Involving GPs in out-of-hours triage decisions within NHS 111 could reduce attendances at A&E, according to a new study published on BMJ Open on 29th November 2015 by Professor Martin Roland (co-Director, Cambridge Centre for Health Services Research) and Andrew Anderson (Cambridge and Peterborough CCG).
Since 2014, telephone calls for urgent medical advice have been handled in the English NHS by ‘NHS 111’ which employs non-clinical call handlers using computer algorithms in order to advise patients on what they should do. The software is designed to deliver risk averse outcomes when used by non-clinicians – so the call handlers can send ambulances to the patient, advise them to go to A and E, or suggest they visit a GP out-of-hours centre.
NHS 111 was widely criticised in its early days, including concerns that the service was sending too many patients to A&E departments, contributing to the rise in A&E attendance. Clinical advisors are on hand but the ratio of clinical advisers to call handlers is relatively small (averaging 1:4 to 1:6 in NHS 111 call centres, which may contain many call handlers).
So is this a good way to organise out-of-hours medical advice? What happens if GPs take a look at the decisions made by the call handlers?
Martin Roland and Andrew Anderson considered the effect of using experienced GPs to review the advice given by NHS 111 call handlers. The GPs reviewed 1474 cases in which NHS 111 decision support software would have advised the caller to attend A&E. For 400 of these cases (27.1%), the GPs also decided A&E was the recommended course of action. But it turns out other care options were indeed available – so GPs recommended a primary care out-of-hours centre or minor injury unit for 665 cases (45.2%), and self-management or an alternative strategy for 409 cases (27.8%).
This study generated substantial media attention, with headlines in the Daily Mail concluding that NHS 111 call handlers were “needlessly sending hundreds of thousands of people” to A&E, while The Independent suggested that most people told to go to hospital after calling NHS 111 did not need emergency treatment. The study itself suggests that there could be substantial benefits, and possible cost reductions, by engaging experienced GPs in out-of-hours triage decisions within NHS 111.
Anderson A, Roland M. Potential for advice from doctors to reduce the number of patients referred to emergency departments by NHS 111 call handlers: observational study. BMJ Open 2015;5:e009444.doi:10.1136/bmjopen-2015-009444