NHS Scotland redesign of urgent care: second national staging report

Appendix K: RUC Equity in Access Report

Assessing the impact of the redesign of urgent care (RUC) on equity in access – Contribution to second staging report (September 2021)

Introduction Approach/Methodology

Analysis was performed by PHS to look at whether and how the use of urgent care changed over time following the soft launch of RUC, and whether this differed between populations defined in terms of age, sex and level of deprivation in the area in which they lived. The number of groups used in the analyses were as follows:

• Scottish Index of Multiple Deprivation (SIMD) – Five groups (quintiles)
• Age – Three groups (Under 18, Age 18-64 and Age 65+)
• Gender – Two groups (male and female)

These analyses were undertaken separately for four different urgent care access pathways (A&E self-presentations, A&E attendances, OOH contacts and NHS 24 calls) and for the latter three pathways combined (total contacts). Trends of average numbers per week for the different pathways (with 95% lower and upper confidence intervals) were explored for the following time periods:

• Period 1: pre-COVID-19 to start of COVID-19 (1^st January 2017 to 15^th March 2020)
• Period 2: start of COVID-19 to soft launch of the RUC (16th March 2020 to 29th November 2020)
• Period 3: soft launch of the RUC to end of the dataset (30th November 2020 to 18th July 2021).

The analyses compared Period 1 to Period 2 and Period 1 to Period 3.

Additional analyses were performed to track whether there is evidence of a worsening trend in the outcomes of NHS 24 calls (call termination by the caller before triage is possible). Trends of average numbers per month were explored for the following time periods:

• Period 1: pre-COVID-19 to start of COVID-19 (January 2017 to February 2020)
• Period 2: start of COVID-19 to soft launch of the RUC (March 2020 to November 2020).
• Period 3: soft launch of the RUC to end of the dataset (December 2020 to June 2021).

The analyses also compared Period 1 to Period 2 and Period 1 to Period 3.

High level findings

• Average numbers of contacts fell between Period 1 and Period 2 for all equality groups across all the separate urgent care pathways and all the pathways combined; average numbers of monthly call terminations increased over the same period for most equality groups.
• Average numbers of contacts fell between Period 1 and Period 3 for most equality groups across most of the separate urgent care pathways and the pathways combined; average numbers of NHS 24 calls and call terminations increased over the same period for most equality groups.
• There was no evidence of differences in A&E self-presentations, A&E attendances or total contacts between levels of deprivation. There was evidence of a SIMD gradient for OOH contacts, NHS 24 calls (higher percentage drop for levels of use in the most deprived areas) and NHS 24 call terminations (higher number of terminations for more deprived areas).
• There was no evidence of a gender gradient except with NHS 24 calls (higher percentage increase for males).
• There was evidence of an age gradient for all separate pathways and combined pathways (higher percentage drop for under 18s) and for NHS 24 call terminations (higher number of terminations for the 18-64 age group).

Recommendations/future

These exploratory analyses can be summarised in Table 1. These analyses suggest, for OOH and NHS 24 pathways, a worsening of inequalities in access for the more deprived areas and, for all separate and combined pathways, a worsening of inequalities in access for the under 18 age group. These are worthy of further exploration through further analysis or triangulation. It will be worth replicating these analyses and comparing trends to an additional time period (one that commences from start of the national communication campaign (summer 2021) to the end of the period under consideration) once more data becomes available to see if these inequalities are consistent.

NHS 24 call terminations are defined as calls made to the helpline which were terminated by the caller before they reached triage. Termination findings should be interpreted with caution as they make up only around 0.2% of all NHS 24 calls.

As these are initial exploratory analyses only they are relatively narrow in scope: they do not consider pre-existing inequity in access, do not try directly attributing any observed change to the redesign process and do not consider unmet care needs. As such, these analyses do not seek to give a definitive answer to the question of whether any changes in access have been the direct result of the redesign process or whether they represent an improvement or worsening in equity of access to urgent care following redesign. Rather, they seek to offer initial insights into potential inequalities in access to urgent care between population groups and whether these have changed following redesign.

Table 1: Summary of RUC equity initial exploratory analyses

It may be worth exploring the feasibility of tracking the appropriateness of (non-emergency) self-presentations in A&E and/or incidences of harm (such as suicide attempts) that could have been prevented by access to urgent care and if such incidences are more likely among certain equality groups.