Redesign Urgent Care: paediatric pathway to flow navigation centres - review

4. Discussion within SLWG

The potential risks to the individual against the potential benefits to the whole population were identified and discussed by the SLWG in depth to inform recommendations.

Benefits

• FNC system is regulated by allocating appointment time if appropriate or avoiding it altogether; this is Realistic medicine (getting the right treatment in the right place, by the right person, at the right time)
• Appointment system means ED/MIU will be less busy should the patient be advised to attend; reduced exposure to infection (increased due to COVID 19) from other ED attendees in unregulated environment with poor ventilation
• Potentially shorter time to assessment by Senior Decision Maker
• Pathway would capture minor injuries and direct children to MIU, relieving pressure on ED.
• Parents/carers save on time and transport costs, and having to make childcare arrangements for siblings
• Under 2s potentially not automatically taken to ED by SAS unless necessary to do so
• Moving from reactive to proactive unscheduled care

Risks and Mitigations

1. Senior Decision Maker (SDM)

There was considerable discussion on this issue.

• The Group acknowledged that additional provision to boards had been made to provide SDM time for working in the FNC. The group also acknowledged that there was an inevitable delay between funds being available and staff starting to work in the FNC. The expectation is that the RUC will in time reduce footfall in ED and thus free up more time for SDM to work in FNC.
• Ensuring consistency between boards: Not all boards who have an FNC may have a SDM with confidence and competence in remote telephone/video assessment of <12s.
• Regional working: Might regional networks (e.g. East, North and West) of paediatric staff (e.g. on call middle grade staff) provide support to the SDM in FNC. If so, considerations could be then given to the implication for paediatric services and governance.
• Island boards: The group noted that NHS Highland provides the FNC for NHS Orkney, Shetland and Western Isles.
• A set of standards to be applied across all Boards was established as part of the rollout of the RUC programme. De-Minimis Document (Annex 5)
• The group reviewed the De-Minimis document and recommend the following addition to mitigate risks:

Outcome: Senior decision maker to be available for each health board and needs to be competent to give remote assessment to children under 12; may be supported by input from a paediatrician if required.

The group also discussed how the de-minimis document could include a "home first" statement for all ages, i.e. wherever possible keep the patient at home.

2. Age

The experience of the group was that triaging of children by phone/video may be challenging.

The group discussed the current age cut-offs

• Upper age cut-off. Discussion around whether the current ceiling of <12 was appropriate, or could be made higher. Current NHS 24 decision making is different for <12s compared to older patients so change would involve some redesign. Most presentations to NHS 24 of individuals aged 12-16 would be more similar to "Adult" than "Paediatric" presentations.

The group agreed there was insufficient justification to change the age ceiling for inclusion in FNC.

• Lower age cut off. Serious Events investigated by NHS 24 occur most commonly in the <5 year age group and especially the < 2 year olds. The group considered whether children aged 5-12 or 2-12 could be included in the FNC whilst younger children are directed by NHS 24 to ED and not FNC. This will not reduce serious events continuing to occur in young children. NHS 24 processes for under 18 month olds, which are separate to those for older individuals, are currently in place.

3. Time to assessment

Rapid deterioration of young children may occur during the wait for call back (up to 4 hrs) from FNC SDM. It is possible to 'highlight' <12s on the Adastra system therefore enabling boards to identify referrals of <12s and review as a priority. It should be noted that NHS 24 currently advises all callers that if they deteriorate or are worried they should call back.

• 4. Workforce and System Capacity

The group acknowledged that all current workforce resources are stretched due to the COVID 19 surge and particular consideration should be given to assessing whether FNCs have capacity in the current environment to accommodate <12s.

In more general workforce terms, MIUs would need to have sufficient capacity to see cases of <12s referred from FNC and should consider any additional training needs for the nurses staffing the MIU.

If <12s were introduced within the current pandemic surge there could be negative consequences on the whole system. Conversely, as unscheduled paediatric activity is currently low there may be a case for including <12s within FNC provision if the boards can confirm there is adequate FNC staffing available.

Clinicians in NHS A&A were contacted to ask about their experience after <12s stopped going through the FNC in December 2020. However, due to the current surge in activity – system pressure due to COVID 19 – it was not possible to make a meaningful assessment of this and the group had to rely on the evaluation of the pathfinder. The SLWG agreed that if <12s were included in the FNC this should continue to be independent of COVID pathways.

Public expectations of ED

Data shows that 90% of ED attendances for under 12s (Annex 3) are self- presentations and 10% come through NHS 24. If more parents/carers of <12s call NHS 24 instead of self-presenting to ED then this may increase overall activity in some areas of unscheduled care (e.g. MIU, GP out of hours) although self-care advice may reduce ED presentations. In the group's opinion, parents/carers who are worried about their young child and have contacted NHS 24 may not wait at home for a call back from FNC, they will likely go to ED.

The national media campaign for Right Care, Right Place launched with a mail drop in January and will incrementally increase reach and coverage across digital media, press, radio and TV. None of the campaigns mention any age exclusion specifically however at the NHS 24 clinical triage stage, all children <12s are referred directly to ED, excluding them from the FNC.

Scotland-wide comparisons

The Royal Hospital for Sick Children, Edinburgh undertook a trial looking at GP triaging of attendances. Wishaw General Hospital and the Edinburgh Royal Infirmary have had (adult) versions of flow navigation for at least 5 years in the in-hours period.

Incremental roll out

It is not possible to undertake a further pathfinder for this cohort of presentation due to the need for geocaching the specific area for NHS 24 to provide a safe and effective service. This means NHS24 are unable to separate out different board callers. If a decision is made to include <12s in FNC then all FNCs must go live on a national basis at the same time to allow safe transfer from NHS 24.