North West NHS 111 GP Bulletin
October 2015This briefing is designed to update you on key service developments and changes as we mobilise the NHS 111 service across the North West. We hope you find this bulletin helpful. If you have any comments or queries, please contact the North West NHS 111 Communications Team at: .
Service Commencement Phase 1 – 1st October 2015
The first phase of the new North West NHS 111 Service, which is being delivered by the North West Ambulance Service (NWAS) in partnership with two GP Out of Hours services, FCMS and Urgent Care 24 (UC24), became operational on Thursday 1st October at 11 am.
This phase included the transfer of the existing NW NHS 111 service and the calls for all GP Out of Hours Services in Cheshire and Mersey to NWAS’ new telephony and IT systems. Overall the transfer went smoothly, and over the first 7 days service performance has exceeded the “95% of calls answered in 60 seconds” target, with performance averaging 98.2%, despite the significantly higher call volumes.
There were, inevitably, some local issues with call transfers and electronic links with a couple of OOH providers but these were quickly identified and remedied. The rapid feedback of these issues and good collaborative working between providers made this possible – thanks to all those involved.
Recent National Press about NHS 111
Many of you will have read the recent negative press articles regarding NHS 111 services outside of the North West. To provide some reassurance regarding NHS 111, and in particular the North West NHS 111 service, the concerns and allegations raised do not apply to the North West service.
Staffing
NHS 111 frontline staffing consists of two main roles – health advisor, which is a non-clinical role, and clinical advisor, who have a variety of clinical backgrounds, mainly nursing and paramedic. Whilst other areas do have difficulties recruiting sufficient staff to deliver the service, this is not an issue in the North West. One of the benefits of having five NHS 111 call handling centres across the North West is that recruitment has taken place across a geographical area. Indeed, for the new NHS 111 service the providers have recruited to their full planned staffing levels ahead of the planned phasing schedule, for both health advisors and clinical staff, and are currently recruiting additional staff to help manage the predicted increase in activity over the forthcoming winter period. Rotas are only filled with fully trained staff.
NHS Pathways Clinical Decision Support System
North West NHS 111 uses NHS Pathways as its Clinical Decision Support System. NHS Pathways is a suite of clinical content designed to support triage of telephone calls from the public, based on the symptoms they report when they call. It has an integrated directory of services, which identifies appropriate services for the patient’s care. Nationally NHS Pathways is used by all NHS 111 Providers and approximately half of the Ambulance providers for their 999 emergency services to support the assessment of calls from the public. NHS Pathways has the full support of several medical Royal Colleges and professional bodies with an interest in urgent and emergency care and general practice, who actively participate in the governance of the system.
Training
NHS Pathways has a strictly defined minimum training requirement for all staff – non-clinical health advisors and clinical advisors – prior to anyone being allowed to receive calls from members of the public. The training programme for the North West NHS 111 service covers 6 weeks (6x37 hours) for health advisors and 10 weeks (10x37 hours) for clinical advisors. This includes dedicated classroom time and assessments which must be successfully completed prior to a period of ‘preceptorship’ in which staff take calls with an experienced member of staff sat alongside them to provide any support required. It is only following the successful completion of all elements of this training that staff begin taking calls from the public.
Staff are trained to probe the answers given to them to ensure that correct dispositions are reached across the spectrum of urgency and acuity, from self care to ambulance responses. Throughout the system there is detailed supporting advice available to staff.
At all times there are clinical supervisors available to provide support to health advisors, and when a complex call is received these can be transferred to clinicians who are able to utilise their clinical training in conjunction with NHS Pathways to arrive at the correct outcome for the patient. Staff are actively encouraged to seek support from clinicians and supervisory staff within the NHS 111 service when they are uncertain of the correct outcome. Approximately 25% of all calls are passed to a clinician within the North West service, and the majority of these are warm transferred whilst the caller remains on the line.
Outcomes of NHS 111 Assessments
The spread of dispositions across the different acuities of care has been very consistent since the start of NHS 111, both in the North West and nationally. Approximately 10% of callers receive an ambulance outcome (which covers all levels of response from 8 minute “Red 1” to 2 hour “Green 4”), 9% an “Emergency Department” outcome (which includes all types of ED such as some walk in centres), 52% are signposted to Primary and Community Care services (including Pharmacy & Dental), 1% to other services (e.g. Social Care, Police etc.), and 28% are closed without signposting to any service.
The greater the range of services available to NHS 111 to signpost to (via the DoS – see section below), the fewer cases will need to be directed through ‘core’ services such as GP OOH / GP Practice for onward referral. Depending on their previous service model, many GP OOH services have experienced a significant reduction in their overall volume of activity because NHS 111 is filtering out cases that previously the GP OOH service would have referred on to other services or closed with ‘no further action’.
Ambulance Dispositions
In respect of cases referred to the Emergency Ambulance Service (999), pilots have been undertaken to investigate whether additional clinical input could reduce the number of referrals. There has been shown to be some potential to reduce the number of ‘green’ (less urgent) ambulance cases through the use of clinicians within NWAS Urgent Care Desk and this is currently being explored. Cases identified as requiring a ‘red’ (emergency) ambulance from NHS 111 are not ‘re-triaged’ as review of ‘red’ ambulance referrals has shown them to be appropriate and pilots elsewhere have resulted in significant numbers of clinical incidents.
Primary and Community Care Referrals
This disposition grouping covers referrals to in and out of hours Primary Care Services including GP in-hours services, GP Out of Hours (OOH) services, Dental Practices, Emergency Dental Services, Pharmacy and other community services. The bulk of the referrals to GP services are in the out of hours period and previous analysis has shown that referrals to in-hours General Practice average less than 1 referral per practice per day. Dental activity accounts for approximately 8% of calls answered by the NHS 111 service until now, and across the North West has been the most frequently used assessment pathway within the NHS Pathways system.
Where services perceive the referrals they receive to be inappropriate, there is a feedback mechanism in place – known as Health Professional Feedback (HPF) – designed to capture the relevant information to enable the NHS 111 Provider to investigate the case and respond directly to the individual reporting the case. We have tried to make this process as simple as possible, and introduced auto-populated templates into GP Practices and GP OOH services in support of this. We are happy to make these templates available where helpful and will be encouraging their wider distribution in the coming months.
We would encourage clinicians and providers to use the HPF process to help us continue to improve the NHS 111 service, the NHS Pathways system, the Directory of Services (DoS) and pathways within local urgent and emergency healthcare systems, and would be happy to work jointly with colleagues where they perceive NHS 111 to be sending referrals to inappropriate services or with inappropriate urgency.
Directory of Services (DoS)
NHS 111 uses the DoS to identify appropriate services to signpost patients to, where the assessment suggests they need further input. The assessment collects information about the patient’s clinical need (the level of service and the urgency), their location, their registered GP etc. and searches the DoS for services that match these criteria. The DoS is a ‘yellow pages’ of health services and each CCG’s Urgent and Emergency Care service offer is populated and maintained on the DoS. NHS 111 can only refer to services that are on the DoS, and then only where the service has indicated it will accept a referral from NHS 111 and it is open.
The greater the range of services on the DoS that will accept a referral from NHS 111, the greater the range of options presented to the NHS 111 staff which enables NHS 111 to refer patients into the correct local pathway for their need, rather than funnelling patients via GP services for onward referral to other services or to the Emergency Department. Where services can only be accessed following a face to face assessment, and they are configured in this way on the DoS, then NHS 111 will signpost the patient to an appropriate service to undertake the face to face assessment.
Significant work has been undertaken with CCGs and their providers to ensure the DoS is as robust and accurate as possible. Undertaking this profiling and maintenance work is a CCG responsibility and is not within the control of NHS 111. Potential gaps in service coverage on the DoS have been highlighted to commissioners to prevent patients being referred to ‘default’ services.
Special Patient Notes (SPN)
NHS 111 is able to utilise the SPNs that GPs share with their GP OOH services to enhance the assessment and appropriate signposting of patients. There are appropriate information sharing arrangements in place regarding this process. SPN are particularly important in End of Life cases where patients have a DNACPR in place. If NHS 111 are unable to confirm there is a SPN in place regarding a DNACPR then they have to treat a death as unexpected, which will result in dispatch of an emergency ambulance, and potentially additional distress for the patient’s relatives. It is therefore important to ensure that existing SPN are reviewed and updated, and any new SPN are passed to your GP OOH service. Guidance has recently been shared to help with the wording of SPN.
We recognise that there are currently different systems in place to collect and share some of the information relating to SPN & Care Plans. There is work underway to clarify the range and scope of the various systems currently in use with a view to simplifying the content of and the processes for recording and sharing this important information in the future. This work is not being led by NHS 111, but NHS 111 are an integral part of it.
Clinical Governance
There is an established Clinical Governance structure in place which constantly reviews and monitors the clinical effectiveness of the NHS 111 service. Each CCG has a nominated Clinical Lead for NHS 111, each County has a nominated County Clinical Lead and there is a Regional Clinical Lead who links in to the National NHS 111 Clinical Governance group.
Each County has a Clinical Quality Assurance Committee (CQAC), comprising the CCG & County Clinical Leads, the NHS 111 Provider and NHS Pathways representatives. The CQACs review all complaints and HPFs for the County identifying key themes and trends and recommending actions to address any issues. There is also the facility to review call recordings in a joint forum with the NHS 111 Providers and where cases have been referred on to other services to undertake a full end to end review of a case should this be required.
This process has enabled enhancements to be made to the clinical content within NHS Pathways, to operational processes within NHS 111, identified anomalies in the DoS and to processes between providers within local healthcare systems.
Key Contacts
If anyone would like to discuss any of the above points further or would like any further information about NHS 111, please in the first instance contact:
North West NHS 111 Lead Commissioner Team:
- Yvonne Rispin - Programme Director:
- Magnus Hird – Regional Clinical Lead:
- Graham Rose - Finance and Contracting Lead:
- Chris Endersby - Programme Manager:
County NHS 111 Clinical Leads are:
- Cumbria – Andrew Rotheray:
- Lancashire – Mark Denver:
- Mersey – Si Perritt:
- Cheshire – Catherine Wall:
- Greater Manchester – Helen Hosker:
County NHS 111 Managerial Leads:
- Cumbria –Caroline Rea:
- Lancashire – David Bonson:
- Merseyside – Ian Davies:
- Cheshire – Jim Britt:
- Greater Manchester - Steve Allinson:
NWAS Key Contacts:
- Kimberley Williams:
- Ian Mose:
Or use the NHS 111 inbox: .
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