Analysis

How effective is the NHS 111 service?

NHS 111, the front door to the urgent care system, handles millions of calls a year, but some question its usefulness
Illustration shows a red telephone with overlapping images of the handset to show it is ringing. NHS 111, the front door to the urgent care system, handles millions of calls a year but some question its usefulness.

NHS 111, the front door to the urgent care system, handles millions of calls a year, but some question its usefulness

  • Some feel NHS 111 sends too many to emergency departments (EDs)
  • NHS England says many more would seek ED help if NHS 111 was not there
  • Integration with clinical services means there is input from clinicians

The NHS telephone health advice service NHS 111 handled more than 15 million calls in England in 2019 and that number could increase this year as people seek advice about coronavirus (COVID-19).

It has existed in its current form since 2014, delivered by 20 separate providers, from ambulance

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NHS 111, the front door to the urgent care system, handles millions of calls a year, but some question its usefulness

  • Some feel NHS 111 sends too many to emergency departments (EDs)
  • NHS England says many more would seek ED help if NHS 111 was not there
  • Integration with clinical services means there is input from clinicians
Illustration shows a red telephone with overlapping images of the handset to show it is ringing. NHS 111, the front door to the urgent care system, handles millions of calls a year but some question its usefulness.
Picture: iStock

The NHS telephone health advice service NHS 111 handled more than 15 million calls in England in 2019 and that number could increase this year as people seek advice about coronavirus (COVID-19).

It has existed in its current form since 2014, delivered by 20 separate providers, from ambulance trusts to social enterprises and large private health firms.

Most incorporate out-of-hours GP services and can book appointments at urgent care centres, while some have links with other local services, such as mental health.

NHS 111 website supports another million a year

The NHS 111 website, launched at the end of 2017, also provides support to almost 1 million people a year.

15.5 million

calls to NHS 111 in 2019-20

Source: NHS England

NHS England refers to NHS 111 as the ‘front door’ to the urgent care system. But some emergency care staff question its usefulness.

Analysis published by NHS Digital has shed light on the effectiveness and impact of NHS 111 in England.

Researchers were able to follow what happened to patients who were referred to emergency departments (EDs) in 2018 by using individual patient NHS numbers.

Close to one in ten callers who were triaged were advised to go to EDs, and 72% did so within 48 hours. That equates to around 1 million ED visits a year coming from NHS 111. But of those who went to a type one unit – the overwhelming majority – only 13% were deemed ill enough to require admission.

Picture of RCN Emergency Care Association chair David Smith. NHS 111, the front door to the urgent care system, handles millions of calls a year but there is disagreement about its usefulness.
David Smith

That is much lower than the overall average admission rate, suggesting many patients directed to EDs by NHS 111 do not need to go.

RCN Emergency Care Association chair David Smith says ED staff are feeling the effect of this, although he has sympathy for the NHS 111 service.

Key question is whether NHS 111 is too cautious

‘Like the rest of the system, NHS 111 is seeing increases in demand. It’s making it difficult for everyone, but as a direct result we are feeling there’s an increase in patients to our EDs.’

He says it is understandable that the service will ‘err on the side of caution’ given the nature of the system – non-clinical call handlers using an algorithm-based software called NHS Pathways to triage calls.

The key question, says University of Oxford professor in medical sociology Catherine Pope, who has carried out research into the effectiveness of NHS 111, is whether it is too cautious.

‘You need to set a risk level that will catch as many serious cases as possible. Chest pain might be indigestion or it might be a heart attack.’

But Professor Pope says just because patients are not admitted it does not necessarily mean that going to an ED is a mistake.

Picture of Professor Catherine Pope of Oxford University, who has researched the effectiveness of NHS 111. The service, the front door to the urgent care system, handles millions of calls a year but there is disagreement about its usefulness.
Catherine Pope

‘There’s an interesting conundrum about people who attend ED and are not admitted.

‘Some commentators see these as inappropriate attenders. But our research suggests there may be some value in ruling out possibly serious conditions and this may not be possible over the phone.

NHS England has addressed some of the criticism

‘In addition, sometimes people are given advice that could help them manage symptoms better or differently next time.’

NHS England looks at it in another way, arguing that if NHS 111 was not there many more would seek ED help. An analysis it released last year suggested journeys to ED could be two to three times higher than they are.

It has also taken steps to address some of the criticism.

Mental health nurses working alongside call handlers

Mental health nurses were brought in to work alongside the NHS 111 services across Hampshire and the Isle of Wight at the end of 2018 in a pilot project.

The NHS 111 call handlers transfer patients through to the nurses if they are experiencing mental health problems.

The partnership arrangement between South Central Ambulance Service, which runs the NHS 111 service, and Southern Health NHS Foundation Trust, which supplies the nurses, has proved to be such a success that it has now been made permanent and the team of nurses increased from six to 12.

During 2019, the nurses dealt with 11,500 patients. Seven in ten did not need to be referred on elsewhere following the call, and ED referrals have been reduced by 75%.

Mental health commissioning manager Sonya McLean says: ‘Because of their expertise, the nurses can deal with a lot of the calls themselves and that has reduced the need to refer people on not only to EDs, but also primary care and to 999.

‘Where needed, the nurses can arrange for the patient to be seen by the community crisis team or the hospital psychiatric liaison service. Records can be shared, which is better for the patient as they don’t have to keep repeating their story.’

1 in 2

calls that are triaged receive input from a clinician

Source: NHS England

The proportion of calls triaged by NHS 111 that are input from a clinician now amount to over half, up from around one third in 2017.

Meanwhile, a move to incorporate NHS 111 with other services has created a more integrated system for patients.

Scope for integration with local health systems varies

This approach – called integrated urgent care clinical assessment services – was set out in detailed guidance published in 2017.

Individual NHS 111 services were given until last year to put it into place. A key requirement was to ensure face-to-face appointments could be booked.

Picture shows an older woman looking at a mobile phone and pressing the keypad. NHS 111, the front door to the urgent care system, handles millions of calls a year but some question its usefulness.
Picture: Alamy

This has been achieved by NHS 111 services linking with urgent treatment centres locally.

But the fragmented nature of the service – the 20 individual providers deliver services across 39 separate service areas – means the scale of further integration that would be possible with local health systems varies greatly. In Wales and Scotland there is one NHS 111 service for each nation, so integration has proved easier.

Different providers have encouraged innovation, although variation is inevitable

In England many services, but not all, are integrated with out-of-hours GP services, while some are able to book appointments with local GPs or direct into mental health services.

 1 in 10

calls that are triaged are referred on to emergency departments

Source: NHS England

Some call centres have 999 and NHS 111 teams at the same location, while others have brought in mental health experts to sit alongside the NHS 111 advisers.

RCN expert representative for liaison psychiatry Sarah Eales says having different providers has encouraged innovation, although it means some variability is inevitable. But she says the bottom line in terms of reducing referrals on to EDs is whether there are community services available.

‘Some people will need face-to-face support, and if there are not good local services available – and that is the same for other services, not just mental health – people will continue to go to EDs. It’s the place people know and trust.’

Quick assessment for vulnerable groups

Out-of-hours service Devon Doctors runs two NHS 111 services, covering Devon and Somerset. It has integrated its services with the out-of-hours GP provision.

Faced with rising demand during the winter of 2018-19, the social enterprise introduced a new streaming system in Somerset, which has led to calls involving under ones and over 75s being automatically passed on to clinicians. It means clinical assessments for these groups start within three minutes.

The move has helped to reduce the number of ambulances dispatched from 18% of cases involving these patients to below 7%.

The initiative has also enabled the service to ensure calls are answered quickly, as advisers are freed up sooner. The service is now looking to extend the new approach.


Nick Evans is a health journalist


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