Impact of the urgent care telephone service NHS 111 pilot sites: a controlled before and after study

Abstract

ObjectivesTo measure the impact of the urgent care telephone service NHS 111 on the emergency and urgent care system.DesignControlled before and after study using routine data.SettingFour pilot sites and three control sites covering a total population of 3.6 million in England, UK.Participants and dataRoutine data on 36 months of use of emergency ambulance service calls and incidents, emergency department attendances, urgent care contacts (general practice (GP) out of hours, walk in and urgent care centres) and calls to the telephone triage service NHS direct.InterventionNHS 111, a new 24 h 7 day a week telephone service for non-emergency health problems, operated by trained non-clinical call handlers with clinical support from nurse advisors, using NHS Pathways software to triage calls to different services and home care.Main outcomesChanges in use of emergency and urgent care services.ResultsNHS 111 triaged 277 163 calls in the first year of operation for a population of 1.8 million. There was no change overall in emergency ambulance calls, emergency department attendances or urgent care use. There was a 19.3% reduction in calls to NHS Direct (95% CI −24.6% to −14.0%) and a 2.9% increase in emergency ambulance incidents (95% CI 1.0% to 4.8%). There was an increase in activity overall in the emergency and urgent care system in each site ranging 4.7–12%/month and this remained when assuming that NHS 111 will eventually take all NHS Direct and GP out of hours calls.ConclusionsIn its first year of operation in four pilot sites NHS 111 did not deliver the expected system benefits of reducing calls to the 999 ambulance service or shifting patients to urgent rather than emergency care. There is potential that this type of service increases overall demand for urgent care.

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

“…With the exception of one US study 109 that assessed impact on both ED attendances and primary care activity, only the UK-based studies of NHS Direct 66 and NHS 111 105 have attempted to assess the impact of telephone services on multiple services within the emergency and urgent care system. Whole-system impact is a key outcome if one objective of telephone-based services is to contribute to improving system efficiency.…”

“…114 The evaluation of NHS 111 pilot sites found no impact on attendances at EDs and contacts with urgent primary care services but a statistically significant increase in ambulance incidents. 105 Five studies found that the introduction of a telephone advice service for low-urgency ambulance service patients resulted in fewer ambulance responses being required. 99,[101][102][103]112 However, some studies reported high call-return rates, where calls are passed back for an ambulance response, or that not as many calls as expected could be resolved by telephone.…”

“…The 330 cases triaged by a nurse or paramedic as not requiring an emergency ambulance were less likely to attend ED, but 9% of these patients were admitted to a hospital bed. The only included study of a service using non-clinical call handlers supported by clinicians was the evaluation of NHS 111 pilot sites, 105 but no comparison was made of decision-making by non-clinical call handlers and clinicians.…”

“…Seventeen studies reported impacts on their own service or other services, either from increased or reduced service use and or increased or reduced staff workload [68][69][70]86,95,98,99,[101][102][103]105,109,112,114,122,126,134 One study found that NHS Direct referred a higher proportion of patients to other services when compared with general practice. 134 A RCT by Lattimer et al 68 reported a 38% reduction in primary care appointments and a 23% reduction in home visits, whereas another study reported no change in primary care appointments but home visits reduced by 18%.…”

“…The early evaluation of pilot sites did show an increase in ambulance incidents after the introduction of NHS 111 (the reasons for which remain unexplained), but not ED attendances. 105 More detailed evaluation of the accuracy and appropriateness of call assessment decisions would answer some of these questions and identify where there is scope to improve it, either through changing the staffing profile or modifying the clinical assessment system.…”