Daily Telegraph: “NHS 111 enquiries will be handled by robots within two years, leaked report suggests”

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Laura Connelly reports in The Daily Telegraph that a leaked report from NHS England that states “smartphones could become the primary method of accessing health services”.

mHealth Insights

I think it’s fundamental that we all realise that in a country like the UK where 50+ million people access the internet with their mobile most Patients/Carers use their mobiles as their primary method for accessing health information. Most of them are just waiting for the NHS to catch up with them and start using the tools of our time.

NHS 111 enquiries will be handled by robots within two years, a leaked report has suggested. The evaluation by NHS England says smartphones could become “the primary method of accessing health services,” with almost 16 million inquiries dealt with by algorithms, rather than over the telephone, by 2020″

I think this is all very misleading. First off most people think of robots as different from computers in that Robots turn specific code into mechanical movement. For most people navigating online questionnaires (even when navigated with a voice interface) isn’t the same as interacting with a robot:

Robots answering NHS 111

Additionally at the moment the 111 service (which replaced the NHS ReDirect service that burnt through more than £100 Million of NHS Funds every year despite the complete lack of evidence that it did anything to improve clinical outcomes or better utilise healthcare budgets) uses algorithms it’s just that the scripts that they produce are being read to Patients done the telephone – often by staff who have no medical training.

“But patients groups have expressed concern about the safety of such models – raising fears that the needs of those without access to computers were being forgotten”

This is a very natural fear. The 111 service has been spending millions advertising the service to drive up demand and then failing to resource the service to such an extent that they’ve been putting suicidal callers on hold (2013).

When we enable Patients/Carers to complete questionnaires online it enables the resources that were wasted when call centre were being paid to do it to be relocated but it should be clear that Healthcare Professionals must refuse to implement uncompassionate form filling and it is not compassionate if a service has no capacity to effectively/efficiently act on the information being shared (which is why I think the NHS should scrap the service entirely and resource/equip GPs to offer online services directly to their Patients).

The reality is there is an abundance of evidence that shows most Patients and Carers in the UK actually have the ability to complete interactive questionnaires one (similar to the ones that the 111 call handlers are reading down the telephone line) and will answer them more honestly when alone (2014).

“The draft report, dated last month, said new solutions were needed to respond to growing pressure on services”

NHS England seems to be perpetually looking elsewhere for new solutions when there are NHS GPs like Dr Amir Hannan who have been sharing how they have moved beyond the office visit only model for years eg. published 5 years ago.

“And it says that one quarter of all 111 cases will be dealt with online by next year –  rising to cover one third of demand by 2020. The report comes amid unprecedented strain on hospitals and GPs, as flu levels continue to rise, with levels in England due to reach epidemic proportions by next week if current trends continue. Official figures show record calls to 111 phone lines over the New Year, with one in five callers giving up in despair on the busiest day. The controversial phone line has been beset by problems since its launch in 2013, and implicated in a string of scandals including the death of a baby after signs of serious illness were missed. The phoneline has hired more clinical staff after being criticised for too great a reliance on call centre workers with no medical training”

NHS England just doesn’t seem able to scrap this poorly designed and failing 111 service. Imagine a commercial business claiming that they hoped to deal with as many customers online next year as they did this year by just not answering their phones…

“However, the research on the NHS schemes, currently covering 7.5 million people, found that younger people were far more likely than older patients to use the online service. In some areas, under 35s made up three quarters of those who used the digital service, after being told about it by texts, posters or messages while on hold after calling 111, the data shows”

Nothing surprises me after I videoed Bob Gann (Head of Digital Inclusion at NHS England) explaining straight faced why he paid NHS funds to fried fast food shops so they could offer free WiFi to their customers in the hope that this would encourage the patrons to cook healthier food at home in the future, but how incompetent must they be to be surprised that Patients will preferentially want to ring the ‘111 telephone’ service? Even their logo on their website is a blue symbol that looks like an old rotary dial landline and states “Call 111”:

I wonder if they’ve hired an expensive Consultancy firm to tell them that they can millions by designing the telephone service to be even more more useless and ineffective as that will discourage more people from calling and then they can just count web traffic (an inexpensive fake traffic generator could then be used to produce some incredible data that they could claim proves the website is saving millions of lives).

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….and many of the adverts clearly try to connect the service with the old landline style of telephone:

NHS 111

Note: If you enter the http://www.nhs.uk/111 advertised URL your browser automatically redirects to https://www.nhs.uk/NHSEngland/AboutNHSservices/Emergencyandurgentcareservices/Pages/NHS-111.aspx

Surely they can see that it needs to be renamed/branded because they’ve wasted millions marketing it as a service that you access by dialling 111 on a phone to talk to someone.

I think they clearly want the call volumes to justify the funding (as that presumably follows the demand they get from callers) but surely if they genuinely wanted to redirect the Patients they could just rename it as a website eg. something like NHS.uk that would make it more obvious that you can do more than just call the service and assure Patients/Carers it’s not some fragmented bolted-on afterthought but part of the joined up way they access their health information and get remote advice.

“Joyce Robins, from Patient Concern, said she was fearful that the services were not taking account of those most in need of healthcare. “I think these plans make very unfortunate assumptions, that everyone has access to computers and smartphones, when in fact many elderly people do not,” she said”

When the NHS is incredibly understaffed because GPs and Hospitals don’t have the funds for wages I think it’s misfortunate that everyone who wants to interact with the NHS must have a call handler read a screen to them down a telephone line because some can’t or don’t want to use the internet to interact with that screen. Surely it’s better and more sensible for the NHS to let Patients and Carers help and relocate the money currently being wasted paying the call handlers to read the screens (that Patients/Carers could probably do a better job of) so that more funds could be saved that could be redirected to care for those Patients that are in greater need of help?

I’m not sure what data would prove it but I think in 2018 Patients and Carers have better access to the tools of our time than NHS staff (2013).

*** UPDATE: 10am Monday 22 Jan 2018 ***

A reader has shared with me a current NHS England tender for an online AI consulting system:

“An artifical intelligence (AI) or machine learning to be able to triage patients most appropriate for their needs based on the interrogation of NHS Standards, NICE guidelines/pathways and previous incidents – system is externally validated.”

It has been shown in peer reviewed publications like the Mayo Clinic Proceedings (in 2013) that taking a high quality history online has been possible for years but the next bit (using the history gathered to decide the next course of action and  change people’s behaviour) is something that takes on another level of complexity altogether. Sounds like the NHS is going to try and develop Paint-by-numbers Medicine.  I wonder what the Medical Defence Societies think of this approach?

When you realise that NHS Hospitals don’t know what one another are paying for basic things like toilet rolls I wonder why they don’t do something much simpler and develop a much more basic AI that could just do the job of NHS England?

*** UPDATE: 28 March 2018 ***

Pulse Today reports that the robots at NHS 111 will now be direct booking GP appointments:

“It comes as Pulse reported in December that CCGs have been told to reserve 5% of GP appointments for direct booking by NHS 111, rising to 30% of appointments by April 2019. At the time, GPs said the scheme would not work unless it was contractual. A pilot scheme has been running in the North East of England since 2016, with participating practices offered a one-off payment of 70p per patient.  Outlining the details of the recently concluded contract negotiations, NHS Employers said that NHS England intends that direct booking by the 111 clinical assessment service (CAS) into practice systems ‘should be rolled out universally as soon as possible’…   …A senior NHS England director previously said that four in five NHS 111 referrals to practices could be avoided if the calls were first taken by a GP rather than a non-clinician.  And a year ago, NHS England announced that one in three calls to NHS 111 were to be assessed by a clinician under plans to ‘beef up’ the helpline.”

The comments make it very clear what’s happening here. Surely an ‘artificially intelligent’ robot could just read the comments threads on these news items and use that to devise a better strategy than NHS England:

“NO NO NO not have appointments filled by these idiots.” GP Partner/Principal 20 Mar 2018 1:21pm

“We already have this as part of a local enhanced service (primary care home funding). It’s rapidly becoming evident that patients are using it as a way of back-dooring into appointments with any old rubbish and bypassing the triage system” GP Partner/Principal 20 Mar 2018 1:22pm

“so some person with 6 weeks training and a flow chart can book appointments ? and clog up A+E ? whose idea is that and have the pilots proven anything ?” GP Partner/Principal20 Mar 2018 5:21pm

“why is everyone fretting about this. IF NHS 111 call handlers fill up our slots with nonsense, so be it. Our genuine patients who needs appointments will not get appointment and they will turn up at A&E and CCG will ultimately will have to solve the problem not us,BECAUSE NUMBER OF APPOINTMENTS WE CAN GIVE IS LIMITED.
I have stopped caring who fills those slots. If we have no appointments left I am not going to create extra slots ,once those slots are filled, everybody else goes to Walk in centre or A&E” Pradeep, GP Partner/Principal 21 Mar 2018 8:39am

“re Pradeep’s point – The problem is that we have some complex patients who we simply have to see or their multiple unsorted issues, kindly identified in print for GP to follow up on, won’t get sorted, and the coroner/CPS/GMC will have, in black and white, the results and discharge summaries showing that GP is to follow up repeat CXRs in case cancer/failing kidneys etc etc.   I’d rather our reception and duty dr system had some discretion so we can get our complex patients in to be seen acutely, or as follow up promptly, rather than see unselected rubbish that could go elsewhere.   If we have no blocked follow up slots for new depressives, patients who need bloods and might need TWR referral etc etc, we are screwed” Big and Small, GP Partner/Principal21 Mar 2018 9:28am

“‘and the coroner/CPS/GMC will have, in black and white, the results and discharge summaries showing that GP is to follow up repeat CXRs in case cancer/failing kidneys etc etc.’   Which is exactly why reform is needed. if there are more cases that blame doctors for systemic health care failings there will be no health care in this country as people will simply not want to enter medicine. why should individuals be blamed for systemic health care failings? the ‘rubbish’ is due to a complete lack of interest in self care which is unique to the UK unlike other countries” Anononymous Doc, GP Partner/Principal21 Mar 2018 10:29am

“this is ridiculous, the anecdotal cases i could bore you with are beyond laughable!  can we start a GP/doctor version of NHS that we make sure we look after are own when the sh*t goes down the pan?!” Cloud cuckoo land | Salaried GP21 Mar 2018 10:34am

“I can see where this is leading. Government wants to make system so bad that it crumbles on its own. Then only public themselves will demand system to be changed and be willing to part fund their health care which is what government really wants. It will happen slowly but surely. It will take few casualties (some patients,Some doctors). Politicians will not shot themselves in the foot by saying public needs to contribute directly for their health care. So friends please be ready for a even worse rough ride in next few years” Pradeep | GP Partner/Principal21 Mar 2018 10:41am

“111 use a very short algorithm. Do you feel ill – No – see GP. Do you feel ill – Yes – see your GP. Do you feel you need to see your GP – see your GP within 12 hours. Do you NOT want to see your GP – see your GP!  I’ve had NUMEROUS patients who wanted simple advice but were TOLD MUST see GP.  As GPs we manage risk well – 111 doesn’t manage risk at all – see GP. So we see the ‘dross’ at the expense of those who might actually benefit – NOT ME – I’m off!!” Pale Male and Stale | GP Partner/Principal21 Mar 2018 10:54am

“The same 111 who have crushed the ambulance service with inappropriate 999 calls, 1. child with 1 hour of earache 2. Man who twisted knee 3 weeks earlier and rang for advice. Saw them as an A&E GP. Complete farce” Ed the ‘Ed ,GP Partner/Principal21 Mar 2018 2:12pm

“mental idea. numpties with little medical trianing following some ridiculous computer flow chart that ends up sending lots of folk needlessly to A+E already. Give them access to 30% of my appts so they can fill it with dross and add to the white noise my practice has become VERY adept at filtering… sod off idiots just fund primary care properly” Jones the Tie | GP Partner/Principal21 Mar 2018 5:30pm

“We are part of this pilot and are being bribed to take part with a sum of money that we can ill afford to refuse. But the comments already posted are valid. We have spent years training our receptionists to perform safe triage and the system works. Political investment in the NHS 111 scheme means that patients are directed to us via algorithm and it is fair to say that a large number of these are inappropriate either in terms of the problem itself or, more usually, in terms of the urgency of care required. We recognise, I am sure along with most GPs, that we are unable to satisfy patient demand while remaining safe and sane. Giving patients what is effectively open access to our appointment systems is not the answer.  My worry is that the political will is to have this declared a success and that the 30% target will become a reality by April 2019 without proper evaluation from those delivering the service” epicureedward, GP Partner/Principal27 Mar 2018 3:24pm

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