The NHS cannot cope with the growing need for care, long delays for treatment are now routine and the staffing crisis is so acute that retired doctors are now being asked to come back and work in hospitals.
Here, a senior nurse describes how the NHS 111 telephone advice service – an important source of urgent medical advice and way of taking the pressure off A&E – is increasingly unable to help those who ring seeking help and voices her fears that patients with serious conditions may be suffering avoidable harm as a result.
I’ve worked in NHS 111 for more than 10 years. But in all that time, I’ve never seen it in the state it’s in now. It’s shocking. In my experience, everybody in 111 is on their knees at the moment. We just can’t deal with the sheer number of calls and requests for help that we are getting.
111 is a very important service, so it needs to be working properly. It’s basically where people can ring to get advice about a whole range of medical problems when GP surgeries are shut. They ring, tell us what the problem is and then they get a call back, depending on how urgent their symptoms are, and then they get help – or at least that’s how it’s supposed to work anyway. We can advise someone to go to see their GP, or send an electronic prescription to their local pharmacy or in some cases request an ambulance to take them to A&E.
Callers ring with all sorts of problems. It might be someone with a respiratory infection or urinary infection, or a child who is vomiting and has diarrhoea, or someone with mental health issues or abdominal pain. So it includes things that may be signs of a serious illness.
People think they can ring 111 and get advice quickly. However, increasingly that doesn’t happen as we are in a state of constant, massive overload. We just can’t cope with the number of people who ring us seeking our help. The end result is that people can wait a long time before anyone calls them back or some people end up getting no care or help at all, which really worries me.
I work nightshifts, usually at the weekend, as my main job is as a nurse in a hospital. When I’m at work I’m the sole clinician with responsibility for the care of an area with a population of 350,000. The clinician is the health professional – usually a doctor or nurse, but sometimes a paramedic – who uses their expertise to decide how urgent cases are and what we should recommend the patient does next. Every caller undergoes triage; I do what’s called “advanced triage”.
Before Covid, when I started my shift there would be 20-30 people waiting on the list to be called back. Now it’s always about 60, so it’s gone up a lot in a short space of time. Bank holiday weekends are the worst; that’s when 111 falls over. When I arrived for my shift on Good Friday last month there were 290 people waiting for a call back. I’d never seen so many before.
Since Christmas things have got worse and worse in terms of demand for our help. Every shift is worse than the previous shift. I don’t know if the public realise it or not but many of the doctors, nurses and other clinicians working for 111 have other jobs and only work part-time. 111 is very understaffed. We get text messages every day saying “please come and work in 111”. They’re basically begging us to spare a few hours to help triage people. I sometimes get five or six messages like that a day. When that happens, it’s because it’s desperate. But it’s not just desperate in my county. It’s the same all over England.
The crisis in NHS ambulance services has made things worse recently in 111. In most places these days if you’ve had a heart attack or stroke or been involved in a car crash you might be waiting two hours plus for an ambulance to arrive. If someone has had a stroke – where you have a “golden hour” to get them to hospital and start treatment – delay can make the difference between them recovering or ending up disabled or even dead. So NHS overload and delays do put patients at risk. Sometimes you ring someone whose symptoms are very worrying and find that they’ve already been waiting for 100 minutes. That’s very frustrating. It could be that a delay in assessing someone means that a skin infection gets missed and escalates into sepsis or that their stroke has gone untreated. It’s impossible to know how much avoidable harm this all leads to, but it does happen.
The pressure on ambulance services doesn’t just mean that patients can’t get an ambulance quickly enough. It can also mean that myself and colleagues have to stay with that person in their own home, trying to keep them alive while waiting for the ambulance. But the long waits for ambulances also mean that the 999 service are offloading patients on to us to look after who they know they’re not going to be able to get to for six to eight hours. That hasn’t happened because the patient doesn’t need 999 help – they do – there just isn’t an ambulance available to go to them.
Ambulance services offload patients on to us because they – as with 111, GP surgeries, community services, A&E units and every other part of the NHS – are so overloaded. Everything is under completely unsustainable pressure. Staff working in all these services carry such an emotional burden because they’re having to make decisions that you wouldn’t want to have to make – about who gets treatment soon and who has to wait, when they all need to be seen – because there isn’t enough resource to respond properly to the huge need for care.
When people are triaged, they’re prioritised as needing a call back within two, six, 12 or 24 hours. But the days are gone when we could get through everyone on the waiting list. Often we only manage to get to all those given a two-hour callback time – the most worrying cases. The others have to just visit their GP when the surgery is next open or see a pharmacist. It’s emotionally distressing, and also professionally distressing, that some people who are sick end up not getting any help at all from 111. But that’s what happens.
I understand why people who were told they were going to get a call back, or who have gone to bed before it comes, get annoyed. People who have called 111, or their relatives, get anxious when no one calls them back.
111 is a great system. For the NHS to work, it needs to work. But I’m at my wits’ end worrying about it because it cannot deal with the pressure it’s under just now.
As told to Denis Campbell