Feature
The drive to refer more NHS 111 callers to community nursing teams The 24-hour helpline has been criticised for failing to ease pressures on emergency departments, however Christian Duffin speaks to two senior community nurses in London about why their referral rates have bucked the national trend Correspondence [email protected] Christian Duffin is a freelance writer Date of submission March 24 2014 Date of acceptance March 24 2014 Author guidelines nop.rcnpublishing.com
Abstract Cutting emergency department admission rates has been a health service priority. The NHS 111 free telephone-based service was created for people who require urgent care or advice for conditions that are not life threatening. Callers may be given advice on self-management or directed to a GP, walk-in centre or pharmacist. However, some policy experts argue that opportunities to divert large numbers of patients who call community nursing teams are being missed. Two senior nurses in London community services with higher referral rates explain how they achieve these by using integrated pathways. Keywords Community nursing, district nursing, emergency services, NHS 111, urgent care A REPORT published by NHS England (2013) criticised the NHS 111 service (see panel) in London for not referring enough callers to community and district nurses. The report stated: ‘Less than 0.1% of all 111 referrals are transferred to community services.’ If referral rates increased there would be less pressure on GPs and on emergency departments (EDs) in the capital, the report said. Co-author Caroline Alexander, chief nurse for the London region of NHS England, did single out two London regions for praise, however – Wandsworth, and the area covering Barnet, Westminster, and Kensington and Chelsea. These districts have significantly higher referral rates to community nursing teams than other areas of the capital, she said.
16 May 2014 | Volume 26 | Number 4
Noyola McNicolls-Washington is a nurse and head of intermediate care services at St George’s Healthcare NHS Trust in Wandsworth. She told Nursing Older People that community nurses are receiving more referrals for NHS 111 patients than other regions because the helpline is integrated with a single point of contact (SPOC) service. The SPOC service had previously been a separate entity where professionals such as community matrons, community nurses, night nurses, heart failure specialist nurses and respiratory nurses visited patients in their own homes. GPs and other professionals phoned SPOC when they were not sure which service was best for patients. Now that SPOC and 111 services are linked there is a ready-made referral route for 111 patients. It means Wandsworth clinical commissioning group has referral routes to 14 community services such as rapid response nursing, district nursing, falls specialists, occupational therapists (OTs) and physiotherapists. A bonus is that some patients phoning 111 are already known to SPOC. Ms McNicolls-Washington says: ‘Someone who is terminally ill and having problems with pain control or someone with a blocked catheter are the type of patients who could be seen by these community nursing services. What usually happens is that a husband or wife rings 111. The call handler asks questions such as whether the patient has been seen by their GP. From their answers there can be a judgement about whether the patient is suitable for community services.’ The way to increase referrals to community services nationally is for the 111 providers, community nurses and commissioners to ‘get round the table’ and work on patient pathways, says Ms McNicolls-Washington. She believes that 111’s relative infancy is a factor in NURSING OLDER PEOPLE
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the low referral rates to community nurses, and that the figures will rise as the service beds in over the next year or two. She says: ‘The 111 service hasn’t been going for long and so what we need is to find examples of where it’s working well. Then we can learn from each other.’ Ms McNicolls-Washington was unable to provide figures showing how many 111 calls are received by community nurses.
Disposition levels NHS England figures for February 2014 show that 3.7% of NHS 111 patients across England were recommended to attend another service – which covers community nurses, district nurses, midwives and the police. This compares with 6% recommended to attend ED and 52% recommended to see their GP. NHS England does not give 111 contract holders or commissioners a steer on where 111 calls should be referred. In other words, there is no national target to drive down the proportion of 111 callers ending up in EDs or at GP surgeries. An NHS England spokesperson says: ‘This needs to be determined locally, depending on the call. Each call should be referred to the services that are most appropriate. NHS 111 providers and commissioners should agree how calls of various types should be handled locally. Providers and commissioners can review their disposition rates in comparison with other areas/providers by looking at the minimum datasets we publish. This will allow them to consider local disposition levels and consider where there may be inappropriate variation and whether this is clinically appropriate.’ She adds: ‘All NHS providers should regularly review their 111 dispositions in conjunction with their commissioners to ensure patients receive the most appropriate care in the most appropriate setting.’
Collaborative pathways London Central and West Unscheduled Care Collaborative (LCW UCC) is a GP-led, not-for-profit organisation that holds the NHS 111 contract covering the London regions of Brent, Hammersmith and Fulham, and Westminster. Between October and December 2013 out of the total number of cases referred, 60% had a primary care disposition and of those, 7% were referred to community nursing. This is considerably higher than the London average of less than 2%, says an LCW UCC spokesperson. She adds: ‘LCW UCC has a long-standing and close working relationship with community nursing colleagues and has worked jointly with them and other local partners to develop and integrate NURSING OLDER PEOPLE
programmes of care. Together we have developed pathways to ensure a consistent community nursing response, for example, to patients with blocked catheters. We now have a large number of pathways to deal with conditions which community nurses are best placed to handle – both routine and rapid response nursing.’ The spokesperson continues: ‘GPs, nurses and NHS 111 call handlers all work together in the same building, which provides them with the best opportunity to provide an integrated service. This ensures that the most appropriate healthcare provider deals with a patient’s problem.’ Darren Jones is interim senior manager for community nursing at Central London Community Healthcare NHS Trust, which covers four London boroughs: Barnet, Hammersmith and Fulham, Westminster, and Kensington and Chelsea. His trust provides services for NHS 111 callers. He believes the higher rates for referral to nursing teams are partly because of experience gained in the area through being one of the pilot sites for NHS 111. His rapid response team includes nurses, physiotherapists and OTs although it is often the nurse who is on the scene first. Most of the people visited by the nurses via 111 referrals are aged over 75, says Mr Jones. Community nurse visits are appropriate if, for example, a patient has had a fall or needs pain control during palliative care, or has an exacerbation of a respiratory illness such as chronic obstructive pulmonary disease. ‘If a patient has fallen then a nurse can help get them off the floor or back into bed and check them over.’
NHS 111: the facts ■■ Available across England, apart from Cornwall, the Scilly Isles, Luton and Bedfordshire. ■■ Staffed by trained non-clinical advisers, supported by experienced nurses. ■■ In February 2014, there were 891,226 calls to the service. Scaled up, this would represent 10.2 million calls a year across England to the service. ■■ Dispositions of calls are recorded in five main categories: ambulance dispatches; recommended to attend emergency department; recommended to attend primary and community care including GP, urgent care, dental and pharmacy services; recommended to attend other service including community nursing, midwives, social services and opticians; and not recommended to attend other service, including home or self-care and health information. May 2014 | Volume 26 | Number 4 17
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Feature Mr Jones believes that the low number of referrals to community nurses in some of England’s NHS 111 services is because the call handler algorithms are ‘inflexible’. He explains: ‘One of the questions is: “Has the person been assessed by a GP?” If the answer is no, then it is considered best for a GP to be called. But that isn’t always necessary. It’s a bit defensive to do that with some patients – because they could be referred to nurses.’
Known patients If a patient who calls 111 is already known to the district nursing services in the trust then a district nurse is sent, but otherwise someone from the emergency response nurse team can visit. Knowing patients is advantageous because it means that the visiting nurse will have access to their records and should have a good understanding of their needs. ‘We’ve found that this is beneficial because some patients use the GP out-of-hours number to get hold of their community nurses,’ says Mr Jones. ‘A call handler can also text a nurse and ask him or her to get in touch. The nurse then phones the call handler and takes instructions.’ During a 5pm-9pm shift there are typically eight nurses available across the four boroughs, says Mr Jones. A downside for nurses on the road is that they cannot access patient records remotely, however. The trust is working on new technology to solve this problem, says Mr Jones. Mr Jones argues that there are several advantages to increasing the number of 111 referrals to community nursing services. One is that patients already known to the service receive continuity of care, and another is that it can save money on GP visits and ED admissions. Mr Jones says: ‘It is hard for us to know whether we are reducing ED admissions because we don’t have access to that data.’ Sometimes a nurse will speak to a patient before visiting them. ‘If it’s the evening and a dressing has fallen off then the nurse might ask the patient if they can put a temporary one on until the morning,’ Mr Jones says. ‘This might be a better option than the nurse coming round a few hours later in the middle of the night and waking them up. Some patients much prefer a nurse coming round to having to go to the ED at some ungodly hour.’ Although Ms Alexander and the other authors of the London report may want to see more NHS 111 referrals to community nurses and rapid response teams, there is a question about whether there would be enough resources in place to cover this demand. 18 May 2014 | Volume 26 | Number 4
Most NHS 111 calls come out of hours, so there would need to be a large cadre of nurses willing to work unsocial hours Most NHS 111 calls come out of hours, and so there would need to be a large cadre of nurses willing to work unsocial hours. However, the number of community nurses is continuing to shrink. The Health and Social Care Information Centre’s figures show that the number of qualified ‘first level’ district nurses has been plummeting year on year. In November 2010 there were 6,693 but in November 2013 the figure was 5,256. Community matron numbers have also been falling. In November 2013 there were 1,394 – an increase of 20 from the same point the year before, but still 129 down on the November 2010 figures of 1,523. The Queen’s Nursing Institute (QNI), which promotes community nursing, has long warned of the decline in district nurse numbers. Its chief executive Crystal Oldman believes that nurses can be used more by NHS 111 but that the latest figures on falling numbers are ‘shocking’. She adds: ‘We have consistently argued that more district nurses are necessary if we are to avoid unnecessary hospital admissions, enable safe early discharges and support an ageing population with complex long-term health needs in the community setting.’ The QNI’s own investigations have revealed that in 2012/13 at least two thirds of district nursing courses running in England had ten students or fewer. Three courses had no more than five students, and seven courses approved by the Nursing and Midwifery Council did not run. Mr Jones takes a similar view to the QNI; community and district nurses could well be important in keeping older NHS 111 callers out of hospital, but this will only work if nurses are not driven into the ground by the extra workload. Mr Jones explains: ‘If the NHS wants to treat more people closer to home then you need more nurses. It’s going to be a challenge.’
References Health and Social Care Information Centre (2014) NHS Workforce Statistics – November 2013, Provisional Statistics. tinyurl.com/pmm75jo (Last accessed: March 26 2014.) NHS England (2013) Transforming Primary Care in London: General Practice – A Call to Action. tinyurl.com/pcvn2n8 (Last accessed: March 27 2014.) NHS England (2014) NHS 111 Statistics – February 2014. tinyurl.com/pw4benf (Last accessed: April 4 2014.)
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
NURSING OLDER PEOPLE
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The drive to refer more NHS 111 callers to community nursing teams The 24-hour helpline has been criticised for failing to ease pressures on emergency departments, however Christian Duffin speaks to two senior community nurses in London about why their referral rates have bucked the national trend Correspondence [email protected] Christian Duffin is a freelance writer Date of submission March 24 2014 Date of acceptance March 24 2014 Author guidelines nop.rcnpublishing.com
Abstract Cutting emergency department admission rates has been a health service priority. The NHS 111 free telephone-based service was created for people who require urgent care or advice for conditions that are not life threatening. Callers may be given advice on self-management or directed to a GP, walk-in centre or pharmacist. However, some policy experts argue that opportunities to divert large numbers of patients who call community nursing teams are being missed. Two senior nurses in London community services with higher referral rates explain how they achieve these by using integrated pathways. Keywords Community nursing, district nursing, emergency services, NHS 111, urgent care A REPORT published by NHS England (2013) criticised the NHS 111 service (see panel) in London for not referring enough callers to community and district nurses. The report stated: ‘Less than 0.1% of all 111 referrals are transferred to community services.’ If referral rates increased there would be less pressure on GPs and on emergency departments (EDs) in the capital, the report said. Co-author Caroline Alexander, chief nurse for the London region of NHS England, did single out two London regions for praise, however – Wandsworth, and the area covering Barnet, Westminster, and Kensington and Chelsea. These districts have significantly higher referral rates to community nursing teams than other areas of the capital, she said.
16 May 2014 | Volume 26 | Number 4
Noyola McNicolls-Washington is a nurse and head of intermediate care services at St George’s Healthcare NHS Trust in Wandsworth. She told Nursing Older People that community nurses are receiving more referrals for NHS 111 patients than other regions because the helpline is integrated with a single point of contact (SPOC) service. The SPOC service had previously been a separate entity where professionals such as community matrons, community nurses, night nurses, heart failure specialist nurses and respiratory nurses visited patients in their own homes. GPs and other professionals phoned SPOC when they were not sure which service was best for patients. Now that SPOC and 111 services are linked there is a ready-made referral route for 111 patients. It means Wandsworth clinical commissioning group has referral routes to 14 community services such as rapid response nursing, district nursing, falls specialists, occupational therapists (OTs) and physiotherapists. A bonus is that some patients phoning 111 are already known to SPOC. Ms McNicolls-Washington says: ‘Someone who is terminally ill and having problems with pain control or someone with a blocked catheter are the type of patients who could be seen by these community nursing services. What usually happens is that a husband or wife rings 111. The call handler asks questions such as whether the patient has been seen by their GP. From their answers there can be a judgement about whether the patient is suitable for community services.’ The way to increase referrals to community services nationally is for the 111 providers, community nurses and commissioners to ‘get round the table’ and work on patient pathways, says Ms McNicolls-Washington. She believes that 111’s relative infancy is a factor in NURSING OLDER PEOPLE
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the low referral rates to community nurses, and that the figures will rise as the service beds in over the next year or two. She says: ‘The 111 service hasn’t been going for long and so what we need is to find examples of where it’s working well. Then we can learn from each other.’ Ms McNicolls-Washington was unable to provide figures showing how many 111 calls are received by community nurses.
Disposition levels NHS England figures for February 2014 show that 3.7% of NHS 111 patients across England were recommended to attend another service – which covers community nurses, district nurses, midwives and the police. This compares with 6% recommended to attend ED and 52% recommended to see their GP. NHS England does not give 111 contract holders or commissioners a steer on where 111 calls should be referred. In other words, there is no national target to drive down the proportion of 111 callers ending up in EDs or at GP surgeries. An NHS England spokesperson says: ‘This needs to be determined locally, depending on the call. Each call should be referred to the services that are most appropriate. NHS 111 providers and commissioners should agree how calls of various types should be handled locally. Providers and commissioners can review their disposition rates in comparison with other areas/providers by looking at the minimum datasets we publish. This will allow them to consider local disposition levels and consider where there may be inappropriate variation and whether this is clinically appropriate.’ She adds: ‘All NHS providers should regularly review their 111 dispositions in conjunction with their commissioners to ensure patients receive the most appropriate care in the most appropriate setting.’
Collaborative pathways London Central and West Unscheduled Care Collaborative (LCW UCC) is a GP-led, not-for-profit organisation that holds the NHS 111 contract covering the London regions of Brent, Hammersmith and Fulham, and Westminster. Between October and December 2013 out of the total number of cases referred, 60% had a primary care disposition and of those, 7% were referred to community nursing. This is considerably higher than the London average of less than 2%, says an LCW UCC spokesperson. She adds: ‘LCW UCC has a long-standing and close working relationship with community nursing colleagues and has worked jointly with them and other local partners to develop and integrate NURSING OLDER PEOPLE
programmes of care. Together we have developed pathways to ensure a consistent community nursing response, for example, to patients with blocked catheters. We now have a large number of pathways to deal with conditions which community nurses are best placed to handle – both routine and rapid response nursing.’ The spokesperson continues: ‘GPs, nurses and NHS 111 call handlers all work together in the same building, which provides them with the best opportunity to provide an integrated service. This ensures that the most appropriate healthcare provider deals with a patient’s problem.’ Darren Jones is interim senior manager for community nursing at Central London Community Healthcare NHS Trust, which covers four London boroughs: Barnet, Hammersmith and Fulham, Westminster, and Kensington and Chelsea. His trust provides services for NHS 111 callers. He believes the higher rates for referral to nursing teams are partly because of experience gained in the area through being one of the pilot sites for NHS 111. His rapid response team includes nurses, physiotherapists and OTs although it is often the nurse who is on the scene first. Most of the people visited by the nurses via 111 referrals are aged over 75, says Mr Jones. Community nurse visits are appropriate if, for example, a patient has had a fall or needs pain control during palliative care, or has an exacerbation of a respiratory illness such as chronic obstructive pulmonary disease. ‘If a patient has fallen then a nurse can help get them off the floor or back into bed and check them over.’
NHS 111: the facts ■■ Available across England, apart from Cornwall, the Scilly Isles, Luton and Bedfordshire. ■■ Staffed by trained non-clinical advisers, supported by experienced nurses. ■■ In February 2014, there were 891,226 calls to the service. Scaled up, this would represent 10.2 million calls a year across England to the service. ■■ Dispositions of calls are recorded in five main categories: ambulance dispatches; recommended to attend emergency department; recommended to attend primary and community care including GP, urgent care, dental and pharmacy services; recommended to attend other service including community nursing, midwives, social services and opticians; and not recommended to attend other service, including home or self-care and health information. May 2014 | Volume 26 | Number 4 17
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Feature Mr Jones believes that the low number of referrals to community nurses in some of England’s NHS 111 services is because the call handler algorithms are ‘inflexible’. He explains: ‘One of the questions is: “Has the person been assessed by a GP?” If the answer is no, then it is considered best for a GP to be called. But that isn’t always necessary. It’s a bit defensive to do that with some patients – because they could be referred to nurses.’
Known patients If a patient who calls 111 is already known to the district nursing services in the trust then a district nurse is sent, but otherwise someone from the emergency response nurse team can visit. Knowing patients is advantageous because it means that the visiting nurse will have access to their records and should have a good understanding of their needs. ‘We’ve found that this is beneficial because some patients use the GP out-of-hours number to get hold of their community nurses,’ says Mr Jones. ‘A call handler can also text a nurse and ask him or her to get in touch. The nurse then phones the call handler and takes instructions.’ During a 5pm-9pm shift there are typically eight nurses available across the four boroughs, says Mr Jones. A downside for nurses on the road is that they cannot access patient records remotely, however. The trust is working on new technology to solve this problem, says Mr Jones. Mr Jones argues that there are several advantages to increasing the number of 111 referrals to community nursing services. One is that patients already known to the service receive continuity of care, and another is that it can save money on GP visits and ED admissions. Mr Jones says: ‘It is hard for us to know whether we are reducing ED admissions because we don’t have access to that data.’ Sometimes a nurse will speak to a patient before visiting them. ‘If it’s the evening and a dressing has fallen off then the nurse might ask the patient if they can put a temporary one on until the morning,’ Mr Jones says. ‘This might be a better option than the nurse coming round a few hours later in the middle of the night and waking them up. Some patients much prefer a nurse coming round to having to go to the ED at some ungodly hour.’ Although Ms Alexander and the other authors of the London report may want to see more NHS 111 referrals to community nurses and rapid response teams, there is a question about whether there would be enough resources in place to cover this demand. 18 May 2014 | Volume 26 | Number 4
Most NHS 111 calls come out of hours, so there would need to be a large cadre of nurses willing to work unsocial hours Most NHS 111 calls come out of hours, and so there would need to be a large cadre of nurses willing to work unsocial hours. However, the number of community nurses is continuing to shrink. The Health and Social Care Information Centre’s figures show that the number of qualified ‘first level’ district nurses has been plummeting year on year. In November 2010 there were 6,693 but in November 2013 the figure was 5,256. Community matron numbers have also been falling. In November 2013 there were 1,394 – an increase of 20 from the same point the year before, but still 129 down on the November 2010 figures of 1,523. The Queen’s Nursing Institute (QNI), which promotes community nursing, has long warned of the decline in district nurse numbers. Its chief executive Crystal Oldman believes that nurses can be used more by NHS 111 but that the latest figures on falling numbers are ‘shocking’. She adds: ‘We have consistently argued that more district nurses are necessary if we are to avoid unnecessary hospital admissions, enable safe early discharges and support an ageing population with complex long-term health needs in the community setting.’ The QNI’s own investigations have revealed that in 2012/13 at least two thirds of district nursing courses running in England had ten students or fewer. Three courses had no more than five students, and seven courses approved by the Nursing and Midwifery Council did not run. Mr Jones takes a similar view to the QNI; community and district nurses could well be important in keeping older NHS 111 callers out of hospital, but this will only work if nurses are not driven into the ground by the extra workload. Mr Jones explains: ‘If the NHS wants to treat more people closer to home then you need more nurses. It’s going to be a challenge.’
References Health and Social Care Information Centre (2014) NHS Workforce Statistics – November 2013, Provisional Statistics. tinyurl.com/pmm75jo (Last accessed: March 26 2014.) NHS England (2013) Transforming Primary Care in London: General Practice – A Call to Action. tinyurl.com/pcvn2n8 (Last accessed: March 27 2014.) NHS England (2014) NHS 111 Statistics – February 2014. tinyurl.com/pw4benf (Last accessed: April 4 2014.)
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
NURSING OLDER PEOPLE
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