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Exclusive: Senior NHS Direct leaders warned 111 was unsafe but were overruled

Senior directors at NHS Direct warned it was not safe to go live with one of its biggest NHS 111 contracts but were overruled, HSJ has learned.

It comes as further revelations have emerged about the fallout for the organisation following its failure to fully deliver the urgent care phone service.

A series of emails, seen by HSJ, reveal discussions between senior NHS Direct figures and commissioners in the run-up to the disastrous launch of 111 in the West Midlands.

The services began failing within hours of launch at the end of March, and GP out of hours and ambulance service providers were drafted in to provide support. Across its nine contracts, of which the West Midlands is one of the biggest, NHS Direct is still only handling 30 per cent of the calls it was originally contracted for. NHS Direct is one of two major national providers of NHS 111.

The emails, about the decision to go live in the West Midlands, show it was taken despite:

  • NHS Direct’s chief nurse Tricia Hamilton warning the service was unsafe due to predictions of high rates of abandoned calls;
  • NHS Direct’s regional director for the West Midlands, Pam Bradbury, also a nurse, telling colleagues she was “very uncomfortable reassuring commissioners that we have the staffing levels right”;
  • forecasts showing that call abandonment rates could reach 71 per cent at some point during the first weekend after launch; and
  • warnings from NHS Direct’s director of service delivery for 111, Laurin McDonald, that last-minute changes to the provider’s service model for 111 would affect “every element of… future operational planning”.

In one email sent in early April, NHS Direct’s director of operational support, Sean Flynn, recalls the conference call during which the decision was taken to go live.

He wrote: “On this call a question was asked should we go live. Tricia Hamilton said something like looking at the figures she thought it unsafe. [Director of strategy and business development Ruth Rankine] reminded her of the position we had created by not going live on time [in February]. Eventually a decision was made that we would go live on that call.”

NHS England’s NHS 111 project director in the West Midlands, Wayne Bartlett, was also on the call.

A spokeswoman for NHS England told HSJ the decision to go live was taken “after very careful consideration of the balance of risk in the urgent care system across the region”.

She said the West Midlands launch had been delayed from an earlier planned date in February. This meant many call handlers for GP out of hours services, whose role was due to be replaced by NHS 111, had already been made redundant. As a result there was a lack of capacity elsewhere in the system to handle the calls, she said.

Emails leaked to HSJ also reveal concerns about late changes to NHS Direct’s service model for providing NHS 111. They show it was designed on the premise that call handling centres would be able to provide overflow capacity to services outside their area. However, commissioners were later assured the vast majority of calls would be handled locally.

On being presented with information showing contract delivery would be “ringfenced” to specific regions, Ms McDonald wrote: “I believe we have consistently warned the mobilisation team and [regional directors] to act with caution and they have not… The position as presented… affects every element of our future operational planning.”

Ms McDonald, a call centre expert, was hired as a contractor to develop the 111 service.

A spokeswoman for NHS Direct said patient safety was a “key consideration” in the decision to go live.

She added: “The biggest single cause of the capacity shortfall at launch was the unexpected length of the calls - which reduced the number of calls that could be handled by the staff.”

Readers' comments (34)

  • Rats and sinking ship sounds to me!

    "Ms McDonald, a call centre expert, was hired as a contractor to develop the 111 service"

    The biggest mistake NHSD made was to foolishly think that contractors from the private sector call centre industry could develop a clinical service. Laughable! they got rid of all theNHSD experts and employed people who had ran call centres that took orders for Tupperware! Calls that took seconds and did not effect patients lives.

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  • Surprising all of these people are saying this now. If you watch their board meetings via the web all seems very happy in the NHSD board room? Clinical staff saying all is fine and non execs just about keeping their eyes open after a large liquid lunch Strange that. Proving the so called NHS "transparency" is just ann illusion. When are the CEO and Chair going to resign and take their big package to go. Not long now me thinks.

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  • A spokeswoman for NHS England told HSJ the decision to go live was taken “after very careful consideration of the balance of risk in the urgent care system across the region”.

    What risk books are these people reading??? They stand there quoting the party line whilst patients are dying have they no respect at all for the patient

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  • GP Out Hours call handling should not have been dismantled ahead of proceeding with 111 at scale. While in theory, it might be best to have a single point of access, it must be able to cope with high call volumes, which 111 was not able to do in many parts of the country, particularly at weekends. This was really a combination of an underfunded model being pushed out by managers who were under pressure to deliver. It was NOT about a private sector failure. We need to beware of the new theory that things need to be rolled out 'at scale and pace'.

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  • NHSD CEO was not daft, saw that it would be a disaster so passed it onto the head bean counter who was stupid enough to take the disaster on. CEO and chair rides off into the sunset with a great package and no guilt about the patients who died.

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  • Harry Longman

    Sure the implementation was botched and I'm saddened but not surprised to see more evidence that it was pushed out with the kind of macho culture that has cost the NHS so dearly.

    But let's not lose sight of the more fundamental flaw in the system. However well implemented, the design is wrong. It puts a computer in place of a clinician, and we have seen the results all over the headlines since then.

    Will someone please come out in person on this and be counted? You might make a difference.

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  • To anonymous 8.26... did patients die due to any failure of 111? This is a genuine question as I don't recall that being reported.

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  • Surely this is about NHSD not getting their model right and not understanding the very clear evidence showing the average call length across the pilots. The commissioners should have also made sure that the staffing model was appropriate with the number of potential calls. This is simple mathematics and does not require any complex formulas. In my view this was a political decision that did not take account of patient safety pushed through by DH bully girls, who should have known better.

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  • ANONYMOUS | 20-JUN-2013 7:23 AM

    Hello Gill, how are you. still bitter and twisted by the sounds of it

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  • NHS 111 did not suddenly go live at Easter. It has been happily and safely live since 2010 in some areas where it is working well.. Poor implementation, absolute lack of capacity, failure to train properly or supervise appropriately does NOT mean the principle is wrong. It means it was badly implemented in some areas. Babies and bath water....

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  • its the sales people that should have been disciplined not trevor. everyone else has had to go because of it but they get of scot free

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  • From experience, you need very hard nosed, highly competent project manager and support at the Commissioner end. That is not common.
    Not sure how West Midlands handled NHSD - it was not a job for one person though.
    The issues above all look familiar and only emerged as the preparation for go live was being done here as well.

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  • Agree Anon 1:07PM - sales and bus dev absolutely have to take their share of the blame.

    Disagree Anon 7:23AM - the contractors were the ones flagging the capacity issues, and the junior and middle staff agreed. The management however didn't want to know, because they'd low-balled their bids to win business, and were forced in a corner as a result.

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  • From experience, you need very hard nosed, highly competent project manager and support at the Commissioner end. That is not common.
    Not sure how West Midlands handled NHSD - it was not a job for one person though.
    The issues above all look familiar and only emerged as the preparation for go live was being done here as well.

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  • Have to say anon at 307 pm has hit the nail on the head. Get the contract, promise anything - that was the message that was out there.

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  • Agree with Mark F 10:57
    NHSD did not get the model right - and they should have been able to do it.
    The commissioners did not question the model - and they should have looked at other areas already live with 111.
    The DH did not question the model - and approved it as fit to go live.
    Staffing 111 is actually very complex - vast numbers are required for short periods in the early evening and weekend mornings - and there is no reserve of suitable staff in the job market. Every single call taker has to be trained from scratch.

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  • Anon 7:38 & 3:07 - absolutely right.

    I should also say that the commissioners need to look at themselves very carefully. The word "collusion" springs to mind in terms of both commissioners and providers knowing the spec was wrong and undeliverable, and pressing on anyway.

    More than that, both NHSD and the commissioner wanting to "save NHS jobs" and "please political task-masters" and therefore being willing to accept clearly and obviously unworkable promises from NHSD with little or no oversight. For me this points to:

    (a) a systemic failure of the NHS commissioning the NHS to do NHS business. It just can't be a level playing field that way.

    (b) a general failure of NHS commissioning in placing the timescales of politics and senior management ahead of the timescales of reality, patient safety and workability. Francis report anyone?

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  • Sure, but this is hardly a unique example of

    "(b) a general failure of NHS commissioning in placing the timescales of politics and senior management ahead of the timescales of reality, patient safety and workability. "

    This happens everyday, everywhere in NHS commissioning and is the reality of balancing the needs of the masters: politics, patients and pounds.

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  • So NHS England haven't really learnt a lot then?

    Meanwhile the poor bloody infantry do their best to provide a decent NHS.

    Pass the parcel.

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  • I have just had personal experience of 111 my husband had a suspected DVT. We were told the GP would call us back within the hour. After 3 phone calls to check progress we eventually got a GP just over 6 hours later. It turned out the call centre had passed the call to the wrong GP out of hours service.......we went to A and E

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