Globally, public healthcare systems are facing an increasingly complex challenge: guiding patients to the appropriate level of care efficiently, safely, and equitably. However, effective patient navigation is fraught with barriers and inefficiencies.
Consider the all-too-common experience of Anna. She notices a rash and visits her local pharmacy for advice. Her pharmacist suggests she book an appointment with her GP. When she calls her GP that afternoon, they have no appointments available and advise her to call back tomorrow morning at 8 am. Concerned, Anna instead calls NHS 111 and speaks with a non-clinical call handler. The call handler, lacking direct access to GP slots, suggests Anna go to the local urgent treatment centre. After a two-hour wait, Anna is finally seen and treated by a clinician.
Anna’s journey reflects a fragmented and convoluted healthcare pathway experienced daily by millions in the UK. Each interaction — the GP, the 111 service, the urgent treatment centre — repeats steps without advancing her care. At the heart of this navigation problem lies the need for effective triage.
Triage involves accurately and safely assessing patients and directing them to the most appropriate care to meet their needs.
It is a complex and high-risk task, yet current methods of triage and navigation fail to reflect this reality. This responsibility is often left to staff with little clinical training or patients are expected to self-navigate to the appropriate “front door” in an increasingly complicated healthcare landscape.
Complexities of the current system: dangers of neglecting triage on a system level
Current navigation within healthcare often involves multiple touch points and stages of triage. Let’s take NHS 111 as an example.
NHS 111 is a national, 24/7 telephone health advice service in England that provides patients with urgent care advice, receiving >50,000 calls a day, with growing demand (NHS England » Monthly Operational Statistics – September 2024). A comparable service to NHS 111 exists across almost all public health systems in Europe.
After calling NHS 111, patients initially undergo primary triage by a non-clinical call handler, who uses a decision tree algorithm to triage the patient. Following primary triage, approximately 24% of patients are sent an ambulance or advised to attend the emergency department (ED); 50% of patients are deemed to require urgent clinical attention and are referred to an urgent care provider for secondary triage; 15% of patients are advised to self-care; 8% are referred to other services (Sexton et al. 2023).
*approximate % figures
A study by Lewis et al. 2021 highlighted the high rate of incorrect triage advice given by NHS 111 as well as poor compliance by patients with 111 advice. In their analysis of over 3 million NHS 111 calls, 11% of patients advised to self-care later attended ED. Of this cohort, 88% of patients were classified as requiring urgent medical care in ED and 37% subsequently admitted to hospital. In addition, 9% of patients who are sent an ambulance or advised to attend ED are classed as non-urgent on ED attendance.
These figures reveal a system that often misdirects patients, leading to delayed access to appropriate care as well as unnecessary strain on emergency services. On a system level, this leads to a considerable financial burden and risk to patient safety.
A phenomenon often observed in triaging is the tendency to ‘overtriage’ (directing patients to a more acute or urgent service than is required to meet their needs). Sexton et al. 2023 found 74% of NHS 111 calls were downgraded by clinicians following initial triage by non-clinicians. Overtriaging is also observed in other triage methods, such as symptom checker technologies (Gilbert et al. 2020).
At the heart of overtriage lies a critical imbalance: for an individual “triager” — whether a clinician, organization, or digital tool — the risks of undertriage (directing patients to a less acute or urgent service than is required to meet their needs) are stark, while the consequences for overtriage are minimal, especially when it involves referring patients to other services such as ED.
However, the broader system impact of widespread overtriage is substantial: it leads to unnecessary strain on emergency services, increased healthcare costs, and longer wait times for patients who truly need urgent care (Fernandes and Ray 2023).
The risks of non-clinical triage
Studies have suggested that clinicians are substantially less risk averse in their triage recommendations compared to non-clinicians and digital triage algorithms (Sen et al. 2019, Anderson and Roland 2015, Stilwell et al. 2022). Paramedics have also voiced frustration with overly cautious triaging decisions when responding to patients referred by non-clinical call handlers (such as NHS 111) (Philips 2020). NHS 111 callers are more likely to make an avoidable ED attendance if they receive advice from a call handler and not a clinical advisor (Egan et al. 2020).
Despite this, a large portion of triage activity in the UK falls into the hands of non-clinicians. In general practice, which handles the largest share of patient contacts in the NHS, receptionists with minimal clinical training are often responsible for the remote triaging of patients and allocation of urgent same day appointments (Litchfield et al. 2022).
Triage is a complex, risky task that necessitates clinical experience. Evidence shows that clinically led triage leads to more appropriate and cost-effective decision-making, alleviating pressure on emergency services.
At Visiba, we believe clinical involvement in the triage process results in more appropriate, safe and effective triage that enables optimisation of healthcare resource allocation.
Systemic Inequity in Navigation: the role of system literacy
Navigating an increasingly complex and overstretched healthcare system requires considerable knowledge and effort on the part of patients (Dalgarno et al. 2023, Fisher et al. 2024). With a range of options — ED, GP, pharmacy, walk-in centres, or self-referral services — patients often struggle to determine which route to take for a given issue. This decision can be even more confusing as availability and services may vary between postcode and time of day. This reliance and requirement for “system literacy” introduces another layer of complexity, potentially perpetuating healthcare inequalities.
Patients who are familiar with healthcare processes, comfortable questioning decisions, and able to advocate for themselves tend to fare better in such a fragmented system. In contrast, individuals who are less equipped— often due to socioeconomic, educational, or linguistic barriers — may struggle to access appropriate, timely care.
Poor healthcare navigation further undermines the system's credibility – how can we expect patients to trust a system which is so fragmented and has such high rates of inaccurate advice?
Patients are left to navigate these ambiguities alone, placing those without the skills to advocate for themselves or grasp the intricacies of the system at a significant disadvantage.
Rethinking navigation for equitable, efficient care
To enhance healthcare navigation, a fundamental shift in approach is essential. Triage should be recognised as a complex, high-stakes process that has a profound impact on system demand and capacity — and should be resourced accordingly. Rather than adding layers of triage to existing systems and workflows, we should take a step back to reassess the triage challenge from first principles.
By designing a system that prioritises accurate triage at the patient’s first contact with the health system —without overtriaging or overwhelming resources — we can transform healthcare navigation to better meet the demands of a modern healthcare system. This system can be further enhanced by integrating triage with population health segmentation tools, enabling a more tailored and effective approach to care delivery, particularly for individuals with increased medical complexity.
At Visiba, we believe that evidence strongly supports the role of clinically led triage in ensuring patient safety and cost-effectiveness. Our focus is on empowering clinicians with the critical information and tools they need to make confident, efficient and effective triage decisions — routing patients to the right care at their first point of contact.
Authors: Dr Katherine Leung; Dr Annabelle Painter
References
Sexton V, Atherton H, Dale J, Abel G. Clinician-led secondary triage in England’s urgent care delivery: a cross-sectional study. British Journal of General Practice. 2023 Jun 1;73(731):e427-34.
Lewis J, Stone T, Simpson R, Jacques R, O’Keeffe C, Croft S, Mason S. Patient compliance with NHS 111 advice: analysis of adult call and ED attendance data 2013–2017. PloS one. 2021 May 10;16(5):e0251362.
Sen B, Clay H, Wright J, Findlay S, Cratchley A. Impact of emergency medicine consultants and clinical advisors on a NHS 111 clinical assessment service. Emergency Medicine Journal. 2019 Apr 1;36(4):208-12.
Anderson A, Roland M. Potential for advice from doctors to reduce the number of patients referred to emergency departments by NHS 111 call handlers: observational study. BMJ open. 2015 Nov 1;5(11):e009444.
Stilwell PA, Stuttard G, Scott-Jupp R, Boyle A, Kenny S, Maconochie I. Paediatric NHS 111 Clinical Assessment Services pilot: an observational study. Archives of Disease in Childhood. 2022 Mar 1;107(3):e14-.
Phillips JS. Paramedics' perceptions and experiences of NHS 111 in the south west of England. Journal of Paramedic Practice. 2020 Jun 2;12(6):227-34.
Egan M, Murar F, Lawrence J, Burd H. Identifying the predictors of avoidable emergency department attendance after contact with the NHS 111 phone service: analysis of 16.6 million calls to 111 in England in 2015–2017. BMJ open. 2020 Mar 1;10(3):e032043.
Litchfield I, Burrows M, Gale N, Greenfield S. Understanding the invisible workforce: lessons for general practice from a survey of receptionists. BMC Primary Care. 2022 Sep 9;23(1):230.
Dalgarno E, McDermott I, Goff M, Spooner S, McBride A, Hodgson D, Donnelly A, Hogg J, Checkland K. The patient experience of skill mix changes in primary care: an in-depth study of patient ‘work’when accessing primary care. Journal of Public Health. 2023 Dec;45(Supplement_1):i54-62.
Fisher R, Beech J, Alderwick H, Price E, Ansari A. Rethinking access to general practice: it’s not all about supply.
Fernandes A, Ray J. Improving the safety and effectiveness of urgent and emergency care. Future Healthcare Journal. 2023 Nov 1;10(3):195-204.
