Authors' objectives: 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. NHS 111 services are a key plank in the NHS Five Year Forward View designed to improve access to (appropriate) services under the banner ‘right person, right place, right time’. NHS 111 online is a web-based triage and assessment service, which was launched in England in late 2017. As with the telephone NHS 111 service, it uses a computerised decision support system or algorithm, with a suite of questions designed to elicit symptoms or concerns and generate a ‘disposition’ (referral or recommendation). Dispositions include advice about self-care, a call back from a clinician, direct appointment booking to primary or urgent care, or (in some locations) a booked arrival time at an emergency department. Evidence about how online triage and assessment systems are used, their effectiveness and their impact on wider health services is limited. This research study responded to an NIHR call for research about NHS 111 online and it examines patient and workforce interactions with this service. •Describe the pathways of care and services used by patients who access NHS 111 online. •Describe the extent of differential access to and use of NHS 111 online. •Describe the workforce for NHS 111 online and assess the impact of different work arrangements on the urgent and emergency health-care system. •Compare the workforce implications of NHS 111 online with Healthdirect in Australia.

Authors' results and conclusions: 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. NHS 111 online is not clearly differentiated from the NHS 111 telephone service. It lacks visibility to staff and stakeholders in the primary, urgent and emergency care system and it is obscured by other digital technologies and other urgent and emergency care services. Pathways to care are confusing and difficult to navigate. There are opportunities to better integrate NHS 111 online with other services and digital platforms in ways to better support help seeking and access to care. Generic NHS 111 services are perceived as making more work for other parts of the NHS; notably by increasing administrative work, encouraging staff to duplicate triage and assessment and creating ‘inappropriate’ demand for Emergency Department (EDs) services. There are differences in eHealth literacy between those who have and those who have not used NHS 111 online and alternative pathways to advice and care are needed to ensure that provision does not increase health inequalities and exclusion. NHS 111 online users were more likely to have used other NHS urgent and emergency care services, and had higher cumulative use of health services compared to those who had not used NHS 111 online. This suggests NHS 111 is additional to and not substituting for other healthcare services.

Authors' methods: 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. 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. We used a multimethod parallel design with two work packages to investigate patient pathways to care, and the work and workforce implicated in the use of NHS 111 online. Work package 1 described and mapped the imagined and real pathways or patient/user care journeys associated with the use of NHS 111 online; a survey was administered to examine eHealth literacy and preferences for using NHS 111 online for different symptom scenarios. Work package 2 comprised an interview-based exploration of the work, workforce and organisational impacts of the deployment of NHS 111 online, drawing on the views and experiences of NHS staff and stakeholders. This work package also contained the international comparison with the Australian Healthdirect system using interviews with key workforce and organisational stakeholders to explore workforce implications of this service. This research took place before and during the pandemic 2020–2021 and findings may change as the NHS and 111 services adjust further coming out of the pandemic. NHS 111 online has been rolled out in the United Kingdom (UK) so it is not possible to conduct randomised trial research. Restricted working during the COVID-19 pandemic reduced the scope of some of the planned qualitative work, removing the ethnographic research in healthcare settings which could have provided more detailed evidence about the workforce, work arrangements and impacts of NHS 111 online. Nonetheless we were able to complete 80 interviews in the UK and 41 interviews in Australia, providing robust sample sizes to support our thematic analyses. Changes to our research timetable reduced the opportunities to integrate data collection and analyses with the Sheffield study also looking at NHS 111 online, but we have identified areas where our work augments and/or confirms their findings in the discussion. Data collection was digitally-based, with interviews and surveys conducted online. Some surveys were completed on a computer tablet with help from a research nurse in face to face clinical settings. Despite this shift to online working we met our minimum sample size for the qualitative interviews, and we were able to adapt the design of our survey to substantially increase the sample size. The changes to the survey have resulted in the first and largest analysis of eHealth literacy among people who have sought help or advice from urgent care services. It is important to acknowledge that the use of digital methods of survey data collection mean that there is a bias towards some level of digital literacy in our sample. Some groups, such as older people, are less well represented. However, this means that our finding that there is differential use of NHS 111 online may under-estimate the digital divide. Digital exclusion may be greater than suggested in our analysis as people with very poor or no literacy, those without sufficient written English language comprehension or digital skills, and people with no access to digital technologies were unlikely to have taken part in the survey.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/NIHR127590

Year Published: 2023

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/YTRR9821

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/YTRR9821

Organisation Name: NIHR Health Services and Delivery Research programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk