Undercover in NHS 111
By: Luke Denne
This article has been written by Luke, the undercover reporter in 'NHS Undercover' (29 July 2013).
Designed to be the sole access point for urgent care, NHS 111 had already been making headlines, mainly for the wrong reasons, when I began applying for a position.
I was keen to get inside and managed to get myself a job as a call handler – known as a ‘Health Adviser’ - in the Dorking call centre run by Harmoni, a private health care company with the largest number of NHS 111 contracts. They were on a recruitment drive and I gave my bank details and my documents and did an interview.
Working undercover, I was shocked by what I found. Halfway through the training a manager in the call centre admitted to me and the other trainees that on the weekends the service was ‘unsafe’ because they didn’t have enough staff to handle calls.
The first two weeks of training was spent learning how to use the computer system, known as 'Pathways'; a computer algorithm that prompts the call handler to ask certain questions and analyses the responses in order to direct the patient to the most appropriate care. I worked hard, but sometimes found the training a little confusing, as explanations given by our trainers were not always clear, and they sometimes struggled to answer questions from me and my fellow trainees.
After four weeks of training I started taking live calls from members of the public.
The idea is that, as the call handlers only need to ask what is prompted on the computer screen, it is clinically safe to have non-medically trained staff answering calls and clinicians on hand to deal with the more complex ones.
I found the job quite challenging. You receive calls relentlessly, often from quite distressed individuals. I was taking calls about mental health problems, heart attacks and other serious medical problems. There was no doubt that many callers required urgent assistance. I was dispatching ambulances on most of my shifts.
All too frequently I would wish to have a second opinion from a clinician to ensure I was making the right decision for the patient, but staffing issues meant problems sometimes arose.
I was often unable to access clinical support, which meant that my questions were sometimes answered by more experienced call handlers or supervisors, rather than clinicians. On one occasion when I requested clinical advice on whether I should send an ambulance, the member of staff who came over to my desk told me she was 'pretty much' clinical. In fact, she wasn’t, she was a Health Advisor – another call handler - just like me. The clinicians were too busy on that occasion to help. Non-clinical staff making clinical decisions made me feel very uncomfortable.
If a caller needed to speak to a clinician - either because they required medical advice or the call was too complex for me to complete on my own - I was meant to be able transfer them straight through. But the lack of clinicians also meant that patients were frequently being put in queues for callbacks. If this happened they were mean to get a callback within ten minutes, but as one of my trainers admitted, they often wait longer than that.
I was also concerned to discover there did not seem to be enough quality control in place to ensure calls were being correctly dealt with. A call handler who had been working in the centre for several months told me that he hadn't received any feedback at all on his performance, so he had no idea if he was doing the job properly.
A trainer also admitted to me that the call centre had previously been sending out too many ambulances, increasing the strain on emergency service resources.
Like some other staff I met in the call centre, I took my job very seriously, but a lack of clinical support meant that I worried about the service being provided to patients. It seemed to me that it cannot be allowed to continue like this.
Harmoni told Dispatches:
We provide a clinically safe service.
Our call centres answer around 95% of calls to the NHS111 number in less than sixty seconds.
We are increasingly able to directly transfer patients to a clinician, and when return calls are needed, they are made on average within 25 minutes. The timescales involved in warm transferring calls are dictated by contract and the ability to directly transfer a call isn’t what makes the service safe. Our services are all clinically led, underpinned by the same NHS diagnostic tool used by emergency 999 centres and we don’t compromise safety.
We ensure that all employees undergo appropriate training and meet the NHS Pathways standards. We have sufficient headsets and splitters to allow all trainees to listen to calls as part of training. Our staff are audited as required by our contract and feedback is given where appropriate.
We expect all staff to only provide advice according to their role and their level of training and take a zero tolerance approach to any breach. Our audits show no evidence of widespread poor practice.
NHS Pathways is a risk averse method of assessment and that can lead to an over cautious approach and inappropriate 999 response. However currently around 10% of calls to the NHS111 service result in ambulance dispatch. This is the level expected by the NHS locally and doesn’t represent an increase in pressure on ambulance services
Our staffing levels are extremely robust with around one clinical advisor to every four health advisors. Staffing levels are agreed and shared with local commissioners and NHS England and are reviewed weekly
While it has been acknowledged that NHS111 services generally did not get off to a good start, we and other providers have successfully delivered substantial improvements including recruiting 180 more advisors
Most providers found the pace and timing of the rollout of a new national service receiving a mix of calls created initial challenges.
We will fully investigate any specific concerns raised within this programme