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A Helpline That May Harm: NHS 111

Posted on May 31, 2013 by Sergio Ulloa ()  | Tags: 2013, advice, Ae, call, emergency, England, helpline, NHS 111, NHS Direct

England's 24-hour medical information and advice service has been redesigned and rebranded since the coalition government took over in May 2010. After several years of discussions and plans, the new NHS 111 service was launched last month. Despite the Health Secretary, Jeremy Hunt's, positive statements about the service being "up-and-running now in 90 percent of the country," NHS 111 has been in the English press almost non stop - and for almost all the wrong reasons. Delays, bad service and even tragedies: it seems that lots of people in England - medical professionals included - are not convinced that 111 is the way forward.

Until March this year, patients who required medical information and advice were encouraged to contact the 24-hour NHS Direct service which was available by calling a helpline, web chatting online or using a downloadable app. One of the main purposes of this system was to remotely assist members of the public to assess the seriousness of their condition and to avoid unnecessary trips to doctors, dentists and in particular to reduce pressure on Accident and Emergency rooms and adding to A&E waiting lists unnecessarily. NHS Direct was also a solid solution for people who were not easily able to visit a doctor's surgery, those who fell ill outside of doctor's surgery opening hours or those who wanted more information about symptoms.

Despite the widespread use of the service, in August 2010 announcements were made about the termination of the NHS Direct in place of a new phone service called 111. The tag line for the service is: "Call 111 when it's less urgent than 999," and while this seems like a straightforward choice between medical help and life-saving assistance, the pilot schemes and the first few months of operation indicate that the new 111 helpline is not as clear cut as it claims to be. From the very initial planning stages of the service, health professionals voiced concerns that the introduction of the new phone number would mean that members of the public would have to make vital decisions about the seriousness of their condition themselves before choosing which number to call.

Confidence in the new 111 helpline system has been increasingly shaky since the beginning of 2012 when seven primary care trusts were selected for a 111 pilot scheme. During this pilot implementation of the 111 system, administrative authorities came across difficulties in working out the similarities and differences between the 111 helpline, and the pre-existing NHS Direct. The job of preparing for a new system was found to be more time consuming than expected, and in February 2012 there were public warnings that the NHS 111 service would not be ready for the launch date in April 2013.

Another clear concern at that stage was that new NHS 111 service would be provided by call centres where 'call advisors' would be responsible for making the initial caller assessments before referring calls to someone more qualified to ask medical questions. These call advisors, however, are not medically trained, and may receive just four weeks training before receiving qualifications to answer urgent medical calls from the public. Some medical professionals felt like this was another example of the National Health Service being privatised by outsourcing responsibilities. Importantly, this move to employ call advisors meant that a number of healthcare professionals - nurses and dental nurses who had worked with NHS Direct - would see their jobs cut.

Fast forward to May 2013. Despite warnings from the British Medical Association as late as the end of March this year, the nationwide launch of 111 went ahead on April 1, 2013. Almost inevitably, the new service has been clouded by bad press and stories of problems and errors and as many as 22 "serious untoward incidents." Of course there are standard tabloid shocker stories about 111 cases being overestimated (ambulance services dispatched to deal with an ingrown toenail and period pains) and other instances when 111 calls are underestimated (one unexpected death in the first few weeks of the service is already under investigation). Generally though, the complaints indicate that the service is failing on those same areas that were highlighted as weaknesses as far back as 2010: understaffing and underskilled staff.

The new service was launched over Easter weekend (a tricky start date since bank holidays in England are notorious for a sudden increase in the number of people requiring emergency medical attention), and reports indicate that over this weekend and the first few weeks of the service, there were serious delays, with many patients unable to get through the helpline for hours and some parts of the country reporting a 40 percent abandoned call rate on Good Friday. Other reports tell of callers waiting 11.5 hours for a callback. In other areas, 111 helpline providers have had to hire more call handlers to deal with demands.

This understaffing issue is married with problems associated with the clinical advisors' lack of medical knowledge, and this has resulted in exactly the problems that the NHS 111 service was designed to reduce. Since 111 call centre staff have limited medical experience, there have already been reported cases of misdiagnosis which have resulted in callers requiring emergency care; in addition, 111 call centre staff are reported to have been overly cautious with their advice, meaning that A&E departments over the country have had more visits than normal. Paramedics have claimed to be overworked as a result of the automated phone service, which asks each caller a list of questions that often lead to the "call an ambulance" option.

It is quite normal that such a major overhaul of national health services will experience problems, but in this instance the government is under attack for rolling out the new 111 system before it was ready for launch. The government is now claiming that NHS 111 will be completely ready for an official launch by the end of this summer, but many medical professionals will not be holding their breath.
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