The recent NHS performance statistics paint a concerning picture of how well non-COVID-19 related health care needs are being met. Since the start of the coronavirus (COVID-19) pandemic we have seen big drops in A&E attendances, fewer people with suspected cancer getting urgent referrals to a specialist and fewer first treatments for cancer.
NHS 111 is the 24/7 telephone and online service for people who need advice and information about urgent medical problems. Amid changing patterns of health service use, we ask what role has NHS 111 played in shaping public demand for NHS services in England?
What role has NHS 111 played?
On 18 February 2020, guidance from NHS England outlined that the public should call NHS 111 if they had been to a region affected by COVID-19, or in close contact with confirmed cases of the virus. The same guidance also stated that NHS 111 should not refer suspected COVID-19 cases to GPs or community pharmacies but that recommendations should remain the same for non-COVID-19 callers.
In a letter dated 17 March, NHS hospitals in England were told to suspend all non-urgent elective surgery before 15 April but to continue to deliver emergency care, cancer treatments and other clinically urgent care. However, sharp falls in A&E attendances led to concerns that people were not seeking care for urgent conditions such as strokes and heart attacks. In late April, this prompted ministers and senior officials, including NHS Chief Executive Simon Stevens, to urge people to still seek help for urgent health care needs as well as cancer screening and care, maternity appointments and mental health support.
During the initial stages of the outbreak, when non-essential movement was restricted, there was a critical role for NHS 111 in helping people with medical problems without the risk of unnecessary exposure to COVID-19. The service handles more than one million calls every month, and is able to give health advice, dispatch ambulances or recommend that people should attend A&E, primary care, or other services. As such, recommendations from NHS 111 could be an important driver of health care seeking behaviour.
Callers getting through to the service are getting different advice to last year. Close to 130,000 more callers were recorded as ‘not recommended to attend other service’ in March 2020, a 75% increase on the same month. Just over 90,000 more callers were ‘recommended to attend other service’, which could include community nursing or the police – a 132% increase compared to March 2019. This advice may have been entirely appropriate, but the unusual increase in callers given such advice coincided with the reduced availability of some NHS services. Whether this led to some callers being redirected to alternatives that were not the most suitable for their needs is not clear from the data.
After lower than usual numbers in March and almost normal levels in April, almost 30,000 more callers were recommended to attend A&E in May 2020 compared to the same month in 2019. This could be in response to worries that more people who needed urgent medical treatment were calling NHS 111 rather than going straight to A&E. However, it is unclear whether people are following NHS 111 advice to attend A&E – actual attendances in May 2020 were higher than in April 2020, but still 42% lower than May 2019. This may be a sign that the public remained nervous about using local hospital services during the pandemic.
After a lower than expected number of ambulance dispatches through NHS 111 in March and April 2020, ambulance dispatches are back to expected numbers. Analysis by the Health Foundation shows that overall ambulance dispatches were stable but that what ambulance crew did changed, with more patients being treated at the scene and fewer patients being taken to A&E. This change in behaviour explains in part the drop in A&E attendances discussed above.
The number of NHS 111 callers being recommended to attend primary care in May 2020 was still somewhat lower than in May 2019 but an increase from March and April 2020, which were 12% and 19% lower respectively than the same months in 2019. The April national GP appointments data recorded a substantial fall in the total number of appointments, though the collection was affected by data quality issues as fewer GP practices contributed data and the collection may not have recorded all activity.
Why has the use of A&E dropped?
Despite the lockdown being gradually relaxed, there have been sharp falls in people using health services, including by those with serious health conditions. The substantial reductions in people using a range of health services does not appear to have been offset by an increase in calls to NHS 111. The demand for NHS 111 reached a record high in March 2020, but virtually returned to normal levels in April and May.
In March and April, the advice being given by NHS 111 may have, in part, contributed to the falls in A&E attendances we have seen. Now, after a few months of not recommending callers to attend A&E or primary care unless necessary, NHS 111 seems to be slowly changing recommendations. This could be as a response to public statements that the NHS is ‘open for business’, but it could also be a sign that more people with urgent and serious health conditions are going through NHS 111 rather than directly to A&E. Whether or not callers to NHS 111 will listen is yet to be seen. Recommendations are after all just that. If the public remains apprehensive about using the NHS during the pandemic, behaviour may be slow to change.