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Facing the facts on 111

Thu, 15th Aug 2013

No apologies for returning to health this week. On BBC Radio 4, a Face the Facts edition by John Waite perfectly summed up the cul-de-sac we have run ourselves into with the NHS: having given a forensic description of what went wrong with the disastrous 111 number, the programme utterly failed to draw the conclusions of its own story and offered no hint of a way out of the vicious circle of rising demand and rising cost.

111 had its genesis in a 2010 decision to replace NHS Direct, in the official narrative an accepted, well-respected resource for patients, especially at night and at weekends when the rest of the NHS was closed, and for the NHS a means of relieving pressure on GP surgeries and A&E departments. The 'problem' was that it was expensive (about £123m a year); so the idea, no doubt underpinned by expensive consultancy advice, was to use technology to make efficiency gains by economising on highly-paid professional medical staff.

In other words, 111 was conceived of as a network of standard call centres of the kind that every customer loves to hate, manned by call handlers with no technical knowledge, reading a script from a screen, with professional expertise 'on call' behind. Just as classically, NHS England put contracts out to tender based on unit cost, or cost per call. The benchmark, according to Peter Carter, general secretary of the Royal College of Nursing, was £7 for a non-clinical call and £10 for one that had to be referred on to a clinician. Carter said: 'The only way they [the contractors] can do it is by compromising the staff mix – they're trying to do it on the cheap'. 

When the system went live in April, the result was as wearily predictable as the 111 computer script. Technology malfunctions were the least of it. Lives have been endangered if not lost because neither patients nor computer programmes can easily distinguish between conditions that are really non-urgent and those that look it but aren't (as a doctor noted, some conditions are almost impossible to diagnose over the phone but easy and instant for a trained physician in person). In other words, the system is unable to absort the presenting variety – a computer script is an utterly inadequate substitute for trained human judgment.

Meanwhile, as at any script-driven call centre managed for cost, call-handler morale was low and turnover consequently high. Staff felt undertrained and overworked and looked on in dismay as many colleagues treated it as casual work, clocking on for a few hours and then drifting away again. Call handlers left because they found it 'just a really depressing environment'. 

But as ever, cheap actually isn't cheap: managing costs breeds more costs. Under the previous regime the original incumbent, NHS Direct, had been getting £24 a call, and its first bid for 111 contracts was too high. So it 'reworked the figures' to get under the hurdle and was duly awarded 11 areas, the largest provider. Unfortunately, its first calculations were nearer the mark. Calls were taking double the five and seven minutes estimated for unreferred and unreferred-on calls, for which it was paid from £7 to £10. It pulled out of two contracts even before the launch and now wants to give up the rest as financially unviable.

As depressing as the litany of failure is the response to it. NHS England claims that 111 provides a 'safe, proven, consistent clinical assessment of callers' symptoms', and that 96 per cent of calls are answered within 60 seconds. Even critics assume that the issue is teething problems and poor execution. NHS Direct is blamed for 'getting its sums wrong', and the government for rolling 111 out too quickly and trying to cut corners on cost. Rising demand is taken as a given. Also taken for granted is that 111 is necessary – so the only solution is to do it better (read: more expensively).

In fact, everything about 111 was wrong from the beginning, including its purpose and starting point. But you wouldn't know that. Nowhere is there a hint that the 111 story is not about doing things wrong, but doing the wrong thing. Nowhere is there a hint that the cost and time that matter are not cost and length of call, still less the time taken to pick up the phone, but the end-to-end cost of solving the problem so it doesn't recur. Nowhere is there a hint that the only sensible way forward is to establish the real, as opposed to repeat and knock-on, volume of underlying demand and design a system to meet it, 24/7. 

There being, in short, no sign that anyone has learned anything at all, the prospect is that we will do the same thing all over again and expect a different result. Which, as Einstein declared, is one definition of insanity.

 

 

 

 

 

 

 

 

 


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User comments

Henning :: 19th Aug 13
Couldn't be more right!
Alan Tomlinson :: 20th Aug 13
Thanks, Simon, for so clearly restating what I take as the basis of systems thinking but fumble in explaining: the cost and time that matter are not cost and length of call, still less the time taken to pick up the phone, but the end-to-end cost of solving the problem so it doesn't recur. But then I suppose that end-to-end cost is hard, if not impossible to measure, which is one reason why people fall back on what is clearly measurable.
Harry Longman :: 18th Sep 13
Thank you Simon for putting this so well. I've blogged on this subject a couple of times and was interviewed for the programme (didn't hear it as I was away - did they quote me?)
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