NHS England/Improvement commenced the rollout of ‘NHS 111 First’ across England on 1 December.

This initiative encourages those who have an urgent healthcare need, but not a true emergency, to call NHS 111 rather than attend an emergency department. Those who require an ambulance or who have a true emergency are encouraged to use the 999 service as before; makes sense perhaps?

Certainly, the efforts to reduce the pressure on EDs (emergency departments), which has been massively increased by the pandemic, have been welcomed by the RCEM (Royal College of Emergency Medicine) and indeed frontline emergency medicine clinicians.

But is there a risk in rolling out such a big change to the way the public accesses urgent and emergency care? And do we have evidence that these changes will achieve the desired effects?

Because of the pandemic, capacity in the UEC (urgent and emergency care) system has been drastically reduced, particularly by the need to maintain social distancing in waiting rooms (reducing capacity by 50-70% in many) and to comply with infection control measures in hospitals.

It is worth noting that, while there has been rapid work to improve separation of patients in EDs, many still have completely inadequate ventilation systems, potentially further increasing the risk of infection, particularly where there are excessive patient numbers.

Limits on patient numbers are essential, even in the presence of other transmission precautions.

The demand for UEC is now returning to pre-pandemic levels, after a transient reduction in demand through the first peak. NHSE/I estimates that demand will soon exceed capacity to safely manage patients in EDs unless an alternative is found.

It is deemed unacceptable for patients to be placed at risk of nosocomial infection by allowing overcrowding of EDs and, indeed, the whole hospital.

NHSE/I has explained that the main objective of the proposed changes was to ensure that 10% of the cohort of unheralded patients who self-present to EDs (approximately 1.5m or the entire attendance of 25 EDs in England annually) could get the right care in the right place and avoid unnecessary visits to emergency departments.

Put in other words, the objective is to manage the flow into EDs. (This is focused on flow into acute hospitals, not on the ‘exit block’ [flow out] which RCEM has highlighted for many years as the cause of overcrowding.)

To achieve this, patients who are thinking about attending an ED are now being encouraged to call ‘NHS 111 first’ (unless they have a true emergency or ‘life-threatening emergency’).

We are told that the proportion of calls that are ‘clinically validated’ is being significantly increased by recruiting more clinicians to work for NHS 111 in the CAS (clinical assessment service), and that this will result in an increased proportion of patients being directed to settings other than EDs for their healthcare needs to be addressed.

These settings include primary care, pharmacy services, hospital home-type schemes, other community services, SDEC (same day emergency care) units [1], hot clinics, urgent treatment centres, and district nursing.

The aim is that clinicians will ensure that the disposition – the direction to a particular healthcare setting so the patient can be treated – that the algorithm gives them is the most appropriate one, and will also ensure that all secondary care providers and some community care providers will be able to deliver the services as required.

Examples of similar initiatives around the world, including Denmark, have resulted in 10-50% of patients being managed in settings other than ED. However, comparison is very difficult owing to the number of differences in the provision of healthcare services in these models. 

As a result of these proposed changes, hospitals are being asked to expand SDEC rapidly, so that by the end of 2020 every acute site can deliver SDEC 12 hours a day, seven days a week. Consultants from all acute specialties will be expected to lead the delivery of SDEC clinics.

NHSE/I estimates that 80% of all SDEC episodes will be completed within six hours, and that these changes would free up approximately 4,000 acute beds per year.

Investment

During the pandemic, NHS 111 has increased the number of clinicians it hires by 50% (mostly GPs doing additional hours) and will receive, as indicated above, £24m in revenue funding until the end of the financial year.

In terms of capital spending, £450m has been earmarked for this year for ED. reconfiguration, with an average of £2m per hospital with an ED. 

Timeline

Trials were launched in the summer in Cornwall, Portsmouth, South East Hampshire, Blackpool, Newcastle and Warrington; subsequently it was announced that another 25 hospitals were to become pilot sites.

However, the outcomes at these pilot sites have not been shared with the BMA, despite our asking for this information. We have also heard worrying reports from some sites that they are receiving inappropriate referrals via the clinical assessment service.

Despite this, NHSE/I commenced rolling out NHS 111 First nationally on 1 December.

But reducing the demand on overstretched emergency departments sounds like a good idea; why not roll this out?

The BMA absolutely supports the aim of reducing the pressure on EDs. We have consistently called for the Government to address the ever-worsening pressures on the urgent and emergency care system over many years, and specifically highlighted the need for thousands of additional hospital beds to address issue of ‘exit block’, which is caused largely by hospitals being run at excessive occupancy levels.

We are very interested in finding ways to reduce the additional pressure on EDs that the pandemic is driving. That’s why we have been meeting with NHSE/I regularly to hear about the progress of the pilot sites.

But as yet we have not seen evidence that this initiative actually achieves those aims. Without this evidence we do not know if there is a significant benefit to rolling it out. And there is a risk that increased pressure is being placed on other parts of the healthcare system as a consequence of this initiative.

For example, GPs are understandably concerned about where the GPs that are picking up the increased NHS 111 clinical validation work are coming from; are they doing this work instead of work in GP surgeries for instance?

And if the aim of NHS 111 First is for 1.5m patients to have their healthcare needs met somewhere other than an ED, then how many of these will need appointments with their GP?

Importantly, how many will need appointments in SDEC hospital clinics? How will already overstretched consultant staff from acute specialties accommodate additional clinical work in their packed job plans?

Where is the engagement with consultants who have shown incredible flexibility and resilience in the response to the pandemic? Where is the commissioning and funding for these patients to be managed in these settings?

Lots of important questions and very few clear answers. We have put these questions to NHSE/I but we do not yet have the information that we need to make an assessment of whether any benefits of NHS 111 First outweigh the risks.

If this was a potential treatment that I was being offered, I would want to have those questions answered before I agreed to have it.  

Simon Walsh is a consultant in emergency medicine and deputy chair of the BMA consultants committee

[1] This is the term which is being used by NHSE/I instead of ambulatory and emergency care.