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Background NHS 111 online offers 24-hour access to health assessment and triage. Objectives 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. Design 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. Results 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. Conclusions 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. Limitations 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. Future work Further investigation of access to digital services could address concerns about digital exclusion. Research comparing the affordances and cost–benefits of different triage and assessment systems for users and health-care providers is needed. Research about trust in virtual assessments may show how duplication can be reduced. Mixed-methods studies looking at outcomes, impacts on work and costs, and ways to measure eHealth literacy, can inform the development NHS 111 online and opportunities for further international shared learning could be pursued. Study registration This study is registered at the research registry (UIN 5392). Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research Programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 5. See the NIHR Journals Library website for further project information. Plain language summary NHS 111 services help people who need health advice or care by telephone (using the 111 number) and online (using the web on a smartphone or a computer). Demand for general practitioner and emergency care services keeps increasing, and there are concerns that sometimes people do not use the right services for the health problems that they have. NHS 111 can direct people to services and give advice that helps them carry out more self-care. Previous research suggests that not everyone finds online services easy to use. There is a worry that NHS 111 services may increase work for other health services. Our research used interviews and surveys to find out about the NHS 111 online service. We interviewed 80 people working in or with NHS services to find out about their experiences of NHS 111 online. There was low awareness of NHS 111 online, partly because there are so many other computer technologies and different services available. Interviewees often mixed-up NHS 111 online with the 111 telephone service. People are confused about where to get help. Interviewees also said that NHS 111 creates ‘extra work’, especially for emergency departments (accident and emergency). We interviewed 41 staff and stakeholders linked with a similar system used in Australia, called Healthdirect, and they had similar concerns. Our survey found that people who had used NHS 111 online were younger and had higher levels of education. People who had used NHS 111 online also had higher eHealth literacy (they were more able to access and understand online health services); however, they were also sicker, reported having more long-term conditions and used more health services. Our research suggests that we need to reduce confusion about what NHS 111 online does, get rid of unnecessary extra work and see whether or not it improves access to care for everyone. Scientific summary Background 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. Aim The aim of this study was to examine patient pathways and workforce implications of NHS 111 online. Objectives •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. Methods 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. Qualitative interviews and documentary materials We undertook semistructured interviews with 80 staff in primary, urgent and emergency care, and dental services, and with representatives of charities representing vulnerable and disadvantaged groups in England. We also interviewed 41 staff and stakeholders associated with the Australian Healthdirect system. We asked about awareness of NHS 111 online/Healthdirect and impacts on work and workforce arrangements and on the wider health-care system. We collected copies of relevant policy documents, system specifications and updates, adverts and health education materials produced by NHS and other organisations to understand more about pathways to care and the services associated with NHS 111 online. Survey We carried out a cross-sectional survey of 2754 people to explore eHealth literacy skills using the eHealth Literacy Questionnaire (eHLQ). The eHLQ is a validated 35-item 7-scale questionnaire measuring the use of technology to process health information; the understanding of health concepts and language; the ability to actively engage with digital services; feeling safe and in control in using online services; motivation to engage with digital services; access to digital services that work; and access to digital services that suit individual needs. The survey also collected basic sociodemographic details and asked about preferences for using NHS 111 telephone and online services for a range of different symptom scenarios. The survey was designed to be available in paper and online formats, but pandemic risk mitigation measures meant that only online completion was possible. Consequently, the survey was made available for self-completion via a hyperlink/QR code, and for assisted completion using an iPad and with support from a research nurse. Findings Pathways to care NHS 111 online has low visibility in the primary, urgent and emergency health and care system, and it is obscured by the presence of a number of other digital technologies, including online triage and assessment tools, notably in primary care. There were suggestions that awareness of the NHS 111 online service had increased in the pandemic and was beginning to be seen as helpful by some. We have corroborated the findings of the Sheffield study (NIHR127655) that NHS 111 online has added another access point for urgent and emergency care in the NHS and the result is that pathways to care are confusing and difficult to navigate. Workforce and impacts on work in the wider health system The workforce potentially associated with NHS 111 online services not only includes staff in primary, urgent and emergency care but also encompasses staff in dental services and a range of charity and non-NHS organisations who serve vulnerable population groups. Some staff and stakeholders perceived that NHS 111 services generate additional tasks or demand, although it was not clear that they attributed this extra work to NHS 111 online per se. Similar issues were raised by interviewees associated with the Healthdirect virtual triage services (where there was also a problem of low awareness by the public and professionals about these services). Dental services did not perceive that they received extra work as a result of NHS 111 online. In some areas, there was a direct emergency dentist booking facility via the NHS 111 telephone service, which was seen as meeting patient needs. There appears to be an opportunity to direct users of NHS 111 online who require emergency dental care to dental services, but this would require closer integration of these services than at the present time. Comparison of NHS 111 with Healthdirect A small team comprising service managers/operational leads, developers and a small number of clinical staff members develop and manage NHS 111 online. The Australian Symptom Checker has a similarly small team within Healthdirect. Outside these organisations, a wider network of care providers are implicated in, potentially provide services to or have contact with users of these online advice, triage and assessment technologies. Our interviews with staff and stakeholders associated with Healthdirect identified similar concerns to those voiced in English primary, urgent and emergency care interviews about the lack of integration between virtual triage and other parts of the health system. There was also a similar lack of awareness or understanding of the Symptom Checker in the wider network surrounding Healthdirect’s online provision. There was less evidence from the Australian interviews that staff and stakeholders perceived that Healthdirect’s virtual triage created additional work for their services. While there was a suggestion that Healthdirect’s virtual triage services inflated demand for emergency care, this was tempered by the suggestion that the users of its services may be augmenting other care/help seeking and, particularly for the Symptom Checker, that these were less serious presentations. We conclude from this that any additional work associated with assessment, re-assessment and navigating the health system is borne by patients and users, rather than the healthcare workforce in these settings. Patient preferences (scenarios where patients want to use NHS 111 online) A third of survey respondents had not used NHS 111 online or telephone services. The survey found differences in the types of symptoms for which people said they would use NHS 111 online. Those who had previously used the service were more likely to use it for each symptom scenario offered. These differences were significant for ‘an itchy bite or sting’, ‘a young child with a temperature and crying’, ‘a scalded hand’ and ‘pain when urinating’. A sizable proportion of respondents reported that they would be likely to use NHS 111 online for a young child with a temperature and persistent crying, and for severe pain in the chest that goes away after a few minutes. Those who had used NHS 111 online reported having used a wider range of urgent care services than those who had not used NHS 111 online. They also had higher cumulative use of a range of other NHS health services than those who had not used NHS 111 online. eHealth Literacy among users and non-users of NHS 111 online Our survey found evidence of differential use of NHS 111 online across key demographic characteristics: use was associated with younger age groups and those who had some more formal educational qualifications. Those who reported previously using NHS 111 online had higher levels of self-reported eHealth literacy across 5 of the 7 eHLQ domains. People with long-term conditions (LTCs) had lower eHLQ scores but were more likely to have used NHS 111 online. Limitations 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. Conclusions 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. Research recommendations The research reported here is one of just two studies that have looked at NHS 111 online in the period just before and during the COVID-19 pandemic. The service has rapidly grown, in scope (adding COVID-19 symptom assessment and advice) and use. New functionality has been added, notably the 111 First initiative allowing the service to triage and book arrivals to EDs. Further research will be necessary to support the ongoing development and integration of the urgent and emergency care system and the development of NHS 111 services, including NHS 111 online, within this. Future work indicated by this study includes: 1.Further investigation of access to digital services including NHS 111 and eConsultation systems by those with LTCs and people in vulnerable and marginalised groups to address concerns about digital exclusion. 2.Evaluation of different online advice, triage and assessment systems to understand the affordances and cost–benefits of different systems for users and healthcare providers. 3.Examination of patient, public and professional trust in computer-assisted and patient self-completed online assessments and consideration of how to reduce the burden of re-assessment and duplication for patients and healthcare staff. 4.Examination of multiple use of different entry points to the health system and adherence to the triage outcome(s), possibly with statistical analysis/modelling of linked data to explore health outcomes. 5.Further qualitative study of the additional work created by NHS 111 services for the wider network of services urgent and emergency care system, augmented with costings to support cost consequence analysis. 6.Further development and use of other measures of eHealth literacy to explore the impact of ‘digital first’ policies in health and other service settings. 7.Opportunities for further international comparative research and shared learning from other similar online triage and assessment systems. Study registration This study is registered at the Research Registry (UIN 5392). Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Services and Delivery Research Programme grant number 127590 and will be published in full in Health Services and Delivery Research; Vol. 11, No. 5. See the NIHR Journals Library website for further project information.

Behavioural science constructs can be incorporated into messaging strategies to enhance the effectiveness of public health campaigns by increasing the occurrence of desired behaviours. This study investigated the impact of behavioural science-informed text message strategies on COVID-19 vaccination rates in 18-39-year-olds in an area of low uptake in London during the first vaccination offer round in the United Kingdom. This three-armed randomised trial recruited unvaccinated residents of an urban Central London suburb being offered their first vaccination between May and June 2021. Participants were randomised to receive the control (current practice) text message or one of two different behavioural science-informed COVID-19 vaccine invitation strategies. Both intervention strategies contained the phrase "your vaccine is ready and waiting for you", aiming to evoke a sense of ownership, with one strategy also including a pre-alert message. The main outcome measures were vaccination rates at 3 and 8 weeks after message delivery. A total of 88,820 residents were randomly assigned to one of the three trial arms. Each arm had a vaccine uptake rate of 27.2 %, 27.4 % and 27.3 % respectively. The mean age of participants was 28.2 years (SD ± 5.7), the mean index of multiple deprivation was 4.3 (SD ± 2.0) and 50.4 % were women. Vaccine uptake varied by demographics, however there was no significant difference between trial arms (p = 0.872). Delivery was successful for 53.6 % of text messages. Our choice of behavioural science informed messaging strategies did not improve vaccination rates above the rate seen for the current practice message. This likely reflects the wide exposure to public health campaigns during the pandemic, as such text messages nudges were unlikely to alter existing informed decision-making processes. Text message delivery was relatively low, indicating a need for accurate mobile phone number records and multi-modal approaches to reach eligible patients for vaccination. The protocol was registered at clinicaltrials.gov (NCT04895683) on 20/05/2021., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The UK COVID-19 vaccination programme began in December, 2020. By February, 2021, eight North West London Clinical Commissioning Groups (CCGs) had the lowest vaccination rates nationally. This study evaluated the impact of behavioural science-informed (BI) letters on vaccination uptake., Methods: Unvaccinated residents of the Central London CCG who were deemed uncontactable (through text messaging and phone calls) were identified with the whole systems integrated care database. BI letters were sent to residents in the intervention CCG between May and June, 2021. Three neighbouring CCGs in London with similar non-responder data were used as control groups. A linear difference-in-difference analysis was undertaken to assess change in vaccine uptake rate across all four CCGs. Percentage point change was adjusted for selected covariates including ethnicity, age, gender, and index of multiple deprivation (IMD) quintiles. Approval was obtained from the quality improvement and audit office of Imperial College Healthcare NHS Trust (London, UK)., Findings: Within the intervention Central London CCG, 10 161 residents received the BI letter. The control CCGs contained 27 383 uncontactable residents. All CCGs showed an increase in vaccination rates in this population. The linear difference-in-difference analysis showed an increase in vaccination uptake in the intervention CCG (relative change 31·9% (95% CI 30·5-33·3; p<0·0001). Residents in IMD quintile 5 (least deprived) showed the largest rate of change (4·1%; p<0·0001). Residents with a mixed or multiple ethnic background were less likely to receive a COVID-19 vaccine (-4·1%, p<0·0001)., Interpretation: BI letters improved the rate of vaccine uptake. The percentage point increase of 31·9% equates to 436 additional previously uncontactable residents being vaccinated. Our data highlighted differences in the effect of BI-informed interventions in population subgroups. BI letters are a cost-effective and trusted communication tool, effectively engaging residents where other communication strategies did not work., Funding: None., (Copyright © 2022 Elsevier Ltd. All rights reserved.)