NHS Scotland redesign of urgent care: second national staging report

6. Recommendations

The RUC-FNC-A&E services pathway in its current format requires review and rapid refinement to deliver benefits for patients and the system. This includes recognising the different levels of activity and service effectiveness over time, known as periodicity, which exhibit different patterns between in-hours, OOH and at weekends to inform further design and improvement.

1. Utilise person and carer centred redesign and equity of access based on evidence - including patient experience

It is important at all times, to maintain a person-centred approach to urgent care redesign, with a focus on what matters to people and carers. This includes support and valuing of all staff and organisations who provide that care.

a) Health Boards should continue to use agreed national standardised questions to monitor patient experience

b) The RUC Programme and NHS Boards should implement the recommendations of the HIS Gathering Views report to ensure a focus on equity - what matters to people who may experience barriers or disadvantage when accessing urgent care services

c) PHS should continue to monitor data on the impact of the RUC Programme on equity of access, to identify relevant trends, risks and issues

d) The external independent evaluation being commissioned by Scottish Government Urgent and Unscheduled Care Programme will include a health economic assessment including value for money and an independent assessment of patient experience.

2. Ensure there is clear workforce planning to support sustainable services for patients

a) NHS Boards should identify the risks to sustaining local services that are currently provided through use of non-recurrent funding and temporary/short term/voluntary staffing

b) The RUC Programme should support the development of data driven sustainable workforce plans to build multiagency, multi-disciplinary teams

c) All NHS Boards to collaborate closely to develop a multiagency multidisciplinary development programme for local delivery in both secondary and Primary/Community Care settings to:

• build capability, capacity and confidence in virtual patient assessment and decision making
• build resilient teams, improving relationships and trust, and supporting continuous learning and improvement

3. Review of NHS 24 staffing and call processes

As the primary first point of contact, NHS 24 is designed to ensure that there is responsive, efficient and effective care. NHS 24 should:

a) Continue to build with urgency, sufficient workforce capacity and capability, optimally aligned to meet timely and responsive urgent care demand 24/7 - across in-hours, out-of-hours, weekends and public holiday periods

b) Continue to review at pace clinical disposition pathways and outcomes, working with key partners and stakeholders, including SAS and local NHS Boards. This includes ongoing work to review the appropriateness of the use of 1-hour, 4-hour and 12-hour pathway dispositions – see Recommendation 4.

4. Patient pathways and dispositions

The evaluation and data from focus groups, undertaken as part of this report, suggest there is a need to review the patient pathways (dispositions) at all relevant touchpoints described within the RUC Programme.

a) All stakeholders should work collaboratively to optimise existing care pathways and dispositions to improve the patient care journey

b) This must involve the public (service users) and care professionals (service providers) and should recognise the needs of local populations, service configuration and available resources, including best use of public health skills and assets.

5. Locally-led care

a) All NHS Boards should continue to focus on right care, right place, right time and widening access to place-based urgent health and care provision. This includes promoting self-care, self-management support, where appropriate, and anticipatory care, initially focusing on pressure points in the urgent care service

b) Ensure ongoing wide engagement with local service users and providers, to take a whole system focus for the RUC Programme as it evolves, including OOH services, Primary Care- including General Practice, Community Pharmacy ((NHS Pharmacy First Scotland^[16]), Mental Health, Social Care and non-statutory services.

6. Broader collaborations

a) Develop/explore closer working, collaboration and partnerships across NHS Boards, where appropriate, as a way of improving synergies and efficiency of services - including best use of collective resources

b) Take into account additional recommendations in the earlier report: 'Pulling together: transforming urgent care for the people of Scotland' (2015)^[17]

7. Flow Navigation Centres

Current performance characteristics for FNCs suggest activity/care episodes would need to increase demonstrably to reduce overall A&E services total attendances. This must be measured against the total impact of the RUC-FNC-A&E services pathway to ensure no unintended consequences and recognise system constraints, particularly workforce and system design.

The National RUC Programme to lead work on:

a) Better understanding and promoting optimal models for FNCs, recognising the differences in scale and geographical issues, including remote and rural

b) Promoting the most appropriate and effective modality for assessment and consultation, whether in-person or remotely. This includes improving the capability and confidence in appropriate use of digital technology, mitigating any digital exclusion risks

c) Review the RUC workforce model, developing greater use of multidisciplinary teams and skills including: Medical, Nursing, Pharmacy, Allied Health Professional (AHP), Paramedic, Social Care and support staff.

NHS Boards should:

d) Ensure flow navigation adds value to the patient journey as part of the development of local place-based and where appropriate regional care provision (see also Recommendation 6)

e) As for the National RUC Programme - develop, maintain and support a resilient workforce model, incorporating optimal multidisciplinary skills, teams and leadership

f) Optimise scheduled care, increasing the focus beyond A&E services with extended access to community and outpatient provision

8. Data and Digital infrastructure

The National RUC Programme should:

a) Accelerate access to the clinical portal and the single shared care record

b) Digital team to work more closely with local Board digital teams to extend professional to professional communications, including Near Me

c) Improve data quality, including completeness and consistency

d) Resolve existing data challenges, including standardised coding and reporting at NHS Board level across the patient pathway, which limits the ability to analyse and monitor changes effectively.

The following should be addressed:

A&E services

• Improve consistency of coding of "new planned" attendances i.e. referrals from FNC.
• Improve diagnostic coding to provide insight into the case-mix of attending patients.
• Obtain more granular data on individual MIU, rather than aggregate returns.

FNC activity

• Improve consistency and completeness of disposition/outcome recording (recorded in A&E services and ADASTRA datasets).

Primary Care – General Practice In-Hours data

• Provide patient level GP IH data to enable linkage across pathways.
• Provide aggregate data for high-level assessment of patient flow in urgent and emergency patient pathways.

Urgent Paediatric care

• Ensure ongoing data analysis and evaluation of RUC paediatric pathways and outcomes, to agreed timelines.

Urgent Mental Health care

• Mental Health RUC pathways to be evaluated in line with future RUC implementation.

9. Equality and diversity

a) NHS Boards should ensure equality and diversity data is collected and monitored in line with statutory requirements and as outlined in Recommendation 8 above

b) Boards must undertake equality and other impact assessments as necessary to ensure they can mitigate against any unintended negative impacts for people who may use the newly redesigned urgent care service, reflective of their local and regional demographics. These should go beyond the protected characteristics and include socio-economic factors such as digital exclusion. Further Information can be found in the Care services - planning with people: guidance^[18]

10. Public messaging

a) The RUC Programme must ensure that communications meet the needs of people with protected characteristics, including socioeconomic factors such as digital exclusion (see Recommendation 9)

b) NHS Boards need to nuance and align local messages with the national media campaign, securing best use of all urgent care assets and resources

c) Increasing patient/public activity via NHS 24 111 call activity is unlikely to improve the patient journey and experience alone, unless:

• The importance of the urgent care role of Primary Care is emphasised (see Recommendation 5)
• Disposition pathways are reviewed and optimised for patient benefit including FNCs (see Recommendation 4)
• NHS 24 call response times improve across the week (see Recommendation 3)

11. Local improvement

NHS Boards should provide dedicated improvement and change management support to enable a culture of improvement learning that:

a) Actively involves patients, public, care providers and staff

b) Works across pathways and systems

c) Engages Quality Improvement Teams and Fellows as local champions for change

d) Optimises use of available public health skills and assets to support RUC development (see Recommendation 4)

12. National support and improvement

The RUC Programme should build on current support to:

a) Ensure improvements in the RUC pathway are informed by best practice and the application of improvement and systems learning

b) Undertake a rapid and time-limited re-assessment of the current RUC pathway, based on the recommendations, including patient need and evidence, to define and develop the next phase priorities of the RUC Programme.

c) Recognise ongoing robust data accrual and analysis are essential, including establishing clear improvement goals which can be measured timeously (see Recommendation 8) and should seek to ensure this is in place

d) Extend improvement learning to multiagency, multi-professional teams through collaborative style regional and national learning exchanges when there is capacity in the system for fuller engagement of front-line teams (see Recommendations 5 and 7)

e) Co-ordinate synergistic activity with partner organisations to enable local organisational development, change management and build the capability and capacity for improvement learning

This report will be considered by the RUC Strategic Advisory Group and the Scottish Government to determine how the recommendations will be incorporated to the RUC Programme plan.