The news has been visible and intense. For the last month the news, to some extent internationally is growing stronger and stronger into the crashed and clashed NHS. The National Health Service is as seems to be described, as a system that has buckled. It is an infrastructure that can no longer deal with the population size of the UK, where more people and less money are two direct causes of collapse to a system that cannot sustain itself.
In this regard I will only look at the 111 helpline. I am not an MD or a member of the Medici family; I do however have the knowledge of call centres and technology. So, I will go with my strengths.
If you want to read some additional material (quality information), then take a look at http://www.guardian.co.uk/society/2013/jul/29/nhs-direct-pullout-111-helpline, where most information is available. There was additional information on TV; however as Channel 4 chose not to transmit their service to Sydney, I cannot tell the content of that special.
When we look at another Guardian article we read “Channel 4’s Dispatches programme, NHS Undercover, found the non-emergency 111 system had staff shortages, long waits for callers, and in some cases ambulances were being called out unnecessarily.”
The second quoted from the initial mentioned article is “NHS Direct had worked on the assumption that it would cost on average £13 per call to cover salaries and other expenses for employees, but then found the actual payment it was receiving for its services was closer to £8, leaving it far short.”
The last quote comes from the NHS site itself (at http://www.nhs.uk/NHSEngland/AboutNHSservices/Emergencyandurgentcareservices/Pages/NHS-111.aspx)
You should use the NHS 111 service if you urgently need medical help or advice but it’s not a life-threatening situation.
Call 111 if:
you need medical help fast but it’s not a 999 emergency
you think you need to go to A&E or need another NHS urgent care service
you don’t know who to call or you don’t have a GP to call
you need health information or reassurance about what to do next
For less urgent health needs, contact your GP or local pharmacist in the usual way.
When we look at this in a clinical way, then we should look at this with the cold IT heart we need to have when running a call centre.
1. Staff shortages.
This is plain and simple a management issue. How many calls were expected, how many came, what staff is available and what needs to be added. This in the best of terms is nothing less than a mere exercise in Excel. Even if there was a shortage, then we see there are two sides. On one side we need more people which mean there is a budget part; on the other side we see the expectation of quicker times, again all part of a budget.
2. Long waiting time.
When you go to the hospital, when you are NOT in a life threatening situation, then how long until you receive medical assistance? Would more staff solve this (would that actually solve it)?
There is a Dutch expression which boils down to mopping the floor next to a running tap. Basically it means that the floor will never get dry. That seems to apply to the situation people face with the 111 helpline.
In addition, this quote “its reporters found many patients were left waiting for longer than the 10-minute target for a call-back from a clinician”. Is that truly a bad thing? Let us not forget that this line was not for REAL emergencies. I have been to a hospital after a heart attack, and even though I got excellent care and they saved my life, the doctor was more than 10 minutes away. It happens! I am not the only one in need, and the hospital has excellent nurses. I wonder whether some expectations, as set for the 111 helpline, really are realistic.
3. Time and money.
When looking at the second quote earlier, we see that between £13 and £8, there is a definite discrepancy. When you get the needed and actual target wrong by 40%, management either did not do their homework, or they have not ample dealt with all the elements in play.
One of the clear signs as was mentioned by Sky News is that calls took much longer. When we consider call centre etiquette, not unlike what physicians do, we need to get to the crux of things. We need structured questions and we need to keep control of the conversation. This all leads to reduced times. Letting the patient (or customer) ‘waffle on’ is just a waste of time for all parties. So it boiled down to asking the right open and then closed questions to get the show on the high speed road. Here there is a slight problem. Nurses (Doctors too) rely on what they see and what they smell, these factors are now lost to them. This means that any assessment will take longer then they think, yet call centre protocol approach would limit these losses to some extent. This is a skill that nurses might not have. They can get trained in this and over time they will get good at it, but are they given the time needed? In the end this could also reduce the amount of ambulances getting called out unnecessarily.
The last part in this matter comes from the 111 site itself. “You don’t know who to call or you don’t have a GP to call” & “you need health information or reassurance about what to do next“.
Are those truly the right expressions? In that regard the 17 year old girl dealing with the statements to tell her dad “I had sex” and “you’re going to be a grandfather“. They fit the description, yet, let us be fair whether this is an emergency? (To the girl it really is!)
The generic description gives way that all in need of more than a band aid might call. This even includes mental health issues. Is that what the 111 number is for? If so, was the budget aim correct? These are all raised issues that I could have told them before the service launched. So the question becomes were they raised at all? Perhaps they were which takes us right back to the issue of 40% budget offset. What was missed?
In addition the following quote gives way to another question in the Guardian article “was replaced by a new system in which private providers and NHS Direct bid against each other to win regional contracts“. Really? So the cheapest won? Perhaps the indication is there on how the 40% difference of income is set. How is that a solution? I get the idea behind it. The NHS must find a cheaper solution to get part of their pressure removed and as such the solution of a call-centre makes sense. However, as the human element will remain in the system, we see the need that the problem could be managerial not systematic. In addition, we need to realise that coaching the health care teams is a necessity that usually takes 20% longer than most expect. That is not bad expectations, but when those in their field move to other mediums, they need to reset the scope of their skills. (Like the loss of information by not being face to face with the patient in person). That is just a reality.
This all is visible before additional factors are added. If you think work in a hospital is intense, wait until these people get to the patients who will scream into a phone because they feel that the connection is too un personal. It will happen. Take a person under pressure and a situation where that person cannot vent, then your goose is cooked. This will result in burnouts and spiking stress levels. Were these factors included in the costs of this project? If not, then you will see further escalations of costs and shortages.
The Chief Operations Officer Dame Barbara Hakin has her work cut out for her. I reckon that this is a system that could work. I personally belief that it has a future, yet, a system that is spread over a large area, with 45-50 contractors involved means that there are additional issues to content with. Is it true that this is just about taking over and restoring confidence (as Sky News reported)? I think it needs to be about communicating realistic goals (not the golden cost reduction some politicians claimed it might be) and attending to these needs and fighting towards those goals.
It is also about looking at all of the contractors and aligning views, requirements and systems. There is for example the NHS phone App. (or website), which could help a person in determining where they need to go to, or who to call. It could be that they need to call 111, yet these few seconds of going through that path, if that is an option, might even reduce pressure to the 111 service for up to 10%. That would be a big relief for both patient and service!
Lawrence van Rijn - Law Lord to be 