NHS Scotland redesign of urgent care: second national staging report

1. Executive Summary

Context: This is the third of three reports assessing the Scottish Government Urgent and Unscheduled Care - Redesign of Urgent Care Programme (RUC). The first report assessed early progress of the NHS Ayrshire & Arran RUC Pathfinder^[2] in November 2020. The subsequent report, the RUC First Staging Report^[3], covered the period December 2020 - March 2021. This report, the RUC Second Staging Report, covers the period April 2021 to September 2021. The Scottish Government National Urgent and Unscheduled Care Programme is in the process of commissioning an independent external evaluation of RUC, which will examine public and staff experience, care outcomes and will also include a health economics assessment. This independent evaluation is planned during 2022.

Impact: At present, it is not possible to fully assess the impact of the RUC Programme on patient needs and care responses across NHS Scotland although there are evident patterns. The RUC national launch (December 2020) coincided with the second wave and subsequent unprecedented and ongoing COVID-19 service pressures for both urgent and elective patient care throughout NHS Scotland. Assessment of the impact and worth of RUC in this Second Staging Report provides a further assessment of progress. Data have been analysed and collated with monthly reports to the RUC Strategic Advisory Group (SAG) from January to September 2021. The main purpose of this Second Staging Report is therefore:

1. To inform and improve iteration of the present RUC model by using patient pathway data and incorporating the experience and views of the Scottish public and care professionals

2. To assist in the provision of optimal 24/7 urgent care for the Scottish public and to nurture and support all multidisciplinary teams who deliver essential care

Acceptability: Focus group discussions undertaken as part of this Report, indicate that there is broad-based professional support for the intent and principles of the RUC programme. However, there were notable exceptions and caveats from some groups. Specific challenges remain across the RUC pathway including:

• Workforce resilience - different operations of 24/7 Flow Navigation Centre (FNC) operations/working across Scotland. This needs to take into account local circumstances including scale, critical mass, remote and rural issues, and specifically impact on other Primary Care urgent care services, particularly Out-of-Hours (OOH) services
• Clinical leadership (Senior Clinical Decision Maker (SCDM) role) and how to optimise
• Unresolved Information Management & Technology (IM&T) incompatibilities and how to urgently resolve
• Relevant public messaging, in all aspects, to support the Scottish public to secure optimal urgent care in the right place at the right time.

Progress: Increasing use of NHS 24, as one of several entry points to urgent care, has been well adopted by the Scottish public as promoted by recent national media publicity. As yet, significantly increased call demand for the NHS 24 111 service, primarily during in routine working hours (0800-1800, Monday-Friday), has not translated into major changes in demand for A&E services. Activity across other parts of the RUC programme is largely stable except for FNCs, where activity has grown and is stable over recent months. The additional step of seeking immediate help for urgent problems via NHS 24 (111 service), diverted to local FNCs may add to the complexity and length of the care journey for some patients. This requires further elucidation about the nature of recent changes.

NHS Boards are all at different stages of implementing RUC, which may be partially explained by size, geography and organisational capacity. There is scope for greater collaboration across all NHS Boards, adopting a partnership approach, continuing to actively involve NHS 24 and Scottish Ambulance Service (SAS).

Risks and mitigations: The most significant risk identified is workforce resilience and capacity. There is an overall sense of skilled and experienced staff being moved around the urgent (unscheduled) care system as a whole and staff working across or between services. Ongoing challenges of responding to the COVID-19 pandemic continue unabated for both urgent and elective care. These pressures are significantly impacting on staff fatigue levels, with high levels of short-term sickness, often compounded by longer term vacancy factors. System capacity and capability to manage the overall RUC patient pathway demand remains a concern in relation to the timely assessment and management of patient needs. These risks need to be addressed urgently by engaging all stakeholders in improving the existing pathway, ahead of the imminent winter pressures.

Future/Next Steps: Overall, this Second Staging Report suggests a need to refine and optimise aspects of the RUC programme, rather than increasing activity/volume across the whole pathway. Going forward, encouraging all NHS Boards to take a locality 'place-based' approach - focused around the specific needs of communities - should enable the development of appropriate local services and encourage further partnership working. This must include: consideration of distinctive remote, rural, urban, sociodemographic and equity/accessibility requirements. As the RUC Programme evolves, it will be imperative that shared learning of implementation issues and solutions should continue to be assimilated and effectively deployed throughout NHS Scotland.