HSIB investigation: NHS 111’s response to callers with Covid-19-related symptoms during the pandemic (29 September 2022)

Summary

At the start of the Covid-19 pandemic, demand on the NHS 111 system exceeded capacity and only around half of calls were answered during that time. This investigation by the Healthcare Safety Investigation Branch (HSIB) aimed to support improvements in the delivery of NHS 111 and other telephone triage services during a national healthcare emergency. HSIB first identified a potential safety risk associated with NHS 111’s response to callers with Covid-19-related symptoms when concerns were raised through HSIB’s Citizens’ Partnership.

The national investigation aimed to understand:

• 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.
• the context and contributory factors influencing the pathway for patients calling NHS 111 with Covid-19-related symptoms.

The investigation used four real patient safety incidents involving patients and their families who dialled NHS 111 for advice during the Covid-19 pandemic. All four patients in these reference events—Vincenzo, Ali, Patrick and Dr C—died of Covid-19 having been advised by NHS 111 to stay at home.

Content

National investigation findings

• 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.
• Evidence from families indicated that aspects of NHS 111 telephone triage, such as routing all Covid-19-related calls to the Covid-19 Response Service (CRS), did not function as intended.
• 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. Callers would only be transferred to a clinician/receive a clinical call back if they were “so ill that…[they’ve] stopped doing all of …[their] usual daily activities.”
• The healthcare system specified that patients with Covid-19 related 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.
• NHS 111 call handlers do not usually have access to a patient’s medical history. This increases the importance of appropriate ‘safety netting’ – that is, telling a patient or their carer what they should do if their condition does not improve or they have further concerns about their health.
• Text messages that told a patient they had a positive polymerase chain reaction (PCR) test result included information about isolating and the legal requirements. It did not include sufficient safety-netting advice regarding symptoms to watch for and when and from where to seek medical advice. While this is not related to NHS 111 services, the investigation considers it important to highlight for the future.
• 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.

Safety recommendations for NHS England

• HSIB recommends that NHS England ensures any Single Service contract or additional services contracts reflects the minimum requirements of the core NHS 111 service for audio-recording calls.
• HSIB recommends that NHS England reviews the risks associated with increased use of telephone triage in response to national healthcare emergencies. Consideration should be given to applying any recommendations of this review across telephone triage services within the wider healthcare setting.

Safety observations

HSIB makes the following safety observations:

• It may be beneficial to review triage software and safety-netting/worsening advice to ensure the language used by health advisors does not deter seriously unwell people from calling back or seeking medical advice if necessary.
• It may be beneficial, when dealing with a novel virus, for consideration to be given to the benefits of a face-to-face assessment for callers with comorbidities.
• It may be beneficial for strategic stakeholders in the healthcare system to understand and articulate adjustments in risk tolerance and thresholds in critical situations.

Safety actions

During the investigation, HSIB became aware of changes the UK Health Security Agency made to processes in a number of areas. These ‘safety actions’ are noted below.

• The UK Health Security Agency has taken steps to ensure governance arrangements are in place to assure themselves that contracted services are monitored and delivered as intended.
• The UK Health Security Agency has taken steps to assure itself of the safe and effective delivery of telephone triage for future healthcare emergencies. These have been tested through the delivery of services for Monkey Pox and Avian Flu.
• The UK Health Security Agency has taken steps to review contractual arrangements to ensure flexibility and the opportunity to implement the most appropriate contract for future public health issue.