Redesign of urgent care: equality impact assessment

Stage 1: Framing

Extent/Level of EQIA required

The outbreak of COVID-19 in early March and subsequent risk of hospital-associated infection accelerated the requirement to redesign our urgent care services – work which was already in development prior to the pandemic – in time for the winter period when A&E departments are often busy and overcrowded. As work now begins to further develop and refine these pathways it was timely and essential to produce the national EQIA. Local EQIAs are already in place and we will work with Boards to ensure these are further developed and informed by the national EQIA.

Understanding the patient experience is fundamental to the redesign of urgent care. A key principle of this work is to ensure we do not further health inequalities. To support this ambition we need to we need to:

• understand the needs of all citizens and key stakeholders;
• explore the impact of the Redesign of Urgent Care on all parts of the system; and
• identify if patients are receiving right care first time.

Following the identification of the protected characteristics relevant to the policy, a broad evidence base was collated to allow the Scottish Government to properly assess the strategy's impact on each relevant characteristic. This evidence base included a number of national statistics gathered by the Scottish Government or other national bodies and various other relevant studies, reports and surveys that are referenced throughout this report.

Results of the framing exercise

An initial scoping exercise was carried out using Management Information from Public Health Scotland covering Emergency Department (ED) attendances (including specific data on self-referrals), contacts with the NHS 24 on 111 service, contacts with Primary Care Out of Hours services and Scottish Ambulance Service (SAS) attended incidents broken down by sex, age and Scottish Index of Multiple Deprivation (SIMD). Demand of these services by age and sex varies by service, while those from the most deprived SIMD areas use a higher service.

• The NHS 24 on 111 service is used more by women (57%; January to July 2020), particularly among younger working age adults (aged 15-34) where women make up over 60% of contacts and contact rates per population are also substantially higher among women for this age group.
• Women are more likely to have childcare responsibilities and be parents to children under 5, therefore are more likely to access urgent care.
• Annually over half of all contacts with NHS 24 on 111 are 15-64, and over a fifth are aged 14 and under. Over three quarters of younger age groups (5-9, 10-14) were self-referrals to emergency departments.
• Volume of demand at Emergency Departments is broadly similar among men and women (51% male; January – July 2020), though men tend to attend (and also self-present) at a slightly higher rate than women across most age groups.
• Older age groups attending Emergency Departments are also much less likely to self-present: a quarter of Emergency Department attendances aged 85+ were self-referrals. Older age groups (aged 60+) represent a larger proportion of Scottish Ambulance Service attendances compared to other services such as NHS 24 on 111.
• Urgent care services are more likely to be used by people from more deprived areas: around twice as many more (self-presenters) attending Emergency Departments and contacts with NHS 24/111 are from the 20% most deprived areas than the 20% least deprived areas.
• It was identified that there were some data gaps particularly around disability and race.

To understand the impact on users/ potential users an analysis of existing evidence was undertaken. Key issues identified suggested that any protected characteristic groups identified as being more likely to experience socio-economic deprivation will also be more likely to access urgent care services.

Groups of people noted as being more likely to experience poverty include:

• minority ethnic people (including Gypsy/Travellers, migrants, refugees and asylum seekers);
• people who are Muslim;
• a person with disabilities
• care-experienced young people;
• people experiencing homelessness; and
• people living in the most deprived areas of Scotland according to the Scottish Index of Multiple Deprivation.

The NHS National Services Scotland 'Who Attends Emergency Departments' report notes that people living in the most deprived areas accounted for twice as many attendances to emergency departments compared to those living in the least deprived areas. The was linked to a number of potential reasons, including poorer health, more complex social needs and service provision in areas experiencing higher deprivation. It was also noted that people with children under 5 and people aged over 65 were also more likely to access urgent care.

Further issues identified were:

• the lack of digital enablement may be a barrier for some people experiencing socio-economic disadvantage;
• a lack of access to transport, particularly in remote and rural areas, or during the out of hours period, might be an issue for people experiencing socio-economic disadvantage, if they are directed to attend a healthcare setting that is outside their local area;
• it was noted that the new model could have a positive impact in relation to travel and transport, as more people will avoid A&E attendance due to advice virtually and may be directed to care at a hospital which suits them or at a time where they can organise transport;
• minority ethnic and disabled people were identified as groups more likely to experience socio-economic disadvantage;
• those whose first language is not English may experience greater barriers with the introduction of a telephone triage system and the move to more appointments being offered using digital technology; and
• therefore communication of the changes to urgent care should be targeted at the groups identified as being more likely to experience socio-economic disadvantage.

'Discovery Project': user research

In developing this EQIA, an eight-week discovery project was undertaken by the Scottish Government Digital Transformation team to better understand the needs, motivations and potential issues that self-presenting citizens accessing urgent and emergency care may encounter, with a specific focus on the impact that the change in service will have on vulnerable citizens.

The project team targeted three user groups they deemed most likely to be disadvantaged by the change of service; those whose first language was not English, those experiencing homelessness, and those with anxiety and depression. The reasons for this are set out below.

As outlined above research shows urgent care services are more likely to be used by people from more deprived areas. Among homeless individuals there exists a higher level of depression and suicide than in the general population. The conditions many homeless people are exposed to can have a negative impact upon their mental health and this is a common reason for attending A&E. Previous primary research has also found that, as a result of the coronavirus pandemic, BAME individuals (a higher proportion of whom do not speak English as their first language, compared to the general population) are more likely to develop anxiety and depression as a direct result of lockdown. It has also been noted that a disproportionate number of individuals experiencing homelessness – when compared to the general population – are refugees (a demographic group that is less likely to speak English as their first language.^[2,3,4]

Overall the report finds that those who encounter little or no difficulty interacting with the redesigned urgent care pathway can expect to experience many benefits from the changes including:

• avoiding the cost of transport;
• accessing medical consultation from the comfort of home;
• scheduling visits to the hospital around care responsibilities;
• access to local specific information hubs;
• avoiding or minimising the discomfort of attending A&E;
• avoiding unnecessary travel;
• source of reassurance;
• minimising risk of infection; and
• minimising crowding in waiting areas.

However, by improving access to urgent care for some, without providing additional measures for those who already experience barriers to technology-enabled care, we risk widening health inequalities. A number of potential mitigations were identified which focus on improving access to digital; improving telephone services for those with language barriers; ensuring call handlers have appropriate training to ensure appropriate and equitable care; targeting national messaging at disadvantaged groups; ensuring collaborative working with partner agencies.

A strong theme was concern that moving to a system where video consultation is the default would be detrimental to certain protected characteristic groups. It is therefore important to reinforce that the continued use of Face to Face appointments is important. A further mitigation of this potential inequality could be to ensure that there are options of local places outside the home where people can have access, support, and privacy to have their appointments.

Workforce

The impact of specific staff groups was considered particularly in cognisance of the increased focus on staff wellbeing in national and local policy, the very size of the workforce, and what we know about the links between staff experience and positive patient outcomes. It was recognised that there may be many potential benefits for staff including reduced crowding and attendance to A&E departments leading to improved staff experience and the opportunity to potentially work from home.

After reviewing the policy and the initial evidence gathering, no significant potential negative impacts have been identified for the workforce. This will be further explored in future consultation.

Overview high level summary analysis

Feedback from public engagement highlighted potential benefits and barriers across the characteristics. This was also the case within each protected characteristic reflecting their heterogeneity.

A strong theme was concern that moving to a system where video consultation is the default would be detrimental to certain protected characteristic groups particularly older age groups. Connected to this was a worry that for various groups, including women and the LGBT community who are in difficult domestic situations, where families may not be aware of a particular health issue they want to discuss, that it would not be appropriate to have a consultation from home. Domestic abuse is another related consideration, particularly since we know a higher proportion of women are accessing urgent care. Women or others in abusive situations may not feel/be safe to seek or receive medical advice within the home environment. The Near Me Public Engagement report^[5] highlights this risk in their findings, citing that one of the main barriers identified was lack of private space for video calls.

It is important to note that for some, often those with mental health issues, it was important to see a healthcare professional face to face; it has also been established that not all people can confidently take part in a virtual consultation. Consideration needs to be made for people who are unable or prefer not to access digital technology, who lack the necessary digital skills and/or who may require support from paid/unpaid carers to take part in a virtual appointment; mechanisms need to be put in place which appropriately identify and support these individuals.

A number of barriers were linked to age, particularly linked to digital access with those in older age groups less likely to engage digitally. It is also important to consider that older age groups are more likely to attend an emergency department and are more likely to be admitted to hospital following their attendance. As such the necessary mitigations must be put in place to ensure the change of service is not detrimental to this age group.

It was noted that those with a disability are more likely to require urgent care. Pertinent to this is a concern that those experiencing a disability are more likely to be digitally excluded and as such may feel disenfranchised by the change in service. It has also been acknowledge that disabled people whose condition(s) impact their verbal communication could be deterred from accessing urgent care further to the introduction of the requirement to call NHS 24.

Sociocultural and linguistic barriers was noted also noted as a key theme. It was noted that many ethnic minorities seek medical advice within their own communities before approaching NHS services often resulting in their first experience of NHS services being in A&E. It is also important to acknowledge the lack of awareness in these communities of services such as NHS 24 and NHS Inform. An important mitigation strategy will be to ensure communication plans consider many channels for communication to ensure they reach as many people as possible across different communities. Of equal importance is ensuring appropriate measures are built into the new system to meet the needs of those for whom English is not a first language.

As outlined above research shows urgent care services are more likely to be used by people from more deprived areas. Potential mitigation strategies include ensuring that the NHS is free at point of access for all and that those who cannot afford data costs or do not have access to WIFI. It was also suggested that providing temporary accommodation facilities with training and resources would support access to NHS remote consultations, to provide targeted support to people with significant emotional and practical barriers to accessing care.

In the next section, Stage 2, the detail behind the analysis of the evidence is summarised. The supporting evidence gathered is summarised in Appendix 1.