A former 111 clinician speaks out on rising pressures and a staffing crisis at the NHS non-emergency call service. Josiah Mortimer and Max Colbert report
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Before pharmacies, and before GPs, NHS 111 is often the main gatekeeper into the health service - handling millions of calls a year and playing a critical role in triaging patients, from suspicions of flu to what could be the early signs of cancer. But we don’t often see through the gatekeepers’ windows.
In an exclusive interview with Byline Times, Andrew Champion, a former NHS 111 operator, has revealed allegations of systemic issues plaguing the UK's health service hotline. Champion worked for the Hertfordshire Urgent Care NHS 111 call centre, and his account paints a concerning picture of a service on the brink of crisis. He continues to receive constant requests for urgent staffing, seen by this paper.
"Pressure on the system is high," Champion explained. “The system cannot cope. There are not enough bums on seats, and the people taking calls are too inexperienced. They burn out and make mistakes.” Herts Urgent Care is contracted to run the NHS call centre not just for Hertfordshire, but also for some calls from London, as well as GPs in Devon.
The clinician worked in the service for a decade from 2012 to the middle of last year. The health service “was already struggling" at the start of the pandemic, he said, noting the impact of a decade of austerity on services.
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According to official figures, 3.6 million calls to the 111 service were abandoned throughout 2022, with analysis by the House of Commons library finding that callers were left waiting so long that nearly one in five (18%) gave up with the process before reaching an operator.
This number rose to 41% in December, when the average waiting time was 25 minutes, the highest on record. And while there were around 55,000 calls to the service every day before the pandemic, the latest figures show there are now around 64,000 calls a day. Call numbers have risen since Champion left last June too.
There is also a significant "brain drain" as many NHS 111 staff are not from the UK and returned home after Brexit, the former clinician says. The demand for staff with his experience was so great that he was allowed - contrary to protocol - to work from home despite not having worked in call centres for long enough to be based out of office.
Messages seen by Byline Times requesting *urgent call centre cover* for clinical advisors show that throughout 2022, sometimes daily, both home-working and on-site shifts were frequently being requested due to “services pressures” and sickness. Champion explained that these staff were likely asked to cover shifts “on off days or already working, so potentially exceeding safe working levels”.
Champion's role involved triaging calls from the initial stage, an essential task given that many patients were waiting far longer than was safe. "I was cherry-picking those that didn't need to be in a queue to speed things up," he said. "That's all 111 does - signposting.”
However, the clinician’s ad hoc attempt to streamline the process resulted in a formal complaint and professional misconduct charges. One Covid patient, whom Champion had referred to a specific team for rapid treatment and a call back about their vulnerabilities, launched a complaint because Champion had not personally called them back. He had ticked a box saying that they had been spoken to.
Hertfordshire Urgent Care found him guilty of misconduct - despite the patient having gone on to the right team.
He is currently unable to practise, a situation he finds hard to reconcile with his 36-year career in the profession. But he has taken the opportunity to expose what he sees are major vulnerabilities in the system. Champion, now retraining, expressed his dismay at the current state of the NHS, believing it to be "up for sale" and headed towards a two-tier system where patients either "pay or go under."
Champion also highlighted the alarming cutbacks in training for staff. He was initially trained in 2002 over a 10-week period to be a clinical advisor on the NHS 111 line. When he left last summer, new clinical recruits were receiving just two weeks of specific training for 111, Champion says, a reduction he believes is detrimental to the service.
"They've decided you don't need communication skills, psychological background training," he said. "All that is very important when you can't see someone in person. You need to know your stuff."
He said that non-clinical call handlers now receive just a week of training, before being tasked with “vital responsibilities” such as checking demographics and linking calls to previous records. There are obvious serious implications to mishandling calls, with Champion referencing fatal accidents in the past where people with urgent bacterial meningitis had been wrongly triaged to a pharmacist and then died.
A spokesperson for Herts Urgent Care, which runs the 111 service Hertfordshire as well as some calls from London and elsewhere, disputed the claims, saying: “Before taking any patient calls, all new HUC NHS 111 call handlers have to undergo stringent training on NHS Pathways, a clinical decision support system which underpins NHS 111 services. This is a requirement set by NHS Digital for all NHS 111 staff.
“Regarding the former employee's comment, we can say that rather than decreasing the training requirements, HUC have actually increased the mandated training timetable. This is now six weeks for all new non-clinical call handlers (previously 4 weeks) and 9 weeks for clinical call handlers (previously 7 weeks).”
Speaking to Byline Times, NHS England said that “the initial training for NHS111 Health Advisors spans a period of approximately 10 weeks, [rising to] 14 weeks for clinicians”, and that the training is “under constant review”.
However, trusts like the London Ambulance Service, as well as private accreditors, often advertise a ‘five week training course’ to become a health advisor. When reached for clarification on the length of time it takes to train regular service advisors as well as health advisors, NHS England said “the 10 weeks training applies to all 111 providers”.
But responding to the comments, Champion said: “I was already Pathways qualified clinical advisor as a Locum with Connaught Resourcing when I began working with Herts Urgent Care in October 2021. I had to do five calls audited with a “buddy” clinical advisor, sat with me which took a few days. I was then signed off as competent to take calls in the call centre independently.” He was then allowed to work from home. But he added he was “glad” HUC appeared to have improved its training for new starters since he left.
UNISON head of health Sara Gorton said the service, run by different trusts across England, was under huge pressure nationwide: “The wider pressures on the NHS, especially in GP practices, social care and mental health, mean more people are turning to 111 services.
“That has meant a huge increase in calls and pressures facing staff. It’s also having a detrimental impact on call handlers who’re dealing with patients’ increasingly complex needs on the phone.
“The extra demands are causing many to leave as quickly as they joined for better paid and less stressful jobs outside the health service.”
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Clean Up Job
The government recently published its new Primary Care Recovery Plan, which outlines an intention to expand the role of pharmacists to be able to distribute prescription medication without first contacting a GP. The initiative also aims to tackle the 8am rush for GP appointments by either giving patients an appointment immediately or signposting them to ‘a more appropriate service such as NHS 111 or their local pharmacy’.
In January, Prime Minister Rishi Sunak promised to deliver the “largest and fastest-ever improvement in emergency waiting times in the NHS’s history”, in part by using 111 to take pressure off hospitals by increasing access to the service for children and young people with mental health concerns.
As part of plans to expand the role of 111, the Department of Health and Social Care have said they want to increase the ‘number of NHS 111 call handlers to 4,800’. The recovery plan includes giving NHS staff ‘better flexibility’, by ‘making it easier for them to move between hospitals and work in services like 111’.
But following last winter, issues stemming from high stress and intense pressure on staff within the health service could mean going forward that the workforce is still underpopulated, throwing doubt on whether this figure will be reached. A record number of NHS staff quit in the last quarter of 2022, with 42,400 staff leaving their roles voluntarily, with 7,200 giving “work-life balance” as the reason.
Speaking to Byline Times, a DHSC spokesperson said “No one should have to wait longer than necessary to access urgent and emergency care. Answering times have improved significantly and in March this year, 43% of 111 calls were answered in 60 seconds and we have increased the number of 111 call handlers.
“Our Urgent and Emergency Care Recovery Plan will allow people to be seen quicker by scaling up community teams, expanding virtual wards, and getting 800 new ambulances on the road.”
Lessons Not Learnt
Dr Tony O'Sullivan, co-chair of campaigning group Keep Our NHS Public and a former NHS consultant, told Byline Times: “Time and again the Government launches headline-grabbing initiatives to disguise its fundamental failure to plan and provide the NHS workforce we need for good and safe patient care and staff working conditions.
“It is a real concern that NHS 111 must not be a cover for insufficient GPs, community nurses, mental health resources, pharmacists, hospital beds and staff etc. It is yet more worrying if the 111 telephone triage service has cut back on core training of its staff and cannot recruit a safe complement of staff.”
Not enough lessons have been learned from the pandemic, Champion argues. The hotline set up during the pandemic for Covid patients, 119, was outsourced by the South Central Trust to two companies based in France. Neither company recorded the calls, a protocol Champion describes as an "absolute requirement for auditing."
He branded it “ludicrous” that untrained people in France had been “giving advice to people with Covid symptoms on the basis of a conversation that is not recorded.” Staff who lost loved ones got apologies, but there is no way to know what the conversation entailed and whether it had lethal consequences.
These “systemic failures” have had a profound impact on Champion's faith in the NHS. The focus, in his eyes, has shifted from patient care to cost-cutting and profit. As he moves on to a new career, he leaves behind a service he feels is in a state of crisis, with no clear path to resolution.
The spokesperson for Herts Urgent Care said: “Even before we start training our new joiners, we are committed to recruiting individuals who share our passion for high-quality patient care. That is why we take time during the initial recruitment process to highlight the training commitment to potential candidates as well as the need to pass a final exam before they join other colleagues in our contact centres.
“All members of the NHS 111 team, regardless of their length of service, receive a range of support to ensure we provide high-quality care to our patients, including regular audits as well as feedback from our Quality Improvements teams if there are areas for improvement. We also take the wellbeing of our colleagues very seriously and offer support during challenging calls, including opportunities for one-to-one debriefing amongst others.”
Last June, Herts Urgent Care which runs the 111 service was offering £500 referral fees to staff who knew someone who could provide staffing, emails seen by Byline Times show.
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