Health - redesign of urgent care: evaluation - main report

6. NHS Staff Views and Experiences of the RUC pathway

This section describes the findings from focus groups with NHS staff involved in the delivery of urgent and unscheduled care about their experiences of the RUC pathway. The aim was to understand how the changes to urgent care have affected practice and workforce experiences and what key learning and challenges have arisen from the implementation of the RUC pathway.

Notes for consideration when interpreting the findings

Some care should be taken when interpreting the findings. Not all boards were represented in the focus groups and there was mostly just one person per board and so the nature of their role may impact on their level of knowledge or insight into the implementation of the RUC pathway within their board. It is for this reason that it was not attempted to make detailed comparisons between individual health boards’ characteristics, nor have any health boards (in either the text or any quotes presented) been identified. However, as NHS 24 and SAS are national boards, reference has been made to these boards within some discussion points or quotes presented.

Some of the points discussed were only raised by one or two participants. This is unsurprising, given that many NHS Boards were only represented by a single participant, and that different Boards are likely to be experiencing different benefits and challenges as a result of their involvement in the programme. This makes drawing conclusive findings challenging, but since the purpose of this research is to understand staff experiences, these opinions have been included, even if a view was only raised by one person. Where a view was only expressed by a single individual, it is indicated that this is the case. When a personal perspective was shared, this may not reflect the views of other staff.

Since this evaluation was commissioned, the landscape of the RUC pathway has moved into Phase 2. Some of the points discussed in this section refer to some of the activities associated with this phase, such as providing direct access to FNCs for referral, scheduling and professional to professional advice for SAS and care homes. The Phase 2 principles are outlined in Annex H of first national staging review report^[46].

6.1 What do staff understand the purpose of the RUC pathway to be?

There was consensus across the groups that the main objective of RUC was to develop alternative and more suitable pathways to reduce the demand at A&E services so that patients get the right care at the right place and right time. A few members of staff also noted other aims, including scheduling more urgent care, creating opportunities for partnerships between services and having a single point of access via NHS 24. One participant felt that there are differences across Scotland, and even within their health board, in how the objectives of the redesign have been understood and are being implemented:

“So, the purpose of the redesign was, from the patients' perspective, to ensure or to best endeavour to get them into the right place at the best time … if we're looking at the whole of Scotland the difficulties with adopting that was always going to be a massive task, and it was going to default to those individual areas and how they adopted their understanding. When we speak with colleagues, even as part of [NHS Board], we see differences there already, which is I found pretty stark considering we're using the same team.” [FG3 P3]

Interestingly, some differences in participants understanding of the objectives of the RUC pathway were evident within the focus groups. This is highlighted in section 6.2.4.1.

While there was general support amongst staff for the concept of RUC, the discussions highlighted some difficulties experienced with implementation (as detailed in section 6.4) and a few participants in the first group also questioned the relative value of RUC.

6.2 What are staff views on how the RUC pathway is measuring up against its purpose?

During focus groups, participants made observations about differences between how the RUC pathway was working from place to place, inconsistencies in the availability of different urgent care services available for patients to be referred to across the day and changes in staff resourcing or service configuration. These are explored below.

6.2.1 Variation between NHS Boards

A ‘Listening Exercise’ conducted in 2021 with NHS staff as part of the second national staging review showed there were variations across Scotland in how the RUC programme had been adopted, including differences in how FNCs were operating. Findings from the focus groups conducted as part of this research showed variations exist between NHS Boards.

The focus groups conducted as part of the current evaluation found differences in the volume of calls being managed by FNCs and the scope and scale of FNC input into the urgent care pathway. Whilst one participant said their FNC receives around 1,200 calls a month with most patients being referred to an alternative pathway, another explained that their FNC receives very few calls a day and is essentially providing administrative support. A participant from a different NHS Board commented that much of the triaging was their responsibility as a GP when working in out-of-hours care. The reasons for the difference between NHS Boards appeared to be related to available resources, staff capacity and engagement (these are discussed further in section 6.4.1).

Variability between FNCs in terms of the role of the Senior Clinical Decision Maker (SCDM) was highlighted during focus group discussions. It was noted by one participant that decisions made by the SCDM are different depending on their role (e.g. Emergency Clinician, GP, Advanced Practitioner) due to differences in their knowledge base and appetite for risk. Their opinion was that a GP is best suited as a FNC SCDM as they understand all the specialities and can redirect patients appropriately. The different resources available across NHS Boards was raised by another participant; whilst some FNCs were set-up with ED Consultants as the SCDM, other FNCs had to find staff from existing staff pools. This point was reflected in the Listening Exercise conducted as part of the second national staging report with different levels of clinical resource highlighted. The level of financial resource was also perceived as being key by a participant in another group:

“One thing … that made a big difference was there was a good investment within the redesign of urgent care and with the Unscheduled Care Collaborative. And we looked at, you know, bolstering our urgent care team with senior clinical decision-making capacity.” [FG2 P2]

The discussions showed variation between NHS Boards in the extent to which alternative pathways had been developed for people who need urgent care. Some staff spoke about different pathways working effectively and/or ongoing improvement work within their Board, such as piloting new pathways or ways of working (see section 6.3.1). In other areas there appeared to have been less ‘activity’ associated with implementing the RUC pathway. For example, it was noted that the presence of Consultant Connect (professional to professional decision support call line) is not consistent across all health boards. A lack of alternative pathways or capacity within services was viewed by multiple participants as a challenge to the implementation of RUC in some areas (see section 6.4.1).

6.2.2 Scheduling of urgent care

One of the aims of the RUC programme was to schedule non-emergency attendances at A&E services to avoid peaks in demand and manage waiting times. Although staff were not directly probed about progress against this objective, staff in managerial roles (Focus Group 2) expressed views that the scheduling of unscheduled care has not been particularly successful:

“Personally, from the FNC perspective…, I'm not sure whether it works very well in [NHS Board] because a lot of redirections that happen from FNC actually go into the out-of-hours primary care. So, I'm not really sure whether it's a success because to me, redesign of the urgent care pathways was about making unscheduled care scheduled. Whereas what we see in [NHS Board] in the out of hours is that it goes from one unscheduled care service into another one, so it's not really scheduling anything to some extent.” [FG2 P4]

“The whole scheduling of unscheduled care, that we talked about at the start, hasn't really happened, so it's … who can see this patient tomorrow at two o'clock? And that bit's not really kind of come into place, and so we're still seeing that-, 'Well, I can't-, I don't know if you're going to get seen tomorrow.' So the easiest thing for them [patients] is to go, 'Well, I'll go to ED because I might have to wait, but I'll be seen.” [FG2 P2]

Within the chat function of this focus group, another participant wrote “GP primary care is scheduled so its going to be saturated all the time [and] we need to schedule more urgent care in hours” which received a ‘thumbs up’ (implying agreement) from three other participants. In a different focus group, one participant felt there is a lack of public awareness that it’s possible to get a scheduled appointment at A&E via contact with NHS 24.

Although one participant said they understood the rationale behind scheduling next-day appointments at Minor Injury Units (to avoid patients needing to attend at night), they argued that a) not all patients are able to attend in-hours and b) that the minor injuries pathway is working well, with patients likely to be seen within four hours and so perhaps is least in need of scheduled appointments. It was their perceived understanding that there is a growing evidence base to indicate that deprivation and inequality influence when, and how, people can attend urgent care services.

Some participants noted that the availability of alternative pathways can differ depending on what time of day a patient requires care. Whilst this may reflect local resources and demand, a few staff expressed views to suggest that scheduling of care does not necessarily align with what is needed:

“We've got a real difference in what's available out of hours and at the weekend, compared to what's available in hours. So, that depends at what time you require care, as to whether we can offer you an alternative, basically.” [FG1 P6]

“If you think about the FNC … what I would say is we maybe haven't seen the returns that we aspired to in the beginning, you know, and the percentages haven't been that high. And, you know, I think part of the challenge on that has been the limited end points that we've had for patients available during the day. And actually, it feels as if there is more available out of hours, at times, than there is during the day.” [FG2 P3]

One participant highlighted a difficulty in being able to measure the effectiveness of alternative pathways for patient journeys. They noted that it was challenging to get access across the system to get feedback due to working with multidisciplinary agencies and issues with accessing electronic records.

6.2.3 Changes in staff resourcing or service configuration

One of the downsides of implementing the RUC programme, highlighted by one participant, was the loss of experienced Band 7 staff from their A&E to other roles in RUC. They noted it had taken the department three or four years to build back up the portfolio of experienced staff.

A few staff from NHS 24 noted changes in how the RUC programme was being implemented since its inception. It was acknowledged by a participant from NHS 24 that there are currently too many pathway dispositions (relating to the specification of the level of care and time frame that a patient needs) and that they are working to review and condense these with the medical director. As noted in section 6.4.2, the appropriateness of the disposition assigned by NHS 24 to some patients was questioned by a clinician. Since December 2023, NHS 24 have provided the option of a virtual queue for patients to wait in a virtual queue, which is triggered after a certain wait time. The participant commented that the virtual queue option was having a good uptake and it was their view that the public are learning that NHS 24 can offer an option where they can continue with their daily tasks knowing that someone will call them back.

As noted in section 6.4.2, it was highlighted by one participant that their Board had changed their approach to how they manage calls from NHS 24 to their out of hours service.

A few participants spoke about the importance of understanding the challenges for staff working in different parts of the urgent care pathway. Concerns were raised by a few participants about how well urgent care services are working together. One person felt that due to services being stretched, different parts of the urgent care system do not communicate with each other or consider the pressures faced by the other service. Similarly, concern was expressed by a participant in a different group that new services that are often designed to improve flow can add an extra silo.

6.2.4 Wider challenges within the health care system

6.2.4.1 Urgent care

Some staff, largely in the first focus group, felt that whilst the redesign of urgent care may have reduced the number of A&E attendances in some NHS Boards, challenges remain within the wider urgent care system. The issue of ambulances queuing or ‘stacking’ outside hospitals, long waiting times in EDs and the challenge with discharging patients from hospital (which in turn can impact the flow of patients through A&E) were noted [Box 1]. Whilst the RUC pathway aims were to improve how the public access urgent and unscheduled care in non-life threatening situations and reduce self-presentation at A&E services (by providing care closer to home), two of these quotes highlight that some staff perceived the objectives of the RUC were to reduce A&E waiting times and address SAS hospital turnaround times. It would be interesting for further research to explore why and how NHS staff views differ on the aims of the redesign.

Box 1: Staff views on pressures within the urgent care system

“I think a concept which a lot of us will recognise is this whole thing [RUC programme] was, kind of promoted … as the answer to the issues surrounding urgent and unscheduled care. So, if we did this, then problems like long waits in emergency departments, ambulance stacking, etc, etc, would be solved by this problem. Now, I'm not sure-, well, I know it-, I don't think that's the case.” [FG1 P2]

“We're [SAS] facing something we've never faced before and that's hospital waiting outside ED, and that's having a massive impact into patients' lives … we have not been able to meet targets such as life-threatening response, because we're stacking outside hospitals. It's not every hospital and it doesn't really affect the remote and rural hospitals much, but when it does, it has a massive impact because they're smaller.” [FG1 P5]

“The waiting times have not reduced. From what I understand, for the unscheduled care, it's supposed to reduce the waiting times, but it hasn't reduced [them]” [FG1 P4]

“But there's just so little capacity and it's that whole system piece and then that's what impacts on-, let's say we [SAS] wanted to do a kind of direct admission to a ward, which we do in some areas, they can't get the patient out because they don't have the social care packages to support the discharge.” [FG2 P2]

The Listening Exercise, conducted with NHS staff as part of the second stage review of RUC, previously found that some staff felt the focus on self-presenting patients was not addressing the issue of delays experienced in admitting patients to hospital^[47].

6.2.4.2 Primary Care

Across the three discussion groups, capacity challenges within primary care due to high demand were discussed by several participants; a GP said they were seeing around a third more patients each day than before the Covid-19 pandemic. There was a sense that self-presentations at A&E remain a challenge due to the difficulty for patients to get a General Practice appointment and/or due to perceived NHS 24 wait times, as illustrated by these example quotes:

“I've just actually been sat this morning auditing our bank holiday weekend pharmacist referrals-, and that's actually been really interesting, the amount of comments within those notes …'Couldn't get an appointment with GP, couldn't wait.' So, when our staff have phoned these patients back on an advice call, 'Couldn't wait for callback,' and they've just taken themselves or their child to ED” [FG3 P6]

“The feedback I'm getting from the department, it's … people are at their wits’ end trying to get GP appointments. …If you can't get a GP appointment, your next call is A&E, there's no next escalation step for them [patients], I guess. The number of self-presenters that we've seen come through in the department the past few months has rocketed compared to what it was last year. …I had experience of it myself, you phone 111 and you're told it's a 90-minute wait time to get to even to speak to someone. So, if you are in pain or you're desperate or you need help, the next best thing for you to do is to rock up at A&E, to make sure that you get seen by someone.” [FG2 P5]

A few participants argued that greater investment and support within primary care was required to support the redesign of urgent care.

“To get to the end point where we have got the right people at the right time, at the right care, I think we do need to think about-, so, there's a lot of work gone into the front door and, you know, urgent care referral pathways. But there is something really needed to be looked at around … GP primary care in-hours model and how that can respond to the urgent care needs of the population as well.” [FG2 P6]

6.2.5 Future considerations

In addition to more investment within primary care (noted above) and the perceived need for greater public awareness and knowledge of accessing urgent care (as discussed later), a few other suggestions for how the RUC programme should evolve were mentioned by staff.

One participant referred to an urgent care hub that is being developed and tested in their area where General Practices can refer patients for urgent care in working hours. They felt the concept of a ‘hub’ - where there are concentrated services with a multidisciplinary team (including for example, mental health, pharmacy, physiotherapy and paramedic support) - could be applied to the wider Scottish model with regional urgent care hubs being developed. It was felt that if boards work together to provide resources for a regional model, this builds resilience and capacity within individual boards and would reduce the demand at A&E. Similar findings were found in the previous evaluation where staff had suggested there are opportunities to provide services at a regional level in partnership with NHS 24 and SAS, and that collaboration between smaller NHS Boards could be more cost-effective due to efficiencies resulting from economies of scale^[48].

A few staff discussed the pros and cons of a primary care walk-in centre model but it was recognised that there could be challenges with staffing and funding. It was also noted by one participant that such a model does not allow for care to be scheduled but there is need to replicate the out-of-hours scheduled model to in-hours urgent care.

A few participants highlighted the importance of recognising that one model or one size does not fit all as every board has its own challenges. The importance of listening to staff feedback on any new services or systems introduced (based on it working well in another NHS board) was emphasised by one participant:

“I think it's just important just that one size doesn't fit all. So, that when you have a new system in one area it's important that that's not railroaded through …I'm thinking of things like virtual minors, which did not work for us, we didn't have the staffing, and the processing at all. Despite … negative feedback with real good solid data, it took a long time for that to gradually disappear. So, I think that's probably an important point just to recognise is that if something works well in one health board, it might be able to be moved, and altered, but it wouldn't necessarily work in that form in another one. So, it's important not to just push it through without listening to feedback on it.” [FG3 P1]

6.3 What benefits have staff identified from the implementation of the RUC pathway?

The main benefits arising from the implementation of the RUC programme discussed by staff during the focus groups were centred around the development of alternative pathways and the increased opportunities for partnership working.

6.3.1 Development of alternative pathways/services

The development of alternative pathways as part of the RUC programme were recognised by some staff, across all three groups, as having had a positive impact within their health board. The examples given were largely the pathways and relationships developed with SAS. Professional to Professional clinical advice support and access to ambulatory care were noted as key changes by one participant, and the ability for SAS to admit patients straight to the ward was highlighted by a few as being beneficial. The support from SAS within GP primary care was also mentioned by staff working at two different boards, in terms of conducting some of the home visits or supporting the urgent care response. The development of the FNCs was felt to have enabled SAS to use alternative pathways with access to a senior clinical decision maker to support decision-making [Box 2].

Box 2 Examples of perceived successful alternative pathways

“Historically the big thing we've seen is obviously, the majority of ambulance patients who needed secondary care access that via ED. Some areas had an acute pathway and ultimately, it's still the same front door, ultimately. Whether it's ED or acute, it's still really stretched. P2P [Professional to Professional] systems and that RUC access to ambulatory has been that big change. And for us that's been one of the huge benefits because it's allowing us to recognise it” [FG2 P2]

“We're very lucky in [NHS Board] that our paramedics and our ambulance crews can go straight to wards and we're very lucky as in the FNC does filter out a lot of things that don't need to come to the emergency department”. [FG3 P5]

“We worked really closely with the SAS. We do have advanced paramedic practitioners supporting some of the work within [NHS Board] as well, within GP primary care, to support our urgent care response. And that is working really well” [FG2 P6]

“In GP practices, they've got a lot of support from SAS now as well in [NHS Board], they do have dedicated teams doing the home visiting element of it”. [FG2 P7]

“I think the Flow Navigation Centres have opened up an extra, kind of, arm for us [SAS] to be able to use that redirection and alternative pathways that gives us, mostly, a senior decision-maker added into our tool that we've already got for making decisions within the clinical process” [FG1 P5]

6.3.2 Professional to Professional decision support

As mentioned above, professional to professional decision support was regarded positively by staff. Both Call-Before-You-Convey and Consultant Connect call lines were mentioned by some as beneficial for supporting staff in clinical decision making, although it was noted that in certain areas these were set-up before the implementation of RUC. In addition to supporting staff in decision making, one participant explained that a Consultant Connect line within their A&E helps to avoid miscommunication by ensuring staff are aware of a patient coming in and, if necessary, preparations can be made for that patient:

“We have in our department … a consultant connect phone. …It is basically a phone that NHS GPs, paramedics, can all use, but it's more just that second of, 'I think that they should come to hospital, but I just want to double-check with you if they should come to the hospital, and if so this is what's happened to them, this, that, and the next thing.' That just gets put up on our board, so that we know that they're coming in. So, that there is no miscommunication, as in somebody rocks up having seen their GP, but the GP has told them to come up, but we know about them. …Also, we know that … if it's, like, an elderly person that's fallen a couple of days ago … we can get them on a trolley, and we can send them for an early X-ray before our ED clinicians have even seen them.” [FG3 P5]

Whilst it was agreed the Call-Before-You-Convey call line was beneficial and utilised effectively by SAS within their Board, a participant felt it was not well advertised to other sectors, such as primary care which they thought can result in patients being directed to A&E due to staff being unaware of it and/or do not use it due to a previous poor experience in being able to access it in a timely way. These findings corroborate those from the Listening Exercise which found that staff valued the professional to professional calls but that there is a need to widen the access and support for more professional to professional discussions^[49].

In addition to the alternative pathways developed with SAS, some participants spoke of other new pathways that were regarded as being beneficial. Two participants, from the same health board (but in different focus groups), highlighted that a large proportion of the care homes in their area are signed up to a service which allows them to have a direct line to the Flow Navigation Centre’s pathways. Rather than contacting NHS 24, care home staff can have a direct professional to professional advice call with a senior clinician to decide on the best course of action. Staff noted the positive impact of this service and thought it had led to a reduction in the presentation and admission of patients from care homes to A&E.

6.3.3 Change in SAS approach

A change in the approach to how the SAS manage patient care was referred to in the discussions. A participant explained that the RUC programme provided the opportunity to discuss and change the SAS approach to the care of patients at the end of their life, when being conveyed to A&E may not be in the patients’ best interest. They explained that SAS can now give ‘just in case medication’ and can link to alternative pathways, such as hospices, via the FNC. This change required educating SAS frontline staff on how to manage the care of end-of-life patients differently.

Transformation to the working practices of SAS staff resulting from the redesign was acknowledged by a participant in another group who described it as a ‘cultural change’:

“Historically we've always said, 'Let's take the person to ED,' that's the only, kind of, point of destination that we've got. …But now it's a bit of a culture change. With the redesign, I think that it's never going to happen overnight, and I think we're doing a lot of work with the staff through CPD [Continual Professional Development] sessions of their clinical decision-making. …It's going to take a wee while, but I've certainly noticed changes so far, just with the different alternative pathways that we've put in place over the last couple of years…It's certainly going in a different direction, which is really nice to see.” [FG3 P7]

The increasing role of paramedics in making a clinical assessment was regarded as being important by an A&E consultant for adding a ‘filtration’ to the triage process which benefits A&Es.

6.3.4 Other pathways

Other alternative pathways/services that were working well and developed as part of the redesign were also briefly mentioned by staff – each by one participant:

• Rapid triage unit where patients are referred for diagnostics, so they don’t have to be admitted to hospital
• Urgent Nursing Care Team that accepts referrals from GPs, SAS and community nurses and will either visit the patient or see them in an assessment area which was regarded to be a success for reducing self-presentations at A&E. It was noted, however, the development of this team was primarily driven by the GP contract change in memorandum 2 [i.e. Boards are responsible for providing an urgent care service from 2023-23]
• Improved pathways for people with mental health problems with better access to phone advice via mental health hubs

6.3.5 Partnership working

A benefit from implementing the RUC pathway identified by staff, particularly those in managerial roles, was the increased joint working between services. Participants noted that the redesign of urgent care has provided them with opportunities to bring partners across the urgent care system together, with positive relationships being developed with the SAS. One person highlighted that joint working has allowed them to not only develop services within a short period of time but also to test different ways of working in places where they may not have previously done so:

“Joint working has probably been one of the big benefits of the redesign of urgent care … [it] has really allowed us to push on with things in [NHS Board]. …It was quite a quick development in terms of it went from, kind of, a concept to actually being tested in weeks in terms of some of the call-before-you-convey-work. And I think because we had that … space for redesign of urgent care to bring those partners together and people willing to take a little bit probably more risk than previously. It really allowed some of that … service development and it's probably opened the door to SAS for a lot of places. I know my colleague [Name] has probably been dealing with [Name] at the moment and allowing them just to test things out differently and probably in places where we wouldn't have tested things before.” [FG2 P2]

Both a nurse working in A&E and a manager for primary care OOH services (from different NHS Boards and participating in different focus groups), reflected on the benefit of having regular briefing sessions with a representative from their FNC. One commented it allows them to understand how it’s developing and enables positive and negative interactions to be “shared and aired.” The other participant explained that the meetings are used to understand how the management of referrals can be improved:

“We have regular meetings with FNC to help us redesign those pathways, identify any inappropriate referrals or referrals that could be handled in a different way. So, we try to pull as much learning as we can. We can identify that some of the calls, instead of being redirected to us, could have been actually admitted directly to hospital, instead of, you know, jumping from one service to another and then having multiple clinicians asking the same questions to find out what-, you know, extending that patient journey effectively is what we do. So, we try to improve this on a regular basis.” [FG2 P4]

6.3.6 Other positive experiences

Access to alternative pathways and the opportunity for partnership working were the two main themes staff discussed when reflecting on aspects of the redesign that were working well and/or having a positive impact. However, the following benefits were also noted - each by one participant:

• Improved patient access to services in rural areas in terms of a) the FNC being able to schedule x-rays closer to the patient’s home and b) increased acceptance of using digital technology which has positively impacted on staff recruitment, retention and access for patients.
• SAS focus across all Boards and ensuring a level of quality to the development work. The example provided was that a rural NHS board which does not typically have a challenge with SAS turnaround times, may not have had the same focus from SAS previously, but due to RUC and the board looking to work differently, it has ensured a quality in what is being developed across the board.

6.4 Challenges arising from the implementation of the RUC pathway

6.4.1 Lack of alternative pathways/lack of capacity within alternative pathways

One of the benefits of RUC identified above was the development of alternative pathways. However, a lack of alternative pathways available was highlighted by some staff (primarily in managerial roles and those working within FNCs or NHS 24), as a challenge to the successful implementation of RUC. Staff expressed views that there are not alternative pathways available for re-directing patients from their FNC or that there is a lack of capacity within alternative end points. This may result in patients not accessing services that best meet their needs. A clinical supervisor at NHS 24 explained that staff are not always aware when alternative pathways are unavailable, leading to a poor patient journey:

“We've been having issues particularly with minor injuries, where … they've been assessed and sent to minor injuries, there aren't staff to make those appointments, so they don't go anywhere, which means those patients sit for longer, turned back into the [NHS 24 111] service, or present at A&E. So, there are times where we are following a process. …but the service isn't there to actually provide. On occasion we are not informed through NHS 24, so it ends up being this … cycle where you're told X, Y and Z, and you'll wait for a contact from minor injuries, but that isn't going to happen because we don't know that there's no one there. … So, if things are working it's great, and people go places they're supposed to go, but if they don't, they either end up going in this cycle, which is a poor patient journey, or they present somewhere to a service that is already massively stressed, where they don't necessarily have to be, like Accident and Emergency.” [FG1 P1]

A participant who had worked in the pilot site for RUC noted that a risk of alternative pathways being at capacity is that patients may re-attend A&E. As the pilot site for the RUC programme, they explored data which showed that patients who had been redirected to alternative pathways attended A&E three or four weeks later because the services did not have the capacity to meet the patient’s needs. The adverse impact on staff of not having alternative pathways developed as part of RUC were highlighted; two FNC staff expressed feelings of pressure to meet referral targets which they felt were unachievable, whilst the clinical supervisor at NHS 24 noted their feelings of concern after referring patients to a FNC which was not operational at the time [see Box 3].

Box 3: Impact on staff experience of a lack of alternative pathways

“As a Flow Navigation Centre, we are under a lot of scrutiny, and criticism. Ultimately, I'm very aware that these services a lot of the time are at capacity. I think the other thing that I'm aware of is that, we're sometimes trying to deliver other things where there hasn't been any additional resource. So, if we're saying, 'Oh yes, we want to use this pathway, this is what you need to be doing with these types of patients,' but actually if they haven't been given the resource to increase their staffing, and what they can … deliver, you're setting people up to fail, and I feel a little bit sometimes that's what's happening as I say with these targets. Actually, if there's no resource and staffing to go with that, we can't deliver it, and yes, then we take the criticism, and continue to be under a lot of scrutiny.” [FG1 P6]

“And I completely agree with the point that if there's nowhere else to send people, which, for the majority of our areas, there literally isn't, because you've got a minor injury unit that sometimes functions, that doesn't want to engage with the Flow Navigation Centre … achieving those targets is nigh on impossible without any kind of consideration to the complexities of having one service that operates in an identical fashion across [several] end points.” [FG1 P7]

“We usually find out [a pathway is not available] after and it's usually flagged up on a return call. … So, (1) you worry about not just that current person, but also possibly, 'How many other people have you triaged that you said are fine to wait, and they're not?' … so you feel that you're working with a hand tied behind your back that you can't complete what you want to complete, and get those patients appropriate and timely care. So, it doesn't leave a nice feeling for you, or for the patient.” [FG1 P1]

One participant felt an opportunity had been missed in their Board with the redesign of urgent care, as new pathways were not yet available or linked up to their FNC effectively resulting in two ‘systems’:

“We developed an urgent care nursing team that used to be just out of hours, but now, could do in hours. …But what I would have liked to have seen is actually that pathway be available through the FNC, because it isn't at the moment. And it feels like a bit of an opportunity missed and hopefully, that's what I would like to see progress. …I had maybe high hopes that the FNC would be able to coordinate that all. So it almost feels like we've got two systems, one through the FNC and one locally.” [FG2 P3]

The reasons for the lack of alternative pathways in some areas mentioned by staff were a lack of financial resource, issues with staff capacity or challenges with staff engagement to develop alternative pathways. Some staff also alluded to the length of time it can take to implement change [Box 4]

Box 4 Factors affecting the development of alternative pathways: resource, staff capacity and engagement

“Some of the big challenges we've seen relate to, I suppose, then the areas of focus for within the different boards and that, kind of, willingness, I suppose, to do some of the things differently. So, we've developed similar pathways in different parts of the country. So, one of those is, kind of, the RUC ambulatory care access and you've got some boards where they're actively hunting out patients … And it makes it really easy to develop that pathway and to … reduce those touchpoints. …But then you've got other areas who are developing the same pathway but they don't have the same capacity.” [FG2 P6]

“There's no pathways. We are scheduling patients and there's not been an uptake or a desire to try and develop that any further. So, patients are basically walking in to A&E, and those small numbers [referred to FNC] have never changed. … We've tried to see if those small handful could be triaged by an advanced practitioner in A&E, some sort of initial triage to even stop them coming through the door … but, they're just stretched and there's no funding to bring extra resources in.” [FG2 P7]

“I think our lack of flexibility is around the money. We have not implemented most of the things that you guys are talking about, because we are so broke. My personal feelings on this are that it's to do with a lack of understanding of how the money is implemented in small populations but large geographic areas. The pot as money doesn't go as far when you need to cover-, the jam needs to be spread so thinly.” [FG3 P2]

“They [a different NHS Board] use Consultant Connect and have done [so] for about twelve years. So, what we're working against is a process that's been in play for ten years more than what we have been. So, that's a real big fight to try and get to that same level of expertise.” [FG1 P5]

Whilst a lack of resource and staff capacity were perceived as barriers to developing the FNC in one Board, it was also noted there has not been the “uptake or desire” by some staff to develop alternative pathways via their FNC. The challenge of staff engagement in the implementation of alternative pathways was highlighted by a participant working for SAS who had experienced variations between Boards in their willingness to work differently to develop ambulatory care pathways. These findings echo those reported from the Listening Exercise conducted with NHS staff previously, where it was suggested transformational change takes time and support^[50].

6.4.2 Initial triage and risk management

Clinical staff in the third focus group spoke about the importance of the initial healthcare assessment and triaging for the redirection of patients to appropriate urgent care pathways. Participants highlighted different issues relating to the challenges and complexity of the risk-management aspect of the triage process, whether this related to avoiding suboptimal prioritisation decisions and delays in providing care to patients in need, or ensuring that staff in triaging roles had the right skills to be able to manage risk appropriately in their clinical decision-making.

It was recognised that the initial assessment of a patient can be challenging if carried out over the phone when a clinician, such as a GP, may not have ‘eyes on’ a patient – particularly if there is not any professional to professional decision-making support (such as Consultant Connect) and/or in more rural areas due to the time it can take patients to reach a clinician. It was noted by a GP however, that even if there was a Professional to Professional call line, they would have concerns about the time waiting for a consultant to respond as they are unable to see other patients in their waiting room (or waiting to be called back) who may be very unwell.

Concerns were expressed by a few participants that patients can be directed to an inappropriate pathway by NHS 24, which can be frustrating for both the patient and clinician working within that service. One participant also felt that NHS 24 decision-making on the disposition given requires reviewing, as some patients on a one-hour disposition have less urgent care needs than a patient on a four-hour disposition (a disposition will specify the level of care and time frame that a patient needs to be seen/assessed following an assessment)

There was an acknowledgement that having a senior decision maker at the point of triage can be very effective in ensuring patients are directed to appropriate pathways and services. However, it was noted that such an approach is expensive and therefore not sustainable:

“I took part with about three, or four other ED colleagues in the primary care re-triage pilot …which was incredibly effective. …Every call coming through from NHS 24 [we] were phoning up patients individually and re-triaging them. It was instrumental in reducing the number of home visits, the number of patients needing to come in. …Again, something like that is very expensive. It's top heavy. You need to have people who are not risk averse sitting in those chairs. Also, it's almost impossible to maintain that.” [FG3 P1]

Whilst an out of hours service had initially attempted to re-triage all referrals from NHS 24, it was highlighted by a participant to be unsustainable, resulting in long waits for patients to be called back. However, the service has assigned some time for ‘digital clinicians’ to triage the advice calls to help manage the demand:

“For a long time post-COVID [we] tried to do, like, just triage all our stuff that came down from NHS 24, but it became unsustainable, and patients were waiting extensive lengths of time to get a call back. We found it was becoming quite dangerous. We were missing things. So, we reverted back to a process where we now allow NHS 24 to appoint all our patients, but we have a section within our rotas now where we have digital clinicians who come in and basically … triage all of our advice calls. …They'll also pick up, you know, if the service is getting a bit heavy, they will re-triage things like home visits to see if they really need to be a home visit to try and disperse that to getting the right clinician to the patient.” [FG3 P6]

As noted in section 6.3.1, the increasing role of paramedics in making a clinical assessment was highlighted as being beneficial for triaging patients effectively. It was suggested that where a patient is to be seen in person, whichever clinician can see the patient face-to-face should be empowered to make a triage decision as that filtration process benefits A&Es due to redirecting patients to alternative pathways.

6.4.3 Managing patient expectations

There were consistent views shared by staff that managing patient expectations for accessing urgent care is challenging. Some staff recognised that it is difficult for patients to understand what constitutes an ‘urgent’ care need and that there is a public perception that if they have a health problem/concern, they should be seen by a healthcare professional rather than self-managing. Some staff felt the desire for patients to be seen by a healthcare professional had increased following Covid-19.

There was a widely held view amongst staff across the discussion groups that there is a need for greater patient education and awareness to help understandings of the difference between urgent and non-urgent health problems and to provide people with the confidence to self-manage, where appropriate. Some staff highlighted the importance of making the public aware that although there may be a wait when accessing NHS 24, this is likely to result in a shorter patient journey overall than accessing the care they need via A&E. One participant noted that people who self-present at A&E (perhaps due to difficulties with accessing NHS 24) may have an extended patient journey – such as being directed to out of hours care - only to be given self-care advice.

“Obviously waiting to come into NHS 24 for 90 minutes is not acceptable and it's not something that we would work towards. However, if that same person turns up at an A&E department the likelihood is that they're going to have an hour’s wait for triage, and then they're going to have a four to six hour wait to be seen by someone. So, actually hammering down to the public that … you may have a wait, but we will get you to the correct end point, is probably the angle that I'm coming at.” [FG2 P1]

“We're finding a lot of people just presenting to our service. They'll try and go through NHS 24. They can't get through, so they'll take themselves to ED…then be redirected to out of hours. Then they're having to wait for an appointment. So …their journey is really appalling. …Often these patients have been on a twelve-hour pathway, and they come into our service, and we go, 'Here's some self-care advice. Here's some worsening advice. Off you go,' with nothing. That must be really frustrating for these people as well. So, I think there's a lot of public education needed.” [FG3 P6]

However, a few participants noted that educating patients about appropriate care pathways is not straightforward. One participant noted the difficulties of ‘undoing’ changes in health seeking behaviours that have developed over many years. Another participant highlighted the risk of conducting an advertising campaign focused on, for example, reducing the number of children with viruses taken to the A&E by parents and carers, because occasionally there are adverse outcomes.

A view expressed by a few was that patients have high expectations about accessing urgent and unscheduled care quickly with no public messaging that the NHS is unable to deliver that. One participant suggested that having 24/7 access to NHS 24 may have contributed to these expectations and led to increased demand:

“…all the good that NHS 24 does, I do wonder whether it has created a bit more of the… Amazon Prime culture of, 'There's this thing available at the end of a phone at any time.' So, some minor thing, which, perhaps, previously you might have dealt with, you now just make that phone call and once you're in the system … we have to deal with them then. That's another person to triage. It's another person to try and direct. So, I do wonder sometimes…NHS 24 is great but …are we too available? And actually, are we-, is it actually turning into a bit of a negative sometimes because of the numbers of patients that come through that route?” [FG2 P6]

The challenge for staff managing patient expectations about which services or pathways are appropriate for their condition was highlighted by a few participants:

“From my experience with patient callers [to NHS 24], they would believe that they should have access to care when they think fits, not when you think fits. …Sometimes, it's very difficult for you to handle such people because, you know, they get upset when you keep them waiting for long and then they don't get access when they feel they should.” [FG1 P4]

“…the public will still come up [to A&E] with dental pains, looking for a dentist, and unfortunately, it's up to us [A&E staff] to then go and say, 'No, you need to be redirected to your dentist,' and stuff. That doesn't always go swimmingly, because mostly people come to A&E at their last tether.” [FG3 P5]

This finding supports previous work conducted with NHS Board Chief Executives as part of the second stage review which noted the challenge for staff in A&E to redirect patients to primary care services when the patient has informed them that they are unable to access an appointment at their General Practice^[51].