NHS 111 increases ambulance and urgent and emergency care use

Research from the University of Sheffield has shown that the NHS 111 service has not reduced pressure on ambulance and emergency services during the first year of operation, as intended.

The report, conducted by researchers from the University's School of Health and Related Research (ScHARR) and published in the British Medical Journal Open, found that the call handling service increased the use of ambulance and urgent and emergency care services during its first year of operation.

NHS 111This is despite the fact that NHS 111 was set up with the intention of relieving pressure on these services by ensuring that patients are directed to care that is appropriate for their level of need.

The team, led by Janette Turner and Professor Alicia O’Cathain from the Medical Care Research Unit, was commissioned by the Department of Health in England to evaluate the use and impact of NHS 111, a new 24/7 telephone service for non-emergency healthcare problems, which was rolled out nationwide in March-April this year.

The service is staffed by trained call handlers, who are not clinicians, but who have back-up from nurse advisors. They triage calls to other services or home care, using an algorithm based assessment system, NHS Pathways.

The researchers analysed 36 months of routine data—to include the first year that NHS 111 was up and running (2010-11), and the two years before it started (2008-10)—in the four pilot sites, and in three comparable sites, covering a total population of 3.6 million.

The routine data analysed covered the use of emergency ambulance calls and incidents; attendances at emergency care departments; contacts with urgent care services; and calls to the telephone triage service NHS Direct.

During its first year of operation at the four pilot sites, over 400,000 calls were made to NHS 111, just over 277,000 of which were triaged using NHS Pathways.

Of the triaged calls, 28 per cent were referred to a nurse for clinical advice. Quality standards were met in all four services.

The number of calls to NHS Direct fell by almost 20 per cent during the study period, which is not unexpected, says lead author Janette Turner, in an accompanying podcast, as NHS 111 is intended to replace this service.

But compared with the three other sites, NHS 111 did not reduce the overall number of emergency ambulance calls or attendances at emergency departments at the four pilot sites during the study period.

And contrary to expectations, NHS 111 did not reduce emergency ambulance incidents, which rose by just under three per cent—equivalent to an extra 24 incidents per 1000 triaged calls, each month. The authors estimate that this could translate into an additional 14,500 call-outs for an ambulance service attending 500,000 incidents a year.

Nor did it curb overall emergency and urgent care activity, which rose by between five-12 per cent, per month at each site.

The report highlights that a triage system designed to be used by handlers without clinical expertise will inevitably err on the side of caution and might offer less flexibility than one designed for clinicians.

Janette Turner said the findings raise other key questions, including the potential increase in volume of callers prompted by the planned closure of NHS Direct, and therefore the service’s sustainability, and whether NHS 111 is actually creating rather than curbing demand.

She said: “It is probably unrealistic to expect any one service, such as NHS 111, to do everything, and real improvements in how the emergency and urgent care system is used may only be gained when a series of coordinated measures designed to increase efficiency across all services are implemented.

"The provision of a single point of telephone service that quickly guides people needing urgent care advice to the most appropriate service is sensible, given the public’s confusion about which service to access.

"NHS 111 also offers an easily remembered number, with an emphasis on fast triage and smooth transfer to ‘the right service first time,’ all of which patient's say they want."

Additional information

For more information about the School of Health and Related Research visit http://www.shef.ac.uk/scharr

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