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NHS 111
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NHS 111
Organisation NHS, Local Ambulance Service Body
Country United Kingdom
Launched August 23, 2010
Format Online, Telephone, BSL
Related numbers 999 112 101
Website nhs.uk

111 is a free-to-call single non-emergency number medical helpline operating in England, Scotland and Wales. The 111 phone service has replaced the various non-geographic 0845 rate numbers and is part of each country's National Health Service: in England the service is known as NHS 111;[1] in Scotland, NHS 24;[2] and in Wales, NHS 111 Wales.[3]

The transition from NHS Direct (0845 4647) to NHS 111 in England was completed during February 2014[4] with NHS 24 Scotland (08454 24 24 24) following during April 2014.[5] NHS Direct Wales started a phased roll-out of a similar 111 service in late 2016[6] and completed it in March 2022.[7]

As of June 2018, the 111 number was not in use across Northern Ireland.[8] The NHS 111 service was extended to Northern Ireland from February 2020, although this is for advice relating to the COVID-19 virus only.[9] After dialling, callers will be asked to follow prompts to determine what nation they are calling from.[citation needed]

The service is available 24 hours a day, every day of the year and is intended for 'urgent but not life-threatening' health issues[10] and complements the long-established 999 emergency telephone number for more serious matters, although 111 operators in England are able to dispatch ambulances when appropriate using the NHS Pathways triage system.[11][12]

Origins and development

[edit]

During 2007, the Department of Health's Our NHS, Our Future report identified confusion surrounding access to certain NHS services in England and suggested the introduction of a national, three-digit number for out-of-hours healthcare services could help simplify the situation. Arrangements to identify and secure a suitable non-emergency number for England began in July 2009,[13] with the number 111 allocated by telecommunications regulator Ofcom in December of that year.[14]

In late August 2010, the Conservative-Liberal Democrat coalition government proposed that 111 would replace the existing NHS Direct (084546 47) telephone helpline in England.[15][16] This suggestion proved controversial as some critics feared that NHS 111 would be a "cut-price" replacement for NHS Direct, because NHS 111 would be staffed mainly by telephone advisors whereas NHS Direct had been staffed by nurses. Health Secretary Andrew Lansley said that the only major change would be the phone number, and that the service would be provided by existing staff.[15][17][18]

In July 2015 NHS England decided that what was required was an integrated urgent care access, treatment and clinical advice service which would operate over a large area. Clinical Commissioning Groups were told to stop any procurement exercises until revised commissioning standards and supporting procurement advice for integrated services were produced.[19] These service specifications for England were published in 2017.[20]

In June 2020 it was announced that there were plans to integrate LIVI software into the service in three regions of the UK.[21]

111 First

[edit]

The 111 First system, which allows patients not in medical emergencies to call 111 to "book" urgent care, was launched in 2020, as a response to the impact of COVID-19 pandemic in England on emergency services. In July 2021 Healthwatch England found that it had potential to be a useful service, but the public "don't really know what it's for". They said the messaging from the NHS "has not been strong enough". Only 3% of English A&E attendances in June 2021 were "booked" in advance via NHS 111.[22] The figure was similar in February 2022. According to Healthwatch England people "really welcome" the opportunity to book emergency appointments via 111, provided they know about it.[23]

Management of the service

[edit]

In England, the service is accountable at a Clinical Commissioning Group level but was originally commissioned on a regional basis, with a number of service providers. NHS Direct staff provided some of the 111 service during the original launch of the number, with other providers including regional ambulance trusts, and out-of-hours GP providers.

The lack of clarity as to accountability was criticised in a Deloitte report into the service launch failure by NHS Direct. As of December 2013 all NHS Direct contracts are being serviced by "stability partner" organisations such as ambulance trusts or GP co-operative organisations.

The service operates 24 hours a day. When GP surgeries are closed normally between 6.30 pm and 8 am, at weekends and at Bank Holidays the service will refer many patients to an out-of-hours service. This can also happen if practices are closed for training purposes.[24]

The service uses a clinical decision support system which structures the response to a call, which may range from telephone advice to the dispatch of an emergency ambulance. Calls are initially assessed by a call handler and may be passed to a clinician. The service has been criticised for being too cautious and directing too many patients to A&E departments.[25] GPs have complained that the service has not been inspected by the Care Quality Commission and that it may jeopardise the safety of out-of-hours services.[26]

Between 2010 and 2015 the service has handled 24 million calls with an average call length of 14 minutes. Although 111 is a helpline for non-emergency cases, 10% of calls trigger the dispatch of an ambulance - 93,000 in the 12 months from April 2014 to April 2015.[27] A 2017 article in the British Medical Journal that studied the performance of the 111 service concluded that patients were "largely satisfied" with the service, while "its success against some key criteria has not been comprehensively proven."[28] Of calls answered by NHS 111 in March 2021, 78.2% were answered within 60 seconds. In March 2020 the figure was 30.2%.[29]

In January 2020 the Association of Ambulance Chief Executives called for a more joined up approach to the commissioning of 111, urgent care and ambulance services. The lead commissioner for 999 services is generally different, as those services operate over a wider area. The associations wants single regional specifications for integrated 999 and 111 provision, with no new tendering of 111 contracts which end this financial year. They want contracts for at least 5 year terms.[30]

West Midlands Ambulance Service took on the service across most of the West Midlands in 2019 but withdrew from the contract in 2022. NHS England is moving to larger geographical areas, advocating single virtual contact centres, allowing for calls to be answered quicker by utilising spare capacity across the country.[31]

Launch and initial service failures

[edit]

The first NHS 111 trial, in County Durham and Darlington, started on 23 August 2010. Nottingham, Lincolnshire and Luton began trialling the service later that year.

NHS 111 was launched in a limited number of regions in March 2013 ahead of a planned national launch in April 2013. The British Medical Association wrote to the Secretary of State for Health to request that the launch be postponed.[32] Its chair, Dr Laurence Buckman, warned that the service as "a disaster in the making", and recommended delaying the full launch for safety reasons.[33][34] The public sector trade union UNISON also recommended delaying the full launch.[35]

The initial launch was widely reported to be a failure.[36][37] On its introduction, the service was unable to cope with demand; technical failures and inadequate staffing levels led to severe delays in response (up to 5 hours), resulting in high levels of use of alternative services such as ambulances and emergency departments.[33] The problems led to the launch being delayed in South West England, London and The Midlands[38][39][40] and the service was suspended one month after its launch in Worcestershire.[41]

The NHS 111 service was gradually launched in England over the course of 2013, with the rollout being completed in February 2014.[4] It was announced in October 2013 that NHS Direct would be closed down in 2014.[42] The 111 number was launched in Scotland in April 2014.[5]

Coverage

[edit]

The 111 number for NHS services is currently available in all of England, Wales and Scotland. Coverage was extended to include crisis mental health support in 2024.[43]

As of early 2020, the NHS 111 service is available in Northern Ireland for advice relating to the COVID-19 outbreak.[9]

NHS 111 online is a triage system also available for members of the public aged 5 or over in England, owned by the Department for Health and Social Care, commissioned by NHSX and developed and delivered by NHS Digital. It used the NHS Pathways series of algorithms.[44]

Coronavirus

[edit]

During the pandemic, NHS England asked people with suspected COVID-19 infection to call 111. This was intended to reduce the risk of hospitals being overwhelmed by huge numbers of people who did not need to see a healthcare professional. An analysis by Yorkshire Ambulance Service showed that 111 triage has similar accuracy to the triage used in emergency departments and urgent care settings for other conditions suggesting it could be a good option for future pandemics.[45][46] Portions of the service were outsourced to Serco, Sitel, and Teleperformance, resulting in uneven service quality and an inability to record calls for feedback.[47]

A separate number NHS 119 is used for information and services relating to COVID-19 as of 18 May 2020. This number operates in England, Wales, and Northern Ireland, with lines being open from 07:00 to 23:00 hours. It allows people to book NHS drive through tests, order home testing kits, and apply for tests in a care facility.[48]

In Scotland, 0300 303 2713 is the non-geographical telephone number instead of 119.[48]

European number

[edit]

Within certain EU member states and territories a similar type of service may be available via the harmonised European number for medical advice 116 117 as one of a number of optional 'Harmonised Services of Social Value'.[49][50][51]

Cyber attack

[edit]

On 4 August 2022 at 07:00, Adastra, the computer system used by 85% of NHS 111 services was removed from service after a ransomware attack.[52] As of 11 August 2022, the service had not yet been restored [53] with some question as to whether patient data had been exfiltrated.[54] On 23 August 2022, London Ambulance Service was reported [55] to be the first service to return to use of Adastra after the cyber-attack, with no clarification of patient data leakage during the incident.

See also

[edit]

References

[edit]
[edit]
Revisions and contributorsEdit on WikipediaRead on Wikipedia

NHS 111

View on Grokipedia
from Grokipedia
NHS 111 is a 24/7 telephone and online triage service operated within England's National Health Service, designed to deliver clinical assessment and direct individuals with urgent but non-life-threatening health concerns—encompassing physical and mental conditions—to suitable care pathways, such as primary care consultations or emergency services. Launched in 2013 as a successor to the nurse-led NHS Direct, it employs standardized algorithms to streamline access to healthcare advice, reducing reliance on general practitioners or accident and emergency departments for non-critical issues. The service processes over 16 million calls yearly, with approximately 48% resulting in primary care dispositions, though empirical analyses indicate substantial mis-triage rates—potentially hundreds of thousands annually—correlating with unintended rises in emergency department attendances. Early implementations drew criticism for protracted wait times, inconsistent advice quality, and inadequate clinical oversight, prompting inquiries and operational adjustments. In 2024, enhancements integrated comprehensive mental health crisis support, marking one of the first national efforts to consolidate such access via a unified non-emergency line. Despite these developments, disparities persist in digital uptake, with lower usage among those without higher qualifications, highlighting access inequities tied to technological and demographic factors.

History

Origins and Pilot Programs

The NHS 111 service emerged as a response to limitations in the existing telephone helpline, which operated on the 0845 prefix and charged callers standard rates, complicating access for urgent but non-emergency health queries. In July 2010, the Department of Health announced plans for a new free-to-call service using the simple three-digit number 111 to provide faster and advice, distinct from the 999 emergency line, with the intent to eventually supplant nationwide. Pilot programs commenced in four English regions to evaluate the model's feasibility, beginning with and in August 2010, operated by the North East Ambulance Service. Subsequent launches followed in Nottingham City, , and between October and December 2010, with these sites managed by . These pilots served populations totaling approximately 1.8 million and handled 277,163 calls in their first operational year, focusing on telephone-based clinical assessment to direct callers to appropriate care pathways such as GP visits, pharmacies, or emergency services. Independent evaluations of the pilots, commissioned by the Department of Health and conducted by the , assessed service uptake, clinical safety, and integration with local urgent care systems, revealing initial substitution effects where callers shifted from without overall reductions in emergency ambulance dispatches. The pilots informed refinements to protocols and before broader implementation, highlighting challenges in achieving consistent response times and clinician availability across diverse provider models.

Nationwide Rollout and Replacement of NHS Direct

The nationwide rollout of in began in phases starting from February 2013, following pilots in select areas since December 2010, with the service designed to supplant 's nurse-led telephone advice line on 0845 4647. Initially planned for full implementation across by 1 April 2013, the timeline encountered delays due to commissioning complexities and performance shortfalls, extending the deadline to October 2013 in some regions. Early rollout phases revealed acute operational strains, particularly around Easter 2013, where increased call volumes overwhelmed capacity, leading to handover rates to ambulance services exceeding 20% in affected areas and prompting temporary reliance on for coverage. , which had secured 11 of 46 regional contracts for NHS 111 delivery, withdrew from all by July 2013 after identifying unsustainable risks, necessitating rapid reprocurement by local commissioners and alternative providers like private firms and ambulance trusts. These disruptions highlighted algorithm limitations and staffing shortages compared to 's model, which employed more qualified nurses. By February 2014, the service achieved full coverage in , with NHS Direct's operations fully phased out on 31 March 2014, marking the complete replacement nationwide except in , where NHS 24 transitioned to 111 in April 2014. The rollout integrated NHS 111 as the unified non-emergency access point, redirecting approximately 20 million annual calls previously handled by to a system emphasizing clinical assessment by trained advisors using standardized protocols. Post-transition, reported stabilization, though initial data indicated higher unintended referrals to emergency departments than anticipated.

Post-Rollout Evolution and Digital Expansion

Following the nationwide rollout completed by March 2015, NHS 111 underwent operational refinements to handle escalating demand, with monthly call volumes increasing from 1.1 million in January 2015 to 1.6 million by January 2025. These changes included integration into broader Integrated Urgent Care frameworks, enhancing triage linkages to and services, as evidenced by dispositions directing approximately 48% of callers to options based on analysis of over 16.6 million annual calls. Empirical evaluations post-2015 highlighted persistent challenges in reducing referrals, with one study of 2015–2017 calls finding that for every 20 cases where 111 advised against ED attendance, one resulted in avoidable ED visit within 24 hours. A key aspect of post-rollout evolution was the introduction of digital alternatives to supplement telephone triage. NHS 111 online, launched in 2017 following pilot implementations in select areas, employs the NHS Pathways clinical assessment system to enable self-triage via a web interface, yielding around 550,000 completed assessments monthly by 2025. This service expanded access for digitally literate users but showed minimal effect on overall telephone demand, as quantitative impact assessments indicated no significant reduction in triaged or total calls post-launch. Digital expansion accelerated with integration into the NHS App, announced in January 2023, allowing over 30 million registered users to initiate 111 digitally and book into urgent care pathways directly. By 2025, policy directives emphasized "digital first" approaches, urging online symptom checks via 111 or the app before A&E attendance to optimize resource allocation. Further enhancements encompassed specialist paediatric advice lines and virtual ward referrals, rolled out regionally by September 2023, alongside adaptations in 2020 that directed users to online assessments. Long-term plans target full app-enabled booking for urgent services by 2028.

Operations and Management

Triage Process and Clinical Protocols

The triage process for NHS 111 begins with callers connecting to trained health advisors, who are non-clinician staff, to gather initial details including the caller's identity, location, reason for calling, and whether the concern pertains to themselves or another individual. These advisors employ the NHS Pathways system, a clinical decision support tool comprising algorithm-driven pathways that prompt structured questioning based on reported symptoms to determine urgency and appropriate disposition. NHS Pathways functions as a non-diagnostic triage mechanism, prioritizing symptom-led assessment over clinical diagnosis to categorize needs and route callers to self-care advice, pharmacy consultation, general practitioner referral, urgent treatment centers, emergency departments, or ambulance services as required. Clinical protocols within NHS Pathways are derived from evidence-based guidelines, with pathways structured as flowcharts that guide advisors through escalating questions to identify potential risks, such as life-threatening conditions. The system supports remote assessment for urgent and emergency care direction, incorporating dispositions that may involve clinician callbacks for further evaluation by nurses or paramedics if the initial triage indicates complexity beyond advisor scope. Protocols are maintained through a clinical enquiries management process, where healthcare professionals submit and review updates to ensure alignment with evolving medical evidence, with changes implemented following rigorous validation to minimize errors in real-time triage. In practice, the triage adheres to safety-first principles, aiming to reduce inappropriate attendance by directing lower-acuity cases elsewhere, though the system's reliance on caller-reported data can introduce variability in accuracy. For higher-risk cases, protocols mandate immediate escalation to 999 services or clinical hubs, with performance monitored against standards like response times and disposition appropriateness. The same algorithmic framework underpins NHS 111 online , ensuring consistency between and digital modalities in .

Commissioning, Providers, and Staffing

NHS 111 services in are commissioned by local Integrated Care Boards (ICBs), which replaced Clinical Commissioning Groups in July 2022, as part of broader Integrated Urgent Care (IUC) frameworks to ensure coordinated access to urgent care including telephone triage, clinical assessment, and referrals to GP out-of-hours or emergency services. National oversight and service specifications are provided by , mandating standards for patient feedback mechanisms, performance monitoring, and integration with digital tools like NHS Pathways for clinical decision-making. Contracts typically cover 24/7 operations, with commissioning focused on outcomes such as reduced inappropriate A&E attendances and efficient , often bundled with out-of-hours GP services to streamline urgent care pathways. Service delivery is outsourced through competitive tenders to a mix of organizations and NHS trusts, reflecting a model where local ICBs select providers based on capacity to handle call volumes exceeding 20 million annually. Notable providers include DHU Healthcare, which secured the regional contract in May 2024 covering multiple counties, and Practice Plus Group, operating eight NHS 111 contracts including sites in , , and as part of IUC bundles. Other operators encompass entities like PHL Group for clinical assessment services and regional NHS-led providers such as HUC for integrated 111 and out-of-hours care. Contracts emphasize performance metrics like answer times under 60 seconds for 90% of calls and clinician availability for complex triages, with telephony infrastructure supported by partners like under agreements. The workforce comprises non-clinical call handlers for initial assessments, healthcare advisors, and qualified clinicians including nurses, paramedics, and pharmacists trained in the to standardize and reduce variability. As of December 2023, NHS 111 employed 4,645 call handlers nationwide, representing a 4.7% increase from the prior year to address peak demand periods. supports workforce development through blueprints emphasizing role optimization, in remote clinical assessment, and drives, though providers manage day-to-day staffing under stipulations for minimum ratios during high-activity hours.

Coverage and Service Availability

NHS 111 operates as a free, nationwide non-emergency service across , , , and [Northern Ireland](/page/Northern Ireland), providing 24/7 access for urgent medical advice when services are unavailable. The phone line, dialed as 111, connects callers to trained advisors who symptoms using standardized clinical protocols, directing users to appropriate care such as pharmacies, GPs, or emergency services as needed. Calls are free from both landlines and mobiles, with no geographic restrictions within the , making the service available to residents, visitors, and anyone requiring assistance for non-life-threatening conditions. Digital access complements telephone services, particularly in where NHS 111 online at 111.nhs.uk offers symptom assessment for individuals aged 5 and over, operating continuously as an alternative to calling. Children under 5 and those preferring voice interaction must use the phone line. In , the 111.wales.nhs.uk platform provides 24/7 online health advice, symptom checkers, and tools for managing appointments and prescriptions. Scotland's NHS 24 integrates 111 calls with online symptom checkers via nhsinform.scot, supporting 24/7 access including textphone options for hearing impairments and multilingual support. Regional commissioning leads to operational variations, but core availability remains consistent: the service excludes life-threatening emergencies, which require dialing 999, and integrates mental health crisis support where callers may be transferred to specialists. Peak demand occurs evenings and weekends, potentially resulting in wait times or callbacks, though targets aim for rapid access. Northern Ireland's implementation, rolled out from 2020, aligns with this model under the framework, ensuring UK-wide equity in non-emergency .

Effectiveness and Impact

Empirical Outcomes and Cost Analyses

NHS 111 handled 22.3 million calls in the 2022/23 financial year, reflecting sustained high demand amid winter pressures. Empirical studies of outcomes indicate mixed effectiveness in diverting patients from emergency departments (EDs). An analysis of 16.6 million calls from 2015–2017 found that 77.8% received non-ED advice, yet 5.4% resulted in avoidable ED attendance within 24 hours, equating to approximately one avoidable visit per 20 such calls. Clinical input during calls reduced the odds of avoidable ED attendance (adjusted OR 0.52, 95% CI 0.51–0.53), highlighting the role of involvement in improving accuracy. Further evidence from 3.6 million calls in (2013–2017) revealed that 76.2% were disposed to or , but 11% of these attended ED within 48 hours, with 37% of those requiring admission, suggesting substantial mis-triage of low-acuity cases and contributing to hundreds of thousands of potentially avoidable ED visits annually. metrics show no significant reduction in emergency dispatches post-implementation, and while 87% of callers reported satisfaction, concerns persist over inappropriate referrals and failure to meet targets like 95% of calls answered within 60 seconds. has claimed over 12 million unnecessary A&E visits averted, but this lacks robust independent verification and contrasts with data showing persistent high ED utilization following 111 contact. Cost analyses underscore operational efficiencies in specific modalities but limited systemic cost-effectiveness. Pilot costs averaged £12.26 per call, with no established overall value in reducing downstream service use. A cost-consequences evaluation of NHS 111 versus found online contacts at £39 per person compared to £106.80 for telephone, yielding £67.90 savings per case, primarily from lower subsequent urgent care utilization. National projections indicated potential savings if online substitution exceeded 38% of telephone volume, though self-selection biases and short-term data limit generalizability. Broader impacts on urgent care costs remain difficult to quantify, with frameworks developed for assessment but concluding that cost-effectiveness has not been definitively proven.

User Experiences and Satisfaction Data

The NHS 111 service has garnered mixed user feedback, with official surveys indicating moderate overall satisfaction. In the period from October 2023 to March 2024, 74.3% of surveyed patients reported being very or fairly satisfied with the service, while 20.1% were very or fairly dissatisfied. These figures derive from follow-up surveys conducted with callers across integrated urgent care contract areas in , focusing on aspects such as advice utility and service accessibility. Positive experiences often highlight the service's role in providing reassurance and directing users away from higher-acuity care. Approximately 75% of NHS 111 online users found the advice helpful, with 67.5% complying with recommendations, though telephone users reported higher rates of perceiving advice as "very helpful" and full compliance. Many users appreciate the non-emergency , noting it prevented unnecessary visits to accident and departments; surveys consistently show that without NHS 111, a substantial portion of callers would have sought GP appointments or emergency care instead. Dissatisfaction frequently centers on operational delays and accuracy. Around 13% of users in a Healthwatch report cited difficulties contacting the service, primarily due to extended waiting times, with callbacks often delayed 3-6 hours. Online users exhibit lower satisfaction than users, with only 50% rating it as "very satisfied" compared to 71% for calls, and they are less likely to recommend the service (57% very likely versus higher for ). Anecdotal reports include instances of misdiagnosis, such as overlooked , and failures in referral handovers to other services, contributing to user frustration despite generally positive aggregate feedback.

Broader Systemic Effects

The introduction of NHS 111 aimed to divert non-emergency cases from accident and emergency (A&E) departments, services, and general practitioners, thereby optimizing across the urgent care system. However, empirical analyses of pilot implementations revealed no overall reduction in emergency calls or A&E attendances, despite a 19.3% decrease in calls to the predecessor service. Patient surveys have estimated that NHS 111 prevented up to 8 million additional A&E or visits over three years ending in 2017, based on self-reported diversions, though these figures rely on subjective compliance data rather than objective utilization metrics. Linked dataset analyses of over 16 million calls from 2015–2017 indicated that for every 20 instances where NHS 111 did not recommend A&E attendance, one avoidable ED visit occurred within 24 hours, suggesting modest but imperfect efficacy in reducing downstream emergency demand. Approximately 48% of calls are triaged to dispositions, such as GP consultations, potentially shifting workload to already strained services amid broader access challenges. This redirection has not demonstrably alleviated waiting times, as modeling studies highlight persistent demand pressures without corresponding capacity expansions. Economic evaluations framework NHS 111's value through cost-consequence models, comparing service delivery expenses against potential savings from averted contacts, yet comprehensive nationwide cost-benefit data remains limited, with pilots showing neutral net impacts on urgent care utilization. The service's reliance on non-clinician staff for initial has been critiqued for funneling borderline cases to A&E, exacerbating queue pressures without robust remote assessment safeguards. Expansions like NHS 111 Online have minimally offset demand, with some users forgoing further care (31% vs. 16% for users) but others receiving higher rates of referrals, indicating variable systemic relief. Overall, while facilitating centralized , NHS 111 has not substantially mitigated escalating NHS-wide pressures from demographic shifts and post-pandemic backlogs.

Controversies and Challenges

Launch Failures and Early Incidents

The national rollout of in commenced in early amid high expectations for streamlining non-emergency care, but the service rapidly encountered operational breakdowns. Within the initial weeks, seven "potentially serious" incidents were documented, stemming from breaches, IT system failures, telephony disruptions, and failures to provide appropriate clinical advice. By May , this escalated to 22 serious untoward incidents, including three patient deaths under investigation; one case involved a 47-year-old individual who succumbed to a suspected overdose after family members repeatedly failed to connect with the service despite urgent calls. Callers frequently faced prolonged delays, with reports of holds extending to hours, overburdened lines preventing connections, and inconsistent triage leading to inappropriate ambulance dispatches or referrals. responded by initiating an inquiry into systemic deficiencies, including poor-quality advice, inadequate clinical oversight, and sluggish response protocols that risked . These lapses prompted medical leaders to criticize the service for sowing confusion among users, resulting in avoidable burdens on hospital departments handling redirected minor cases. The fallout necessitated delays in the full rollout, postponing nationwide coverage until 2014 in areas like , , and , where services were temporarily suspended or scaled back. Early data from rollout sites indicated unintended consequences, such as a monthly 3% rise in ambulance incidents—equating to roughly 24 additional call-outs per 1,000 NHS 111 interactions—attributed to over-cautious triage algorithms and referral pathways. Despite pilot evaluations from 2010–2012 showing reasonable user acceptability in controlled settings, the scaled national deployment exposed underestimations of demand volume and resilience.

COVID-19 Response and Overload

In response to the emerging , guidance directed individuals with symptoms to contact NHS 111 rather than general practitioners or emergency departments, resulting in a sharp surge in demand beginning mid-February 2020. In March 2020, the service received 2,962,751 calls offered, equivalent to 95,600 per day—more than double the 46,700 daily average from March 2019—while weekly volumes escalated from 300,000–350,000 to 800,000. This influx overwhelmed system capacity, with only about 50% of calls answered and 38.7% abandoned after waiting longer than 30 seconds, compared to 2.4% abandonment in March 2019; merely 30.2% of calls were answered within , versus 85% the prior year. Long queues formed for clinician callbacks, and routing errors directed many queries to the core NHS 111 service instead of the newly established Response Service (CRS), exacerbating delays. To address the crisis, launched the CRS in March 2020, recruiting nearly 6,000 additional call handlers and handling approximately 1.2 million -related calls through spring 2020, separate from standard NHS 111 metrics. Broader response services, including CRS components, managed over 2.8 million calls from February 2020 to March 2022. Healthcare Safety Investigation Branch (HSIB) scrutiny revealed safety gaps, including inadequate clinical assessment of comorbidities in early calls, leading to advice that delayed hospital admission for some patients with vulnerabilities; for instance, certain callers received no review despite risks. NHS Pathways algorithms underwent 35 updates in 2020—far exceeding the typical 6–7 annually—but some symptom recognitions, such as loss of taste or smell, were added with delays. A subsequent analysis of over 40,000 calls from March to June 2020 found the process reliably identified cases requiring urgent care, with low rates of adverse outcomes among those directed to .

Cyber Attacks and Security Vulnerabilities

In August 2022, the LockBit ransomware group targeted Group (Advanced), a key third-party provider of software for NHS 111 services, leading to widespread disruptions across the . The attack encrypted systems used for patient check-ins, medical notes, and NHS 111 , rendering the online service unavailable and impairing call handling in multiple regions for several days. It affected nine NHS trusts, disrupting ambulance referrals, access to patient records, and social care operations, with some healthcare staff unable to view critical data during the outage. The breach exposed sensitive data of 82,946 individuals, including medical records, phone numbers, and home access details for 890 patients receiving care packages. Advanced's security shortcomings, such as failure to implement on remote access tools, inadequate , and unencrypted storage of , directly enabled the intrusion and . These vulnerabilities highlighted risks in the NHS's reliance on external suppliers, where a in the could cascade to national services handling millions of non-emergency calls annually. In response, the (ICO) issued a monetary penalty notice in March 2025, fining Advanced £3.07 million—reduced from an initial £6.1 million proposal after settlement—for violations of the UK GDPR, including insufficient data protection impact assessments and delayed breach reporting. NHS England activated contingency plans, diverting calls to manual processes and alternative systems, though full restoration took weeks and underscored ongoing third-party risk management gaps. No further major cyber incidents specific to NHS 111 have been publicly reported as of October 2025, but the event prompted enhanced cybersecurity mandates for suppliers, including regular penetration testing and zero-trust architectures, amid broader NHS efforts to fortify digital infrastructure against targeting healthcare.

References

  1. https://www.england.nhs.uk/urgent-emergency-care/nhs-111/accessing-nhs-111/
  2. https://www.nhs.uk/nhs-services/urgent-and-emergency-care-services/when-to-use-111/
  3. https://www.hssib.org.uk/patient-safety-investigations/response-of-nhs-111-to-the-covid-19-pandemic/investigation-report/
  4. https://pharmaceutical-journal.com/article/feature/the-evolution-of-nhs-111
  5. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0300193
  6. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0251362
  7. https://www.bmj.com/content/346/bmj.f3382
  8. https://www.bmj.com/content/349/bmj.g5393
  9. https://www.england.nhs.uk/2024/08/nhs-111-offering-crisis-mental-health-support-for-the-first-time/
  10. https://www.ncbi.nlm.nih.gov/books/NBK593433/
  11. https://www.theguardian.com/politics/2010/aug/27/nhs-direct-health-phone-service
  12. https://www.gov.uk/government/news/rolling-out-the-nhs-111-service
  13. https://www.england.nhs.uk/wp-content/uploads/2013/04/030512-item8.pdf
  14. https://pubmed.ncbi.nlm.nih.gov/24231457/
  15. http://data.parliament.uk/DepositedPapers/Files/DEP2012-1694/HL3309-LibDoc.pdf
  16. https://pmc.ncbi.nlm.nih.gov/articles/PMC3831104/
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  18. https://www.bbc.com/news/health-18450428
  19. https://www.hsj.co.uk/analysed-the-rollout-of-nhs-111/5052244.article
  20. https://publications.parliament.uk/pa/cm201314/cmselect/cmhealth/171/171vw25.htm
  21. https://www.bmj.com/content/347/bmj.f6482
  22. https://pmc.ncbi.nlm.nih.gov/articles/PMC5623427/
  23. https://www.england.nhs.uk/2013/10/111/
  24. https://www.nuffieldtrust.org.uk/resource/nhs-111
  25. https://bmjopen.bmj.com/content/10/3/e032043
  26. https://digital.nhs.uk/services/nhs-111-online
  27. https://bmjopen.bmj.com/content/12/7/e058964
  28. https://www.journalslibrary.nihr.ac.uk/hsdr/HSDR09210
  29. https://pmc.ncbi.nlm.nih.gov/articles/PMC9316045/
  30. https://www.england.nhs.uk/2023/01/expansion-of-nhs-111-to-transform-patient-access/
  31. https://www.telegraph.co.uk/news/2025/10/24/emergency-go-online-before-going-to-ae-nhs-urges-patients/
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