Internal documents obtained by GP reveal NHS Direct's clinical lead for NHS 111 in the north-west of England moved to a new role the day after it went live, leaving it without a full-time top clinical official.
The revelations came as NHS Direct announced it had pulled out of contracts to provide the service in Cornwall and North Essex, where NHS 111 was put on hold.
In a report to its board, NHS Direct chief executive Nick Chapman admitted its NHS 111 contracts were 'financially unsustainable', raising questions over its long-term viability.
NHS Direct's 111 services in the West Midlands and north-west of England have continued handling just 30-40% of contracted calls because of arrangements made to share calls with other providers - including GP out-of-hours services.
GP previously reported that NHS Direct's 111 operation was £1.5m in deficit and the board was expecting financial penalties for failing to meet targets.
Internal risk registers obtained by GP reveal concern over the clinical lead in the north-west of England. An entry on 7 March, the first time the risk was flagged and just weeks before the go-live date, reads: 'Newly appointed clinical lead to start on 22 March, one day after we go live but will also have responsibility for (West Midlands). (North West & West Midlands) are massive contracts. Can one person really look after these two alone?'
NHS Direct chief nurse Tricia Hamilton said the last minute reorganisation had not contributed to the service's problems. 'The problems were due to us not having the capacity to handle the volumes of calls,' she said. Calls were longer than expected and handlers took time to get up to speed, she added.
The North West risk register also flagged potential problems with staffing, recruitment, training, call volume forecasts and insufficient staffing at out-of-hours providers in the weeks leading up to the roll-out.
An internal review into the service's failings by consultants Deloitte found NHS Direct's training programme failed to deliver the required number of staff, it underestimated average call length by about 200% and its forecasting of required resources was 'significantly adrift'.