Last one out at NHS Direct unplug the phone will you.

As someone who managed a roll out of a UK wide call handling operation the National Rail Enquiries programme and was prior to the launch of 111 had a spell as interim COO of NHS Direct I have to say this news saddens me. 

http://www.bbc.co.uk/news/health-23465966

I had the opportunity last year to review a 111 contract and the outputs required from both supplier, vendor and stakeholder elements of the contract.  It was clear to me then that 

(1) The complexity of pathways and multiple service providers all with differing hand off processes would be risky and drives patients to Doctors or A&Es
(2) This complicating the feedback loop in patient care 
(3) A National "big bang" roll out with what I suspect was a political decision rather than an operational one was frankly bonkers, the limited trials certainly gave not enough evidence to support such a move.
(4) I had very little confidence in the project management team and risk model developed to stem the flow of patients to A&E and Doctors surgeries.
(5) That 111 was meant to address the fact that "Primary care" i.e Doctors surgeries are closed after 5pm on a Friday and the burden is expected to absorbed by the the emergency parts of the NHS.
(6) A perverse logic that could allow providers who had different outcomes such as Ambulance providers to meet their targets by working the system by directing a pathway which resulted in a failure elsewhere in the system.

It was clear from the early rounds that respected "tele-health" operators such as Devon Doctors on call withdrew after a lengthy and expensive bidding process.  There reasons was simply that contracts could not be delivered at the cost expected.  This should have been a warning to NHS Direct who if they continue will be 25 million pounds in the red by the end of this financial year.  The failure to undertake such due diligence beggars belief.

111 has lost the confidence of the English public.  I suspect so has the Board and the Senior team of NHS Direct who obviously failed to "price the job" accordingly and understand the risks. I suspect with no business senior heads and hopefully the Board's heads will role, but NHS Non Executive Directors have a back of avoiding the blame, despite the fact they are ultimately accountable for decisions made to sign contracts with 111.  The failure to pay due diligence to the bidding process and the contracts has let down the staff of NHS Direct.

The 111 idea in principle is a cracking idea but it is complex and difficult to introduce.  The chief architect former Health Secretary Andrew Lansley has already gone and i am sure more people will fall on their swords in the coming weeks.  

Throughout the process 111 has attracted criticism from GPs and out-of-hours services and from clinical commissioning groups. I have heard that 111 refers too many patients to A&E, out-of-hours, and practices.  Clogging an already busy service.  

CCGs had expressed their concerns over the tight deadline for getting NHS 111 in place means they are being given little chance to influence the service, or the award of contracts.  The Department of Health offered a six month extension, which i suspect points to a political decision.

In 2012 Andrew Lansley said "It is not just the technology, which means that if somebody calls from a mobile phone they can be located and directed to the right provider, it is an example of a joined-up service that delivers care in the right place at the right time,"   Hardly rocket science is it. Well telehealth is not easy as many are finding out.

The consequences are this are:

- Increased cost or service for the provision of 111 services as replacement service providers demand a premium for taking over NHS Direct 111 contracts, staff and liabilities.  
- The saying good bye to many NHS Direct professionals who not all will TUPE across to new suppliers.
- 111 losing further credibility as the change management process is unlikely to be seamless, seeing Doctors surgeries and A&E departments in England taking the hit.
- The lack of a competitive market place as supplier base shrinks and everyone else runs away from it.


The answer perhaps is to do what happened on the East Coast Mainline when greedy private sector types handed back the franchise when they realised that like NHS Direct they had failed to read the small print.  Nationalise the remaining services with a view to bringing them under an umbrella trust to ensure consistency of delivery.  Oh hang on that is what we had with NHS Direct!

The final consequence is the end of NHS Direct, a national treasure stripped of it's dignity and respect by frankly poor leadership at Board level.

Last one out take the phone off the hook!