Healthcare organisations throughout England collaborate to deliver NHS 111, which is a non-emergency clinical advice and triage service in England (Dayan, 2017; NHS Improvement, 2018). NHS 111 call handlers are non-clinical staff who use a triage software called NHS Pathways to determine the services and support required. Call handlers refer a large portion of callers (one-fifth) to clinicians working for NHS 111, such as paramedics, where cases are complex and require deeper investigation (Dayan, 2017).
NHS 111 supersedes NHS Direct. The transition was completed in 2013. However, Triggle (2013) reported there were inconsistencies in its rollout across different services and providers, which hindered its effectiveness. Between 2011 and 2013, a pilot study revealed that this led to fragmented and chaotic emergency service provision across England (Turner et al, 2012; Dayan, 2017).
When NHS 111 referrals are passed to the ambulance service, trusts cannot recategorise calls unless there is new information on the patient's clinical condition (NHS England, 2017). Therefore, it is imperative that the initial triage is accurate.
Studies have highlighted concern around patient safety (O'Cathain et al, 2014; Iacobucci, 2014; 2016; Mckew, 2017). No literature has investigated how paramedics view the NHS 111 service, or its impact on their workloads and the ambulance service.
Methodology
A qualitative research design was adopted, and seven frontline paramedics working within South Western Ambulance Service Foundation Trust (SWASFT) were recruited to the study. They met the inclusion criteria of: operational on a frontline vehicle; responding to both NHS 111 and 999 calls; employed by SWASFT; and working in the Bristol locality. Ethical approval was gained from both the University of Cumbria's ethics committee (where the author was completing his MSc dissertation from which this work derived) and SWASFT. Consent was also gained from participants. Data were collected using semi-structured interview questions. Interviews were electronically recorded, transcribed then thematically analysed (Braun and Clark, 2006).
Bias
The recruitment process was subject to selection bias, as the researcher was known to the local ambulance service and participants. The researcher was careful to minimise any social desirability bias in their interviews (Dodou and de Winter, 2014).
Results
Some of the main themes are explored below.
Advantages of NHS 111
All participants were asked what they thought the advantages of NHS 111 were. Even after interviewer probing, unanimously, this was the question that received the shortest answer. Two main themes emerged. These were: the service reduced demand on the 999 service; and that NHS 111 filled the gap for a necessary, non-emergency medical advice line including referral to non-emergency care pathways/providers.
Reduced demand on the 999 service
Four participants thought that NHS 111 reduced the number of calls that the emergency 999 service would receive, as it facilitated a non-emergency medical advice line. They argued that, if this service was unavailable, callers would either attend accident and emergency (A&E) themselves or ring 999 unnecessarily:
‘I think 111 has taken a lot of pressure off 999 … because people know to call 111 for advice.’ (Participant 5)
Access to care pathways
Four participants highlighted that NHS 111 offered signposting and referrals to various services:
‘They are good as a sort of filtration system for the non-life-threatening, non-ambulance sort of calls for people to be signposted to a doctor or a pharmacy.’ (Participant 3)
Disadvantages of NHS 111
Participants were asked about the disadvantages of the service, and most of them spoke at length about the problems they had experienced. Many themes emerged, most of which were connected. The main themes are discussed below.
Call-taker constraints
All participants acknowledged that the initial call takers are not clinicians and are limited in how much they can deviate from the call script. Participants raised concerns and linked this to generating inappropriate ambulance referrals among other problems. Participants thought that a lack of clinical knowledge was a barrier to choosing the most suitable triage pathway. They thought that a lack of common sense was present as well as a culture of risk aversion:
‘The call-takers are non-medical, which doesn't help. It's cheaper to put someone on the phone who's got no medical degree … run through some questions; the computer will then ping up a pathway and the person will just do it.’ (Participant 3)
Questioning
Many participants communicated that a lack of deeper, ‘off-script’ questioning on the original call meant calls lacked context which could have informed a more accurate triage:
‘I think their questioning is quite structured, strict … I appreciate that the initial call taker is not a clinician … But I think there needs to be more flexibility in their questioning … because if … somebody's had chest pain for 6 months, it doesn't necessarily warrant an ambulance. It could direct them down a path that's more appropriate for them.’ (Participant 5)
‘So, it's almost like they ask one question, jump to a huge conclusion, but there's no real sympathy for the middle ground and the consequences. The ambulance service is bearing the brunt of these consequences … I think it's just too easy for them to have us as their fall-back option.’ (Participant 2)
Five participants gave examples of how a lack of contextual questioning resulted in an inappropriate emergency ambulance referral:
‘We went to a lady of 60 and we were given it as “chest pain, unable to breathe”. the patient had drunk a class of water too quickly and got a bit of air stuck and was unable to burp.’ (Participant 5).
‘A lady, 25, scratched her knee on a nail… it was a scratch and that's all, but because her foot felt cold, that was an emergency?’ (Participant 6)
‘The last one I remember was she could see her veins, on her arm, “oh, yes, but I can't normally see my veins”. They sent an ambulance because it could have been blood poisoning or something.’ (Participant 7).
Refusal
Five participants expressed frustration and concern around being dispatched to patients who tell them that they did not want an ambulance and even specifically declining an ambulance referral:
‘A lot of patients say “oh sorry, I didn't want an ambulance I just wanted to speak to a cancer nurse or palliative care” … people almost embarrassed that we've been called and they've said to 111 “I don't want an ambulance”.’ (Participant 5)
Triage accuracy and call categorisation
The largest overarching theme identified, which was entwined throughout the results, was that of triage and categorisation inaccuracy. There was a wide perception that NHS 111 was too cautious and as a triage service failed to effectively and accurately triage patients, often resulting in unnecessary referrals:
‘Their questions … are too quick to jump to the worst possible suggestion of what might be wrong.’ (Participant 2)
‘Their triage system … is too risk-averse … when they're overprioritised and undertriaged and they're scoring higher than what they really are, they're going to get a response quicker when they don't necessarily need it…Is the patient completely alert? No. So that gets a Category 2 call. A lot of the time they're asleep or, it's the middle of the night. Well, of course they're not completely alert, because it's 3 o'clock in the morning… Especially with paediatrics..’ (Participant 3)
‘The whole premise of … right care, right time, right place, goes out the window with them [NHS 111].’ (Participant 7)
Impact of inaccurate triage
Six participants highlighted concerns over regularly attending NHS 111 calls that had been incorrectly referred, raising concerns over the impact on them, professionally and personally:
‘We're now doing a lot more primary and urgent care stuff … What I don't like doing is driving around, seeing people who I then just make a doctor's appointment for or just give them some advice … When you're doing that day in, day out … it just drains you, it gets you down and you just get fed up.‘ (Participant 3)
‘Constantly, I am worried my practice is slowly changing because I'm just being abused every day.’ (Participant 6)
‘You can become quite judgmental … you can then develop a bit of an attitude before you even walk in the door. If you think “oh, that's another 111 for somebody who's had chest pain for 6 months” … it can be quite a frustrating part of the job … I try not to let it show but sometimes it does … It's not the patient's fault. They called 111 for advice.’ (Participant 5)
A participant also highlighted the impact of inaccurate categorisation on the ambulance service and other patients waiting to be seen by an ambulance:
‘If the call's been categorised as a high priority, we're obviously getting diverted from other higher priority calls … If you do have that person who … stops breathing … I then can't go to that because I'm stuck on a [inappropriate] 111 call.’ (Participant 3)
Chest pain
Chest pain and associated problems with triage and categorisation were mentioned by every participant. When asked for examples of inappropriate referrals they had attended from NHS 111, chest pain was the most popular example. Some participants focused on patient age as a factor making it inappropriate while others linked this back to inadequate questioning:
‘If chest pain is mentioned, well, that must be cardiac … there's no deviation. They see chest pain; they cannot deviate from those two words.’ (Participant 6)
‘Your young people with chest pain, I don't think they're appropriate for us. I think they can be managed over the phone, especially if you can get a good history.‘ (Participant 3)
‘A lady had a termination at 16 weeks … Her breasts were hard because there was milk in them, they were very painful … But because she had chest pain … that was a cat-2 life-threatening emergency.‘ (Participant 6)
With inaccurate triage comes inaccurate advice for those patients. One participant highlighted this concern:
‘The fact that they advise to give young people with vague-sounding chest pain aspirin just in case it could be a cardiac-related problem, it's just bizarre! … The number of people under 30 I see being advised to take four 75 mg aspirin tablets is massive.‘ (Participant 1)
Increased demand
There was a perception by some that NHS 111 has increased demand on the ambulance service and that many of these referrals are unwarranted:
‘Just the obscene amount of workload they pass to the 999 system. Nine times out of 10, any call they pass to us is inappropriate. I think I've gone down the route a lot of saying it's negligent.’ (Participant 6)
‘So, weekdays, not as many 111 calls come to me … I think that's because the doctors are open … Weekday nights and weekends, I go to lots of 111 calls … Sometimes, when it's really busy, like on a Friday, Saturday night, I can just go to 111 calls only.‘ (Participant 3)
Liability and clinical risk
Every participant commented that fears over clinical risk and liability were barriers to accurate triage/categorisation and a disadvantage of NHS 111. A couple argued that NHS 111 was too risk-averse. Participants spoke about there being a higher risk with remote triage than with face-to-face assessment and therefore had a level of sympathy for the notion of sending an ambulance ‘to be on the safe side’:
‘Clinical risk, the little child that died in Cornwall, where 111 had failings. Clinical risk is enormous, isn't it? I think we do it as paramedics all the time, “well you know, it doesn't sit quite right so … better get it checked out”, when in reality most of these people would be quite fine … and I guess it just takes someone at some level to take that responsibility for clinical risk.‘ (Participant 1)
A participant gave an example of attending a patient who had already called NHS 111 ten times on one evening wanting someone to apply some cream to his body. These requests had been declined but, on the 11th call, he said he had chest pain:
‘Now either he's the unluckiest guy in the world and the odds were stacked against him and he just happened to get chest pain the 11th time he called … or he's playing the system. Their triage system, I think, is too risk-averse… it's very sensitive … I think this country is very risk-averse, and everyone's scared of getting sued and the tabloids love jumping on a … case that people have waited or people have died.’ (Participant 3)
One participant communicated a fear of personal liability when driving in emergency conditions to inappropriate referrals:
‘My biggest fear is driving to a job on emergency conditions when I know … it is not life-threatening. If I crash, kill someone or injure someone, the police will then scrutinise my actions because I know it wasn't an emergency, yet I've gone on blue lights because 111 have told me to [because of the high categorisation] … These blue lights are only meant to be used for life threatening.‘ (Participant 6)
Paramedic frustration
Paramedic frustration with NHS 111 was conveyed in all interviews. This focused around the disadvantages discussed in this section:
‘They are making the ambulance service's morale very low … I frequently, daily, hear someone moan about 111 … They make me want to question my job daily … I'm actively looking for other jobs and … education to leave this role because I'm tired of being used as a 111 doctor … I've got nothing good to say about 111.’ (Participant 6).
Three participants linked their frustration to the inappropriate referral of incidents and two identified how their attitude towards NHS 111 could affect their practice:
‘So, if you think “oh, that's another 111 for somebody who's had chest pain for 6 months”, you're then going to go in with that attitude, aren't you? … and I think that's unprofessional … I get my frustration out in the ambulance and then be completely open when I walk through the door.‘ (Participant 5)
‘Because it's just behaviour … You go to it all the time. You think, the next one's going to be rubbish.‘ (Participant 6)
One participant explained how their experience of NHS 111 had affected their mental health:
‘Rightly or wrongly, I take it home … it makes me very upset and very angry how abused I feel every day when I go to work … This year … work referred me to … counselling because I was getting so frustrated with 111.’ (Participant 6)
Possible improvements to NHS 111
Participants were asked what improvements could be made to NHS 111. This was an open question, allowing participants to suggest areas for development. Their suggestions, naturally, addressed many of the issues that were raised as disadvantages and all linked to ensuring that the service's triage and referral process was as accurate as possible.
More clinicians working for NHS 111
Six participants suggested that having more clinicians working within NHS 111 centres would help improve the service, by increasing triage accuracy, reducing inappropriate demand on other services and ensuring the right care was provided the first time:
‘They [clinicians] are four or five people sitting around a table. I'd argue you need an entire floor full of those people … because they do struggle to intercept these calls. The sheer volume of them—are you ever going to have enough clinicians?’ (Participant 2)
‘More clinicians in 111 and the ability to have more autonomy.’ (Participant 6)
Three participants suggested that clinicians should be taking calls from the outset and should replace non-clinical call takers:
‘Clinicians answering the phone in 111 may be more expensive initially [but] will save ambulances in the long run, which again will save money.’ (Participant 3)
‘I'm wondering whether they should all be clinicians … as the call comes in, there's a clinician on the other end … no matter what the outcome's going to be, why not cut out the person that doesn't know what they're talking about and just go straight to someone who does?’ (Participant 7)
Accessible alternative care pathways
Participants highlighted that one reason they may receive inappropriate referrals is a lack of alternate options available to NHS 111. Furthermore, it was argued that if community healthcare and social care were more accessible in the first place, this would negate patients having to call 111 or 999:
‘It's about providing … the right care. If we can add more services into 111 to help people access these services, especially at night and on weekends … healthcare doesn't stop at 5 o'clock on a Friday afternoon, does it?’ (Participant 5)
Discussion
Advantages of NHS 111
NHS England (2017) data indicate that 45% of service users who called NHS 111 state that without NHS 111, they would have called 999 or attended A&E. The data reveal that in these cases, NHS 111 prevented 20% of callers using A&E or ambulance services, indicating it reduced the effects of calls to these services (Dayan, 2017).
Participants in this study did recognise a need for the provision of signposting and support for non-emergency cases. Acknowledging the need for an alternative number other than 999 that specialises in this service, participants argued it should meet the needs of callers to promote service efficiency and patient care and reduce demand on the 999 system.
In contrast to Turner et al (2012), who deemed the initial pilot to have been a success, the findings of this study evidence little perceived advantages with NHS 111 in the south west of England as far as paramedics are concerned. Previous studies reported service users' dissatisfaction with NHS 111 service efficiency (Turner et al, 2012; 2013) and this was apparent in participants' accounts.
Call categorisation and prioritisation inaccuracy
Perceived inaccuracies in the triage process and subsequent ambulance referrals is a theme that runs throughout this section as it did in the data analysis process. The narrative of most participant interview data followed a line of thought around NHS 111 not being able to accurately triage patients, resulting in incorrect and inappropriately high categorisations that wrongly mandated an emergency ambulance response. A fear was that NHS 111, being a computer-led, remote triage system, failed to recognise the importance of ensuring accurate call triage, categorisation and prioritisation. Given that NHS care is built around a person-centred model of care, where care is represented as being tailored to patients' unique needs, this is a key failure in the existing NHS 111 triage system noted across the findings (Department of Health and Social Care, 2013).
Concerns around non-clinical call handlers
Pope et al's (2017) study highlighted that, across five NHS 111 sites, issues with non-clinical staff managing calls were being addressed using clinical staff in remote triage who call handlers could refer to in more complex cases. Pope et al (2017) also demonstrated that an increasing percentage of calls required a clinician call-back, suggesting that callers are not getting a one-stop service and NHS 111 is not meeting one of its aims. This may affirm the concerns of the participants in this study that call handlers lack knowledge and skills, and clinician-led triage and changes in practice are required.
A key concern raised by participants was the way in which clinical decisions were being made by non-clinical staff, offering support, advice and subjectively interpreting the most suitable system pathways to follow. In particular, the accounts revealed that paramedics felt call handlers lacked effective training as well as the knowledge and skills to engage in effective decision-making, while the set script and computer-based triage system led to a lack of autonomous questioning, which impeded effective clinical decision-making and accurate call categorisation. This was viewed as the major flaw in NHS 111, causing inappropriate ambulance referrals. It is unclear what knowledge (if any) the participants of this study had of training received by NHS 111 call handlers. Nevertheless, this finding supported Pope et al's (2017) questioning of how an NHS 111 service implemented in such a way could increase care standards, and offered further support for Anderson and Roland's (2015) concerns over call handlers using decision support software to make critical decisions, which could place a burden on ambulance service provision.
Paramedics' views in this study also corroborate Turner et al's (2012) findings, where five clinicians analysed 54 NHS 111 cases, highlighting issues in the accuracy of the call handlers' advice provided and impact on referrals to the ambulance service. Recently, of all calls answered by NHS 111, 21.8% were transferred to or answered by a clinical adviser and 13% were offered a call-back of which only 38% were made within 10 minutes (Turner et al, 2012).
A strong case for a clinician-led system was made by Pope et al (2017) using NHS 111 data, which shows that non-clinical call handlers' referrals to GPs were largely inaccurate, with many clinical errors recorded in the triage system.
Caution and liability
Caution and liability were key themes, which could be linked back to a policy call for greater focus on patient safety issues (NHS England, 2014). Participants perceived NHS 111 call handlers and the triage system to be too cautious, contributing to unnecessary ambulance referrals. This finding was corroborated with the findings of Turnbull et al's (2014) study, which indicated that these difficulties were inherent in the NHS 111 triage system because non-clinical staff used set scripts, which did not reflect the uniqueness and diversity of patients and impeded effective prioritisation. Indeed, rather than a triage system that minimised risk and promoted patient safety, Turnbull et al (2014), Pope et al (2017) and the present study all argue that NHS 111 increases clinical risk, as patients are not accurately prioritised, which can result in inappropriate or delayed ambulance responses.
Furthermore, most participants mentioned numerous occasions in which they had attended a patient via NHS 111 where the patient had clearly declined or had communicated their concern over an ambulance referral. Sometimes the NHS 111 service sending an ambulance caused unnecessary worry as people thought they had something serious and this exacerbated their symptoms.
The process around patient refusal of an ambulance should be examined to ensure that service users can make informed decisions. The present study suggests that patient refusal and non-consent of an ambulance referral are often being ignored.
Increased demand
Annually, NHS 111 has seen demand rise for its service, as has the ambulance service, but increases in funding have not matched the demand (National Audit Office, 2017). During the winter period 2017–2018, NHS 111 dealt with on average 100 000 more calls per month, a 41% increase on the previous year. During this period, for all callers to NHS 111, 13% had an ambulance dispatched and 8% were recommended to attend A&E (NHS Improvement, 2018). Likewise, ambulance service demand rose with conveyances to A&E increasing by 8%.
High variation has been observed in the number of calls that are referred to ambulance services by NHS 111 (NHS England, 2017; Carter, 2018). In the north east of England in 2016, 17% of calls were referred to the ambulance service, compared with only 8% in south Essex (NHS England, 2017). This highlights great variations across England; it identifies potential caller demographic variations, varying reliance on the service and health inequalities in care quality and accessibility for service users in different areas of England.
NHS 111 clinical input into triaged calls doubled from 25% to 50% in March 2018, possibly avoiding 2.3 million more A&E visits than the previous year (NHS Improvement, 2018). This figure doubling over a single month is linked to a policy change effective March 2018 whereby NHS England required all NHS 111 providers to clinically revalidate all category 3 and 4 calls before referring them to the ambulance service (Carter, 2018). This increase highlights a more clinically-focused approach to triage within NHS 111 and, arguably, a safer and more comprehensive service to patients. Within the first 2 months, the number of calls passed to ambulance trusts by NHS 111 fell by 40%, supporting the finding of this study regarding perceived inappropriate ambulance referrals and adding to the evidence base that transitioning to a model with more clinician-led triage will enable a more efficient and safe service.
Interprofessional conflict
Findings highlight how issues fostered interprofessional conflict between paramedics and NHS 111. Participants felt frustrated with the service and how it failed patients, negatively affecting the paramedics personally and professionally. Some participants highlighted how their perceived negativity around NHS 111 could affect their own mental health as well as the way they approach incidents and care for patients. As the Francis (2013) report highlights, interprofessional conflict can have serious implications for patient outcomes and safety, and so must be addressed.
The future
The NHS Five-Year Forward View (NHS England, 2014) sets out a strategy to improve NHS 111. As part of this transformation and in a bid to move towards an integrated urgent care and NHS 111 workforce, NHS 111 service users who need clinical input will be directed to a dedicated clinical assessment service where it is envisaged they will speak directly to a relevant clinician who will seek to complete the call without the need to transfer the patient elsewhere.
To meet the needs of this initiative, NHS England (2020) and Health Education England (2020) are working together to develop an integrated urgent care workforce. It is perceived that this concept will increase the proportion of calls resolved through telephone advice and decrease inappropriate ambulance service referrals.
There are also plans to roll out NHS 111 online to the whole country. To date, pilots of NHS 111 online have been launched, which covered 34% of the country; however, the service faced challenges such as engaging with stakeholders and technological capabilities (NHS Improvement, 2018).
Strengths and limitations
As participants were employed by the same ambulance trust and working in the same geographical location, it is not possible to generalise the findings of this study to all NHS 111 providers and all ambulance services in England (Parahoo, 2014). Including a small sample of paramedics in SWASFT does, however, offer an exploratory snapshot of the issues that NHS 111 presents to ambulance services and paramedics (Bryman, 2016).
A strength of this study is that the results are aligned with the findings of other studies and reports (Turner et al, 2012; 2013; Turnbull et al, 2014; Pope et al, 2017; Carter, 2018), which enabled a triangulation process that could act as a validation method to confirm the credibility of this study's findings (Creswell and Clark, 2017).
The methods used in this study could be replicated in other regions to build a high-quality evidence base that can generate improvements at a national level. This study is the first to examine paramedics' views and experiences of NHS 111 in England and the problems they experienced with the service.
Recommendations
More clinicians
NHS 111 should consider maximising their use of clinical call handlers, who can provide a more autonomous triage service at the first point of contact. There is a need, as evidenced by Lord Carter's review (Carter, 2018), to increase the number of clinicians to ensure patients receive efficient clinical triage and reduce unnecessary ambulance referrals.
Ensuring more autonomous clinical staff are available and supported will ensure a more thorough and accurate clinical triage service. Additionally, they will be able to support call handlers, promoting a more accurate and efficient triage process.
Refusal of ambulance referral
The NHS 111 process around patient refusal of an ambulance referral and ensuring service users are able to make informed decisions is of great importance. This ability should be honoured even if deemed unwise. The narrative from this study is that patient non-consent to an ambulance referral is often ignored and this is unacceptable. Therefore, the process involved in assessing mental capacity, informed decision-making and refusal of a service needs to be addressed and re-examined by NHS 111 providers.
Accurate, evidence-based triage
Policymakers should examine existing pathways and questioning within the NHS Pathways software that is used to triage and categorise calls. This study has highlighted clearly that all participants felt that the NHS 111 triage process should be improved urgently as ambulance referrals are often deemed inaccurate and inappropriate. Examples of these were given by participants for several patient groups, the most evident being ‘young chest pain’ patients; participants explained how they regularly attend this patient group and warrant the referral to be inappropriate.
A more evidenced-based and thorough triage process, using clinical judgment with relevant further questioning and an evidence-based assessment of the level of risk and likelihood of serious pathophysiology would support more appropriate care pathways for patients.
Conclusion
Participants agreed there was a need for a non-emergency telephone and online advice service like NHS 111. However, overall, they are disillusioned with the current service. They feel that NHS 111 lacks accuracy in its triage process, resulting in an increased, inappropriate and unwarranted demand on the ambulance service and that NHS 111 increases risk to patients.
To improve, participants recommend that triage processes are re-examined to ensure there is an effective, evidence-based, accurate triage process that is clinician-led and where clinicians are supported to use their professional autonomy. In turn, patient safety and care will improve while inappropriate demand on ambulance services will decrease.