NHS Scotland redesign of urgent care: second national staging report

Appendix M: Summary report of progress by Health Boards with the recommendations of the First National Staging Report

Update on Redesign of Urgent Care Programme

NHS Board Chief Executives Private Session - 31^st August 2021 (Summary)

3.0 Redesign of Urgent Care

The Redesign of Urgent Care programme has focussed on developing the FNCs across all mainland boards in Scotland to ensure patients appropriately access the right pathway of care for their urgent care needs. As this is a redesign and transformation programme it is expected that the model and the pathways will continually evolve as we learn from the data and patient and staff experience.

As part of the continual improvement approach the Programme Director has visited every FNC and ED department on the mainland seeking to understand the impact and the challenges of delivery from the staff at the frontline. There is a general consensus from the teams, that the FNC model is the right direction of travel for urgent care and has potential to reduce self-presentations to ED.

There have however been several confounding factors which have impacted upon and had the potential to derail the FNC model and the overall RUC work.

• There has been a dramatic change in the pattern of health seeking behaviour by the public which is impacting across the system
• The requirement for boards to staff multiple additional areas/ services along with staff having to isolate etc. has impacted on the available staffing resource to fully staff the FNC in some boards.
• Due to perceived barriers in accessing the healthcare provider they wish to see, patients are contacting NHS 24 111 or are self-presenting to our ED departments which has the potential for them to be 'bounced' around the system with multiple clinical handoffs.
• Without exception every ED has described the challenge of managing the current level of self-presentations which, in their view, a high proportion could have been more appropriately managed within a primary care setting. It is very difficult in the current circumstances for ED teams to initiate redirection of attendees who would be more appropriately managed in primary care when they are being advised by the patient they have been unable to access primary care
• NHS 24 111 are receiving calls from patients who are advising they have been unable to access an appointment at their GP practice, when the nurse advisor disposition is 'advised to contact their GP practice' there is a significant level of discontent expressed. Initially there was a level of patients defaulting inappropriately into the FNC work flow, however through the feedback system, this was quickly addressed internally by NHS 24 leadership team.
• Current lack of consistent electronic data from board FNCs makes it difficult to contrast and compare across the FNCs and therefore shape the model to maximise its potential. Work continues with all boards and the PHS team to progress this.
• There is an urgent imperative for national public communications focussed on primary care to inform the public that GP practices are open, and explain the options of telephone or face to face appointments.

The above factors have had an impact on the progress of the new urgent care pathway however it is imperative that we remain fully committed to the progress of this model which has the potential to impact significantly by ensuring patients receive the right care by the right person as quickly as possible and thereby help relieve pressure on our ED departments and potentially beyond into the wider system.

4.0 RUC Evaluation

The first internal SG staging review of the RUC, undertaken by Sir Lewis Ritchie and Professor Derek Bell, was published in June. This was based on the learning and data available to date, including from NHS Boards. This was shared with NHS Boards and will inform the Second Staging Report.

The Second Staging Report is due for completion by 30th Sept, covering the period April to September and will offer recommendation for further redesign based on a range of data sources and interactions. The plan is to present the work, as far as possible, in line with the patient journey.

The data sources are:

• Implementation updates from NHS Boards, including progress against recommendations from the First Staging Report
• Stakeholder and staff experience – 12 focus groups being held during August and early September 2021
• Patient experience; Patient focus group (HIS), NHS Board data and HIS Gathering Views Report
• Equity review (PHS) focused on hard to reach groups
• Patient pathway review work being piloted in GG&C
• Public messaging
• Management information derived from PHS data source

9 of the planned 12 focus groups have been held to date with over 100 stakeholders including representatives from all territorial boards, NHS 24 and SAS, including front line staff, operational and programme leads and senior leaders/execs. Focus groups for exec leads and PC are scheduled for Tuesday 31^st August.

Analysis of the feedback from the groups has been commenced however the findings require to be validated. The focus group for the professional bodies is scheduled for 10^th September.

Initial findings will be considered over the next week to understand what further work/deep dives may be needed.

The Evaluation Advisory Group has a key role in the initial validation of findings and we plan to present the draft findings to this group on by the end of September.

A further external evaluation will be commissioned in the Autumn which will augment the two Staging Reports by focussing on a specific set of research questions with final report out by end March 2022.

The research is required to understand the impact on staff experience; patient and public experience; cost benefits and to better understand the whole system response and what additional data is required. In preparation, Chief Executives have been asked to ensure work is underway locally to assess patient and staff experience and ensure appropriate processes are in place which will allow the external team to develop a cost benefit analysis.

The second stage evaluation report on the RUC programme will help inform the model as we continue to move forward ensuring we are delivering a service that is fit for the future and results in better outcomes of care and experience for our patients and our staff.

5.0 Flow Navigation Centre (FNC) Model – current

The FNC model launched across all mainland boards on the 1^st December 2020 based on the 'de minimus' requirements (appendix 1) with boards progressing towards the additional requirements detailed by 31^st March 2021.

In essence these requirements can be described in 4 core elements:

• FNC available 24/7 to receive from NHS 24;
• Access to a senior clinical decision maker (SCDM, agreed at ST4 and above) 24/7;
• Ability to schedule into ED and Minor injuries
• Use of Near Me technology

Each FNC has been visited on two occasions by the Programme Director since launch to support teams and encourage progress towards the agreed model, based on the 4 core elements above with the latest visits having taken place over August and into early September 2021.

The picture across Scotland is not unexpectedly one of variation in the delivery of the model. It is clear that the FNC model has evolved to meet local circumstances such as location of FNC; utilisation of pre-existing facilities; levels of demand; staffing resource and ability to recruit locally.

Table 1 describes the variation in the models of FNC being delivered across all boards as of 31^st August 2021 based on the 4 core components. There are many reasons for the variation however the overriding factor is availability of staffing resource.

Whilst at this stage it is not possible to conclude if there is a 'best' model for delivery, the second stage evaluation will inform the position, alongside with further analysis of the data will help determine the next iteration of the model.

The key headlines are: -

• all boards have an FNC in place that can receive calls from NHS 24 over the 24/7 period, staffed 24/7 with call handlers.
• Grampian and Tayside have the only FNCs which are ED consultant led 24/7
• Across other boards SCDMs are predominately ANPs in hours with access to ED or GP support if require
• Scheduling is predominately used for Minor injuries
• Activity in the out of hours' period in 7 of the 10 FNCs continues to be managed by ANP/GP/ED consultant with the remaining boards defaulting to call handling and directing into ED

Table 1: Summary of FNC model across Scotland

FNC Core Model signed off 31st March 2021	FNC 24/7	SCDM available for FNC 24/7 (may be virtual)	Using Near Me for virtual consultations	Scheduled appointments to ED/ MIU
NHS Ayrshire & Arran	Y	24/7 Urgent Care clinicians (ANP/GP)	Low/variable	Minor injuries and ED
NHS Borders	Y	24/7 ANP, GP / OOH ED consultant	Low/variable	Minor injuries only
NHS Dumfries & Galloway	Y	No clinician in FNC ED consultant virtual only	No	Scheduling into ED
NHS Fife	Y	24/7 ANP OOH by GP or ED	Increasing / variable	Minor injuries only
NHS Forth Valley	Y	0800-2000 ANP OOH by ED consultant	High	Minor injuries / limited scheduling to ED
NHS Grampian	Y	24/7 0800- 0000 ED OOH by ED consultant	Good/ variable	Minor injuries and ED
NHS Greater Glasgow & Clyde	Y	1000 -2200 ANP, GP, ED OOH by ED consultant	Good / Increasing	Minor injuries and ED (in OOH)
NHS Highland & Islands	Y	0800- 0000 GP, REP's EP's OOH by GP	Very Low	Inverness MIU only at present
NHS Lanarkshire	Y	0815 – 2015 Band 5 – 7 RN's Medical clinical shifts offered 1200 -1600 or 1600 -2000 OOH by ED consultant	Very low	Minor injuries only
NHS Lothian	Y	24/7 clinical nurse advisor 0800-0000 GP (also covers COVID) OOH ED consultant	Good / Minor injury only	Minor injuries / limited scheduling to ED
NHS Tayside	Y	24/7 0800 -2200 / OOH ED consultant	Low/variable	Minor injuries and ED