NHS 111 pilot scheme 'had teething problems'

"NHS 111 helpline adds to pressure on A&E, according to study," The Guardian reports after a study has suggested that the new NHS 111 helpline needs further work to improve its effectiveness.

The large study looked at government figures for the use of NHS emergency services before and after the NHS 111 helpline was introduced in 2010.

The NHS 111 helpline is designed to deal with urgent but non-life-threatening situations. It was introduced in a number of regions as a pilot scheme before being rolled out across England in 2013.

The study found that ambulance attendances increased by 2.9% in pilot areas with the NHS 111 helpline. However, there was no statistically different change in emergency department attendance, emergency ambulance calls or urgent care (GP out-of-hours, walk-in and urgent care centres) compared with similar areas that did not have the helpline.

The increase in ambulance attendances is of potential concern. As a recent report about recommendations in emergency care pointed out, many people who access emergency care don't actually need it.

Where did the story come from?

The study was carried out by researchers from the University of Sheffield and was funded by the Department of Health.

It was published in the peer-reviewed medical journal BMJ Open. Articles from the journal are available on an open access basis from the BMJ Open website.

The study's figures were reported reasonably by the media, with responses from the Department of Health included in the articles.

However, they all assumed that the increase in ambulance use was inappropriate, but the study did not measure or assess the impact of NHS 111 on health outcomes.

Some of the reporting also did not make clear that this study was an analysis of the 111 helpline when it was initially being rolled out in a series of pilot schemes, a time when teething problems could be expected. 

What kind of research was this?

This was a study designed to determine the impact of the NHS 111 telephone service on a range of NHS services, particularly the emergency and urgent care system.

It is arguably difficult to assess the impact of NHS 111 using this sort of study design, as there could have been other events or changes that affected emergency and urgent care use.

What did the research involve?

The researchers compared the use of NHS services in four pilot geographical areas before and after they implemented the new NHS 111 service, and compared them to three control areas that did not have the service.

These areas were matched by 18 criteria, including population demographics, lifestyle, health profile and health service use.

The four geographical areas chosen and population covered were:

• Durham and Darlington – 606,000
• Nottingham – 300,000
• Luton – 200,000
• Lincolnshire – 700,000

The three areas that did not plan to implement NHS 111 chosen as the closest match were:

• North of Tyne – 780,000 (match for Durham and Darlington)
• Leicester – 280,000 (match for Nottingham and Luton)
• Norfolk – 740,000 (match for Lincolnshire)

The researchers looked at data for the first 12 months of NHS 111, which commenced during 2010, and the preceding 24 months. Available data included:

• ambulance calls (calls to the ambulance service)
• ambulance incidents (an ambulance is sent and arrives at the scene of an emergency incident)
• emergency department attendance
• urgent care (GP out-of-hours, walk-in and urgent care centres) 
• NHS Direct calls

They also collected details of any other changes to the emergency and urgent care services during the 36 months that could account for any differences found.

The statistical analysis accounted for any seasonal change in rate of service use. They also estimated what the effect would have been if all NHS Direct and GP out-of hours calls had gone to NHS 111 first, as this is the intention for the service in the future.

What were the basic results?

Following the introduction of NHS 111, in individual pilot sites there was a statistically significant:

• reduction in urgent care attendances in one site
• reduction in calls to NHS Direct in three sites
• reduction in ambulance emergency calls in one site and increase in one site
• increase in ambulance incidents in one site

For all sites combined, compared with sites without the service, there was:

• a large and statistically significant reduction in calls to NHS Direct of 19.3% (confidence interval [CI] -24.6% to -14.0%) per month
• a small, statistically significant increase in the number of ambulance incidents of 2.9% (CI 1.0% to 4.8%)
• no change in emergency ambulance calls or emergency department attendances or urgent care use

How did the researchers interpret the results?

The researchers concluded that, "There was no evidence that NHS 111 changed use of most of the emergency and urgent care services it was possible to measure.

"There was a large reduction in use of NHS Direct as calls transferred to NHS 111, but an increase in numbers of emergency ambulances sent to patients, and there is potential that overall demand for services across the emergency and urgent care system could increase." 

Conclusion

This large study provides information on the use of NHS emergency services before and after the implementation of the NHS 111 service. The study's strengths include the large population base of 3.6 million and good attempts to match the control sites to the NHS 111 sites. Limitations include the fact that this study did not assess the impact on health or the outcomes of any of the calls.

In addition, it is difficult to assess the effect of NHS 111 using this sort of study design. The researchers point out that they identified 13 other changes made during the study period that may have affected the results. They were also unable to assess the impact of NHS 111 on GPs.

The increase in emergency ambulance incidents was statistically significant for one of the four pilot sites, and 2.9% higher than in the control sites when all the results were combined. Though this equates to a greater demand on the service, it does not tell us whether the increase in the number of emergency ambulances was appropriate or saved lives.

The NHS 111 service is still at an early stage and it is likely that its form and functions will evolve over time. Claims that it is "doing more harm than good" are perhaps a little unfair.