The NHS 111 Service – a procurement failure?

As the problems with the new UK health service non-emergency telephone “111” service hit the press over the last few months, I didn’t comment because frankly I didn’t really have anything to offer beyond what every newspaper was saying. Some providers clearly weren’t prepared for the new service, which raised some questions of the procurement process.

Then the largest provider of the service, NHS Direct, a public body themselves, who previously provided a national telephone service along very similar lines, announced that it is pulling out of two contracts in Cornwall and North Essex which it had won and were at the mobilisation stage. NHS Direct already run 9 other areas, handling about a third of the national volume of 111 calls. NHS Direct’s statement said:

“We are unable to take forward the service and NHS Direct have no option but to exit from the contract. The reason for this is that since the launch of NHS Direct's other 111 services, we have established that the contract terms which NHS Direct had entered into are in fact, financially unsustainable”.

 According to NHS Direct, this is because it is only handling 30-40% of the expected call volume, so is receiving less income, whilst it is fully staffed for 100%. What is not clear is whether this is because simply fewer people are calling, or whether each call is taking much longer – I can’t establish that from the material NHS Direct published. If it is the former, that may be because of the all the bad publicity the service received in its early days – perhaps people are just going to their doctors, or hospital emergency units, rather than calling 111? I have also heard comments that the service was not well publicised or marketed when it was launched.

Before we get into the fundamental issues, this illustrates one of the problems when you get public organisations contracting with each other – it is hard to apply normal contract disciplines. If this was a private sector organisation pulling out of the contract, you can’t help thinking the commissioning organisations might have looked at some hefty penalties.

But the more important issue is how to make this service sustainable, particularly as NHS Direct has actually said that all their other contracts are also financially unsustainable. And if this is true for them, is it true for all the other providers?  Apparently, there was no centrally defined commercial model for these contracts, so areas run on different basis, hence there may be different levels of issue in different places.

So how did we get to this unsatisfactory place - here are some procurement-type questions that need answering:

  • Was the requirement properly understood by the commissioners and the potential suppliers before the contracts were taken to market?
  • Was the market competitive enough in terms of having enough suppliers who were and are truly capable of doing the job?
  • If the volume of work was uncertain, why weren’t payment mechanism designed to reflect that uncertainty? It’s not too difficult to do that and there are plenty of other examples that could have been drawn upon.
  • Why didn’t the buyers look at the resilience of the suppliers and their financial models if the volume levels proved to be different from the best estimates – again, given it was a new service, that would have seemed sensible?
  • Did the organisations running the procurement have enough resource and the right resource to do a proper procurement job?
  • What is being done to look carefully at all the other providers' situations - if NHS Direct can’t make a go of this commercially, why should any other provider be able to do so?

This sounds like a job for a real procurement expert both to look at the historical issues and to draw some lessons from what has happened, and then come up with some solutions. What’s David Shields up to these days...?

You might also wonder what this says about the brave new world of health commissioning we’re about to get into - this is a relatively straightforward service compared to some that will be commissioned in the future.

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Voices (6)

  1. Caroline Brook:

    I thought that the experts in the field were shocked by what was asked from them, ie cheap as chips medical advice for peanuts. They did not bid. You pay for what you get….

  2. Trevor Black:

    There a dilemma for many in the procurement profession in the public sector where procurement can be blamed for projects which have no hope of success in the first place. There is a big difference between having a well constructed and considered business case and a politically driven good idea. Those pointing out the potential failings in the political driven environment are side lined which places those with the professional abilities (who don’t speak up) having to consider carefully how they can survive in that arena. The NHS 111 project is doomed to failure as it is outside of the mindset of the public and was just another of those ill thought out ideas.

  3. Anon:

    I worked on one of the NHS 111 pilots for about 18 months including procurement and implementation. One of the (many) reasons as to why it is where it is, is indeed the procurement process – although not the ones posed here.

    The in-house procurement and finance advice the programme team received in our area was forensic in nature and revealed a degree of ‘figure massaging’ from all the bidders. In the real world the Commissioners may well have decided to scrap the whole thing and start again. But it was not the real world and the situation NHS 111 is in now is not the fault of commissioners or providers – although NHS Direct could have been more honest with their customers. But like everyone else experiencing the new world order in health, the culprits were the Department of Health and their regional arms – providing ‘advice’ aka thinly veiled threats; ‘support’ impossible deadlines; ‘intelligence’ too little, too late and too incomplete; ‘technical advice and support’ systems we couldn’t see or adapt quickly enough to meet the needs of local populations; and “freedom” or ‘you’re on your own if this doesn’t work’ . NHS 111 remains essentially a good idea mired in the political will of people who are unconcerned about taking the time properly pilot and evaluate complex and complicated programmes that require resources and from multiple stakeholders. Too little time, too little attention until too late – too often the narrative of change in the NHS.

  4. bitter and twisted:

    My IT skills are a bit rusty, but im this can be easily updated

    10 Print ‘Welcome to 111’

    20 Input ‘Are you really ill?’ , X

    30 IF X = ‘Yes’ then Goto 60

    40 Print ‘Please contact your GP for an appointment. But if youre really not sure, go to A&E.’

    50 End

    60 Input ‘Have you got chest pains, and/or a head injury, and/or a non-blanching rash, and/or a pre-existing life-threatening medical condition?’, x

    70 If x = ‘yes’ goto 90

    80 Goto 40

    90 Print ‘Please go to A&E’

    100 REM Copyright bitter and twisted medical solutions LLP, 2013

    110 On Error print ‘All our lines are engaged. Please call again , or go to A&E’

  5. Anon:

    To answer your questions 2/3rds of calls are diverted away from NHS direct 111 services to gp out of hours providers and old NHS Direct contingency. This is because the assumptions for Call length (average handling time) were exceptionally bad, about 50% of what they are in reality.

    The call forecasts have actually been fairly good for a new service but as each call is taking twice as long staffing requirements go through the roof and the £7-£9 per call is not enough to cover costs. There’s a report about NHSDs rollout on their website

    Can anyone else do it for that price? Maybe over time, but until the call scripts are shortened, systems and processes are tightened up everyone will be losing money.

  6. bitter and twisted:

    Surely the question is: why start from scratch, why not just improve the existing NHS direct service?

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