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Evaluating the impact and cost benefits of NHS 111

NHS 111 is a telephone-based (111) and online (111.nhs.uk) service that provides quick and easy access to patients with urgent but non-emergency healthcare needs. Both telephony and online services are freely available 24/7 and provide advice, guidance, referral and booking services. The Health Economics Unit (HEU) was asked to help evaluate the service for the first time – helping the NHS to understand whether it offers value for money, and how it might be systematically improved.

Understanding an evolving model

Over the years, NHS 111 has become a core part of the Integrated Urgent Care Service as well as the wider NHS landscape. Its models have also evolved over time, resulting in variations in the design, delivery, and commissioning of the services. For example, whereas 111 Telephony was launched in 2011, 111 Online was not available until 2017. The evolution and variations make it challenging for policymakers and commissioners to assess the effectiveness of NHS 111, whether it offers value for money, and how it might be systematically improved.

The HEU, in collaboration with The Strategy Unit (SU), were commissioned by NHS England to generate evidence to tackle the above challenge – evaluating NHS 111 services. The main objectives were to:

  • Create an evidence repository to identify and collate published and internal evidence on the effectiveness and cost-effectiveness of NHS 111 (both telephone and online) to inform improvement areas and future investment decisions.
  • Identify evidence gaps in the existing evidence base to inform future research areas.
  • Develop an economic framework for NHS 111 to assess the overall value for money of NHS 111 as well as the impact and cost-benefits of various NHS 111 service models

Analysis integrated with engagement

To achieve the above objectives, the project was divided the project into three workstreams.

Workstream 1 – Evidence synthesis

The SU developed a search protocol that specified the appropriate study setting, inclusion and exclusion criteria, and methods of evidence appraisal. Using this, the SU collated internal and published studies and conducted an evidence review according to the pre-specified protocol using the Rapid Evidence Assessments developed by the civil service, which balances rigour and timeliness, suitable for informing policy and strategy decisions.

Workstream 2 – User journey mapping and logic modelling

Identify and map stakeholders. The HEU held a stakeholder mapping session immediately after the project kick-off meeting to visually represent all the stakeholders of the NHSE 111 evaluation project by engagement and importance level. This allowed the HEU to decide when and how to interact with stakeholders at later stages of this project.

111 stakeholder mapping
Stakeholder mapping

Map user journeys. The HEU team started with a rapid review of published and internal literature to gain a high-level overview of the structure of various NHS 111 service models, and then engaged eight stakeholder groups along the user journeys to gain a more in-depth understanding of the journeys.

Develop a logic model. To develop a logic model for NHS 111, the HEU hosted two logic modelling sessions, each lasting 90–120 minutes, involving the UEC policy team and key stakeholder groups along the 111 user journey, from entry, triage, disposition and direction to redirection.

Workstream 3 – Economic framework development

To assess the value for money of NHS 111, the HEU developed an economic framework using the social cost–benefit analysis (SCBA) approach. SCBA is the most inclusive approach of economic evaluation, considering the full range of costs and benefits as well as the interests of stakeholders that are often ignored in traditional economic analysis. SCBA is particularly relevant for valuing NHS 111 because it values not only the health outcomes, but also the preferences of the patient to engage with the IUC services. It also provides a framework by which holistic results can be presented in a cumulative format.

Building a comprehensive picture of the 111 service

Evidence repository and synthesis The SU identified a considerable quantity of existing studies that varied by type and quality. To curate the existing evidence on the impact of the NHS 111 services and facilitate easy access to the evidence pool, The SU created an evidence repository, allowing users to filter studies by outcomes measured, setting, evidence type and quality. The SU also drafted an evidence review report that summarises the findings to inform future decisions regarding investment in and improvement of NHS 111.

User journeys The user journey maps provide an up-to-date generalised structure of NHS 111 service models. They help illustrate how the service components connect and interact with each other, and identify key areas where resources are required and consumed by the system as a whole and by component.

Below is a high-level diagram of NHS 111 user journey. The user journey has been simplified to achieve the following aims:

  1. Show the typical stages patients go through when using the 111 service: entry, triage, disposition and direction, and redirection.
  2. Fit various service models of 111 in the same picture, illustrating the potential overlap and interactions between 111 telephony and 111 online.
  3. Highlight stages where clinical resources are involved and referral redirections beyond final dispositions to help future economic modelling work.
111 user journeys
111 user journeys

Logic model.  The logic model provides a structured framework that enables us to identify and define impacts and outcomes that matter most to the NHS 111 stakeholders as well as the inputs and activities that contribute to those outcomes. It also allows us to frame the economic framework by illustrating at a high level the direct impacts of NHS 111 services on its patients, its workforce, and the wider NHS systems.

111 logic model
111 logic model

SCBA framework. The analysis will estimates the net benefits of the NHS 111 service in terms of the social value generated from the societal perspective by the service, compared with the costs of delivering it. The analysis provides stakeholders and decision-makers with a clear understanding of the costs and benefits associated with different NHS 111 services, as well as the potential value for money of the service. There is also an opportunity to adapt the current framework in the future to compare the costs and benefits of NHS 111 services against alternative service models.

Valuable insights to inform services

This evaluation project has provided valuable insights and evidence to inform future decisions and investments in the service. The evidence synthesis and repository have curated a wide range of existing studies and reports, enabling easy access to the evidence pool and facilitating informed decision-making. The user journey mapping and logic model have provided a comprehensive understanding of the structure and interactions within NHS 111 service models, identifying resource requirements and areas for improvement. Additionally, the development of an economic framework using social cost-benefit analysis has enabled the assessment of the overall value for money of NHS 111 and its various service models.

The results of the evaluation have provided a strong foundation for policymakers and commissioners to make evidence-based decisions regarding NHS 111. The evidence repository, review report, user journey maps, logic model, and economic framework all contribute to a better understanding of the service’s effectiveness and cost-effectiveness. The social-cost benefit analysis has a clearer understanding of the main types of costs and benefits associated with the NHS 111 services, allowing decision makers to prioritise investments and make more informed choices. Furthermore, the evaluation has highlighted areas where further research is needed, offering opportunities for ongoing improvement and refinement of the service.

Overall, the evaluation of the NHS 111 telephone and online service has brought clarity to its performance, value, and potential areas of enhancement. This comprehensive assessment will undoubtedly support the continued development and optimisation of NHS 111, ensuring that it remains a vital and effective component of the Integrated Urgent Care Service and the wider NHS landscape.

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