Dial ‘F’ For Failure

111The NHS recently launched its non-emergency 111 number. Staffed by ‘a team of fully trained advisers’, the scheme’s aim is to quickly and accurately identify the most appropriate medical response to the caller’s needs.

What’s important to note is that the ‘fully trained advisors’ aren’t doctors, nurses or paramedics, and do not make clinical decisions themselves. Rather, they use a ‘clinical assessment system’ to assess caller’s needs, and are ‘supported’ by clinical advisors such as doctors, nurses or paramedics.

In other words, expertise is positioned away from the front end (where contact occurs with service users), and the operators work their way through menu-driven options, much as in the same way as when you call up your internet service provider to inform them that your connection has crashed again. This type of model builds in failure, and the 111 service is no different.

The 111 helpline has attracted a lot of media attention recently, as the following examples demonstrate:

As you can see, there have been lots of problems. Why does this failure occur? Bad people?


It’s the inherently unstable system design, coupled with a management mindset that ensures all the wrong buttons are pressed when the cracks begin to show.

Putting aside the potential confusion caused when someone who needs medical help tries to figure out whether their situation is ‘less urgent than 999’, let’s look at the bigger picture and try and understand some of the systemic effects of this type of model. For this, I will use one of my drawings:

111 drawingAs you can see, the deficiencies inherent in the 111 model lead to adverse reactions within and around it. Other parts of the system, already subject to their own dysfunctional constraints (such as in A&E) bear the brunt of the badly designed front end. Failure leads to failure and this places further strain on all parts of the system. Faced with a buckling infrastructure, management does what it knows best and reverts to the counterproductive reactions listed, which serve only to intensify the problem. Meanwhile targets are still often met.

The antithesis to this type of self-perpetuating mess is simple. You’ve heard it before:

  • Adopt a whole system perspective.
  • Design the front end to handle predictable demand.
  • Ensure expertise is positioned at the point of contact with the service user.
  • Remove targets.

This will help both the patient and the system get better.

About InspGuilfoyle

I am a serving Police Inspector and systems thinker. I am passionate about doing the right thing in policing. I dislike numerical targets and unnecessary bureaucracy.
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5 Responses to Dial ‘F’ For Failure

  1. Dolly says:

    Isn’t this the call centre approach the police have adopted?

    *Staff with no experience of the law or policing taking calls from the public.
    -Risk adverse organisation = everything gets recorded.
    – Call centre unable to give relevant advice at first opportunity = more workload for front end staff.
    -Calls get badly graded = 1. officers sent to non police matters. 2. response to incident not in order of priority in the circumstancs. 3. Valuable policing opportunities missed.
    – Frustrated public.
    – Frustrated front end staff.

  2. Dave Hasney says:

    Another great post Simon and, from first-hand knowledge/experience, I can only echo the points/observations offered by Dolly (above)… Today service quality is (too often) governed by targets, budgets, politics and personal agenda and/or management self-interest – but not necessarily in that order. Sad days… Where’s my beer???

  3. me says:

    Beginnig to think you employ a “designer” for these lovely drawings…. Smashing as always 🙂

    beyond my understanding why there cannot be a simple demand/supply approach to customer/patient care

  4. Geoff says:

    Reminds me of the passer-by; who said he was a hydraulics engineer and who kept offering guidance to a guy who ignored him, who had pulled a drowning woman on to the canal bank and was pumping her leg up and down. A crowd gathered round and the man asked “Does anyone here know anything about resuscitation?” No offers were forthcoming! At last the guy attempting resuscitation asked the engineer “OK, so what do you know about resuscitation?”. The engineer replied, “Well, if you pulled her head out of the water before pumping her leg; there may be a chance of resuscitating her!”

    So many times designers develop systems without talking to end-users or service providers. The MBA qualified managers of the frontline service providers (to whom they never speak!), eager to impress their bosses, are too eager to grab the King’s New Coat, glitzy, all singing – all dancing system demonstrated on screen by the very expensive design consultants they engaged. Naturally the intending system operating company is private sector with names like G5X and keen to put in a bid for the revamped Government (knows better) NHS Direct system; newly branded “111” to avoid confusion with silly numbers like 101 or 999 !!

    RESULT – just like the one you describe with egg on lots of faces and the media rubbing their hands together with glee 😉 ……. oh, and dissatisfied users either dying, moaning, voting for some other party or becoming very depressed and presenting themselves as s136 cases!

  5. Paulette Sedgwick says:

    I work in nursing after having to make a call to 111 whilst not on duty and told to expect a call out in 6 hours didn’t make me happy. Then when asked can the person swollow painkillers okay which she could was told to wait till monday to call her dr out. Whats the point of 111? There advice is same as NHC Direct. Father has Prostate cancer we called 111 over christmas to be told they were bizzy were drunks …. apparently being drunk and nasty to police comes first to those who need help (we called 999 but told wasnt an emergency so to call 111)

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