Health - redesign of urgent care: evaluation - summary report

Redesign of Urgent Care Evaluation Summary Report

Background

The Redesign of Urgent Care (RUC) programme was implemented in December 2020 to manage increased system-wide demands for urgent and unscheduled care. It aims to redirect patients who self-presented to A&E services to NHS 24 111 where they would be directed to the most appropriate pathways, rather than them attending A&E services as the first point of contact. By way of context, a total of 1,723,884 calls were made to NHS 24 111 in 2023, of which 26% (n=452,343) entered the RUC pathway after selecting this option from the Interactive Voice Response options.

Key findings

Long waits cause some to end their call to NHS 24 111

• Among survey respondents who discontinued a call to NHS 24 111, the most common reason for doing so was that it was taking too long to be answered. Of discontinued callers who contacted NHS 24 111 out of hours, around one third reported waiting more than 30 minutes before ending their call.

Once the service is accessed experience is largely positive

• Patients who accessed the RUC pathway after calling NHS 24 111 were largely positive about their experience of doing so, particulary in terms of their interactions with staff. However, patients who had a primary care endpoint (as recorded by NHS 24) reported a poorer overall experience when compared with the sample overall.
• Following a call to NHS 24 111, patients who had a booked appointment at A&E or a Minor Injury Unit as a result of accessing the pathway reported shorter waits there compared with those who attended without a booked appointment.

There is some variation between Health Boards

• Mixed views and experiences of implementing RUC were shared by NHS staff. Some were positive about the development of alternative pathways and the increased opportunities for partnership working. However, some noted variations between Health Boards in the way the RUC pathway has been adopted, including differences in how Flow Navigation Centres were operating.

Changes can be seen with delivery metrics since RUC implementation, but this may be driven by a range of factors (including COVID-19) not just RUC

• Interrupted Time Series Analysis at a national level compared a 2 year period post RUC implementation (January 2022 to mid-December 2023) with a projected position based on continuation of trends during a 2 year period pre implementation (January 2018 to December 2019). This found:
  • an increase in use of NHS 24 111 in hours (weekday 8am-6pm)
  • an increase in use of primary care out of hours
  • a reduction in all A&E attendances, A&E self-referrals and admissions following A&E attendance
  • an increase in waits of more than 4 hours at A&E
  • a reduction in Scottish Ambulance Service attended incidents and conveys to hospital

Recommendations

1. It is recommended that NHS 24 reduce the length of Time to Answer – particularly at the weekend - and are given the support and additional resources/funding to enable this. This would reduce the number of patients that discontinue their call.

2. Work with NHS Boards to address challenges with the availability and capacity of alternative pathways available via Flow Navigation Centres, as well as capacity challenges elsewhere, including within Primary care. This would be further supported by clearer national policy, guidance, and standardised definitions. The development of high-level Clinical Pathways would promote national standards when it comes to delivering care for certain patient cohorts.

3. Explore opportunities to improve scheduling such as ringfenced capacity for scheduled patients which should be separate to existing workstreams such as minor injury units, ambulatory care etc.

4. To support services to work well together, there should be a mechanism in place to improve professional - to - professional communication, for example a national communication system.

5. Explore opportunities for increased collaboration between smaller NHS Boards to support with resourcing issues.

6. Public messaging: continue to educate the public on when to contact NHS 24 111 and why accessing alternative services might be more suitable for some health concerns.

7. Improve data collection of Flow Navigation Centre activity and planned attendances. Addressing this is contingent on other recommendations.

RUC aims and interventions

RUC aims

• To increase care nearer to home for patients and carers
• To convert some unscheduled care activity to planned care activity
• To reduce patients who self-present to A&E services
• To reduce overcrowding in A&E services

RUC interventions

• Public messaging to encourage patients and carers to use NHS 24 111 more.
• Increase capacity in NHS 24 111 service.
• Establish new local Flow Navigation Centres to help navigate patients to most appropriate local services and provide rapid access to a Senior Clinical Decision Maker.

Approach

The findings set out in this summary are based on the following four approaches:

1. Discontinued Caller Survey: an online panel survey with people who called NHS 24 111 between September 2023 to February 2024 but ended the call before speaking to anyone. Responses were received from 387 people.

2. Patient Survey: a survey with patients who called NHS 24 111 between March and April 2024, who selected the A&E (RUC) pathway option, and had their call answered. Responses were received from 662 people, representing a response rate of 21%.

3. Focus groups with NHS staff: three online focus groups (each with 7 participants) were held with staff working across urgent care.

4. Analysis of existing data: Interrupted Time Series Analysis at a national and Health Board level.

Findings

Positive findings from patients and staff

Quality of care from staff

For those patients that accessed the RUC pathway via NHS 24 111, positive experiences were reported for the care received from both the call handler at NHS 24 111 and the health professional from a Flow Navigation centre.

Flow Navigation Centres

Patient survey findings suggest that patients who had a Flow Navigation Centre endpoint were generally satisfied with the time they waited for a health professional to call them back. There is some evidence to suggest that those patients who had a referral to a Flow Navigation Centre reported more positive experiences on some measures compared to the overall sample. Furthermore, patients who had a booked appointment at A&E or a Minor Injury Unit were more positive about the length of time they waited compared to those without a booked appointment.

Alternative pathways and partnership working

The development of alternative pathways and the associated increased opportunities for partnership working between services - particularly with the Scottish Ambulance Service - were regarded by some urgent care staff as positive outcomes of the RUC. A cultural change in the approach to how the Scottish Ambulance Service manage patient care due to the redesign was positively acknowledged by staff.

Negative findings from patients and staff

NHS 24 Time to Answer

The main reason patients discontinued their call to NHS 24 111 was due to the time waiting for the call to be answered (or the advised waiting time via the Interactive Voice Recognition menu). Of this group who contacted NHS 24 111 out of hours, around one third reported waiting more than 30 minutes before ending their call. Those who discontinued their call were less positive about their overall experience if they waited longer before ending the call.

Lack of alternative pathways and/or a lack of capacity within services

An insufficient number of available alternative pathways and/or a lack of capacity within services were reported by NHS urgent care staff as challenges to the successful implementation of the RUC pathway in some areas. Capacity challenges within primary care were mentioned by a number of urgent care staff. It was suggested that difficulty accessing General Practice services was driving some patients to access NHS 24 111 or to self-present at A&E. Challenges with staff engagement and increased service demand were among highlighted possible reasons for such difficulties. Urgent care staff reported some variations between NHS Boards in the scope and scale of Flow Navigation Centre implementation and delivery as part of the RUC pathway, as well as differing perceptions of the objective and scope of RUC.

Wider pressures within the urgent care system

Concerns were raised by some urgent care staff on the demands or pressures in other parts of the urgent care system. These include: ambulances queuing or ‘stacking’ outside hospitals, long wait times in EDs and the difficulty with discharging patients from hospital. Whilst it was not an explicit aim of RUC to address these wider challenges, an aim was to reduce demand on A&E services and ensure patients are seen ‘at the right time’. It is therefore important to recognise the view that wider pressures may limit the implementation and impact of RUC and that a whole system approach should be taken.

Services working together

Patients reported less positive experiences regarding how well different services worked together within the urgent care pathway. A few staff members in the focus groups also shared concerns about how well urgent care services are working together. Further research is required to understand this finding in more detail and to inform what necessary improvements can be made.

Managing patient expectations and support understanding

Managing patient expectations on accessing urgent care quickly – and care that is appropriate - was perceived as a challenge by some NHS urgent care staff. They identified a need for greater public education and awareness to help people understand differences between urgent and non-urgent health problems and to provide people with the confidence to self-manage where appropriate.

Improvements in patient experiences/perceptions of primary care endpoints

Poorer overall patient experiences were found if survey respondents had a primary care endpoint (as recorded by NHS 24) when compared with the sample overall. Further exploration is needed to understand this finding.

Findings from analysis of existing data

When compared to the projected position based on a continuation of trends from a 2-year period pre RUC-implementation (January 2018 to mid-December 2019), the national level analysis of existing data found that during a 2 year period post RUC-implementation (January 2022 to mid-December 2023) there was:

• increased use of NHS 24 111 in hours
• increased use of primary care out of hours
• an increase in waits of more than 4 hours at A&E
• reduction in Scottish Ambulance Service attended incidents and conveys to hospital
• reduction in all A&E attendance
• reduction in admissions following A&E attendance
• reduction in self-referrals to A&E.

Analysis at health board level found that there was little variation in the performance of health boards relative to their control health board(s).

It is important to note that causation of any change between these comparators cannot be conclusively determined, and is likely to have been driven by several factors, including but not limited to the introduction of RUC. Such factors will notably include impacts of the COVID-19 pandemic, some of which is not yet quantifiable. Furthermore, it should also be noted that these results may not directly mirror simple comparisons or trends of these metrics pre- and post-RUC pathway implementation.

How to access background or source data

The data collected for this social research publication:

☐ are available in more detail through Scottish Neighbourhood Statistics

☐ are available via an alternative route

☒ may be made available on request, subject to consideration of legal and ethical factors. Please contact dlhscbwsiawsiaa@gov.scot for further information.

☐ cannot be made available by Scottish Government for further analysis as Scottish Government is not the data controller.