NHS 111 can still learn from NHS Direct

Across the country, several events arranged by NHS England have recently discussed the future of NHS 111, focusing on what the service may offer in future and how commissioning of this service may be supported by NHS England.

‘NHS Direct was founded on the central premise that safe effective self-care advice delivered by a clinician could reduce the burden on healthcare services’

Having secured 34 per cent of the contracts to provide NHS 111, NHS Direct found itself unable to service the contracts at the agreed price points and it withdrew from its 111 obligations in late autumn 2013. With the progressive turning off of NHS Direct’s 0845 number, the organisation will close at the end of this financial year. When reviewing what we want NHS 111 to do, is it worth considering what is currently not offered, which was by NHS Direct? 

• How HSJ has covered the troubled rollout of NHS 111

Direct differences

NHS 111 is a triage and signposting service for “urgent” problems, whereas NHS Direct offered a nurse led advice line. The subtle difference may be illustrated by means of an example: patient A has injured their ankle.

Both services would assess the relative urgency of the caller’s presenting symptoms using algorithmic software: NHS 111 using NHS Pathways, and 0845 using NHS Direct’s in-house clinical assessment system and call streaming and prioritisation tool.

NHS 111’s objective would be to triage the patient depending on their symptoms, and so to direct the patient onwards to the appropriate service for their needs in the correct timeframe. Should the outcome of the assessment be “self-care”, the call would be passed to a nurse to deliver this advice.

This is where the two services diverge. In 0845, most calls would be directed to a nurse and the objective would be to deliver self-care advice. NHS Direct was founded on the central premise that safe effective self-care advice delivered by a clinician could reduce the burden on healthcare services. This point is well established and borne out by extensive evidence. The self-care advice may well have been to attend a minor injuries department if appropriate. The decision was left to the patient on what to do, having been equipped with the advice.

In 111, if ankle fracture could not be ruled out, and a minor injuries unit was considered (by the software) to be the appropriate level of care for the patient, the operator would have the facility to direct the caller to the nearest suitable unit. For most of its lifetime NHS Direct did not have this facility: this certainly marks and improvement.

Earlier clinician input

In the case of the ankle injury, NHS Direct would use non-clinical staff to question and sort the callers using CAS and CPST as described above. Thereafter, a nurse would take a more complete history of the event. This is rather different from NHS 111.

A caller to NHS 111 may have their enquiry dealt with entirely by a highly trained, but non-clinical, call handler using NHS Pathways software. That is not to say that there is no role for clinicians in the 111 service.

At present, in-house clinicians remain the backstop for difficult or complex cases, as well as in delivering self-care advice and negotiating outcomes if the caller disagrees. Here though they “validate” that the call handler has correctly recorded the responses given by the patient. Unfortunately such a model may not take advantage of the experience and understanding of experienced clinicians. Furthermore it is not in alignment with Sir Bruce Keogh’s vision for the NHS of providing early access to a senior clinician.

Last summer’s Commons health committee report on urgent and emergency care also  recommended greater involvement of clinicians in remote triage and assessment. There is a growing body of evidence that such interventions have a positive impact in reducing costly face to face contacts with clinicians in both primary and secondary care.

‘The input of highly trained clinicians in telephone triage positively impacts on both patient outcomes and reducing burden to health services’

However, the current model of clinician validation should be considered. Third party histories are notoriously unreliable, even when recorded by a trained member of staff. Medicine textbooks recount that 80 per cent of diagnoses are made on history alone, and my medical training tells me that I should always take the patient’s history for myself.

Things change, and situations evolve. This often adds much to suitably “disposing” or directing patients. Such skills in listening and accurately recording information are currently used in primary care settings, both in and out of hours.

The evidence is clear that the input of highly trained clinicians in telephone triage positively impacts on both patient outcomes and reducing burden to health services. As the health service considers what it wants NHS 111 to do, a greater role for clinician input seems an obvious choice.

Personalised care and data

The means to communicate patient information between GP practices, their local GP out of hours and on to the local 111 service already exists. This is usually done by means of a rather clunky and outdated method of paper based communications known as special patient notes, which were primarily developed to manage end of life care, but have expanded to include some other chronic disease care plans.

Sir Bruce Keogh’s urgent and emergency care report, published last November, put enhanced access to patient data at its heart. By so enabling access to health records the report suggests that 111 could be “a 24-hour, personalised priority contact service”, one that has “knowledge about you and your medical problems, so the staff advising you can help you make the best decisions”.

Of course, the road to a more electronically joined up health service has not run smoothly to date. Although this may feel like an aspirational notion at the moment, there are certainly moves towards realising this ambition. It certainly seems that movement to a modern and slick service would be safer and more effective.

More self-care on more platforms

In an increasingly instantaneous and digital world, patients seek health advice online. Non-NHS sites and platforms do exist. However, these unverified sites and services do not offer the general public assurance or safety that can be ensured in similar NHS services.

Self-care advice should be interactive and allow patients to contribute their particular situation. Whether delivered in person, or remotely, by digital means or by a clinician, it depends on a robust evidence base.

Before we lose NHS Direct completely, perhaps we should consider what it did so well, which was to help patients to choose, in a complex health system.

Dr Mona Johnson, Tameside and Glossop Clinical Commissioning Group