Health - redesign of urgent care: evaluation - main report

8. Key findings and recommendations

This section sets out the key findings from the evaluation, and the subsequent recommendations.

8.1 Positive findings from survey respondents 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 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 FNC 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 A&E/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 in 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 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.

8.2 Negative findings from survey respondents and staff with recommendations

NHS 24 Time to Answer (TTA)

Nearly half the patients who got through to NHS 24 111 had to wait over 20 minutes for their call to be answered. Up to 71,985 calls were discontinued between June 2023 to May 2024 based on statistics from NHS 24. Of those who were part of the Discontinued Caller survey around one third of respondents who contacted NHS 24 111 out of hours (weekday evening/night and weekend) reported a wait of 30 minutes before ending their call to NHS 24 111. 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.

Recommendation 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.

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 FNC 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 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.

Recommendation 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 through 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.

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 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 objective and scope of RUC suggest further staff engagement may be of value. Furthermore, it is also important to recognise the view that pressures within the wider system may limit the implementation and impact of RUC and that a whole system approach should be taken.

Recommendation 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.

Services working together

Patients reported less positive experiences on 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 would generate a more in depth understand this finding and help inform necessary improvements.

Recommendation 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.

Recommendation 5

Explore the opportunities for smaller NHS Boards to work more closely together - in partnership with NHS 24 and SAS - to provide resources to build resilience, capacity and the flexibility to implement changes.

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.

Recommendation 6

Public messaging aimed at continuing to educate the public on when NHS 24 111 should be contacted and why, including when and why self-care or accessing alternative services, such as Pharmacy First or General Practice might be more suitable for some health concerns.

8.3 Findings from analysis of existing data and recommendation

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

• an increased use of NHS 24 111 in hours (137%)
• an increased use of weekend primary care out of hours (15%)
• reduction in SAS attended incidents (-16%) and conveys to hospital (-19%)
• reduction in all A&E attendance (-17%)
• reduction in admissions following A&E attendance (-31%)
• reduction in number of self-referrals to A&E (-28%)
• an increase in waits of more than 4 hours at A&E (-16%)

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 at a national level 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. Again, causation behind a relative divergence of a delivery metric within a Health Board away from another or others with similar trends during the pre-period cannot be conclusively determined. 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.

There were several gaps in the data available for the analyses, which included FNC available data. FNCs were one of the three main interventions introduced as part of the RUC pathway.

Recommendation 7

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

8.4 Remaining evidence gaps identified

In addition to the findings and recommendations set out above, this evaluation has also allowed for identification of remaining evidence gaps which may require exploration. It is acknowledged that filling these evidence gaps may require expanding the scope of future analysis to areas beyond RUC itself and with consideration of the wider system. Areas for exploration include:

• More detailed understanding of areas where patients reported their experiences were less positive
• More detailed understanding of patient experience of NHS 24 111 given the introduction of the virtual queue service.
• Understand any impact of the RUC pathway on equity of patient experience
• Scoping the feasibility of undertaking a Cost Benefit Analysis of the RUC Pathway, with important consideration of the wider system and the RUC’s place within this.