Dial M for Mistake
The ‘call 111 cock-up’ has shown why competitive tendering, outsourcing and the fragmentation it brings are hopeless for safe, coordinated emergency care. Many NHS staff, academics and government advisers predicted the risks, but the government ploughed on regardless. It has ‘delayed’ minimum pricing for alcohol and plain cigarette packaging to await ‘more robust evidence’, and yet rushed through massive, unmandated market reforms of the NHS that have no evidence base at all. And as MD pointed out (Eye 1340), out of hours care is high risk and dangerous, triaging calls is extremely complex and the system has to have experienced clinical staff on hand, have a clear safety net, agreed and enforced quality standards and be joined up with the rest of the NHS. Since when was rushed outsourcing on the cheap going to be the solution?
Health Minister Earl Howe told the Lords that contractors were offered ‘an extra six months to bed in NHS 111’ but only two took up the offer’. NHS England should have insisted on the 6 month delay to make the service safer. Howe now claims ‘the NHS 111 service is not unsafe ? it is a safe service. In the vast majority of the country it has been provided very well for patients’ – a statement that may well come back to haunt him. Where 111 is being run by ambulance and GP out of hours services, it seems working well. But evidence of safety is distinctly lacking.
Like the Liverpool Care pathway, the principle of 111 is sound – it’s the variable implementation by staff, some of whom have inadequate expertise and all under extreme time pressure, that’s the problem. The simplification of out of hours calls to two numbers – 999 and 111 – sounds reasonable but it’s never that simple. Patients are expected to be able to differentiate between life-threatening 999 emergencies, and urgent but not life-threatening 111 problems. Even experienced GPs who know a patient well have trouble separating the two over the phone, so what chance a call centre employee with no medical training, an algorithm and possibly the odd nurse to ask for help if he can attract her attention? Risk-averse call handlers are likely to refer to 999 to cover their backs, others may completely miss the cues of subtle, but life-threatening illness. Safer advice would be to try your GP first. You might get lucky – or you might get referred onto 111.
Labour came up with the idea a national, three-digit number for out-of-hours healthcare services in 2007, but for once Hunt has decided not to blame them. Labour did not intend to replace NHS Direct, which was not perfect but was at least staffed by experienced nurses and had developed into a good service. Instead of building on that, Lansley decided to rip it all up and replace NHS Direct with 111
NHS Direct could still bid for the tenders and, in a panic, put in ridiculously low bids despite knowing the complexity of the work it would be doing. Even worse, the Department of Health accepted the bids and awarded them 11 of the contracts. NHS Direct has now realised – as many callers have – that it can’t provide a safe, reliable service at such a low price and is pulling out of all 11 contracts, leaving NHS England scrabbling around for a ‘failure regime’ which will doubtless mean paying other companies over the odds to take on work they don’t have the capacity for. And patients with urgent health problems will just have to shop around in the out of hours market.
NHS Direct is at least tax-payer owned, so the government and NHS England can blame it without tarnishing private sector providers. But as Channel 4’s Dispatches showed, Harmoni is also struggling to deliver a safe, low cost service too. As one (secretly filmed) manager put it: ‘We had a very bad service. Still realistically on the weekends we still are unsafe. We don’t have the staff to deal with the calls that are coming in.’
NHS England now claims that 90% of 111 calls are answered within a minute, a simplistic target that says nothing about whether the advice is competent. Harmoni has a third of contracts, and will probably now mop up some more. It beat Care UK to the contracts, 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’.
Hunt Balls
Mr Justice Silber’s ruling that Jeremy Hunt’s decision to cut services at Lewisham hospital in south London was unlawful was spot on. Lewisham was being used as collateral damage in a battle it had nothing to do with, namely to bail out nearby South London Healthcare NHS trust (SLHT) , which is losing £1m a week and will be £356m in debt by the end of the year. And a significant chunk of that debt is to service two ludicrously expensive PFI debts for Queen Elizabeth hospital in Woolwich and the Princess Royal hospital in Bromley.
The Lewisham campaign was evidence-based, united clinicians and patients, and was funded by donations via 38 Degrees. There was no rational case for downsizing such a high performing and popular hospital, and neighbouring trusts would not be able to take on the extra work without patients suffering. The decision does not, alas, solve the looming disaster of PFI debt (Eyes passim ad nauseum). As MD observed back in 1997, PFI is ‘political diktat triumphing over common sense, open debate and the will of the people.’ (Eye June 20) 21 PFI NHS trusts now have debts of £130 million between them, and the total bill for repayments has risen by £200 million (18%) in 2 years. The government seems desperate to keep PFI shareholders sweet, but the contracts either have to be renegotiated or the debt spread right across the NHS rather than punishing nearby hospitals.
Spare a thought also for Mid Staffordshire NHS Trust, which has greatly improved its care, come in the top 10 for the Friends and Family test in its A&E department and achieved a glowing CQC report. The Trust Special Administrator has recommended that it doesn’t open its A&E overnight again, and that it loses its maternity and paediatrics services, which have never been criticised. Local campaigners may well appeal this, just as Jeremy Hunt may appeal the Lewisham decision. The issue for the government is that is simply isn’t trusted. It promised to protect hospitals or departments from closure in opposition, and an end to top down reorganisation. It then foists a massive market-driven structural reorganisation on the NHS, and further service reorganisations – even if clinically rational – are seen as another ‘top down’ betrayal. The biggest winners, as ever, are likely to be lawyers.