor advice. Frankly, that doesn’t sound too hard, or even too dissimilar to what NHS Direct was. For those Labour fans out there, they even mentioned it in their 2010 manifesto.

Realistically, what the report recommended could have been implemented by changing 08454647 (NHS Direct’s old number) to 111. In fact, that is what the Conservatives said they would do. Until they stopped saying that and changed their minds. Now I’m not an expert, but how many times do you have to ‘change your mind’ before it becomes apparent that your minds haven’t changed and what you said originally was just a big pile of horse dung? 

Instead of simply phoning up Vodafone and asking for their SIM card to have its number changed, Andrew (I’ve Tried Nothing and I’m All Out of Ideas) Lansley, and his successor, Jeremy (I’m A) Hunt completely overhauled the way telephone triage services were done in the NHS, essentially phasing out NHS Direct, and letting private companies pick up the slack. These include Harmoni, a company previously criticised for being unsafe at running GP out-of-hour practises. You’ll glad to know they run 8 NHS 111 services across clinical commissioning groups (CCGs), including most of London. Interestingly, I’m pretty sure that Westminster is in one of the few bits of London covered by a not-for-profit scheme, though I’ll have to look into that.

NB: I used Vodafone as an example due to the fact that they diverted some of the tax-dodging gains through to me. I also rode a flying pig to work at the magic bean factory. No, I actually used them as they run part of the 111 telephone network and suffered a huge technical fault last November. To their credit, they seemed to respond OK-ish and it hasn’t happened since

Click here for Part 3.

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6 thoughts on “If It Ain’t Broke, Don’t Fix It – A Lesson From NHS Direct (Part 2/4)

  1. How about this for an idea (which my GP told me they are trying to implement in Rotherham): leave GPs as they are and what they do – although I do think they should get given more than 10mins for all they have to do in that time – and for out of hours or emergency care have ONE CENTRE, a place where everybody looking for OOH or emergency care goes.

    At this centre triage will take place (by ?nurse/HCA) on arrival (like A&E) and then they get directed to who they need to see: A&E/OOH GP/Pharmacist/Nurse Practitioner/Psychiatry/COTE Specialist/Medical Student who are all sitting in various rooms ready to see patients. Admittedly it needs some more thought but I do feel if people aren’t sure where to go, they inevitably end up at a&e anyway so may as well provide the services that are needed there and then you can scrap 111, save money and use the staff at these centres.

    I am aware that a limitation is that people have to travel to the centre rather that just pick up the phone, but: ambulance for emergency, people who can’t be bothered clearly aren’t that ill, and people who need transport to the centre, we can provide free transport for. That way, OOH Drs can spend their time seeing patients and not driving around and you simply pay for drivers which I believe would be cheaper than paying dr’s lots of money to drive. So instead of 1 nurse on telephone then 1 doctor in A&E seeing a 111 patient, you have a simple triage tool in use then get seen by the relevant specialist.

    Also the fact that there are staff from many different skilled areas – you can discuss patients MDT style much more rapidly than paper referrals to and from each other.

    Thoughts?

    I realise my grammar is atrocious..

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    1. Thoughts:
      1) GPs should have more time – agreed
      2) If the OOH centre is staffed by everyone you suggest, it basically sounds like a small A&E with some specialists on call. I still think this will need a level of distance triage before it otherwise patients for whom self-care would be more appropriate will still turn up (like they already do at A&E)
      3) I still think you’ll need driving doctors – what do we do for the elderly patient in a care home, palliative patient in a hospice or the single mum who can’t leave their kids to go to a triage centre?
      4) ‘People who can’t be bothered clearly aren’t that ill’ – disagree massively. Yes, malingerers might not want to go a triage centre three miles away. If your stoic Yorkshireman ends up having an MI because the only advice was a three mile drive away and he didn’t want to trouble a driver for what he thought was a bit of bad reflux – is he ‘clearly not that ill’? The general public aren’t that aware of what is a bad sign and just because they don’t think soemthing is worth calling or visiting for doesn’t mean they are right.

      4) Like I said before, I think your idea works best with a distant triage first. Step 1 – call 111 and ask for advice. Step 2 – they direct you to A&E for emergencies or likely admissions to hospital; OOH unit like you described for minor things (stitches, sprained ankle, need some replacement insulin at short notice) or a 24 hour pharmacy if self-care is your best choice. You could also add a doctor call-out option for the aforementioned trickier cases.
      5) I think NHS 111 is supposed to be the simple triage tool that you suggest for the OOH unit – it just doesn’t work that well.

      Overall, I think something like a centralised OOH unit is a potentially a very good thing. It would serve to keep A&E for the absolutely necessary, and it has a pretty good potential to help with things outside of medical stuff (diabetics who’ve left their insulin in their home town and need a quick replacement, psychiatric patients in a crisis stage who need somewhere safe for a few hours before they can be reviewed, a drunk tank etc.). I think having enough different specialities to make MDT discussions possible is going to very pricy, though ideally you’d want a radiographer, a few GPs, a pharmacist and nurses hanging about so may be possible. Though if a patients management needs an MDT syle discussion I’m starting to wonder whether an A&E trip might’ve been more appropriate! That or they’ll need referring to an in-hospital MDT at some point anyway.

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  2. I agree with a lot of what you’ve said here and yes that’s a good point about the yorkshireman. Essentially what I think I’m trying to get at is what you mention in part 3 – there needs to be a system whereby experienced clinicians are triaging people face to face – there is simply no substitute! Its just trying to work out the best way of doing that efficiently and in the most cost effective way.

    Also, I’m astonished by the statistics in the later parts about the efficacy of 111 compared to NHS direct and I 100% support your ideas that politicians need to look at making changes over longer periods of time and more importantly be willing to put more money to the NHS.

    On an unrelated note, I think it a shame in a way that Lib-Dem can’t put in place some of their healthcare manifesto because I totally agree that Mental health and social care need a lot more attention and funding than what it already gets.

    Really enjoyed reading these, and look forward to reading more good quality journalism.

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