Wednesday, December 29, 2010

NHS Direct Vs NHS 111?

Once again we discover the Tory led government are being profoundly devious. They have stopped calling NHS Direct; NHS Direct, instead they now refer to it as "Urgent Care Phone Line" (NHS 111). Few could argue with giving this service such an easy number to remember I can go along with that. However, it is not this we object to, it is this government getting rid of NHS Direct by stealth and hoping that no one will notice what they have done, that we object to

When the story first broke that the government were thinking of axing NHS Direct, they managed to halt the bad news coverage by insisting that they were only piloting the NHS 111 Urgent Care phone line to see if it is a viable prospect, there is four regions taking part in this pilot scheme: County Durham and Darlington, Nottingham City, Lincolnshire and Luton.

Now the Government has suddenly announced it will rapidly expand the number of areas piloting the new 111 non-emergency telephone line, ahead of GP consortia taking control of the service.

I do not remember Andrew Lansley stating this when news that the government were *THINKING* of disbanding NHS Direct first broke.
The Department of Health wants to expand the NHS 111 service in England prior to universal coverage by 2013. Now the government has announced that GPs will be charged with buying in replacement services for the soon to be scrapped NHS Direct helpline, with private firms to compete with NHS bodies to offer a competing versions of the new 111 number across England.

How is this all going to work? How is the NHS going to work? How are patients and NHS staff going to know who does what and who is responsible for who and what and which service and when?

As they themselves have demonstrated, this Tory led government cannot even get one simple policy right, they seem utterly incapable of seeing something through without causing drastic problems. This can be seen in policies such as Child Benefit; Education; Sport; Transport/snow;  Flu Vaccine; Etc. So given their level of inexperience and incompetence, how will this government oversee the health service most radical reforms that have never been attempted anywhere else in the world?

What is going on in the Health Service is not so much top down reform, as it is a dismantling of every single nut and bolt that holds the NHS together, taking it all apart and then jumbling it all up without having a blue-print , or the first clue on how to re assemble it.

 People are rightly worried about all the talk of slashing spending, and cutting the number of qualified nurses that are available to take calls in the NHS Direct 0845 46 47 service, so worried that petitions were set up which collected thousands of signatures and thousands also emailed our MPs and sent a strong signal that we want to support NHS Direct service as it stands today.

Now we learn that the Department of Health, plans for its new NHS 111 service, to be available nationwide from 2013. But there are still concerns about the qualified medical professionals being replaced by quickly-trained telephone operators. Now we learn from the Health Secretary that this is not just a pilot scheme, they are going ahead with disbanding NHS Direct and making it reapply along with private companies for a part of running the service.

Three of the main concerns were:

1) That there would be a reduction in the number of trained nurses taking calls from the public
2) That this would not produce the required savings the government were after making, as it would increase the number of people sent to Accident & Emergency Departments and
3) Also increase the number of calls to the 999 ambulance service.

On 19 October 2010 the Chair of the Health Committee, Stephen Dorrell, wrote to the Secretary of State for Health, Andrew Lansley, to ask him about his plans for NHS Direct. Here is the text of the letter:
“In late August and early September there were a number of stories in the news media reporting that the Department of Health was to close NHS Direct and to replace it with a new helpline, NHS 111.
In view of the considerable interest this has stimulated both inside and outside Parliament, the Committee would be extremely grateful if you could set out the government’s position on this issue, and in particular:
  • How NHS 111 differs from the NHS Direct Helpline
  • Whether the online and other services NHS Direct currently operates will continue in their present form
  • Whether NHS Direct is included in the QIPP programme of efficiency savings and if so what targets it is seeking to achieve
  • What estimate the department has made of the cost savings to the NHS from patients contacting NHS Direct as a first port of call (the NHS Direct Annual Review 2010 says “Our research identifies that we recommend to around 49% of all our callers that they should go to a less urgent and lower cost point of care than they would have gone to if they had not sought our advice.”)
  • Whether it is the intention to staff NHS 111 in a broadly similar way to NHS Direct when it is rolled out across the country (that is, NHS Direct has around 3,400 staff of whom 1,400 are nurses – is that what NHS 111 will look like?)
  • How long the pilots of NHS 111 will run for, and when the assessment of those pilots will be made available
  • What criteria the pilots will be assessed against
  • Whether a cost benefit analysis of the change to NHS 111 has been carried out, and what were its conclusions
As this is a matter of considerable interest I would be grateful if you could reply to us by 8 November.”

Here is Andrew Lansley's reply to Stephen Dorrell MP, chair of the House of Commons health committee,

                                                                                            Department of Health
                                                                                            4 November 2010

Dear Stephen

Thank you for your letter of 19 October 2010, in your role as Chairman of the Health Select Committee, about the new NHS 111 service, and the future of NHS Direct. I am happy to be able to set out the government’s position on both these issues.

The White Paper, “Equality and Excellence: Liberating the NHS” set the Coalition Government’s commitment to developing an integrated approach to the delivery of 24/7 urgent emergency care:

“develop a coherent 24/7 urgent care service in every area of England that makes sense to patients when they have to make choices about their care…we will make care more accessible by introducing, informed by evaluation, a single telephone number for every kind of urgent and social care and by using technology to help people communicate with their clinicians”

This commitment makes it clear that the new NHS 111 service will make it easier for patients to access the services they need at the right time. However, we have only recently launched the first NHS 111 pilots in the North East of England and so it is still a little early to say exactly how NHS 111 will look when it’s rolled out nationally. We need robust data before taking important decisions about the wider roll-out of the service and we have commissioned a full evaluation which is designed to provide this.

I have provided answers to each of your questions in turn:

How NHS 111 differs from the NHS Direct Helpline
NHS 111 is a free to call service, available through the easy to remember three-digit number. It will provide a more comprehensive service by providing consistent clinical assessment of patient needs and using a comprehensive directory of service to ensure they are sign-posted to a service which is best able to suit these needs, taking into account their location, the time of day, and the capacity of local services. It will also deliver an improved telephone experience, by booking appointments in the appropriate service and eliminating call-backs, wherever possible.
Whether the online and other services NHS Direct currently operates will continue in their present form:
In launching the first NHS 111 pilot, I announced plans to phase out the NHS Direct number - 845 4647 – so that, by 2013 we have two numbers for people to call: 999 for an emergency, 111 for non emergencies. This will have two advantages: first 111 is an easier memorable number than 0845 4647, which, independent studies show is not recognised by a significant proportion of the population; and second, 111 will be free of charge. When 111 is rolled out nationally, it will replace the NHS Direct 0845 4647 telephone number. Until then NHS Direct will provide its current service. While its telephone number will no longer exists in the long term, we do expect an ongoing role for NHS Direct alongside other providers, in delivering the NHS 111 service in line with an  any other willing provider approach.
The health information content from the NHS Direct website moved to the NHS Choices website in November 2008, creating single NHS online health information website. NHS Direct continues to create online content, such as interactive self assessment tools, and these are available via both websites.

The Department of Health’s recent consultation document, “Liberating the NHS: An Information Revolution” discusses transforming the way information is accessed, collected, analysed and used by the NHS and patients. This consultation notes the need for a “channel strategy” to provide a coherent view of the nationally-managed information channels needed to support access to information. The role of information sources such as NHS Choices and NHS Direct’s website, alongside NHS 111 will be considered as part of this strategy. Further information will be made available following conclusion of the consultation.

Whether NHS Direct is included in the QIPP programme of efficiency savings and if so what targets it is seeking to achieve
NHS Direct is not included in the QIPP programme of efficiency savings. However, the National QIPP Urgent and Emergency Care workstream, led by Sir John Oldham, outlines plans for revisions to the urgent and emergency care system to eradicate overlap and duplication and to make it easier for patients to navigate. The future roles of NHS 111 and NHS Direct are key considerations of this programme.

However, efficiency gains are already being made. Over the last two years operating costs for NHS Direct’s 0845 4647 service have reduced significantly with a drop in the contract value, from £136.5 million in 2009/10 to £123.3 million in 2010/11. Through its commissioner, we continue to expect further savings in future years.

What estimate the department has made of the cost savings to the NHS from patients contacting NHS Direct as a first port of call (the NHS Direct Annual Review 2010 says “Our research identifies that we recommend to around 49% of all our callers that they should go to a less urgent and lower cost point of care than they would have gone to if they had not sought our advice.”)
The department has not made any estimate of the cost savings to the wider NHS from patients contacting NHS Direct, although I am aware of  NHS Direct own research in this area. NHS Direct undoubtedly offers value to the NHS by helping patients find the most appropriate place to seek care; however, I believe that NHS 111 will be more widely used. Especially by patients who would default to 999, because the number is more memorable, and it’s free to call. The independent NHS 111 evaluation is accessing the exact impact of the new service on the rest of the NHS.

It is well established that creating a more integrated urgent care system can result in significant savings. For instance, Commissioning Support for London has estimated that introducing a single point of access into urgent care could realise savings of up to £13m a year, in London alone, through reductions in A&E attendances and ambulance despatches.

Whether it is the intention to staff NHS 111 in a broadly similar way to NHS Direct when it is rolled out across the country (that is, NHS Direct has around 3,400 staff of whom 1,400 are nurses – is that what NHS 111 will look like?)
The most appropriate staff mix for NHS 111 call handling must be evidence based and reflect the needs of commissioners, which is exactly why we are piloting the service. There will not necessarily be a “one size fits all” approach to staffing NHS 111 – commissioners will be free to determine what is best for patients.

In the current NHS 111 site in County Durham and Darlington, 38 per cent of staff are trained nurses, compared to 48 per cent in NHS Direct 0845 4647 service. This assessment system requires a smaller proportion of nurses to call handlers and is based on clinical evidence supported by many of the major royal colleges including RCGP and the BMA. However, if any caller to any NHS 111 site needs to speak to a nurse, they will speak to a nurse. Likewise if the caller needs to see a doctor, then the service will arrange for them to see a doctor.

It is also worth noting that the same assessment system in the North east pilot site is used in parts of the 999 ambulance service, where call handlers are not clinically trained, yet the service has been shown to be safe by the Emergency Call Prioritisation Advisory Group (ECPAG).
How long the pilots of NHS 111 will run for, and when the assessment of those pilots will be made available
To assure we understand and assess the full impact of the service the pilots will run  for a period of 12 months and the evaluation will be available in November 2011. The Department has commissioned the University of Sheffield to conduct an independent, academic, evaluation of the service, and baseline population surveys of the pilots sites, and comparative control sites, have already been completed. The evaluations will assess the success of the service itself, as well as look at the impact of the introduction of the service on the wider health economy.
We will also expand the range of current pilots underway and produce a minimum dataset to ensure accurate and consistent information about these pilots is collected, and made available to GP consortia so that hey can make informed decisions about how NHS 111 should be commissioned and delivered in their area. We will accelerate the publication of this data so that it is available during 2011. Each of the pilots will be compliant with the NHS 111 specification, but will be free to decide which operating system and clinical content they use.

We will also ask the Care Quality Commission (CQC) to clinically assure future providers of NHS 111, and ensure they meet the national service specification.
What criteria the pilots will be assessed against
The pilots will be evaluated against five benefits. They are:

  • Improving public access to non-emergency healthcare services;
  • Increasing the efficiency of the NHS by ensuring that people are able to quickly and easily access the healthcare services they need;
  • Increasing public satisfaction and confidence in the NHS;
  • Enabling the commissioning of more effective and productive healthcare services that are designed to meet peoples’ needs; and
  • Increasing the efficiency of the 999 emergency ambulance service by reducing non-emergency calls to 999.
We will also be looking to assess the impact that the NHS 111 pilots have on the wider health economy, as we hope patients will feel able to call 111 when they do not know where to seek help. This will enable commissioners to make informed decisions about how NHS 111 is delivered, and how the service fits into their local urgent care systems.
Whether a cost benefit analysis of the change to NHS 111 has been carried out, and what were its conclusions
The Department published an Impact Assessment for the pilot phase of NHS 111 on 18 December 2009, which is attached at Annex B. It concluded that:

“There are many uncertainties in the costing, cost savings and potential benefits of 3DN [three-digit number] including the uncertainty around volume of calls a 3DN would receive. However the possible efficiencies that could be gained, the opportunities to lever integration across urgent care services and to benefit patients by providing a simple point of access lead us to point to considerable gains that could be made.”

We are continually updating the cost benefit analysis work and the final, evidence based conclusions will be published in external evaluation.

It is important to note that while it is essential that NHS 111 is delivered in the most cost effective way, the primary reasons for its introduction is to improve access to NHS services for patients, to end confusion about where to go for urgent health needs, and to support a more integrated and effective urgent care service.

I hope this response is helpful.

Yours Ever

Andrew Lansley  CBE

Mr Lansley confirmed for the first time that GP consortia will have responsibility for commissioning the new service, including the ‘appropriate skill mix’ of the call handlers used by their chosen provider.
NHS Direct, local ambulance services and out-of-hours provider Harmoni have already thrown their hats into the ring to provide 111 services.
Pilots of the service have begun, with the first run by a local ambulance service in County Durham and Darlington, having a workforce comprised of 38% trained nurses, compared to 48% on NHS Direct’s 0845 line.

The Government’s decision to scrap the NHS Direct telephone hotline which cost the NHS £123m this year - has been welcomed by the majority of GPs.

But there have been claims from NHS Direct insiders that early results of the trial have seen a big increase in the number of patients sent to hospital, with one claiming the rate had shot up from 3% to 11%.

There are a number of questions NHS 111 throws up, to me this looks like it is going to be far more than the old NHS Direct 0845 4647 service.

The government talks about putting people in touch with the services they need.


  • Who is going to make the decision as to what service is required? Medically trained or non medically trained?
  • Exactly what services can callers to NHS 111 be expected to be put through to?
  • If this is going to be controlled by GP Consortia, then who has control for a region?
  • Will people call NHS 111 and then be put through to their area?
  • How many GP Consortia will there be in the entire country?
  • Will there be closures of medical centers and individual GP practices?
  • Will there be extra funding for GP Consortia to run NHS 111 or will it come out of the existing £80 billion budget?
  • Will this initiative affect the number of receptionists attached to GP led medical centers?
  • Is there expected to be an axing of staff? ie receptionists who at present book appointments etc?
  • You say there will be a "consistent clinical assessment of patient needs and using a comprehensive directory of service to ensure they are sign-posted to a service which is best able to suit these needs, taking into account their location, the time of day" who is to carry out such assessments, or are staff going to be relying on a sign post list and if so, how likely is it that non medically trained staff will miss something very important and vital to the patient's well being? Why should time of day and location matter to the person presenting with a set of urgent medical problems?
  • So basically what Lansley is saying is that NHS Direct can apply to run the new service alongside " any other willing provider approach"? Meaning they can compete for the contract alongside private companies?
  • By QIPP I am assuming that Lansley is referring to "Quality, Innovation, Productivity and Prevention". Efficiency targets were identified by the previous Labour administration, identified and acted upon and good efficiency savings of around £13m and increasing, being made, then why is Andrew Lansley pushing for still more efficiency savings, at the the same time as trying to what appears to be carry out a vast expansion of the NHS Direct programme, leading it into NHS 111 with expanded services? Is Lansley hoping to achieve this by NOT employing adequately trained physicians and nurses?
  • Is Sir John Oldham holding a revision of urgent and emergency care system to eradicate overlap and duplication? If so then why is the NHS 111 being carried out and piloted before the outcome of the revisions is fully known? If this is to be rolled out nationally, then errors in the system will be rolled out nationally too!
  • I have grave doubts that patients would defer to NHS 111, when they know the chances are they will speak to an unqualified telephone operator working from a sign post list of symptoms to check off against symptoms a caller is presenting with. Confidence is a big thing in medicine, if it is not there, then this will lead to increasing number of people turning up at their local Accident & Emergency Departments and more people calling the 999 emergency service. In fact I have inside information from the areas the pilot schemes are running in, that attendance to Accident & Emergency departments in those regions has increased by something like 3%, from 8% to 11%, since NHS Direct has given way to NHS 111. It is also reported in the same regions that calls to 999 have also increased.
  • It does not automatically follow that every caller who needs to speak to a trained nurse or doctor gets to speak to them. This depends on the operator taking the call and this is the crux of the matter, if these operators are not medically trained how will they know when to refer a call to a qualified member of staff, some people will fall through the net, this is very worrying. No amount of check lists with sign posts are going to be able to replace medical experience.
  • On one hand the Health Secretary is saying they piloting the scheme to discover all about it, yet on the other he says he is increasing the number of pilot schemes operating in other regions, why is he doing this before he knows how the pilots are operating in the four regions? I suspect, that he has already decided that NHS Direct is going and that his replacement NHS 111 is coming in, complete with all the changes, regardless of how many problems the system picks up!
Throughout Lansley's reply to Stephen Dorrell, it is plain that the only thing that is driving change in NHS Direct is money. It is all about efficiency savings and NOT about increasing patient care, patient satisfaction and making the service a better service for its callers. It is being driven by savings and it appears that Health Secretary, Andrew Lansley, is just trying to pile as many services onto NHS 111 as is possible and not increasing the budget, but DECREASING it.

If you look at this one initiative, NHS Direct/NHS111 is but one very small part of the NHS, yet to change it involves, studies, pilots, commissions and a compete dismantling and reassembling of the service. There must be reports and the linkage of patient care must literally cover conception to the grave. The previous NHS Direct service 0845 4647 was working perfectly well, it had a place, it had a purpose and it was saving the NHS millions in reducing the number of people turning up at A & E's and calling 999 emergency service, it took many years to get it to this stage and in the latter years it was beginning to save itself money in efficiency savings. It appears to me that the Tory government want to continue this service but they want to reduce its funding yet increase its workload.
I am also worried at a cursory look at the figures it seems that this new scheme could very well end up costing far more than it saves and if it doesn't, then the number of extra services being load upon it will suffer and inevitably, so will patient care.
I am very concerned that this is the doorway to creeping privatisation by stealth, it seems to me that at every possible juncture, the use of private health care providers is going to be considered. The Consortia scheme itself is going to turn GPs into accountants and GP practices into private businesses.
The idea of having 111 to access the service is excellent, but so far this is the only plus I can give this new scheme, which is turning out to be a private wolf in sheep's clothing.

I remain concerned that the government can make all these radical reforms at a time when the country as well as the world is in recession and will be going through severe austerity over the coming years. We are talking about a government, that can hardly bring out one simple policy without making horrendous blunders, it took the education Secretary SIX attempts at his policy right and he still did not manage it. Since then we have had several fiasco's and above that why would the government want to carry out such radical forms in the NHS, at the same time they are carrying radical reforms out in the economy, education and welfare, with unemployment set to increase sharply over the next 2 years?

What is the rush? The NHS is working extremely well, it can make efficiency savings without dismantling and disbanding it and totally disrupting the day to day running of it. In fact NHS Direct with its efficiency savings of £13m per year under the Labour government, is a case in point! Why are the Conservatives in such an unseemly rush to fix something that is no longer the broken third world service it was after the last 19 years of Conservative governments?

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