A crucial part in urgent care is an increase in telephone advice provided by a mix of clinicians through the IUC clinical assessment service (CAS). It can be argued that, at least in the out-of-hours period when the large majority of 111 calls are received, the pendulum is swinging partway back. In the old model, a caller
A crucial part in urgent care is an increase in telephone advice provided by a mix of clinicians through the IUC clinical assessment service (CAS). It can be argued that, at least in the out-of-hours period when the large majority of 111 calls are received, the pendulum is swinging partway back. In the old model, a caller
was effectively guaranteed a telephone assessment with a clinician. Then we had an algorithm-driven solution delivered by non-clinical call-handlers using NHS Pathways. The new IUC CAS, where perhaps 50% of cases will be referred to a clinician, is a move back to the middle ground.
The commissioning standards for IUC have provided an opportunity for commissioners and providers to look at how the service operates. It empowers them to make changes so that patients receive the best care (including advice and reassurance over the phone) and, crucially, are directed towards the right service and skill group. Having worked with 111 and out-of-hours services, benchmarking and analysing their data, NHS England asked us to develop a financial and capacity model of how such a service might operate. It has been a privilege to work with the dozen areas applying the model,
exploring potential benefits and pitfalls of introducing a CAS. This article focuses on the operational processes and I hope it captures the richness of the debate.
First some facts about NHS 111. Even today, there are places where GP out-of-hours callers do not dial 111. Demand has stabilised or is rising only slowly in places where the arrangements are consistent.
The demand during the in-hours period is only just over twice that at 3am. Less than a quarter of all demand is during the in-hours period and, for primary care dispositions to ‘contact GP’ (a face-to-face consultation) or ‘speak to GP’, only one in six occurs in hours. This is not surprising with the availability of local services during the working day, but it is also a clear indication that 111 needs to be well integrated with face-to-face services during the traditional out-of-hours period.
Finally, in looking at the features of a CAS there is a worry that the additional clinical input will increase cost with, potentially, uncertain benefits. This is unfounded. In many areas, all the calls passed to primary care out of hours are assessed on the phone by a clinician, and many are completed at that stage, which reduces the numbers seen face to face. In these areas the clinical resource for the IUC CAS is already in place, although there may be good reasons for adjusting the mix of skills to meet the need at different times. The existing resource is sufficient to allow 50-60% of cases to be assessed in an IUC CAS. In areas where ‘contact GP’ dispositions are booked directly, that system is in place too – but it is deployed seeing more patients face to face.
Given this, how does the IUC CAS need to operate? There are a number of factors providers will need to address if the service is to reduce pressure on both the urgent and primary care systems by satisfactorily completing cases on the phone.
Minimising the occasions on which a caller speaks to more than one clinician
If a call is passed from a call-handler to:
a nurse to a GP and then to a mental health specialist much more resource is used than is desirable and the process is frustrating for the caller. There are a number of approaches that will help:
• Using rules to categorise patients is one approach. These are based on combinations of age bands, symptom group, disposition and the use of flags to identify frail or palliative care patients. Those with
a symptom group of ‘unwell, under one year old’ are highly likely to be seen face to face. But those with a symptom group of ‘pain/frequency passing urine’ who are less elderly are more likely to be suffering from uncomplicated lower UTI and can often be assessed by phone and given a prescription without being seen face to face.
• The use of interactive voice response systems allows patients with, say, toothache or those seeking advice about medication to identify their need so that they can be directed to a dental nurse or pharmacist.
• Clinical navigators can be used to manage the queue of cases waiting for phone assessment, directing them to particular skill groups or encouraging clinicians, within limits, to pick cases that they feel competent to deal with and leaving the obviously complex case to the GP.
• Making more use of call handlers, training them to recognise complexity and to flag calls for the appropriate clinician.
• Arranging for a senior clinician to provide support to other clinicians, perhaps through ‘floor-walking’ (as used for call handlers), through the clinical navigator or by arranging clinicians in groups.
• And, finally, clinicians must be clear
that their objective is to complete the case on the phone themselves if that seems possible. Otherwise, they must recognise the need for the patient to be seen face
to face early and direct them to the right place. To support this, we should measure and feed back to clinicians comparative
information about cases completed with homecare advice, cases passed on for further phone assessment, cases referred to ambulance and, perhaps when we can join the data, information about the proportions of patients that followed the agreed plan.
Call handlers can maximise the value added by clinicians
There is little value in a clinician assessing a patient on the phone to reach the same disposition as the call handler (except when reassurance is needed) – the extra step just introduces delay. Yet we know that often clinicians can successfully and satisfactorily provide reassurance, advice
be necessary to be seen I can book you an appointment in … hours at…’ This approach might offer advantages. Certainly, we know that NHS Pathways is poor at identifying which cases might be completed over the phone. More than half of recommendations to speak to or see a GP are completed by phone when assessed by a clinician.
• The second step is to build on the suite of information in NHS Pathways that supports call handlers in giving advice
on the management of symptoms. Call handlers are already trained in providing this advice. Although NHS Pathways was designed for self-care advice to be provided by the call handler, a decision was taken that a clinician should always follow up with patients given self-care advice. We might reduce the instances when clinicians add little value if call handlers then asked ‘Would you like me to arrange for a clinician to ring you to explain more, or are you happy with the advice I have given?’
Manage the call so that the patient follows the plan
Call handlers and clinicians using NHS Pathways get extensive training. But there is inconsistency in how they manage the call. Some, early in the process, ask an open question along the lines of ‘How can I help you?’. By referring back to the answer that the patient gives (‘I know that you wish to speak to the doctor about Thomas, but first I need to ask some questions for safety’) the call handler is better able to manage the conversation. This is, I believe, a lesson that needs spreading.
But there is something else too. When the call handler reaches the end of the assessment, more than 5% of cases are identified as ‘disposition refused’. But, as commissioners and providers join A&E data to that from 111 they see this is only the tip of an iceberg. Significant numbers of patients use a different service from the one we expected from the call. Training call handlers and clinicians to agree the plan with the patient is important. If the recommendation is ignored, there is little value in the process.
Not using 111 for everything
The 111 portal should be the default number. But it should not be the only number.
There are great advantages if those with a palliative care need are given a different number to call, and also those suffering a mental health crisis. It is then possible to route these calls to the right group.
Conclusions
The ideas described are mainly untried and untested – so the first step is to experiment and develop them (with appropriate clinical oversight and risk management). But these are things that can and should be tested. Providers and commissioners should work closely together on this as it will be an important part of delivering a clinical assessment service that works. Meanwhile commissioners will also be well advised to consider the likely impact on demand of some of the other changes in the offing. Have they, for example, assessed the impact of extended hours working? Will it reduce the demand at weekends near to that of the weekday? What about the introduction of an online clinical decision support tool – will this head off demand or fuel its growth? And the role of the IUC CAS in providing support to clinicians across the system – how much will this be used by general practice, by hospitals looking to discharge patients
as well as by community services and paramedics? There is much to be done – and there will still be a need for contracts to recognise the levels of uncertainty building flexibility into the arrangements. But smart commissioners and providers are working hard to answer these questions.
Henry Clay is a director of the Primary Care Foundation, which seeks to support the development of best practice in primary and urgent care
References
1 NHS England (Sept 2015) Commissioning standards – Integrated and Urgent Care
2 NHS England (to Jan 2017) NHS 111 Minimum data set available at england.nhs.uk/statistics/statistical-work- areas/nhs-111-minimum-data-set/nhs-111-minimum-data- set-2016-17/
3 Primary Care Foundation (March 2017) Analysis of data from a number of providers
