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‘Risk-averse’ 111 service sending more callers to struggling A&E and ambulances

NHS 111 is sending growing numbers of callers to A&E or ambulances because the service can be too risk-averse to deal with illnesses, which health leaders believe can be contributing to the mounting strain on emergency services nationwide.

A Nuffield Trust investigation found that the proportion of 111 callers being dispatched to emergency services has risen over the last three years, particularly with regards to people being passed to ambulances.

There is also a lot of variability between areas in how likely the call service is to send people to A&E or the ambulance service, which suggests some areas are too likely, or even not likely enough, to send people to emergency services, the think tank found.

“NHS 111 is also more likely to dispatch an ambulance than to simply send people to A&E – which is the reverse of the usual pattern of NHS use,” its briefing added. “This lends credence to claims that the service is too risk-averse in some cases.”

The 24/7 helpline, which replaced NHS Direct after being piloted in 2011 and firmly established in 2013 “following a chaotic and patchy roll-out”, has been handling more than twice as many callers each month than its predecessor.

NHS England figures also show that the target of answering 95% of calls within 60 seconds hasn’t been met since the summer of 2014, which the Nuffield Trust argued was another case of a target being “a long way off”.

Former care minister and Liberal Democrat health spokesperson Norman Lamb argued these numbers are “yet another sign of the unbearable pressure our health system is under”, adding that it also “appears the overly cautious algorithm used by 111 call handlers is increasing pressure on already overstretched ambulance services and A&E”.

The think tank said there is indeed an element of truth to this criticism, which was also echoed by shadow health secretary Jonathan Ashworth. While primary care is the main destination for 111 callers – in fact, it has largely “soaked up the spikes of demand” that occurred in the winters of 2014-15 and 2015-16 – the numbers of people sent from 111 to emergency services have increased from around 150,000 to “well over” 200,000 a month.

While the main reason for this is that there are simply more callers, the Nuffield Trust did find that a higher proportion of people were being sent to emergency services. In its first years, around 18-19% of callers were dispatched to ambulances or A&Es; this has now risen to 20-22%. Ultimately, this means around 20,000 more people are being sent to emergency services a month than they would have been if NHS 111 stuck to its original pattern.

Variation is also significant: last year, 17% of north east callers were transferred to an ambulance, whilst only 8% of callers in South Essex were. While the make-up of callers may differ due to demographic reasons, it is still a “very high level” of variation.

“Another surprising fact is the consistently higher number of people sent to ambulance services compared to A&E. This is the opposite of what happens with patients in general, where far more people attend A&E than have an ambulance sent. It does lend some plausibility to the suggestion that NHS 111 is too risk-averse with people who have more urgent problems,” explained the briefing.

“Again, looking at the variability across areas deepens the mystery. The gap varies greatly across England. Two areas, south east and East London, reverse this pattern: they send more people to A&E than to ambulances. What are they doing differently, and is it something other areas should learn from?”

The benefits of NHS 111

But despite these criticisms, the think tank stated that overall, the 111 service in fact seems to steer people away from emergency services. Patient surveys have suggested that around eight million more people would have gone to A&E or ambulances over the last three years were it not for the helpline.

Other surveys carried out by NHS 111 have discovered that since the service went live in 2013, around 45% of callers say they would have gone to A&Es without the helpline. But once they call, only around 20% are dispatched to emergency services.

“Overall, it is hard to conclude based on the evidence we have that the call line acts to drive people to A&E and ambulance who otherwise would not have gone. This is the basis for criticism which counts the number of people sent by 111 as if they were simply added on to the normal number of attendances,” said the Nuffield Trust.

“In fact, it seems likely that many of those people would have come to A&E anyway, and indeed they would have been joined by even more if the helpline had not been serving as a filter.

“However, as Simon Stevens recently made clear in a speech to NHS England’s board, there is also plenty of room for improvement. The proportion of people being transferred to ambulances has crept up – despite patient surveys showing that callers themselves feel they are no more likely to need an ambulance than they used to be.

“And like staff across the NHS, the hard-pressed call handlers at 111 continue to see demand for their services rise relentlessly, and notional targets for performance drift ever further out of sight.”

Prof John Appleby, the think tank’s chief economist and director of research, added that the mixed picture and varying numbers identified by this analysis are also enough to warrant an investigation by NHS England or the Department of Health.

But an NHS England spokesman assured that the increased numbers of people referred to emergency care is proportionate to the higher number of callers, adding: “NHS 111 continues to do an important job helping patients to get the right care, at the right place and at the right time, and in protecting both A&E and ambulance services from unnecessary attendances and callouts.”

(Top image c. London Ambulance)