We turn now to 111 and I am going to ask Barbara to introduce her paper on assuring operational
delivery for 111.
Assuring NHS 111 Operational Delivery Barbara Hakin
National Director: Commissioning Development Preamble
Thank you, Chairman.
It is interesting that many of the papers we have had this morning have been introduced
by the watershed moment of April 1st, and that is certainly the same for the real change
to the way that services for patients when they took over on April 1st, was that of the
NHS 111 service.
Of course, at that point we would take on our role as the oversight of CCGs in supporting
them and commissioning the best services for their patients.
The paper is designed to give the Board an update on where we are with 111 and seek the
Board's approval for the way forward.
111 It would only be appropriate for me to start
this discussion acknowledging the problems that we have had with performance and some
providers who have not been able to meet the key standards the commissioner set for them,
and not been able to answer the phone to patients quickly enough and respond quickly enough.
That has been, undeniably, unacceptable in many places -- not in many places, sorry,
I will rephrase that -- that has been unacceptable in some places.
I do think that in all of that it is really important that we remember that in most places
111 has provided a very good service to patients for virtually all of the time, and that 111
has made a real difference to patients who have had difficulties and needed someone to
help them navigate the system, and needed to help them to receive medical and clinical
health and advice.
The service was designed to prevent the confusion that I think a lot of patients had as to who
they turned to, mostly commonly outside normal working hours when their GP surgery is not
open, and when the patients did not think that dialling 999 was appropriate because
they felt that the condition that they had was not that urgent, and there were a plethora
of numbers that they could ring and people that they could turn to.
111 is designed to replace all that with a single, simple, 'You can dial 111 and you
can get the advice you need'.
As I say, for the most part, people are receiving good and prompt advice, so there are lots
of stories we hear about where 111 has made a real difference.
My own daughter, who has a new baby a couple of weeks ago, dialled 111 when the baby was
not well -- fortunately it was not anything very serious -- and she received a fantastic
service.
The phone was answered quickly, she was given the right advice because baby was fine, and
she was booked into a local out-of-hours clinic quickly and swiftly.
We hear of patients who decided they would ring 111 when they might not have done anything
else.
They might not have bothered to seek medical advice because they had what they thought
was indigestion, and it transpired that actually this patient was having a heart attack and
an ambulance could be dispatched immediately, and that made a huge difference to that patient.
I think the most compelling story for me is something that happened near to us in Yorkshire,
in Huddersfield -- the parents chose to go public on this -- where parents of a child
were concerned that the child was not very well but were not desperately anxious at that
time.
They rang 111 and the call handler on 111 was able, through talking to the patient,
to recognise that the child was potentially, very seriously ill, despatched an ambulance
immediately.
The child, who is now well I am very pleased to say, did turn out to have a very serious
illness -- had meningitis -- and the hospital doctor said that the swift and prompt action
of getting that patient to the hospital was what made all the difference.
Standards We must get this service right but we must
not underestimate the advantages to this service because, unlike its predecessors, it is able
to dispatch ambulance, make appointments for patients and put them immediately in contact
with the medical care that they require.
However, as I said, some of our providers let us down very badly.
The standards that we look for, for patients, are gold standards.
We measure our standards on two main indicators: how quickly the phone call is answered and
the number of patients that abandon the phone call and put the phone down.
The standards in the contracts that the CCGs have negotiated are gold standard.
They are higher than standards that we have expected in previous, similar services.
As I said, for the most part, across the whole country which is covered by 111, during the
week those gold standards are being met by pretty much all providers.
At weekends, over the weekends, we have had some significant problems with some providers
really having very, very poor response times; patients waiting completely unacceptable lengths
of times and too many patients abandoning those calls.
Improvements Now, over the last few weeks NHS England has
worked with the CCGs to work with providers to make sure that the service is safe and
the best it can be, and we have seen a very significant improvement.
Three or four weekends ago, the Easter weekend, where the standards in a number of places
were very poor, through to last weekend where for 90% of the country that is covered by
111, the gold standards were being met even at the weekend.
That does not mean we are complacent.
We have another Bank Holiday coming up.
We have put a lot in place to achieve those improvements.
As I say, we have worked with providers who have taken on more call handlers.
We have put in place contingency, back up whereby other organisations or other groups
who could handle these calls, including the original out of hours and 0845 number could
be switched back on, to just manage the risk.
We will be doing the same over the Bank Holiday weekend to make sure our patients get a great
service.
90% of the country is covered by 111.
We only have 10% of the country, slightly over 10% of the country where we need to rollout
111.
Again, we have put in place a process whereby there will be no further rollout of 111 in
any area until, working with our CCGs and nationally across the country, we in NHS England
are satisfied that that rollout can be delivered safely.
Also, we are working with our CCGs in order to take actions with providers where the service
has been unsatisfactory.
NHS England will not shy away from working with our CCGs to support them to invoke the
financial penalties where services have not been the standard for patients, or indeed,
to revoke the contracts where we believe that a provider cannot show that they are going
to be able to improve on the current standards and make sure that they deliver the sorts
of services our patients want.
A sustainable service That is the position we are currently with
performance on 111.
I think that we now have to move forward and make sure that we have a fantastic and sustainable
service over the coming months and years.
There are a couple things that we are doing in order to make sure that is the case.
We will want to look at precisely the nature of 111 in the future, how it is commissioned
and the balance between national and local.
The scope of 111 -- have we got the scope right?
Is the potential for 111 to do more as a direct service to patients?
The clinical input: are we absolutely certain that the balance between lay call handling
and clinical input is right in all the call centres?
The shape of provision: we have 46 sites at the moment with a number of different providers
so are we confident that that shape of provision is appropriate?
We will, over the next months bring regular reports to the Board.
We have a programme oversight group, including our CCGs which will look at all those aspects.
In addition, the Board asked last time that we put in place [break in audio] -- and again,
that the lessons learned from the national coordination
versus local sensitivity, both of which are important so that review will look at all
of those things.
Q&A Malcolm Grant: And that will be a review conducted
by an external reviewer?
Would you like to add anything to that, Bill?
Bill McCarthy: No; I think Barbara has covered it very well.
We are committed to learning so we need to learn how best to do the most complex, large
projects.
An awful lot of this we took the baton on at a fairly late stage but there will be times
in the future where similarly complex challenges we will be taking forward so we should use
this opportunity to get ourselves into really smart shape to do those.
I have been talking to an independent, external person but I do not have that name for you
today, I am afraid.
Malcolm Grant: Thank you for that.
Moira?
Moira Gibb: Thanks, Malcolm.
Obviously, the public have had a picture of a bad service even if they have not experienced
it directly; what they have read in the newspapers or heard about it is probably giving them
a very negative impression.
Who is responsible for the information flow to the public about using it, when to use
it, how to use it, etc?
Is that us or individual CCGs?
Is there a thought, whoever it is, of doing something that helps people understand again,
hopefully, not dissuading people from using, for example, when it is appropriate for them?
Barbara Hakin: Thank you.
I think we both have a responsibility.
I think CCGs have a responsibility to communicate with their patients locally, but I think NHS
has an important role in the national message in helping and supporting patients.
First and foremost, we have to ensure that this service is gold standard everywhere because
I think then that speaks for itself; that is how patient's confidence and the public's
confidence will grow.
I do think we have an important role, firstly in reassuring the public nationally that this
is a really very good service, for the most part, which does save lives.
I think we also have an important role in being clear to patients what they should do,
because I think that a lot of this has created some confusion for patients, 'Who should I
ring and when'?
The message is simple.
At the moment, in areas where we have 111 working, as I say which is almost 90% of the
country, as a safety net we still have the 0845 number and the GP out of hours number.
They are switched through to 111.
At the moment, if you are in that 90% of the country where 111 is working, it does not
matter which of those numbers you ring you will get through to a call handler in 111.
For the 10% of patients who still are not covered, if they were to ring 111 they will
receive an answer phone machine saying, '111 is not operational yet' and giving them the
numbers to ring -- obviously, if they use 0845 or their GP out-of-hours then that, for
the moment, continues the same.
Our ambition continues to be that over the next few months we have 111 nationally available.
Malcolm Grant: Margaret?
Margaret Casely-Hayford: Barbara, thank you for the explanation of the oversight programme,
which I think is going to be absolutely critical to making sure that the providers who have
not met the standard, actually begin to improve and that we gain assurance on the improvement.
It was also really helpful to hear that there are sanctions available to you.
Will you actually publish the sanctions or somehow inform us of what happens if there
has been the ultimate failure?
Barbara Hakin: We certainly will report that to the Board.
The contracts with providers are with CCGs and those contracts are available, and an
understanding of the penalties in those.
I know that in certain areas those financial penalties have been significantly brought
into play.
The problem with that, of course, is that it does not help our patients get the better
services, which is what we need, and we will constantly, I think, in terms of looking at
providers, have to measure the balance between continuing to support a provider in order
that they can deliver a better service, but at the same time looking at an alternative
and being sure that an alternative would be an improvement.
I am happy to report to the Board, with the very small number of providers, a couple of
providers who have had some seriously poor performances, how discussions with them and
their CCGs supported by us are going, and the outcomes.
Malcolm Grant: Victor?
Victor Adebowale: Two questions really.
One, are we measuring public perception and the impact of the disproportionate -- and
it is a disproportionate view -- that the public are getting a bad service on the usage
of 111?
Are we measuring that going forward because public perception may well affect usage?
Are we also measuring the use of 111 going forward by demographics?
Are some areas using it more than others?
Some people are using it more than others because that will tell us, in a sense, quite
a lot about whether it is having an impact on improving healthcare.
Barbara Hakin: The use of 111 is rising because, of course, one of the ways that 111 was introduced
-- it was a soft launch so that actually, where the 0845 and the out-of-hours calls
were switched over until the service settled in, and then locally, the CCGs could advertise
this service to their patients.
Of course, the recent media interest in this means that many, many more patients are aware
of 111; it has had a very high profile.
We will be doing everything we can to get the message across that, for the most part,
patients get a really good service from 111, and give patients the confidence which is
absolutely vital that patients have confidence in the service, and for the most part they
should have that confidence.
I would hope we could perhaps rely on media colleagues to help us with that message about
the areas where the service is working really well, because there are parts of the country
where this service has been exemplary throughout.
Malcolm Grant: Thank you very much for that report, Barbara.
This is an absolutely critical service and I think for all the reasons that Barbara has
outlined.
There is the potential here for 111 to be quite transformational in the way in which
NHS improves its responsiveness to patients.
Tim, it would be useful, would it not, to be able to understand how we could reflect
on the dashboard the level of demand on 111?
It is another important indicator of public engagement.
I am going to ask the Board if you would please endorse the operational delivery plan, the
setting up of the external review which I think is critical for the reasons that Bill
mentioned, not just to learn lessons of what went well and what did not go so well with
111, but how we would go about such a major project in the future when it arises for us
to do that; then finally, also to endorse the longer-term strategy for the development
of 111.
Are we content to do that?
We are?
Thank you very much.