In recent years there has been continued criticism of the places with poor GP cover at evenings and weekends and the increased pressure on emergency departments who have been unable to cope.
In 2010 it was envisaged that there would be a separate number which patients could call providing additional support and care. This was the NHS 111 Service which would be operational 7 days a week 365 days per year. It would be free of charge from any landline, mobile, internet, phone or phone box.
The idea was that the service would provide clinical assessment at the first call and although approximately 20% would need further assessment, the vast majority of calls would be dealt with by staff working to questionnaire type formats. However the advisors are not necessarily medically trained although they are supported by nurses. This is similar to the NHS Direct. Indeed it is difficult to see the differences between this completely new innovative service and the last tired telephone service.
Leaving that aside, whilst its limitations are fairly obvious, additional support for people would seem to be a reasonable and helpful approach to healthcare.
The trouble is that this isn’t additional support. It is in place of GP cover for a good proportion of the time.
The NHS confirmed early last week that 7 potentially serious helpline incidents had occurred already. These incidents occurred between mid March and April. The system isn’t fully operational yet.
Of the 46 services across England, 7 are not in operation but a proportion of those that are have developed problems. The system has crashed, patients are facing long delays before the calls are answered and it now appears that a good proportion of patients are abandoning calls altogether. Recent statistics indicate that over 29,000 people abandoned their calls in March which is a substantial number of people who need to seek medical advice from some source or other. If not NHS 111 then who?
Although NHS 111 is being delivered with the assistance of private companies such as Harmoni, it remains under the control of the NHS. The issue of profit therefore arises.
I recently represented a client who is taking a claim against NHS Direct for failing to recognise the severity of illness in a young child with chicken pox complications. During the course of the case it became obvious that the person dealing with phone call with NHS Direct had little or no expertise and did not realise or seem to recognise the significance of illness in young children in particular. Moreover there was a somewhat farcical issue of them listening to the breathing by the telephone and determining from that brief review that the breathing sounded fine. In fact the child was rasping and desperate for breath. By the time the family recognised the severity of the condition (having been completely reassured by NHS Direct) the child was seriously ill and shortly afterwards stopped breathing. He was not able to be successfully resuscitated.
How do we get to a system where the breathing difficulties of a child are diagnosed by someone without any clinical experience manning a phone?
The old system where GP provided a service at weekends meant that although there was a delay GPs were able to attend and at least the person on the telephone was medically qualified. Likewise most hospitals now particularly in the South East run a system of local GPs who deal with the non emergencies through the after hour service. They however are not familiar with the patient, often with no access to records and therefore working from a disadvantaged position.
The problem with the telephone point of contact with non qualified individuals is that they do not always recognise the issue with which they are dealing. Patients do not present with a coherent list of symptoms and issues. Claimants do not present with a coherent list of complaints about hospital treatment. Quite often a client will come into the office dealing with one issue when in fact the case is something completely different. It is not their fault – they simply do not have the medical expertise and they have not had access to the medical records.
The problem with NHS Direct and the problem with its successor NHS 111 is that the same format is in place in both. If it didn’t work before, why should it work with a private profit making company? How does the introduction of private contracts make the clinical decisions from non clinical staff any better?
If the NHS is to deliver a service under its legal obligations to provide appropriate medical care that should mean medical care.
It is likely that claims against NHS Direct will increase. There is increasing emphasis on people being encouraged to turn to non-medically qualified people for advice.
There is no doubt that once GPs were removed from the out of hours service, people have started to use emergency departments and other services. The answer is not to provide telephone systems staffed by non clinical practitioners. The answer is to provide GPs. People do not get ill between 9 and 5 Monday to Friday and there is no reason why the NHS should provide such a poor service out of that time. If the vast majority of times GPs are not available then logically a proportion of clinical negligence cases will occur in that time.
It is recognised that the NHS pays for a considerable amount of the clinical negligence litigation. It must be more cost effective to provide appropriate medical care through the evening and weekends than it is to continue to be sued for the poor provision that currently exists. All we hear about is the rising cost of claims. This is part of the reason. Reduction in clinical provision. Why is no one doing the maths here?