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

Mental Health and Wellbeing

Because of its key importance, a separate section on Mental Health has been included in this report.

The document: Role and Management of Psychosocial Wellbeing in the Redesign of Psychosocial Wellbeing in the Redesign of Urgent Care was commissioned and provided by Mr Jacques Kerr and Craig Whyte.

It is attached as Annex 3. It indicates that over the period 2014-19 (Public Health Scotland - PHS) statistics show a 4.1% increase in all ED attendances compared to a stark 68.4% increase in mental health attendances over this period. It flags the impact of the Covid-19 pandemic, not only on physical health presentations but also on psychosocial wellbeing. It describes redesign of urgent care initiatives in place or underway to promote closer collaboration between health, social care, third sector and justice.

NHS 24 has and will continue to play a pivotal role for mental health care via its longstanding Breathing Space service and more recent Mental Health Hub, both integral to its overall service. The NHS 24 Mental Health Hub commenced part-time operation in March 2019 and moved to 24/7 full time operation in July 2020. Optimising urgent mental health care is an intrinsic part of the broader RUC programme and should be promoted and carefully monitored.

Key Risks and Mitigations for All Boards

Risks and mitigations for the RUC programme are being continuously assessed at both national and individual Board level, by frequent readiness assessments, as indicated before. SG and individual Boards must continue to regularly seek assurance, via robust governance mechanisms, as the RUC programme is introduced, implemented and further evolves. The early encouraging and ongoing pathfinder experience from NHS A&A is being disseminated and will continue to inform progress throughout NHS Scotland.

It is suggested that are a number of key (but not exhaustive) risks for RUC implementation, requiring adequate recognition and effective mitigation:

• Covid-19 uncertainties
• Failure to sufficiently assimilate on-going findings, issues and solutions from the NHS A&A Pathfinder Programme by other territorial Boards in Scotland
• Workforce planning (including induction and training) and resilience for Flow Centres, with competing requirements from Covid-19 Pathways and Primary Care Out of Hours services
• Inadequate communications with staff and stakeholders. NHS A&A has invested heavily in regularly communicating with staff, including GPs and other independent contractors. This has paid dividends, by providing feedback and diminishing uncertainties
• Insufficient clinical leadership and administrative support at the launch of the programme and ongoing. NHS A&A has invested intensively and productively in this, with benefit
• Unforeseen Information Technology and electronic records transfer issues
• Robust Clinical Governance mechanisms must be in place and regularly scrutinised to ensure safety and quality of care
• Potential changes in urgent care help seeking behaviour by the public over time, may put undue and growing pressures on the capacity of NHS 24, particularly during the in-hours (daytime) period. The majority of in-hours urgent care should continue to be appropriately provided by GP practices and by community pharmacies (Scottish Pharmacy First Programme), as is happening at present. Persistent concerns about this matter have been expressed to SG, by GPs and other community practitioners. Public messaging must fully embrace these issues. Going forward, in-hours case flows as well as OOH flows must be closely monitored, as is intended, to determine and adequately respond to any changing patterns and trends
• Diversions of urgent care away from ED/MIU self-referrals ('walk ins') towards community-based alternatives, as envisaged by the RUC model, may divert significant numbers of individual urgent care episodes towards in-hours GP and OOH services. The latter service is more vulnerable to capacity and resilience issues. Again, this needs to be closely monitored by all Boards, so that sufficient workforce capacity and capability is present across the whole spectrum of the urgent care service on a 24/7 basis
• There is a potential risk of widening health inequalities, including digital exclusion - this should be formally assessed. An Equality Impact Assessment (EQUIA) is currently being undertaken by SG and all Boards who have been asked to complete an EQUIA. (Note: EQUIAs focus on legally protected characteristics, which do not include digital exclusion, those with communication problems, or are otherwise vulnerable)
• It is possible that an additional step (Flow Navigation Centre) in the urgent/emergency care pathway may lead to optimal treatment delay for some individual presentations. This needs to be closely monitored and evaluated - in relation to safety, quality and public experience.