NHS Scotland redesign of urgent care - first national staging review report: 1 December 2020 – 31 March 2021

1. Executive Summary

The RUC programme by definition includes the entire patient pathway from the time of patient or carer need to the conclusion of that episode of care. This evaluation has therefore attempted to explore the whole patient journey in terms of data and feedback from stakeholder groups to understand both intended and unintended consequences.

The other major factors which impact on an analysis at this stage are the short time window from inception in December 2020 and the overlap with the second wave of COVID-19 and Winter. It is clear over this period the rate of innovation and staff responsiveness to the challenges has been outstanding and we continue to recognise this.

Based on this review key themes that have evolved fall in to two main headings:

a. Challenges or configurations of services that pre-date the RUC programme which have been highlighted as part of this review.

b. The potential impact of the NHS 24 111 and Flow Navigation Centre pathway which was central to Phase 1 of the programme.

a) Challenges or configurations of services that pre-date the RUC programme

By looking across the patient journey several factors have come to light. Existing services had challenges which pre-date the RUC programme. NHS 24 111 has expanded its offer as part of the COVID-19 response and also planned, for example, new mental health pathways and created new pathways to link to the new Flow Navigation Centres. Historically NHS 24 111 performance in time to answer and call abandonment rates are poorer at weekends (Sunday better than Saturday). This pattern persists and is poorer (2021 vs 2020) and cannot be directly attributed to weekend activity as this has remained unchanged (as expected) with the introduction of RUC which increased mid-week NHS 24 111 activity. RUC Phase 2 will increase focus on spreading and implementing Mental Health pathways.

GP OOH service activity has remained stable and not increased despite initial concerns pre Go-live in Dec 2020. Data coding and collection for GP OOH has not changed over this period but there is the additional impact of 'shared staffing' with the COVID-19 assessment hubs. As such the RUC programme has not impacted directly on GP OOH activity but has highlighted the more longstanding GP staffing issues which contribute to service fragility.

Data information infrastructures limit the ability to 'read across' the patient journey. This relates to both the IT systems in use, including suppliers, and the access to data as well as non-standardisation of coding. This impacts across all organisations and systems across the patient pathway including primary care (no routine data access), NHS 24, GP OOH and FNC as well as acute and community care data.

b) Potential impact of the NHS 24 111 and Flow Navigation centre pathway

All boards have established Flow Navigation Centres. The infrastructure including staffing levels vary and validated data remains limited. The FNC main functions are to maintain care closer to home by providing clinical advice including self-care and for those who require additional services to plan that efficiently. FNC's are currently largely dependent on referrals from NHS 24 111 and advertising this to the public has been part of a 'soft' communication plan through local mechanisms.

The new pathway was launched on December 1^st 2020 and provides a single point of access. Overall the impact of the NHS 24 111 – FNC pathway to date is difficult to assess and may be contributing to up to 5% reduction in all ED attendances or potentially up to 10% of ED self-presenters. NHS 24 111 have increased their direct referral rate to ED mid-week consistent with the 24/7 service which may offset some of the potential gains.

The impact of stronger public messaging is likely to increase the NHS 24 111 – FNC pathway as the NHS 24 111 demand would increase. This represents a potential risk to both service delivery and quality of care. Opening the under 12 children NHS 24 111 pathway has potential to increase NHS 24 111 demand as families and carers begin to use the new pathway. This carries some risks and the impact will need to be actively monitored. Staffing challenges are recognised in several areas (NHS 24, GP OOH and overlap with FNC and COVID pathways) with competition for staff resources. (The provisional launch date was 29^th April 2021. An update has been submitted to Cabinet Secretary advising delay and fortnightly readiness assessments to determine all Board preparedness.)

The previous pathway for patients presenting directly to ED was predominantly a one-stop-shop. In the new pathways the number of stops to complete the episode will vary. For those who complete at NHS 24 (1 stop), FNC (2 stops) and for onward referral including ED (3 stops).

These questions do not take into account potential improvement in patient experience (as yet to be measured) or if successful reducing overcrowding at various stages of the patent journey. They do provide a potential direction of travel for the RUC programme with a greater focus on the re-design of the pre-hospital and primary care aspects of the patient journey and linking it to the proposed interface care developments to minimise in-patient hospital care.

Summary of Recommendations

NHS 24 Capacity

• The NHS 24 Board must continue to bear down resolutely on current service pressures and seek to build on recent improvements in time to answer calls (TTA) and call abandonment rates. (In the first instance, NHS24 are working towards a 10 minute TTA)
• These endeavours include ongoing recruitment, retention, staff wellbeing and support, with external support as necessary.
• NHS 24 should undertake a readiness assessment and impact modelling before further national marketing goes live to provide assurance on their ability to manage additional demands.
• Decisions about future expansion of The RUC programme, including timing, for both adults and children, must be carefully considered by NHS 24 and SG, taking account of satisfactory service resilience and robust contingency measures. (We are working towards full roll out in the summer)

Flow Navigation Centres

• Effective planning and resource allocation to secure delivery of timely care for patients and carers to manage peaks and troughs of demand (this can be the same for NHS 24). Further expansion will require resource allocation
• Improve communications for patients arriving at ED around their expecting waiting time which should be more clearly communicated
• Maintain regular and robust communications and relationships between NHS 24, SAS and territorial Boards within Scotland to ensure continuous learning
• Formalise/standardise patient experience and staff evaluation approach at local level
• Ensure feedback mechanism in place to staff on progress and next steps
• Ensure robust clinical workforce resilience with a review of the balance of primary and secondary care staffing. Robust and agreed escalation processes must be in place.
• Strong and visible clinical leadership must be assured and the role/responsibilities of the senior decision maker (SDM) must be clearly defined and understood – including ready in-situ or remote availability, as required by local circumstances and needs

GP Out of Hours

• Address challenges in relation to staffing levels in GP OOH. given the risk to service delivery due to continuing COVID-19 pandemic and impact on staffing and resources as highlighted in the pathfinder report, a SG decision was taken to launch RUC nationally on 1 December 2020, on a minimum specification – with a readiness assessment to ensure agreed compliance by all NHS Boards
• Continue to monitor any impact of the RUC Programme on activity, including case mix and capacity

Future analysis

• More in-depth and a longer period of analysis are required to ascertain the true impact of the RUC Programme and direction of further re-design of urgent care.
• Data suggest that risks remain in the ability of NHS 24 111 to deliver urgent care pathways in relation to activity and timeliness.
• Improvements in data collection across the RUC pathway are necessary, particularly in relation to in-hours general practice/primary care and FNCs.
• Improved recording and monitoring of FNC should be assured including coding, time stamp data and care dispositions.
• The roles and contributions of community pharmacy and other primary urgent care services must also be considered, going forward.

Paediatric urgent care pathway

• All Boards must meet the minimum specification detailed in the Report reviewing the optimal RUC Paediatric Urgent Care Pathway before national roll out (Annex E).
• The overall impact of this redesigned pathway on FNC and ED activities will require close on-going monitoring, and clinical governance review.

Mental health pathway

• For the next (Second) Staging Report, due end September 2021, more detailed analysis of use and outcomes of rapidly evolving urgent mental health care services is recommended.

Person-Centred redesign

• An evaluation of Patient experience should be part of the planned external evaluation.
• Establish a process to collect more standardised locally and centrally available patient experience data working with HIS
• Boards to ensure they have the appropriate privacy statements and Data Protection Impact Assessment (DPIA) are in place which are clear and transparent about how personal information is used reflecting that patients may be contacted to discuss their experience.
• Ensure those likely to experience barriers to care are continually consulted with to shape, refine and improve pathways to better meet citizen's needs, mitigate against harm and minimise inequalities and inform national programme approach.

Public messaging and marketing

• Develop a revised national incremental public communication strategy.
• NHS 24 should undertake a readiness assessment and impact modelling before further national marketing goes live to provide assurance on their ability to manage the additional demand.
• Undertake an evaluation covering those elements which have been delivered so far, including social media, digital marketing and press advertising, as well as local comms, which would then give more formal data and inform a (more) effective campaign.