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

Findings and Recommendations

Operational Issues

• Initial feedback from the local public regarding the NHS A&A pathfinder site has been positive, including venue of care and scheduling of attendance. (There have been no informal or formal complaints to date, in this early inception stage).
• Processes have been in place in NHS A&A to manage phone calls where there is a requirement for British Sign Language or translation services to be engaged.
• Initial feedback from NHS A&A staff working in the Flow Centre has been broadly positive. Further discussions with NHS A&A colleagues working in both primary care and secondary care have expressed caution about ongoing staffing resilience, tempered by Covid-19 uncertainties.
• Robust feedback mechanisms are apparent within NHS A&A for key stakeholders to raise any issues arising, during the immediate implementation phase.
• Managerial and clinical leadership have been readily in place within NHS A&A to rapidly identify and address any issues arising during the immediate implementation phase. The omnipresence of a senior clinical decision maker was a key recommendation of the 2017 Public Holiday Review^[2] for service resilience over public holidays.
• Scotland wide, SG should look to maximise the engagement of Quality Improvement Fellows (QIFs) and Scottish Clinical Leadership Fellows (SCLEFs).
• Scottish Directors of Public Health have also signalled their support for RUC and desire to be more engaged going forward.
• The role and engagement of Healthcare Improvement Scotland (HIS) in the RUC programme needs to be defined and agreed.
• Clinical review of the circumstances and outcomes for individual cases should be scrutinised regularly on a systematic basis, to ensure robust clinical governance processes in all Boards,
• NHS A&A has been conducting GP practice local calls every day, for the first two weeks of implementation and twice weekly thereafter, to inform, seek advice and to diminish uncertainties. This approach should be taken forward by all territorial Boards. This process should be replicated in acute and other care settings to ensure that all clinical and support colleagues engaged in the RUC programme are fully informed of emerging and evolving issues.
• NHS A&A has had good engagement with local/regional SAS crews and this approach should be replicated by all territorial NHS Boards.
• Some issues have been identified regarding optimal transport of individuals who are advised to attend an ED or Minor Injury Unit (MIU) but who do not have ready access to transport. NHS A&A are continuing to explore this and this needs to be resolved nationally.
• NHS A&A had the opportunity to test their Business Continuity Plans in place, following a short IT system outage in the first two weeks of the RUC programme. NHS A&A has indicated this experience was valuable and has strengthened their Business Continuity Plans. It is recommended all Boards test their Business Continuity Plans in the early stages of RUC implementation.

Workforce Issues

• There are key workforce risks for the establishment and sustainability of Flow Centres, while preserving the Covid-19 pathway and Primary Care Out of Hours (OOH) Services. While NHS A&A have mitigated these risks and stabilised these services in these early stages, continued monitoring is required with expected additional changes and volumes in urgent care flows. This applies to all territorial Boards.
• This also holds true for NHS 24, where unexpected changes in urgent care help seeking behaviour over time may result in significantly increased demand and call volumes.
• Induction and staff training issues for Flow Centre staff in NHS A&A should continue to be shared across NHS Scotland.
• Workforce resilience may be further enhanced by identifying appropriate skillsets, multidisciplinary teams including advanced nurse practitioners (ANPs), clinical pharmacists, paramedics and allied health professionals (AHPs).
• Workforce resilience may also be bolstered by maximising flexible home working opportunities, using Near Me and similar technologies, to optimise the best balance between in-person and remote/virtual care. This needs to be evaluated further.

Data Issues and Communications

• NHS A&A, in conjunction with NHS 24 has undertaken daily assessment of numbers of all care episodes and dispositions and has been reporting on a daily and weekly basis. There have been no unforeseen data issues of note.
• Communications and relationships between NHS A&A, NHS 24 and SAS have been of a high order. This needs to be maintained and promulgated throughout Scotland, However the high levels of regular oversight by NHS 24 and SAS Executive Directors will not be possible for 14 Boards simultaneously, therefore robust alternatives will need be in place. From discussions with NHS 24, SAS Executive teams and SG officers, I understand that these are in hand.

Workstream 1: Data & Intelligence was established by the Redesign of Urgent Care Advisory Group (Workstream Chair: Professor Derek Bell). He and his group (of which I am a member) have supported the work of this review. Analysis is continuously ongoing and the NHS A&A pathfinder will inform data collection and interpretation for, and assist all Boards, going forward. Early findings are appended as an Adjunct Data Report which can be found in supporting files section of the webpage. In summary, Workstream 1 concludes in the first three weeks of operation, that:

• There is no evidence that the RUC programme has disadvantaged any individuals in terms of age, gender or index of deprivation, compared with historical organisational patterns of demand, since the inception of the NHS A&A pathfinder on 3 November 2020
• NHS 24 contacts have increased since the beginning of the NHS A&A pathfinder. This in part reflects the measurable increase in NHS 24 in-hours contacts, as expected
• There has been a small increase in referrals to GP in-hours services (Monday-Friday), as well as a small increase in GP Out of Hours (OOH) activity, compared to the baseline period
• Covid-19 Hubs and Clinical Assessment Centres (CACs) activity have been stable over the study period
• There has been a small decrease in both SAS cases attended and conveyed
• As yet, there is no significant change in ED attendances or target performance since 3 November 2020
• There is an early indication that the number of people who self-present to Emergency Departments (EDs) and Minor Injury Units (MIUs) is decreasing during the early NHS A&A pathfinder experience. Further analysis is ongoing to fully establish this and to monitor trends
• Respiratory data remain stable for both SAS and NHS 24
• Mental health data remain stable for ED attendances - see also Annex 3.

Unlike all other NHS care sectors, there is presently an absence of knowledge and understanding of activity data within general practice and primary care in Scotland. This hampers a full assessment of care flows, future changes in activity and trends analysis. This is well recognised and is presently being addressed by SG.

Public Messaging

• Public messaging within NHS A&A and nationally has been developed and tested in conjunction with public participation groups. Feedback from focus groups has influenced the design and message to the wider public. It is recommended that this is closely monitored and that any change in messaging is developed with the public.

Evaluation

• Transformational change on this scale and impact must be underpinned by robust evaluation, going forward, in terms of health services and economic impact. In major transformational change, robust health services research and economic evaluation will be required. It is recommended that this is formally commissioned by SG, via the Chief Scientist Office (CSO). This should include systematic surveys of public and staff experience, to help determine both advantage and any unforeseen disadvantage. This should also embrace, as appropriate, the eight guiding principles, cited earlier, which have informed this review.
• NHS A&A, supported by Healthcare Improvement Scotland (HIS), are carrying out a quality improvement approach to the new RUC model of urgent care. I understand that their preliminary findings have been shared with SG.