Anne McIntosh: When my father was dying, he needed a GP... but the NHS out of hours service let him down

MY starting point is that I believe the 111 telephone service, due to be rolled out to North Yorkshire next month, could be a useful tool for out-of-hours services and patient treatment, but that some alarm bells have already been set ringing in areas where it has been rolled out.
Quality of careQuality of care
Quality of care

In my view, the service might offload problems on to accident and emergency and, indeed, the ambulance service. A lot depends on the content of the script that is used and who sets the script, because the time taken should be as short as possible to allow the swiftest access to nurses and medical advice for those in palliative care, terminal care and other regular patient care, such as catheter patients.

I want to refer to my family history to illustrate the very real problems that are currently being experienced. It relates to one of the pilot areas, County Durham, where my father was a GP, but had long been retired.

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The carers looking after him in his home, or occasionally me, had had consistent recourse to the 111 service. The last occasion when we used the service in relation to my father was on Sunday, November 4, last year. I had reason to call the number, and I explained that my father showed worrying signs of a urinary tract infection. Being a doctor’s daughter, I was well qualified to talk about such infections, which my father had had, on and off, for some two or three years.

When I called 111, I got the ritual reply of sticking very closely to a script, which I found completely inappropriate at times. I explained my father’s condition, but the responder insisted on sticking religiously to the script – asking whether the patient was breathing, whether they were bleeding and I kept saying that I was not reporting an accident but a regular condition, the symptoms of which were extremely plain, and asking whether I could, please, just be passed to a nurse or doctor.

I said that we probably needed a doctor to attend to confirm that there was an infection and to administer the relevant antibiotics.

I have to say that in the end I hung up in sheer frustration, 10 or 15 minutes into the call, because I could tell that I was not getting anywhere quickly. I had previous experience of using the 111 service, and I like to think that I am not prone to flap unnecessarily, but I found that the system failed.

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I then called 999, and an ambulance was dispatched immediately and attended to my father within half an hour. The paramedics confirmed my suspicion that the condition was an infection, and said that the patient was too ill and frail to travel some 25 miles on country roads in an ambulance, so that was not an option.

They used their direct line to call a doctor, but even then, it took three hours for one to attend. In that case, from first calling 111 to the doctor’s arrival, about three-and-a-half to four hours had passed.

My father subsequently died on the Thursday of that week, November 8, and I believe that the infection had obviously taken such a grip that his death would have been very difficult to prevent. He had lived to a very grand age, and we were just grateful for the treatment he did receive.

For the 111 service to work effectively a degree of flexibility has to be built into the system and the script.

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What is particularly poignant for me and my family is that my father had been a local GP in that area for some 30 years. He retired as a senior partner, ironically, through ill health. He attended patients in all weathers and at all hours. My father was from a generation of GPs who worked all hours: he worked every other night on call and every other weekend on duty, and he always put his patients first. It is obviously a source of some regret that he did not have similar access to a GP in his own hour of need.

The 111 service was piloted in several areas, and I am drawing on my experience of the one in County Durham before the service was 
rolled out nationally. I want to make some suggestions and pose some questions. It would clearly make 
sense for regular patients – such as those in palliative care, terminal 
care and catheter care – to be 
diverted to nursing or other medically qualified staff as early as possible in
the process.

In North Yorkshire, the intention is that that will happen when the service is rolled out, but I want confirmation that, now the problem has been identified, it is being addressed in all areas.

We must all be aware that if a patient or someone on behalf of a loved one phones, they tend to be quite distressed and distraught, and they do not want an automatic responder to stick blindly to some script that does not fit their or their loved one’s condition.

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If calls are not responded to quickly, those calling will simply divert to other emergency services – I am the first to admit that that is what I did in those circumstances – because people are just desperate to get medical care.

The key to the success of the 111 service is the speed and efficiency with which one’s calls are responded to and, as I have mentioned, with which access is given to medical advice from doctors or nurses, so I want answers to these questions.

What is the current average ratio of call responders—those reading out the script—and GPs and nurses on duty? It would be helpful to know that average ratio in each area where the 111 service is in use. What is the average response time to the initial call? What is the worst response time and what is the best?

What is the average length of time before a caller is transferred to a medically qualified person? Is it normal to expect a delay of up to two hours before a medically qualified person or even the initial responder returns the call? Concerns have been raised in North Yorkshire about the governance framework. How are those are being addressed?

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We have an historic debt of £12m built up by North Yorkshire’s primary care trust. There is real concern locally that that debt will affect the funding of GP practices, and especially of the new 111 service. The funding issues 
are absolutely the key to 111 going forward.

As a GP’s daughter, a GP’s sister and the niece of a late surgeon, I believe that people just want to see their GP. They want to walk in to the surgery or phone up and speak to their own GP.

Sometimes 111 can be seen as a barrier, as NHS Direct was, to seeing one’s own GP.