Questionnaire survey
A total of 3515 questionnaires were dispatched. From these, 1190 were returned completed, giving a corrected response rate of 34.1%. Table 1 shows the characteristics of the questionnaire responders.
Table 1. Characteristics of questionnaire responders
Almost half (49.5%, n = 589) of the questionnaire responders had never used the NHS 24 telephone service. The most common reasons for non-use were: lack of need (79.4%, n = 462), a preference to see their own GP (23.5%, n = 137), and not knowing the telephone number (15.8%, n = 92).
‘Ever users’ of the service (50.5%, n = 601) were significantly more likely to be female than male (AOR = 1.70, 95% CI = 1.29 to 2.25), aged 25–34 years (AOR = 2.19, 95% CI = 1.11 to 4.29) (with an overall trend of declining use with age), and have at least one child (AOR = 1.75, 95% CI = 1.19 to 2.58). Those who had not consulted a health professional in the previous year were significantly less likely to use the service than those who had (AOR = 0.54, 95% CI = 0.36 to 0.82) (Table 2).
Table 2. Logistic regression analysis of using NHS 24 compared with not using NHS 24
Over half (58.9%, n = 351) of the ‘ever users’ reported that they had used the service more than once and just under half had used it in the last year (47.4%). Most calls (92.4%, n = 549) were made out of hours and from the caller’s own home (88.7%, n = 526). Over half (54.6%, n = 327) of the calls were made on behalf of someone other than the caller, usually the caller’s child or partner. The most common reasons given for using NHS 24 were: the problem occurring out of hours (87.5%, n = 484), being too ill to leave home (16.5%, n = 91), and not knowing who else to contact (8.9%, n = 49). A new symptom accounted for 69.0% (n = 414) of calls, whereas 28.5% (n = 171) were about an ongoing problem, and 2.5% (n = 15) were for general health advice or information about local services. (Table 3).
Table 3. Responders’ use of NHS 24
Over one-third (38.6%, n = 219 out of 567) of users reported contacting another health professional about the problem following their call to NHS 24. Of these, 71.7% (n = 157 out of 219) had been advised by NHS 24, 24.2% (n = 53 out of 219) resulted from a decision of the responder themselves, and 4.1% (n = 9 out of 219) resulted from family advice. Of those who contacted another health professional, 58.9%, (n = 129 out of 219) contacted their GP, 23.3% (n = 51 out of 219) contacted A&E or 999, and 11.4% (n = 25 out of 219) contacted the local out-of-hours centre.
Satisfaction with the service was high, with >80% of users stating that they were either satisfied or very satisfied with a range of aspects of the service (Table 4). Education was the only sociodemographic factor associated with satisfaction (P = 0.012), with higher educated participants being less satisfied. Most users (93.9%, n = 539 out of 574) said that they would use NHS 24 again, because they had little choice if they needed out-of-hours care (71.7%, n = 386 out of 538), they found it helpful (61.5%, n = 331 out of 538), it was convenient (29.6%), and it was quick (26.0%). Of the small number who said that they would not use it again (n = 35), 48.6% (n = 17 out of 35) had found it unhelpful, 34.3% (n = 12 out of 35) would rather speak to their own GP, and 31.4% (n = 11 out of 35) would prefer to see someone in person.
Table 4. Satisfaction with calls to NHS 24
Only 8.4% (n = 78 out of 928) of responders reported that they had used the NHS 24 website, although 38.1% (n = 428 out of 1123) were aware of it. Females, younger responders (18–44 years old), those with higher education, those who were not retired, those with a higher household income, and those with internet access at home were significantly more likely to have used the website. Of the website users, 83.8% (n = 62 out of 74) rated the information provided as either good or very good, 85.1% (n = 63 out of 74) rated it as easy or very easy to use, and 92.1% (n = 70 out of 76) said they would use it again. Only 4.6% (n = 53 out of 1150) of responders reported ever having used the NHS inform telephone service and 2.3% (n = 21 out of 927) the NHS inform website; awareness of these services was 33.6% (n = 381 out of 1134) and 17.6% (n = 178 out of 1010), respectively.
Telephone interviews
Interviews were conducted until data saturation was reached. A total of 30 people were interviewed. Table 5 shows the characteristics of interviewees. Some interviewees were unclear about the role of the service:
‘Em, that it exists is probably about all that I do know.’
(K4645)
Table 5. Characteristics of interviewees
However, most saw NHS 24 as an out-of-hours alternative to the GP; that is, to be used when their health problem was serious enough to need medical advice, but not serious enough to telephone 999:
‘Em, just I suppose it’s kind of em, emergency contact that’s somewhere between your GP and calling 999 … if you’ve got a sort of, sort of serious medical em, complaint that doesn’t merit phoning an ambulance, you would, you genuinely feel you need either advice or direct treatment or information, that you think you shouldn’t wait until, you know, the doctors open the next day.’
(A39)
Many interviewees said they would not use NHS 24 if the symptom was minor:
‘I wouldn’t waste somebody’s time if I was, if I didn’t think it was worthwhile, you would have, it would have to be, you know, you wouldn’t phone up for like a cold, or a headache or something like that, but if it was something like really, really, if you had a nasty rash of some sort, you know, all of a sudden it appeared, it kind of, all of a sudden kind of thing, or, or, you passed out, or fainted you know, that kind of thing.’
(D1697)
Reasons for using the service related predominantly to a lack of alternatives for out-of-hours care, particularly in rural areas. Many interviewees said they would only use the service out of hours:
‘I don’t use it if I’ve got another alternative, like if I can reach my own doctor, so I think it should only be used when you don’t have another alternative, you know, i.e. out of clinic hours.’
(G3101)
‘Well, I mean, in an emergency, I mean, if it’s a weekend, then there’s no surgeries are open, and we live quite a long way from em, well we’re 20 odd miles from [place], and em, you know, if you take ill, you can’t go anywhere, can you, I mean I don’t drive you see, so I mean, I could, I mean if I fall down now, and nobody knows about it, I would probably have to call NHS 24.’
(J4195)
‘Yeah, I think what I’ve learned from using NHS 24 is that if you can see somebody within hours, that knows you, in your local practice, that’s optimal, but if you really feel you can’t wait, then NHS 24 is, it’s good, it’s there, somebody with medical em, expertise is available, which is great, but like I say, optimally seeing your doctor, who knows you.’
(K4574)
Others had used it during the day when they could not be seen quickly at their local practice. NHS 24 was seen to be a convenient and accessible choice for advice without having to leave home, especially if there was uncertainty about whether medical attention was required and meant avoiding ‘wasting’ other NHS resources:
‘Unless you get an appointment with her [doctor] somewhere like 8.30 in the morning, they generally tell you to call NHS 24, you know, because you can’t get, it’s difficult, you don’t know when you’re going to be ill these days, but you can only really get an appointment in a fortnight.’
(G3219)
‘I don’t like to waste time, anyone’s, you know, time if the situation is not severe enough that it really needs to be addressed in that situation, so I’d rather be able to speak to someone over the phone and decide this can wait until she can go into her regular doctor, you know, I like being able to have that service where we discuss it and I can make a decision with someone over the phone, em rather than taking her in if she doesn’t need to be, you know, seen in that sort of a situation.’
(G3101)
The most common reason given for not using NHS 24 was that it had not been needed, often because there was a good GP service. Other reasons given included not feeling comfortable talking on the phone, ease of going to A&E, a previous poor experience, a preference to see someone (usually their GP) in person, and concern about NHS 24 staff not being doctors:
‘My GP has a phone-back service, so if you have a problem, you phone the GP, they then call you back and assess whether or not you need an appointment, so I would not anticipate requiring NHS 24 during doctors’ hours.’
(G3104)
‘I prefer speaking to somebody face to face and getting, reading them, rather than listening to them, I’m not a big phone person anyway, to be truthful.’
(J4101)
‘I still would go on my own instincts rather than listening to somebody at the other end of a phone or on the computer, I would say, well, if I thought it was bad enough I’d just go to A&E … what I think about NHS is, you’re just speaking to somebody like myself, rather than a doctor, you know, it’s not doctors you’re speaking to really, is it?’
(J4101)
For a few, mostly older interviewees, there was a lack of knowledge about when or how to use the service, and some simply had a preference for more familiar services, such as 999:
‘Em, I, I think, it’s maybe because I’ve never used it, but em, actually I wouldn’t know where to start to use, if you see what I mean, I know it exists, and I know somehow I must be able to get in touch with it, but I couldn’t honestly tell you how I would get in touch with it, you know.’
(D1712)
‘Well, I automatically went for 999, because … em, I felt, you know, it was just, in my head was 999, forever, it’s been there.’
(G3018)
Interviewees were broadly satisfied with most aspects of the staff and service:
‘Well, I don’t think it could have been done any better, I mean obviously the first person that I spoke to was purely a telephone operator, you know what I mean, a person that manages the calls, and they listened, and fortunately, you know, she’d spoken, the operator spoke to my wife, she immediately em, put her onto a doctor, and the doctor asked the questions and my wife answered, and then you know, there was no delay in the action NHS 24 took, so as I say, that’s the repeat, it was first class, and I wouldn’t fault it in any way.’
(A217)
People generally understood the reasons for delays, accepting that the service can be busy and needs to prioritise calls:
‘Em, sometimes they can take a wee while phoning back, but that’s because they are prioritising after assessing, and you know, obviously mine, the things I’ve been anxious about have never been so bad that I would, you know, that I should, I should take priority, but you can’t have an infinite number staff waiting to answer the phone.’
(A39)
The most common area of dissatisfaction related to the initial triage questions. Although most interviewees understood the need for these questions, they felt they were lengthy, repetitive, and prescriptive:
‘I was really ill, and eh, I was getting angry because eh, because I just felt that, she should get me onto a nurse and stop asking me questions, you know, I felt it went on too long.’
(A111)
‘I gave him a brief, em, history of my husband’s cardiovascular problems and said what had happened that evening, but he wasn’t listening or getting the picture, he was still ticking boxes, “is he blue in the face?”, em, “has it sagged on one side?”, these sort of questions. He was obviously thinking of a stroke, or he’d got his list of questions, which he felt he had to tick the boxes, em, and after a while I got a bit em, concerned, because this was going on and I wanted my husband looked at quickly.’
(G3018)
Interviewees also expressed dissatisfaction with the length of time it took to receive visits and not being kept informed:
‘They don’t give you … you could be sitting there for under an hour to up to 6 hours, it would be better if they would say to you, “listen, we’ll try and get someone there within 2 hours”. At least then, you are not just sitting looking at the clock and checking every time you hear a car outside the house. And if I’d known it was going to be as long as 6 hours, I would have taken my mother to the hospital myself.’
(G3219)
The most common barriers reported related to the triage questioning, not knowing how to access NHS 24, concerns about the fact that NHS 24 staff do not have access to existing medical records, finding it difficult to talk about illness on the telephone, and believing it is more difficult to tell over the phone whether someone is really ill:
‘I know there’s quite a lengthy process of em, em, what do you call it, just like eh, “what’s your name, where do you live, what” … it takes quite a while to get through, so I think if I was really stressed about something, I’d probably phone 999, just for, just eh, it’s just a lengthy process before you actually get to somebody to give you medical advice.’
(K4574)
‘It’s just so difficult over the telephone, whereas a GP would just take one look at your child and say “well, he’s okay”, or “he needs to go and get an X-ray”, em. So yeah, it’s reassuring, but it’s also, it also can lead you into a bit of a, a panic as well, em, I mean in the instance, our son, they told us what to look for, and he was fine in the end, but because we were looking so hard for these signs, we almost over-reacted, so, yeah.’
(K4574)
The most common facilitators related to the convenience of not needing to go out (especially for those with young children and those with mobility difficulties), availability out of hours, not needing to make an appointment, being easily accessible, feeling that other NHS resources were not being wasted unnecessarily, ‘anonymity’ of speaking to someone over the telephone, and the benefit of getting early medical attention for a problem:
‘Em, just the fact that you know somebody will answer the phone, and will speak to you, which if you, I mean we live quite far out, we are an hour out from [place], and em, obviously it was out of hours, if something happens in the night or whatever, and you do feel a bit, what’s my options here, so knowing that you can pick up the phone and that somebody will answer and give you some advice, is good.’
(K4574)
‘I’m confident in the fact that the earlier I make a complaint, or ask a question, eh the better the outcomes, you know, the better the results, although they’re never guaranteed of course, but the probability of, what I would view a success goes up the earlier I present it, so I think NHS 24 in that scenario is absolutely fantastic.’
(G3155)
Interviewees living in rural areas reported benefits of living in a community where you can get appointments and home visits relatively quickly, factors mitigating against the need for NHS 24:
‘We live in a rural area, which has an exceptionally good GP service, for this day and age, eh compared to most people I know, you know, we actually have GPs who you can phone out of hours, who will even just pop round and see you unexpectedly, just to see if you’re all right, so em, things like that, so yeah, good GP, small rural community, em, it’s the best place to be, I think, sometimes, but that’s why personally I haven’t had the need to, for those two reasons.’
(K4645)
However, concerns about distance to the nearest out-of-hours centre or A&E, and the small number of doctors and ambulances covering large geographical areas, meant NHS 24 was seen as useful:
‘Well, in these four occasions, very useful, eh as I said, a moment ago, we are 40 miles from the nearest A&E, other, there’s minor eh, accident A&E at [place], but that’s just really small stitches and things like that, but eh, you don’t want to go an 80 mile return trip just to find out something, so it is very useful to have a contact to, eh to consider whether something is serious enough to see a doctor.’
(K4688)
Some interviewees highlighted that poor local knowledge of NHS 24 staff was sometimes problematic:
‘Em, the only slight problem was the fact that the lady that I spoke to initially, em, clearly, I mean it’s not her fault, but she was not familiar with the area of where I am, and she didn’t know whether to send me to [place] or em, [place] that there’s a small hospital there, and that was only because, you know, she’s probably looking at a computer screen, and em, you know, she could have been in Manchester or somewhere, I don’t know where these people are based.’
(K4607)
Suggestions for improving NHS 24 included quicker response times, having more medically trained people answering the phone, less repetition, and making people more aware of how and when to use the service:
‘Em, I think eh, more medically trained people answering the phone and able to know what people are saying to them.’
(G3018)
‘I would say that if you’re the patient could you please give your details once, maybe have them a little bit checked if the em, gentleman at the other end has a little bit of concern, em, I can’t see that you need to go through things so many times.’
(J4200)
‘Slightly better publicity, em, perhaps to what the numbers and reasons are for using NHS 24, and to be honest for someone like me, I’d most like to see that in a GP’s practice, because I’m, I’m regularly in the practice, so I’m more likely to see it there.’
(J4098)
