"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Saturday, 6 August 2011

Our safety at stake in Lala land?

The 999 service is a lifeline to all for us, but in healthcare the ambulance service is expensive and open to abuse. Such abuse is often not intentional, how do you know whether your condition is an emergency? You are not trained to make such triage decisions. According to the NHS Information Centre the ambulance service receives almost 8 million 999 calls per year of which 2.5 million (32%) are classified as urgent rather than emergency and 37% of Emergency Department attendances are classed as "minor" problems. Clearly there is a potential issue that non-emergency calls are delaying access to emergency calls, and their is an issue of cost.

This is the reason for NHS Direct, if there is any doubt whether the condition is an emergency, you can call 08454647 (remember that number!) and a trained clinician will advise you. Of course NHS Direct is more than that, their clinicians will advise you on less urgent conditions too: support for patients with long-term conditions, pre and post operative support for patients and help and advice during health scares (like swine flu). Their primary aim is to give you advice which will ultimately mean that the NHS will work more efficiently and effectively by making sure that you get the most appropriate treatment.

NHS Direct was always intended to be an initial solution, and in 2009 the previous government commissioned pilots to extend the service with closer integration with urgent care providers and to use a software system called NHS Pathways. This new system was piloted in four areas of England to assess the effectiveness against NHS Direct. In 2010 the new government - before the assessments were completed - announced that the new NHS 111 service would be rolled out to the entire country. Sadly, this service is yet another one that the government wants to privatise by opening up to other providers.

Last year there was a fuss when it became apparent that the government wanted to close NHS Direct, and as a result of the outrage the service was given a reprieve. But like everything with this weasel government, the "reprieve" was only partial because the government merely said that NHS Direct would be expected to be just one of several providers of the new NHS 111 service. Yes, that is right, the government thinks that there has to be competition. Bizarre? Indeed. We live in Lala land ruled by people who think that nothing can work without enforced and inappropriate competition. My anger is not just with the government, Labour has accepted this situation: they thought the reprieve was a result. In fact it was a result: it was exactly what the government wanted, you cannot have competition without competitors and NHS Direct is, and always was intended to be, one of the competitors in this contrived competition.

Let's just look at the headline issue. After April 2013, the 08454647 number (did you remember it?) will be replaced with the 111 number (in the government's documents referred to using the management-speak as 3DN or a "3 digit number"). The government is making a big thing about this, and for good reason, why was NHS Direct given the entirely forgettable 08454647 number in the first place? In fact the policy to replace 08454647 with 111 is not Lansley's bright idea anyway (he does not have bright ideas) the last government intended to make the change too (as this document from OFCOM in July 2009 shows). I will leave it up to the conspiracy theorists as to why the Department of Health under Labour chose to allow NHS Direct to be created with a number that was not fit for purpose. However, the difference between a Labour government replacing NHS Direct with a 111 service and a Conservative government doing this is not simply the number (nor the new services that NHS 111 will deliver), it is who will provide the service. Lansley says that there has to be competition over who will provide the 111 service in your area. Lala land indeed.

How big is each area? Well, it would be plain stupid to make each area the size of the clinical commissioning groups (currently the median population size is 170k, but there are many who cover 100K or less, and one that covers just 14,000). Ultimately, it will be the CCG who will pay for the service and so we are in the bizarre situation that the CCG commissioners will have to pay for a service that they cannot commission individually because they only sensible way to provide the services is with other commissioners that have been contrived. At the moment the 111 services are to be rolled out on a Strategic Health Authority basis, and it is each SHA has to decide ("with full support of local Clinical Commissioning Groups and PCTs") who will provide the service.

Bizarrely, the we will move from the national service of NHS Direct (national: so people are familiar with its services and how to use it) to more localised ones so if you use 111 in a different area you'll have to re-learn what services they have and how to use them. (You, dear reader, may find this trivial, but will everyone? The service has to work with everyone.)

David Flory, Deputy NHS Chief Executive says:
"The NHS Operations Board also re-stated the need for commissioners, led by local clinicians, to take the lead in planning for the roll out of NHS 111, and developing a comprehensive directory of services, and associated referral protocols to underpin the service. We should remind you that the Department will not mandate specific content or software for NHS 111. This will be for local commissioners to determine, with appropriate clinical advice and support."
Remember that the NHS 111 services (like NHS Direct) will provide both a telephone service and a website. It makes sense to have local clinicians involved in the design of the telephone service since the service will use local providers: ambulance services, out-of-hours services (ie private GP companies who do the service that GPs used to do before the last Labour government privatised this service), GP "in hours" home visits (yet to be privatised as the government's "urgent service") and hospital A&E. But NHS Direct also provides a website with a symptom checker. It makes no sense whatsoever to have separate local websites to do this work, yet that is implicit in Flory's statement that "the Department will not mandate specific content or software for NHS 111".

I regularly read the websites of local hospital trusts across the country and the most irritating aspect is that they are all different, with different ways to get the same information. It is an issue for someone with reasonable eyesight, but what about someone with partial sight or no sight (and relies on screen readers)? Why hasn't someone come up with a brilliant idea like a best practice website design that all hospital trusts have to follow? NHS Choices and NHS Direct are both national systems that give a standard way to access their information regardless of where you live in the country. Yet Flory is now suggesting that SHAs can award the NHS 111 service to anyone using any "content or software". This is mandating fragmentation and confusion.

The NHS 111 telephone service will involve many providers to work together to give a single, comprehensive system within your local area. This is not an easy task, especially as we move to an NHS that is driven by competition rather than collaboration. And to make matters worse, Flory is introducing a deadline on awarding the contracts for these local versions of NHS 111 that GPs are calling "crazy". GPOnline says:

"strategic health authorities have been given seven weeks to tell the DoH how and when they plan to roll-out NHS 111 hotlines across their area ... one senior GP warned the deadline was 'crazy' given that the pilot NHS 111 schemes across the UK were either incomplete, or yet even to begin"

This behaviour is symptomatic of this government: fragmentation of a service that currently works (and was developing), privatisation, enforced unworkable deadlines resulting in an implicit designed to fail outcome. If this is happening to the websites of the new NHS 111 services, what will happen to the telephone services and what will be the knock-on effect to the 111 "urgent service" and ultimately the 999 service? Lala land.

(Updated 2011-08-07 after comments on Twitter)


  1. Excellent summary. A additional point - at present when NHSD is under pressure at one centre, staff at another can pick up redirected calls and demand because everyone uses the same national system. competing providers are highly unlikely to be able or willing to do this. Your conspiracy theorists may also see this as a built-in flaw!