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

7. NHS Board FNC Self Assessments

To support understanding of progress at local level the National Programme requested that all NHS Boards undertake a local assessment of their system infrastructure for FNC, including impact at local level on the patient and staff experience, public behaviours and impact on the wider system. All submissions were collated in March 2021.

FNC board structure:

The majority of NHS Boards have located their FNC within an acute hospital setting, with two operating from community-based facilities. Seven FNCs are co-located with GP OOH services. Of the 11 Boards providing this service (excluding Orkney, Shetland and the Western Isles, covered by NHS Highland), all operate 7-day services supported by a senior decision maker (SDM). Five operate with SDM 24 hours/day, five provide SDM min 12 hrs/day and one has a SDM present 8hrs/day. Staffing infrastructures varied in terms of numbers of staff and professional groups and this will require further understanding as systems embed.

All Boards provide clinician to clinician contact (Professional to Professional), some using a combination of methods. Near Me was made available for patient contact to all boards as part of the roll-out. The majority use standard telephony services.

FNC Patient feedback:

There is limited patient 'experience' data for the FNCs being collected by some boards (6 of 11) using non-standardised approaches. Feedback has highlighted some areas which will require on-going monitoring and potential improvement, including:

• timeliness of telephony response and appointment scheduling, times & expectations
• correct disposition
• clarity about paediatric pathway
• access to near me and telephony
• the need to improve awareness
• transport including SAS
• number of steps in the pathway including imaging

Plans are ongoing to standardise patient experience collection nationally working with HIS to inform fuller evaluation. Overall feedback from patients and staff has been mixed and further external evaluation is required to fully understand the patient journey. The feedback that is available largely relates to limited assessment of satisfaction rather than experience. Common themes of observed benefits include:

• Patients feeling safer having been seen virtually, with reduced travel requirements
• Reduced unnecessary admissions for care home residents
• Easy direct access to direct medical specialties
• Shared decision making and agreed plans between patients and staff
• More personal, quick and efficient care

Staff feedback:

Staff highlighted the improved opportunity for communication and relationship building between territorial boards, NHS 24 and SAS and across multiple teams. Staff satisfaction has been reported as enhanced by enabling patients to undertake self-care or access care in the community and avoid unnecessary hospital attendance.

Concerns raised included technological challenges including being unable to connect when calling a patient back and general IT issues, although the role of virtual communication was well received. FNCs can at times experience very few calls, particularly overnight, and the benefits of a 24/7 service provision were queried given small patient numbers.

Recommendations – 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)
• 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 for staff on progress and next steps
• Ensure robust clinical workforce resilience with a review of the balance of primary and secondary care staffing including links with GP OOH, with robust and agreed escalation processes must be in place.
• Ensure strong and visible clinical leadership with clearly defined roles and responsibilities of senior decision maker (SDM) including in-situ and/or remote availability, as dictated by need
• Ensure Clinical Governance arrangements and case reviews are in place and monitored.

Urgent Care Pathway - Paediatrics

Following the NHS A&A RUC Pathfinder Rapid External Review (which included children of all ages in the new urgent care pathway), concerns were raised by some clinicians notably, SAMD and SEND, about the potential safety risks of including urgent children's (paediatric) care in NHS 24 referrals to FNCs, until pathways were robustly established. Following discussions, Board Chief Executives reached a majority consensus that children should initially not be included. It was agreed to initially exclude all children under 12 years in referrals from NHS 24 to FNCs.

A rapid review was commissioned and undertaken (Professor Stephen Turner, Chair - see Annex E). Recommendations were developed which were discussed and agreed by SAMD, SEND, Board Chief Executives and the broader stakeholder representation of the Redesign Urgent Care Strategic Advisory Group (SAG). This included a minimum specification for all territorial Boards to meet before children <12 years are to be included in the new pathways.

All NHS Boards much be fully compliant with the minimum specification based on their readiness assessments before this pathway is included in the referral to FNC. The provisional launch date is 28 April. All Board readiness assessments are currently being reviewed by SG officials, at the time of writing.

Data Analysis - Urgent Care Paediatric Pathway (under 12 years)

• The paediatric pathway for children (<12 years) was not re-designed in this initial phase of the RUC programme and is more complex to interpret, as patterns of activity are more variable. Paediatric activity data patterns differ from overall urgent care activity.
• Paediatric ED attendances were declining pre-Go-Live and continued to decline, consistent with waning of Wave 2 of COVID-19. However, in March 2021, activities have started to return to pre-COVID-19 levels 'normalise'.
• NHS 24 111 and SAS contacts have shown some reductions, probably consistent with Wave 2 COVID-19 before and after Go-Live. However, again recent activity has started to return to pre-COVID-19 levels.

Recommendation – Paediatric urgent care pathway

• All Boards must meet the minimum specification for the RUC Paediatric Urgent Care Pathway (Annex E) prior to launch
• Monitor impact of redesigned pathway on FNC and ED activities, including clinical governance review.

Urgent Care Pathway - Mental Health (MH)

Mental Health was not part of the initial phase of the RUC Programme and therefore while data is available this was not a major part of the current evaluation. Going forward, the RUC recognised the importance of improving integration of physical and mental health within the urgent care setting. New mental health pathways were being developed in parallel including the NHS 24 Mental Health Hub inception in March 2019 to support the integration of mental health pathways and services.

All stakeholders are working to integrate and support mental health and psychological wellbeing services to enhance existing or develop new pathways. This work will include:

• Embedding pathways between the NHS 24 Hub, FNCs, Mental Health Assessment Services and the Mental Health Enhanced Pathway.
• Embedding mental health unscheduled care pathways for children and young people.
• Continuing to develop Mental Health Assessment Services, including agreeing consistent data collection.
• Establishing multi-disciplinary team test sites to support those with Complex Psychosocial needs.
• Supporting people in distress by continuing the national roll-out of Distress Brief Intervention including an evaluation.
• Continuing to build mental health capacity within primary care settings with a view to implementing Primary Care Mental Health teams
• Further enhancing mental health service delivery through digital innovation.

Data Analysis:

Call demand for the Mental Health hub has increased from approx. 2,000 calls per month in March 2020 to over 10,000 calls per month in March 2021.

Since January, NHS 24 111, SAS and Primary Care OOH mental health activity have shown minor decreases (Note: overall numbers are small which limits interpretation). Note: NHS 24 collects further in-depth mental health data which will be part of further study.

Pre-Go-Live mental health ED attendances were decreasing, with further decrease around the time of Go-Live, but activity has now started to increase, consistent with overall ED attendance data.

Recommendation - 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. This should include the degree of integration with other services and patient and staff experience.