27th August 2015

Dear Colleague

NHS 111 Mobilisation Briefing for North West General Practices

You will all have heard of NHS 111 and will likely have various impressions of it based on the media, patient feedback and perhaps even your own, or relatives’ use of the service. Despite the negative publicity surrounding the failure of the original provider to mobilise their service around Easter 2013, calls to NHS 111 have increased dramatically in the intervening years (now over a million per year in the NW) and have a greater then 90% patient satisfaction rate: patients like the service they receive. Since stabilising the service in autumn 2013 through the transfer of operations to North West Ambulance Service (NWAS) and FCMS (a GP OOH servicefor the Fylde Coast) we have been working to continuously improve quality with these providers whilst undertaking a re-procurement exercise for the longer term. During summer the CQC conducted a pilot assessment of NWAS’ 111 operations and gave extremely positive feedback, regarding the service as “well-led, safe, effective, responsive and caring”.

The re-procurement process concluded in spring 2015 with the appointment of NWAS, FCMS and UC24 (Urgent Care 24: a GP OOH servicefor Merseyside) as the preferred providers for the next five years. Since then we have been working closely with these providers to develop, implement and oversee their mobilisation plan for this autumn.

As part of these mobilisation preparations there are some aspects that impact on in hours general practice and this letter aims to highlight these to you so that you are well placed to take the appropriate steps.Practices will need to:

  1. Make arrangements to adjust their surgery out of hours answerphone message (and any other information, e.g. practice website) on the appropriate transition dates for their area (see below).
  2. Identify patients considered to be in an end of life phase or where a valid DNACPR exists to ensure that they have an appropriate Special Patient Note in place.
  3. Identify patients where a Special Patient Note exists or may be required and review or create its content, considering the suggested phraseology provided (we recognise that this will be an on-going piece of work rather than all necessarily being complete prior to mobilisation).
  4. Consider how your frontline team will respond to calls when patients advise that NHS 111 has recommended that they contact the practice.

The appendices below provide more detail and guidance around each of these elements and will be most pertinent to the individual(s) overseeing these actions.

Should you require further information or advice on NHS 111 please contact your county clinical or managerial lead in the first instance. Their details are appended below.

I hope the information above and attached proves helpful to you and supports better interactions with NHS 111 for you and your patients.

Magnus Hird

NHS 111 Regional Clinical Lead/ Chair of the NHS 111 North West Programme Board

County / Managerial Lead / Contact / Clinical Lead / Contact
Cheshire / Jim Britt / / Catherine Wall /
Cumbria / Caroline Rea / / Andrew Rotheray /
Greater Manchester / Steve Allinson / / Helen Hosker /
Lancashire / David Bonson / / Mark Denver /
Merseyside / Ian Davies / / Si Perritt /

So what is changing and when?

Currently NHS 111 operates across the whole of the North West, providing patients with a free to call, urgent care contact point for when they need medical help but are not sure what to do. If a patient dials 111, they will be connected to 111.

The original goal was for GP OOH call handling to be routed through NHS 111 but due to the problems in 2013 many GP OOH services call handling operations were reinstated. Beginning on 1 October 2015 we will see a phased transfer of this GP OOH call handling back into NHS 111 across the North West.

This has been carefully planned with on-going dialogue with GP OOH services. The phasing plan is as follows:

Area / Mobilisation Dates
Cheshire / Thursday 1 October 2015
Merseyside / Thursday 1 October 2015
Lancashire / Tuesday 20 October 2015
Cumbria / Three locality-based stages at weekly intervals from Thursday 22nd October
Greater Manchester / Tuesday 10 November

This change has a particular implication for your answerphone messages and any other communications / information sources you use to advise patients what to do when you are closed.

Telephone Answerphone Messages

GP practices across the North West have a range of different telephony systems and arrangements when the practice is closed. As NHS 111 goes live for GP OOH call handling these messages/arrangements must be reviewed and updated to reflect the changes on the appropriate transition dates above.

This has been thoroughly considered by the clinical leads across the North West and they note the following:

  • NHS 111 is intended to be a free to call service (pay as you go phones need to be in at least 1p of credit, although no charge is made). If a call to the GP surgery is diverted to NHS 111 the caller will be charged for the whole call (including the NHS 111 element) at the rate they would pay to access the GP number.
  • The number the call is made from appears in the IT system as the call is answered. If the call is lost, for example the line goes dead (perhaps because the caller becomes unconscious) there is the opportunity to trace the call and location of the patient. This is also possible with mobile phones where the patient’s location is triangulated using telephone mast information. Locating the patient in this way is not possible if the call has been diverted from another number; the call will appear to have originated from the number that it has been diverted from, i.e. the GP practice.

For these reasons the clinical leads’ recommendation is that no diverts or auto-diverts should be used and that GP answerphone messages should be adjusted to recommend that patients needing urgent advice hang up and dial NHS 111 directly.

An example message script could be:

As NHS 111 has been procured to provide cover during CCG-approved monthly Protected Learning Time events practices may also need to review other answerphone messages that may be used at these times. However NHS 111 has not been procured to cover other occasions when practices close, e.g. where local arrangements are for practices to close at 6pm, or as part of business continuity arrangements during a practice telephony failure. Provision for these instances remains a local responsibility and messaging should reflect this.

We believe that some GP telephony providers may have significant lead times to make changes and would urge you to make early contact if you require external input to make these changes.

Special Patient Notes

Special Patient Notes (SPN) have existed for many years, being the primary means by which the patient’s own GP alerts anyone providing cover for them, mainly out of hours, of particular or specific facts or needs relating to an individual patient, such as those patients near the end of life or where safeguarding concerns exist. As such creating, reviewing and updating SPN is not a new task.

SPN that have been correctly entered on Adastra (the IT system used by most GP OOH services in the North West) can be shared and made visible to NHS 111. There is also a workaround process in place for services not using Adastra.

SPN are used at two main stages of the patient’s journey. Firstly, at the initial contact point where a call (e.g. to a GP OOH service or NHS 111) is received and assessed and then secondly during the phase when the patient receives contact from a clinician to manage the problem itself.

During the first phase it is vital that the first sentence or two of the SPN clearly states whether there needs to be any variation in the assessment process for that individual. For example if they need a translator or if a reported death would be expected. These latter situations are particularly important: like yourselves, NHS 111 has no desire to send emergency ambulances to the door of a patient who was expected to die and create the upset and trauma of CPR or the involvement of the Police or a Coroner when it is unnecessary. But without a clear instruction that this is the situation those taking calls will not know to over-ride such endpoints and involve a clinician early in the process.

However, over-riding an ambulance outcome is not as straightforward as it may initially appear. Whilst in the example above it could be entirely appropriate to do so, it would not be appropriate to delay ambulance dispatch for e.g. a patient with an advance directive to decline CPR (perhaps due to motor neurone disease) who presents with an eminently treatable problem such as choking or possible heart attack.

To try and assist the clinical leads have compiled a small set of suggested texts, attached, for those initial words, for the most common types of SPN. We would very much encourage you to consider using these going forwards as you add and review your SPN. We also recommend that prior to the transition dates above that you review whether all your patients known to be at the end of life have a relevant SPN in place and whether this is clear regarding any wish to over-ride ambulance responses.

The second part of the SPN is harder to define but should continue to include concise, relevant information on the patient’s circumstances. If a specific care plan exists (e.g. Admission Avoidance, dementia, mental health, end of life / palliative care) then describing how and where it can be accessed is often helpful. There is work underway at a national level, under the auspices of HSCIC, to better specify the data that should make up various types of SPN.

Referrals from NHS 111

As occurs nowyou may be contacted by patients who say that NHS 111 has advised them to make contact with you within a certain timescale. NHS 111 does not advise patients that they have to have a specific appointment, just that they should make contact in that timescale. The practice needs to determine how it will handle these contacts bearing in mind that the patient has already undergone a triage process.Unfortunately in a couple of serious untoward incidents that we have reviewed these arrangements have been a contributing factor to the outcome.

Most important amongst these are patients who are given a short timescale to make this contact, generally indicating a potentially more urgent need for further assessment or care. Where NHS 111 has any concerns about a patient’s ability to make this contact, e.g. they are very unwell or vulnerable, then in order to maintain patient safety NHS 111 may contact the practice directly to handover details person to person.

Based on NWactivity (which would not be expected to change with the upcoming mobilisation) we know that the number of calls referred to patients’ own GPs in hours are very low: less than one per practice per day on average.

As such this should not cause undue pressure on your practice, but should there be any concerns we are happy to look into things with you. You can flag up any issues or concerns by using the established Healthcare Professional Feedback (HPF) system. After receipt of feedback each case is reviewed by the clinical governance team within the NHS 111 providers and you will receive an individual response about the outcome.

The clinical leads oversee this process and review monthly summaries of all HPF and their outcomes as well as being intimately involved in any more serious incident reviews. The significant degree of oversight we have across NHS 111 has helped us further develop the service’s safety and effectiveness and contribute to improvements in the systems that underpin it, namely NHS Pathways and the Directory of Services. Your support to this process is much appreciated.