Key decisions for Scottish Government
Should the Redesign of Urgent Care programme be rolled out to all NHS territorial boards on 1 (early) December 2020?
Early experience (3 weeks and growing) from RUC pathfinder launch in NHS A&A has not produced any unforeseen issues, has provided good internal learning for NHS A&A but also for the rest of NHS Scotland. The decision to conduct this pathfinder approach was prudent. NHS A&A was already in a high state of preparedness, and possibly more advanced than any other territorial Board in Scotland. There may a 'readiness bias' and/or 'volunteer bias' at play here, which must be taken into consideration by SG.
All territorial Boards throughout Scotland have indicated that they are ready for a 1 December 2020 RUC roll-out. While this view is encouraging, there may be the possibility of RUC implementation 'optimism bias'. That concern has been recognised and is being positively addressed and mitigated by ongoing assiduous SG scrutiny of Board readiness assessment revisions.
At this time, the nascent RUC programme has not yet been 'stress tested'. In the NHS A&A pathfinder, numbers routed via their Flow Centre are small but will grow with the passage of time. Forthcoming service 'stressors' include: increased service volume demand from winter pressures, Covid-19 uncertainties and the festive period ahead. Regular monitoring and internal assessment must continue to be undertaken by all Boards, adequately mitigating all known and emerging risks.
The immediate experience of NHS A&A cannot be assumed to cover the circumstances of all Boards, and particularly for the larger Boards in Scotland. SG must be assured that sufficient risk mitigation is in place before national RUC roll-out occurs. Equally importantly, assurance is a matter for individual Boards and their Accountable Officers. At the time of writing (29 November 2020), I understand that all Board Chief Executives have signed off a readiness assessment for a putative 'go-live' date on 1 December 2020.
If SG agrees, as expected, to proceed with a national roll-out, in early December 2020, as for NHS A&A, it is recommended that all territorial Boards should undertake a gradual start. This will help identify any issues they may experience and to resolve these, sharing their individual experiences for the benefit of all. Further findings from the NHS A&A RUC pathfinder, should continue to be assimilated and disseminated. This has been described as a 'soft' launch approach, with no large-scale publicity and national public messaging. This decision is also tempered by Covid-19 uncertainties, winter pressures and the festive holiday period ahead. The optimal timing of any proposed 'full' launch in 2021, should only be determined once SG is satisfied that the service is sufficiently resilient for that to happen, following further assiduous evaluation of benefits and risks.
My report offered here is a snapshot assessment of early findings of the NHS A&A RUC pathfinder and falls far short of a rigorous evaluation. It is one part of a much broader assessment. Growing experience from the NHS A&A Pathfinder and its own internal evaluation processes, positive readiness assessments from all territorial Boards and internal SG evaluation are imperative.
Should the national rollout include both adults and children?
There are a number of ongoing discussions around optimal urgent care for children and whether the RUC model should be confined to adults, at this early stage. There have been differing views expressed within the Chief Executives' Group, the Scottish Association of Medical Directors' Group (SAMD) and the Scottish Executive Nurse Directors' Group (SEND).
The NHS A&A pathfinder programme has included both adults and children and to date, in its earliest stages, no adverse impacts have emerged; rather, positive public/parent experiences have been reported. These early findings are encouraging but are limited and should be tested in all territorial Boards, NHS 24 and SAS, at the commencement of and during intended national RUC roll-out.
The arguments are finely balanced but need to be elucidated further.
SAMD and SEND have taken the view at this time that a cautionary single (adult only) approach is appropriate for the safe urgent care of children. They have proposed that the present urgent care pathway should be preserved for children, while the RUC programme is initially implemented and tested for adults only. Once experience and confidence are gained for the adult pathway, a holistic all-age pathway should be reconsidered.
If this single option is preferred by SG, a clear definition of the age determinant of children in this specific context must be agreed and ratified quickly.
Alternatively, some paediatricians and others have expressed a view that a joint adult and children pathway is appropriate and safe to be implemented, as originally envisaged for the RUC programme and currently in place in the NHS A&A pathfinder site.
A Rapid Short Life Working Group (SLWG) has been mooted to give broader clinical input to this matter. As SAMD has identified, the issue is broader than clinical decision making alone, which is paramount. This should also be reflected in the membership of the proposed SLWG, if agreed. The Chief Medical Officer (CMO) and Chief Nursing Officer (CNO) must be involved in this process.
A critical point here is the capacity and expertise of staff available at local Flow Centres at any given time and the imperative to minimise delay and maximise call-back response times for the urgent care needs of children. Experience from the NHS A&A pathfinder will inform this, but the scope and scale will be different, particularly in the larger territorial Boards. The potential risks and benefits of both single (adult only) and joint (adults and children) options should be fully explored.
I was present at the Board Chief Executives' Group meeting on 24 November 2020 to hear the debate and outcome about their views on RUC. Board Chief Executives came to a majority consensus that the prevailing views of both SAMD and SEND should be heeded and that children should not (initially) be included in the RUC programme, as yet. I concur with this cautionary view and recommend that a rapid Short Life Working Group, as discussed above, should be established with dispatch, to advise on the way forward, in order to secure the best urgent 24/7 clinical care for children in Scotland.
I have appreciated working with colleagues in NHS Ayrshire and Arran, NHS 24, SAS and within Scottish Government. Their teamwork has been exemplary and their labours long and intensive. I have taken part in a number of meetings and discussions (Annex 2) and am grateful to colleagues for their time and assistance throughout. I am indebted for the specific help of Derek Bell, Immogen Connor-Helleur, Fiona MacKenzie, Michael Fox, Milla Marinova for the Adjunct Data Report, Jacques Kerr and Craig Whyte (Annex 3). I thank Karen Ritchie and colleagues within Healthcare Improvement Scotland (HIS) for undertaking a rapid literature review of urgent care models). I am also grateful to my immediate SG support team, Karin Agnew and Katie Morris.
Professor Sir Lewis D Ritchie OBE FRSE
James Mackenzie Professor of General Practice
University of Aberdeen
29 November 2020