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24 September 2012

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NHS 111 is looming round the bend. Will it be a runaway success – or a runaway train?

The official line is that this is all about making urgent care easier for patients. Call 111 when you need medical help but it’s not an emergency and get put through to a trained team of advisers supported by nurses.

They will listen to your story and either give you the advice you need on the phone or point you to the local service that can help you best.

It is already up and running in 10 areas and clocked up its millionth caller in June 2012.

NHS 111 is looming round the bend. Will it be a runaway success – or a runaway train?

The official line is that this is all about making urgent care easier for patients. Call 111 when you need medical help but it’s not an emergency and get put through to a trained team of advisers supported by nurses.

They will listen to your story and either give you the advice you need on the phone or point you to the local service that can help you best.

It is already up and running in 10 areas and clocked up its millionth caller in June 2012.

But that same month concern about the impact of putting the new service in place across England for April 2013 was running so high that the government announced an extension of six months to October 2013 for those areas that need it. CCGs had until July 27 to apply for the extension.

For GPs commissioning services now there are huge questions. Where does 111 fit into a local vision of urgent care? What will the impact be on existing services and in particular the out of hours GP service? What will it tell us about our existing urgent care services – and how will we respond? What will NHS 111 do to demand – and to my bottom line?

Nigel Wylie, an elected member of the NHS Alliance’s leadership group, acknowledges that there are more questions than answers but remains supportive of the 111 idea.

“I think intuitively the case has been made for a single, simple, memorable number that people can call when it is not an emergency,” he says. 

"But it is the biggest single radical overhaul of the front door of the NHS since the introduction of 999 in 1948. If we get it right, there are some huge benefits. But if we get it wrong it could potentially be a disaster.”

In his view, getting it right means placing NHS 111 on top of a well-integrated, co-ordinated urgent care system. In practical terms, that would give 111 a rich directory of services (DoS) from which to direct callers.  The reality is that many areas do not have the services to populate a rich DoS.

Then there are questions about the clinical decision software behind systems behind 111.  These take non-clinical call handlers through set question and answer responses leading to a recommended course of action for a given patient.

So the nub of the matter is this: will 111 lead to an increase in calls to ambulances, admission to secondary care, and calls to GPs or fewer? Since the Department of Health as yet to publish the final results of an evaluation of the first four 111 sites by Sheffield University, we don’t know. The rumour is that it shows increased A&E visits, admission and GP call outs.

Some fear the worst and warn that 111 will see demand rocketing. As one commentator, who asked not to be named, notes: “The downstream effects are very likely to be that admission rates go up – and CCGs will have no control over this. It is a shot gun wedding.”

Mr Wylie takes a different view. He argues that 111 will highlight gaps in service and that it will be up to CCGs to respond. “If NHS 111 finds that they are referring a lot of patients with blocked catheters to hospital or to the GP and that this is because district nurses will not take direct referrals, then this is a service that CCGs could commission,” he says.

The impact on out of hours(OOH) services is also unclear. With NHS 111 in place, patients will call 111 first rather than their GP OOH. NHS 111 will then refer relevant callers back to OOH as needed.

“It’s taking away a whole stream of work from primary care and replacing it with a computer algorithm,” says the anonymous commentator. “It will put more heat in the system, not less.”

These questions are just the tip of the iceberg and in July the NHS Alliance will be undertaking work with two areas – East Kent and Lancashire – to explore what it means to implement 111. A report of their work will be published in the autumn.

Rick Stern, chief executive, says: “It’s no good just implementing 111 and hoping for the best. It is not going to work unless urgent care systems work well together. We are trying to help people understand how the system as a whole needs to work together.”

Daloni Carlisle, health policy journalist

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