Nine-year-old Ryan’s case was highlighted in red on the triage screen, demanding an urgent callback. NHS Pathways, the algorithmic software used by NHS 111, had deemed that an ambulance should be dispatched.
I got through to his father, Tony. “I’m from the out-of-hours GP service,” I explained. “What’s been going on?” “Not a lot really.” Tony sounded bemused. “He was sick on the school bus on the way home.” I ran through a checklist: did he have a fever, rash or headache? Was light troubling him? Did he strike his father as confused? “No, honestly, he’s fine,” Tony assured me. “He only chucked up the once. I put it down to travel sickness.”
It was now seven in the evening. Ryan had eaten a normal dinner. “What made you phone 111 then?” I asked.
Tony explained that kids with vomiting or diarrhoea were supposed to stay off school until they’d been symptom-free for 48 hours. Given that he felt Ryan’s nausea was travel-related, he’d rung the school to ask whether it would be OK to send him in the following day. They’d told him to give 111 a call and take their advice. Not being the slightest bit concerned about his son’s condition, he’d sorted out the evening meal first. It had been a complete surprise when the 111 call handler told him they were sending an ambulance straight away.
These scenarios are common: 111 call handlers are not clinicians; their role is to plug the details of each case into NHS Pathways and follow its recommended action. And Pathways doesn’t generate advice; it simply tries to determine what kind of service the patient should access and how quickly. Pathways is also highly risk-averse. Almost any symptom you can think of might just be indicative of an urgent problem. So Pathways recommends ambulances be dispatched or patients attend A&E when in fact their problem is far from serious.
NHS 111 handles more than a million calls each month and converts around 20 per cent into A&E attendances or ambulance call-outs. Although that is a huge number, 111 is at least halving potential emergency services workload – around 45 per cent of callers say they would have dialled 999 or gone straight to hospital were the helpline not available. Yet only a fraction of the cases Pathways diverts to emergency services are appropriate – perhaps as few as 10 per cent according to a 2018 analysis.
This finding led to the recent integration of 111 with GP out-of-hours services, forming the so-called integrated urgent care (IUC). Around a third of my time on shift is now spent dealing with cases like Ryan’s, unpicking Pathways’ emergency service referrals. Nine times out of ten I can sort the situation myself. But the requirement for a clinician to re-contact the patient causes further delay, prejudicing the care of those with genuinely urgent needs.
NHS 111 is a political project – a way for government to try to satiate demand for healthcare on the cheap. Clinicians are expensive, non-clinical call handlers wielding a computer programme considerably less so. While 111 is promoted as a round-the-clock source of medical advice, it cannot deliver on the promise. Indeed, it is arguably exacerbating burgeoning demand through Pathways’ overdramatic response to simple problems. If the last time your son vomited you had learned this might have warranted a 999 call, your confidence in managing minor illness in the future may well be undermined.
I told Tony the ambulance would be stood down, and as long as Ryan remained well he could attend school the next day. How much more efficient it would have been if his call had gone straight through to a clinician, as used to happen. The government would need to pay many more clinicians’ salaries. But to avoid doing so is a false economy indeed.
This article appears in the 16 Jun 2021 issue of the New Statesman, The Cold Web