Intended for healthcare professionals

Views And Reviews Primary Colour

Helen Salisbury: Plan your emergency

BMJ 2020; 370 doi: (Published 22 September 2020) Cite this as: BMJ 2020;370:m3612
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

When I first read about plans to ask patients to book ahead at emergency departments, I assumed it was a joke: “Hello, 111—I’m thinking of breaking my arm next Tuesday. Can I book an appointment for 2 45 pm?”

But it’s far from a joke. Patients who need to visit the emergency department will be encouraged to phone NHS 111, and the service will advise them when to go.1 Patients may also be advised to self-care or be given an appointment with their GP instead. As ridiculous as it sounds, the idea comes from a genuine attempt to reduce crowding in emergency departments during the second wave of the pandemic, although patients seemed to do this quite spontaneously during the first wave: emergency department attendance in April fell by 57%.2

The appointments system is currently being piloted in London, Plymouth, and Cornwall, ahead of a scheduled national rollout by the end of the year. Our local trust has named 31 October as the starting date, but I can’t find any results or analysis of those three pilot schemes—which slightly calls into question their purpose, if implementation is going to happen regardless.

We’ve been reassured that patients without an appointment won’t be turned away. This is a relief, as the headline news summons images of patients quietly exsanguinating outside the emergency department door as they attempt to phone and navigate the 111 triage system. Many features, however, do ring alarm bells. One is the capacity of NHS 111, which employs non-clinically trained call handlers working from algorithms to reach a decision about where a patient should be seen. My current registrar, fresh from six months in the emergency department, is quite certain that the number of people sent there inappropriately by NHS 111 exceeded the number of ill judged self-referrals.

As GPs, we’re instructed to provide appointment slots for the patients NHS 111 doesn’t deem appropriate for the emergency department. Those slots are already on our systems, having been created for the pandemic, but I think many GPs will be unhappy at this sudden repurposing without negotiation.

And what about the patients? If they know they won’t be turned away, they may just ignore the system: people don’t go to the emergency department for fun—they go only if they’re seriously worried, so they’re unlikely to make a phone call first. Others may be put off from seeking help altogether, leading to further avoidable mortality, as happened at the height of the first wave.3 A few patients may game the system: facing a week’s wait (or two or three) for a GP appointment, they may use NHS 111 to try to bag an earlier slot.

I hope I’m wrong, but I fear that this system may result in a further unresourced transfer of work into primary care. It may also be yet another barrier to care for our least advantaged patients, including those who are unconfident about speaking English or have no phone credit.