For patients confused about who to call and where to go for urgent care, the government believes its NHS 111 service will be the answer.
The plan is that 111 will provide an easy-to-remember and free-to-call number that patients can use for urgent, but non-emergency, care, while 999 remains the number for emergencies.
What is less clear is how the 111 number will fit into the NHS and what it will mean for GP practices, out-of-hours services and commissioning consortia.
Many GPs see the benefit of 111 in cutting down inappropriate calls to 999. Dr Lis Rodgers, a South Yorkshire GP and clinical lead for unplanned care and clinical services review to NHS Doncaster, says that in this respect 111 is a great idea.
Her main concerns are about how the 111 number will work with everything else that's happening in the health community on urgent care. Her area already has a successful GP-led out-of-hours service that is integrated with the A&E department and accessed by patients calling their own GP practice number.
Dr Rodgers says: 'GPs also deal with a lot of emergency care and that is what they are contracted to do. So if 111 sits on top of that, is it going to be swamped with calls that should be dealt with by the practice?'
She says there is currently no information on the volume of emergency calls handled in surgery hours, making judgments about the impact of a 111 service difficult to quantify.
Not enough detail
Dr Chaand Nagpaul, GPC negotiator and north west London GP, believes it will be vital for 111 to be integrated with a local community's other arrangements for unscheduled care and says there is not enough detail to make a sensible judgment at the moment.
He adds: 'There needs to be a coherent approach. At the moment there are parallel entry points into urgent care for patients ranging from NHS Direct to walk-in centres, GP-led centres, A&E departments and so on which does create a lot of duplication.'
Another unanswered question is where control for 111 will lie. Dr Nagpaul believes there is a strong argument for GP commissioning consortia to have some control over the service as it applies locally, although the service will also need to deliver a national role. He says control over unscheduled care will be integral to the success of GP commissioning.
Rick Stern, the NHS Alliance's urgent care lead, believes GPs are in a key position to commission a more integrated urgent care service and that 111 might be part of the answer although it is still early days.
He adds: 'There needs to be a clear understanding of how GPs work with community services and how ambulances and out-of-hours services link in with that. When things go wrong it's in the gaps and handovers. The real difficulty is in putting a seamless and effective 24-hour service into practice.'
NHS Direct
The future role of NHS Direct is another piece in the jigsaw which is still being worked out. When health secretary Andrew Lansley launched 111 this summer the headlines suggested NHS Direct would be scrapped but this appears undecided.
Questions include whether the telephone health advice service will be rebranded under NHS 111 or continue to operate alongside it.
Devon GP Dr Kevin Brown believes NHS Direct is doing a great job in providing advice to patients and handling calls. He says: 'I have been impressed with NHS Direct and it would be a retrograde step if it went.'
However, Dr Jeremy Phipps, a GP in Lincolnshire, argues that NHS Direct may have encouraged patients to take less responsibility for their own care and lose confidence in their own decision making and that 111 could be a better solution. He adds: 'If 111 acts as signposting service only that is a good idea.'
The NHS 111 service is to be staffed by call handlers, not clinicians, but will use the highly regarded and UK-developed NHS Pathways assessment software, which will be populated with a local directory of services.
Nurse advisers will also be available if needed.
Dr Phipps says he has no issue about who has responsibility for delivering NHS 111 so long as there is a degree of local control. Like Dr Phipps, Dr Rodgers also argues that patients want to speak to someone with local knowledge when they ring for advice. She believes that NHS Direct must continue to play a key role alongside NHS 111, certainly in providing online advice.
She adds: 'If we look at the current economic situation we have to get patients to take some responsibility for their own health and the availability of online resources to help them do that will be very important.'
Piloting of the 111 service has begun in County Durham and Darlington, and two more pilots, in Nottinghamshire and Lincolnshire and in Luton, are planned to go live before the end of the year.
Dr Ruth Livingstone, clinical lead for the Nottinghamshire and Lincolnshire 111 pathfinder, hopes 111 will steer patients through what she describes as 'a highly confusing system' and that the pilots will shed light on the best ways to use the service.
Converting the current confusion into a coherent 24-hour urgent care service and finding a place for 111 within it is a task that could take the NHS some time.
