For a number of years, NHS Scotland has been under pressure to manage increased system-wide demands for urgent/unscheduled care. Daily attendances at Accident and Emergency Departments (EDs) increased by approximately 8% between Jan 2016 and Jan 2020, before falling during the COVID-19 pandemic. As of end March 2021, ED attendances have nearly returned to previous pre-COVID-19 historical levels, with similar patterns for hospital acute admissions – see Annex B. This increase in demand with recognised longer waiting times in EDs, led SG officials during 2019/20, to explore alternative models of care drawing on national (UK) and international models, including experience from recent models of urgent care developed in Denmark, where most urgent care activity is managed through local hubs, with early access to a senior decision maker and arranged scheduled care, where required. The aim being to develop a model for NHS Scotland that aims to schedule urgent care where appropriate, to support care nearer to home and ensure the right care is provided at the right place and right time.
The COVID-19 pandemic has had unparalleled impacts on both elective and non-elective care, with specific concerns about the capacity of the whole system (acute hospital and other community-based emergency/urgent scare services) to respond to challenges. Conversely, the COVID-19 pandemic has offered new opportunities to explore and innovate new ways to respond to urgent care needs in Scotland. A specific example is a shift to virtual consultations to support social distancing and maintain essential services for patients. This includes the use of IT platforms such as 'Near Me.'
The RUC programme was created at pace to provide a safer patient experience and an alternative urgent care (RUC) pathway for the cohort of people who would otherwise have directly self-presented to A&E services. This recognised that many patients directly attending A&E services could be more safely and appropriately cared for in their home and community settings, rather than within an acute hospital environment.
The redesigned RUC pathway aimed to provide urgent care as near to home as possible by expanding and promoting NHS 24 (call 111), as the preferred initial contact for patients and carers who had an urgent care need, and to create local Board Flow Navigation Centres (FNCs), with rapid access to a senior decision maker to promote alternative, optimal pathways of urgent care. As necessary, patients would receive scheduled urgent care to the most appropriate place at the right time, improving care experience by reducing unnecessary crowding in A&E services and mitigating 'surge' presentations.
A Strategic Advisory Group chaired by Calum Campbell, CE, NHS Lothian and Angiolina Foster, CE NHS 24 was established to lead development of the redesign (RUC) programme. A conceptual Framework was developed, supported by all NHS Board Chief Executives with agreed principles for Phase 1 (see Annex C).
RUC aims to promote transformational change in how optimal urgent care can be delivered for the people of Scotland. While RUC offers a number of potential benefits in modernising wider urgent care (unscheduled care) pathways, it was recognised that potential risks, including unintended consequences may exist or materialise. They must be clearly recognised, addressed and mitigated within an iterative programme. Independent of the RUC Programme, a number of challenges existed within the unscheduled care pathway in relation to workforce, system integration and data quality and availability. The COVID-19 pandemic combined with the RUC Programme have highlighted these areas including staffing pressures within GP OOH services (see detail in Annexe I) and NHS 24 111.
To support this service transformation NHS A&A agreed to be the first pathfinder site to test the conceptual model and the transferability of the model to a national roll out to all territorial Boards. A Rapid External Review of the NHS Ayrshire and Arran (NHS A&A) Urgent Care Programme Pathfinder site, was published on 30 November 2020. This report considered the impact on the wider system and recommendation to proceed with a national roll-out. The recommendations are listed in Annex D.
RUC launched nationally on 1 December 2020, on a minimum specification – with a readiness assessment to ensure agreed compliance by all NHS Boards (which all Board Chief Executives signed off). This was described as an incremental or 'soft launch and relied only on local media messaging to publicise the new urgent care referral pathways, rather than a high-profile nationwide media campaign
It was also agreed not to include children under 12 years in the broader NHS 24 and FNC pathways in this preliminary phase, to allow these new urgent care pathways, to be tested, to minimise any clinical risks, and to maximise safety. All children under 12 years would be referred directly to local ED services within 1 hour via NHS 24, rather than initial referral to a local FNC. A further review of optimal urgent care of children (paediatric urgent care) was recommended as part of the NHS A&A Pathfinder Rapid Review. SG commissioned this and copy of the report of this paediatric review is appended as Annex E.
Current Risks for RUC Programme
- GP in-hours data are not routinely available, which limits fuller analysis of the impact of RUC on general practices.
- There is an urgent need to improve data quality in relation to FNCs, to better understand their role and to provide consistent and nationally compatible/comparable automated reports, as part of ongoing data monitoring and evaluation.
- IT Infrastructure remains challenging, including consistent coding and access to routine operational data. This limits robust evaluation and elucidation of future areas for improvement. This includes ADASTRA, NHS 24 111 and GP In-Hours systems.
- The ability of NHS 24 111 to scale up resource to the levels required to be able to manage call times (time to answer [TTA]) calls and call abandonment rates. While NHS 24 111 have largely managed the weekday call demand, weekends have remained problematic.
- This is compounded by various factors including: COVID-19 staff shielding, high levels of sickness absence and increased average call handling times. Ongoing NHS 24 recruitment and staff training endeavours are seeking to address these challenges.
- The resource and service performance challenges within NHS 24 have impacted on the ability to move to the next phase of the RUC programme, delaying high-profile national and public communications to seek to influence optimal public urgent care help seeking behaviour.
- Note: NHS 24 collects patient satisfaction data
- Workforce challenges:
- NHS 24 (as above)
- GP OOH services
- FNC staffing
- COVID-19 hubs and clinical assessment centres (CACs)
- GP in-hours services
The latter four service elements have been significantly dependent on ongoing and re-deployed GPs, other primary care clinical and administrative staff, with competing demands.
- There is a proportion of the public who are unable to currently equitably utilise NHS 24 services, due to 111 telephone or NHS Inform internet access issues, described as 'digital exclusion'. These communication difficulties include language - where English is not the first or preferred language and other parameters of health inequality including: homelessness, disabilities, (including blindness/deafness and cognitive difficulties).
- Standardisation of mechanisms to better understand patient and staff experience to improve the RUC patient pathway.
Risks and mitigations for the RUC programme were continuously assessed at both national and individual Board level, by frequent readiness assessments. Mitigation is agreed at local level with the SG National team and the Board Implementation Leads. A full risk register is monitored and highlighted for discussion at each RUC Strategic Advisory Group meeting (SAG). SAG established a number of complementary workstreams, initially met weekly and more recently (as of April 2021) has met on a monthly basis.
To further support risk mitigation, the SG National Team established daily drop-in sessions with the Board workstream and programme leads for RUC, to seek to highlight any issues arising, actions or lessons learned. This has also included weekly national implementation meetings to share lessons learned and weekly local meetings to highlight any issues /actions taken at Board level. These meetings were chaired by the SG National RUC programme Director and included representation from SAS and NHS 24. Additionally, each Board was allocated a SG National Improvement Advisor to provide daily support, as required.