NHS Pathways Clinical Enquiries Management Process

The NHS Pathways telephone triage system is a clinical decision support system supporting the remote assessment of callers to Urgent and Emergency Services, such as NHS 111, 999 and Integrated Urgent Care Clinical Assessment Services (IUC CASs) through a variety of different products.

The system is also the foundation of the Streaming and Redirection Product, which assists the management of patients presenting to Urgent Care or Emergency Departments; the Senior Clinician Module (to be retired late 2021), the Pathways Clinical Consultation System (PaCCS) which supports clinicians giving remote advice; and NHS 111Online, an online self-assessment service. Further products may also be developed in time.

NHS Pathways is integrated into software systems used by clinical Providers who deliver urgent and emergency services. These services are commissioned by Clinical Commissioning Groups (CCGs) for their regions. Core Pathways is used by all 111 telephone service providers in England, and approximately half of England’s ambulance services.

It does not seek to diagnose patients but assesses symptoms to direct them to the most appropriate care setting for further assessment where required. The system is an interlinked series of algorithms, or pathways, that link questions and items of care advice leading to clinical endpoints or “dispositions”.

The system presents a series of questions to the non-clinical Health Advisor in order that the most appropriate clinical response or disposition may be determined based on the answers given. A disposition will specify the level of care and time frame that a patient needs. The system presents questions according to clinical hierarchy; meaning that life-threatening scenarios are enquired about early in the call, progressing through to less urgent symptoms.

NHS Pathways is developed and is maintained by a group of experienced NHS clinicians with an Urgent and Emergency Care background. All the NHS Pathways’ clinical team are registered, licensed practitioners.

The safety of the clinical triage process endpoints within NHS Pathways, is overseen by the National Clinical Assurance Group (NCAG). Members of the NCAG are senior clinicians representing all the relevant Colleges who provide independent oversight and scrutiny of the NHS Pathways’ clinical content.

NCAG membership includes representatives from the following organisations/groups:

• NHS England NHS 111 Clinical representative 
• Emergency Call Prioritisation Advisory Group (ECPAG) 
• Royal College of General Practitioners 
• Out of Hours representative
• NHSx Representative (Commissioner of NHS Pathways)
• Royal College of Paediatric and Child Health (RCPCH) 
• Royal College of Emergency Medicine (RCEM)
• Royal College of Nursing (RCN)
• Royal College of Obstetricians and Gynaecology 
• Royal College of Midwives
• Royal College of Physicians
• Royal Pharmaceutical Society of Great Britain
• Royal College of Surgeons
• Royal College of Surgeons Edinburgh
• Royal College of Psychiatrists
• British Dental Association
• National Ambulance Service Medical Directors (NASMED) 

Alongside this independent oversight, NHS Pathways ensures its clinical content and assessment protocols are concordant with the latest advice from respected bodies that provide evidence and guidance for medical practice in the UK.

This document explains in more detail what happens when providers who use NHS Pathways provide feedback and raise clinical enquiries.

Clinical providers of services using NHS Pathways (‘Providers’) must enter into a Licence Agreement with the Secretary of State for Health and Social Care. NHS Digital welcomes user feedback to improve the NHS Pathways clinical triage system, and the Licence Agreement details how clinical enquiries, sharing of information for learning, requests for change and Coroner’s referrals should be reported to NHS Digital via the NHS Pathways’ clinical enquiries log.

This captures details of any serious incidents, near misses, requests, suggestions for enhancements, or reports from Coroner’s inquests relevant to NHS Pathways that Providers are involved in or aware of.

Clinical enquiries can be logged, or feedback about NHS Pathways products can be given, by all Providers. These are recorded by Providers on the NHS Pathways clinical enquiries log and given a priority ranking by the Provider logging the information. All Providers have access to the log and can see all external issues raised. Only anonymised patient related information is added to the log.

All clinical enquiries logged by Providers are assigned a priority category by the Provider. This is then reviewed by NHS Pathways and, if there is a difference in the priority assigned, then NHS Pathways will inform the Provider and come to an agreement if necessary.

The clinical enquiry log summaries, and the assigned priority shown, reflect the final agreed priority level for an enquiry.

The priorities that are assigned by Providers are as identified in the table below:

A quorate group of NHS Pathways Clinicians will discuss each clinical enquiry. This group will include at least 2 Doctors and 2 Registered Nurses/Paramedics.

Clinical enquiries may be escalated to the National Clinical Assurance Group for approval to proceed with completing work, if required.

Responses to all enquiries may be:

• a one stage fix, issued to Providers as a release – which could be an urgent release in the case of a priority 1 incident
• an interim solution such as a workaround
• providing detail - in the case of a request for further information

Any interim solution will be followed up with a plan for permanent resolution in a specific release of updated clinical content. Any interim solution may be ‘tolerable risk’ until a permanent solution can be implemented.

If a need for change is identified, the NHS Pathways’ team undertake a clinical review.

This may include:

• analysis of NHS Pathways data and data available on the outcome of triages
• gathering available clinical evidence sourced via the NHS Pathways’ chartered librarian
• clinician research
• evidence from external clinical subject matter experts and/or representatives from relevant Royal Colleges or National Bodies
• patient or system user research.

The team also review the likely impact of any proposed solutions, for example the team consider:

• what impact will the proposed solution have on patient/user understanding
• what impact will there be on the length of the call
• what impact will there be on availability or waiting times for national services such as Emergency Ambulances, Emergency Departments and Primary Care services

The clinical enquiries log, including all NHS Pathways’ progress; responses; solutions and resolutions; and full rationales and timescales, is visible to and searchable by all Providers.

Once the agreed work has been completed, a process of checking will validate the work and the solution. These processes include logic checking, proof-reading, clinically checking and scenario testing of the solution work.

Following the checking process, the release is ready to be tested in a live environment. Live testing is undertaken by Early Adopter Providers. Once the Early Adopter period is successfully completed, the changes are deemed suitable for widespread use in the live environment. Training materials to support any new release of the system will be provided so that users can be updated on the changes made.