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

6. Patient Journey Activity Data Summary

The data described below are mostly from the monthly report ending 28 Mar 2021 and data provided for NHS Scotland (Annex F), largely taken from Public Health Scotland validated data sets. Monthly reports and a data prioritisation (Annex G) paper was produced for the RUC programme.

Background:

The COVID-19 pandemic has had a measurable impact on health care utilisation overall both in Wave 1 and Wave 2 although patterns vary. Due to a 'system re-set' after COVID-19 Wave 1, the previous year's historic data alone do not provide reliable background therefore September/October 2020 has been used as baseline for activity, as this was stabilising with comparative data from 1 December 2020 (Go-Live). Importantly, data interpretation is influenced by the Wave 2 of the pandemic and winter pressures (see earlier Limitations Section) with a background of falling ED attendances, including self-presentations pre-Go-Live. Fortunately, apart from the 'usual' festive period the changes seen were not as marked as expected in terms of increased activity, possibly in part because of the lack of a 'flu season' and minimal other seasonal respiratory viral infections. The main challenge is trying to attribute any changes to introduction of the RUC programme relative to the overall impact of the evolving COVID-19 pandemic.

Data challenges:

The data presented mainly focus on demand profile and do not explore illness severity or other factors influencing demand/capacity. Lack of GP In-Hours data remains a major limitation and prohibits fuller analysis with data challenges in relation to use of ADASTRA systems in particular, which impact on data quality, timestamp and disposition data, including data from FNCs. Further analysis is necessary for specific metrics including the use of digital communication systems, including telephony and Near-Me. In the interpretation of RUC activity for the services contributing to the RUC pathway there were three patterns seen, excluding any COVID-19 specific data:

• Activity that increased following RUC
• Activity that remained stable
• Activity that showed a decrease

Inclusivity:

Patterns of access by age and index of deprivation for NHS 24 111, SAS and ED attendances is similar to historical organisational experience. The pattern of use for all organisations is also similar, with SIMD Group 1 (most deprived) being most frequent users and SIMD Group 5 (least deprived) the lowest users. Further in-depth analysis will be part of future evaluations. Ethnicity data are improving but remain incomplete/patchy. Public Health Scotland in conjunction with SG and care providers are presently pursuing how this can be best remedied.

Pre 'Go-Live' (prior to 1 December 2020):

There were reductions in activity for most services suggesting a link to the onset of the second wave (NHS 24 111 mid-week, SAS, ED attendances, individual walk-ins/self-presenters, and Emergency Admissions).

Primary Care Out-of-Hours (OOH) activity (non-COVID-19):

This has remained stable mid-week and weekends. This appears reassuring as there were concerns that this service, which has known staffing pressures, would struggle if the RUC NHS 24 pathway increased referrals to OOH, as this is the dominant source of OOH referrals. This was not seen in overall numbers, but the impact of COVID-19 Hubs and Assessment Centres and case complexity require further analysis, including staffing resources.

COVID-19 hubs and CACs:

Activity in COVID-19 hubs and CACS demonstrated an initial increase in activity around the Go-Live period, but thereafter presentations have continued to decrease, consistent with the decline in Wave 2 of the COVID-19 pandemic.

SAS:

Patients attended and conveyed, with only minor variations, have remained stable from September/October 2020, which is reassuring in the sense this should represent the sicker sub-group of patients most likely to require hospital care in general.

After Go-Live:

NHS 24 111 all contacts saw an increase in activity mid-week which was dominantly in routine working hours. Weekend activity has remained stable, consistent with normal variation with a minor decrease January-March 2021.

Coincident with increasing COVID-19 positive cases there were ongoing reductions in activity for ED attendances, Self-Presenters and Emergency Admissions.

Current position as at 31 March 2021

• Currently NHS 24, GP OOH contacts for mid-week and weekend are increasing
• SAS attended and conveyed incidents are also stable
• COVID-19 hubs and CACs activity continues to show a decrease
• ED attendances and self-presenting cases are steadily increasing as of end of March but have not reached Sep/Oct baseline levels

Patient Journey times:

The total journey time for the NHS 24 111 – FNC – ED patient pathway is currently 217 minutes. This does not include Time to Answer (TTA) times for NHS 24. Time stamp data are available for some areas of the patient pathway but is incomplete.

Note: the NHS 24 process, accessed by phoning 111, has been recently re-designed and moved from a potential call back option, to answering and dealing with calls as quickly as possible, in one contact episode, avoiding the need for call back. This has been in place since early 2020, pre Go-Live, which impacts on comparative data interpretation.

NHS 24 Time to Answer (TTA) Incoming 111 Phone Calls

NHS 24 111 response times have three main patterns which appear to relate to call volumes and day of the week, including the impact of public holidays. Weekend and public holiday activity is greater per day compared to mid-week for current and historical patterns of activity. The most notable current changes are in TTA and call abandonment rates, most apparent at weekends with Saturdays being worse. TTA median response times (January-March 2021) for weekends were between 25-29 minutes on a Saturday, and 12-16 minutes on a Sunday, compared to mid-week 0-2 mins in hours and 2.5-9 mins out of hours (OOH). Call abandonment rates (January-March 2021) were 24-27% on a Saturday and 17-22% on a Sunday, compared with mid-week 9-14% in-hours 14-21% OOH. These difference between midweek and weekends reflect a historical pattern but were poorer in 2021 v 2020. There appears to be an association between TTA's and call abandonment rates. This analysis does not take into account call complexity, repeat callers or impact of staffing levels. Of note, the RUC Programme has had no obvious impact on call volume activity at weekends.

Flow Navigation Centres (FNCs):

FNCs were created as part of the RUC programme and all Boards have an FNC in place. A single FNC operates across NHS Highland and NHS Orkney, Shetland and Western Isles. As there is no historical data for FNC this is summarised from January-March 2021, as data collection has improved. Routine data that are validated are available for 7/11 NHS territorial Boards. Further discrepancies in these data may relate to data entry and training issues within the FNCs. Despite limited data, the overall pattern appears stable at approximately 250 contacts per day. This number is too low to impact on overall whole system activity.

FNC Response:

From initial FNC contact, median call back time is approximately 10min, with call duration 1 min for appointment scheduling and approximately 9 mins for clinical assessment.

Near Me as part of RUC FNC activity:

All territorial boards were supplied with IT infrastructure to support the rollout of Near Me within the RUC Programme and is operational in 11/14 boards. The median Near Me component of NHS 24 FNC activity is 17.4% (range 0-68%) with an average call duration for a consult of 6.4 minutes (range 4.7 to 8.1 minutes) in March 2021. NHS Forth Valley was the greatest user of Near Me 67.7% (n=511 from 1282 total Near Me FNC consults across Scotland).

FNC Disposition:

Data suggest approximately 36% of FNC activity is referred to ED/MIU (29%/7%), with approx. 30% of patients advised to self-care and approximately 16% referred to Primary care. Lack of In-Hours data hampers a better understanding of this pathway including referral quality.

A&E attendances pathway:

A&E attendances remain lower than September/October 2020 baseline and this relates primarily to a reduction in patients who self-present. However, analysis of the overall trends in ED activity and relating this to NHS 24 and FNC activity, suggests that most of the reduction in self-presenters seen to date, could be attributed to the impact of COVID-19 and associated social distancing measures and changing public urgent care help-seeking behaviours. Note: most recent data suggest activity is close to September/October 2020 levels and historical numbers.

The overall impact of the RUC programme to date could be attributed to the reduction of up to 5% of total ED attendances. It should be noted that NHS 24 111 onward referrals to ED mid-week have increased since Go-Live, consistent with increased NHS 24 111 activity.

Recommendation - 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.