The work, workforce, technology and organisational implications of the '111' single point of access telephone number for urgent (non-emergency) care: a mixed-methods case study

Article history

The research reported in this issue of the journal was funded by the HS&DR programme or one of its proceeding programmes as project number 10/1008/10. The contractual start date was in August 2011. The final report began editorial review in November 2012 and was accepted for publication in April 2013. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Declared competing interests of authors

Catherine Pope is a co-applicant on a National Institute for Health Research Programme Grants for Applied Research programme (the Healthlines Study) led by Professor Chris Salisbury on behalf of NHS Direct.

Copyright statement

© Queen’s Printer and Controller of HMSO 2014. This work was produced by Turnbull et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

Rationale

The NHS 111 service represents a large-scale and fundamental change in the way that urgent care is delivered. It is predicated on the use of new digital technologies (notably, but not only, a computer decision support system – a CDSS – and telephony) and significant labour substitution, in particular the greater use of non-clinical staff to deliver health services. It seeks to integrate a range of different health services in the context of an increasingly complex landscape of health services and significant increases in demand for health care. In addition, it is a complex service innovation that has been introduced at a time of significant system reform. All of these factors make the new NHS 111 service a compelling case study. For us, NHS 111 provided a timely opportunity to empirically investigate four core features of health-care innovation and change, namely the way in which work and workforce is organised for this new service and how both the technology and the organisational context shape the way in which services are delivered. The aim of our project was to understand the implications of these inter-related aspects for the organisation and delivery of modern health services and inform workforce planning and organisation. This report presents a comparative case analysis of NHS 111, focusing on these four aspects of work, workforce, technology and organisation. The remainder of Chapter 1 explores the background literature and outlines our objectives and approach.

Urgent care context

Urgent care is typically defined as ‘the range of responses that health and care services provide to people who require – or who perceive the need for – urgent advice, care, treatment or diagnosis’ (p. 12). 1

It may draw on a wide range of services including general practitioner (GP)- and nurse-led care as well as dentistry and social and mental health acute crisis teams. In England there is a range of specific urgent and unscheduled care services including out-of-hours GP services, minor injuries units, NHS walk-in centres and the telephone service NHS Direct (the national nurse-led telephone service) that come under the umbrella of urgent care. At times urgent care may also overlap or interface with emergency care provided by ambulance services and hospital emergency departments (EDs).

The pressures on both emergency and urgent care health services in the UK have been increasing. Calls to the national 999 ambulance service increased by 3.36 million (42%) between 2002 and 2011. 2 The increasingly fragmented nature of urgent care provision has made it difficult to assess demand but Richards et al. 3 reported a 26% increase in out-of-hours calls following the introduction of the new general medical services contract in 2004 [an agreement between general practices and primary care trusts (PCTs)]. 4 Calls to NHS Direct have increased by 20% every year since its introduction in 1997. 5 There continue to be debates about the appropriateness of service use. For example, in 2011–12, 4.17 million 999 calls (37.9%) were classified as category C (presenting conditions that are not immediately serious or life-threatening), which may be considered ‘urgent’ or non-emergency rather than emergency cases. 2 Government policy has sought to tackle rising demand whilst simultaneously aiming to improve services and reduce costs. 6,7 Workforce reconfiguration and digital information and communication technologies (ICTs) are seen as key tools in achieving these ends.

The need to better integrate urgent and emergency care services has long been recognised. The Carson review of out-of-hours care8 argued for geographical integration of out-of-hours services to manage urgent care more effectively, improve access and thereby increase patient satisfaction. The report was followed by a pilot that used the NHS Direct telephone triage and advice service to integrate out-of-hours urgent and emergency care,9 although this model failed to be widely adopted.

Six years on from the Carson review, a National Audit Office report10 concluded that urgent care continued to be characterised by a widely divergent market with multiple providers, leading to understandable confusion on the part of the public. More recent government reports and consultation confirmed this view. 6,11 The NHS 111 service has been proposed as a solution to this problem by providing a centralised, efficient, recognisable entry point to the NHS which can co-ordinate and integrate services to connecting patients to ‘the right place, first time’.

The NHS 111 service

NHS 111 is a new telephone-based service that allows callers to access urgent health care 24 hours a day. It has been publicised as a service for patients to call ‘when it’s less urgent than 999’12 and it is targeted at callers who:

• need ‘medical help fast’ but the problem is not life-threatening

• are unsure about what service they need

• need to access care out of hours

• ‘don’t have a GP to call’

• need health information or reassurance about what to do next.

NHS 111 offers clinical telephone assessment (triage), advice and referral when necessary to an appropriate health-care provider. To date, all NHS 111 services are underpinned by a single CDSS technology, NHS Pathways (see http://systems.hscic.gov.uk/pathways). Trained non-clinical call advisers answer telephone calls to the service and use this CDSS to support questioning to assess a patient’s symptoms, provide health-care advice or direct the patient to the appropriate local service. The NHS Pathways assessment concludes with a ‘disposition’, which sets out the level of clinical care required and the time frame in which is must be accessed. Possible referrals (dispositions) include to accident and emergency (A&E), an urgent care centre (UCC), an out-of-hours GP, a NHS walk-in centre and an emergency dentist or pharmacist, and NHS 111 call-handling staff can directly book appointments with some of these. If necessary, calls resulting in an ambulance disposition are directly routed to 999 services. NHS Pathways was piloted in an emergency (999) ambulance service and a primary care out-of-hours telephone service. It is currently licensed for use by NHS ambulance services for the management of 999 calls and the safety and accuracy of the CDSS has been evaluated in this setting. 13

The landscape of urgent and emergency health-care provision is changing as a result of health-care reorganisation, which has altered both service commissioning and the range of providers in the sector. From April 2013 clinical commissioning groups (CCGs) directly commission these health services. CCGs can commission services that they consider ‘appropriate to meet reasonable local needs’ and from providers who are best placed to deliver the needs of their patients and populations. Services can be provided by ‘any qualified provider’ from the public, private or third sector (p. 4). 14

How this research builds on our previous research

Our previous National Institute for Health Research (NIHR) Service Delivery and Organisation programme project ‘Ethnography and survey analysis of a computer decision support system in urgent out-of-hours, single point of access and emergency (999) care’ (reference no. 08/1819/217),18 published in 2011, highlighted the importance of effective workforce planning, management and training in the successful implementation and continued use of the CDSS that underpins NHS 111. It shed light on the ‘work’ and effort required to bring a CDSS into successful use in a similar service setting. We showed the potential for the CDSS to intensify the work of call-handling, and demonstrated the complex relationship between expertise and experience required for using CDSS on a day-to-day basis.

The current follow-on project extends what we have learnt in the context of the roll-out of the new national single point of access NHS 111 service. The study was designed to complement the PRP-funded University of Sheffield evaluation of NHS 11115 (see Chapter 7) and to focus on how the NHS 111 service changes the organisations that deliver it and the wider organisation of health care, notably the implications for work, workforce configuration and training.

Aims

Our aim was to examine the work, workforce, technology and organisation required to deliver the national integrated three-digit number (‘111’) single point of access to urgent (non-emergency) care services. We addressed the following research questions by undertaking a comparative mixed-methods case study approach to understand the implications of these inter-related aspects of the new service in order to inform the organisation and delivery of modern health services.

Research questions

1. What is the work of NHS 111? This examined the everyday work tasks and activities involved in delivering the services and integrating care provision.

2. Who is the NHS 111 workforce? This examined the experience and skill sets of this new workforce and identified education and training needs of workers and how this workforce might be developed and maintained; and examined role differentiation and division of labour (e.g. how tasks are divided formally and informally between staff).

3. What is the technology for NHS 111? This explored the technologies underpinning the service and the complex sociotechnical interactions required to bring them into use, including configuration and use of these technologies.

4. What is the organisational context of NHS 111? In order to situate questions 1–3, this examined the organisational effort and environment, to compare and describe structures, practices and service integration within the wider political, sectoral and organisational settings (within NHS 111 sites and the wider network of providers); explored the extent to which integration has been achieved; identified how information and knowledge are shared across the full range of services integrated by NHS 111; and examined how trust and knowledge transfer varies across the NHS 111 health economy.

Theoretical approaches

Our previous study used normalisation process theory. 19 For the current study, although the theoretical constructs of normalisation process theory were helpful in addressing the four research questions, we found that it was more helpful to draw on other expertise across the research team in analysing the data. This included, but was not confined to, insights from science and technology studies about networks and in particular the relationship between technology and human actors,20,21 and insights from social psychology around trust and team work, which informed the survey design and analysis. 22,23 These theoretical ideas have informed our analyses and will be drawn on in further outputs from this study. We agreed that it was less appropriate to structure this report around particular theoretical constructs and instead we have used the four research questions to organise this report.

Outline of the report

The remainder of this report is structured around our four research questions. Chapter 2 details our methodological approach and describes the research study sites. Chapters 3–6 present our findings based around our research questions (on work, workforce, technology and organisation). Chapter 7 reports the workshop that we held to discuss and integrate the findings of this project with the findings of the Sheffield PRP-funded evaluation15 and Chapter 8 concludes the report and explores the implications of this work for future research.

Introduction

In this study we used a detailed, comparative mixed-methods case study to understand the inter-related aspects of work, workforce, technology and organisation associated with NHS 111 with the aim of informing the provision of 24-hour urgent care. At the time of our research funding application, we had intended to explore our research questions in the three pilot sites delivering NHS 111 services. These three sites covered three distinct geographical areas. However, for reasons detailed in the following section we increased the number of sites from three to five (see Appendix 1). We used survey and qualitative methods to collect our data. Specifically, we used ethnography (comprising observation, informal interviewing and focus groups) to explore everyday work, workforce configuration and organisational contexts and an online survey to examine staff views about NHS 111, the technology and information sharing between NHS 111 service providers.

Selecting case study settings

Following the launch of four NHS 111 pilot sites in 2010, at the start of our study in August 2011 we were aware that four ‘second-wave’ sites had been commissioned to provide a NHS 111 service and planned to launch during 2011. This offered us a wider choice of settings and organisational models from which to sample. The different NHS 111 providers were characterised by differences in organisational size, form and ethos and in the type of workforce employed and professional roles and skill mix within it. With regard to location they varied in terms of spatial and population characteristics and in the extent to which emergency and urgent care services were co-located. We discussed the choice of sites in the research team and with our advisory group (see Appendix 2). This larger number of possible sites offered the opportunity to explore the implications, benefits and challenges across very different organisational models that include both private and social enterprise providers as well as different NHS organisations. Guided by our discussions with the advisory group we agreed that our main criteria for the selection of case studies should be to maximise variation in type of NHS 111 providers (public/private/social enterprise and different types of NHS trusts) and to reflect geographical variation by including a mix of north and south and urban and rural locations.

In light of the above, five sites providing NHS 111 services in 2011–12 were chosen as case studies rather than three, as suggested in the proposal. We felt that this both was practically manageable and offered the combination of familiarity and detailed understanding of local context and the opportunity to provide systematic analytical and theoretical generalisation. 24 We focused our attention on two core activities of NHS 111 services, namely call handling and UCC provision. This was in part a pragmatic decision as we did not have the resources to examine all of the possible providers of urgent and emergency care services (e.g. late-night pharmacies or emergency dental services). We were also mindful that UCCs received the highest proportion of referrals from NHS 111 (in the form of either transfers for telephone consultation or face-to-face consultation at the centre or requests for a GP home visit). Each case study site described in this report therefore includes both the NHS 111 call-handling centre and its linked UCC(s).

The study combined ethnographic and survey methods and is described in more detail in the following sections.

Ethnography

The ethnographic component of the study included direct observation of staff at call centres and at UCCs, informal interviewing of staff at these locations and a series of focus groups with staff and key stakeholders. This part of the project aimed to provide a detailed, nuanced understanding of the everyday work, workforce configuration and roles, technology and wider contextual factors in each setting. Our previous research18 looking at the same telephone call-handling decision support system in the context of emergency and urgent care using the same methods informed this aspect of the study.

Survey

The case study sites

The case study sites included different models of NHS 111 service provision (Table 4). There were some key organisational differences including:

• The type of organisation that provided call handling. Two sites (sites 1 and 3) were ambulance services, two (sites 2 and 4) were out-of-hours organisations and one (site 5) was a commercial provider. Our study did not include a NHS Direct-led service.

• Length of experience using NHS Pathways and providing NHS 111. Sites 1 and 2 had considerable experience of NHS Pathways prior to the launch of NHS 111 and were two of the earlier sites to pilot NHS 111. In comparison, site 5 was relatively new to NHS Pathways and NHS 111 during the course of our study.

• The size of population covered, ranging from approximately 140,000 to 760,000.

• The existence of UCCs. UCCs existed in all sites. The number (and location) of UCCs reflected the size of the population and urban/rural geography. UCCs at sites 1, 3 and 4 were open to walk-in patients as well as NHS 111 referrals. In site 4 the call-handling organisation also operated the UCCs.

There was some variation in workforce roles at each site (Table 5). All of the sites except for site 2 had call advisers, call adviser supervisors and clinical advisers; in site 2 the clinical advisers were employed by a different organisation in a different location. Site 2 based its GP telephone consultation role at the call centre rather than at the UCC. All services had links with district nursing teams remotely, but site 3 additionally based a district nurse at the call centre during the out-of-hours period. Call advisers are referred to by different titles at different sites, such as health advisers, call assessors and call advisers. For consistency we will refer to this role as call adviser (in line with the Department of Health description). 12 At some sites clinical advisers are also referred to as clinical support desk (CSD) practitioners and nurse advisers. For consistency we will refer to these staff as clinical advisers.

At UCCs all sites employed GPs to provide telephone consultations as well as face-to-face consultations at the centre and home visits. At sites 1 and 4 ECPs worked alongside GPs in this role and undertook similar duties to GPs. Site 4 also employed NPs in a similar role.

In Chapters 3–6 the results of the ethnographic data collection (observation and focus groups) and the survey findings have been combined. The following abbreviations are used in the presentation of the qualitative data to indicate sources:

• CallA – call adviser

• ClinA – clinical adviser

• CallS – call supervisor

• CMgr – call manager

• DN – district nurse

• ECP – emergency care practitioner

• GP – general practitioner

• NP – nurse practitioner

• SMgr – senior manager.

Types of calls received by the NHS 111 service

Many calls made to the NHS 111 service were about symptoms that included coughs, colds, sore throats, rashes, fever, sprains, headaches, abdominal pain, vomiting and diarrhoea. Typically, staff reported higher volumes of calls from certain populations, such as parents of young children and more elderly patients, consistent with the literature on out-of-hours and unscheduled care. 26 Calls were received about a broad range of issues including requests for health information (e.g. contraception advice or medication advice) or a repeat prescription. Staff at some sites, particularly those who had previously provided a single point of access or out-of-hours service (sites 1 and 4), believed that the introduction of NHS 111 had generated calls about a broader range of issues. Staff perceived that this was also the result of changes in patients’ expectations of health services more generally:

[It’s] changed quite a lot, now we’ve took 111 on . . . We get a lot of calls now for patients just wanting a bit of information and advice . . . how to take some medications . . . Before, we just basically helped people who were unwell. Now, it’s help and advice . . . it’s a lot different to how it used to be.

CallA4, focus group, site 4

People want more immediate . . . help now. People are going to come up to [UCC] to get a bottle of Calpol on prescription free of charge [rather] than pay £2.50 or whatever . . . at [the pharmacy], aren’t they?

CallS1, focus group, site 3

Health-care professionals and other services also called NHS 111 to obtain appointments for patients in their care or to seek advice, including calls from nursing or residential care, usually by a nurse or a care assistant/manager. When calls are made by a qualified health professional the patient is not triaged; instead, a decision is made about the type of care and speed of response needed. Other calls are received from the probation service, the police service, social services and paramedics or other health professionals. Site 4 had an alternative, dedicated number for patients who had identified chronic or palliative care needs, with calls answered by NHS 111 staff but referred directly to a clinician for assessment.

Call advisers and clinicians alike spoke of the prevalence of calls concerning ‘social problems’ or mental health problems, with callers seeking reassurance or a friendly ear to talk to. Once a medical need is ruled out, call advisers may provide unscripted reassurance or support (i.e. not prompted by NHS Pathways), relying on their communication skills and experiential knowledge. These types of call were sometimes from ‘repeat’ callers to the service:

So you are getting a bit angry are you? Have you done anything? So you are having a few problems with your ex-girlfriend. Let’s just take a few details and we can get you some care [. . .] Have you got people you work with on this feeling angry? Have you spoken to them?

CallA20, observation, call centre, site 1

[There is a call] from a female repeat caller. She has already made three 111 and 999 calls today and was attended earlier by an ambulance. The clinical adviser says ‘put it through as a doctor [disposition] . . . we can’t keep sending crews’.

Observation, call centre, site 3

Staff suggested that the general public are sometimes confused about when to telephone NHS 111, for example using 111 rather than 999 or vice versa or not being clear what NHS 111 is for. A range of factors is likely to influence a patient’s decision to call NHS 111, but staff believe that the way in which NHS 111 is advertised could create additional demand, exacerbated by ‘111’ being a free telephone number:

One of the biggest hang ups with 111 is the poster; it is kind of like creating a need; ‘if you need medical help fast call 111’; what does that mean?

CallA3, observation, call centre, site 4

At all sites the NHS 111 service received calls from people who reported that they were unwilling or unable to obtain an appointment at their GP surgery or, in some cases, with their dentist. Patients were sometimes confused by the fact that NHS 111 is a 24/7 urgent care number but they were often advised only to try telephoning their GP again, or to attend the local walk-in centre when one was available. This may also be exacerbated by GP surgeries encouraging patients to call 111 when same-day appointments were not available, as well as transferring calls to NHS 111.

When CallA1 finishes the call she says [with sarcasm], ‘they’re good these doctors surgeries! This guy phoned up for a visit and was told by the surgery, “we can’t get someone out now, so phone out-of-hours” ’.

Observation, call centre, site 2

The clinical adviser says that there are a number of patients who are ‘working the system’ – i.e. bypassing routine general practice and presenting to 111 instead.

Observation, call centre, site 4

All sites suggested that some GP surgeries are advising patients to use NHS 111 during the daytime as an alternative, causing tension between those working within NHS 111 (call advisers, clinical advisers and GPs) and those working at GP surgeries. At least two sites (sites 1 and 4) now routinely record all reports that patients have been advised to phone 111 by their GP practice as well as those surgeries that transfer their telephones over to the 111 number early. Some sites were keen to see greater integration with GP surgeries, including being able to book routine GP appointments, but recognised that many surgeries would be reluctant to do this.

The GP tells CallA19 about a GP surgery ‘that were refusing patient appointments from 5 pm and saying they were going in an hour and to phone 111’. The GP appeared quite angry: ‘it’s wrong’.

Observation, call centre, site 2

The surgeries are . . . not joined for us to be able to follow the call all the way through. I’ve just had a call now, where a patient couldn’t see their doctor for two weeks [. . .] A lot of the patients are using the 111 service purely because they can’t get what they need from their doctor’s surgeries. So they don’t even attempt the doctors’ surgeries . . . they go via 111 to start with, thinking that they’re going to get more out of 111 than they are . . . then it’s not the case, because we can’t offer them anything at the end of the disposition.

I’ve had this said to me, particularly at weekends or on a Friday, ‘well, if I ring you, I know that I’m going to be seen . . . because I know that if I wait ’til Monday morning, I’m never going to be seen’.

That’s misuse of the service, though, isn’t it?

It is . . . misuse but . . . we’re always going to generate that.

But some patients wait, don’t they? They’re at work . . . they wait till they get in, and then . . . So . . . that’s all changed.

They’ve got a good service from us in the past, they’ll use us all the time, because you’re not going to get good service from your doctor, are you? You know that. You can ring us, we assess them, takes six minutes, they’ve got an appointment within the half an hour, and they’re happy, aren’t they, really, because they think ‘this is great; I’m going to come here again’.

Focus group, site 4

In summary, the NHS 111 service receives calls about a range of issues that are broader than urgent care and some staff are concerned that the NHS 111 service may have increased the number of ‘non-urgent calls’ (compared with out-of-hours services). There is some confusion for some patients about the purpose of NHS 111 and what it can be expected to offer. The types of calls received by NHS 111 shape the everyday work for call advisers, clinical advisers and UCC clinicians working within NHS 111 care provision.

What is the work of call advisers?

Call advisers are mainly employed to provide clinical assessment using NHS Pathways and to direct patients to the most appropriate care, as indicated by the CDSS disposition. Call advisers are responsible for directly arranging care for patients, when appropriate. This commonly includes transferring a call to a clinical adviser for further assessment or home advice, directly booking a patient a telephone or face-to-face consultation with a clinician at the UCC, arranging for a district nurse to visit a patient or arranging an emergency ambulance. In this section we outline key aspects of the role, including communication, emotion and quasi-clinical work.

What is the work of clinical advisers?

Clinical advisers support and collaborate closely with call advisers. Indeed, NHS 111 is promoted as a service that is ‘staffed by a team of fully trained advisers supported by experienced nurses’. 12 Largely, the everyday work of clinical advisers is dependent on call advisers, who define and prioritise their work. NHS 111 is designed so that calls are transferred to a clinical adviser at the time of the call whenever possible (known as ‘warm transfers’), so that patients experience ‘seamless care’. If no adviser is available the caller is offered a call back, but the call back should be made within 10 minutes. Clinical advisers at call centres are involved in three main activities: (1) supporting call advisers by providing them with clinical advice and taking calls that require further assessment, (2) managing or moderating NHS Pathways dispositions and (3) providing home management advice for patients. Clinical advisers also performed audit and/or training roles (see Chapter 4, Clinical advisers). It is important to note that we did not directly observe clinical advisers in site 2 as they were employed by a different organisation and were located elsewhere.

What is the work of call supervisors?

All sites employed staff to perform a ‘call and/or shift supervisor’ role, referred to by a range of titles (call supervisor, duty supervisor, shift manager); these staff varied in the exact nature of their role and responsibilities. Call supervisors play a key role in the operational management of call-handling and urgent care settings, routinely monitoring workload and workforce and ensuring that NHS 111 or local service standards are met. The role essentially is the operational hub for maintaining the smooth running and integration of the service, with the everyday work being to ensure the management of resources and the adequacy of cover for the whole region. This entails overseeing activities, managing levels of staffing and dealing with emerging problems. In some sites call supervisors also monitor call advisers and provide advice on using NHS Pathways (sites 1 and 2).

What is the work of urgent care centre clinicians?

Clinical assessments and dispositions made by NHS 111 call advisers using NHS Pathways shape the work of the clinicians who provide telephone or face-to-face consultations (at the UCC or during home visits). In sites where premises are shared with walk-in centres they also see ‘walk-in’ patients and have to balance the demands of walk-in patients with the demands of those who have been booked an appointment through NHS 111. UCC clinicians also take calls from other health-care professionals, providing clinical advice.

Summary

NHS 111 receives a wide range of calls, from life-threatening cases to those requesting health advice, dealing with physical and mental health as well as social issues. Building on our previous study, our observation shows that NHS 111 call-handling work is complex, involving high levels of communication and ‘emotion’ work. Call advisers engage in a range of everyday work activities that extend beyond being simple users of a CDSS to assess calls. The ways in which the work ‘gets done’ play out differently at each site, but all call advisers demonstrate a considerable level of skill in negotiation, communication and translation to mediate the assessment process, which enables the CDSS to work most effectively. Clinical advisers provide support and reassurance for call advisers but they are more ‘hands on’ in some sites than in others. They also play an important role in managing the use of ambulances. Variations between sites in how clinical advisers provide support seem to depend in part on the organisational culture of trust in call advisers and NHS Pathways to triage correctly and on idiosyncratic differences between particular clinical advisers related to their professional competence and attitude towards risk. Call supervisors typically are involved with managing and monitoring workload and staffing across NHS 111. In some sites they also play a role in supporting call advisers with their use of NHS Pathways.

Clinicians at UCCs provide further assessment and consultation, either on the telephone or face to face (at an UCC or at home), and their work is shaped by call advisers, clinical advisers and call supervisors working at the call centre, who determine how many patients are seen, who is seen and how quickly patients are seen by clinicians. Overall, staff at UCCs were less positive about NHS 111 than call centre staff.

Work roles

Professional boundaries: clinical and quasi-clinical roles

Within NHS 111, call advisers are non-clinical staff who perform clinical work (triage/clinical assessment) previously performed only by professionals. Call advisers at most sites position themselves as non-clinical workers by identifying themselves as call advisers when answering calls and often explaining to patients that it is not part of their role to diagnose or prescribe.

CallA20 says [to the caller], ‘we are not clinicians so we can’t really diagnose, but we just need to know what the main problem is. Is the rash under the arm the main concern?’

Observation, call centre, site 2

The patient asks CallA9 ‘I’m due for insulin shall I give it to myself?’ CallA9 is quick to inform the patient, ‘I’m not a prescriber’, and asks ‘is the leg the main problem?’

Observation, call centre, site 1

However, at the same time, the nature of the role involves clinical assessment, albeit supported by a computer. The everyday performance of asking clinical questions allowed these call advisers to identify themselves not as unskilled, generic call centre workers but as doing complex health-care work. Offering clinical information and advice, supported by NHS Pathways, adds a greater clinical component to the role. Call advisers often enjoyed being able to give this advice and felt that it was valued. Call advisers internalised knowledge of the system and the clinical information that it contained and consequently were able to anticipate questions before being prompted by the software. This was especially noticeable at sites where NHS Pathways had been deployed for several years. Additionally, those who had worked with the system for some time (999 and out-of-hours) drew on personal and experiential knowledge about medical conditions or health care:

[The manager] says that due to the nature of the work, they have renamed their call handlers as ‘call assessors’ to better reflect the job that they do.

Observation, call centre, site 3

Call advisers from the ambulance trusts tended to assert their ‘clinical knowledge’ to a greater degree and some call advisers spoke of clinical knowledge or knowledge outside of the system and crucially identified themselves as skilled workers, although they clearly recognised the distinction between themselves, clinicians and managers. Call advisers clearly distinguished their call-handling role from other non-health call-handling roles, and felt that their identity was more akin to health-care workers than call centre workers. There were some requests for a recognised qualification for NHS 111 call advisers as a means of formalising and recognising the training undertaken and legitimising call adviser identity.

[I would] like a recognised qualification, and a title as a health care . . . something to do with health in it so that they realise that they’re not just . . . you can be a call handler for a catalogue firm, or anything like that. I’m not belittling that . . . but just to recognise the work that they’re actually doing.

We’re almost health-care providers now, giving health-care advice, aren’t we? [general agreement]

It’s got a lot of responsibility attached to it, and I don’t think people realise [. . .]

. . . the other day, somebody collapsed in [shopping centre] in front of me. I went up to this lady, and says, ‘I’ve got no medical knowledge’, and I waited for this first aid person to come. But I turned to [colleague], and she says, ‘well, really, you shouldn’t say you’ve got no medical knowledge, because you do Pathways. You have got medical knowledge’.

And we do life . . . life support.

. . . basic life support, so . . . but really, we’ve not got a title [. . .] a recognition, that this is a clinical environment.

We’re giving health advice, aren’t we?

Recognised to the outside world that you’ve achieved this qualification . . .

It’s like, when we answer the phone, we say . . .‘111 call handler’ . . . I think some people instantly . . . don’t want to talk to you, because they think, well, you’re not medically trained [. . .] Because we say call handler it sounds more office-y and not health care.

Focus group, site 4

However, balanced against this identity as a ‘health-care worker’ was the belief across all sites that clinical input (from trained clinicians) is necessary to support call adviser assessment and mediate the system. The sense that clinical assessment and decision-making – and the responsibility that it carries – should be a clinical role was particularly strong in site 4. Call advisers at this site often commented that clinical advisers have the clinical skills to be able to manage more risk and the responsibility of home care and are ‘paid’ accordingly. They did not believe that taking such a responsibility was part of their job:

It depends on the nurse, so some nurses might be more confident to say, you can manage those symptoms at home. Depends how . . . how demanding the patient is, on what the nurse has done, why they’ve given them an appointment.

I’ve noticed, if you’re sat with a nurse . . . I was probing, and then she was taking what I thought . . . like, well, more . . . what I would have considered a risk, really, than I would have done as a call handler, reading it black and white.

Yes, because they know more.

Because they know more, and they’ve got more information, and I felt quite uncomfortable that they were trying to push me to go further, with . . . than I would have wanted to go.

That’s how I felt when I started, because I sat with a nurse all the time . . . I found it really helpful in one way, but in another way, not, because they were asking me to think out the box, which I couldn’t. I kept trying to say, I’m a call handler, and I can’t go off from what’s in front of me. I can’t think clinical like you.

Focus group, site 4

CA6 was critical of the call handlers who just exited, rather than triaging further to discover whether this history was relevant to the particular call in hand. She mentioned several times that some call handlers felt that they shouldn’t have to deal with the difficult cases because they weren’t nurses, not trained or paid to do that kind of thing.

Observation, call centre, site 4

CallA16 says that ‘we are not clinically qualified to make clinical decisions’ but ‘probing introduces an element of clinical decision making/can require a degree of this’. He says a number of times about not having clinical knowledge.

Observation, call centre, site 3

‘Inappropriate’ dispositions have a knock-on effect of increased workload, but there were also concerns about patient safety despite slightly contradictory concerns about the risk-averse nature of NHS Pathways. Frustration and blame were levied at call advisers and the technology:

ECP5 comes over and says ‘come into the consulting room so I can show you these calls’ . . . describing 111 as ‘flawed and inappropriate’. He says that [the information about the call says that this] patient is ‘under investigation for cancer and has a productive cough, as reported by his wife . . . but he doesn’t have a productive cough, he doesn’t have cancer and he doesn’t have a wife – she died 20 years ago’. It’s unclear how this error has occurred but the call handler is held responsible for inputting incorrect information.

Observation, UCC, site 1

ECP2 also has concerns about whether the service is safe for patients, which mostly relate to sending patients that need emergency department care to the UCC instead. He says that ‘someone will die’.

Observation, UCC, site 1

As a reaction to this, some call advisers were compelled to demonstrate their clinical knowledge, despite their lack of clinical training, and were forceful in characterising their role as a skilled – albeit non-clinical – job:

CallA27 tells me that someone from [an IT company] has been observing call handlers and is reportedly going to be a Pathways trainer but has not used Pathways before. ‘I think she was shocked by the number of calls and felt she had a lack of qualifications to do the job. I told her the job needs all sorts, qualified clinicians, GPs. You know, we’re not trained; you need all of us. We’re not qualified clinicians, but it’s a qualified job, it takes experience’.

Observation, call centre, site 2

CallA2 perceives that [some] doctors ‘talk badly’ to call handlers and don’t acknowledge their experience or skills . . . She tells me that she often makes it known to doctors calling 111 that she knows something about biology, or understands what is wrong with the person, reiterating ‘I’ll make the doctor know I’m aware; I’ll say “so it looks like it’s a stroke doctor, is that right?” ’

Observation, call centre, site 1

However, these attitudes towards call advisers were by no means universal, with some UCC clinicians acknowledging the skill required by call advisers and the complexity of the work. ‘Blame’ for perceived incorrect dispositions is sometimes directed at the technology rather than at the call advisers themselves:

GP2 says that he thinks the call advisers do a really good job and are ‘undervalued’. He says that they do ‘a very hard and serious job . . . one that sometimes involves quite complex decisions . . . but they are not always given the credit for this’.

Observation, UCC, site 3

ECP2 clarifies: ‘the call handler had not done anything wrong, but the triage didn’t come out right’. She appears a little reluctant to talk further but says ‘call-handling is increasingly becoming a skilled job’. She adds that she used to work for NHS Direct: ‘I had enough of using algorithms as a nurse, I found it hard, let alone as a call handler with no clinical knowledge’.

Observation, UCC, site 4

Some clinicians felt that call advisers could perform clinical assessment but needed additional training to extend their skills. Others commented that call advisers were not the problem and that the ‘system’ might be:

GP1 says that she thinks 111 ‘is better than NHS Direct used to be’. She says that the problem with NHS Direct was that you had ‘clinically qualified nurses who just used to follow the system and send every patient anyway’. She says that you might as well use non-clinical call handlers as they are less costly, but the end result is the same [i.e. most of the patients end up with a 999, emergency department or UCC disposition anyway].

Observation, UCC, site 1

In addition to the blurring of role boundaries between call advisers and clinicians, there was also some blurring of boundaries across different clinical professions. Clinical advisers triage, make decisions and assess clinical risk within NHS 111, so stepping into the domain of the GPs who have traditionally delivered out-of-hours triage. Although there is long history of nurse telephone triage and therefore this is not new, we note its presence within NHS 111. NPs and GPs were performing very similar roles in some sites. Professionals working within NHS 111 are delegating tasks to other disciplinary groups, such as the prescribing of medication by NPs and ECPs. In sites where ECPs or NPs worked alongside GPs in UCCs, typically these staff undertook similar roles across sites in dealing with face-to-face appointments and home visits.

ECP2 says that GPs do ‘99.99% of the home visits’ . . . but they share the UCC attendances. The UCC also sees walk-in patients as well. He says the ECP staff are a mix of nurses and paramedics [he himself was a paramedic].

Observation, UCC, site 1

There were also some differences in the roles they assumed across sites. For example, there was a local protocol in one of our organisations under which only GPs (and not ECPs or NPs) assumed responsibility for call backs to patients with mental health problems and ECPs rather than GPs tended to go on more home visits (site 4).

As with the relationship between clinicians and call advisers, tensions about role boundaries also existed between professionals. There was criticism of clinical advisers at call centres for lacking expertise, being reluctant to make clinical decisions and referring cases ‘upwards’ to the UCC. It is important to note that, although these perceptions were present in all sites, they were more extreme in site 1 than in other sites.

ECP2 questions the experience of the clinical advisers – ‘[they are not] sufficiently knowledgeable to make the necessary clinical decisions’ – and says when the service first started they took on a lot of nurses that had little or no experience of telephone triage, resulting in a lot of cases being ‘referred up the chain’. The call handlers refer the call to the nurse advisers/supervisors [within the call centre] who then in turn, refer the calls to the ECPs and GPs here at the UCC.

Observation, UCC, site 1

I had a child down as an urgent and when I got there they were just asleep and doesn’t need to be seen . . . 111 creates inappropriate prioritisation.

There are also only a handful of nurses who can deal with things fast and effectively, GP triage is better, it’s more efficient than nurse or 111.

Observation, UCC, site 5

Communication and relationships across NHS 111

We have seen in Chapter 3 how call advisers collaborate with clinical advisers and call supervisors. In addition to this, call advisers often worked together with other call advisers on more complex calls, actively helping colleagues (i.e. by looking up information). We have used the term ‘team’ to refer to groups of staff who work together within call centres (call advisers, clinical advisers, managers, trainers and auditors) and also teams of people who work together within UCCs (GPs, NPs, ECPs, reception and administrative staff). Team support was strong at all call centres, both in teams that had worked together for some time and in teams that were relatively new. Support also included praising and reassuring one another:

Call handlers seek advice or reassurance from other call handlers sitting with them fairly often. This kind of group support seems an important part of the role.

Observation, call centre, site 2

After a call where the call adviser found it difficult to obtain an answer from a caller who was ‘difficult’, the clinical adviser suggests that these types of cases really help people learn. She suggests that she herself also learns from this. There is a sense of mutual solidarity against the difficult nature of the work, and displays emotion work to make the call handler feel better [. . .] There is a sense that this type of call can happen to anyone.

Observation, call centre, site 5

The clinician says to one of the call handlers, ‘good investigation . . . well done’. It seems that the call handler’s probing identified a piece of important information that crucially affected the disposition the patient received.

Observation, call centre, site 3

Friendly humour illustrated the close working relationships important in a pressurised and sometimes stressful environment. Among call centre staff, humour contributed to a sense of being a team, community or ‘family’ and was a means of mutual support. Humour and laughing together was a means of bringing people closer together, building trust, cementing relationships, strengthening the team and equipping them to withstand stressful situations:

CallA7’s phone rings again and he exclaims, ‘why is it only me taking calls?’ There’s lots of laughter; CallA7 jokes ‘shh . . . this could be someone dying on the end’, laughing some more, before taking the call and the laughing stops.

Observation, call centre, site 2

There were also typically strong working relationships between call advisers and clinical advisers and call supervisors or managers. There was an inherent respect for the clinical skills of their clinical colleagues from call advisers and call supervisors, and for the most part this respect was mutual in that the clinical advisers acknowledged the skills of their non-clinical colleagues. Relationships were weaker when call advisers and clinical advisers worked for different organisations in different locations.

We’ve always had . . . and we really do have clinical respect, and I think it’s important . . . if I take my children to casualty, I want somebody clinical to see them [laughter].

Yes, but I think what’s changed now is that they’ve got respect for us because they realise . . .

. . . We’ve . . . we’ve got clinical respect for them, and we know, obviously, the importance of their clinical training . . . They’ve also got respect for us, because they know how hard our job is . . . they’re brilliant. They’re trying to help us all the time.

Focus group, site 4

CallA27 says, ‘I don’t know what to do, she has no worsening symptoms, but she’s been told to call back. I need to keep it in-house’. The call advisers opposite advise, ‘you could put it through to the doctor’, which he does. After the call CallA27 says ‘it’s all about keeping it in-house, keeping it with 111 and not sending it to [clinical advisers outside the organisation]. That one was sent internally as GP triage, as a red (urgent) flag, but was probably not red; we just want to keep it in-house’.

Observation, call centre, site 2

There were some differences in communication and team working between staff at different sites. This appeared to be primarily influenced by the spatial configuration of the call centre and by the organisational culture of the call centre. Co-location and close proximity of clinical advisers to call advisers and call supervisors appeared to foster an environment of respect, approachability and mutual support, and supported successful implementation. At sites 1 and 2 there appeared to be a more visible hierarchy between clinical advisers and call-handling staff, with a separation in communication between these. At site 1 this seemed to be partly because the call centre is large (and based over two sites). Although communication levels were high between call advisers and call supervisors, they less frequently called on the clinical advisers for assistance (and this was usually by telephone). At site 2 relationships were weaker with the clinical advisers, who were based elsewhere. Here, there was little communication and no sense of being part of the ‘same service’. The relationship was limited to ‘warm transfers’ of calls, which involved minimal communication between call advisers and nurses. When the out-of-hours GP was on site, relationships with the GP appeared functional, often characterised by a lack of communication in general, although we did observe some informal communication. Supervisors tended to mediate between the GP, call advisers and/or patients if needed. ‘So far this evening, I haven’t really seen the GP interacting with the call advisers or supervisor, other than to say he is staying for an extra hour’ (observation, call centre, site 2).

At site 3 the routine deferral of decisions to clinical advisers (see Chapter 3) suggested a clear hierarchy but there were high levels of communication between all staff in the call centre (including call advisers, supervisors, clinical advisers and the ambulance dispatcher), where there was extensive face-to-face communication, discussion and ‘joint decision-making’ about a particular call. Site 4 appeared to be characterised by a much flatter hierarchy than most other sites and there was not the same sense of division or rank. Call advisers and clinical advisers sat alongside each other in one of the call centres and there was a sense of ‘mucking in’, that is, collaboration, to ‘get the job done’. The supervisor role was undertaken by a non-clinical supervisor or a NP on any given shift. The site had worked hard to reduce tension between workers and there was a strong organisational culture of valuing all workers:

The clinical lead says that ‘it’s important you make yourself approachable and to reassure the [call advisers] I’m here, even if it seems like a silly question’. She says that fostering an environment of approachability is key [. . .] ‘Sometimes they have a clinical question . . . it’s a clinical doubt “niggling” in their minds; I’ve told them it’s best to come and talk to me or a nurse adviser if they are in any doubt’.

Observation, call centre, site 4

At site 5, located in a large call centre, we observed high communication levels, generally via telephony, with call advisers typically phoning through to clinical advisers for assistance, although there were some face-to-face queries. Call advisers and clinical advisers were co-located in one room, with clinical advisers generally stationed at the end of blocks of call adviser stations for easy communication and to offer advice when needed.

There are inevitably individual differences and individual incidents that give rise to tensions between staff, typically because of pressures on the service and/or clinician perceptions of inappropriate dispositions:

After the call the clinical adviser comes over to the call adviser. The atmosphere seems a bit tense. She says, ‘I probably wouldn’t have reached a different disposition, but might have been able to stall them for a bit’ [the ambulance service is under pressure so the clinical adviser would conduct a telephone consultation to ‘buy some time’]. I sense there is a bit of a ‘power struggle’ here.

Observation, call centre, site 3

The clinical knowledge and expertise in using NHS Pathways is shared across call centre teams and has implications for the skills required for call-handling that extend beyond manipulating the computer system. Mutual support is offered as a learning experience. The integration of different workers in a wider organisational hierarchy supports and maintains the NHS 111 service. In all sites the spatial location of the work facilitated – or hindered – communication and sharing of knowledge. The operationalisation of the CDSS and call-handling work played out in different ways determined by the configuration of the call centre, but it seems unlikely that call centre activity would be so successful in environments in which staff did not have this connectivity. The ability to work in and manage teams is therefore an essential set of skills needed for successful implementation of NHS 111 and testing of teamworking skills is actually part of the recruitment process for call advisers at some sites (e.g. site 1).

Strong team relations were also observed amongst staff at all UCCs:

ECP2 compares this [UCC] to [another]. He says [the other] is more private [there are individual consulting rooms rather than cubicles] but the downside is that staff are ‘locked away . . . all day . . . you don’t see anyone . . . [Here] is much more social, we can ask each other for things . . . [it is a] much nicer environment for working in’. They do seem a very sociable team; there is a lot of informal conversation between seeing patients.

Observation, UCC, site 1

However, relationships between UCCs and call centres were sometimes poor. Some of these tensions have been discussed earlier, for example frustration over perceived ‘inappropriate’ dispositions (see Chapter 3, What is the work of urgent care centre clinicians?) and tensions around professional boundaries (see Professional boundaries: clinical and quasi-clinical roles).

ECP2 says that there is some tension with [call centre provider] about triaging and [what the UCC perceive as] incorrect dispositions. He says that ‘they never admit they are wrong’.

Observation, UCC, site 1

Proximity (co-location) and history appear to have influenced the working relationship between call centres and UCCs (see Chapter 6). For the most part call centres and UCCs are separate services (the exceptions are that site 2 has the out-of-hours telephone consultation GP located with it; site 4 has one call centre co-located with the UCC; and at site 5 the UCC is downstairs from the call centre but there does not appear to be a close working relationship between them). Communication between UCCs and call centres is often limited to NHS Pathways information transmitted electronically and some telephone communication to follow up a patient or request additional information; therefore, the relationship is a ‘faceless’ one. In one site it appeared that efforts were made to foster closer relationships and understanding, viewed positively by UCC clinicians.

ECP3 explains that a number of call advisers came to shadow the ECPs: ‘now they understand our role better and send to us rather than A&E, or realise when they don’t need us at all’.

Observation, UCC, site 4

The findings from the survey suggested that sites overall were neither positive nor negative about communication with other NHS 111 services (Table 11). Overall, site 5 was more positive about experiences of communicating with other NHS 111 providers, agreeing that they were easy to contact, that it was not time-consuming and that communication was supportive. However, it should be noted that these data are based on call centre staff only and not UCC staff. It is possible that this could explain the difference.

Training at call centres

The nature of call-handling training was documented in our earlier work. 18 We do not seek to repeat this work; rather, we offer a summary and draw out key differences across sites and present observations about training practice and training needs not identified in our previous research.

Summary

Across all sites, deploying NHS Pathways and piloting NHS 111 led to workforce expansion, with more staff being employed and additional roles created. The ability to engage in effective teamwork is important both to provide emotional support to colleagues and to provide advice in the case of difficult calls. At all sites a number of call advisers were promoted to a new role of call supervisor. Clinical advisers provided home management advice but also had additional roles in managing and sanctioning dispositions and in supporting, training and auditing call-handling activities.

Although formal roles exist in each organisation the boundaries between them are often blurred. Call advisers lack clinical training but there is consistent evidence of them performing complex health-care work, albeit supported by the technology. We observed that clinical knowledge gathered from the system and from clinical staff becomes internalised in call advisers who then draw on this knowledge when handling calls. Despite this there are clear beliefs amongst the workforce that input from clinical staff is essential for supporting call advisers and to allow them to take clinical responsibility for more complex calls.

Participation in training can be challenging for call advisers. It requires considerable commitment in relation to the amount of learning that is required for the role. Completing the required training programme also places demands on their time, which is a particular problem for part-time and night-shift workers. Ongoing formal and informal training was provided at all sites through coaching, support from call supervisors and clinical staff and feedback from the audit process. There is considerable variation across sites in how these activities are performed and by whom.

Introduction

In looking at the technology used by the NHS 111 service we considered the CDSS, which is used by call advisers to triage and manage calls to the service, and the wider network of technologies needed to deliver the service. These other technologies included a range of digital ICTs – telephony, various software and data storage systems including geographical information systems, patient record systems and databases, and the computer hardware. This chapter describes the core technologies used by the NHS 111 service and looks at three particular issues that arose in our analysis: trust in technology, failures related to technologies and integration of technologies.

The technologies used to deliver NHS 111

NHS 111 seeks to deliver telephone clinical assessment and provision of information, including direction to the most appropriate service when necessary. The aim is that these tasks are completed within the first call (i.e. without the need for a call back). Clinical assessment and triage is supported by a single CDSS, and callers can be given health information or self-care advice or can be directed to the most appropriate service available at the time of the call using an up-to-date skills-based Directory of Services (DoS). Calls assessed as requiring an ambulance can be immediately directed to ambulance dispatch without the need for reassessment and, when necessary, calls can be transferred (‘warm transfer’) to a clinician or, if this is not possible, placed in a call-back system. The integration of the CDSS and the DoS should allow callers to be directed to appropriate local services without the need for re-triage, and, when possible, appointments can be made at the relevant service. As well as recording information about the calls for audit and monitoring within the NHS 111 service, the various technologies used also allow records to be shared between health-care providers and services, for example a call summary created during the call can be forwarded to the receiving service or to the patient’s GP.

The core technologies that we focus on here are the software and databases used to manage, record and display information about the calls, the CDSS used to support triage and management of the caller and the DoS used to identify and interface with local care services. The next four sections describe these technologies to provide background information to situate our discussion of failures, trust and integration.

Trust in the technologies for NHS 111

Attitudes towards the CDSS were mixed. Some call advisers were positive about the CDSS and trusted the dispositions made:

CallA18 is incredibly positive about Pathways: ‘Pathways is very good’. She trusts the disposition is correct: ‘Pathways tells me; it follows the symptoms not what the patient thinks is wrong with them; it follows the exact symptom, so for example they might phone thinking it’s food poisoning, but Pathways will pick it up that it’s not food poisoning if it doesn’t recognise it from the symptoms’.

Observation, call centre, site 1

But others, on occasion, wanted greater flexibility around the questions they asked as they felt that the CDSS did not provide sufficient information to direct the call ‘down’ the correct pathway. This was a particular problem for callers who presented with multiple symptoms as these two quotes indicate:

CallA6 is following the ‘cough’ pathway . . . CallA6 calls the clinical adviser and gives her a brief summary of the call before putting the caller immediately and directly through. After the call I learn the call was transferred because the [system] was saying it was a cough, but the child also had a fever so it was difficult to know what pathway to follow.

Observation, call centre, site 1

CallA20 chats to me about the ‘rectal bleeding call’, telling me she got very confused because the caller was reporting ‘multiple symptoms’: pain in the back passage, rectal bleed and difficulty passing urine; ‘so three symptoms, all potentially quite serious’. CallA20 is a little concerned about this call . . . saying that getting someone to report a ‘main symptom’ is sometimes one of the hardest parts of the job.

Observation, call centre, site 2

Sometimes this distrust of the technology waned as experience increased:

The call adviser says, ‘I was thinking, what Pathway do I use, because there is no Pathway for pregnancy, but she did describe pressure down there. The more experience of Pathways you get, I knew there would be a pregnancy question in the abdominal Pathway’.

Observation, call centre, site 5

However, doubts about the veracity of the dispositions made with the CDSS might also be reinforced by other knowledge or experience. Call advisers might look up clinical information to ‘check’ or validate the pathways presented in the CDSS. In some cases the call advisers were able to use the CDSS itself to do this:

[Clinical adviser] says that mostly NHS Pathways is good but there are a few things that don’t seem right. She says that in a call she went down a particular route in the system for a baby and it came out with a particular disposition (go to ED) but when she followed the same pathway for a toddler it came out with a more urgent ambulance disposition. She says, ‘look, I’ll see if I can show you’. She moves over to the laptops which have the training version of NHS Pathways on them.

Observation, call centre, site 3

Some of the doubts expressed about the technologies were related to the rigidity of the systems used, such as in situations in which the caller did not comply with the offered disposition:

ClinA3 took this call and asked the patient ‘is it a numbing pain, like someone is ringing out a sponge?’ The patient still refused an ambulance and ‘despite probing, it still came out as an ambulance’. In relation to this case she says ‘Pathways doesn’t bend, its black and white’.

Observation, call centre, site 4

Another example was when the call advisers did not agree with or ‘trust’ the disposition:

I sense a disparity between what ClinA5 wants the system to do and what it actually does. She explains this saying ‘I knew what I wanted to do with it, but I feel like sometimes it comes up with a disposition that I don’t agree with’. She gives me an example from a call earlier today: ‘I had a young baby with a rash today. The problem with Pathways is that it can only assess one symptom. The child had a rash, was not communicating as usual and had sunken puffy eyes’.

Observation, call centre, site 2

Interestingly, clinical staff working in the call centres reported that they found the CDSS to be too ‘risk averse’, implying that, in their clinical judgement, the system was not offering the correct disposition. This might be seen initially as a mark of distrust of the CDSS. However, they suggested that this feature was positive, that it supplied a necessary ‘safety net’ allowing them to trust the technology when used by non-clinical staff. Some were happy to follow the CDSS themselves because of this:

The clinical adviser likes his job and using the system. He doesn’t find it restrictive despite his clinical knowledge. Says ‘in the end you’ve got to be safe’, describing it as ‘safety netting’. I ask if it’s harder not assessing face to face. He says sometimes because you can listen to breathing but not see if they’ve got sweating or pallor as you would face to face. He thinks NHS Pathways is more cautious.

Observation, call centre, site 5

One clinician suggested that the involvement of doctors in developing the CDSS was used to assert the trustworthiness of the CDSS and she found this difficult:

ECP4 says ‘I can see call advisers just going down the wrong pathway’. ECP4 says that she queried one of the algorithms at a ‘review meeting’ but was told ‘well it’s been designed by doctors [so it must be correct]’.

Observation, UCC, site 1

Others felt that, although the CDSS could be trusted to be sufficiently risk averse when used by non-clinicians, this had to be actively managed by the clinical staff in the call centre:

CallA6 has joined the shift . . . he used to be a paramedic on the ambulances. I ask him what he thinks about 111 and Pathways. He says ‘it’s a very risk averse system . . . you need clinicians as it’s so risk averse otherwise you’d end up with an ambulance for everything’.

Observation, call centre, site 3

This view was also common to external stakeholders, notably GPs, who suggested that some dispositions for UCC appointments and home visits were inappropriate:

I ask GP1 about the types of patients he sees that have come through 111 and if the majority of home visits are to elderly or housebound people: ‘the majority are elderly, but there are also inappropriate visits, people with no transport, things like that. It’s OK if they are housebound, whatever age they are, but for people with no transport; it’s wrong’.

Observation, UCC, site 5

The GPs felt that the technology could not be trusted to deal appropriately with some clinical presentations:

GP2 says that ‘there are some conditions you can pigeon hole [as NHS Pathways does], such as chest pain which are quite clear cut, need to err on the side of caution, but there are other symptoms that are much more difficult for a non-clinician to assess’.

Observation, UCC, site 1

One GP did echo the views of the clinicians in the call centre that the CDSS was necessarily risk averse and that when there were failings this was not because of the technology per se but was the result of human factors:

The clinical lead talks to me about some of her early scepticism in relation to 111: ‘I was very sceptical and tried to find errors, but it is safe and that was my biggest concern. In a lot of cases that don’t work quite right, it’s not the software or the call adviser that has failed; it’s the fact that the patient hasn’t given concise information’.

Observation, call centre, site 3

In the excerpt below a call adviser explains why she has made an ‘untrustworthy’ or incorrect disposition for a patient with (primarily) mental health concerns who also has an apparently more minor physical symptom:

CallA1 explained to me that sometimes in calls like these, where there is a mix of conditions (i.e. blood loss and behavioural/mental health) Pathways is not so good. ‘You have to go down the blood loss Pathway and send an ambulance’.

Observation, call centre, site 1

Call advisers and clinicians alike noted that the pathways relating to mental health conditions were more problematic:

ClinA5 explains that ‘here mental health comes under the behaviour and mood disturbance Pathway’; she seems to be making the point that everything comes under one Pathway as she tells me ‘in NHS Direct we had different algorithms for say depression or anger; here, under 111, we cover everything under one Pathway’.

Observation, call centre, site 4

I mean, I’m mental health trained anyway, so it doesn’t bother me, but I don’t think the pathways accommodate mental illness at all.

Not enough paths to mental health on there . . . just one thing.

Yes, it is. It’s really poor on that, and that’s the other thing, as well, the mental health is . . . really . . . I don’t know if poor is the right word, but it’s not adequate, it’s not sufficient.

It doesn’t cover mental health at all. I mean, I had a call on Sunday, and if I hadn’t have been mental health trained, I’d have been totally lost, but . . . she couldn’t tell me what was the matter, but I were asking her, you know, like, are you hallucinating . . . are you deluded, are you low, or . . .? Whereas you know, sometimes with pathways . . . it’s not there.

Focus group, site 4

Few GPs used the clinical information and triage details provided from the CDSS processes. Typically, they initiated patient consultations – by telephone or face to face – by asking for symptom history and details again, implying that they did not trust the records created using the CDSS. Some GPs made very sceptical comments about the technology and the wider NHS 111 service.

Survey questions that measured trust in NHS Pathways supported these data. Trust was significantly lower amongst staff at site 1 (mean composite score of 3.06) than amongst staff at site 2 (mean score 3.64) and site 5 (mean score 4.29) (F = 12.2; p < 0.001). This higher level of trust overall in site 5 is likely to reflect the fact that the survey was not administered to UCC staff. Conversely, lower levels of trust in site 1 are likely to reflect the negative views of the site 1 UCC staff (Table 14). In all sites trust in NHS Pathways was higher amongst call centre staff than amongst UCC staff (see Table 14).

Technological failures

All sites had contingency plans to cover failures in electrical supply or software malfunctioning. These included having systems for rerouting calls to other sites and/or the use of paper-based back-up systems.

[The call adviser] shows me a paper version of the system used [when there is a system failure]. It involves an input form and a manual with the opening questions from Pathways and then page numbers to move onto dependent on whether there is a yes or no answer. He is very vague on whether he has actually had to use this while he leafs through the pages but notes that on an early page of the manual is a pathway for taking blood results. He follows this and notes it leads to the same disposition as was eventually agreed by the staff.

Observation, call centre, site 5

The sites used training and sometimes rehearsal/practice sessions to ensure that staff could cope with this type of relatively large-scale technical failure affecting the service. We did not witness any lengthy disruptions to services at any of the sites during our fieldwork. However, we did hear accounts of and witnessed first-hand some examples of technology ‘failing’ temporarily and disrupting aspects of NHS 111 services. This included computer systems freezing and occasionally telephony problems. When telephony issues occurred this was mostly callers being cut off because they were using mobile technology or occasional line interference:

CallA11 takes a call but the line is just ‘crackling’. ClinA5 is watching: ‘what’s happening?’ The call adviser comments ‘she’s just getting crackles, that’s it’. CallA11 comments that she will have to call the caller back. There’s a bit of a discussion about what it could be and it is suggested it might be ‘static’.

Observation, call centre, site 3

In one site we witnessed additional telephony problems when transferring calls to nurses at external organisations and patients had to wait for a nurse to call back:

CallA1 explains that ‘I’m going to pass you over to our nurse advisers’, but she is unable to transfer the call immediately and tells the patient that a nurse will call back within 10 minutes. I recall that earlier CallA1 mentioned that there has been some difficulty getting through to the nurses at NHS Direct all night.

Observation, call centre, site 2

Technical problems, such as freezing computer screens, sometimes resulted in callers being put on hold or transferred to another call adviser, or call details having to be re-entered, and this could be stressful for staff, but we observed how well managed such crises were:

The supervisor . . . says that they have been having a ‘difficult’ day – Adastra has stopped working. I later find out is must have stopped or at least been noticed around 1800 because they were trying to book appointments and they were not going through. There is a bit of tension in the air but it feels like a well-managed crisis.

Observation, call centre, site 5

The findings from the survey suggest that staff feel that NHS 111 technology is reasonably reliable (Table 15). Overall, staff at the call centres were more positive about the technology than UCC staff (a finding that was statistically significant in all sites).

There were particular problems associated with the technology for the DoS. Some call advisers were frustrated that the DoS was not accurate or up to date. Sometimes it did not offer the information needed and call advisers worked around this by using their own knowledge. In one site (site 3) there was almost no use of the DoS, possibly because of the site’s geographically small/isolated location: ‘As she reads the survey she reaches the question about whether the ‘DOS is up-to-date’ and comments, ‘well, that would be a “no”; it’s rubbish’ (observation, call centre, site 3).

The findings from the survey with regard to staff views about the DoS broadly confirmed the ethnographic data, with staff across all sites tending to neither agree nor disagree that the DoS is accurate and up to date (Table 16). Staff at site 5 were more likely to agree that the DoS was accurate than staff at all other sites.

Technological integration

The three core technologies – the call management systems, the CDSS and the DoS – need to be integrated to deliver the NHS 111 service. There were some examples in our data of occasions when particular technologies failed and this disrupted the integration of these systems:

There seems to be some concern over Adastra and the fact that the disposition was ‘clinician call back’ but that an ambulance had been sent by the ambulance dispatcher. The dispatcher says an ambulance went anyway, but he appears a little frustrated.

Observation, call centre, site 3

CallA11 still seems to be having some problems with the system and adds, ‘the demographics are meant to be saved, it’s not working. I’ve lost all the demographics details’.

Observation, call centre, site 3

Summary

We examined the core technologies implicated in the delivery of the NHS 111 services. These included the CDSS used to assess and manage calls and the DoS used to locate appropriate services for onward referral when indicated. We also observed the importance of what might be considered peripheral technologies including call activity monitoring and display, internet features including web browsers and e-mail and mapping systems.

Our analysis suggested three main themes of interest for the study, namely trust in technology, technology failures and integration. Trust in the CDSS amongst call advisers is relatively high. There is some appreciation that the system is risk averse and awareness of some areas in which the pathways are less effective or useful (e.g. multiple symptoms). Turning to the theme of technology failures we noted that the providers have established contingency plans for dealing with major faults, but we also noted that the staff in the call centres work hard to make the technology work, often developing workarounds that enable this. The survey suggests that they find the system largely reliable although some problems with the DoS were noted, especially the need to keep this up to date. The key area of integration necessary to deliver NHS 111 was between the CDSS and the DoS, and this appeared to be an area in which there remained some problems, such as dissatisfaction with case records and information about services.

Introduction

The aim of NHS 111 is to provide an integrated service for urgent and unscheduled care, rationalised and standardised to achieve common clinical and bureaucratic outcomes across England. As we have shown earlier, the introduction of NHS 111 has involved the emergence of new types of work, performed by a new workforce, and the careful piecing together of heterogeneous technologies, not just the NHS Pathways CDSS but also secure internet connections, telephone systems, the online DoS and so on. Although so far we have considered this work, the workforce and the technologies involved independently, providing a detailed description and analysis of each, the successful implementation of NHS 111 requires the integration of these elements at the organisational level, in specific settings, and, furthermore, requires new relationships across organisations within the wider health-care economy. In this chapter we explore how this has been accomplished in each of our five case study organisations. The contracts to deliver NHS 111 have been awarded through a competitive process, in which a range of bidders have been active. Our case studies were chosen to capture some of this diversity, allowing us to explore how organisational types, histories and trajectories might impact on the motivation to become a NHS 111 provider and on the delivery of a NHS 111 service in each case.

In this we draw on an understanding of work and organisations which recognises that innovation is not accomplished ‘on the head of a pin’ – in policy documents, management strategies or organisational charts – but is achieved in the everyday activities of individuals and teams with embedded values, practices and relationships. 29,30 It is well known that operational cultures vary across health-care services,31 that professional cultures in health care are quite distinct32,33 and that relations between the different urgent and emergency care services can be characterised by rivalry and a clash of cultures. 34

In what follows we develop a comparative analysis across our case studies. We begin with a description of each, asking:

• What is the nature of this organisation?

• Why did it become involved in NHS 111?

• What is the nature of its relationships with local partners in NHS 111?

Throughout, our concern is to explore if and how these factors shaped the organisation and delivery of the NHS 111 service, with particular attention to how the work of NHS 111 was defined, how the workforce was constituted and how the technologies came into use. Through this discussion it becomes clear that there is considerable variation in the organisation and delivery of NHS 111, shaped both by the nature of contracted organisations themselves and by the nature of their relationships with other organisations. However, our comparative case study approach also allows us to identify the cross-cutting themes that have shaped the development of NHS 111 service delivery. Specifically, our findings draw attention to the importance of the different service ethics associated with the emergency and out-of-hours providers, respectively, the differentiated nature of interprofessional relations across our cases, and the impact of competition for NHS 111 contracts between providers who are also expected to collaborate in the delivery of the NHS 111 service based on interorganisational trust and knowledge sharing.

Site 1

The ambulance trust delivering NHS 111 at site 1 was established by the 2006 reforms, which consolidated 31 providers in England into 12 larger organisations. 35 Site 1 now provides 999 services to over 2 million people and handles over 300,000 999 calls each year, from the public, doctors, hospitals and the police and fire services, as well as dealing with ambulance transport requests from hospitals and GPs. It operates two call centres including one at trust headquarters and one designed to mirror the first centre as a second, independent ‘back-up’ facility. The UCCs, operated by a different foundation trust, are located some 20–30 miles from the call centre and can be accessed either by dialling 111 or by walking in.

Historically, the ambulance service in the UK was intended mainly as a call-handling and transportation service and was characterised by a directive ‘command and control’ culture. 7,36 There have been very clear demarcations between job roles, with little interprofessional working within the service until recent times, and management roles have been occupied by those with a paramedic background. Consequently, there has in the past been relatively little integration between the ambulance service and other parts of the health service, such as urgent care or routine general practice (beyond arranging patient transport). Over recent years, the ambulance service has faced strong pressure to reduce, or at least contain, rising ambulance demand, driven by the introduction of government-monitored performance targets. More recently, policy related to the ambulance service has highlighted the potential for the ambulance service to adopt a more central role in the delivery and performance of services across urgent and emergency care,7,37 and the service itself has called for a move away from a command and control culture to a more ‘visionary, enthusiastic and motivating’ approach to leading the service. 7,36 NHS 111 provides an opportunity for the ambulance service to position itself in this central role.

In this wider national context, site 1 has undergone considerable modernisation and reorientation in recent years. Managers describe this as a dynamic and outward-looking organisation, keen to embrace the move towards greater integration of urgent and emergency care and to develop a range of services in addition to 999. This spirit is evidenced by site 1’s recently successful application for foundation trust status, which, in turn, affords a degree of autonomy and freedom in how services are provided locally and allows the organisation to trade and make surpluses that can be reinvested in service development:

We were always . . . known across the country . . . as a forward thinking ambulance service trust . . . in developing a lot of initiatives. A good example might be the introduction of a controlled drug across the whole of the trust . . . not an easy thing to do, but we . . . took the bull by the horns and worked through the policies and the procedures . . . and then took it nationally . . . presented it at a national conference. A lot of other services picked up the work that we did and, introduced [it] into their service. So we’re always seen as a high performer . . . a service that was looking to develop and move forward.

SMgr2, interview, site 1 (data from previous project18)

We’d been part of an exemplar project, looking at urgent care. And in there, the stuff that people are talking about now at a strategic level, nationally, we’d already realised that five plus years ago: that patient’s want healthcare brought to them, closer. The whole healthcare model’s becoming so complicated it’s difficult to navigate your way through it; it’s not the patient’s fault that they don’t know how to access and who to access.

SMgr1, interview, site 1 (data from previous project18)

In 2006 the trust was one of the early sites to pilot NHS Pathways, the triaging software that underpins NHS 111. NHS Pathways offered the potential to manage the rising demand for the ambulance service as it enabled the service to offer alternative dispositions for less urgent calls. Senior managers had recognised that deploying this new technology resonated with their strategic aims and that its early adoption was also a way of positioning the trust as a leading trust in the wider NHS:

The main reason we moved over onto Pathways was because . . . as . . . a dynamic Trust, we thought, if we get a hold of this tool, and we design the front end of it, you’ll get it designed for a United Kingdom market, for somebody who knows what they’re doing, in other words us, and it should work a hell of a lot better than the alternative.

SMgr1, interview, site 1 (data from previous project18)

I could see the advantages almost immediately . . . even before Pathways had come along, I recognised that . . . we were dealing with an ever, annual increase on the Ambulance Service in demand . . . and we had no control over that. The only way . . . to have an influence on that is to control the outcome, if you like. So even before Pathways, [I was] working with PCTs in developing referral processes across to alternative pathways of care [. . .] I could see that [NHS Pathways] was just an extension of that in the work that I was trying to develop locally.

SMgr2, interview, site 1 (data from previous project18)

This piloting work of NHS Pathways was successful and allowed the technology to be licensed for wider use. At the same time the process of early piloting allowed the trust to accumulate in-house expertise in the work, workforce and technology that would later underpin NHS 111. Despite very early claims by the CDSS developers that no clinicians were needed to run NHS Pathways, the pilot experience led site 1 to introduce clinical advisers to support call advisers’ use of NHS Pathways. Site 1 also developed early expertise in the monitoring and audit of call advisers. Shortly after NHS Pathways was licensed for use, in 2009 site 1 introduced a single point of access urgent care service. This was a new 24/7 single point of access service for two PCT areas in the region (located in a different part of the region), effectively replacing the existing out-of-hours service in these areas. NHS Pathways, along with the acquired expertise in implementing this system, was transferred to this new service. Site 1 had nearly 3 years of experience in recruiting and training staff to use the CDSS as well as monitoring and supporting them and so they were confident that this was viable. The new service combined NHS Pathways with a new CMS allowing call advisers to offer service information (e.g. opening hours of pharmacists) and to book out-of-hours appointments. Building on this experience, in 2011 site 1 replaced the single point of access urgent care service with NHS 111. Being one of the first sites to pilot NHS 111 was a vindication of dynamic diversification and the expertise accumulated over a number of years:

SMgr1 says that NHS 111 has ‘pretty much been my life for the last year or so’ . . . He says that he hopes they are in a strong position (to win the 111 contract), with their previous experience, local knowledge and collaboration with an equally strong partner (well-established out-of-hours organisation).

Observation, site 1

NHS Pathways and the subsequent launches of the single point of access urgent care service and NHS 111 resulted in the diversification of both the work and the workforce at site 1. Some of the existing 999 call centre workforce, who mainly worked full-time, were trained to take NHS 111 calls and additional full-time and part-time call advisers were recruited, which introduced a less homogeneous workforce (in terms of age, qualifications and career aspirations). 26 Additionally, both paramedics and nurses were recruited to clinical adviser roles, offering different professional backgrounds and expertise and diversifying the clinical expertise at site 1 by introducing significant numbers of nurses to the organisation for the first time.

This organisational history has shaped the distinctive constitution of NHS 111 at site 1. Managing down demand continues to be a core organisational value and is reflected in call-handler training, which emphasises (more so than in other cases) the need to enforce NHS Pathways dispositions and negotiate firmly with patients (see Chapter 3).

In terms of relationships with partners in the wider health-care economy, tensions between the site 1 call centre and the local UCC were notable. Historical separation of the ambulance service from other health-care providers may have played a part here. Although the trust has had a number of years of experience working with PCTs and other organisations, UCC staff reported a lack of initial consultation over and engagement with the implementation of NHS 111 as well as a lack of communication about ongoing NHS 111 operations:

ECP2 says there is some tension with [call centre organisation] about triaging and what the UCC perceive as incorrect dispositions – they will ‘never admit they are wrong’.

Observation, UCC, site 1

The GP lead says that ‘staff perceive’ 111 was imposed on them without sufficient prior consultation.

Observation, UCC, site 1

For the most part the two services appear separate – both physically and in terms of communication. Communication between UCCs and call centres is limited to NHS Pathways information transmitted electronically and telephone communication to follow-up a patient or request additional information. There is little sense that the workers at these organisations are working as part of the same NHS 111 service.

Site 2

The general practice out-of-hours organisation delivering NHS 111 at site 2 developed from a general practice co-operative established in the early 1990s that provided out-of-hours call handling and GP-led advice and consultation. This NHS 111 site is a smaller service than many of the others, serving a population of a large town and the surrounding suburban area (approximately 140,000 people), but it is part of a larger consortium with two other organisations that provides NHS 111 across a large region. Based on its roots in general practice, the organisation is proud to offer to the local population what it perceives as a quality service and it appears to have a strong patient-centric culture:

But even if [the patient is] not local and it’s further than local, then we will still attempt to help that person.

No, I think a lot of us, we all do care what we’re doing. You know, we’re not just saying ‘oh well, sorry’. That’s us.

Focus group, site 2

In this context, the short-term motivation for introducing NHS Pathways was to strengthen telephone triaging as the paper-based system did not meet national guidelines for ‘definitive clinical assessment’ within 20 minutes of answering an urgent call:

[Call-handling] staff couldn’t advise patients at that point – it still wasn’t recognised – even though the PCTs were happy with the way we did things. So we knew we had to . . . do something.

SMgr1, interview, site 2 (data from previous project18)

We were very happy with it; it worked very well [previous protocol system] . . . we won a national award for it because it was so effective. The PCTs locally were very happy and they’ve audited it. And we had a clinical governance system that reviews calls and the outcomes of the calls, and the performance of the operators, the GPs, nurses.

GP1, interview, site 2 (data from previous project18)

More widely, though, NHS 111 offered the organisation an opportunity to build on the experience of NHS Pathways and push forward the move towards a more integrated model of urgent and emergency care that had been underway for some time. For example, since 2010 the co-operative had been part of a new local service in which an UCC combined an ED, an out-of-hours service, mental health services and primary care. The out-of-hours service aimed to provide a single point of access for patients, who were encouraged to telephone as the first point of contact. Patients attending the UCC and requiring urgent care were managed at a reception desk, booked in electronically onto an integrated primary and secondary care system (Adastra) and assessed using the CDSS to direct them to the appropriate service (ED or out-of-hours care).

As a long-established out-of-hours provider in the locality, it is also likely that the organisation recognised the potential threat to its out-of-hours business if it did not tender for the NHS 111 contract. In 2011 site 2 became a NHS 111 pilot as part of a consortium arrangement that included two other organisations. Site 2 primarily took calls for patients in its own locality (i.e. its previous out-of-hours population) but also took calls for other parts of the region when busy. Within the consortium arrangement call handling was provided by site 2 and another consortium partner whereas clinical advice was provided by a third consortium partner, whose staff are located in other areas. Similar to site 1, site 2 had considerable early experience and expertise in using NHS Pathways that it brought to the implementation of the NHS 111 pilot and used to assist its consortium partners:

I think it’s . . . highlighted by the fact that when [a partner organisation] went live, they asked us to go down and help them do it our way . . . to do it the right way! [Laughter] [. . .] We were the ones that were brought in to help them go live [. . .] We were up and running. We’d done our bit, but because they were struggling to do it the way we did it, to the standard that we did it, they actually asked us to go down and help them do it . . . For a big organisation to need us to go down, you know, when we’re only a local firm at the end of the day, when [the other larger organisations] go live with their services, it says a lot for what we do.

Trainer2, focus group, site 2

Historically, the organisation employed a predominantly part-time call-handling workforce, many of whom worked a few hours per month on ‘zero hours’ contracts. The introduction of a new technology and a new service required the employment of more call advisers on more substantial contracts. More call advisers were employed on a full-time basis and existing and new staff had to be trained to use the CDSS. In addition, more staff were required to fill a wider range of roles including additional training, auditing and liaison roles. Because of the consortium arrangement (and because nurse advice was provided by a separate organisation), site 2 remained a GP-dominated organisation. NHS 111 served to relocate some of the work and decision-making from GPs to call advisers and to clinical advisers outside the organisation. It is difficult to determine whether a prevailing GP-led culture at site 2 had any bearing on the relationships with the consortium partner that provided nurse advice services. Such blurring of professional and organisational boundaries may potentially have resulted in some difficult relationships. As we identified in Chapter 4 (see Communication and relationships across NHS 111), for the most part call advisers and clinical advisers worked as separate entities. Working relationships between call centre staff at site 2 and clinical advisers were functional, evident in the minimal communication between these organisations. Call centre staff were very aware of the poor communication between themselves and their clinical advisors, based in a different organisation:

CallA20 tells the caller: ‘rather than you wait for a call, I’m going to try and transfer you directly’. When CallA20 gets through to the nurse adviser she says ‘it’s the 111 service with a warm transfer for you’. She gives the case number and the caller’s name before transferring the call. There’s very little else said.

Observation, call centre, site 2

That’s just building the relationships, I think, with the other . . . services [. . .] But it’s their understanding of what 111 is as well, you know. They’ve got to have that engagement.

We’ve learnt that communication at some companies doesn’t happen.

But that’s what’s most important across the board – to communicate properly.

Focus group, site 2

There was no history of these organisations working together before the introduction of NHS 111. The consortium model highlighted some of the difficulties encountered in requiring organisations that have no embedded working relationships to work together. Staff at site 2 reported feeling a loss of control over outcomes and care provided for ‘their patients’. For an organisation that is very oriented to the needs of the local population, which emphasises that it is a local workforce with local knowledge, staff found this arrangement difficult. Staff at site 2 were concerned that consortium partners might not share their values or have their local knowledge. Staff expressed concerns that, if they lost the NHS 111 contract, patients in their local area would see a decline in service quality. Although staff at site 2 were not against change – indeed site 2 was one of the early adopters of NHS Pathways and a NHS 111 pilot site – perhaps as an organisation it could be argued to be quite inward looking with its focus on local services:

I think we’ve lost a bit of the control of ‘the whole’, you know. The control’s going out of your hands at a certain point . . . Before, you could . . . watch the development and the process [of the call] going through. Now sometimes. . . you’re in a situation where you don’t know what’s happening [to the patient].

Focus group, site 2

But . . . they’re not local [another call-handling organisation] . . . they don’t have the knowledge that we have of the patients and the demographic and the services. . .

They’re just going to be another patient . . . just going to be another number in a queue . . . It’s not going to be. . .

A personal service [. . .] The fear for me is that if patients don’t get what they want, and are being passed from one to another, that they will actually just start turning up in A&E departments and walk-in centres, and bypassing.

Focus group, site 2

The lack of a strong relationship between consortium partners was further compounded by the competitive nature of NHS 111 procurement. The three organisations involved in the pilot consortium recognised the potential temporariness of the arrangement in that they were required to retender for the contract from 2013. Competition between consortium organisations destabilised the arrangement for the provision of NHS 111. Site 2 formed a strategic alliance with one of the consortium organisations with another as a competitor (with whom it had a better relationship) but ultimately it lost the contract to the third consortium partner (to which, ironically, it had provided initial training in NHS Pathways). The consortium model, and lack of working relationships historically, appeared to make this model of NHS 111 provision much more difficult than, say, a single organisation providing call handling, nurse advice and UCC provision (such as site 4).

Site 3

The ambulance service delivering NHS 111 at this site was established by the 2006 reforms and provides 999 services to about 140,000 patients. It is one of the smaller NHS 111 sites, covering a more isolated geographical area, which makes it difficult to integrate with a larger population or service. The call handling is based in a smaller call centre located on a main hospital site. If patients require further assessment or treatment they are referred to an integrated urgent and emergency care centre based at the same hospital (which provides services for walk-in patients and ED attendances as well as for referrals via NHS 111). Similar to site 1, there is pressure to manage demand for ambulance services and for the ED. They key difference here is that, even before the launch of NHS 111, there has been a close working relationship with other services in the locality, including primary care, the ED, out-of-hours services, mental health services and community care. Indeed, the call centre has also taken out-of-hours calls alongside 999 calls since 2006, and had shared 999 and out-of-hours technical links. Staff emphasise that there is a willingness to work together and integrated working practices are valued:

And the shared system with [walk-in centre/UCC] . . . we’ve carried over since 2006, we’d already got that really close working relationship.

ClinA1, focus group, site 3

We actually all talk to each other anyway . . . We don’t have the same bureaucracy, we have different bureaucracy, but actually, I can phone up somebody in another department and go ‘can we just talk about this a minute’? Whereas, it’s perhaps not easy when you go across organisations. It is nice that we are . . . all using the same policies . . . We had a lot of it set up already.

SMgr1, focus group, site 3

NHS Pathways was introduced at this site a few months before the introduction of NHS 111 in anticipation of launching the service. The CDSS replaced the prioritisation system for 999 calls and separate protocols for out-of-hours calls (for these calls call advisers recorded basic details about the call and passed them to a GP for telephone triage). The technology introduced standardisation across urgent and emergency care so that both 999 and 111 calls were assessed in the same way. The launch of NHS 111 required the site to employ more call advisers and more call supervisors to manage staff and clinical advisers. Unlike some of the other sites, the introduction of NHS 111 did not radically change working patterns for call advisers (they typically worked 12-hour shifts taking both 999 and out-of-hours calls and therefore just replaced out-of-hours calls with NHS 111 calls). The organisational nature of this ambulance service very likely influenced its decision to employ paramedics rather than nurses in the clinical adviser role (there are only a minority of nurses at this site). The site regards clinical decision-making highly, which is reflected in its decision to have clinical advisers routinely check and sanction all 111 calls that result in a 999 disposition (see Chapter 3, Sanctioning and moderating dispositions), suggesting that it more explicitly values human clinical judgement over technological decision-making.

NHS 111, underpinned by NHS Pathways, was seen as an opportunity to build on existing integrated services, to provide a model of health care that better achieved ‘the right care at the right time and in the right place’ for patients: ‘That’s what 111 is. It’s about sending the most appropriate resource or appropriate care of what the patient needs, rather than what we’ve done historically, one size fits all, because it doesn’t’ (SMgr1, focus group, site 3).

Past experiences of integrated working meant that NHS 111 provision was not such a huge leap in thinking from what was already being provided:

Prior to 111, we had a single number anyway . . . so in essence we were doing the 111 service already in a certain guise . . . I’m not allowed to say it was just a number change for us, because it wasn’t, there was a lot of other things that went with it, but in essence, we . . . did just change the number that people were calling.

SMgr1, focus group, site 3

Tendering for the NHS 111 contract early on allowed the organisation to be in charge of its own destiny, warding off potential threats (such as being taken over by a larger neighbouring organisation). Site 3 was also driven by the desire to continue to provide local services for local people:

We are run from here . . . [The patients] do like that . . . when you say, ‘oh, you’re a patient with [name of practice] . . . which doctor’s it?’

Yeah, [when we say] ‘do you know, it’s in the [walk-in centre/UCC]’. ‘Oh, yes, yes, we know it’. And you say, ‘yeah, that’s it, yeah, go under the canopy’. ‘Oh, you’re on the island, are you?’ And people do . . . like that.

Focus group, site 3

Whilst you could . . . in theory, do it from a national call centre or . . . [another area] take over the calls . . . but, actually, you lose so much more. Again, it’s this integrated working in [the call centre] because you’ve got the local district nurse, you’ve got the local mental health crisis line. Sometimes it’s not all about saving money. It’s about . . . this quality of service to the public.

SMgr1, focus group, site 3

The organisation was motivated to provide an integrated NHS 111 service on a small scale. Indeed, its history as a smaller-scale, integrated service appears to have established strong working relationships. The organisation had a clear vision of co-locating services whenever possible to encourage joined-up working and has fostered interprofessional working relationships by co-locating different types of professional roles including call advisers, clinical advisers, ambulance dispatch workers and the district nursing team (with imminent plans to integrate a mental health team). As we saw in Chapter 4, co-location of workers has aided the sharing of knowledge within teams:

Since NHS 111 . . . district nurses joined us . . . this is a huge advantage because we get 999 calls . . . for, ‘oh, my dressings have leaked’ [or] ‘my catheter’s blocked’, and we can sort it direct with district nursing. Whereas . . . two years ago we’d be sending an emergency ambulance because we were having no choice in the matter because of the triage systems that we used to use and we hadn’t got such good links with the district nursing service.

And some calls, they would sit in the queue . . . for a clinical adviser. Sometimes you can just see that actually a district nurse is more appropriate, so we can just take that straightaway now.

Focus group, site 3

We’re very much looking forward to the mental health teams joining in [. . .] it is going to be a vital link, in the whole organisation of the room . . . If you have the people in their separate locations, you have this silo working, whereas . . . within the room . . . it’s just a matter of, looking across the top of your monitor. You can wave to somebody . . . and you can actually have this exchange of information. We can make computer systems talk to each other . . . but . . . it’s easier to go across and talk across the room, than it is to . . . pick up a telephone [or] send an email.

ClinA1, focus group, site 3

One of the ‘sacrifices’ made when NHS 111 was launched was separating call handling from out-of-hours/UCC provision. Before the launch of NHS 111, call-handling staff worked alongside out-of-hours GPs. Call centre staff report that some information sharing has been lost. There has been some substitution of clinical support so that call advisers are now supported by clinical advisers rather than GPs. Call advisers now ‘control’ the work of the GPs (see Chapter 3, Loss of control over decision-making and workload) but the physical separation of these groups of workers has resulted in less verbal communication:

It was a real break away when we’ve moved . . . we ran with the doctors down there . . . and then we were sent up here and we were like ‘it’s never going to work . . . you’ve got to be with your doctors’. And it’s taken 18 months before we think, ‘well, it’s not so important’ but it certainly still would be easier if they were walking through.

But the difference is that we’ve got clinicians in the room now haven’t we? [. . .]

. . . we’re looking at ways of how we can . . . Do we bring the doctors’ expertise up into this room . . . it’s just tentative discussions [at the moment but] it may well become . . . more of a necessity, a more viable way of working [. . .]

[. . .] We communicate a lot by phone now . . . on an administrative level, saying can you . . . just look into this, I’m worried about such and such. So it would be a lot easier if we were all in one giant room together [laughter].

We’re never going to get the whole building, are we [laughter] as much as I’ve tried.

Focus group, site 3

Although it might be argued that this site is less ambitious than some of the other sites (e.g. site 1 or site 5), and that NHS 111 has come about more as a way of building on its already integrated services, site 3 does have ambitions to provide additional services in the future, pursuing opportunities to develop telemedicine services that would move its services beyond urgent and emergency care to more preventative/monitoring services:

If we can have a desk where we can actually monitor [patients] . . . where we can send them home with specific monitoring equipment and monitor them on an acute desk [from the call centre] . . . [then] we can send an ambulance straightaway or we can send a district nurse round or the GP needs to pop around. So technology is driving the NHS 111 service . . . and this is our next phase – assisted technologies, telehealth, telecare, telemedicine. This is where it’s coming to its own, where we can now send the most appropriate resource.

SMgr1, focus group, site 3

Site 4

In Site 4 NHS 111 is provided by a local social enterprise, established in 2007 from the merger of two large, local GP co-operative organisations. As a social enterprise the organisation has a commitment to reinvest any surpluses and is driven by a strong service ethic of patient care. As an out-of-hours organisation, the social enterprise provided out-of-hours care to approximately 760,000 patients across a diverse geographical area ranging from inner city to rural. The organisation currently runs two call centres and 12 UCCs (four of which are also walk-in centres). Similar to sites 2 and 3, the values of the organisation appear to be characterised by being proud of their locally based organisation that has significant experience and knowledge to meet the needs of the local population: ‘It was a complete . . . whole service as it was, a continuation of the GP service. It was an out-of-hours GP provider service, and it was in [county], run by [county] people, for [county]’ (NP1, focus group, site 4).

Historically, the organisation has had a diverse portfolio of services and, in addition to out-of-hours services, offered forensic/police work, prison services and local community hospital services as well as providing locum GP services during the daytime.

Unlike other providers the organisation has a long history of employing nurses in its services. This includes nurses providing out-of-hours telephone triage and NPs who work alongside GPs in the UCCs. The organisation appears to value the contribution of nursing competencies and certainly the nursing workforce emphasised the career development opportunities within the organisation (see Chapter 4). Before the introduction of NHS 111, call handlers answered calls and recorded demographic details before passing the information to a team of nurse advisers for telephone triage. The nursing workforce view themselves as contributing to offering more holistic care – an approach that appears to fit with the patient-centred ethos of the service (see Chapter 3, Emotion work).

I raised issues [with the CDSS team] about . . . the scenario was a 21-year-old lad with constipation. He was at uni. His granddad had bowel cancer, or something, and he was constipated. The call handler went down the pathway and it was constipation. It was nothing, advice. And I went, ‘yes, but poor lad, he’s doing his exams . . .’ As a nurse, I would have said ‘what are you worried about? Is it your granddad? Do you think you might have . . .?’ And [the CDSS team] said, ‘oh, well, if you want to be pink and fluffy’. . .

But that is part of the caring, empathic service that they would have mainly got . . . before.

. . . I’m not saying a pathway is not clinically safe, but it deals with a clinical situation . . . I trained in the era where a patient wasn’t an appendix . . . it’s a person [. . .]

I think the nurses’ roles have changed . . . are changing a lot, and . . . with the pathways . . . we’re there to support the call handlers, and to do the auditing and supporting, and then do the calls that need to be finished off . . . that are transferred over to us . . .

And you can add the nursing element into that, but initially, Pathways is meant to deal with symptoms and sort symptoms to the most appropriate [service].

Focus group, site 4

At other sites the motivations for piloting 111 mainly centred around the desire to expand their business (sites 1 and 5) or the desire to achieve greater integration of services locally (sites 2 and 3). At site 4 the organisation recognised that NHS 111 was a potential threat to its out-of-hours business. It applied to pilot NHS 111 primarily because it was concerned about the possibility of a separate organisation handling the calls and referring patients to its out-of-hours service. The threat of this was used to garner local support amongst local health-care professionals:

We realised very quickly that if you weren’t doing NHS 111, you wouldn’t be able to front end an out-of-hours service [. . .] So somebody else would have done our call-handling for the out-of-hours service. So it was either, get into the pilot and do your best, or lose the opportunity to front end your own service. So there wasn’t a lot of option.

SMgr1, focus group, site 4

[The senior manager] explains two main factors motivated them to pilot NHS 111 . . . Firstly, the potential threat to their out-of-hours service: ‘[they] recognised the importance of 111’. If they did not bid for the 111 service they would lose the call-handling/triage aspect of their service – ‘worth’ approximately £1.2 million. Secondly, the ‘sell’ (or more of a threat) was that the alternative would be [name of an alternative provider]. Support for [site 4] as the provider was garnered amongst local service providers by ‘threatening’ that [name of alternative provider] would likely be the favoured provider if [site 4] did not go for the contract. [The senior manager] explains that there has traditionally been a degree of hostility from GPs towards [this alternative].

Observation, site 4

In 2011 the organisation began its pilot of NHS 111 but was unprepared for the impact on its existing out-of-hours business. Managers and clinicians described how it was a ‘bigger service’ than they had anticipated. First, staff did not initially realise that NHS 111 would eventually replace NHS Direct. Second, they had not anticipated the volume of NHS 111 calls (over and above the volume of out-of-hours calls). As the organisation pointed out, there were few data about what the likely demand for NHS 111 would be. This uncertainty placed considerable strain on the organisation – on existing staff and on the finances of the organisation. The implementation of NHS 111 required rapid training of existing call handlers as well as the recruitment and training of new call handlers:

111 is replacing NHS Direct, and we weren’t aware of that at the start. We weren’t aware of the fact that, just by being a free number, that would also increase the workload, and attract a different type of clientele than we’re used to [. . .]

It was quicker than we expected [implementing NHS 111]. We thought we were going to do a pilot, and it would be evaluated, and then there would be decisions made. We started this pilot, and then next thing . . . they were going live . . . it did feel sudden.

It very quickly leapt from being . . . a very short term thing to a very long term thing . . . I have a deputy that works with me . . . and I was told she was going to be seconded for three months. And 18 months later, she’s still here [laughter] [. . .]

And what have been the effects of that, do you think?

Stress

Fear . . .

At all levels I think. From . . . senior management, middle management and to the people on the ground.

Everybody’s wearing three or four different hats and doing extra work over and above what they used to do [. . .]

We couldn’t have done it, unless we’d got such a dedicated workforce. The staff have put up with such a lot of change and alteration to what they were used to, that if they hadn’t have been so good and flexible . . . so the goodwill of the staff has been a major part of this.

Focus group, site 4

As a social enterprise, the values and mission of this organisation – driven to reinvest surplus for patient-centred service – are congruent with the overall aim of NHS 111 but the financial reality of this has been challenging, particularly given the unanticipated scale and pace of growth:

We’ve not got enough desks, we’ve not got enough space, we’ve not got enough computers, we’ve not got enough phones . . .

. . . and you have to provide additional resources because the service is growing . . . you can imagine the cost of the training . . . even if you’ve got a part-time person, you still have to give them the full-time training. And the impact of that, because when you’ve got a coach that’s with a trainee, the coach is not taking calls, the trainee’s not taking calls. Well, it’s just so costly to the service. And we’re a not-for-profit social enterprise, so we haven’t got an awful lot of money . . . to absorb such a massive hundreds of thousands of pounds worth of cost [. . .]

The idea of [social enterprise] originally was, it would give the commissioners some reassurance . . . because you could obviously . . . rightly . . . any excess we make . . . we plough back into it. And we all felt that . . . as it was public money that was being given to us, that’s . . . how it should be. But . . . it means it’s very difficult for us to raise any funding because . . . we have got a track record not making money and it’s kind of not what we do. But actually . . . I think the sense of altruism that you get from being a social enterprise does . . . does give far more than it takes away.

You know that . . . corners are not being cut for profit. If we are struggling, and sometimes we do struggle, we know it’s . . . not because . . . they’re trying to cut down so that you can make a profit. Staff know that . . . we’ve got to be a bit tight, we’ve got to do this, it’s because it’s for the patients.

Focus group, site 4

Site 4 recruited more call-handling staff but the introduction of NHS Pathways meant that fewer nurses were required than in the previous model of care. Site 4 was reluctant to make nurses redundant and managed its workforce through the natural attrition of nurses and by reorganising rotas (to match the change from out-of-hours to 24/7 work) and extending the role of nurse advisers to take on additional tasks including training and audit functions. Although the nature of the everyday work of nurse advisers has changed with the launch of NHS 111, they are valued as an integral part of this organisation:

Even though we don’t have the need for as many nurse advisers in the system overall, everybody that we’d got has still got a job . . . The ratio of nurses that you require, say, on a Saturday morning, has lessened, but you would then use those from a Saturday during the week. We have avoided redundancies by being quite sharp with what we’ve done with the staff involved.

SMgr1, focus group, site 4

The organisation still very much positions itself as an out-of-hours organisation rather than a 24/7 urgent care organisation. It perceives that one of its greatest strengths in offering NHS 111 services is its history of integrated call handling and local out-of-hours provision:

You have to remember is that while this is going on 111, our ordinary business that we’ve always done . . . we’re still an out-of-hours service. We’ve still got commissioners’ requirements, CQC [Care Quality Commission] has come in, we’re working on that. We’ve still got our other, everyday business going on, at the same time as 111.

NP2, focus group, site 4

I think we’re in a better position than some of the others that have got a separate 111 service, and a separate out-of-hours. Because I understand that causes an awful lot of conflict, because of . . . systems not flowing properly, patient problems, whose fault was that, and they’re both pointing at each other. We know if we’ve caused a problem in our system, and therefore, we can fix it . . . we don’t realise how good we are at that until you go to other areas, and you see it separate, and you think, ‘my God, how do they possibly work with that? That’s ridiculous’. So we undersell ourselves a lot of the time.

SMgr1, focus group, site 4

The organisation has occupied a dominant position locally in the provision of out-of-hours care and it recognises how changes in policy and commissioning have changed the landscape in which it is operating. The organisation faces a degree of uncertainty in needing to tender for future NHS 111 contracts and has highlighted the nature of competition and its adverse effect on the potential for collaboration and sharing of good practice. Organisations are in the position of needing to protect their existing business:

There is a strong sense [from senior manager] that their organisation is very nervous about the future [their current 111 contract was due to end in 2013 and they were in the procurement process at this time]. He has a ‘horrible feeling’ about the direction in which health care is travelling and is concerned that the contract may go to a commercial provider. . . the general direction is to ‘commoditise health care’.

Observation, call centre, site 4

We’ve found ourselves in a very, very competitive market where everybody wants a piece of our business, hence what I was meaning about the political environment when people decide to ruin your reputation by saying, ‘ooh, you’re sending everybody here, or you’re sending everybody there’.

Yes, it’s because they want the business.

And do you feel some of that has been calculated to achieve . . .?

Yes, definitely. They say it at key meetings, to key people.

. . . everybody is now trying to protect their little bit of the NHS cake, and then we’re trying to provide a clinical service that overarches over all the providers, and it doesn’t work, because whoever’s got the contract obviously has to shift the work to other people. I think that’s going to be an ongoing issue [. . .]

Once all this tendering, competitive process has died down a bit, then maybe people will encourage more cross visits to other sites, to see what they’re doing, and learning from each other, because at the moment . . .

We’ve put some off [organisations] we don’t want to come through the doors until after the competitive tendering is over, because we know that they’re going to be up to no good.

Focus group, site 4

Site 5

Site 5 is a large commercial organisation located on an industrial estate in the suburbs of a major UK city, providing the NHS 111 service to approximately 250,000 patients. The call-handling organisation is well established in delivering out-of-hours care across England. It was originally a GP-led co-operative but over the last 15 years or so the organisation has expanded its business across England, capitalising on 2004 health service reform that allowed GPs to opt out of out-of-hours care. The organisation was successful in securing contracts to provide the service, with its strength being the large network of GPs. The organisation also has a history of nurse-led triage and offering call-handling services to a range of out-of-hours providers.

NHS 111 was a new 24/7 service in this area providing call handling for two PCT areas. Before the launch of NHS 111 in one of the areas the organisation had provided call-handling services for a local out-of-hours service and in the other area it replaced call handling that was previously provided by a GP co-operative. The organisation also provides a range of other services including out-of-hours services, offender health-care services, GP-led health centres and UCCs.

This is an ambitious and expansionist organisation, actively seeking new NHS 111 business as well as looking for other opportunities in other health-care sectors. The motivation for applying for NHS 111 in this area was primarily about the organisation looking for opportunities to continually expand its business across England. The NHS 111 procurement process has offered new business opportunities and the organisation has been very successful in securing new contracts:

[The senior manager] tells me that [their organisation] has won [the 111 contract] and will go live with 111 in September. They have also won [another area] going live in October, [and another] in December. This will give them coverage of 2.5 million people by December. They have very ambitious plans for 10 million by next April and she tells me they are well on the way.

Observation, call centre, site 5

Although NHS Pathways was a new way of operating call handling, the organisation was well established in providing these services. The organisation appears to have drawn on this experience to recruit, train, monitor and support staff during the implementation of NHS 111. Although the organisation had previously provided call-handling services in this area, NHS 111 essentially was a new service for site 5. There were some existing staff from the previous out-of-hours service but many new call advisers (most of whom had little experience in health care before they started) and clinical advisers were recruited. The implementation of NHS Pathways required all staff to undergo CDSS and NHS 111 training. Staff appeared to be excited at the prospect of starting something new but were very aware that the service was, to some extent, untried and untested. Being a new organisation meant that it was able to think in advance about the type of staff it wanted to recruit for this new service rather than training existing staff, as was the case at many other sites:

Well, it was quite exciting wasn’t it, because it was a new service and we were the newbies . . ., but I think being the new ones I suppose, we was like the guinea pigs, but we did have good trainers in all fairness.

CallS2, focus group, site 5

In recruitment . . . we’ve been very careful to look at the gender mix, the skill mix and the age mix of the staff . . . I was the only man in a team of all women [previously] . . . I think that actually from the point of view of the patient . . . certainly you will often have a situation where a male patient will want to talk to a male adviser or clinician, but I think that also helps with the sort of dynamic within the group [. . .] And I think . . . paramedics see things very differently, very much a here and now [. . .] So it’s a good mix of skill mix when you assessing a patient’s needs on the phone.

Trainer2, focus group, site 5

The organisation has a strong ethos of supporting and valuing its staff, with an emphasis on continued learning and opportunities. Staff at this organisation suggested that NHS 111 and NHS Pathways have introduced a greater range of career development opportunities, which appears to fit well with the organisational ethos of opportunities and staff development:

The [senior manager] says, ‘we are all equal here. No one is better to anyone else in terms of clinical compared to non-clinical people – we just have different skills’.

Observation, call centre, site 5

[The] telephone triage is basically the same [as NHS Direct] but we deal with the more complex call . . . it’s quite nice really to be dealing with more complex calls and . . . there’s been opportunities like auditing calls and even interviewing, short-listing. So there’s a variety so we’re not just sitting on the phones. There’s opportunities . . . getting involved and [a] management role as well, doing extra things. And we now have our study sessions every week. One clinician will do a teaching session and so we keep the education system going . . . training and learning and development.

ClinA1, focus group, site 5

If someone becomes proficient in the system then we put an advert out . . . for anyone interested in coaching to encourage an informal interview, and then they’ll attend a one day course here and then . . . get supported being a new coach [. . .] There’s far more developmental opportunities within 111 to actually move within the service.

Trainer2, focus group, site 5

The call-handling organisation has a dominant position in the provision of out-of-hours and urgent care services and has been able to capitalise on opportunities presented by the procurement and commissioning of NHS 111 services. The competitive nature of tendering for NHS 111 contracts has created tensions between partner organisations in this area, however. One of the partner organisations that had previously provided out-of-hours services (including call handling) for the area also tendered for the NHS 111 contract in this area. Although it lost the NHS 111 contract to site 5 in terms of providing call handling, it is still responsible for providing UCC services in the area. Former competitors are therefore now obliged to work together offering different parts of the service, creating a somewhat difficult working relationship:

[The senior manager] talks about how the key relationship between [the organisation providing UCCs] and [the call centre] doesn’t seem to work as it should. She says this is a real shame as they all want the best for the patient. We discuss if it is competition that’s the problem. She thinks it is. [The other organisation] lost out and feels they are undermining what [we] are doing. [The senior manager] is really upset about this. She says they work so hard and have few complaints from anyone else. She worries about the effects this negative information will have on people’s views of the service.

Observation, call centre, site 5

Summary

There is considerable variation in the organisation and delivery of NHS 111 services, shaped by the organisational history, dominant service ethic and professional culture of the varied contracted organisations. Our comparative case study approach suggests that there are some keys factors that have shaped the development of NHS 111 service delivery.

There is an inherent tension in the NHS 111 service – there is a push for rationalisation and standardisation while at the same time there is the pull of local service providers wishing to continue to provide services that will deliver quality care that is aligned with their service ethic and their views about what is needed locally. Organisations were motivated by different reasons to want to pilot NHS 111. Broadly speaking they included more entrepreneurial, business-orientated ambitions about expanding the business of the organisation as well as looking for opportunities to grow new business (sites 1 and 5). The commercial organisation (site 5) and ambulance-led providers (sites 1 and 3) were particularly driven by rationing and systemising – by pursuing the NHS 111 vision of ‘right care, right place, right time’. NHS 111, underpinned by NHS Pathways, was a means of rationing, but it also achieves the goals of developing a more integrated service, which may relieve the pressure on ambulance services (sites 1 and 3).

Sites 2 and 4 were driven by different factors. Both were well-established and respected out-of-hours organisations that stood to lose a significant part of their business – the call centre business – if they did not bid for the NHS 111 contract. Both of these patient-centred organisations were strongly motivated to protect their current out-of-hours business. Sites 2 and 4 also feared the ‘threat’ that an alternative provider might offer a poorer service to their local patient population.

The organisational history has, to some extent, shaped how each organisation has handled these tensions and affects the way in which the everyday work of NHS 111 is carried out. For example, sites with a stronger push towards rationalisation (notably sites 1 and 5) demonstrate a more ‘hard-line’ approach to making dispositions (e.g. the call advisers are trained to provide dispositions) than sites with a strong patient-centred ethos (sites 2 and 4), where there is more negotiation and an expectation that patients ‘should be seen or speak to’ a health professional.

Co-location of services and a shared history has significantly enhanced the co-ordination of work and relationships and interorganisational trust and knowledge sharing between organisations. This was particularly strong in out-of-hours organisations that have historically provided call centre activity and UCC services (sites 2 and 4) and organisations that have a history of integrated working (site 3). A lack of previous engagement or joint working with partner organisations or a lack of shared historical relationships appears to be detrimental to relationships between NHS 111 partners. We see this particularly in sites 1, 2 and 5, and in sites 2 and 5 this poor relationship has been exacerbated by the competitive tendering process.

Sites 2 and 4 in particular were both in a position of needing to tender for the NHS 111 contract to protect their current out-of-hours business and workforce. Contracts were initially awarded as ‘pilots’ so organisations were then required to retender to provide the service from 2013 onwards, introducing considerable stress, uncertainty and a huge amount of work for organisations. The competitive process has resulted in organisations being less open, protecting themselves against the potential loss of their business. The opportunity for sharing early best practice has been hampered as sites have been less willing to ‘open their doors’ to potential competitors for fear of giving away their competitive edge.

Summary of the Sheffield study

Details of the Sheffield study are published elsewhere15 but a short summary is provided here to situate the discussion in this chapter. The Sheffield study evaluated four NHS 111 pilot sites, three of which were led by NHS Direct and one by an ambulance trust. The evaluation was designed to assess processes, outcomes and costs and used a controlled before-and-after design to measure the impact of NHS 111, comparing changes over time in the four pilot sites and three control sites that did not establish NHS 111. The evaluation comprised:

• descriptive analyses of service use, referral patterns and quality standards in the first year of operation of NHS 111 in the four sites

• two postal surveys of user experiences and satisfaction

• a controlled before-and-after telephone survey of the general population and recent users of emergency and urgent care to assess satisfaction with emergency and urgent care services and awareness of NHS 111

• an expert panel review of cases

• interviews with stakeholders exploring implementation

• a cost analysis of providing NHS 111 within an emergency and urgent care system and the potential impact of wider implementation.

The Sheffield evaluation showed that NHS 111 had been successfully implemented, albeit slightly differently, in all four sites and that these services were meeting national service quality standards. Caller satisfaction with the NHS 111 service was, in the main, quite high and stakeholders were enthusiastic about the new service, but also concerned about the challenges for wider implementation. Awareness of the service was higher in two of the sites. The NHS 111 service did not appear to have a statistically significant impact on emergency ambulance calls but a drop in NHS Direct calls and an increase in emergency ambulance incidents were detected. The expert panel concluded that the calls that it reviewed received the right clinical disposition and achieved the objective of ‘right place, first time’. The cost analysis showed that there was a low likelihood of cost saving across the four pilot sites but that national implementation, assuming a reduction in NHS Direct costs achieved by disconnecting the 0845 number, could potentially save the NHS £2.5M per month.

The workshop discussion

Rather than simply reviewing the findings of the two studies, the workshop discussion was structured around three core areas of overlapping interest, namely the impact on the wider health system of introducing NHS 111, the organisational implications of introducing NHS 111 and caller experiences of the NHS 111 service.

Conclusions from the workshop

We concluded that the two studies were indeed complementary. This section of the report has highlighted some important issues to be considered for future commissioning and policy as well as articulating some remaining gaps in our knowledge about this new service. Both studies revealed different organisational models for service delivery and highlighted the considerable organisational effort required to introduce a service and again this may provide valuable lessons for the future roll-out of the NHS 111 service. The Sheffield study provided survey evidence of high levels of satisfaction with the new service but both studies urged caution over the need to understand and manage user expectations and future demands. Finally, the workshop discussion of the economic analysis highlighted the need for further, more detailed work on the costs and benefits of this new service model.

Answering the questions in our proposal

In our proposal we highlighted that the NHS 111 service would fundamentally change the way in which urgent care is organised and delivered, most notably in the use of digital technologies and the greater use of non-clinical staff to undertake clinical assessment. The introduction of this new service, deploying a technology that we had previously studied, provided a timely opportunity to empirically investigate four core features of health-care innovation and change around which our four research questions were framed: the way in which work and workforce is organised for this new service and how the technology and organisational context shape the way in which services are delivered. We proposed to undertake a detailed comparative case analysis of three NHS 111 services (in fact we have undertaken this in five sites) to understand the impact of these inter-related aspects on the organisation and delivery of urgent care services and inform workforce planning.

In this chapter we draw together our conclusions for each research question before discussing the implications of our findings and how this work has built on our previous NIHR Service Delivery and Organisation programme project18 and complements the evaluation of NHS 111 undertaken by the Sheffield team. 15 Finally, we set out our research recommendations and consider the strengths and limitations of the study.

Implications of our findings for workforce planning and organisation

Research recommendations

The conclusions reached in this study raise questions for future research. First, our analysis suggests that NHS 111 is not a standardised service across the UK. Organisational history and culture and the way in which the workforce uses the CDSS mean that the deployment of this technology plays out in different ways in different sites. For example, we have noted that there is variation in how clinical advisers advise on, or sanction, ambulance dispositions. We have argued that this interpretive flexibility has been important to the successful roll-out of services. What is not clear is whether this variation matters. The effect of this variation on patient outcomes is unknown and warrants further research. Taking the example of ambulance dispositions we know from the Sheffield evaluation15 that there has been an increase in ambulance incidents. A detailed assessment of ambulance dispositions is needed as it is unclear to what extent the technology or the call centre workforce is making decisions. UCC staff reported that the implementation of NHS 111 had resulted in an increase in their face-to-face workload (also reflected by call centre managers at some sites) although findings from the Sheffield evaluation did not seem to reflect this. The effects of variations in the way that NHS 111 is provided on its longer-term impact on urgent and emergency services warrants further investigation.

We have identified that there is a complex infrastructure that supports NHS Pathways and its use by non-clinical workers. As highlighted in Chapter 7 there is a lack of robust resource use and costing data surrounding NHS 111 and there are difficulties in accurately costing its implementation. A more detailed economic analysis of NHS 111 is needed to inform future policy and service development and this must include analyses of detailed costs for inputs, activity and outcomes. However, this relies on there being robust data available. There are also commercial sensitivities around financial data from NHS 111 organisations.

We have suggested that lack of integration of NHS 111 services with routine general practice warrants further investigation. Beyond this, a whole-systems approach to considering integration across a wider network of partners is key to understanding the complex relationships between demand, access and the provision of health care.

Strengths and limitations

This follow-on study has built on the extensive work of our previous project,18 which examined a single CDSS used in different emergency and urgent health-care service settings. Through five detailed comparative case studies drawing on ethnographic and survey methods, we have explored the inter-related aspects of work, workforce, technology and organisation of NHS 111, to inform the organisation and delivery of modern health services.

The study was predominantly qualitative with a significant ethnographic component and a smaller survey component. This level of detail across a range of case studies is one of its strengths. We chose five case studies to capture some of the diversity in organisational models and professional cultures and to examine a wide range of different NHS 111 services. One of the limitations is that we were not able to include a NHS Direct model of NHS 111 provision and during the course of our research NHS Direct became a significant provider of NHS 111. The Sheffield evaluation15 included three NHS Direct-led pilot sites, which allows some insights into possible differences and similarities but also makes the synthesis of findings between the two studies more difficult. We studied organisations at different points in their NHS 111 trajectory (some were more experienced in using NHS Pathways and/or had piloted NHS 111 earlier than others). The length of experience and stage of implementation will invariably affect the way in which the everyday work of NHS 111 is undertaken (e.g. how dispositions are reached). However, studying organisations at different stages of NHS 111 has also illuminated the different challenges faced by sites at different points along the trajectory.

The timescale of the project (15 months) meant that it was necessary to limit our investigation to call centre and UCC providers. There is, of course, a wider network of health services involved in the provision of urgent care that we were not able to explore in detail. We aimed to include a wide range of stakeholders in the focus groups but securing agreement to participate from stakeholders proved difficult. Additionally, inclusion of stakeholders required multiple research and development (R&D) applications across a large number of trusts, which was difficult to achieve within a 15-month project.

The survey work was limited by both the potential number of respondents available in the five sites and by the moderate response rates we received at some sites (and from UCC organisations). Because of the constraints imposed by ethics and governance requirements, and the limited time available for the project, we do not have information about the non-responders and possible bias.

What does this study add?

This study has focused on the work, workforce, technology and organisation required to deliver the NHS 111 service, building on earlier work (a study of a CDSS in different urgent and emergency care settings18) and complementing work undertaken by Sheffield university (an evaluation of the activity of NHS 111 and its impact on other urgent and emergency care services, costs and patient satisfaction15). A summary of what our study of NHS 111 adds to earlier work is summarised in Table 19. We have revealed that, although call advisers are extremely skilled in assessing callers using a CDSS, the work requires significant support and monitoring. Some poor working relationships were observed between UCCs and call centre organisations, with UCC staff in particular having low levels of trust in NHS Pathways and in NHS 111. Although there was evidence of technological integration, this alone is not enough to sustain an integrated service. Organisational history, the dominant service ethic and the professional culture of contracted organisations all shape the way in which services are organised and delivered.

Contributions of authors

Joanne Turnbull (Senior Research Fellow) led the research and the preparation of the report and was involved in the conceptualisation and design of the study, data collection and analysis and data interpretation.

Catherine Pope (Professor of Medical Sociology) was centrally involved in the conception and design of the study and the analysis and interpretation of the data. She was also involved in the drafting or revising of the report and has approved the final version to be published.

Alison Rowsell (Research Fellow) was involved in the collection, analysis and interpretation of the ethnographic data and in the drafting and revising of the report.

Jane Prichard (Senior Lecturer) was centrally involved in the design of the study and particularly the survey. She was also involved in the analysis of both the ethnographic data and the survey data and drafted sections of and commented on the final report.

Susan Halford (Professor of Sociology) was centrally involved in the conception and design of the study and the analysis and interpretation of the data. She also drafted sections of and commented on the final report.

Jeremy Jones (Principal Research Fellow) provided health economics support and particularly contributed to the joint workshop held with the University of Sheffield.

Carl May (Professor of Healthcare Innovation) assisted with the design of the study and commented on drafts of the report.

Valerie Lattimer (Professor of Health Services Research) contributed to the conception and design of the study and approved the final version of the report.

Disclaimers

This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health.

SDO PROTOCOL – PROJECT REF: 10/1008/10

Version: v1

Date: 13/11/2011

The work, workforce, technology and organisational implications of the ‘111’ single point of access telephone number for urgent (non-emergency) care

Chief investigator Dr Joanne Turnbull

Sponsor University of Southampton

Funder NIHR SDO programme

NIHR Portfolio number 10885

ISRCTN registration number (if applicable) Nota applicable

1. Aims/Objectives

The study is designed to examine the work required to deliver the 111 urgent care service, the types of workforce and skill mix required, the interlinked technologies that will be brought into use, and the wider organisational implications of the introduction of this new service. This represents a large scale and fundamental change to the delivery of urgent care. The research questions will be addressed by using a comparative mixed methods case study approach to understand the implications of the following interrelated aspects of the new service to inform the organisation and delivery of modern health services.

2. Background

The English NHS provides a wide range of services including GP out-of-hours services, minor injuries units, NHS Walk in centres and NHS Direct. The Next Stage Review (Department of Health 2008) proposed the development of a 3 digit telephone number (111) to provide a single point of access to urgent care services to reduce public confusion about where to seek help, to coordinate and integrate services and improve access. The need to integrate urgent care services has long been recognised (Department of Health 2000; 2008). In 2009 the Department of Health (DH) announced a 1 year pilot of a 111 service as a precursor to a national single point of access service which would provide a central hub to integrate and co-ordinate care. The White paper ‘Equity and excellence: Liberating the NHS’, in 2010, suggested a continued commitment to developing an integrated 24/7 urgent care service incorporating GP out-of-hours services across England. The potential roll out of 111 services nationally would represent a significant change to service provision that requires long term commitment and substantial financial investment at a time when there is pressure on public funding. The DH commissioned a Policy Research Programme (PRP) funded evaluation of four pilot 111 pilots (University of Sheffield, 01/03/2010–30/11/2011) to examine activity (implementation, service use, call and referral patterns and impact on local health economy) and patients’ perspectives (satisfaction, experience and demand). Our project is deliberately designed to complement this work by answering key questions about the work and workforce, and the technological and organisational context underpinning the new 111 service.

The use of new technologies like Computer Decision Support Systems (CDSS) to support new services is consistent with the NHS mission to use appropriate technology to benefit patient care and improve service delivery, but the history of the implementation of new technologies in health care demonstrates that the deployment is not always successful. Previous research shows the importance of attending not only to technological feasibility but also to the complex, dynamic processes through which technologies come into use or, more often, fail to do so (Berg 2001; Mayet al. 2005; Heeks 2006; Haux 2006). By focussing on work, workforce, technologies and organisation our study will capture these important processes.

The CDSS NHS Pathways has been identified as an underpinning technology to support the 111 service. This CDSS was the focus of our previous NIHR SDO study (08/1819/217, completed August 2010) and has shed light on the ‘work’ and effort required to bring a CDSS into successful use in a similar service setting. We have demonstrated the complex relationship of expertise and experience required for using CDSS on a day to day basis. This project aims to examine the work required to deliver 111 nationally, the different types of workforce implicated (clinical and non-clinical), the deployment of computer technologies to support this service and the particular organisational settings and configurations surrounding it.

3. Need

HEALTH NEED: By informing the evaluation of the new service and filling the research gaps by explaining the work, workforce, organisation and technology of 111 we will enable a more holistic understanding of this new way of delivering and accessing urgent care and see how it contributes to health care. This project will inform the work, organisation and delivery of urgent care services to the whole population, and will also speak to the wider issues surrounding the implementation and use of technologies like CDSS to meet health needs.

SUSTAINED INTEREST AND INTENT: The roll out of 111 services nationally represents a significant change to service provision that requires long term commitment and substantial financial investment at a time when there is pressure on public funding. The use of CDSS to support new services is consistent with the NHS mission to use appropriate technology to benefit patient care and improve service delivery. However the history of the implementation of new technologies in health care demonstrates that the deployment is not always successful. It is therefore imperative that such technologies are thoroughly understood.

GENERATING NEW KNOWLEDGE: We do not know enough about the work and organisation of this kind of service at national scale nor do we fully understand how new workforce and new technologies are brought into use and sustained. Our current project has shed light on the ‘work’ and effort required to bring a CDSS into successful use in a similar service setting, showing the potential for CDSS to intensify the work of call-handling, and demonstrating the complex relationship of expertise and experience required for using CDSS on a day to day basis. No research has been commissioned to examine the work required to deliver 111, the different types of workforce implicated in this service, the particular organisational settings and configurations surrounding it or the deployment of computer technologies to support this new service. It is essential to fill these knowledge gaps to ensure effective and efficient roll out of this particular service, and to inform wider debates about service development and technologies in use.

4. Methods

5. Plan of Investigation

The team will undertake some initial work before the study fully commences in August 2011, including initial meetings and/or contact with case study sites; ethical approval: and research governance applications; invite and brief advisory group members. The chart below sets out a monthly timetable:

• Months 1–3: liaison with sites, initial visits; finalize ethical approval and governance; literature review; ethnography (site 1); initial survey design; initial team meeting

• Months 4–6: Team and advisory meetings; ethnography (sites 1–4), data clinics/analysis; brief progress report for SDO; focus group design/preparation

• Months 7–9: Ethnography (sites 1–4) data clinics/analysis, survey preparation; focus groups data collection, team meeting

• Months 10–12: Survey administration, team/advisory meetings; update of literature review; ethnography (sites 2–4), survey analysis, ethnographic data analysis; brief progress report for SDO;

• Months 13–15: Update of literature review; advisory and team meetings; integrative workshop with PRP funded study researchers; final report writing and paper writing

6. Project Management

The team combines disciplinary expertise in sociology and psychology and considerable experience of health services research. Turnbull will lead and supervise the project, manage the researcher, oversee ethics, governance and fieldwork/surveys, and lead the analysis and reporting. Pope and Halford will contribute to the ethnography and take lead roles in analysis and reporting. Prichard will supervise the surveys and take a key role in analysis and dissemination. Jones will provide expertise in economic modelling, statistical approaches and evidence review, for the integration of our findings with the parallel PRP funded project. May will contribute theoretical expertise, advise on the ethnography and analysis and will make a major contribution to dissemination of findings. Lattimer will support stakeholder liaison/site access, advise on the surveys and analysis of workforce planning implications.

7. Dissemination and user engagement

Research will be disseminated summatively through reports and journal articles and formatively to current and future user groups, to maximise the impact of our findings to the future planning and development of the workforce. Outputs will include final reports, and papers for relevant journals to inform the research and policy community in the range of disciplinary and practice fields implicated in this research (e.g. J Hth Serv Res & Policy; Soc Sci Med; Sociology; Work Employment & Society; BMJ; Lancet; Health Informatics J). Building on work underway as part of our previous project we will seek to use emerging web technologies (the semantic web) to enable effective dissemination via the web to allow wider engagement. We will seek to disseminate to the health research and provider communities, as well as liaising with SDO network by presenting at service services research conferences (e.g. HSRN SDO Network annual conference, Organisational Behaviour in Health Care), in addition to other appropriate urgent/emergency care and sociology conferences. We will work closely with SDO and our advisory group to prepare findings that can be readily disseminated to target audiences of urgent care service providers, workforce planners, healthcare managers, policy-makers and users of new technologies. We would look to disseminate findings via the NHS Forum.

Relevant stakeholders were consulted (at the Department of Health and urgent care providers) to secure their involvement in developing the proposal. As this new service has potential to impact on the whole population our definition of ‘user’ is broad and includes patient/lay users of services, staff and organisations using CDSS, and key local and national stakeholders (e.g. CDSS developers, strategic planning/policy, clinical, and IT managers). We will include representatives of these in our advisory group and dissemination plans. The advisory group will meet 3 times during the project. In addition we plan to link the user engagement aspects of our project with the activities of the PRP project by holding at least two joint meetings where the user representatives from both projects meet to discuss the issues and findings from both strands of work.

We will also have links to, and support, of the Work Futures Research Centre at the University of Southampton via the newly formed special interest network on the health and social care workforce. This give us access to an interdisciplinary network of researchers, healthcare policy-makers and NHS managers concerned with innovation in working and organisational practices across health care in the 21st century. We hope to organise a joint workshop/seminar with WFRC to present and discuss our ongoing analyses to facilitate a broad exchange of knowledge and ideas surrounding the study.

In the research sites we will build on successful engagement mechanisms developed in our previous research linking to local R&D and strategic committees to facilitate and disseminate the research. We will also make effective use of regular electronic bulletins and feedback to ensure that staff and stakeholders are kept up to date with the project progress and findings.

9. References

Advisors

Tracy Finch (Senior Lecturer, University of Newcastle)

Shelley Noble (Senior Clinical Nurse Manager, Solent NHS Trust)

Alicia O’Cathain (joint principal investigator of the PRP-funded NHS 111 service evaluation, University of Sheffield)

Francine O’Malley (Senior Nurse in Unscheduled Care and Lecturer, University of Southampton)

Stephen Peckham (Professor of Health Policy, University of Kent and the London School of Hygiene and Tropical Medicine)

Nicholas Reeves (Department of Health advisor)

Arjan Shahani (lay advisor)

Ann Short (lay advisor)

Helen Smith (Professor of Primary Care, University of Brighton)

Janette Turner (joint principal investigator of the PRP-funded NHS 111 service evaluation, University of Sheffield)

Purpose and activities

The advisory group assisted the project by providing external research and theoretical input and by informing us about relevant practice and policy issues. The group members were invited because of their experience and interest in issues related to the use of technologies in health-care settings and they are drawn from academic, policy-making and health-care arenas. The group also included public/lay representatives with the aim of helping to keep our research relevant and accessible to a wide range of audiences and users.

The group played an important role in helping us think about the implications and dissemination of our findings. We held two meetings over the course of the project in January 2012 and September 2012.

The main focus of each meeting was as follows:

• January 2012: introduction to the research, choosing the case study settings and discussion of urgent and emergency care policy.

• September 2012: feedback on the main findings and structure of the final report.

111 URGENT CARE STUDY: WORK, WORKFORCE, TECHNOLOGY AND ORGANISATION

Further information for staff and stakeholders at participating sites about the observation and focus groups

111 URGENT CARE STUDY: WORK, WORKFORCE, TECHNOLOGY AND ORGANISATION

Focus group topic guide for staff and stakeholders

111 URGENT CARE STUDY: WORK, WORKFORCE, TECHNOLOGY AND ORGANISATION

Further information for staff and stakeholders at participating sites