Jump to comment:

• The analysis makes no comparison with a baseline position and is selective in reporting only some costs
  Henry Clay
  Published on: 17 June 2017
• Emergency Department referrals from NHS 111
  Steven Rawstorne
  Published on: 19 January 2016

• Published on: 17 June 2017

  The analysis makes no comparison with a baseline position and is selective in reporting only some costs

  • Henry Clay, Management Consultant Primary Care Foundation

  The need to compare with a Baseline
  The analysis describes how cases were chosen "where the NHS Pathways software indicated that a patient should be instructed to go to an A&E department" (so dispositions to an emergency department with codes such as Dx02 or Dx03) and how "the call handler told the patient that they would be called back by a GP".
  However, as part of the normal process in NHS 111 a further conversation takes place with the patient after the Dx code has been generated during which the specific location of the service that the patient should attend is agreed. As this is done a number of callers are directed to WIC, MIU etc. and to other services. The exact level will depend on various factors, most noticeably the number and location of these alternative services, but analysis from elsewhere of the referrals by call-handlers to Emergency Departments with a time frame of 1 and 4 hours (Dx02 and Dx03) concluded that 15% of those cases go to WIC + MIU 3% to other services, whilst perhaps 7 or 8% were referred to the ambulance service (so may well have been transported to the Emergency Department).
  Since, in the study, this conversation with the call-handler was effectively delayedto the later conversation with the GP the comparison should have been with a baseline case, not simply with the nominal NHS Pathways disposition. It seems likely that the impact if the authors had compared with a baseline period using informa...

  Show More

  The need to compare with a Baseline
  The analysis describes how cases were chosen "where the NHS Pathways software indicated that a patient should be instructed to go to an A&E department" (so dispositions to an emergency department with codes such as Dx02 or Dx03) and how "the call handler told the patient that they would be called back by a GP".
  However, as part of the normal process in NHS 111 a further conversation takes place with the patient after the Dx code has been generated during which the specific location of the service that the patient should attend is agreed. As this is done a number of callers are directed to WIC, MIU etc. and to other services. The exact level will depend on various factors, most noticeably the number and location of these alternative services, but analysis from elsewhere of the referrals by call-handlers to Emergency Departments with a time frame of 1 and 4 hours (Dx02 and Dx03) concluded that 15% of those cases go to WIC + MIU 3% to other services, whilst perhaps 7 or 8% were referred to the ambulance service (so may well have been transported to the Emergency Department).
  Since, in the study, this conversation with the call-handler was effectively delayedto the later conversation with the GP the comparison should have been with a baseline case, not simply with the nominal NHS Pathways disposition. It seems likely that the impact if the authors had compared with a baseline period using information available within NHS 111 they would have concluded that some form of management alternative to A&E attendance would have been recommended in perhaps 55% of cases that would otherwise have been sent to the emergency department by the NHS 111 call handler (instead of the 73% quoted)

  Selective reporting of costs
  The study reports the costs of the saving in attendances at A&E, but it does not include the costs of the attendance at the MIU or WIC nor the cost of the face to face consultation in the out of hours service. This selective reporting of the cost has led to at least one instance (in Pulse) of a saving being reported, when actually the intervention cost more than the saving.

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top
• Published on: 19 January 2016

  Emergency Department referrals from NHS 111

  • Steven Rawstorne, NHS 111 National Medical Advisor
  • Other Contributors:
    • Jonathan Benger

  Anderson and Roland offer a useful contribution to the question of how telephone requests for help and advice through NHS 111 should be assessed.[1] We agree wholeheartedly with their conclusion: "our results demonstrate the need for further research to establish the cost effectiveness of different approaches to triaging telephone requests for care".

  Such work is already under way, through the NHS 111 Learnin...

  Show More

  Anderson and Roland offer a useful contribution to the question of how telephone requests for help and advice through NHS 111 should be assessed.[1] We agree wholeheartedly with their conclusion: "our results demonstrate the need for further research to establish the cost effectiveness of different approaches to triaging telephone requests for care".

  Such work is already under way, through the NHS 111 Learning & Development Programme, established during 2014. The lessons we have learned to date have been incorporated in the latest guidance to commissioners, published in October 2015.[2] This specifically suggests that commissioners of NHS 111 services should "assess the potential benefits and consider if Emergency Department (ED) dispositions should be subject to early clinical assessment within Integrated Urgent Care (111)".

  We have, however, been circumspect in offering this guidance on account of the lack of evidence about the actual impact of such review on patient outcomes. In particular, caller compliance both with advice to attend A&E and offered alternatives is unknown, as acknowledged by Anderson and Roland. We are also concerned that a recommendation to utilise general practitioners (GPs) in this role, as opposed to other clinical professionals, is premature. It is important before making any change that the cost effectiveness of both GPs and alternative approaches are fully understood, and that in assessing this cost effectiveness the impact on the whole Urgent and Emergency Care pathway is considered. In particular, the expertise of GPs is a valuable but finite resource, and the workforce implications must be carefully considered. We have no desire to replicate past mistakes.

  References

  1. Anderson A, Roland M. Potential for advice from doctors to reduce the number of patients referred to emergency departments by NHS 111 call handlers: observational study. BMJ Open, 2015;5:e009444. doi:10.1136/bmjopen-2015-009444.

  2. NHS England, NHS 111 with CCGs. Integrated Urgent Care Commissioning Standards (2015). Available at: https://www.england.nhs.uk/wp- content/uploads/2015/10/integrtd-urgnt-care-comms-standrds-oct15.pdf

  Conflict of Interest:

  Dr Steven Rawstorne is NHS England NHS 111 National Medical Advisor. Prof. Jonathan Benger is NHS England national Clinical Director Urgent Care.

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top