Why NHS 111 has to stay 'risk-averse' – and thus doesn't save money | Colin Leys

Why NHS 111 has to stay 'risk-averse' – and thus doesn't save money | Colin Leys The new telephone line has non-medical staff doing computerised triage. So it has to err on the side of caution, which just shifts the strain to other parts of the NHS.

A new potential scapegoat has recently surfaced for Jeremy Hunt to blame for whatever goes wrong in the NHS – the "risk-averse computer". Apparently, the computerised system used for the crisis-ridden new NHS 111 call line is too averse to risk, resulting in ambulances being despatched unnecessarily, pushing up costs instead of reducing them, and adding to the burden of both GPs and hospital A&E departments instead of lightening their load. Never mind the fact that Sheffield University's evaluation of the pilot studies predicted this – ambulance callouts rose almost three times faster in the test areas where NHS 111 was introduced (as usual, the findings were ignored). But at least in this case there is an obvious remedy – make the computer program less risk-averse.

But on second thoughts, maybe not. When we are flying somewhere, don't we want the plane's computer programs and the pilots to be as risk-averse as they can possibly be? Why would we want anything less from our health service?

What this story highlights yet again is the fact that in healthcare you can rarely save money by reducing qualified staff without lowering the quality of care, and even risking patient safety. NHS 111 is a computerised triage programme operated by non-medical call centre staff. It is meant to become the sole route of phone access to all NHS out-of-hours care, and was supposed to save money by reducing the need for medically trained staff. But to keep down the obvious risks the system has to be risk-averse, and so more cases are directed to GPs or hospitals. Therefore the cost is not reduced, but redistributed.

And the risks are serious. In the first three months of operation 22 "serious untoward incidents relating to NHS 111" were reported, including three where the patient died.

The causes remain to be determined, but the fact remains that the difference between being slightly ill and dangerously ill is not one that any computer algorithm can be trusted to detect. One GP commented: "It's very difficult for a computer program to distinguish between a heart attack/asthma attack/Gord [gastro-oesophageal reflux disease] etc. It's hard enough for a clinician with 10 years' experience. Asking untrained operators to do this with an inflexible computer program is doomed to failure … there are some things in life which just can't be dumbed down."

Another said: "It makes the triage system for urgent care one where the least experienced person in the chain is the first point of contact and major decision maker. It is therefore inherently unsafe."

Fixing the problem is going to cost money – as the Sheffield evaluation also warned. NHS England is already talking about introducing clinicians at an "earlier stage" of the triage process, which begins to make nonsense of the computer-based approach, and about changing the business model on which the service has been based. The business model needs changing because even using non-medical call centre staff, providers can't make it pay. NHS Direct, which used to run the national 0845 advice line, won 11 of the 46 local contracts to provide the NHS 111 service, but has already given up on two of them (Cornwall and North Essex), and is losing money on the other nine. Why? Because it is paid per phone call, and the volume of calls is only 30-40% of what was expected, while the staff can't be reduced correspondingly. If the call volume remains too low, either the payment per call will have to rise, or a different financial model will have to be adopted, and it will cost more.

The Commons health select committee is going to review the operation of NHS 111. It must grasp the nettle and state plainly that applying the business approach to efficiency – substituting capital for labour, and substituting cheap labour for more expensive labour – can't be done safely in healthcare. But the provision of NHS 111 has been outsourced to a variety of providers with contracts that could be costly to terminate. Unless the public gets angry enough to force a rethink we had better hope that at least the computer stays risk-averse. Otherwise we must expect a growing number of "serious untoward incidents", in which some people will die. The Guardian