NHS Ayrshire and Arran - redesign of urgent care - pathway finder programme: rapid external review

Key Messages

The Urgent Care Redesign (RUC) pathfinder model adopted by NHS Ayrshire and Arran, NHS 24 and the Scottish Ambulance Service (SAS) has involved unprecedented close and harmonious working, together. The RUC model has been implemented well with no major pitfalls encountered, to date. Initial concerns about workforce resilience have been resolved but longer-term vigilance will be required to ensure ongoing stability. Data (adjunct data report in supporting files section of the webpage) have shown that during this initial three-week review period, use of services is stable, with a slight expected increase in out of hours (OOH) referrals and as yet, no unintended consequences have been reported.

At present in NHS A&A, significant diminution in ED self-referred (walk-in) attendances have not (yet) been confirmed. Encouraging emerging data have been presented, which may signal this prospect. These are early days; progress is under continuous review, both by comparative local NHS A&A (NHS 24 and SAS) and national data analysis. Any assessment of significant change (or otherwise) in urgent care access patterns require sufficient time to elapse from the NHS A&A RUC pathfinder instigation and ongoing comparison with other territorial Boards, NHS 24 and SAS.

To date, changes in arrangements for access to urgent care help for the local A&A populace have been largely signalled in limited and local, social media messages. Only more recently in A&A has local hard copy (newspaper advertisements) been deployed, in the absence of national publicity for a RUC NHS Scotland roll-out. Changes in help seeking behaviours by the public will occur gradually and any assessment of progress must fully recognise that.

Early and evolving learning continues to be assimilated from the NHS A&A pathfinder site and has been discussed and shared throughout Scotland, facilitated by SG officers. This forms a key component part of Scottish Government (SG) RUC readiness assessment for all Boards:

• Good governance arrangements within NHS A&A appear to be in place along with regular system-wide feedback. NHS A&A is undertaking ongoing vigilance, due diligence and scrutiny, as local public awareness and access to the redesigned RUC programme expands
• Initial daily and subsequently twice weekly meetings with GP Practices have enabled regular dialogue to help understand the impact of the service change.
• No negative feedback has been reported by GP Practices of this new model to date.
• There has been an initial indication that there has been a small shift of activity to in-hours (daytime) general practice - the numbers however remain small.
• A regular 'safe space' for clinicians working in the urgent care service to discuss individual cases and resulting dispositions has proved valuable to all involved.
• Significant and ongoing senior medical and management resource has been invested in the NHS A&A pathfinder with benefit, in the early inception of RUC. This is a key learning point for all Boards.

All territorial Boards have signalled to SG that they are ready for a RUC launch on 1 December 2020. If SG endorses an early December national launch of RUC, as expected, it is suggested that all other territorial Boards adopt a gradual but resolute start (a 'soft launch' approach), as in the NHS A&A pathfinder. In effect, this would pursue the same start-up route taken by NHS A&A, assimilating and sharing learning from growing local A&A and broader pan-NHS Scotland experience.

All territorial Boards face local and sometimes unique circumstances and challenges (for example remote and rural issues). Further Covid-19 uncertainties, winter pressures and the festive period public holidays also loom large.

A 'soft launch' approach, with limited initial local publicity as in NHS A&A, should assist other Board Flow Centres to be fully stood up and to be stabilised in both workforce (induction, training, resilience, leadership support) and operational terms (IT and other infrastructure, bedded in and performing well).

If a 'soft launch' approach is agreed by SG, the decision for, and timing of a further full or 'hard' NHS Scotland RUC launch/roll-out, with associated large-scale national publicity drivers and messaging, should be judiciously considered in the light of changing circumstances and accrued experience, in the weeks ahead.

This external review considers the optimal 24/7 urgent care for the whole populace, but rightly there is a specific focus on best urgent care for children in Scotland.

There have been a number of discussions about optimal children's (paediatric) urgent care and whether the RUC model should be confined to adults only, in early inception. The NHS A&A pathfinder model incorporates both adults and children. To date, albeit with small numbers only, there is no evidence of children being adversely affected by the RUC model of care. Early feedback from parents in A&A has been positive, including scheduling of appointments and in some cases avoidance of hospital attendance altogether.

Public messaging, which should be as consistent as possible, may be compromised by mixed messages for adult and paediatric care. This issue, predicated on safe and effective care, continues to bring differing professional views, including the views of Board Chief Executives, the Scottish Association of Medical Directors (SAMD), the Scottish Executive Nurse Directors (SEND) and the paediatric clinical community. At a meeting of Board Chief Executives on 24 November 2020 a decision was reached on how to proceed. This is discussed in more detail later.