Casualty in crisis: A&E - a service in meltdown

Damning report says NHS Trusts were pressured to introduce new 111 service before they were ready

Doctors were placed under “unprecedented pressure” to go live with the new NHS 111 helpline before some were ready, contributing to the A&E crisis in Britain's hospitals, documents seen by The Independent on Sunday reveal.

Paramedics have been sent out to treat patients who did not feel ill enough to need an ambulance and were "more than willing" to see a GP instead, according to a damning assessment by the NHS Alliance, which represents GP surgeries and other primary care trusts.

In a separate official report by NHS England, presented to the Health Secretary Jeremy Hunt 10 days ago, officials told him that A&E performance has "deteriorated significantly over the last six months" as a result of increased numbers of patients arriving at casualty, job losses and social care pressures leading to elderly people remaining on wards.

The introduction of NHS 111 last month has exacerbated the crisis, the officials said. Mr Hunt now faces questions in Parliament over his handling of the crisis in emergency care.

The NHS Alliance said warned in its report that providers of the new non-emergency telephone number did not feel prepared to "go live" with the service on 1 April but felt they were put under "unprecedented pressure" by the Department of Health.

In one incident in Bristol, because of 111 call mishandling, police were called to a palliative care patient despite an attempt by a doctor to intervene.

The Health Secretary is due to respond to the crisis with a speech on Thursday announcing changes to GPs' out-of-hours working, including a "greater role" for primary care.

Mr Hunt has insisted for the past month that the growing crisis at accident and emergency units is a result of Labour's 2004 GP contract, which allowed family doctors to opt out of out-of-hours care.

Yet both the NHS Alliance and the report by NHS England – the quango overseeing the delivery of the newly restructured health service – say that the introduction of the 111 service has piled pressure on Britain's emergency units. The NHS Alliance document says that in one area surveyed in April, GP out-of-hours referral rates soared to 27 per cent on the first weekend after the launch of 111, compared with a normal rate of 3 per cent. Six weeks on from the launch, the rate is still double the normal level, at 6 per cent.

"In many cases, it is clear that providers were put under unprecedented pressure by the Department of Health to meet their agreed go-live dates, even if the providers felt they were not prepared," the NHS Alliance document says.

"Though delays might have been disruptive, in the interest of patient safety, greater flexibility might have helped providers learn from the mistakes of others, delivering a more robust system further down the line."

It adds: "In some cases the tender assessment criteria were heavily skewed towards cost."

Separate analysis by The IoS shows that waiting times in A&E departments have increased as a direct result of 111. In 73 out of 92 NHS Trust areas, more patients were forced to wait longer than four hours before receiving treatment in the week after 111 was introduced than the week before. For control purposes, out of 19 trusts where 111 has not been introduced, the comparison was fairly even: 10 had worse performances over the same time period, while nine performed better or the same.

Despite the Health Secretary's repeated claims about the 2004 GPs' contract being the driving force behind the A&E crisis, nowhere in the 23-page NHS England report does it list this as a factor.

In the Commons last Monday, Mr Hunt admitted that NHS 111 had had "teething problems" leading to "unacceptable levels of service in some parts of the country which we are in the process of sorting out". But he added: "We also need to look at the long-term causes of the problems of out-of-hours provision and the fact that the general practitioner contract of 2004 has led to a removal of GP responsibility for out-of-hours care, which means that there is much less public confidence than there needs to be in the whole picture."

Mr Hunt also wrote on Twitter to shadow Health Secretary Andy Burnham last Thursday: "4m [million] more [patients] going to A&E every year since Labour's catastrophic mistake on GP contract – and you still think no connection?"

Mr Burnham said last night that Mr Hunt needed to return to the Commons to explain why he had not told Parliament the full details of what NHS England had advised in its dossier. He said: "For weeks, Jeremy Hunt has sought to blame the 2004 GP contract for the pressures on A&E. We now know that the official advice he was receiving in private from NHS England did not support his claims.

"Perhaps more than with any other cabinet minister, people and patients need to have confidence that the public statements of the Secretary of State for Health are based on the evidence. This embarrassing revelation will damage confidence in the current incumbent. Jeremy Hunt needs to remember that he is the Secretary of State for Health, not his department's spin doctor-in-chief."

NHS 111 was launched in some pilot areas last year before being rolled out in most parts of England on 1 April. But since its introduction, there have been warnings that the failure of call handlers to deal with patients correctly has triggered an influx in people arriving at A&E.

According to official statistics, in Yorkshire and Humberside, only 22 per cent of calls made to NHS 111 on 30 March were answered in less than a minute.

Some callers in Dorset were waiting more than half an hour for 111 operators to answer, with the longest wait on 30 March recorded as 33 minutes, 41 seconds.

In Gloucestershire and Swindon on 29 March, 43 per cent of calls were abandoned after callers waited for more than 30 seconds.

A spokesman for the Department of Health said: "We worked with the local NHS and emerging clinical commissioning groups on the go-live dates for NHS 111 in areas across the country, to ensure a safe service was provided for patients.

"The Secretary of State for Health also offered areas who needed it an extension of up to six months to the roll-out deadline of April this year. However, many areas did not take this offer up as their services were able to continue with their existing plans."

Case study: 'An ambulance was called out to a patient who had diarrhoea'

NHS 111 operators have sent Kevin Long, a paramedic, and his colleagues to deal with a variety of non-emergency cases, he says.

Mr Long, who works for South East Coast Ambulance Service (SEACamb), recalled one recent incident. "A young lady had a chest infection and phoned up NHS 111 to seek advice and ended up having a 999 ambulance," he said.

"She became so distressed that we ended up taking her in as an A&E admission because the stress had started affecting her breathing."

Mr Long, from Hastings, said another paramedic had been called out to a patient with diarrhoea. "Again the patient called NHS 111 for advice, the crew was sent and agreed with the patient that he wasn't an accident and emergency case.

"The system they use has various trigger phrases that track it to saying a 999 ambulance service is required, which I think is where the problem is arising."

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