Corrigendum: Impact of NHS 111 Online on the NHS 111 telephone service and urgent care system: a mixed-methods study

BackgroundThe NHS emergency and urgent care system is under pressure as demand for services increases each year. NHS 111 is a telephone triage service designed to provide advice and signposting to appropriate services for people with urgent health-care problems. A new service, NHS 111 Online, has been introduced across England as a digital alternative that can be accessed using a website or a smartphone application. The effects and usefulness of this service are unknown.ObjectivesTo explore the impact of NHS 111 Online on the related telephone service and urgent care system activity and the experiences of people who use those services.Design and methodsA mixed-methods design of five related work packages comprising an evidence review; a quantitative before-and-after time series analysis of changes in call activity (18/38 sites); a descriptive comparison of telephone and online services with qualitative survey (telephone,n = 795; online,n = 3728) and interview (32 participants) studies of service users; a qualitative interview study (16 participants) of staff; and a cost–consequences analysis.ResultsThe online service had little impact on the number of triaged calls to the NHS 111 telephone service. For every 1000 online contacts, triaged telephone calls increased by 1.3% (1.013, 95% confidence interval 0.996 to 1.029;p = 0.127). Recommendations to attend emergency and urgent care services increased between 6.7% and 4.2%. NHS 111 Online users were less satisfied than users of the telephone service (50% vs. 71%;p < 0.001), and less likely to recommend to others (57% vs. 69%;p < 0.001) and to report full compliance with the advice given (67.5% vs. 88%;p < 0.001). Online users were less likely to report contacting emergency services and more likely to report not making any contact with a health service (31% vs. 16%;p < 0.001) within 7 days of contact. Thirty-five per cent of online users reported that they did not want to use the telephone service, whereas others preferred its convenience and speed. NHS 111 telephone staff reported no discernible increase or decrease in their workload during the first year of operation of NHS 111 Online. If online and telephone services operate in parallel, then the annual costs will be higher unless ≥ 38% of telephone contacts move to online contacts.ConclusionsThere is some evidence that the new service has the potential to create new demand. The service has expanded significantly, so it is important to find ways of promoting the right balance in numbers of people who use the online service instead of the telephone service if it is to be effective. There is a clear need and preference by some people for an online service. Better information about when to use this service and improvements to questioning may encourage more uptake.LimitationsThe lack of control arm means that impact could have been an effect of other factors. This work took place during the early implementation phase, so findings may change as the service expands.Future workFurther development of the online triage process to make it more ‘user friendly’ and to enable users to trust the advice given online could improve use and increase satisfaction. Better understanding of the characteristics of the telephone and online populations could help identify who is most likely to benefit and could improve information about when to use the service.Trial registrationCurrent Controlled Trials ISRCTN51801112.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 9, No. 21. See the NIHR Journals Library website for further project information.

BackgroundRecent increases in emergency admission rates have caused concern. Some emergency admissions may be avoidable if services in the emergency and urgent care system are available and accessible. A set of 14 conditions, likely to be rich in avoidable emergency admissions, was identified by expert consensus.ObjectiveWe aimed to understand variation in avoidable emergency admissions between different emergency and urgent care systems in England.MethodsThe design was a sequential mixed-methods study in three phases. In phase 1 we calculated an age- and sex-adjusted avoidable admission rate for 2008–11. We located routine data on characteristics of emergency and urgent care systems and used linear regression to explain variation in avoidable admissions rates in 150 systems. In phase 2 we undertook in-depth case studies in six systems to identify further factors. A key part of these case studies was interviews with commissioners, service providers and patient representatives, totalling 82 interviews. In phase 3 we returned to the linear regression to test further factors identified in the case studies.ResultsThe 14 conditions accounted for 3,273,395 admissions in 2008–11 (22% of all emergency admissions). The mean age- and sex-adjusted admission rate was 2258 per year per 100,000 population, with a 3.4-fold variation between systems (1268–4359). Characteristics of the population explained the majority of variation: deprivation explained 72% of variation, with urban/rural status explaining 3% more. Systems serving populations with high levels of deprivation and in urban areas had high rates of potentially avoidable admissions. Interviewees described the complexity of deprivation, representing high levels of morbidity, low awareness of alternative services to emergency departments and high expressed need for immediate access to urgent care. Factors related to emergency departments (EDs), hospitals, emergency ambulance services and general practice explained a further 10% of variation in avoidable admissions. Systems with high, potentially avoidable, admission rates had high rates of acute beds (suggesting supply-induced demand), high rates of attendance at EDs (which have been associated with poor perceived access to general practice), high rates of conversion from ED attendances to admissions, and low rates of non-transport to emergency departments by emergency ambulances. The six case studies revealed further possible explanations of variation: there was variation in how hospitals coded admissions; some systems focused proactively on admission avoidance whereas others were more interested in hospital discharge, for example use of multidisciplinary teams based at acute trusts; there were different levels of integration between different services such as health and social care, and acute and community trusts; and some systems faced more challenging problems around geographical boundaries operating for different services in the system. Interviewees often described admission as the easy or safe option.ConclusionsDeprivation explained most of the variation in avoidable admission rates. Research is needed to understand the complex relationship between deprivation and avoidable admission, and to develop interventions tailored to avoid admissions from deprived communities. Standardisation of coding of admissions would reduce variation.FundingThe National Institute for Health Research Health Service and Research Delivery programme.

To identify factors affecting variation in avoidable emergency admissions that are not usually identified in statistical regression. As part of an ethnographic residual analysis, we compared six emergency and urgent care systems in England, interviewing 82 commissioners and providers of key emergency and urgent care services. There was variation between the six cases in how interviewees described three parts of their emergency and urgent care systems. First, interviewees' descriptions revealed variation in the availability of services before patients decided to attend emergency departments. Poor availability of general practice out of hours services in some of the cases reportedly made attendance at emergency departments the easier option for patients. Second, there was variation in how interviewees described patients being dealt with during their emergency department visit in terms of availability of senior review by specialists and in coding practices when patients were at risk of breaching the NHS's 4-hour waiting time target. Third, there was variability in services described as facilitating discharge home from emergency departments. In some cases, emergency department staff described dealing with multiple agencies in multiple localities outside the hospital, making admission the easier option. In other cases, proactive multidisciplinary rapid assessment teams were described as available to avoid admissions. Perceptions of resources available out of hours and the extent of integration between different health services, and between health and social services, also differed by case. This comparative case study approach identified further factors that may affect avoidable emergency admissions. Initiatives to improve GP out of hours services, make coding more accurately reflect patient experience, increase senior review in emergency departments, offer proactive multidisciplinary admission avoidance teams, improve the availability of out of hours care in the wider emergency and urgent care system, and increase service integration may reduce avoidable admissions. Evaluation of such initiatives would be necessary before wide-scale adoption.

Surveys of patients' experiences and views of health care usually focus on single services. During an unexpected episode of ill health, patients may make contact with different services and therefore experience care within an emergency and urgent care system. We developed the Urgent Care System Questionnaire and used it to describe patients' experiences and views of an emergency and urgent care system in England. A market research company used quota sampling and random digit dialling to undertake a telephone survey of 1000 members of the general population in July 2007. 15% (151/1000) of the population reported using the emergency and urgent care system in the previous 3 months. Two thirds of users (68%, 98/145) contacted more than one service for their most recent event, with a mean of 2.0 services per event. Users entered the system through a range of services: the majority contacted a daytime GP in the first instance (59%, 85/145), and 12% (18/145) contacted either a 999 emergency ambulance or an emergency department. Satisfaction with all aspects of care diminished when four or more services had been contacted. This is the first study to describe patients' experiences and views of the emergency and urgent care system. The majority of patients experienced a system of care rather than single service care. There was an indication that longer pathways resulted in lower levels of patient satisfaction. Health care organisations can undertake similar surveys to identify problems with their system or to assess the impact of changes made to their system.

BackgroundDespite the policy principle that “children are best cared for at home whenever possible” children continue to have high rates of emergency department (ED) attendance and emergency hospital admission. Community Children’s Nursing Teams (CCNTs) can care for acutely ill children at home but their potential to provide an alternative to ED attendance and hospitalisation depends on effective integration with other services in the urgent care system, such as EDs and Observation and Assessment Units (OAUs). Although challenges of integrating CCNTs have been identified, there has been no comparative assessment of the factors that facilitate or hinder integration of care of acutely ill children by CCNTs with the urgent care system. The aim of this study was to identify enablers and barriers to integration of CCNTs with urgent and emergency care.MethodsComparative case studies were conducted of two CCNTs serving Primary Care Trusts in North West England. Twenty-two health professionals including CCNT managers and staff; paediatricians; nurses; children’s ward, ED and OAU staff; commissioners of children’s services; GPs and primary care staff were interviewed between June 2009 and February 2010. Qualitative data were analysed thematically using the Framework approach.ResultsBarriers to integration included paediatricians’ perceived lack of ownership of the CCNT, poor communication between consultants and community children’s nurses (CCNs), and weak personal relationships. This prevented early referral to the CCNT as an alternative to hospital care. Enablers of integration included co-location and rotation of CCNs through urgent care settings including OAUs and EDs. This enabled nurses to develop skills, make decisions about referral to home care and gain the confidence of referring clinicians.ConclusionsIntegration of CCNTs at multiple points in the urgent care system is required in order to provide an alternative to inappropriate ED attendances and emergency admission. The principal enablers and barriers are both aspects of normative integration, which involves shared understanding of the contribution of CCNTs and trusting relationships between practitioners. Co-location and rotation of CCNs through acute services can promote integration and appropriate referrals to CCNTs to support families to care for children at home.

Background The NHS currently faces increasing demands on accident and emergency departments. Concern has been expressed regarding whether the needs of vulnerable groups are being handled appropriately or whether alternative methods of service delivery may provide more appropriate emergency and urgent care services for particular groups. Objective Our objective was to identify what interventions exist to manage use of the emergency and urgent care system by people from a prespecified list of vulnerable groups. We aimed to describe the characteristics of these interventions and examine service delivery outcomes (for patients and the health service) resulting from these interventions. Review methods We conducted an initial mapping review to assess the quantity and nature of the published research evidence relating to seven vulnerable groups (socioeconomically deprived people and families, migrants, ethnic minority groups, the long-term unemployed/inactive, people with unstable housing situations, people living in rural/isolated areas and people with substance abuse disorders). Databases, including MEDLINE and the Cumulative Index to Nursing and Allied Health Literature, and other sources were searched between 2008 and 2018. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion. In addition, we searched for UK interventions and initiatives by examining press reports, commissioning plans and casebooks of ‘good practice’. We carried out a detailed intervention analysis, using an adapted version of the TIDieR (Template for Intervention Description and Replication) framework for describing interventions, and an analysis of current NHS practice initiatives. Results We identified nine different types of interventions: care navigators [three studies – moderate GRADE (Grading of Recommendations, Assessment, Development and Evaluations)], care planning (three studies – high), case finding (five studies – moderate), case management (four studies – high), front of accident and emergency general practice/front-door streaming model (one study – low), migrant support programme (one study – low), outreach services and teams (two studies – moderate), rapid access doctor/paramedic/urgent visiting services (one study – low) and urgent care clinics (one systematic review – moderate). Few interventions had been targeted at vulnerable populations; instead, they represented general population interventions or were targeted at frequent attenders (who may or may not be from vulnerable groups). Interventions supported by robust evidence (care navigators, care planning, case finding, case management, outreach services and teams, and urgent care clinics) demonstrated an effect on the general population, rather than specific population effects. Many programmes mixed intervention components (e.g. case finding, case management and care navigators), making it difficult to isolate the effect of any single component. Promising UK initiatives (front of accident and emergency general practice/front-door streaming model, migrant support programmes and rapid access doctor/paramedic/urgent visiting services) lacked rigorous evaluation. Evaluation should therefore focus on the clinical effectiveness and cost-effectiveness of these initiatives. Conclusions The review identified a limited number of intervention types that may be useful in addressing the needs of specific vulnerable populations, with little evidence specifically relating to these groups. The evidence highlights that vulnerable populations encompass different subgroups with potentially differing needs, and also that interventions seem particularly context sensitive. This indicates a need for a greater understanding of potential drivers for varying groups in specific localities. Limitations Resources did not allow exhaustive identification of all UK initiatives; the examples cited are indicative. Future work Research is required to examine how specific vulnerable populations differentially benefit from specific types of alternative service provision. Further exploration, using primary mixed-methods data and potentially realist evaluation, is required to explore what works for whom under what circumstances. Rigorous evaluation of UK initiatives is required, including a specific need for economic evaluations and for studies that incorporate effects on the wider emergency and urgent care system. Funding The National Institute for Health Research Health Services and Delivery Research programme.

BackgroundThis article describes the development of a system-based data platform forresearch developed to provide a detailed picture of the characteristics ofthe Urgent and Emergency Care system in 1 region of the United Kingdom.Data Set DevelopmentCUREd is an integrated research data platform that describes the urgent andemergency care system in 1 region of the United Kingdom on almost 30 millionpatient contacts within the system. We describe regulatory approvalsrequired, data acquisition, cleaning, and linkage.Data Set AnalysesThe data platform covers 2011 to 2017 for 14 acute National Health Service(NHS) Hospital Trusts, 1 ambulance service, the national telephone adviceservice (NHS 111), and 19 emergency departments. We describe 3 analysesundertaken: 1) Analyzing triage patterns from the NHS 111 telephone helplineusing routine data linked to other urgent care services, we found that thecurrent triage algorithms have high rates of misclassifying calls. 2)Applying an algorithm to consistently identify avoidable attendances forpediatric patients, we identified 21% of pediatric attendances to theemergency department as avoidable. 3) Using complex systems analysis toexamine patterns of frequent attendance in urgent care, we found thatfrequent attendance is stable over time but varies by individual patient.This implies that frequent attendance is more likely to be a function of thesystem overall.DiscussionWe describe the processes necessary to produce research-ready data that linkcare across the components of the urgent and emergency care system. Makingthe use of routine data commonplace will require partnership between thecollectors, owners, and guardians of the data and researchers and technicalteams.HighlightsThis article describes the development of a system-level dataplatform for research using routine patient-level data from theurgent and emergency care system in 1 region of the UnitedKingdom.The article describes how the data were acquired, cleaned, and linkedand the challenges faced when undertaking analysis with thedata.The data set has been used to understand patient use of the system,journeys once in the system, and outcomes following its use, forexample, patterns of frequent use within urgent care and accuracy ofreferral decisions within the system.

Introduction: System integration to achieve sustainable systemic change is not a new concept and something that has been around in International practice for a number of years. Experiential, comparative exploration of system models in Alzira, Boston and Washington DC (via an AQuA fellowship) highlight significant similarities with that of the Oldham economy, at the same time as identifying the stark difference in progress to develop and deploy sustainable system models in the UK. Oldham has taken learning from International best practice and used the intelligence and information to better shape the system in Oldham, aligned to the greater Manchester Devolution mandate. By deploying the same strategic approach as International models to the urgent care system in Oldham (via a multi agency alliance partnership) we are able to demonstrate sustained quality improvements for people and system flow via a number of innovative, transformational approaches that have sustained positive impact on a reduction in unplanned admissions in excess of the National expected average (3.5%). This achievement has received National recognition (NHS England) and also shortlist for two HSJ awards (integration and quality improvement). Description of practice change implemented: Oldham Urgent Care Alliance’s (a partnership of 8+ multi agency organisations) aim is to improve the urgent care system across the Oldham locality. It had a number of objectives: to reduce unplanned admissions to hospital by 3.5%, deliver a number of integration projects and take a performance management approach to the use of resilience funding. Via this approach a number of practice changes are evident, Development of a frail elderly unit which has reduced length of stay by 70-50% Development of a multi agency discharge to assess service, impacting upon admissions to residential and acute provision and improving quality of life Development of a multi agency Primary Care practice before the front doors of AE Pennine Acute Hospitals NHS Trust; Pennine Care NHS Foundation Trust; GotoDoc (a social enterprise providing an out of hours GP service) MIO Care, (a limited company owned by the council to provide homecare and re-ablement services), Voluntary Action Oldham; First Choice Homes; GP representation and Oldham CCG. Timeline: 12 months Highlights: (innovation, impact and outcomes) Sustained improvement in quality of care and life chances are evident as a result of deploying this systematic approach. A sustained reduction of 5.8% in unplanned hospital admissions achieved, despite an annual 6% increase in A&E attendances over the same period Total estimated system saving of £2.79m. Paediatric admissions Triage system introduced to assess conditions prior to admission. Almost 600 fewer paediatric admissions in 2015 compared with 2014 Alternative to transfer (minor injuries) A physiotherapy and occupational therapy service established enabling initial assessment of patients quickly to divert the patient from admission. Over 250 deflections from hospital achieved in 2015. Long term conditions Pro-active and self-management within the community. Almost 500 hospital deflections achieved in 2015, compared with the previous year. Early supported discharge for stroke rehabilitation 15 hospital deflections for stroke patients achieved in 2015. End of life care An overall reduction of the number of deaths in hospital per 1,000 population of 2% Intermediate care, A&E – therapy in-reach Over 250 additional hospital deflections in 2015. SPRINT (Senior persons resilience independence team) Reduced length of stay for over 85yrs by 70% Reduced length of stay for 65-85 yrs by 50% Comments on sustainability: Analysis of performance metrics continue to demonstrate sustained system impact despite growing demand. Review of quality impacts continue to yield positive impacts upon quality. Comments on transferability: The model can be replicated in any system/ care setting. Conclusions: The development of a systematic system leadership and governance approach via integrated working across a number of public, private and voluntary sector organisations has yielded a sustained impact upon quality and performance improvements within the urgent care system. The introduction of the Programme Management Office to co-ordinate and manage multiple projects across multiple partners was critical to the success of the transformation programme and the demonstration of sustained outcomes delivered. Discussions: This theory of change continues to be deployed within the Oldham urgent care economy and there are a number of other innovations that have been deployed as a result. This theory and concept has been driven forward by a sustained fastidious leadership approach across the system with interrogation of quality and performance data to evidence outcomes. Lessons learned: Sustained system leadership is critical to success Interagation of International systems has demonstrated the similarities between UK systems, which has been deployed further than theory and concept and implemented to make real and sustained system change Relationships across organisations are key to success Integrated working is a critical success factor Despite perverse financial incentives front line staff working in an integrated way can make real and sustained impact upon quality The deployment of quality improvement methodology enables and embeds rapid improvement

BackgroundPatients seeking emergency and urgent care tend to experience a system, making choices about which service to use and making use of a number of services within a healthcare episode....

NHS 111 online offers 24-hour access to health assessment and triage. This study examined pathways to care, differential access and use, and workforce impacts of NHS 111 online. This study compared NHS 111 with Healthdirect (Haymarket, Australia) virtual triage. Interviews with 80 staff and stakeholders in English primary, urgent and emergency care, and 41 staff and stakeholders associated with Healthdirect. A survey of 2754 respondents, of whom 1137 (41.3%) had used NHS 111 online and 1617 (58.7%) had not. NHS 111 online is one of several digital health-care technologies and was not differentiated from the NHS 111 telephone service or well understood. There is a similar lack of awareness of Healthdirect virtual triage. NHS 111 and Healthdirect virtual triage are perceived as creating additional work for health-care staff and inappropriate demand for some health services, especially emergency care. One-third of survey respondents reported that they had not used any NHS 111 service (telephone or online). Older people and those with less educational qualifications are less likely to use NHS 111 online. Respondents who had used NHS 111 online reported more use of other urgent care services and make more cumulative use of services than those who had not used NHS 111 online. Users of NHS 111 online had higher levels of self-reported eHealth literacy. There were differences in reported preferences for using NHS 111 online for different symptom presentations. Greater clarity about what the NHS 111 online service offers would allow better signposting and reduce confusion. Generic NHS 111 services are perceived as creating additional work in the primary, urgent and emergency care system. There are differences in eHealth literacy between users and those who have not used NHS 111 online, and this suggests that 'digital first' policies may increase health inequalities. This research bridged the pandemic from 2020 to 2021; therefore, findings may change as services adjust going forward. Surveys used a digital platform so there is probably bias towards some level of e-Literacy, but this also means that our data may underestimate the digital divide. Further investigation of access to digital services could address concerns about digital exclusion. Research comparing the affordances and cost-benefits of different triage and assessment systems for users and health-care providers is needed. Research about trust in virtual assessments may show how duplication can be reduced. Mixed-methods studies looking at outcomes, impacts on work and costs, and ways to measure eHealth literacy, can inform the development NHS 111 online and opportunities for further international shared learning could be pursued. This study is registered at the research registry (UIN 5392). This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research Programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 5. See the NIHR Journals Library website for further project information.

ObjectivesTo measure the impact of the urgent care telephone service NHS 111 on the emergency and urgent care system.DesignControlled before and after study using routine data.SettingFour pilot sites and three...

ObjectivesRising demand for emergency and urgent care services is well documented, as are the consequences, for example, emergency department (ED) crowding, increased costs, pressure on services, and waiting times. Multiple factors have been suggested to explain why demand is increasing, including an aging population, rising number of people with multiple chronic conditions, and behavioral changes relating to how people choose to access health services. The aim of this systematic mapping review was to bring together published research from urgent and emergency care settings to identify drivers that underpin patient decisions to access urgent and emergency care.MethodsSystematic searches were conducted across Medline (via Ovid SP), EMBASE (via Ovid), The Cochrane Library (via Wiley Online Library), Web of Science (via the Web of Knowledge), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; via EBSCOhost). Peer‐reviewed studies written in English that reported reasons for accessing or choosing emergency or urgent care services and were published between 1995 and 2016 were included. Data were extracted and reasons for choosing emergency and urgent care were identified and mapped. Thematic analysis was used to identify themes and findings were reported qualitatively using framework‐based narrative synthesis.ResultsThirty‐eight studies were identified that met the inclusion criteria. Most studies were set in the United Kingdom (39.4%) or the United States (34.2%) and reported results relating to ED (68.4%). Thirty‐nine percent of studies utilized qualitative or mixed research designs. Our thematic analysis identified six broad themes that summarized reasons why patients chose to access ED or urgent care. These were access to and confidence in primary care; perceived urgency, anxiety, and the value of reassurance from emergency‐based services; views of family, friends, or healthcare professionals; convenience (location, not having to make appointment, and opening hours); individual patient factors (e.g., cost); and perceived need for emergency medical services or hospital care, treatment, or investigations.ConclusionsWe identified six distinct reasons explaining why patients choose to access emergency and urgent care services: limited access to or confidence in primary care; patient perceived urgency; convenience; views of family, friends, or other health professionals; and a belief that their condition required the resources and facilities offered by a particular healthcare provider. There is a need to examine demand from a whole system perspective to gain better understanding of demand for different parts of the emergency and urgent care system and the characteristics of patients within each sector.

ObjectiveTo measure the effect of an urgent care telephone service NHS 111 on population perceptions of urgent care.DesignControlled before and after population survey, using quota sampling to identify 2000 respondents...

BackgroundSome emergency admissions can be avoided if acute exacerbations of health problems are managed by the range of health services providing emergency and urgent care.AimTo identify system-wide factors explaining variation...

A “model of care” (MoC) is defined as a way of the health services delivered by system of care. It outlines the best practices for care and services for people and population groups; At the right place, by the right team, at the right time, and right care plan. MoC aims to transform the prevailing pattern of accessing healthcare services by transforming from: Hospital to home, Activities to results, Treatment to prevention, Institutions to integrated systems, Facilities to virtual services, Fragmentation to integration, Passive individual to active and accountable individual. The six healthcare systems were selected for the new model of care in a way that addresses the primary questions of individuals in the community [1]. Preventive Care System –How does the system help me maintain my health? , Urgent Care System – How does the system help me when I face an urgent health problem? , Scheduled Care System – How does the system help me in achieving better outcomes for planned procedures? , Maternity and Child Care System-How does the system help me safely have a chilled? , Chronic Disease Care-How does the system help me cope with the chronic illnesses I suffer from? Palliative Care -How can the system provide me with the best level of care? [2]. MoC Adapted at KHN in 2018 by 2 initiatives and increased gradually through years by 2024 it become 23 initiatives they result in increasing the quality of care and outcomes to our population, which will be embedded to the health care system according to Saudi Arabia Vision of 2030 [3].