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Fewer pieces of software are more important than NHS Pathways when it comes to the life and death of NHS patients.

Every year, the software, run by NHS Digital, is used by NHS 111 and 999 call handlers when 16 million patients call with a health concern, from minor to life-threatening.

These call handlers have not been clinically trained and rely almost completely on NHS Pathways to advise them on what to tell patients, whether to call them an ambulance or whether to tell them to call the GP in the morning.

In most cases, this system works. But sometimes it doesn’t, and, as an HSJ investigation has uncovered, this has contributed to the deaths of at least 11 people.

More troubling is that, after three of these deaths, coroners raised concerns about NHS Pathways’ advice that had been raised before – sometimes years before – with little effect.

Multiple ambulance trusts raised concerns about how NHS Pathways handled life-threatening agonal breathing long before coroners identified this same “fault” as playing a part in the deaths of two women.

When a coroner raised concerns about the NHS Pathways advice for patients alone after the death of a man in 2016, NHS Digital dismissed them. When another man died more than two years later, those same concerns regarding NHS Pathways’ advice for patients alone were raised again. And, again, they were dismissed.

NHS Digital has contested any suggestion it has been anything other than responsive to safety concerns raised about NHS Pathways. On two occasions, it has asked the coroner to strike from the record concerns ambulance trusts raised after patients died.

The argument rests on the assertion that many of the NHS Pathways’ failures ambulance trusts identified are actually local service failures and nothing to do with the software. Or, if they are, it is a local service not using the software properly that is the issue.

Coroners’ and ambulance trusts’ concerns are dismissed only after due consideration, NHS Digital has said. In some instances, changes were made to the software, NHS Digital has said, despite coroners and ambulance trusts saying these concerns persisted.

HSJ’s investigation focuses on coroners’ reports and shines only the smallest of lights on concerns raised by NHS 111 and 999 providers directly with NHS Digital after a serious incident.

There is a central system that logs all such concerns, but NHS Digital has declined to share any of these with HSJ. It said extracting figures and outcomes would be too onerous. If true, this would suggest this is not a task routinely performed internally by the organisation either.

Responses to date from NHS England – which is technically responsible for NHS Pathways – the Care Quality Commission and the Department of Health and Social Care also suggest there has been no systemic review of how concerns about NHS Pathways are handled since 2014. This is despite coroners contacting all these organisations after patients’ deaths.

NHS Pathways also now powers the NHS 111 Online app and website (essentially the software minus the call handler). This already accounts for one in 10 uses of the software and the government wants it to eventually cover a third of all NHS 111 patient contacts.

NHS Pathways’ usage is only going to grow, as will the use of algorithms more generally to support decisions about patient care.

As such software becomes increasingly ubiquitous, so must robustness of systems to ensure its safety.

Bursary back on the table?

Comments made by Simon Stevens last week have sparked debate on whether the nursing bursary could be brought back to life after a hiatus.

Speaking at a King’s Fund summit, Mr Stevens said the debate over reintroducing the bursary was “clearly back in play”, because of the NHS’ need for a bigger pipeline of new nurses.

He said it was an important question to answer as a nation and added he would make sure the NHS’ voice was heard.

Although NHS England did not want to elaborate on the comments, for example on whether Mr Stevens’ views stretched as far as advoctaing for bringing back the bursary, many struggling with nursing shortages might see his comments as a reason to be optimistic.

But such words also raise questions about the spending review – are there ongoing discussions about the nursing bursary? Or perhaps more money will be invested in clinical placements? Perhaps chief nursing officer Ruth May’s announcement at HSJ’s patient safety congress – that directors of nursing to be paid directly for clinical placements – perhaps it’s an area the government is keen to invest in. Though of course, it will not be the same government come next Tuesday, with the result of the Conservative leadership contest on Monday.