NHS 111 – can the ‘call first approach’ work effectively in uncertain times?

With the second wave of Covid-19 rapidly appearing, the role of NHS 111 in the management of the pandemic is under close scrutiny, and the service is currently very much in the media spotlight. Recently, an alarming article was published in The Guardian after an audit of NHS 111 calls relating to Covid-19, showed that over 60% of these calls were not handled safely in one clinical division (1). While details of this audit have not been made available, it hasn’t come as a surprise to the Covid-19 Bereaved Families for Justice UK group (2), some of whom believe that inadequate and inappropriate care advice by NHS 111 may have contributed to their relatives’ deaths.

Although the validity of these claims is not yet clear, there is additional urgency to clarify the adequacy of NHS 111, as the ‘NHS 111 first’ scheme is piloted in parts of England. This system proposes that all patients wishing to access emergency care (including the emergency department) should call NHS 111 first, which will make appointments with emergency departments on behalf of patients where necessary (or an alternative primary care appointment if deemed appropriate).

This scheme is not the first of its kind: a similar system already exists in some Scandinavian countries such as Denmark, with apparently satisfactory results (3, 4). Despite this, the decision to implement the call-first approach has been met with mixed responses, some deeply critical of the feasibility of such an approach in practice, as well as the potential for it to be a barrier to care for those most likely to need it (5).

The advisability of this scheme clearly depends on the effectiveness of NHS 111, which largely depends on non-clinical call handlers interpreting symptoms presented using an algorithm. The appropriateness of the algorithms and guidance that help call handlers determine their recommendations, and the ability of its call handlers to deliver that advice clearly and cogently, contribute to the effectiveness of the service. Critically, it also requires that the services it recommends (for example, out of hours GPs) are available when recommended, pointing to the necessity of close co-ordination between NHS 111 and these healthcare services.

However, there is a lack of research available on this critical matter. While questionnaire responses from patients are generally positive (6), beyond one recent study (7) there is little evidence regarding whether patients comply with NHS 111 advice, and whether NHS 111 advice is appropriate to manage callers’ care needs. ARC YH recently undertook an analysis to understand what happens next when patients call 111 and receive advice (8).

After looking into over 3 million NHS 111 calls and subsequent emergency department (ED) attendances made in the Yorkshire & Humber region between 2013-2017, we found that many patients do not comply with advice and many patients attend ED even when they are advised to self-care or see their GP (figure 1). Some key findings from this initial analysis include:

  • 88% of these patients required urgent care, and almost 40% subsequently admitted to hospital (figure 2).

  • Almost 10% of patients sent an ambulance or told to attend ED did not require urgent care.

This suggests that NHS 111 is not currently triaging to a high level of accuracy, and that patients frequently do not comply with the advice they receive.

Figure 1: This graph shows proportions of patients advised to seek different sources of care (blue), and later attending ED regardless of the advice given (orange, blue)

Figure 1: Proportions of patients advised to seek different sources of care (blue), and later attending ED regardless of the advice given (orange, blue)

Figure 2: This graph shows proportions of patients who attended ED, considered not to require urgent care (blue), and those admitted to hospital (orange).

Figure 2: Proportions of patients who attended ED, considered not to require urgent care (blue), and those admitted to hospital (orange).

These are interesting and important findings but there are further questions to answer. A pressing one is whether those patients who are told to see their GP have actually tried to do so and failed… We know, for example, that across the UK many patients find GP waiting times unacceptable (9), so patients may be giving up and turning to ED as an alternative. We also found in our analysis that in some circumstances patients are more likely to take advice from clinical staff – given that NHS 111 is largely staffed by non-clinical call handlers, there are questions around whether patients have trust in their decisions, or whether call handlers feel sufficiently qualified and confident to deal with patient queries. We plan to look into these and other questions in future research.

This blog was written by Dr Jen Lewis, Urgent and Emergency Care theme, Y&H ARC.


21 October 2020


References:
  1. Nurses barred from NHS 111 Covid clinical division after 60% of calls unsafe: The Guardian; 2020 [Accessed 8th October 2020]. Available from: https://www.theguardian.com/world/2020/oct/01/nurses-barred-from-nhs-111-covid-clinical-service-after-60-of-calls-unsafe.
  2. Covid Families for Justice 2020 [8th October 2020]. Available from: https://www.covidfamiliesforjustice.org/.
  3. Andersen MS, Johnsen SP, Hansen AE, Skjaerseth E, Hansen CM, Sørensen JN, et al. Preventable deaths following emergency medical dispatch–an audit study. Scandinavian journal of trauma, resuscitation and emergency medicine. 2014;22(1):74.
  4. Andersen MS, Johnsen SP, Sørensen JN, Jepsen SB, Hansen JB, Christensen EF. Implementing a nationwide criteria-based emergency medical dispatch system: a register-based follow-up study. Scandinavian journal of trauma, resuscitation and emergency medicine. 2013;21(1):53.
  5. Salisbury H. Helen Salisbury: Plan your emergency. BMJ. 2020;370:m3612.
  6. Pope C, Turnbull J, Jones J, Prichard J, Rowsell A, Halford S. Has the NHS 111 urgent care telephone service been a success? Case study and secondary data analysis in England. BMJ open. 2017;7(5):e014815.
  7. Egan M, Murar F, Lawrence J, Burd H. Identifying the predictors of avoidable emergency department attendance after contact with the NHS 111 phone service: analysis of 16.6 million calls to 111 in England in 2015–2017. BMJ open. 2020;10(3):e032043.
  8. Lewis J, O'Keefe C, Jacques R, Simpson R, Stone T, Mason S. NHS 111 calls and subsequent attendance at ED: analysis of routine linked urgent and emergency care data: HSR UK Conference; [July 2020]. Available from: https://www.youtube.com/watch?v=zdPmxQhPmKc.
  9. The King's Fund UK. Public satisfaction with the NHS and social care in 2019: Results from the British Social Attitudes survey [Accessed 8th October 2020]. Available from: https://www.kingsfund.org.uk/publications/public-satisfaction-nhs-social-care-2019.