Report advocates ‘futureproof’ NHS telephone triage services after examining 111 COVID response

The report charts the investigation into the NHS 111 response to COVID-19 related symptoms during the early months of pandemic (March-June 2020). The investigation not only reflected on past events but also considered how similar healthcare systems could be mobilised quickly in the future and the investigation’s overall purpose is to support improvements in the delivery of NHS 111 and other telephone triage services. 

The investigation was started following a referral by the HSIB’s Citizen’s Partnership, raising initial concerns about patient safety risks associated with the NHS 111 responses to COVID-related symptoms. Following the identification of the safety risk, the investigation team held two focus groups with families that wanted to share the NHS 111 experience of their loved ones. They told the investigation team that they had seen delays getting through to NHS 111 and that there were issues with the advice provided by NHS 111, both of which contributed to delays in their family member receiving treatment. 

To explore the concerns further, the investigation examined four cases in more detail, tracking from their first call to NHS 111 until their last contact (March to April 2020). The four patients all suffered from medical issues including diabetes, hypertension, and multiple sclerosis and sadly all died due to COVID-19.

National investigation analysis and findings 

Following analysis of the four cases, HSIB’s national investigation focused on the set-up, design and delivery of the COVID-19 telephone triage service accessed by the public by dialling 111 in response to the pandemic. In assessing and analysing the patient safety risks, the investigation looked at system demand and delivery, pace of change, call handling (non-clinical and clinical), impact of remote assessments, system improvement that had since taken place, and risk tolerance. Key findings included:

• In March 2020, demand on the NHS 111 system increased. Demand exceeded the system’s capacity, and around half of calls were answered at that time.
• Strong national messaging advised people with suspected COVID-19 to stay at home. This may have impacted on patients’ willingness to seek medical advice from elsewhere, even if their condition deteriorated. 
• The CRS algorithm did not allow for an assessment of caller's comorbidities to establish whether a clinical assessment would be beneficial. 
• The healthcare system specified that patients with COVID-19 symptoms and underlying conditions (including diabetes) who went through to Core NHS 111 (instead of CRS) should be escalated to a clinician for assessment. However, some patients did not receive a clinical assessment.
• The intent was that COVID-19-related calls would be diverted to the CRS, which was operationally independent from NHS 111. Many COVID-19-related calls continued to go through the core NHS 111 service. Once callers had reached the core NHS 111 service, there was no way to route them to the CRS. 
• Calls that went via the core NHS 111 service should have been audio-recorded, as per NHS 111 guidance. The CRS contract manager told the investigation that CRS calls were also required to be recorded, and all but one CRS provider were initially set up with a recording function. However, no recordings of CRS calls were made available to the investigation.
• Ahead of the COVID-19 pandemic, there was limited understanding of the risks of such a novel virus to the healthcare system. 
• The decision to redirect the public to call NHS 111 rather than access healthcare advice in other ways (for example, through their GP) shifted the immediate burden of managing patients with COVID-19 in the community. This increased capacity, in the wider healthcare system, but risked disrupting continuity of care for patients with complex health needs.
• Learning and developments throughout the pandemic have led to improvements in how callers to NHS 111 are assessed and managed. These included recognising the importance of pulse oximetry (that is, measuring blood oxygen levels) to identify silent hypoxia (when a patient has low oxygen saturation levels without becoming breathless) in patients with COVID-19.

Looking to the future 

The findings from the investigation have overall highlighted: 

• The importance of stand-up flexible services which can adapt accordingly and the need to understand risks within the system and the risk appetite.
• The importance of clear communication across the healthcare system and to the public, which includes letting the public know the importance of accessing healthcare if they need it, especially if the national messaging places emphasis on people staying at home and protecting the NHS. 

HSIB’s report concludes with two recommendations, three observations and noted three safety actions. These are focused on assuring that the options in place for future healthcare emergencies are patient focused, flexible and suitably governed. 

Amber Sargent, National Investigator at HSIB said: “We recognise that the events in this report were from the earliest months of the pandemic and that systems had to be put in place at incredibly short notice – there were many unknowns as the NHS tackled a novel virus. Our investigation has focused on how quickly the healthcare system identifies major risks, responds accordingly, and adapts as knowledge grows.

"However, while we know there has been much learning and improvement since March 2020, the stories the families told us during the investigation were incredibly moving and emphasised the importance of future planning. Anyone may need to access NHS 111 or other telephone triage when there is an emerging healthcare crisis. It is critical that services can be stood up within a short timeframe and that communication of messages and advice to the public is as clear as possible to help them get the crucial care and treatment they may need.”

Click here to download the report.