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

Annex D: NHS Ayrshire & Ayrshire Pathfinder Rapid External Review: Summary & Recommendations

Rapid External Review of the NHS Ayrshire and Arran (NHS A&A) Urgent Care Programme Pathfinder site, published on 30 November 2020

Recommendations and Risks identified in Pathfinder

Risks

• 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
• 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 (EQIA) is currently being undertaken by SG and all Boards who have been asked to complete an EQIA. The national EQIA will also include socio-economic status and digital exclusion.
• 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.

Recommendations

• Scotland wide, SG should look to maximise the engagement of Quality Improvement Fellows (QIFs) and Scottish Clinical Leadership Fellows (SCLEFs).
• 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.
• 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
• 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,
• webpage. In summary, Workstream 1 concludes in the first three weeks of operation, that:
• 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.
• 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.