6EA Learning Workshop October 2019

1. Rising Unscheduled Care Attendances
Helen Maitland
Unscheduled Care Director

2. A&E attendances for Scotland
(core sites only)
week ending, 2016/17 to 2019/20
Source: Scottish Government Unscheduled Care Database, Management Information.

4. Rising Attendances
• Attendances at A&E have increased by 63,750 in last 2
years.
• rise of 4.8%.
• The majority of people who attend A&E self-refer, and
the volume of self-referrals have increased by 3.6%
• There has been a substantial increase in attendances
from 0-4 years old age groups.
• The increase has been seen across all hours of the day
and not just out of hours period
• More people were admitted, discharged or transferred
within 4 hours in this calendar year so far, when
compared to the equivalent period in 2018
• for both all and core sites

5. Scotland wide
• The level of increase varies across hospital sites and
health boards; the biggest increases in attendances
over the past two years are seen in:
• NHS Highland - up 7.9%
• NHS Greater Glasgow & Clyde - up by 7.2%
• NHS Fife – up by 7.1%
• NHS Lanarkshire – up by 6.8%
• Only two of the eleven mainland boards have seen a
decrease in attendances over the past two years; NHS
Dumfries & Galloway with a fall of 3.5% and NHS
Ayrshire & Arran with a fall of 2.0%.
• These two boards have seen changes to the configuration
of their hospitals and introduction of assessment units for
GP referred patients, who previously would have followed
an A&E pathway.

6. Age of Referrals
In the last year, we have seen
increases in A&E attendances in
all age groups.
The largest increases in A&E
attendance by age have been
seen in:
• 35-39 (5.4%)
• 60-64 (7.1%)
• 70-74 (5.8%).
However, per rate of 1,000
population the highest increases
are seen:
0-4 (5.2%)
15-19 (4.8%)
60-64 (4.7%).
While rates increased for all age
groups those associated with
the 85+ had the lowest increase.
2017-18* 2018-19** %change 2017-18* 2018-19** %change
0-4 126,859 130,957 3.2% 450 473 5.2%
5-9 64,950 65,577 1.0% 215 218 1.3%
10-14 70,708 72,745 2.9% 252 253 0.1%
15-19 77,292 79,478 2.8% 266 279 4.8%
20-24 91,485 93,115 1.8% 257 266 3.5%
25-29 87,323 89,481 2.5% 228 234 2.4%
30-34 78,964 81,860 3.7% 222 227 1.9%
35-39 71,793 75,656 5.4% 212 217 2.7%
40-44 64,459 65,347 1.4% 198 206 3.8%
45-49 74,295 73,921 -0.5% 193 197 2.4%
50-54 79,511 81,271 2.2% 195 201 2.8%
55-59 73,528 77,223 5.0% 194 200 2.9%
60-64 63,116 67,576 7.1% 192 201 4.7%
65-69 59,484 61,170 2.8% 195 204 4.4%
70-74 61,015 64,569 5.8% 235 238 1.4%
75-79 56,758 58,594 3.2% 301 307 1.7%
80-84 53,016 55,114 4.0% 384 393 2.2%
85+ 62,266 63,179 1.5% 511 512 0.2%
Not known 31,783 31,969 0.6% N/A N/A N/A
Total 1,348,605 1,388,802 3.0% 249 255 2.7%
*From w/e 02/04/2017 to w/e 25/03/2018
**From w/e 01/04/2018 to w/e 24/03/2019
Age band
A&E attendances Rate per 1,000 population
Number of A&E attendances and rate per 1,000
population by age group, 2017/18 to 2018/19
Source: A&E data mart, ISD. Management Information.

7. Source of Referral
• Self-referrals to A&E accounted for around 60% of all
attendances.
• Over the last year this cohort of patients has increased by
3.6%. (40,000 people)
• 999 Emergencies accounted for 20% of all A&E
attendances in 2018/19.
• The number of emergency cases conveyed by SAS increased
by 2.3% over the last year. (from 370,00 to 380,000)
• NHS24 Referrals accounted for 5% of attendances to
A&E.
• There has been an 11.4% increase over the last year and a
6.1% increase in admission in this cohort.
• Only 2% of referrals to A&E comes from GP:OOH.
• There has been an increase of 2.8% from this source in
2018/19. (which equates to under 4,000 referrals from OOH.)

8. Source: A&E data mart, ISD. Management Information

9. Public Attitudes to A&E Attendances
National Centre for Social Research (August 2019)
• The study population believe that A&E (and 999) are over utilised
• largely unnecessarily
• Almost half the population agreed it was hard to get a GP appointment
• People living in deprived areas are more likely to prefer A&E departments over
their GP to get tests done quickly
• find it more difficult to get an appointment with their GP
• think A&E doctors are more knowledgeable than their GPs
• 58% of people with internet access say they would look on line to understand a
problem and 47% would look to find what to do about it.
• young people aged 18-24 were twice as to research their problem
• Parents with children under 5 are more likely to have used an A&E in the last year,
• think it is hard to get an appointment with their GP,
• less likely to trust their GP
• are more likely to use the internet to try to decide what the problem might be.
• Men are less knowledgeable about how to contact a GP out of hours
• less likely to use the internet to research a health problem.

10. Primary Care / NHS24/ SAS
In Hours Primary Care
• Significant redesign
• Focus on MDT working
Out of Hours
• 85% of activity without recourse
for onward referral
• Due to service change – some
reduction in number of
consultation
NHS24
• Call from NHS24 to A&E has risen
from 7.2% to 8.5%
• Assoc with older cohort of users
• Increase calls from SAS – as part
of dual response. Increased calls
back to A&E
• Sepsis protocol
SAS
• Increase See & treat and Hear &
treat

11. Integration
• Health and Social Care Partnerships are invited annually to submit
improvement aims against a set of key measures including number of
A&E attendances.
• Their aims generally focus on attendances in adults (aged 18+)
• although where the Integration Authority has responsibility for children’s
services, they may additionally submit improvement aims for <18/all ages.
• Numbers of A&E attendances in people aged 18+ have increased over the
past few years in most partnerships.
• Similarly, in nearly all partnership areas the total number of A&E attendances in
2018/19 exceeded the totals they had aimed for,
• typically by around 5% but in 6 areas the difference was over 10%.
• Health and Social Care Partnerships have set objectives for the level of
A&E attendances they anticipate in 2019/20.
• Five partnerships have still to offer objectives for this year.
• Assuming those five (which account for about 14% of all attendances)
remain static at 2018/19 levels, the anticipated number of attendances in
adults this year is 1,166,018, a reduction of 2.3% on last year.

12. Mental Health
• There has been a year on year rise in mental health (MH)
attendances at A&E departments; data from ISD shows some
boards have seen an increase in the region of 50% over the last 5
years.
• Data also shows that individuals presenting with MH problems
are, on average, twice as likely to breach the four-hour
Emergency Access Target as those with any other condition
• The general trend over the twelve-month time period 1st July
2018 to 30th June 2019 shows the proportion of MH
presentations compared with general presentations at A&Es
throughout Scotland is significantly higher at almost every
hospital site.
• The Distress Intervention Action Group are working to understand
the cause of attendances and developing interventions to provide
appropriate care closer to home. NHS 24, SAS and Police Scotland
are collaborating on a Mental Health Hub initiative which went
live in March 2019

13. Acute Services
Redirection/Signposting
• Redirection levels are currently around 1-3% of all attendances to other care providers but
this does vary by board and there is work underway to capture this more accurately and
properly quantify inappropriate presentations and options for redirection.
• This will be a key focus to refresh the national guidance and building on successful redirection policies in
NHS Tayside and Grampian.
Social Media Campaign
• To accompany the revised guidance on redirection and signposting we propose to launch a
national social media campaign that will build upon the successful West of Scotland
campaign “Meet the Experts” to promote health care services and alternative care closer to
home.
• This will provide signposting across the year and develop a targeted approach at key pressure points
recognising high attendance dates such as post public holidays.
Managing A&E referrals
• All sites have a mechanism of accepting referrals from GPs SAS and NHS24 via: Hubs, Direct
Professional To Professional triage and nurse led triage services.
• There are many examples of these services successfully redirecting emergency referrals to
urgent or planned with advice, availability of hot clinics and access to consultant advice.
• NHS Tayside Consultant Direct service has implemented a shift of all calls from PRI junior Drs, NHS24,
GP and SAS emergency referrals to consultant led consultation/triage to shift call to urgent or planned
care.
• NHS Lanarkshire have implemented a Consultant led triage service of all referrals from NHS24, SAS and
GP referrals
• NHS Lothian Hub is well established and manages referrals across Lothian hospitals aiming to ensure
optimal flow. Many sites have visited this hub over the past year with review of transferability to other
sites.