Analysis

NHS 111: help or hindrance for emergency care?

Nurses have admitted frustration at the rising number of people who are not seriously ill being directed to emergency departments by NHS 111.
111 phone line

Nurses have admitted frustration over the rising number of people who are not seriously ill being directed to emergency departments (EDs) by NHS 111.

More ambulances are being dispatched through the non-emergency 111 helpline than ever before and nurses on the front line have complained they often see patients with trivial problems and minor illnesses.

But NHS England says the phone line is keeping millions away from EDs and has diluted increased demand this winter.

1,169,296

triaged calls

Regional-based 111 call centres replaced the nationally organised, nurse-led NHS Direct in December 2013. The number of callers signposted to EDs or sent an ambulance has since increased by about 3%.

Nurses tell Emergency Nurse they are unhappy with the number of people with minor illnesses who have been told to access urgent care by 111 non-clinically trained call-handlers following

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Nurses have admitted frustration over the rising number of people who are not seriously ill being directed to emergency departments (EDs) by NHS 111.

More ambulances are being dispatched through the non-emergency 111 helpline than ever before and nurses on the front line have complained they often see patients with trivial problems and minor illnesses.

But NHS England says the phone line is keeping millions away from EDs and has diluted increased demand this winter.

1,169,296

triaged calls

Regional-based 111 call centres replaced the nationally organised, nurse-led NHS Direct in December 2013. The number of callers signposted to EDs or sent an ambulance has since increased by about 3%.

Nurses tell Emergency Nurse they are unhappy with the number of people with minor illnesses who have been told to access urgent care by 111 non-clinically trained call-handlers following strict questionnaires.

One advanced nurse practitioner said: ‘I find that I spend a good part of my shifts telling people they are not ill.

‘I understand that 111 is not a face-to-face service, but some of the cases that we see referred to ED or brought in by 999 are laughable.’

150,258

ambulances dispatched

Another nurse said: ‘I had a patient who’d called 111 after hitting their thumb with a hammer. As part of a flowchart of questions, the patient was asked if the appendage was blue and discoloured. On answering "yes", an ambulance was sent.’

A primary care nurse said: ‘We have exactly the same experience in primary care; it's not a patch on NHS Direct where people spoke to a registered nurse.’

In December of last year, more than 150,000 ambulances were dispatched following calls to 111.

This represents an increase of around 60,000 in three years, with less than 90,000 dispatched in December 2013, when 111 first started covering the whole of England.

But, this increase has much to do with rising demand on 111, with around 300,000 more calls received each month than in December 2013.

Some nurses have been sympathetic, with one telling EN: ‘They don’t have the benefit of seeing the patient, which makes a decision more difficult.’

88,378

callers recommended to attend EDs

According to Mark Dayan, writing in a recent Nuffield Trust report: ‘Contrary to criticism that it adds to the pressure on the ED, the service overall seems to steer people away from emergency services. Patient surveys suggest as many as eight million more people would have gone to the ED or called 999 over the past three years without 111.’

An NHS England spokesperson said 111 also ‘soaks up’ extra demand during winter months, redirecting people to primary care or helping them to self-care.

He said: 'In a poll of people who have used 111, around 45% said, without the line, they would have gone to their nearest ED or called for an ambulance but, once they call, only around 20% are sent to these services.'

716,422

callers recommended to primary care

NHS England suggested that three million people were redirected away from 999 or an ED between October 2015 and September 2016.

Call handlers, who are set to deal with around 1.1 million calls a month this year, have a specific set of questions to follow, with answers triggering different courses of action as determined by a computer algorithm.

The system is not foolproof though and a doctor using 111 in January was told not to attend ED when he had a corneal ulcer and needed urgent treatment.

‘If I wasn’t a doctor and didn’t have the training to know that the advice 111 had given me was dangerous, I’d be blind’ he told a national newspaper.

In September 2014, a one-year-old boy called William Mead died of sepsis because a 111 handler could not recognise the symptoms.

The doctor who called William’s mother back in the obligatory six hours equally failed to spot red flags, suggesting that no call system is totally infallible.

NHS 111 v NHS Direct
  • NHS 111 replaced NHS Direct and other regional call services in December 2013, after a pilot scheme started in August 2010.
  • NHS 111 call handlers often have no clinical experience, whereas NHS Direct was manned by nurses.
  • NHS 111 call handlers are usually paid between band 2 and band 3 salaries.

 

Having more nurses in NHS 111 call centres could help with reducing patient numbers being sent to emergency departments (EDs) and retaining experienced staff, a leading nurse has said.

RCN lead for acute, emergency and critical care Anna Crossley said regional steps to bolster the number of clinical staff working in 111 call centres would help improve the service.

She said: 'NHS 111 definitely fulfills a service for a huge number of people.

'Our concern is workforce; we know we don't have enough nurses across the UK and we know experienced nurses are leaving and bursary cuts mean less are training.

162,658

callers not recommended to other care of whom:

  • 18,013 given health information
  • 58,777 recommended home care
  • 91,873 not a clinical issue

'It's mainly experienced band six nurses who are leaving, so there is an opportunity to work in a slightly different way. I don't think we exploit telemedicine enough in this country.'

Ms Crossley thinks nurses could be offered rotations in 111 centres and even work some shifts from home, allowing their work to be more flexible.

This, she said, will benefit callers by providing assessment from a variety of specialist nurses, reduce demand on EDs and hopefully encourage experienced nurses to stay in the profession.

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