The NHS 111 telephone service was designed to direct people to the right help for urgent medical problems but has faced a barrage of criticism since it was implemented in April. The most recent blow was the withdrawal of one of the main private providers of the service.
Some of these problems might have been avoided - or anticipated - had the government waited for the results of an evaluation of four NHS111 pilots that began in 2010. Instead, the 24/7 service was rolled out nationally before this was completed.
Setting up the service
NHS111 was developed in response to a review that showed that people were confused about where to seek urgent care. The aim was to direct people to the most appropriate level of care and relieve some of the burden on emergency services by providing a free, memorable telephone number – 111 - that would also improve the experience of users.
All NHS111 calls are answered by trained non-clinical call handlers who do an initial assessment. If someone needs to be assessed by a nurse, this should be done during the same call.
The call handling system is also linked to an electronic directory of local services so that callers can be directed to appropriate services in their area. There are direct links to other services so if someone needs out-of-hours care that would normally be done by a GP or an ambulance they should also be able to do this through NHS111 without having to make another call.
While England adopted NHS111, the same system as its predecessor, NHS Direct, is still used in Wales and Scotland (NHS Direct Wales and NHS24). These services were primarily set up as advice lines although they now also handle some - and in the case of NHS24 all - calls for out-of-hours urgent GP care. More calls to NHS Direct services are also assessed by nurses although people may have to wait for the nurse to call them back.
Findings from the pilots
Set up of NHS 111 began in 2009 when four pilot sites were chosen to test the new service. At the same time the Medical Care Research Unit at Sheffield University was commissioned to conduct an evaluation of the impact on users, the rest of the emergency care system and associated costs that would provide evidence to inform future decisions.
In May 2010 there was a change of government and they set a deadline of 1st April 2013 for a national rollout, although this was later extended by six months. The four pilot sites went live in the autumn of 2010 and we evaluated them after their first year of operation. Our final report was published in the autumn of 2012. This meant that health services had already started the process of developing NHS111 for their local areas ahead of any findings from our evaluation.
Our evaluation found a high level of user satisfaction and a call handling service that exceeded national quality standards in pilot areas but a higher overall use of emergency and urgent care services and an increase in use of emergency ambulances rather than the decrease expected.
During the pilot phase NHS Direct was still also operating, so the two services were running alongside each other. We cautioned that the full impact of moving NHS Direct calls to NHS111 was unknown. However, by this time there was little opportunity for commissioners and providers to learn from the lessons of the pilots.
By the end on 2012 there were 14 NHS111 services operating that had managed 1.6m calls with no apparent problems or adverse publicity.
But major problems started during the later launches close to the original April deadline with many reports of calls left unanswered, systems failing and callers waiting for long periods for clinician call backs - although this was not true of all services. This led to an inquiry by NHS England and a parliamentary Health Select Committee session, which concluded “the national deployment for NHS 111 was undertaken prematurely and without a sufficiently sound evidence base”.
Our experience and evaluation of the pilot sites gives us a few insights into possible causes of current problems with NHS111: a period of testing the full impact of moving NHS Direct calls to NHS111 would have been helpful; the complex procurement systems meant there was little time to develop and test new NHS111 services; more work was needed to minimise the effect of NHS111 on ambulance services; and there wasn’t enough time to train new non-clinical call handlers in some areas to a high standard.
As with any new service, the introduction of NHS111 may also have created new demand.
The saga of the implementation of NHS111 is a salutatory lesson in ignoring the basic principles of providing care on the basis of sound evidence rather than political expediency and highlights the need to fully test, learn from and review pilot schemes, and then give sufficient time for further development before instigating wholesale change.