Redesign of urgent care: equality impact assessment

National Equality Impact Assessment

Screening

Policy Vision and Aim

The Scottish Government is undertaking a system redesign of urgent care.

The aim of the Redesign of Urgent Care is to provide an accessible, efficient, effective and safe urgent care service for the public ensuring patients receive the right care, in the right place, at the right time, first time.

Objectives

1. Introduce a new clinical pathways that will see patients spending less time waiting to be seen.

2. Provide alternative, accessible and innovative solutions to A&E for urgent care needs using technology, including a Telephone and Digital First approach via NHS 24 on 111. (Access to emergency care will not change in emergency situations.)

3. Deliver a safe and robust process for scheduling attendances to our A&E and Acute Assessment Units reflecting the multiple ways that these systems can be accessed and ensuring that attendance is accessible to everyone across multiple entry points.

4. Provide equitable access by delivering effective, accessible and inclusive communication and public messaging to improve access to urgent care services with a particular focus on seldom heard groups.

Background and Context

The Scottish Government launched the Redesign of Urgent Care in December to ensure patient safety during the winter period while the NHS continued to respond to the pandemic. Further work continues to refine and enhance the new urgent care pathways to ensure equitable access and optimal patient experience.

The need for new ways of delivering services during COVID-19 has demonstrated what can be achieved to keep people safe and improve access to healthcare. The new pathway builds on the lessons learned from the COVID-19 outbreak to date. It is fundamental that, as far as we can, we deliver a service that meets the needs of everyone; particularly those most in need.

Prior to COVID-19, there was an over-reliance on Emergency and Urgent Care in Scotland, as evidenced by a rapid increase in the number of people attending A&E. This suggests more people were self-presenting at emergency departments when more appropriate care could/should have been provided by another service i.e. Pharmacy, GP, 111 etc.

Data published from Public Health Scotland shows this was underlined during the early phase of the pandemic when attendance levels dropped significantly during late March to less than 50% of normal levels^[1] and the public sought alternative care through www.NHSinform.scot, as demonstrated by a sharp rise in traffic to the NHS Inform website during that period. This confirmed what we had expected for many years – that many people attending A&E could receive right care via digital channels without exposing themselves unnecessarily to a hospital setting.

The Redesign of Urgent Care (RUC) programme promotes a significant change in how we best serve the people of Scotland to provide safe and effective urgent and emergency care, on a 24/7 basis. Offering a number of significant benefits to modernising our wider unscheduled care pathways to ensure the public access the right urgent care, in the right place, at the right time, on a 24/7 basis.

Introduction

Based on the available evidence to date this document represents the first National EQIA for the Redesign of Urgent Care. It assesses some potential impacts for each of the protected characteristics, socioeconomic factors, and remote and rural settings. National and localised mitigation strategies to address any barriers to accessing the new programme are considered. This will be reviewed later this year, but several mitigating actions have already been highlighted. The EQIA has been prepared on behalf of the Scottish Government under the leadership of Helen Maitland, National Director for Unscheduled Care and Carol Goodman, Programme Director for the Redesign Urgent Care Programme.

In developing this policy the Scottish Government is mindful of the three needs of the Public Sector Equality Duty (PSED):

• eliminate unlawful discrimination, harassment and victimisation;
• advance equality of opportunity between people who share a protected characteristic and those who do not;
• foster good relations between people who share a protected characteristic and those who do not.

The Scottish Government recognises that while the measures may positively impact on one or more of the protected characteristics. The introduction of the measures may have a disproportionate negative impact on one or more of the protected characteristic groups.

Where any negative impacts have been identified, we have sought to mitigate/eliminate these. We are also mindful that the equality duty is not just about negating or mitigating negative impacts. We also have a positive duty to promote equality. We will seek to do this through accessible information support and guidance, inclusive communication and language. We will seek to do this through the provision of guidance and support in relation to accessible information and communications.

Who will it affect?

The Redesign of Urgent Care applies across the Scottish population and does not specifically target groups or sections of society. However, we know that particular socio-demographic groups are more likely to need urgent care and will have different needs and experiences. This assessment explores how impacts from the programme will be experienced differentially in relation to the protected social-economic characteristics.

Key changes relating to access to urgent care: instead of direct access to A&E departments for non-life threatening conditions help will be firstly available through NHS 24 (via dialling 111) who will assess and advise on next steps. NHS 24 will be available 24/7 for urgent care needs and where conditions cannot wait to be seen at the GP practice. If, following this initial assessment, the patient is deemed to require an A&E attendance they will either be directed to A&E or receive a virtual consultation with a senior clinician. This will involve technology, a telephone or video call in the first instance.

Following this consultation, if the citizen should attend A&E they may arrange for them to arrive at a certain time, to provide a safer patient experience. If the assessment shows that the citizen does not need A&E they will help them get the care they need as quickly, safely, and as close to home as possible. This could include self-care and support, and direction to a local pharmacy, who can prescribe treatments and offer advice to book an appointment with a local GP Practice.

The policy will have an impact on everyone coming into contact with urgent care services. This will include:

• people who may have one or more of the protected characteristics – everyone is a potential user of urgent care;
• the workforce, who again may have one or more of the protected characteristics – who will be expected to deliver this new model of care;
• specific groups of people, including, but not limited to, disabled people, older people etc. who are more likely to contact urgent care services. For example, previous analysis of historical data published by Public Health Scotland shows population rates of contacts with unscheduled care services on the whole are higher for those from specific age groups (aged under 5, and those aged 80 and over), females, and those from more deprived areas.

The changes aim to result in less people waiting in Emergency Departments thereby minimising the risk of infection, providing better patient outcomes and care closer to home.

What might prevent the desired outcomes being achieved?

• People do not know about or understand the new system. It is imperative that we ensure good and effective public communications and messaging on the new systems encompassing of all groups in a range of languages and formats i.e. Easy Read and in different languages including Braille & Moon and British Sign Language (BSL and tactile BSL). Channels for communication must be considered too, to ensure they reach as many people as possible across different communities. The framing of the message must also be adequate to ensure people are not deterred from accessing care.
• The resources and workforce are not in place to deliver the right care, in the right place, at the right time to meet everyone's needs. It will be vital that we have adequate staffing levels at each stage of the urgent care journey and staff have the correct skills, knowledge and competencies to meet people's needs. We also need a workforce that has the ability to support people with communication or language barriers.
• Digital exclusion of certain groups in the community. This is based on lack of connectivity, limited IT literacy, lack of device, income (including phone and data costs) associated with mobile data.
• Unconscious bias in dealing with citizens accessing urgent care services, leading to care needs being unrecognised and / or unfulfilled.
• Citizens or particular groups of citizens lacking confidence in their care needs being adequately identified and met through the digital or telephony first approach.

To ensure the successful delivery of the Redesign Urgent Care programme, the Scottish Government is working with citizens and key stakeholders as equal partners, to consult, engage and co-design the new urgent care service and ensure there is buy-in from the public, clinicians and other stakeholders.

Specifically, the EQIA assesses any impacts of applying a proposed new or revised policy or practice against the needs relevant to a public authority's duty to meet the public sector equality duty.

The needs are to:

• eliminate discrimination, harassment and victimisation;
• advance equality of opportunity; and
• foster good relations.

In developing this policy we are consulting with a range of external stakeholders in Scotland. However, this EQIA has also sought to use existing and emerging information and evidence and analysis, as part and parcel of the decision making process.

Engagement and evidence gathering

In developing this EQIA, a range of engagement and evidence gathering approaches have taken place to further understand the potential benefits and barriers of the new pathway. An eight-week discovery project was undertaken by the Scottish Government Digital Transformation team. Additionally a scoping exercise has been carried out to further understand existing demand on these services.

This EQIA will be revised throughout this year as we continue to engage and consult with the public and evaluate the impact of the new system on different groups, monitoring the changes as they embed. A number of data gaps have been identified through this process and work is underway with the Scottish Government, Public Health Scotland and Healthcare Improvement Scotland to allow improvement.