Health - redesign of urgent care: evaluation - main report

1. Executive Summary

1.1 Context

The Redesign of Urgent Care (RUC) pathway seeks to improve the way members of the public access urgent and unscheduled care in non-life threatening situations, by ensuring people access the ‘Right Care in the Right Place at the Right Time.’ The objectives of this evaluation were to understand patient and staff experiences of the RUC pathway (including the experience of patients who end a call to NHS 24 111 before speaking to a call handler), provide analysis of changes to key Urgent Care delivery metrics, by comparing performance pre and post implementation of the RUC pathway and establish the foundations for further evaluation. The aim was to enhance the Scottish Government’s current understanding of what is working well in the pathway and identify areas for improvement.

1.2 Approach

The methodologies used in delivery of this evaluation can be categorised into three sections:

1. Insight from patients who interacted or tried to interact with the RUC Pathway

2. Insight from NHS staff working across the urgent care pathway

3. Analysis of changes to key Urgent Care delivery metrics, by comparing performance pre and post implementation of the RUC pathway.

1.2.1 Insight from Patients

An online survey (hereafter Discontinued Caller survey) was conducted which sampled people who tried to access the RUC pathway by calling NHS 24 111 at any point between September 2023 and February 2024, but who ended the call before speaking to anyone. 387 people responded to the Discontinued Caller survey, which focused on their views from this experience, and subsequent actions.

Additionally, a survey (hereafter Patient survey) was conducted which sampled patients who had accessed the RUC pathway via NHS 24 111 during March to April 2024. 662 people responded to the survey, which focused on their experience of the service, constituting a 21% response rate.

1.2.2 Insight from NHS staff working across the urgent care pathway

Three online focus groups were held with a total of 21 NHS staff working across the urgent care pathway. These focused on understanding their experiences of the implementation of RUC.

1.2.3 Analysis of existing data

Finally, Interrupted Time Series Analysis was undertaken to assess changes to key Urgent Care delivery metrics, comparing pre and post implementation of the RUC pathway.

This analysis was undertaken at a national and Health Board level. Specifically, at national level, the analytical approach compared data from a 2 year period post RUC implementation (January 2022 to mid December 2023) with a projected position based on trends during 2018 to 2019 (pre RUC implementation). For each delivery metric, this offers a comparison between actual state of play during the 2 year period post RUC implementation with a counterfactual state of play at the same time point, based on a scenario where there is continuation of baseline trends from 2018 and 2019.

At a Health Board level, the delivery metrics for each Board were compared with one or more ‘control’ Board(s), which were identified for each delivery metric based on similar trends during the pre-implementation period (2018 to 2019). Changes for each Board are therefore presented as relative to their ‘control’ Board(s), which could differ for each delivery metric.

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.

A total of 26 metrics were identified and assessed. These metrics, the process for their selection and more details on the Interrupted Time Series Analysis are given in Section 3.4 and the accompanying Technical report ^[1].

1.3 Key findings and recommendations

1.3.1 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 of the relational aspects of care received from both the call handler at NHS 24 111 and health professional from a Flow Navigation Centre (FNC) were found.

Flow Navigation Centres (FNCs)

Patient survey findings suggest that those patients who had a FNC endpoint are 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 FNC reported more positive experiences on some measures compared to the overall sample (such as the number of different services contacted to get the most appropriate care or advice). Furthermore, those patients who had a booked appointment at Accident & Emergency (A&E)/Minor Injuries Unit (MIU) were more positive about the length of time they waited to be seen which suggests a positive impact of the RUC pathway.

The data from the Patient survey suggests a positive patient experience of contact with FNCs as part of their pathway. Although, it was also observed in the focus groups with NHS staff that there are variations between NHS Boards in the scope and scale of Flow Navigation Centre input to the RUC pathway.

NHS 24 111 as the entry point to RUC pathway

Survey findings suggest there is a good patient awareness that NHS 24 111 should be accessed first for urgent health concerns. This should be interpreted alongside the necessary caveat that both surveys undertaken sampled patients who had accessed (or tried to access) NHS 24 111, and did not sample others who had accessed care via other routes.

Alternative pathways and partnership working

The development of alternative pathways and the associated increased opportunities for partnership working between services - particularly with Scottish Ambulance Service (SAS) - were regarded as positive outcomes of the redesign by some NHS staff.

A cultural change in the approach to how SAS manage patient care due to the redesign was positively acknowledged by staff during the focus group discussions.

1.3.2 Negative findings from patients and staff

NHS 24 Time to Answer (TTA)

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 (IVR) menu). Those who discontinued their NHS 24 111 call were less positive about their overall experience if they waited longer before ending the call.

Among Patient Survey respondents (who did have their call to NHS 24 111 answered) the length of time for NHS 24 111 calls to be answered, particularly for those contacting NHS 24 111 on a weekend evening/night, was one area where patients reported less positive experiences than other measures. However, there were no significant differences in overall rating of experience by NHS 24 111 TTA for those who had a call to NHS 24 111 answered (i.e. the Patient survey).

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 and more broadly, were reported as challenges by NHS staff to the successful implementation of the RUC pathway in some areas. Capacity challenges within primary care was mentioned by a number of urgent care staff participants. It was suggested that difficulty accessing General Practice (GP) 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.

Wider pressures within the urgent care system

Concerns were raised by some staff on the demands or pressures in other parts of the urgent care system. These include, ambulances queuing or ‘stacking’ outside hospitals, long waiting times in Emergency Departments (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’. The differing staff perceptions of the aim and scope of RUC suggest further staff engagement may be of value. It is also important to recognise the view that such 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 within the urgent care pathway worked together. 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 to inform necessary improvements can be made.

Managing patient expectations

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

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.

1.3.3 Findings from analysis of existing data

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

• an increased use of NHS 24 111 during weekday in hours (8am-6pm)
• an increased use of primary care out of hours
• an increase in waits of more than 4 hours at A&E
• reduction in SAS 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 these results may not directly mirror simple comparisons or trends of these metrics pre- and post-RUC pathway implementation.

1.3.4 Recommendations

A summary of recommendations are outlined below. Further detail is provided in Sections 8.2 and 8.3

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

1.4 Summary

Findings from the Discontinued Caller survey showed that of those respondents who contacted NHS 24 111, just under half of the respondents (45%; n = 173) reported that they waited 20 minutes or more before discontinuing their call with 105 of these respondents (27% of the sample) reporting they waited for more than 30 minutes before discontinuing their call. Most respondents ended their call because it was taking too long for it to be answered and/or the recorded message advised them the call would not be answered quickly. Of Patient survey respondents who had their call to NHS 24 111 answered, more than one third (36%) reported that they had to wait either a ‘bit’ or ‘much’ too long. These findings indicate an area where patient experience could be improved and that challenges remain for patients trying to access urgent care services.

However, insight from patients who had successfully accessed urgent care services via NHS 24 111 were largely positive about their experience of doing so, particularly in terms of the relational aspects of care received from the NHS 24 111 call handler and from the FNC. For example, 86% said when they called NHS 24 111 the person they spoke with ‘definitely’ listened carefully, including 95% of those calling on behalf of a child.

Findings from the focus groups with NHS staff showed the perceived impact and success of RUC were mixed. Variations between Boards in the progress of the RUC pathway against its aims were highlighted, such as differences in the scope and scale of FNC input and the availability and capacity of alternative pathways.

The analysis of existing data to assess changes to key Urgent Care delivery metrics, comparing pre and post implementation of the RUC pathway, showed some positive indications. At national level this included an increase in the volume of contacts to NHS 24 111, and a reduction in the volume of unplanned A&E and ED attendances when comparing actual state of play during 2022-2023 (post RUC implementation) with a counterfactual state of play at the same time point, based on a scenario where there is continuation of baseline trends from 2018 and 2019.

However, an increase was observed in the proportion of patients waiting more than 4 hours in A&E. At Health Board level, there were very few statistically significant differences. This indicates that there was minor deviations in the individual performance of Health Boards relative to those with similar pre-trends (please see section 7.3 for a list of where significant differences were found at Health Board level). It is important to note that causation of any change between these comparators, both in the national and Health Board analyses, cannot be conclusively determined, and is likely to have been driven by several factors. This includes but is 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.