NHS 111 sending increasing number of callers to A&E and ambulances

The NHS 111 telephone service in England is sending not just an increasing number, but also an increasing proportion, of the people who call it to A&E departments and to ambulances, new research by the Nuffield Trust health think-tank has revealed (see note 1).  However, there is a high level of variation in how likely callers in different parts of the country are to be sent to emergency services.

It’s a concern for the NHS that the proportion of callers sent to A&E and ambulances is growing all the time; but surveys of callers appear to show that even higher numbers would have opted for these emergency services if they hadn’t been able to ring 111.

John Appleby, Chief Economist and Director of Research, Nuffield Trust

The report (see note 2) draws on data on NHS 111 from NHS England’s weekly winter operational updates, published every year from 1st December to the end of February, as well as the monthly figures the NHS issues.  It  finds that over the three years the service has been up and running in England,  the number of people calling it who have either been advised to go to their local A&E unit, or been sent an ambulance, has increased from around 150,000 a month to over 200,000.  That is perhaps not surprising as the population grows and the service becomes better known – but crucially the proportion of callers sent to A&E and ambulances has also been rising, from around 18% – 19% in the early period of the service to around 20% – 22% now.  The researchers point out that although that doesn’t sound like a big difference, given the high volume of calls to the service, it translates into around an extra 20,000 people a month.

However, the researchers say that when the performance of 111 is compared with what people intended to do before they rang, a different picture emerges, appearing to indicate that the call line is reducing, rather than increasing, pressure on emergency services.  Surveys of its callers that 111 conducts from time to time specifically ask what people would have done had they not been able to call the service.  Since it went live, around 45% of those surveyed have said they would have gone to A&E or called an ambulance if they hadn’t been able to access 111, but call handlers only actually send around 20% of callers to these services.  On the other hand, just over a third of users surveyed say they would have gone to primary and community services such as their GP if 111 hadn’t existed – but 111 actually sends around 60% of callers to these services.   So the evidence appears to suggest that over the three years it has been in operation, NHS 111 has redirected a large number of people from emergency care to general practice.  

The NHS 111 telephone service replaced NHS Direct in 2013.  It is a call line that operates around the clock for people whose health needs are urgent but not life-threatening, and runs in parallel with the existing 999 ambulance service.  Most callers are dealt with by call handlers with no clinical background, but around a fifth are referred to nurses or paramedics.  The service has a range of options open to it, from despatching an ambulance or advising callers to go to A&E, to sending a GP or district nurse or advising people to see a pharmacist.  It suffered a patchy and chaotic rollout, and faced criticism after its inception that it was increasing pressure on A&E departments and Ambulance Trusts by sending too many callers to those services.  Conversely, there have also been cases highlighted of callers whose symptoms were not recognised as serious or even life-threatening by call handlers and advisers.   

In the second of their ‘Winter Insight’ series of briefings looking behind the numbers of winter pressures on the NHS, the Nuffield Trust’s researchers find that:

• The proportion of callers advised to attend A&E or for whom an ambulance is despatched has increased from around 18% – 19% to around 20% – 22% over the three years it has been in existence.  However, there is a high level of variation in these figures when we look across the 42 separate 111 services operating in England.  17% of all callers in North East England, for example, were transferred to an ambulance in 2016, but only 8% in South Essex – less than half the proportion.  Meanwhile, the percentage of people who were not recommended on to another service ranges from 8.45% in Hampshire and Portsmouth to 25% in inner North West London.
• The service still answers the vast majority of calls within a minute (an average of 87% this winter), and few people hang up after having to hold on for more than 30 seconds (an average of 2.5% this winter).  However, it has not met its target of answering 95% of calls within 60 seconds for two and a half years.
•  In particular, each Christmas and New Year since its inception, 111 has struggled to deliver the standards set for it (such as answering calls within 60 seconds, or minimising the number of people who hang up after 30 seconds) when hit by a combination of the higher call volumes it gets in winter, and the higher numbers it receives at weekends and on Bank Holidays.  This is despite the fact that these are very predictable patterns which the service ought to be able to anticipate.
• However, when compared with surveys asking callers what action they would have taken had they not been able to ring the service, 111 seems to do a good job at steering people whom they think don’t require it away from emergency care, with only around 20% of callers advised to go to A&E or sent an ambulance, compared with 45% who say they would have pursued those options had 111 not been available. 

Prof John Appleby, Nuffield Trust Chief Economist and Director of Research, commented: 

“Halfway through one of the toughest winters the NHS has endured in recent times, we wanted to see whether there was any truth in the assertion that referrals from NHS 111 may be contributing to the pressure on A&E departments and ambulance Trusts.  What we found was a bit of a mixed picture.  It’s a concern for the NHS that the proportion of callers sent to A&E and ambulances is growing all the time; but surveys of callers appear to show that even higher numbers would have opted for these emergency services if they hadn’t been able to ring 111.  What’s not clear is why different areas are sending such varying numbers of callers to ambulances and A&E, and it would be worth NHS England or the Department of Health investigating the reasons for this”.