Reliance of 111 on non-clinical staff has increased pressure on emergency departments, MPs say

The 111 urgent care telephone hotline has failed to relieve the pressure on accident and emergency departments in England since its introduction in April and needs to be remodelled to give greater priority to early clinical assessment, MPs have concluded.

In its report on urgent and emergency care services, published this week,1 the House of Commons health select committee said that the reliance on non-clinically trained staff to triage 111 calls had led to some patients attending emergency departments unnecessarily.

The inquiry has been prompted by growing fears about the strain being placed on emergency departments and comes after the College of Emergency Medicine warned that problems with the new urgent care hotline had contributed to the “severe pressure” on emergency departments.2 3

MPs concluded that NHS 111 was introduced “without a sufficiently sound evidence base,” undermining previous ministerial claims that a pilot study had provided enough evidence to support a national rollout.4

The committee said, “In its current configuration we do not believe NHS 111 will help keep people from inappropriately attending A&E.” It added that the way to deal with this was for NHS England to review the balance between triage and early access to a senior clinician in 111 services, to give “higher priority to the principle of early clinical assessment.”

The report, which will feed into NHS England medical director Bruce Keogh’s review of urgent and emergency services,5 cited delayed discharges from hospital and staffing shortages as contributory factors to the pressure on the system. MPs expressed “considerable concern” that only 17% of emergency departments in England have recommended numbers of consultants on duty and said that more must be done to recruit trainees to emergency medicine.

The committee said that it was concerned that the government had failed to give sufficient clarity on how new urgent care boards would oversee local arrangements across the country. It added that the introduction of the new boards alongside clinical commissioning groups and health and wellbeing boards could blur the lines of responsibility, and said it was vital that a single commissioning team for urgent care was in place in each area of the country.

It recommended that NHS England should ensure all urgent care plans are agreed before 30 September 2013 to help avoid a repeat of this winter’s crisis, when nearly 40% of hospitals missed the emergency department waiting time target in the last quarter of 2012-13.6

Longer term, the committee said that NHS England should also explore ways to develop integrated community based urgent care services, but it added that this would require “substantial restructuring of existing services,” with primary care in its current form unable to absorb additional work.

The committee said that during the course of the inquiry it had heard conflicting evidence from the likes of health minister Earl Howe,7 College of Emergency Medicine president Mike Clancy, and the chairwoman of the Royal College of General Practitioners, Clare Gerada.8 It called for the government to ensure that the root cause of the problems was established, as accurate information was “fundamental to the delivery of high quality care.”

Stephen Dorrell, chairman of the health select committee, said, “The A&E department is the safety valve. When demand for care is not met elsewhere, people go to A&E because they know the door is always open. It is vital to ensure that the needs of patients who don’t need to be at A&E are properly met elsewhere so that those who do need to be there receive prompt and high quality care. We were not convinced that the plans presented to us represented an adequate response to the challenges the system faces.”

He added, “It is disappointing that the decision was made to launch NHS 111 when so little evidence had been gathered to support it. We are concerned that having to speak to a call handler and going through a laborious triage process will only encourage patients to see A&E as their first port of call.”

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