Recent news reports have shown that the NHS out-of-hours hotline service is facing a crisis. Serious failings have emerged which have been linked to the deaths of two babies.
The 111 helpline which replaced NHS Direct is designed to deal with urgent cases on an out-of-hours basis. The previous NHS Direct system which was staffed predominantly by medically trained staff was replaced in 2013 to the current 111 system. The call centre staff who deal with calls have had only three weeks of training and have no medical qualifications. The staff follow a system of on-screen computer prompts, or 'pathways' and a referral to a nurse can be made if it is felt necessary.
Staff Shortages
The system is designed so that at any one time, there is one clinically trained person on duty, such as a nurse. However, the reports have indicated that the centres are completely understaffed and overwhelmed. As a result of staff shortages, one nurse is often covering for a number of counties. In order to meet the desired target of answering 95% of calls in 60 seconds, these nurses are spending their time answering routine calls when they should instead be allowed to focus on the more serious cases that require their expertise. The reports also show that 75% of calls can go unanswered at times.
A Flawed System?
The system works by staff inputting the symptoms described by the patient and then following an on-screen flow-chart and a series of questions. The solutions can range from advising that an ambulance be called immediately, to advising attendance at a walk in centre. The issues arise because of the inflexibility of this system, where answers cannot be overridden and extra information cannot be considered.
The failings of the 111 helpline were demonstrated in the death of an eleven week old baby who died from a rare strain of meningitis. Despite having a temperature of 39 degrees when the call was made, this high temperature was not flagged up because of a defect in the computer system used. The adviser focused on the baby's cough rather than his high temperature. The on duty nurse also failed to recognise the severity of the situation.
In similarly tragic circumstances, a one year old child died after his mother called the NHS helpline. On calling the helpline, the child's mother was advised to give her son Calpol. The Adviser had focused on an incorrect pathway by following the computer system. Despite advising the mother that her child should remain in bed, he died hours later from a lung abscess caused by a bacterial infection.
This devastating mistake was caused by the Adviser incorrectly inputting that the child was "not in pain" rather than correctly inputting that he was in "severe pain" as his mother had explained. A further error occurred when the pathway posed the question of whether the child had been crying for over an hour. The answer was that he had not been, but this was only because he could not stay awake. However, the Adviser having only two options, yes or no, input that the answer was "no".
My Thoughts
To adequately assess someone's medical needs, there should be some medical knowledge on the part of the Adviser. It is clear that rigid computer pathways requiring yes or no answers are not appropriate in diagnosing certain medical conditions, or at least in realising the urgency of certain situations. The shortage of staff and lack of time that can be spent on each call is also leading to these devastating errors being made.
It is tragic that lives have been lost and obvious that changes are needed to the current 111 system to ensure that it does the job it is designed to do. The system is in place to reduce the number of people going to A & E who could be helped over the phone. In the cases above, the families should have been urged to seek medical care immediately.
By Laura Penny, Trainee Solicitor