Before NHS 111 First is rolled out nationally, we need data from more extensive and longer term pilots, say Simon Hodes and Neena Jha

Our medical advent calendars this year are a little different—1 December 2020 marked the start of the little advertised NHS 111 First scheme. [1] As the name implies, this is an initiative which requires all patients who do not have life threatening emergencies to call NHS 111 First for assessment before attending emergency departments or urgent care centres. [2] 

Limiting the spread of covid-19 by attempting to offer an appointments-based system while reducing overcrowding in emergency departments is a good idea to keep both patients and staff as safe as possible. In theory, NHS 111 First will be able to triage a medical problem by phone, give advice as needed to avoid unnecessary escalation, direct patients to the most appropriate service (including the ability to book them a same-day appointment with their own GP practice) or book a slot in a local emergency unit allowing people to wait safely at home until their allotted appointment time. By redirecting patients to more clinically appropriate services, it should be possible to reduce demand on emergency departments. [3]

This new “call-before-you-walk” service has the ability to offer people direct appointments online, with a variety of health services, including urgent treatment centres, a patient’s GP, specialised mental health crisis services, dental services, and pharmacists for urgent repeat prescriptions and advice. If needed, an ambulance can also be dispatched. [4] The service is run by a combination of call handlers and clinicians—nurses, doctors, pharmacists and paramedics—who take over half the calls. [5]

The pandemic caused a huge surge in demand for NHS 111, which resulted in callers waiting longer and, not surprisingly, an increasing number of calls being abandoned due to people having to wait longer than 30 seconds. [6] Many clinicians are concerned about the potential impact of the changes planned with the new service and would like to see robust data before a major health policy is rolled out nationally. However, there is very little information about the pilot scheme openly available.

Like any new system, it is imperative that the NHS 111 First service is straightforward to use for all patients. As a “secret shopper” accessing the new system online and picking an example symptom (abdominal pain), there were 34 pages to click through before reaching the advice page. Each page has multiple choice, tick-box questions. The scope for error seems significant, particularly for patients where there is a language barrier, or who are unwell or less comfortable using technology. This may increase health inequalities further, a major risk factor already exposed by covid-19. [7]

How well has this new service been advertised and communicated to the public? There have been significant concerns about clear communication throughout the pandemic, and patients have struggled with the many changes already imposed by covid-19. This has resulted in hostile reporting by some media and abuse towards medical staff from patients. [8, 9] If patients arrive at an emergency department with something regarded as a “non-threatening emergency” and are told to leave and call 111, only to be sent back in again after a prolonged conversation or wait, how will they respond? Access to the NHS should be fair and equal, and there is a risk that this could be compromised.

The overarching concern expressed by healthcare professionals about NHS 111 First is patient safety. Triaging patients takes time, can add unnecessary delays, is complex, and is not without medical risk. Clinical risk increases when triage does not happen face to face. When directing patients to different services, there must be an understanding by call handlers of what those services entail. 

There are no set entry requirements to become an emergency medical dispatcher or call handler. All trusts require applicants to be aged 18 or over, and most require a GCSE in Maths and English at Grade C/4 level or above. [10] Given the limited healthcare experience of call handlers it is imperative that the algorithm is risk-averse, which in itself may lead to increased attendances.

While the possible advantages of NHS 111 First are clear—by hopefully reducing the number of people in emergency departments, shortening queues by offering appointments, directing patients to the most appropriate service, and preventing the spread of covid-19—there is still very little data from the initial pilots. Given the scrutiny a new NHS guideline or medication must comply with, it is hard to understand how NHS 111 First can be confidently and safely rolled out without significantly more knowledge.

We remain concerned about the potential risks to patients who may be put off attending services altogether or may be delayed due to a triage-first approach, especially if there are long waiting times for calls to be answered. Non-medical call handlers using algorithms could lengthen call waiting times, may cause an avoidable escalation of care and, conversely, increase attendances in emergency departments and primary care, but without these services receiving adequate investment or increased resource. 

We can see the potential advantages and wish NHS 111 First every success, but before it is rolled out nationally in the midst of a pandemic we hope that all factors will be studied carefully, ideally through more extensive and longer term pilots including patient consultations.

See also: Helen Salisbury: Plan your emergency

Simon Hodes has worked as a GP partner in the same Watford practice since 2001, and is also a GP trainer, appraiser and LMC rep. The views expressed above are his own. Twitter: @DrSimonHodes

Neena Jha is a salaried GP in Hertfordshire with an interest in emergency care and global child heath. The views expressed above are her own. Twitter: @DrNeenaJha

Competing interests: None declared

References:

1. https://www.england.nhs.uk/urgent-emergency-care/nhs-111/next-steps-for-nhs-111/
2. https://www.pulsetoday.co.uk/news/urgent-care/nhs-england-aiming-to-roll-out-111-first-ae-model-nationally-by-winter/
3. https://www.rcem.ac.uk/docs/Policy/NHS111_FAQs_October_2020.pdf
4. https://www.imperial.nhs.uk/about-us/news/imperial-college-healthcare-joins-nhs-111-first-service
5. https://www.england.nhs.uk/urgent-emergency-care/nhs-111/accessing-nhs-111/
6. https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2020/04/NHS-111-MDS-April-2020-Statistical-Note.pdf
7. https://www.bmj.com/content/371/bmj.m4134 Covid-19: Tackling health inequalities is more urgent than ever, says new alliance
8. https://www.bmj.com/content/371/bmj.m3986 David Oliver: How not to do covid-19 comms—copy our government
9. https://blogs.bmj.com/bmj/2020/11/04/abuse-against-doctors-must-not-be-tolerated/ Abuse against doctors must not be tolerated
10. https://www.healthcareers.nhs.uk/explore-roles/ambulance-service-team/roles-ambulance-service/emergency-medical-dispatchercall-handler/entry-requirements-call-handleremergency-medical