11 - NAIJB-16.03.23-Urgent Care Update
North Ayrshire Council · 16 March 2023
Back to Integration Joint Board — 16 March 2023 and its agenda
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North Ayrshire Integration Joint Board 16 March 2023 Subject : Primary Urgent Care Update Purpose : This report aims to provide an update to the Integration Joint Board (IJB) on provision of primary urgent care services through the Ayrshire Urgent Care Service (AUCS) and an update on new pathways delivered through the service as a result of the introduction of the national Redesign of Urgent Care (RUC) Programme. Recommendation : It is recommended that the Integration Joint Board: a) Note the progress of the Urgent Care agenda across Ayrshire and Arran; b) Note the new pathways introduced through the RUC Programme; c) Note the increased activity within AUCS and proposals being progressed to sustain the successful person centred delivery model and patient pathways. Direction Required to Council, Health Board or Both Direction to :- 1. No Direction Required X 2. North Ayrshire Council 3. NHS Ayrshire & Arran 4. North Ayrshire Council and NHS Ayrshire & Arran Glossary of Terms ANP Advanced Nurse Practitioner AUCS Ayrshire Urgent Care Service ED Emergency Department FND Flow Navigation Centre GP General Practitioner / General Practice HSCP Health and Social Care Partnership NHS AA NHS Ayrshire and Arran OOH Out of Hours RUC Re-design of Urgent Care SARC Sexual Assault Response Co-Ordination SAS Scottish Ambulance Service
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1. EXECUTIVE SUMMARY 1.1 AUCS was previously an out of hours (OOH) GP (General Practitioner) led multi- disciplinary service and since 2020, operates 7 days per week 24 hours a day as a GP led Flow Navigation Centre (FNC). Further information on this joint approach and new pathways developed are provided within this report. 1.2 Since the establishment of the Flow Navigation Centre (FNC) within AUCS as the Pathfinder Board in December 2020 the service has continued to develop and evolve various joint working models aligned to the national Redesign or Urgent Care (RUC Programme. 1.3 The paper outlines the activity and impact of the new additional pathways in operation 24/7 to support an improved patient journey, with a focus on community services. The data presented demonstrates the effectiveness of the new pathways avoiding hospital attendances or avoidable admission to hospital which has better outcomes for patients. 1.4 The success of the new pathways and ways of working is a result of good working relationships across Ayrshire and Arran and wider system partners including NHS 24, Scottish Ambulance Service (SAS), and Police Scotland. All new service developments are developed in partnership across clinical and managerial leadership teams from all parties. 1.5 This report has / will also been presented to: i. Ayrshire GP Sub-Committee – 31 January 2023 ii. East Ayrshire IJB – 1 February 2023 iii. South Ayrshire IJB – 15 February 2023 iv. NHS Ayrshire & Arran Board – 27 March 2023 2. BACKGROUND 2.1 The Public Bodies (Joint Working) Scotland Act 2014 provides a legislative framework for the delivery of Primary Care Services in Scotland with powers and duties delegated variously to both the NHS Board and the IJBs. Through these arrangements the three Ayrshire IJBs commission, through Directions, NHS Ayrshire & Arran (NHSAA) to provide Primary Care Services. This includes provision of OOH Primary Care Services through AUCS. This is delivered through the Director of East Ayrshire Health and Social Care Partnership (HSCP) in a lead partnership arrangement. In addition, NHSAA directly commission East Ayrshire HSCP to conduct Primary Care Contracting on behalf of the Board, this being a function that cannot be delegated to IJBs at this time.
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2.2 Following the work of Sir Lewis Ritchie in 2015 ‘Transforming Urgent Care for the People of Scotland’, AUCS had embraced the vision of developing a multi-disciplinary integrated approach to OOH services in Ayrshire. This included integrating social work, community nursing and emergency mental health service. We have continued to build on this to develop a 24/7 model ensuring there is a senior clinical decision maker supporting a multi-disciplinary approach to urgent care, not only internally but facilitating joint working and decision making with various agencies across primary care, community services and hospital front doors. This creates a fully person centred pathway for all patients, getting the right care in the right place at the right time with a focus on the patient/carer need through to conclusion of that episode of care. 2.3 The RUC programme was introduced in 2020 to reduce Emergency Department (ED) attendances by 15% across Scotland to prevent overcrowding in ED waiting rooms and to improve the urgent care experience for patients and staff. This is achieved by directing those whose care requirements are not an emergency, to more appropriate, and safer care closer to home, by optimising clinical consultations through telephone and digital consultations. The percentage of reduction has been achieved in Ayrshire and Arran. 3. PROPOSALS 3.1 AUCS Service Overview There are various services and pathways now included within AUCS. Some of which are available 24/7 and others during the OOH period (Monday to Friday 6 pm – 8 am and Saturday/Sunday). All professional and service management arrangements sit within the current AUCS management structure with the exception of OOH Social Work who are managed through East Ayrshire HSCP and the OOH Mental Health Crisis Team who are managed through North Ayrshire HSCP. An outline for each of the services is detailed below and the service is also supported by a number of disciplines in addition to this including shift team managers, urgent care call handlers, dispatchers, receptionists and drivers. Call handling service 24/7 with the highest volume of activity in the OOH period when the service acts as a single point of contact for various services across East, North and South Ayrshire HSCPs. The service takes an average of 4967 calls through the single point of contact per month. The volume has grown year on year and includes calls from families and patients trying to reach: • Care at home • Social work • District Nursing Services
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GP Out of Hours Service – The OOH service should only be used by those who require an urgent service and cannot wait until their own GP Practice is open. To access patients will call NHS 24 on 111. Dependant on the outcome of the call, the patient will receive telephone advice with no further action or be referred onto AUCS with a response time based on clinical need of one hour, two hours or four hours. The OOH service sees around 8,500 patients monthly in centres or as a home visit. This is an increase of 20% activity prior to 2022. On average 89% of patients are clinically assessed within the set time-frame from NHS 24. Factors that impact this performance is mainly periods of high demand where clinicians will prioritise the most vulnerable, including one and two hour response times. It should also be noted there are a cohort of patients that cannot be reached for several hours which also impacts on the response performance. All patients that are referred to AUCS OOH from NHS 24 go through a full clinical assessment within the triage time set by NHS 24 with an outcome of either: • Self-Care • A prescription issued for collection at local pharmacy • An Appointment at a local Primary Care Urgent Care Centre • A home visit undertaken by GPs/Advanced Nurse Practitioners (ANP) in dedicated cars with driver support colleagues. A patient transport service is available to take patients to OOH urgent care centres, in Ayr, Kilmarnock or Irvine if they have no other means of transport. Due to improved ways of working and introducing a ‘clinical triage first model’ for all GP OOH calls from NHS 24, this has reduced the number of urgent care centre appointments across the three sites as well as less mobile clinician cars on the road. A total of 46% of calls are closed off remotely therefore this has allowed opportunity to re-design the service delivery model. It should be noted that a full clinical remote assessment can still take 15 minutes therefore the clinical capacity is still required. The current model relies heavily on GP engagement for service delivery. There are currently over 200 GPs on the workforce database within AUCS with 144 GPs actively doing shifts throughout 2022. There are also three ANPs within the service along with sessional bank ANPs from General Practice who support the service. For the service to be fully operational it requires 12 GPs/ANPs for a weekday service and 39 clinicians each day over the weekend. This gives an average weekly demand for 138 shifts to be covered. There has been an increase in the number of GPs and ANPs signing up for shifts in the last year with feedback on the variety and various pathways, as well as flexible working being an attractive feature to work with the service. 111 Emergency Department/Minor Injuries – patients who think they require to attend the ED are directed to contact NHS 24 (111) for their urgent care needs as a first point of contact. NHS 24 assess the patient’s needs and then route patients who require further assessment to the FNC operational within AUCS over the 24/7 period.
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The Senior Clinician, usually a GP, will clinically assess the patient remotely and determine the best outcome through the most appropriate care pathway which could include: • Closed as assessment and care provided by a clinician over the phone with self-care advice; • Directed to their GP practice (during in-hours); • Scheduled for a home visit by an AUCS clinician (during out of hours) • Appointed to a Primary Care Treatment Centre (during out of hours); • Onward refer to a community service and • Appointment at the Minor Injury Unit. The OOH District Nursing Team - operate within AUCS and provides planned and urgent community based care to patients including palliative care where necessary. The OOH District Nursing Service is staffed between 5pm and 8.30am seven days per week with registered and non-registered staff. Requests for a visit can be made by patients, family members, carers, GPs and in-hours district nurses via the professional line and single point of contact. The OOH District Nursing service provides an Ayrshire wide service, with the exception of the two islands (Millport and Arran). The service supports on average 500 planned visits per month and 1500 unplanned visits. Planned visits are the same as pre-COVID levels with unplanned seeing an increase of 500 per month. It is noted through continuous data review, that the majority of workload is now palliative care with a large proportion of unplanned visits due to workforce and service pressures with day time services. This has been acknowledged through the community nursing service review. Pan Ayrshire OOH Social Work team - a range of Senior Practitioners and sessional social work staff ensure the delivery of a professional OOH response to the immediate needs of individuals and families across all social work services, including those considered as vulnerable or at risk. They work closely and have positive relationships with their colleagues within Police Scotland and Health and Education, both locally and nationwide. Since April 2022 the service has received an average of 561 referrals per month. There has been a steady decline with the volume of referrals to the service over the last number of years, including 2020-2021 and 2021- 2022. The service are currently undertaking an in-depth service data analysis in relation to the service trends since 2019. This will hopefully provide more information on the reasons for the reduction in referral rates. Mental Health Crisis Team operates as part of AUCS in the OOH period providing urgent access to relevant community mental health services. This service is also fully integrated with the Police Scotland and SAS pathway described later in the paper. Any referrals via the NHS 24 pathway that are identified as requiring mental health support, and no physical health need, are passed directly through to the crisis team from the AUCS dispatch staff. The wider service will also seek input from the crisis team as required. The Mental Health Crisis Team support a range of services outwith AUCS in the OOH period with an average 150 calls via NHS24/ AUCS on a monthly basis.
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Covid-19 Therapeutic Service - First opening 21 December 2021, the 7 day COVID- 19 Therapeutic service is delivered through AUCS within the COVID Treatment Centre. This supports a specific cohort of patients deemed as very high risk of progression to severe disease and/or death if they develop COVID symptoms and test positive for the virus. The service was funded 2022/23 on a non-recurring basis for 1 year through the three HSCPs at an annual running cost of £256k. People identified as potentially eligible have been notified by letter with information on how to access this treatment locally as part of their care. There is also a facility for patients to self-refer or via their GP if they think they are eligible for treatment. Some of the treatment options must be started within the first five days of when people start to have COVID symptoms so it is important eligible patients are referred into the service at the earliest opportunity. As at the end of December 2022, 1784 patient referrals had been received into the service with 901 going onto to receive treatment. Following treatment, only 10 of the 901 patients then went on to be admitted to secondary care services for further care specifically for COVID-19. The COVID-19 Therapeutic Service is delivered by a cohort of clinical (mixed skill level) and admin staff 7 days a week. Recent recruitment was undertaken to strengthen the clinical workforce during the winter period which is funded until March 2023. Due to these being only temporary fixed term posts, the team struggled to recruit to a sustainable workforce, with clinical staff from other areas being used to fill the gaps. Further work is required to understand the future need and funding requirements for this service. 3.2 National Hub - Sexual Assault Response Coordination Service (SARCS) self- referral service – following a successful bid late 2021, AUCS was selected as the national hub for all SARCS self-referrals Scotland wide, working in collaboration with NHS 24. The National Hub went live in April 2022 receiving referrals from NHS 24 with 24/7 access so that all referrals, regardless of where the person is in Scotland is managed in a timeously and in a safe way. The Hub ensures that all referrals from NHS 24 are triaged and directed to the appropriate Board pathway and are handed over using a consistent process to the appropriate SARCS regardless of what operational model a health board operates. The Hub operates as a back office function without the need to speak to the person self-referring into the service. Due to the National Hub being a new service, all Hub staff required to be trained with SOPs and frameworks developed to support the processes and systems. A total of 274 referrals have been processed by the National Hub between 1 April and 20 December (241 x acute; 28 x historic; 5 x 13-15yr old). Strong positive relationships have developed with NHS 24 and national SARCS Policy Unit colleagues within Scottish Government through regular engagement to share learning, identify emerging issues with solution focussed discussions.
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Embedding the Hub within an already established service has benefitted from established systems and processes already in place to support incidents and resilience. The email process for sending all referrals to Boards has proved successful and consistent. Most Boards who have received referrals are now familiar with the requirement to confirm receipt of referrals by email for assurance of hand-off. The initial funding proposal for Year 1 for the National Hub was £76.5k. Project implementation arrangements to develop the Hub model and service have been provided by Ayrshire and Arran as the host Board whilst activity was understood. Non- recurring funding of £47.5k has been agreed for 2xWTE Band 2 call handlers (1.9.22 to 31.3.23) within the existing host service to allow resilience and flexibility and also enable a greater understanding of the service demand over Year 1, a saving of approx. £30k from initial projections. Demand has grown each month and there are ongoing discussions with Scottish Government to determine future resource requirements for 2023/24. 3.3 Redesign of Urgent Care Programme – Update on Phase 2 Implementation Throughout 2022 the service has been developing and embedding Phase 2 key priorities that build on the earlier de Minimis specification to deliver six principles of care via the FNC. The main aim is to reduce the number of ‘touch points’ a patient has when navigating through the system for an urgent care need. The FNC supports a number of pathways to wrap the professional services around the patient with an average 1644 calls per month over and above OOH activity. It is noted that only 25% (411) of the calls received via FNC attend hospital within 48 hours. The remaining 1,233 are assessed and treated with via services within AUCS or navigated back to community services. This has also been linked to the sustained reduced level of ED attendances post pandemic. The FNC operates with one clinician and call operator 8 am – midnight 7 days per week. The model fully integrates with the wider OOH team during the OOH period. Moving to a 24/7 service with multiple pathways there was also a requirement to increase the shift team managers to ensure sufficient management oversight during shifts as well as increased clinical support to ensure the pathways operate efficiently and safely. The additional running costs for the 24/7, 7 days per week service is £750k. This was funded in 2022/23 from non-recurring IJB reserves set aside to support implementation of the urgent care programme. An overview of the new pathways are noted below. Care and Nursing Home Pathway - provides direct access to the FNC within AUCS during the OOH period as an alternative to the NHS 24 process to expedite the management of Care Home residents’ care, and to reduce any delay with using the NHS 24 route. This replicates the service provided to care and nursing homes in-hours Monday – Friday via their own GP Practice.
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This pathway was introduced following a detailed data review identifying that staff were being held up on the phone to NHS 24 for long periods of time as well as a large number of care and nursing home residents were being directed to Scottish Ambulance Service following an NHS 24 assessment. From January 2022 there has been 2632 direct calls to the FNC for clinical advice/assessment. Referral process in place for GP Practices to schedule minor injury appointments via the FNC where patient transport can also be arranged. This has reduced the number of ambulances being requested and the majority of patients are seen within the minor injuries unit around their appointment time therefore reducing the crowding in EDs. There have been 905 GP Practice referrals to the FNC since January 2022, which also includes any referrals from GP Practices to request a revisit or patient follow up from a clinician in the OOH period. Community Pharmacy - a dedicated professional to professional pathway into AUCS in the OOH period should a patient present at community pharmacy and the Pharmacist is unable to fully treat them or needs support from a senior clinical decision maker from FNC. If a senior clinical decision maker is not available a call back for the patient will be arranged within an agreed timeframe with the pharmacist. Prior to this pathway, patients would normally be directed to NHS 24 if community pharmacy are unable to help therefore reducing the amount of services the patient has to navigate through. This pathway is still in development with learning gathered routinely – a total of 614 patient referrals have been received into FNC from Community Pharmacy to the FNC OOH to date. Emergency Services Mental Health (ESMH) pathway - was fully launched on 30 May 2022 following a successful pilot in early 2022. SAS and Police Scotland refer mental health related calls which do not require emergency medical intervention to the FNC. This process involves the FNC facilitating the call to the Emergency Mental Health Team for initial assessment which includes conversations with the referrer and the patient, after which a joint decision is made about whether an in-person mental health assessment is needed, either at the patient’s own home or a specific location within the community. This is a more individualised and person-centred approach, providing the right care in the right place at the right time, and reduces pressure and capacity on Police Scotland, SAS and the ED teams as well as the opportunity for ongoing follow up within the community. A total of 748 calls were received at the FNC and routed to the Emergency Mental Health Team from Police Scotland or SAS. These patients would otherwise have formerly been conveyed to the EDs by Police Scotland or SAS colleagues which was not always the most appropriate place for the specific care needed by these vulnerable individuals. The new pathway is the first in Scotland to be embedded within the FNC and has gained national recognition and interest from other NHS Boards. NHS Ayrshire & Arran continues to promote the pathway and work across national improvement networks to refine and enhance the service.
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Scottish Ambulance Service (SAS) Pathway - this can be accessed by SAS crews attending calls or reviewing calls on their dispatch screens to consider what input and support the FNC could provide. This might also provide an option to discuss other potential pathways for patients. It is noted that many calls that come via SAS have very similar acuity to those that already come from NHS 24 to AUCS for clinical assessment. Throughout 2022 AUCS has also been attending to confirm life extinct non-suspicious deaths for SAS and Police Scotland to support our emergency services prioritise life threatening conditions. When SAS refer to the FNC for advice, this results in any of the following scenarios: • A conversation between the crew or referring paramedic to agree outcome • A full remote clinical consultation between the patient/carer and the GP • Some calls are referred over to the FNC and closed allowing SAS crews to move to their next call. • SAS notifies all patients that their call has been passed to the FNC for follow up and a clinician will contact them within one hour (on average patients/crews are contacted within 20 minutes). Following contact with the FNC, various outcomes for the patient are identified which can include: • No further assessment needed: • A GP at issuing a prescription which can be collected directly at the local pharmacy • The patient appointed for an in-person consultation at a Primary Care Treatment Centre • Referral to another community service, including district nursing, integrated care teams, hospital at home, and respiratory service • A home visit by a GP facilitated by the FNC or direct referral to the local ED or Combined Assessment Unit. The SAS pathway has been a working progress since spring 2021 with the implementation escalated over the festive period in 2021 to support contingency plans at the hospital front door and improve patient journeys. From December 2021 to December 2022 there were 1730 referrals to AUCS from SAS, of which only about 10% went on to be referred to hospital as final outcome. Approximately 90% of referrals didn’t require a SAS crew to convey to the hospital front door. There is an additional benefit involving the FNC as the AUCS Clinicians are able to access hospital clinical systems, emergency care summary, and previous encounters with AUCS to try build the bigger picture for each patient and assess the risk on an individual basis.
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Normally any SAS contact with patients is not reported back to general practice whereas all referrals logged via the FNC are recorded via the FNC clinical system (Adastra) and reported back to general practice. This allows visibility for the GP Practice to follow up where appropriate. SAS clinicians have fed back they feel positive about the joint working which not only improves the patient journey, but supports staff to get their meal breaks and end shift at the appropriate times. AUCS clinicians shared that they recognise how their input and the service is facilitating an improved patient journey and supporting patients to be treated in their homes or having end of life discussions where more appropriate, as opposed to referring to hospital. This SAS model is now fully integrated into AUCS as business as normal. 3.4 Anticipated Outcomes The main aim for AUCS is to provide a prompt and seamless experience for citizens across Ayrshire and Arran as well as an opportunity to schedule an appointment or home visit when necessary. Clinicians and administration staff within the service feedback on a daily basis that patients are happy with their outcome either when they receive a scheduled appointment or are directed to the right service first time, and often at home. Continue to sustain the core OOH service and clinical engagement from our local clinical workforce to ensure we are learning and improving from the current service delivery model. It is noted through the data that demand, overall activity and patient need for urgent care has changed, and continues to change on a regular basis. The learning to date offers important opportunities seen in the context of the aim of the Caring for Ayrshire programme which is to design a fully integrated system wide approach to ensure people are able to access the right care at the right time in the right place. 3.5 Measuring Impact Continuous review of all new pathways is undertaken to evaluate impact and effectiveness to ensure improved patient journeys. Work will also progress under the RUC vision collaborating with acute and community professionals to identify areas of improvement which will benefit citizens of Ayrshire and Arran to access appropriate care at the point of contact wherever possible. 4. IMPLICATIONS 4.1 Financial The AUCS GP OOH budget was originally set in 2016/17 based on activity at that time.
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Despite the gradual increase of activity (now 20% in 2022) the service has continued to manage within budget, working efficiently and re-designing where possible using data and trends to match the required workforce to demand. Due to additional unfunded public holidays in 2022, increasing GP pay rates, and an increased workforce required during December 2022 to cope with demand this has been more challenging in year. The main clinical system (Adastra) used within AUCS was impacted by the national cyber-attack and was offline fully for five weeks during August to September. This required manual workarounds and increased clinical capacity to safely manage the demand. The system has only recently gone fully live again in December 2022. There is confidence the service will still end the year within budget due to other vacancies in the management team, but with consideration required for future years funding to match winter demand in particular. A full business case will be developed in collaboration with other system partners and acute services to determine the future of the FNC model beyond 31 March 2023 and funding to support this. A review of the COVID-19 Therapeutics Service is currently ongoing to understand future resource requirements beyond 31 March 2023. Funding confirmation is required from Scottish Government regarding the 2WTE call handlers required to support the National Hub SARC model. This has been covered with extra hours during 2022/23 with clarity required on sustainable funding. 4.2 Human Resources The medical workforce across AUCS has stabilised over recent years and even with the introduction of new pathways maintains good cover provision. Like most OOH systems across Scotland the GP workforce is built on a GP sessional volunteer rota. The clinical roles offered within AUCS offers variety supporting the various pathways which has supported attracting new GPs and ANPs to the service. Recent developments has saw the senior management workforce model strengthened along with a wider multi-disciplinary team approach to deliver core urgent care services to patients. A number of staff supporting the FNC and delivery of the COVID-19 therapeutics are current staff doing additional hours, booked bank shifts or fixed term contracts. Time has been invested training and developing clinical and non-clinical staff over the last 12-24 months. If these service delivery models continue beyond 31 March 2023 it would be recommended permanent posts are advertised to recruit and attract the workforce required. Recruitment to fixed term posts has been unsuccessful to date.
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4.3 Legal None. 4.4 Equality/Socio-Economic Changes to how urgent care services are accessed may positively impact patients who have reduced mobility or multi co-morbidities where travel can be difficult as there will not be a need to travel and the infection risk will be reduced. Current and future users of urgent care will continue to access all services through NHS 24 / 111 route. This will ensure patients are seen in the right place with the right team at the right time. Access will remain unchanged for all emergency care needs and access to GP will remain unchanged. The additional pathways also allow for more seamless care patient health and care professionals for patients who try to access urgent care rather than patients trying to navigate various systems or having various ‘touch points’ across the system. 4.5 Risk Like most other NHS Boards, the ability to fill sessional GP shifts remains a consistent risk to service delivery. By utilising a multi-disciplinary clinical team providing OOH services along with the recruitment of GPs with Extended Roles who work between primary and urgent care, this core workforce mitigates the risk of solely using sessional GPs. There is a risk to the future of the FNC model and impact on the hospital front doors if sustained funding can’t be identified beyond 31 March 2023. The business case will outline the benefits and impact of the FNC to reduce attendances to the ED as well as avoiding unnecessary admissions to hospital. 4.6 Community Wealth Building The wellbeing of people and communities is core to the aims and successes of Community Planning. Ensuring we deliver the right care in the right place at the right time, is an integral part of the Wellbeing Delivery Plan, Integration Authorities Strategic Commissioning Plan of both the NHS and Council, will contribute to support this wellbeing agenda. 4.7 Key Priorities The strategy and programme outlined in this report will assist the IJB to deliver the following Strategic Objectives from its Strategic Plan to: • Provide early and effective support • Improve mental and physical health and wellbeing • Develop and support our workforce
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5. CONSULTATION There is an ongoing commitment to engage with the public and wider services on the pathways available within AUCS. How to access the services via NHS 24 111 is widely publicised on television, radio social media and community venues. National and local messaging is also continuously issued across all platforms to our communities to ensure people are directed to the Right Care, at the Right Time in the Right Place. The teams within AUCS also actively engage with and seek the assistance of the wider services with pathway design and expand the use of the use of the FNC as a central hub for intersecting services. The team is fully engaged with the National Urgent and Unscheduled Care Collaborative and work is ongoing to enhance a number of pathways at pace through this programme. Vicki Campbell Head of Primary and Urgent Care Services Vicki.campbell@aapct.scot.nhs.uk 19 January 2023