911 call Conclusion

As stated before, telephone triage is limited, sometimes there is no option but to have a clinician on scene to rule out things which may (or may not) require immediate attention. I'm genuinely sorry that this often means engaging ambulance clinicians who might otherwise be attending more obviously life-threatening situations, but that is a problem created by a lack of ambulance service resources and a growing population of elderly, infirm and vulnerable people, exacerbated by a broader failure of government to provide appropriate support and prevention measures.

Millions of people rely on the service provided by NHS 111 and for most, it is effective and useful. It is something of a Pandora's First Aid Box. Now the system exists and the box has been opened, it is nigh on impossible to put everything back, even if we wanted to. I believe to remove the facility altogether would increase pressure on other services, not protect them. It would be better for ambulance and 111 services to work together to improve the relationship between them.

In conclusion

I accept that NHS 111 is an imperfect system and that it does contribute to the pressure which impacts of the daily experiences of 999 crews. But I hope you will see that there are valid reasons for the calls generated. If there were enough ambulances to shoulder the demand, it wouldn't be an issue.

For what it's worth, I certainly hope to participate in making the process more effective, but even if there was a way to guarantee every ambulance referral was appropriate to the skillset of an emergency ambulance crew (which there really isn't), I suspect it would make little difference to the intolerably high utilisation rates under which crews toil.

The truth is that the general public will always seek the quickest route to solving their problem and healthcare organisations will always try to provide this on the lowest possible budget. There is a lack of high-level foresight in the utilisation of ambulance crews; the powers that be seem to work on the principle that replacing is more acceptable than protecting when it comes to the workforce. The beancounters think an ambulance crew not dealing with an attendance is one that is wasting money. This is compounded by the current ideologically-led efficiency savings suffered by ambulance services and by the competitive market model which 111 providers have to adhere to, creating all sorts of limitations (underbidding leading to cost-cutting measures, private provider need for profit, unwillingness to work openly with potential competitors).


The accessibility and convenience of NHS 111 and 999 services means that initial contact with primary healthcare has never been easier. Along with a growing and aging population, I believe this is the cause of the rise in demand. Like ambulance services, NHS 111 cannot deny the public treatment if there is any possibility that it may be appropriate. Making that determination is the key factor here – what  an individual wants and what they need are not necessarily the same thing. And making that decision over the phone is even trickier than doing it on scene.


Ultimately, 111 and 999 are on the same side and should find ways of working more closely together to deliver the right care to the people who need it. There's little to be gained from animosity.


Of course, if even after taking all this into account, you feel you need to continue scapegoating 111, then I can't stop you. I've been there – sometimes you just need someone or something to kick. But at least you'll hopefully now be doing it from a more informed position.

Ambulances are sent even if the caller has refused one.

Within the Pathways process, this is not true. Any 'disposition' [the recommended course of action arrived at by the assessment process] offered by a health advisor can be refused by the caller, at which point the call will be passed over to a clinical advisor.

At this point, the judgement of the clinician takes precedence over the Pathways disposition. Of course no ambulance is going to be sent without good cause and if there is an appropriate alternative treatment pathway, that would be explored - and in many cases it enables us to work with the caller to arrive at an informed and safe decision. However, in certain circumstances, healthcare professionals have a duty of care and may be required to act in the patient's best interests in spite of their preference. We would only do so if there was no other option, and would ensure that ambulance dispatch was informed of the situation.

These circumstances are relatively rare, but with increasing challenges faced by community mental health, patients discharged prematurely without appropriate home support, and other underfunded and buckling systems, it's a sad truth that the ambulance service is the only option in certain circumstances, lest the system abandons these people entirely.

6. Abandoning NHS 111 altogether and leaving the public to decide on the most appropriate treatment pathway would relieve pressure on 999 and other services.

This is hard to prove without actually doing it, but it seems very unlikely. With GP services facing a national crisis, A&Es already overburdened and ambulance service utility spiraling out of control, I would imagine a significant proportion of people who currently rely on 111 and out-of-hours GP services would simply call 999 or attend A&E out of desperation.

I believe some ambulance personnel are suffering from confirmation bias. Every ambulance attendance generated by 111 which turns out not to be as it initially appeared is held up as an example of failure, whereas the thousands of calls which might otherwise have resulted in a 999 call are never seen by ambulance staff.