Guest Blog Part One: How can ‘Call First’ be delivered quickly to help with the backlog of demand following the Covid-19 lockdown?

By Mark Cockerton

Could the Covid-19 pandemic be the catalyst that finally brings GP Out of Hours services and NHS 111 together, to jointly support the flexible implementation of a ‘Call First’ model across England? I use the description ‘Call First’ deliberately rather than ‘NHS 111 First’. The anticipated service was not, in my view, included in the specification when NHS 111 contracts were awarded following a competitive tendering process. More of that later.

I’ve worked at CEO and Director level for more than 20 urgent care services across England as well as several years as an Advisor to the Department of Health urgent care team.  I’ve seen all the changes in call handling and clinical assessment systems from the days of the GP Co-operatives, to the present day.

I’ve seen first-hand how the competitive tendering of call handling and clinical assessment services, that started following the new GMS contract in 2004, has so often adversely affected co-operation and joint working between the organisations involved in urgent care provision. Local providers that lose long-standing contracts for services they often delivered to a high standard are expected to work closely and constructively with organisations, often from outside the area and unknown to them, that take on the contracts.  Whilst most deal with the change in a professional manner there is often friction that manifests itself on occasions. Most specifications for integrated urgent care services make references to the Commissioner’s expectations for ‘integration, joint working and seamless care’, however, achieving that requires more than writing appropriate words in a tender response.

To put a modern slant on an old saying ‘necessity can be the mother of innovation’. The extreme urgency of bringing in additional call handling and clinical assessment capacity must now encourage creative thinking so that the existing infrastructure already in place and underutilised, often as an outcome of competitive tendering processes, can be brought into use and contribute hugely to dealing with the demand backlog built up during the months of lockdown.  With speed of the essence, it’s simply much better to use the capacity that is already there and can quickly be brought on stream, than following any process that adds delay.

Since the start of the pandemic NHS service commissioners and providers have moved at an unprecedented pace to jointly develop and provide innovative services to deal with Covid-19. Long-standing barriers between organisations have been broken down and we can now see what is possible when co-operation and goodwill are willingly provided for the common good.  There has been a rapid growth in home working for example. The perceived barriers to clinical and non-clinical staff working from home were broken down through necessity and that has been a positive change that will help to deliver more resilient services in future.


News that pilot schemes are beginning in London and Portsmouth of a ‘Call First’ model where patients are asked to phone to make an appointment in A&E instead of just turning up, is confirmation that the NHS is wanting to move speedily towards a phone ahead scheme. Those with life-threatening problems will be told to attend straight away; however, those with a broken limb, for example, may be told to wait.

As A&E departments return to pre-Covid levels of demand the NHS is looking at how patient flow can be best managed, together with how social distancing can be enforced and overcrowding avoided. It would be impossible to enforce social distancing when there are people waiting for care in a crowded waiting room or on trolleys in corridors; as can be the case at the busiest of times.

There is a huge backlog in dealing with demand from patients who steered clear of hospitals at the height of the pandemic.  Few would be surprised if there is a speedy implementation of a ‘phone before you go’ model, once the learning from the pilot models has been disseminated.

Whilst it is not envisaged that a ‘Call First’ model will be the only way patients access A&E; appointment booking is likely to be strongly encouraged in order to help the NHS avoid overcrowding in services that were previously predominantly used by walk-in patients.

How could this work?

Patients would ring a number as a first point of contact, if they need help but it is not an emergency.  That is very likely to be the NHS 111 line but alternatives are available given the flexible way that calls can be readily diverted from existing NHS telephone numbers without the patient needing to be given a different number.

Call handlers and/or Clinicians will then be able to book patients into a timed slot to attend A&E, an Urgent Treatment Centre or a ‘hot clinic’. Patients who are deemed to be urgent and at risk of death will still be told to go straight to A&E.

Urgent care call handling approaches in England – NHS Direct to the advent of NHS 111

Since the mid-1990’s the NHS has been developing increasingly centralised and larger scale call handling services. That development picked up pace in 1998 with the launch of NHS Direct, which was mainly based in large scale call centres. At the time of its launch, the intention (formalised as an NHS plan target) was for NHS Direct to become the front end of all urgent care calls by the end of 2004, replacing the call handling services carried out by the GP Out of Hours providers. Indeed, at the time of its launch, there was even an ambitious vision for NHS Direct to eventually also become the front end of ALL Primary Care calls, replacing the call handling undertaken by GP Practices.

That vision was never close to being fulfilled. NHS Direct struggled to recruit clinical staff in sufficient numbers partly because, by their nature, regionally-based contact centres meant they had a limited geographical area for nurse recruitment.  Also, it’s fair to say that implementing NHS Direct using a national top-down approach often led to a lack of ownership and support from local healthcare communities. GP Out of Hours services were often well regarded by the local Community, generally fully compliant with the national quality standards and most enjoyed a high level of emotional ownership from local Primary Care providers.

Most GP Out of Hours services strongly resisted the loss of the call handling and clinical assessment components of the service. They considered that to be a vital part of the patient journey and that separating it from the provision of face-to-face care would lead to a disjointed, less accountable service.   In 2003, the Department of Health accepted that the NHS Plan target for NHS Direct to front-end all urgent care calls was not going to be met. By the end of 2004, the National Technical Links Programme (which I led) had secured the future of call handling and clinical assessment by those GP Out of Hours Services that wanted to continue to provide it. An electronic link to and from NHS Direct meant that patients did not need to make a second call.

The vision of the Technical Links programme was to create a ‘hub and spoke’ model for call handling services. A regional hub would be the major front-end for urgent care calls and be supported by a network of smaller spokes to supplement call handling at key times and add resilience. That model had some success. However, competitive tendering of GP Out of Hours Services following the new GMS contract in 2004, led to consolidation of call handling over the next decade. Smaller local Provider’s contracts were taken over by national and large wide-area Providers.

NHS 111

Following the roll-out by 2014 of NHS 111 (the replacement for NHS Direct in England), there has been considerable further consolidation of urgent care call handling. The majority of telephone access to urgent care is now via NHS 111 Providers. They can be NHS (typically Ambulance Trusts), not-for-profit Social Enterprises or Commercial organisations, selected by a competitive tendering process and with a contract of up to 5 years.  A detailed specification sets out the service requirements.

There are some ‘hub and spoke’ models in place where sub-contracted Providers support the call handling service at times of pressure. In addition, there are some areas where the workload of the newly established Clinical Assessment Services is supported by non-NHS 111 Providers working in their local area.

See Part 2, looking at the Implementation of the Call First model…

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