The '111' emergency service fails again.

For the last few years I've highlighted the catastrophe of the closure of the highly effective 'NHS Direct' phone line created by the 2002 Labour government.

The Conservative Liberal alliance closed it down and replaced it with the 111 service which is staffed by people who have no medical qualification.

There have been many examples of failure to spot serious conditions - this is just the latest. This inquest report makes it clear once again that 111 needs Nurses and Doctors available for patients; 


William Mead's 'fate was sealed' after NHS 111 call handlers failed to identify his deadly illness, says mother

The report called into question the NHS non-emergency helpline’s ability to identify deadly illnesses
Kate Ng  
The Independent

The mother of a one-year-old baby who died of sepsis said his "fate was sealed" after NHS 111 call handlers failed to identify his deadly illness. Melissa Mead, mother of William Mead, told BBC Radio 4: “When I dialled 111… we were told William’s condition was non-urgent and didn’t require any emergency treatment, and that we would get a call-back within six hours.

“But when the doctor called back after three hours, I think William’s fate was sealed. He died within 12 hours of that phone call. We found him just after 8 in the morning… he had been passed away for a little while [already].”

Her interview follows an NHS England report into William’s death in 2014, which found there were 16 missed chances to save his life.
The report, seen by the Daily Mail and the BBC, said he might still be alive today if NHS 111 call handlers had realised he was in a life-threatening situation.

The NHS 111 non-emergency helpline’s ability to identify deadly illnesses in children and babies has been called into question.
NHS 111 call handlers are not medically trained. The report suggested that if a doctor had taken the call instead of 111 staff, they would have most likely recognised the need for "urgent medical attention".

The report detailed the opportunities missed to save William’s life.

Out of 16 missed chances, the five main windows were:
 
William’s GP had not recorded all the relevant information in his notes
 
The severity of William’s symptoms had not been recognised
 
Inadequate advice was given to William’s parents about what to do if his condition worsened
 
The out-of-hours GP service had no access to the baby’s primary care records

 
The pathway tool used by NHS 111 call handlers was not sensitive enough to pick up “red-flag” warnings of sepsis

It also included failure by GPs, who saw William six times in the months prior to his death, to spot pneumonia which could have prevented his circumstances.

The report said: “Had any of these different courses of action been taken, William could probably have survived.”

Recommendations made by the report included training call advisors to spot when there is a need to probe further into the condition of the patient, and when to escalate cases.

It also called for better recognition of the signs and symptoms of septicaemia by GPs.

The report is the result of a year-long campaign by William’s parents, Paul and Melissa, to find out what really happened to cause their son’s death.

Director of nursing with NHS England in the south west, Lindsey Scott, told the BBC: “One of the significant learning points for us is how difficult it is for both professionals and parents to diagnose septicaemia.

“Everyone involved in this report is determined to make sure lessons are learned from William’s death, so other families don’t have to do through the same trauma.

“None of this detracts from our profound regret at the loss of William. For that loss, on behalf of all NHS organisations involved, I would like to apologise publicly to Mr and Mrs Mead,” she told BBC.

Neil Harris
(a don't stop till you drop production)

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111 Emergency - still an emergency.

This is an article from The Daily Telegraph today – figures are now coming through which prove what this Blog has been saying for over a year.

The old ‘NHS Direct’ phone line was a real help to patients; it offered quick access to experienced nurses who could confidently divert patients away from Accident and Emergency.

The new ‘111’ line is staffed by unqualified staff who use a computer programme to advise patients.

If in doubt? Send them to A and E because you can’t go wrong.

It’s not the whole answer, of course. The real delays are because too many Nursing jobs have been lost, too many beds are empty and too many wards have shut.

The effect of this is that when patients are treated in A and E but need in patient time – there aren’t the beds.

Every one waits, operations are cancelled, simple problems become emergencies.

By  Laura Donnelly, Health Editor

Daily Telegraph.

14 Jan 2015

NHS 111 is to blame for almost all of the last year's rise in Accident & Emergency admissions, one of the country's most senior medics has said.

 

Dr Cliff Mann, president of the College of Emergency Medicine, said it was "absurd" to suggest patients were wrong to go to casualty units, when large numbers were being directed there by the telephone service.

 

Speaking at a session of the Commons health select committee on Wednesday, he said the NHS needed to change its systems so they work better for patients.

 

 

He told MPs that the 111 phoneline, which was supposed to help patients and relieve pressures on hospitals has had the opposite effect.

 

 

"The reason these people are attending these emergency departments is because we told them to," he said.

 

"Of the 450,000 extra attendances in the system in the last year, 220,000 were advised by NHS 111 to come to the emergency department and another 220,000 had an ambulance despatched to them by NHS 111.

 

"If you put those figures together you have more than 95 per cent of the rise in type 1 [major A&E unit] attendances. I don't think we should blame people for attending the emergency department when we've told them to go there. It's absurd."

 

Earlier this month, emergency medicine experts said that when nurses handled calls on the helpline's predecessor, NHS Direct, they had the experience to know when an A&E visit was not appropriate.

 

It came as figures emerged showing that NHS 111 sends an extra 50 per cent more patients to A&E at the weekend, when GP surgeries and other clinics are shut - increasing the strain on already stretched hospitals.

 

Latest figures show A&E waiting times in England are now at their worst levels in more than a decade.

 

Suzanne Mason, professor of emergency medicine at the University of Sheffield said the numbers of patients being sent to A&E after calling 111 was a huge problem.

 

She said ambulance services in some parts of the country had been "brought to their knees" by call handlers, who follow a risk-averse computer symptom checker, that defaults to A&E as a safety-first option.

Neil Harris

(a don’t stop till you drop production)

 

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Contact me: neilwithpromisestokeep@gmail.com

 

 

The cost of 111 is getting clearer.

Hangin’ on…

V 111

 

It’s always a bad sign when my Blog produces another bad logo. The NHS 111 service has been a running sore and it will get worse. This article from the Independent misses the point rather.

The service was launched before the pilot schemes to test it out had been completed. The point was to save money – a clinician led service (NHS Direct) was to be replaced by a call centre (111) which had a few back up clinicians.

End result? If in doubt send them to Accident and Emergency.

Solution? More Nurses and Doctors at the Call Centres. Result? It costs a lot more.

 

Cahal Milmo   

 Thursday 02 January 2014

 The service designed to lessen the burden on hospital casualty units by assessing non-emergency cases was thrown into chaos last summer when NHS Direct, one of the main providers, pulled out of its contracts saying it could no longer afford them.

 

An investigation by the British Medical Journal has now established that the cost of re-tendering the contracts is likely to run into millions as managers attempt to reshape the service to meet concerns that it is diverting people to hospitals and needs to improve access to trained clinicians.

In the West Midlands, just one of 11 regions where NHS Direct had won contracts, the cost of securing a new operator has been put at £500,000, leaving the health service with a potential bill of £5.5m if the charge is repeated across the country.

 

Doctors’ leaders and Opposition politicians said that the public was paying the price for the premature launch of NHS 111 and problems persist with the quality of call handling and an over-reliance on computer algorithms. NHS England said it had acknowledged initial difficulties and insisted 111 was now “a stable and improving service”.

 

Andrew Gwynne, a Labour Health spokesman, said: “It is now clear that ministers wasted millions on flawed contracts. We warned the Government at the outset that 111 was fundamentally flawed but they pressed ahead with the rollout regardless.

 

“Now, profits are being put before patient care as private companies run the advice line – with call-centre operators directing too many to A&E. Patients in large parts of England still face uncertainty over their 111 line.”

 

NHS Direct, which ran the original health service helpline, won nearly a quarter of the 46 contracts across England to provide the 111 service from Merseyside to Cornwall. But it announced in July that the contracts, which covered more than a third of the population, were “financially unsustainable”.

 

The organisation, which will now close after running up a £26m deficit, denied that it had deliberately underbid for the contracts despite evidence unearthed by the BMJ that it had underpriced the cost of running NHS 111 by as much as £30m and launched in some areas with a quarter of the recommended staff.

 

Dame Barbara Hakin, chief operating officer at NHS England, acknowledged that at the launch of the service some NHS 111 call centres had not been properly staffed and there had been an increase in A&E attendances but the issues had been “very shortlived”.

 

She added: “NHS 111 is now a stable and improving service and we are confident it will continue to get better.”

 

The award of the new contracts has been delayed until 2015, leaving a number of “step in” providers, dominated by NHS ambulance trusts, to manage 111.

Neil Harris

(a don’t stop till you drop production)

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Drips - dying from ignorance.

This is obviously significant in itself.

Then again, one or two ignorant or disinterested staff could be regularly killing many and no one would be any the wiser. Which may be one explanation for variations in mortality rates where there aren't obvious explanations.

 

Thousands of patients dying from incorrect use of IV drips, warns Nice

 

National Institute for Health and Care Excellence says one in three patients die within days of surgery from too much fluid

Haroon Siddique   

 

 

The Guardian, Tuesday 10 December 2013

 

Patients' lives are being put at risk by an "astonishing" lack of knowledge surrounding the correct administration of intravenous (IV) drips in hospitals in England and Wales, experts have warned.

 

The National Institute for Health and Care Excellence (Nice) has issued guidelines for medical practitioners on their use amid fears that tens of thousands of patients are suffering complications each year because most doctors do not know how to prescribe them properly.

 

There is a risk of pneumonia or heart failure if a patient is given too much fluid, or kidney failure if they are given too little.

 

Dr Mike Stroud, a gastroenterologist who chaired the group that developed the guidelines, said: "We are very confident that it has not been done well in the past and it needs to be done better … Doctors and other medical professionals are not well educated in terms of what a patient needs and that's astonishing really … It is as important or more important than anything else in terms of making hospitals safer places."

 

Stroud said that IV drips were probably the second most commonly used therapy in acute hospitals, and yet surveys suggested nine out of 10 doctors do not know the correct dosage and timing. He attributed the lack of knowledge to it not being a specialism. "This has fallen through the cracks because it's no one's baby," he said.

 

Experts say it is difficult to pinpoint the consequences of mistakes, because most patients on a drip are also receiving other treatments. But Stroud estimates that tens of thousands of people are experiencing complications.

 

In 1999, the National Confidential Enquiry into Patient Outcome and Death said one in five patients on IV fluids and electrolytes suffered complications owing to inappropriate administration. In 2011, the same organisation found that a fifth of hospital patients who received too little fluid before surgery and a third who received excessive fluid died within 30 days of having their procedure.

 

The Nice guidelines say that hospitals should identify an IV fluids champion to be responsible for training, clinical governance and auditing, and monitoring patient outcomes, with incidents of fluid mismanagement reported.

 

Dr Jerry Nolan, a consultant in anaesthesia and intensive-care medicine who was part of the Nice guidance group, said the costs of implementing the guidelines, including training staff, would be more than offset by the reduction in complications. "We know that some elements of the undergraduate curriculum will include the physiology of fluids but it appears that there is some disconnect between what they learn at medical school and a lack of practical application when they become doctors," he said.

 

"I think it is really important that healthcare professionals understand that fluids are effectively drugs, and just as is the case with any drug, the dose of fluid therapy is very important and that is something that is often being forgotten."

 

Katherine Murphy, chief executive of the Patients Association, said: "It's disgraceful that staff are allowed to go through their professional life without having the right training and support. The trust boards need to listen to this and treat it as a high priority. It's all very well Nice coming up with the guidelines, but they need to be put into practice."

 

In June, the use of starch drips in UK hospitals was suspended because the Medicines and Healthcare Products Regulatory Agency said that "their benefits no longer outweigh the risks" after it was found that the drips were linked to hundreds of unnecessary deaths.

Neil Harris

(a don’t stop till you drop production)

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Latest Accident and Emergency analysis.

I’ve edited this Guardian article, based on Accident and Emergency statistics published yesterday. It’s almost word for word what the BBC said today, so someone’s been copying a press release.

In fact if you’ve been following this Blog or my other one, you’ll have been reading me making provocative statements – all of which are borne out by these statistics.

1) While the number of elderly people attending A and E is rising it isn’t rising more than the proportion of elderly people in the population.

2) 53% of people attending A and E need treatment and it’s usually urgent. Only 47% don’t. How do they know they don't need treatment until they receive that advice?

3) Closing the NHS Direct helpline is probably responsible for the increase in those attendances.

4) The increase in attendances is not at A and E but in the walk-in centres and minor injury units that are there to take pressure off A and E. I have often complained that their stats should be excluded – they only inflate the figures. A and E attendances have barely risen.

5) The long waits are caused by too many beds and wards having closed –there aren’t enough to admit those patients who need admitting to hospital.

Of course it's so much easier to blame the patients....

Haroon Siddique         

The Guardian, Tuesday 3 December 2013

 

 

Attendances at A&E departments in England have risen significantly in recent years, with more than 600,000 more people using their services last winter than under the previous government, official NHS statistics have revealed. The figures show comprehensively for the first time the rise in numbers presided over by the coalition government, as fears mount of an impending "winter crisis", and prompted charities to warn that the situation could get worse.

 

Caroline Abrahams, charity director at Age UK, said: "The numbers could continue to increase since the social care system is being stripped to the bone, with access to high-quality social care becoming ever more difficult as vital services are withdrawn or reduced as a result of the current crisis in care. The NHS will struggle to cope with the increasing pressures brought on by lack of social care provision unless the system is radically reformed and given adequate funding."

 

The figures, published on Tuesday by the Health and Social Care Information Centre (HSCIC), show that the most deprived 10% of society are twice as likely to go to A&E as those in the least deprived 10%. They also reveal that the proportion of old people attending major A&E units has risen from 19% to 21% over the past four years, with nearly half of them being admitted to hospital, a situation Jane Harris, policy director at disability charity Leonard Cheshire, claimed was avoidable. She said the government "should be investing in a better care system. Disabled and older people and families shouldn't feel they have to go to A&E unless it really is an emergency".

 

Attendances at A&E departments were up 11%, to 21.7 million, over the past four years, compared with a 3.2% growth in the population during the same period, mainly due to a rise at minor injury units, the statistics showed. Almost half (47.2%) of people who attended A&E received only guidance or advice or no treatment, which will add to concerns that A&E services are seeing patients who could be treated more efficiently elsewhere.

 

Measures taken by Jeremy Hunt, the health secretary, to alleviate pressure on A&E include a named GP for elderly patients in their local surgery and making surgeries open for longer hours, although the HSCIC statistics show that attendances overnight are a small proportion of the total.

 

Dr Mark Porter, chair of the council of the British Medical Association, said patients needed to know how and where to access appropriate care. "Key to this is having an effective out-of-hours telephone service, yet the disastrous introduction of NHS111 replaced a clinician-led service with a call centre and was responsible for many people being wrongly directed to emergency departments," he said.

Last winter, 10.6 million people attended A&E, compared with 10 million in 2009-10. The number of people visiting A&E has been above 5 million in every quarter since the coalition government came to power, compared with exceeding 5 million in only three quarters (from April to December 2009) between April 2004 and March 2010. In the last full quarter (January to March 2010) of the previous government, attendances stood at 4.9 million, compared with 5.3 million in the same period this year.

Neil Harris

(a don’t stop till you drop production)

Sir Bruce Keogh - could do better.

Some of you will realise that compared to the truly dreadful Sir David Nicholson (Chief executive NHS England) so often described as ‘The Man with no Shame’ I hold Sir Bruce Keogh in some regard. He’s the NHS England Medical Director and has different priorities.

He’s just issued a report on Accident and Emergency treatment and it’s quite good. ‘Quite’ because I have some issues, good because it is at least intended to improve things.

1) Reduce the number of A and E’s dealing with Strokes, Heart Attacks and Trauma.

Great idea – in London the number of Stroke units were reduced from over 20 to 8 with the result that the death rate fell dramatically and outcomes improved.

For these three areas specialising works really well, getting early, good treatment is vital.

Before stroke victims waited all weekend for someone to turn up – by then it was too late. Heart Attacks are not the killers they were because of specialisation. Complex trauma needs highly skilled surgeons.

2) A revamped and improved 111 service – with more clinicians and Nurses available on the phone to reduce the number of A and E admissions. Great idea – that’s what we were arguing for when NHS England closed down NHS direct which did that.

Sir David Nicholson – well done again. You just finished off NHS Direct and still have time to watch the failing 111 service being turned back into a pale shadow of NHS Direct at enormous public expense to try and put right another mistake of yours.

3) Improved paramedics, dealing with more cases at home rather than taking them to A and E – who could object to that.

Problems;

1) Where I have a real problem was watching Sir Bruce on a ‘Newsnight’ interview last night. He repeated the nonsense that 40% attending A and E do not need to do so.

It’s nonsense because no one knows that until after the event. The 40% includes all who attend with suspected broken bones for an X-Ray, the abdominal pains, the suspected thrombosis etc. All require tests no Doctor does or paramedic can do. Failing to send those people in for the tests is just negligent; no Doctor would take the risk. So the 40 % includes those who needed a test but luckily they then didn’t need treatment.

2) Keogh expects to downgrade 70 out of 170 A and E’s.

The problem with that is that we have a pretend market not planning. It won’t be the best A and E’s that survive it will be the pushiest, grabbiest Foundation trusts. The others will lose the revenue from admitted patients and decline further.

Losing Cardiology, Stroke and Trauma will remove a massive proportion of any hospitals revenue and that means more closures.

No planning means no concern for local communities and no real search for expertise.

PFI contracts are so binding (an act of parliament could easily unbind them) that being lumbered with a catastrophic PFI is likely to safeguard a poor and inefficient hospital rather than ensure that quality survives.

So Sir Bruce, this paper doesn’t get full marks from me, which is a shame. You were doing quite well up till now. Don’t forget that while you may be thinking about best practise, the managers are only thinking about money.

Neil Harris

(a don’t stop till you drop production)

If you also look at helpmesortoutstpeters.blogspot.com I warn you that tomorrow this article will be repeated - I'm not so well at the moment and the Doctors seem to be out for revenge! Normal service will soon be resumed.

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A harmonious arraingment.

Hangin’ on…

 

‘M.D.’, who is ‘Private Eye’s medical correspondent is someone I don’t always agree with – I suspect our politics are very different. What we do have in common is a pretty similar analysis of the problems.

This week in the ‘eye’, he has a go at the new ‘NHS 111’, the non-emergency call service. For once we are saying much the same things about it. He deals with Channel Four’s exposure of what goes on at Harmoni, one of the contractors providing the new service as well as NHS Direct’s withdrawal from its 11 contracts as it has found them uneconomic.

 I’ll quote M.D. directly, I’m sure he won’t mind;             

“Harmoni has a third of the contracts and will probably now mop up some more. It beat Care UK in the tenders, but Care UK retaliated by buying Harmoni and then recruiting, as its managing director, Jim Easton, who was lured from the Department of Health and then NHS England having, er, “overseen the NHS 111 procurement process”.

I think, given the possibilities of legal action that I won’t comment further on the ethical position of losing a tender and then buying out your successful rival, then poaching the person who set up the process, to manage your organisation which is providing that service to that person’s previous employer.

I just don’t like it at all.

Meanwhile:

I haven’t forgotten about Professor Berwick’s report on the NHS – my review of his review is coming up.

Neil Harris

(a don’t stop till you drop production)

Home: helpmesortoutthenhs.blogspot.com

A rough guide to the 111 non urgent NHS call service.

Hangin’ on…

I’ve been very critical of the new ‘111’, service since it started in some regions in April this year.

Life has a habit of making fun of us all; I’ve had to use the service twice in the last month, which probably serves me right.

I’ve always been completely honest in my Blogs – so it’s time for an honest review of the service.

Although I’ve been doing the calling, I’ve been doing it on behalf of someone else, so there will be no details that could identify anyone. Wherever I’m a bit vague it’s because I was in an emergency situation and didn’t have doing this in mind at the time!

Call 1).

Answered: fairly quickly.

Description:

Call Centre operator about 10 minutes.

Separate call back from a Nurse lasting about 10 minutes.

Result: Attendance by emergency callout Doctors, which prevented an A and E attendance.

Call 2).

Answered: Fairly quickly.

Description:

Call Centre Operator: about 12 minutes.

Separate call back from a Nurse lasting 15 minutes.

Result: The Nurse carried out a complex calculation which indicated that an 999 callout and A and E attendance wasn’t needed.

 

You can (I hope) work out from this that the medical advice from the experienced Nurses was excellent, and in both cases prevented a difficult attendance by ambulance to A and E. This saved the NHS money, freed up two ambulances, reduced other peoples waiting time at A and E and improved life for patients, Doctors and Nurses.

Problems:

The service we got was pretty much the same as we used to get from NHS Direct which was entirely staffed by Nurses – because I ended up having two lengthy conversations with nurses.

The new system employs far fewer nurses, calls are taken by unqualified people, using a computer programme with a series of prompted questions which I am now getting very familiar with – all warning signs for serious problems which need help quick.

While this may have the effect of filtering out silly timewasting calls, I actually doubt that there are so many of these. All my research on A and E attendances tells me that the number of unnecessary attenders are exaggerated.

NHS Direct has just announced that the organisation is quitting its franchises to supply services to ‘111’, because the volume of calls breaches the terms of its contract.

The real reason is that the duration of calls and the need for fully qualified staff makes it uneconomic.

NHS Direct assumed that it would receive about £20 a call, in fact it’s been paid £8 to £12 and cannot afford to lose that kind of money.

If you look at my calls; I rang ‘111’, because I already had doubts that we needed an ambulance but I wasn’t qualified to make that decision.  As a result, both were long, both needed a qualified Nurse and both would have lost the provider money. It worked well for us, but in a real emergency I wonder whether the extra time spent on the first part of the 111 call could have unfortunate results?

Conclusion

Good quality service, time wasted on talking to unqualified staff is not a problem unless it is a real emergency.

Back-up Nurses are vital to the service – if there are enough it will be an uneconomic contract. If the provider reduces the qualified staff to save money, the service will become useless.

 

Neil Harris

(a don’t stop till you drop production)

Home:   helpmesortoutthenhs.blogspot.com

The end of NHS Direct.

Hangin’ on…

The Largest provider of the NHS England ‘111’ non-emergency telephone service is walking away from its contracts.

NHS Direct used to cover the whole of England with its fine telephone advice service – provided by nurses. It got the axe to save money (thanks to Sir David Nicholson).

The creating of the ‘111’ service has been one big problem, as this Blog has reported before and as these  two stories today confirm;

NHS Direct won 11 of the 46 regional contracts for the new service, covering 34% of the population.

In June it pulled out of two areas, Cornwall and North Essex but now says the remaining nine are "financially unsustainable" as well. It had complained that the volume of calls at North West and West Midlands had fallen short by 30 to 40% of the contracted amounts and the service was now  "financially unsustainable". There haven’t been enough calls to make it pay (people don’t trust the service) and the calls take too long (unqualified staff).

Here’s the real problem;

NHS Direct used to be paid more than £20 per call while the payment to the new 111 call centres is only between £7 and £9 per call. This reflects that NHS Direct was based on advice from nurses, the new service uses call centre staff and a computer check list.

 

 NHS Direct has lost £2.8m since April and was "heading for a deficit of £26m if we continue to run the same volume of 111 services until the end of this financial year".

 

The organisation is now seeking a "managed transfer" of its 111 contracts, which have between two and five years left to run, to another provider.  

NHS Direct's current 111 services are;

Buckinghamshire

East London and the City

South East London

Sutton and Merton

West Midlands

Lancashire and Cumbria

Greater Manchester

Merseyside and Cheshire

Somerset

 

‘111’ was supposed to be running in April, some areas won’t now have coverage until next year – the NHS Direct areas will have a pretty uncertain future until a new operator can be found.

 

                            =======//=======

There’s no harmony at ‘Harmoni’, a private ‘111’ provider. Channel 4’s Dispatches programme has been doing some snooping and found  ‘staff shortages, long waits for callers and some cases of ambulances being called out unnecessarily.’

 

One call centre manager is recorded saying that ‘the service was "unsafe" at weekends because there were too few staff to deal with the calls coming in.’

NHS Direct was a real success story, appreciated by all of us who used it. It gave good, helpful advice and saved unnecessary visits to A and E which was saving the NHS money and saving patients unnecessary problems as well.

NHS Direct walking away from the ‘111’ contracts kills off the remainder of the organisation and ensures that it won’t be economically viable to revive it. So, while we will regret it, I doubt NHS England will.

Meanwhile, I’m sure Nicholson, so keen on leaving behind his ‘legacy’, can chalk this one up as another victory – I don’t.

 

Neil Harris

(a don’t stop till you drop production)

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