NHS 111 Wales website: an evaluation of signposting changes

Introduction

NHS 111 is a free-to-call UK NHS telephone service available 24 hours a day, seven days a week, aimed at helping people to get the right advice and treatment when they urgently need it.¹ Whilst NHS 111 offers this telephone-based service, there is an increasing drive to provide more services and access to information through ongoing digital transformation (NHS Long Term Plan, 2019), including online content, websites, online symptom checkers, APP-based care, and interfaces with wearable technologies.

In Wales, the Minister for Health and Social Services published ‘Six Goals for Urgent & Emergency Care.² This strategic plan is based on patients accessing the right treatment, at the right time, in the right place, and the NHS 111 Wales website serves to achieve some of these outcomes and was visited by over 3 million users in 2021.³ The 111 Wales website allows patients to access healthcare advice and signposting online via 76 symptom checkers, approximately 1,000 health encyclopaedia articles, and a searchable directory of health and community services.
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This article describes, discusses and, to an extent, evaluates a proactive change made to the NHS 111 Wales website, designed to signpost patients directly to pharmacy-based services instead of the telephone-based NHS 111 Wales service over the 2022 Jubilee four-day bank holiday weekend, using the previous 2022 Easter four-day bank holiday weekend as a comparison.

It is hoped that the findings and discussion from this comparison work can inform the use of such tactics in the general design of 111 websites, the management of further public holidays, and inform signposting for other practice areas, such as physiotherapy and ophthalmology.

NHS 111 calls suitable for pharmacy

UK NHS 111 services continue to receive a significant number of calls for urgent repeat prescriptions, which have historically peaked over bank holidays and weekends.⁴ Such calls often result in booking patients into the NHS 111 Clinical Support Hub, or General Practice Out of Hours (GPOOH) slots, for assessment, obtaining a prescription, arranging for collection, and writing up clinical notes. This all takes up time, which could be used for assessing and managing patients with other complicated and often higher acuity needs.

However, to truly comply with the Six Goals strategy,² such patients should not even be triaged or managed by NHS 111 services; rather, many should contact local pharmacists directly, and the NHS 111 Wales website and telephony messaging should act as a signpost to such services.

Access to unplanned care is offered through community pharmacies in the way of self-care advice, sale of over-the-counter medications, and via the Clinical Community Pharmacy Service, which is currently available from 98.8% of community pharmacies in Wales⁵ and comprises three unplanned care services which are available to all residents of Wales, including those who are temporarily resident. They are provided by registered and accredited pharmacists using the Choose Pharmacy software system. Table 1 provides an outline of these services.

Table 1. Pharmacy services

The Emergency Medicines Service (EMS)	The  EMS uses regulation 225 in the Human Medicines Regulations 2012,6 which permits a pharmacist to supply Prescription Only medicines (POM) to patients where there is an immediate need for the medicines, which is not practicable to obtain a prescription without undue delay. The NHS-funded service remunerates the pharmacy for the medicines supplied and the time taken to complete the supply and documents this in the Choose Pharmacy software system. However, owing to limits in the legislation, medicines can only be supplied to patients where they have previously been prescribed by a UK or European Economic Area (EEA) prescriber, and certain controlled drugs cannot be supplied via this route.
The Common Ailment Scheme (CAS)	The CAS covers 28 common ailments, including head lice, hay fever and thrush. Under this service, accredited pharmacists can provide free advice and a range of evidence-based treatments, many of which are over-the-counter medicines, but also include a selection of prescription-only medicine provided under patient group direction. The service can be used by any patient who lives in Wales or is registered with a Welsh GP practice, and the GP will be sent information about the advice and treatment they have received. The service was used 74,624 times in 2020-2021.7
The Emergency Contraception Service	The Emergency Contraception Service provides free access to emergency hormonal contraception under PGD and includes advice on safer sex and sexual health. It is delivered in a private consultation with the pharmacist in the pharmacy consultation room. The service was used 25,523 times in 2020-2021.7
The Choose Pharmacy System	The Choose Pharmacy clinical system enables the pharmacist to access the Welsh GP Record for the patient, allowing them to confirm, amongst other things, what medication is currently prescribed for the patient, including the strength and dosage.

Accessing care in the right way at the right location

Calls to UK NHS 111 service for repeat medication requests predominantly relate to the patient not being able to access their usual supply owing to the prescription not having been requested on time, it not having been passed to their pharmacy, or their usual pharmacy being closed. In addition, tourists forget to bring one or more of their medicines on holiday with them, which is a common reason for such calls during the peak holiday season and Bank Holiday weekends.

Many of these calls could be handled by the Emergency Medicines Service offered by almost all community pharmacies in Wales (Table 1), as seen in the work by Nazar et al, where 65% of referrals from NHS 111 in England were given an emergency supply of medication⁸ as opposed to being referred to a prescribing pharmacist or one of the GPs working in the NHS 111 or GPOOH service; a model that NHS 111 Wales also operates.

Morecroft et al showed that emergency supply requests in community pharmacies in England historically increase over a bank holiday period;⁴ especially during Easter, and NHS England estimates that up to 30% of all calls to NHS 111 services on a Saturday are for urgent requests for repeat medication.⁹ This year for NHS 111 Wales, a significant proportion of the Easter demand was for medication requests. In addition, an internal analysis conducted by Betsi Cadwaladr University Health Board over the 2022 Easter bank holiday period noted that requests for repeat medication were the top clinical code entered in the clinical patient management software system over the whole four days and that the number of these requests were highest on the Friday and Saturday, which are indicative of normal non-holiday behaviour.

Table 2 outlines the medication requests made to NHS 111 Wales, covering all health boards for the 2022 four-day Easter holiday. Showing that Friday and Saturday were similarly the busiest.

Table 2. Medication requested via 111

Method

Several interventions were implemented between the Easter and Jubilee bank holidays (Table 3). These were primarily aimed at patients who accessed the NHS 111 Wales service via the phone with medicine requests and were designed to prompt behaviour change amongst this group steering them towards accessing care from more appropriate services and, in particular, the Emergency Medicine Supply Service from community pharmacy. However, messaging was also included about other available pharmacy services.

A banner was added to the top of every page on the NHS 111 Wales website.

The banner temporarily replaced a banner that gave coronavirus advice and contained a link to a new webpage comprising out-of-hours advice and signposting users to the services in table 1. The banner and out-of-hours services webpage was added to the website on May 23 2022, ten days before the four-day Jubilee Bank Holiday weekend, allowing users time to act on the advice, particularly regarding the ordering and collection of repeat prescriptions.

Communications strategies used by NHS 111 Wales and the seven Local Health Boards (LHBs) across the two bank holiday weekends were largely the same, apart from the changes made to the NHS 111 Wales Website. Table 3 outlines these communication strategies and evidences the degree of consistency, which is helpful by way of consistent comparison.

Table 3. Communication Strategy

Communication Strategy	Easter	Jubilee
NHS 111 Wales and LHBs social media adverts and posts.	x	x
Communications were sent from NHS 111 Wales via the Community Pharmacy Lead in each LHB to ask them to remind patients of upcoming bank holidays and encourage them to order prescriptions in plenty of time from their surgery for any regular medications they may need.	x	x
Communications were sent from NHS 111 Wales via the Community Pharmacy Lead in each LHB to ask them to actively promote their opening hours over Bank Holiday weekends to encourage patients to collect any medicines they need ahead of time.	x	x
Communications were sent from NHS 111 Wales, via the Community Pharmacy Lead in each LHB, to ask pharmacists who were unable to meet the patient’s request via the Emergency Medicines Supply Service to support patients to access the service at another pharmacy or, where this was not available, to consider the urgency of the medicine request, and only advise a patient to call NHS 111 where it was deemed essential.		x
The Interactive Voice Response (IVR) system message for the 111 Wales phone service was amended, and a section was added, signposting patients to the NHS 111 Wales website for information on pharmacy services.		x
A banner was added to the top of every page on the NHS Wales 111 website, signposting users directly to pharmacy services.		x

NHS 111 Wales uses a data visualisation and discovery platform to collect and review call data entered into the 111-computer decision support system, where calls are passed on to the Clinical Support Hub or GPOOH clinicians that the Adastra Clinical management system records data.

All the call data for the out-of-hours period of each bank holiday weekend was collected and analysed. The out-of-hours period was defined as being from 6 pm the evening before the bank holiday commenced until 8 am on the morning after the last day of the bank holiday weekend.

The call data was extracted, and advanced filters in Table 4 were applied to identify calls that pertained to medicines advice and repeat prescription queries only. In addition, further filters in Table 4 were applied to remove calls that were unlikely to be suitable for a community pharmacy to deal with, for example, calls about palliative patients or where an overdose had occurred.

Table 4. Filters used

Advanced Filters to identify valid cases	Script Medicine Meds Pump Inhaler Run out Medication
Further Filters to exclude the invalid cases	Overdose Silent Ingest Palliative End of life

A request covering the same periods was submitted to Digital Health and Care Wales (DHCW) for the data from the Choose Pharmacy platform. Google Analytics was used to obtain usage data for the NHS 111 Wales website.

Results

During the period that the banner was available, the new OOH page on the NHS 111 Wales website received 2,218 unique visits making it the 18^th most visited page on the website over that time. In addition, medicines request calls formed 5.2% of all calls for both bank holiday weekends. Although this does not show a reduction in telephone call volume on the NHS 111 Wales service, it does not show the increase in demand that the authors envisaged due to nuances of the Jubilee bank holiday, discussed later.

Table 5 shows the data for calls received by the NHS 111 Wales service over both bank holiday weekends and the final outcome recorded by the computer decision support system for medicine request calls.

Table 5. Total number of calls to NHS 111

Total number of calls to NHS 111 Wales		Easter Weekend	Jubilee Weekend
		20,808	18,667
Final outcome of NHS 111 Wales medication request calls	GPOOH	676 (62%)	639 (65.7%)
	Self-Care / No Further Action	183 (16.8%)	112 (11.5%)
	Pharmacist	148 (13.6%)	153 (15.7%)
	Other Outcome	35 (3.2%)	15 (1.5%)
	Primary Care Services	19 (1.7%)	21 (2.1%)
	Health Information/Quick Call	17 (1.6%)	18 (1.9%)
	Failed Contact	5 (0.5%)	8 (0.8%
	111 First	4 (0.4%)	2 (0.2%)
	Administration	2 (0.2%)	5 (0.5%)
	Referral to Secondary Care	1 (0.1%)	0
Total		1090	973

The percentage of filtered calls resulting in a prescription issued by NHS 111 Wales fell between the weekends from 59% over Easter to 52% over the Jubilee weekend. However, the Emergency Medicine Supply Service saw an increase of 18.17% in consultations over the same period, while the Common Ailments Service and the Emergency Contraception Service saw a combined increase of 12.14%.

As part of the Emergency Medicines Supply Service and Common Ailment Service, the pharmacist asks the patient what action they would have taken if their chosen service had not been available. The Choose Pharmacy platform also captures this data.

Table 6 shows the data from the Choose Pharmacy platform for the Emergency Medicine Supply Service.

Table 6. Unique consultations 

Count of Unique Consultations (Emergency Medicine Supply Service)	Easter weekend	Jubilee weekend
	1420	1678
Count of patient action if medicine had not been supplied
A&E urgent service	24 (1.7%)	24 (1.4%)
Contacted GP practice	50 (3.5%)	79 (4.7%)
Gone without medicine	647 (45.6%)	749 (44.6%)
NULL	9 (0.6%)	3 (0.18%)
Other	15 (1.1%)	20 (1.2%)
Out of Hours Service	675 (47.5%)	803 (47.9%)

The data for Emergency Contraception Service and the Common Ailment Service is summarised in Table 7.

Table 7. Unique consultations

Count of unique consultations	Easter weekend	Jubilee weekend
Common Ailments Scheme	456	523
Count of patient action if medicine had not been supplied
Attended the accident and emergency department at a hospital	2 (0.4%)	1 (0.2%)
Bought medication from the pharmacy	86 (18.9%)	93 (17.8%)
Called NHS Direct or NHS 111 for advice	12 (2.6%)	16 (3.1%)
Done nothing	12 (2.6%)	12 (2.3%)
Made an appointment to attend the out-of-hours service	30 (6.6%	37 (7.1%)
Made an appointment with a GP	308 (67.5%)	360 (68.8%)
Made an appointment with a nurse or health visitor	1 (0.2%)	1 (0.2%)
Made an appointment with another healthcare professional	4 (8.8%)	3 (0.6%)
Count of Unique Consultations (Count of Patient Action If Medicine Had Not Been Supplied is not available for the Emergency Contraception Service)
Emergency Contraception Service	250	274

Discussion

Users of urgent and unscheduled care have historically faced issues, including a lack of awareness of available services and a lack of understanding over which service to access.¹⁰ In Wales, Goal two of the Six Goals strategy aims to “signpost people with urgent care needs to the right place, first time”.² The interventions described in this exercise were designed with that goal in mind, to direct patients away from calling the NHS 111 Wales telephone service for medicines requests and for them to attend a community pharmacy to receive care quicker and from the most appropriate source. The authors are aware that other possible factors may have caused the reduction in NHS 111 prescriptions and increased use of pharmacy services seen in the results; however, while it is not possible to directly assign these to the interventions described in this work, the website intervention cannot be ignored – with 2,218 unique visits.

There was an expectation that the cohort of patients requiring prescription services would increase from the already high levels seen over the Easter weekend because of the unique format of the Jubilee bank holiday weekend. Elderly patients account for 60.4% of prescription items,¹¹ and it is reasonable to assert that because these patients are not part of the workforce, they are less aware of the occurrence of bank holidays and are, therefore, more likely to experience prescription supply issues over these periods. Taking this into account, along with the Jubilee bank holiday being four days in length, not a usual annual event and also incorporating a Thursday for the first time, the authors were expecting a significant increase in demand for the NHS 111 Wales telephone service compared to Easter as patients may not have factored this holiday into their regimes.

Across the UK, Easter has traditionally placed greater demands on urgent care than other bank holidays, as demonstrated by Harcourt et al.¹² They reported the highest call rates to NHS 111 in England in 2014 on Easter Saturday. In Scotland, calls from the Royal College of Emergency Medicine over concerns of increased health and social services pressure during the Christmas and Easter festive periods led to a public holiday review report.¹³ This recognised that the closure of many associated services and the prolonged nature of the holiday (four-day bank holiday, for example) were contributory factors in placing greater pressures on the health and social care sector than other bank holidays. There were greater pharmacy trading hours over the Jubilee bank holiday rather than Easter due to larger pharmacies and pharmacies within supermarkets being forced to close by law,

The static nature, or indeed, arguably the containment of the growth of medicine request calls over the Jubilee holiday, rather than a marked increase, is a positive result and perhaps demonstrates that some behaviour change did occur amongst patients making medicines requests as a result of interventions such as the website banner with the new OOH information page which had 2,218 unique visits amongst others.

The results from the Choose Pharmacy platform demonstrate that community pharmacies can help to reduce demand for the NHS 111 Wales telephone service. This is particularly true of the Emergency Medicine Supply Service, where 47% of patients would have contacted NHS 111 Wales to obtain their medication if the service was unavailable. Almost 50% of patients stated that they would have gone without their medicine if the service had not been available, and these results mirror those seen elsewhere.¹⁴

This could have led to an increase in patient safety issues and subsequent admissions due to patients missing critical medications such as insulin. The greater increase in the use of The Emergency Medicine Supply Service suggests that patient behaviour had altered, most likely due to an increased awareness of the service, possibly due to the new web page. Potentially the reduction in the percentage of filtered calls resulting in a prescription from the NHS 111 service could also be attributed to the increase in the use of the Emergency Medicine Supply Service.

This usage was driven by the presence of a clear and simple banner on every page of the website. The intervention described in this article was simple, and its application required little effort and the use of resources. If such an intervention did lend itself to behavioural change, reduction in NHS 111 demand, and more prompt and appropriate patient care, the demonstrated impacts greatly exceeded the work involved in its implementation. Thus, exploring how such interventions may work for other practice areas is important. haler and Sunstein¹⁵ named and popularised the “Nudge theory” and introduced the concept of “mapping” in health care. haler and Sunstein suggested that choice architecture could improve patients’ ability to map choices into end results and to select options that would lead to improved outcomes.

Future work will move towards further improvements to the scope of the OOH web page, in particular widening the information provided to include not just pharmacy services but also those unplanned care services offered by other associated health professions such as opticians who offer the Eye Health Examination Wales service which includes urgent eye care and also LHB physiotherapy services that offer self-referral options without the need for pre-assessment by NHS 111 for conditions such as lower back pain. The benefits of this approach are twofold for NHS 111. Firstly, by signposting patients via the NHS 111 Wales website whose needs can be accommodated by a more appropriate service than NHS 111, there is a potential to reduce unnecessary calls to the phone service and free up valuable clinician time to provide a prompter service to patients. The second benefit is that with the reduction in calls, it should be easier for those patients with more complex needs to access the phone service and receive the care they require faster.

Intervention-based work, using the NHS 111 Wales website, has scope to improve other urgent and unscheduled care areas, such as ED admissions for minor illnesses and injuries. As the prevalence of Pharmacist Independent Prescribers increases, for example, services such as Sore Throat Test and Treat and other infection testing and treatment becomes more widespread; ensuring patients have easy and, if required, engineered access to information at key times of the year will be vital. Fielding et al¹⁶ also showed that GP and ED consultations for minor ailments place a significant cost burden on the NHS as these are higher-cost settings. This is also true for a consultation with an NHS 111 clinician for routine medication requests when compared to a community pharmacy supply.¹⁴ The cost implications of the interventions were outside the scope of this exercise, but the authors plan to attempt to identify cost savings in future work.

Conclusion

This article has described, discussed and evaluated a proactive change made to the NHS 111 Wales website, designed to signpost patients directly to pharmacy-based services instead of the telephone-based NHS 111 Wales service over the 2022 Jubilee four-day bank holiday weekend, using the previous 2022 Easter four-day bank holiday weekend as a comparison. The results from the Choose Pharmacy platform demonstrate that community pharmacies can help to reduce demand on the NHS 111 Wales telephone service and that intervention-based work can be an effective tool in facilitating this. Using the NHS 111 Wales website in this way is an example that can be applied to other areas of primary, urgent and unscheduled care also, such as vaccinations, minor illnesses, ophthalmology, and physiotherapy. In addition, work designed to change behaviour and advertise more direct and appropriate access points to health services can improve patient experience, operational efficiencies, and usage of commissioned services. Hopefully, the example used in this paper might inform other services, policymakers, and clinical leaders to effect such positive change.

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Mark Allen, Specialist Clinical Lead NHS 111 Wales Website, Welsh Ambulance Service NHS Trust.

Adam Mackridge, Strategic Lead for Community Pharmacy, Betsi Cadwaladr University Health Board.

Alexandra Gibbins, Professional lead for 111 Pharmacists, National 111 programme.

Dr Mike Brady, Consultant Paramedic NHS 111 Wales, Welsh Ambulance Service NHS Trust.

Corresponding author – Dr Mike Brady, Consultant Paramedic NHS 111 Wales, Welsh Ambulance Service NHS Trust. [email protected]

Acknowledgements: N/A

Conflict of interests: No conflict of interest exists.

Funding : This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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