The NHS has made headlines this week with the new 'NHS 111' phone service, its national helpline for non-emergency calls. Patients have struggled to get through. GPs complained the system was triaging patients inappropriately and wasting their time. One patient died after an ambulance was two hours late, which the GP blamed on the 111 service diverting calls and overwhelming ambulances elsewhere. At least three deaths are now being investigated in connection with the service.
This is the exact opposite of what the 111 service was meant to do. It was meant to give patients better access to medical services outside of normal GP hours. It was meant to free up the emergency services for real emergencies, not send them thousands of calls by mistake. It was meant to save GPs' time and patients' lives.
So what went wrong--and what can we learn from the mistakes?
Firstly, we make sure we don't learn the wrong lesson. The NHS 111 concept was solid. Many patients don't know what to do when they need a doctor at night or on the weekend, and end up going to Accident and Emergency as a last resort even when they don't really need it. A&E then gets overcrowded, and can't focus on the people who really need emergency treatment. NHS 111 was intended to help by staffing the phones with people who understood all the local out-of-hours options and could give helpful advice. (NHS Direct, the old NHS helpline, was national rather than local, with no local 'directory of services'.) All this makes sense.
The trouble was that it was implemented poorly. The deadline for the new system to 'go live' was far too tight. Political pressure stymied attempts to delay the launch. Everyone had to scramble to get ready. There wasn't enough testing of the system, or training of those who were meant to answer the calls. Meanwhile, the rest of the NHS was in chaos too. The organisations meant to oversee most of the system--the Clinical Commissioning Groups--themselves came into existence on 1 April 2013, mostly led by people who had never run organisations of this scale before.
With this background, the big lessons are pretty obvious:
1. Don't rush implementation. We all want fast solutions, but sometimes more haste means less speed. In recent days there has been a lot of criticism of the details of the NHS 111 triage system. These details should have been ironed out before the system went live all across the country, but there wasn't time. The testing phase of any innovation is vital, and simply cannot be skipped. This is healthcare--there are consequences.
2. Don't change all the moving parts of a system at once. Sometimes, innovation can't happen unless several parts of a system change at once. But this wasn't one of those times. The 111 service could have waited a year, rather than be implemented during the same month that those overseeing the system were taking on new jobs.
3. Overinvest in communication. According to its website, 111 is for 'when you need medical help fast, but it's not a 999 emergency'. With the best will in the world, this distinction is tricky to understand. Getting the public ready for 111 needed a really great public campaign--a much better one than we actually saw.
Terrible as the stories emerging this week are, we need to be careful not to throw out the NHS 111 concept. There is nothing inherently wrong with giving health advice over the phone. There is nothing inherently wrong with non-clinicians answering the phones. There is nothing inherently wrong with a national number that directs patients to a local service. Over time, a service like NHS 111 could be extended in lots of helpful directions: more clinical advice over the telephone, the ability to book an appointment for you, advice tailored to your patient record, referrals to NHS services and other services like community pharmacies, and so on.
If the NHS is going to survive for the next generation, it simply must evolve new models of provision. NHS 111 is moving in exactly the right direction. In fact, it should be going further. It is just a shame it was sent off prematurely, an unfinished car with a new driver on a half-built road.