Unplanned and Urgent Care in the NHS

The efficient management of unscheduled care across NHS Scotland is predicated upon a clear, hierarchical taxonomy of patient need and an effective system architecture designed to match clinical acuity with appropriate resources. This system, which provides for the urgent and unscheduled care needs of the population through a variety of services including GP practices, minor injury clinics, and pharmacy treatment , has recently undergone significant structural reform.

1.1 Establishing a Foundational Taxonomy of Unscheduled Care

The necessity of defining urgency stems from the need to ensure that life-saving resources are preserved for critical events while less acute needs are managed promptly to prevent deterioration.

Defining Acuity Levels

The highest level of clinical need is designated as Emergency Care. This category covers health and wellbeing issues that present an immediate risk of significant or permanent harm, or death, if intervention is not delivered instantaneously. Such conditions demand access via the 999 emergency services or immediate presentation at a Type 1 Emergency Department (A&E).

The second key category is Urgent Care, often referred to as Unscheduled Primary Care (UPC). These are issues that must be dealt with quickly to prevent significant or permanent harm, typically requiring resolution within the next 8 hours. This classification is crucial for addressing less serious conditions that will nonetheless get worse if left untreated, particularly outside of standard working hours (OOH), such as during the night or at weekends when routine healthcare services are unavailable. The expansive definition of unscheduled care, which ranges from severe life-threatening conditions to minor injuries and conditions that are merely inconvenient but progressive if left unmanaged , necessitates the complex, multi-tiered response established by the NHS.

1.2 The Redesign of Urgent Care (RUC) Pathway: Rationale and Objectives

The structural complexity of UUC was formally addressed through the Redesign of Urgent Care (RUC) pathway, launched in December 2020. This policy was required because traditionally, Accident and Emergency (A&E) was viewed by the public as the primary, and often sole, location to receive urgent and unscheduled care. For many patients, the A&E will not be the most appropriate place for their healthcare need, leading to unnecessary pressure on acute services.

Core Objectives of the Redesign

The core objective of the RUC is to improve patients’ access to urgent care by encouraging members of the public to first contact the NHS 24 111 service for non-life-threatening situations. This centralized contact point is intended to better direct patients to appropriate support, operating under the "Right Care, Right Place" doctrine. The dual goals are to offer care closer to home and to reduce overcrowding and persistent waiting times in critical emergency departments.

The evaluation of the RUC pathway captured patient and staff experiences, enhancing the understanding of successes and areas for improvement. Notably, the necessity for new service delivery methods during the COVID-19 pandemic demonstrated the utility of digital platforms, such as video calls, in providing access to a range of NHS services alongside traditional face-to-face care.

While the RUC strategy aims to filter demand away from acute settings, statistical review indicates that the policy has encountered significant challenges in achieving its desired systemic impact. The policy intent, focused on establishing an efficient triage filter at the front door , has not been matched by a concurrent reduction in downstream performance failures, as demonstrated by A&E compliance remaining below 80% since summer 2021. This suggests that although the initial triage pathway benefits users who successfully secure appointments , the overall acute system remains overwhelmed by fundamental capacity limitations, an issue often termed "exit block." The efficacy of the RUC triage mechanism is thus highly dependent on the resilience and capacity of the downstream primary and acute care services it directs patients toward.

Architecture of Decentralized and Acute Urgent Care Provision

The unscheduled care architecture is multilayered, distributing care delivery across primary, community, and acute settings, with differentiated roles for each unit based on the severity and nature of the patient’s complaint.

2.1 The Role and Capacity of Primary Care Out-of-Hours (OOH) Services

Primary Care Out-of-Hours (OOH) services are integral to managing unscheduled needs that occur when general practice is closed, addressing urgent medical treatment that cannot reasonably wait until the GP practice opens.

Operational Structure and Access

The OOH service maintains a structured operational schedule, running from 6:00 pm to 8:00 am during the week, and operating continuously (24 hours a day) throughout weekends and on public holidays. Access is strictly regulated: patients must contact NHS 24 on 111 first, as the OOH system does not permit walk-in presentations.

Initial assessment is conducted by NHS 24, and if further clinical assessment is required, the case is passed to the OOH service. Service delivery is robust and includes consultations at Primary Care Emergency Centres (PCEC), Home Visits, and telephone or video advice. For instance, Primary Care OOH services typically handle around 5,600 consultations per day over a standard weekend. Depending on the severity of symptoms, the clinician review may result in advice for managing symptoms at home, referral to a local pharmacy, an allocated appointment to attend an out-of-hours centre, or a home visit if the patient is elderly or frail. It is crucial to remember that OOH services are not designed for routine healthcare matters.

2.2 Hospital-Based Urgent Care: MIUs, UTCs, and A&E Distinction

The acute sector distinguishes between core Emergency Departments (Type 1) and Minor Injuries Units (MIUs, categorized as Type 3) to stream care based on acuity.

Minor Injuries Units (MIUs)

MIUs are tailored for the assessment and treatment of injuries that are non-life-threatening but often painful, such as strains and sprains, wounds and minor burns, simple eye injuries, minor bumps to the head and face, and insect bites.

MIUs are predominantly staffed by specialist nurse, paramedic, and physiotherapy practitioners, employing a multidisciplinary team (MDT) approach. This strategy is foundational to resource efficiency, maximizing the treatment of predictable minor trauma without engaging highly scarce medical consultant time. Staff noted the growing importance of the increasing role of paramedics in providing a clinical assessment, which adds a crucial "filtration" capability to the triage process, ultimately benefitting Type 1 A&E departments.

MIU access is managed: patients must call 111 first to secure an appointment, which may be a video or a face-to-face consultation. MIU opening hours vary by site and board (e.g., 8:00 am–11:00 pm at the Royal Infirmary of Edinburgh, or 9:00 am–9:00 pm in Lanarkshire and Forth Valley).

Emergency Departments (A&E)

Emergency Departments (Type 1 Core EDs) are reserved for critical emergencies and life-threatening situations, operating 24/7 with consultant leadership and full resuscitation facilities. Examples of conditions mandating 999 or immediate ED attendance include unconsciousness, heavy blood loss, suspected heart attack or stroke, deep wounds, severe injury, and difficulty breathing. If patients self-present at A&E with minor problems, they risk preventing others with critical emergencies from receiving immediate care and may be redirected to a more appropriate service.

While some urgent care centres (UTCs) elsewhere in the NHS are mandated to operate for a minimum of 12 hours a day, 7 days a week, and report as Type 3 services against the 4-hour A&E standard , the Scottish system heavily utilizes the MIU model, with centralized triage via 111 streamlining patient flow to these units.

2.3 The Acute Avoidance Strategy: Hospital at Home (H@H)

A key structural component designed to improve flow in the acute sector is the Hospital at Home (H@H) program. This model provides acute-level care within the patient’s residence, serving as a vital mechanism for acute avoidance. H@H extends across specialized complex areas, including general care for older people, community respiratory services, Outpatient Intravenous Antimicrobial Treatments (OPAT), heart failure, and paediatrics. By successfully managing these patients in the community, the program prevents unnecessary admissions to scarce acute beds, directly addressing the systemic congestion that often manifests as prolonged A&E waiting times (the "exit block").

The Central Triage Mechanism: NHS 24 (111) Performance and Integrity

The entire Redesign of Urgent Care rests upon the integrity and effectiveness of the central triage system, NHS 24 (111), which acts as the mandatory gateway for unscheduled care that is not life or limb threatening.

3.1 NHS 24 (111) as the Single Non-Emergency Gateway

NHS 24 (111) serves as the core provider of digital health and care services, offering symptom checkers and advice, while also serving as the primary telephone point of contact for urgent needs when primary care is closed. This includes access to GP Out-of-Hours service, urgent dental care after 6 pm , and immediate mental health support.

The evaluation of the RUC pathway confirmed the positive impact of this streaming model for those who successfully navigated it. Patients whose call to 111 resulted in an appointment being booked at an A&E site or a Minor Injury Unit reported experiencing significantly shorter waits compared to those who arrived unannounced. This confirms that the proactive scheduling and management of patient flow via centralized triage is an effective method of mitigating overcrowding and improving individual waiting times. Furthermore, patients reported high levels of satisfaction with staff interaction, with 86% confirming that the person they spoke with at NHS 24 111 ‘definitely’ listened carefully.

3.2 Analysis of Service Coordination and Operational Gaps

Despite the documented success of the triage process itself, the efficacy of the entire pathway is jeopardized by operational failures in downstream coordination. Clinical staff working within the system noted a persistent operational contradiction: there are times where the triage process directs a patient to a service that is, in fact, not available to provide the intended care. This results in a breakdown where the patient may wait for contact from a unit, such as a minor injuries clinic, which has not been properly informed of the referral or is temporarily unstaffed.

This deficiency in real-time coordination and service availability introduces two major systemic risks. First, it causes immediate delays in providing care to patients in need. Second, and perhaps more critically, the failure to deliver the promised service after a patient has complied with the "Call 111 First" mandate fundamentally erodes public confidence in the RUC pathway. When patients follow the correct procedure but encounter a non-existent or failed service pathway, they are likely to revert to the most reliable method of access: bypassing triage and self-presenting at A&E, which was the very congestion point the RUC was designed to alleviate. Sustained public trust requires guaranteed service availability following triage.

Furthermore, the integrity of the pathway depends entirely on the initial assessment. Participants highlighted the immense complexity and significant risk-management challenges inherent in the triage process. There is a recognized need to ensure that staff performing these high-stakes triaging roles possess the appropriate skills to avoid suboptimal prioritization decisions and ensuing delays.

Specialized Urgent Care Pathways and Demand Diversion

A core strategy within the RUC is the development of dedicated, specialized access pathways to manage highly specific, complex, and high-volume needs that are unsuitable for a general ED setting.

4.1 Mental Health (MH) Crisis Intervention

Unscheduled mental health care has been significantly structured under the RUC through the development of the 24/7 Mental Health Hub, accessible via the 111 service. This Hub provides a compassionate, continuous response for anyone requiring mental health support when their routine GP or usual mental health service is closed.

Structure and Integration

The Hub is staffed by specially trained psychological wellbeing practitioners (PWPs) and mental health nurses (MHNs), providing a dedicated, expert MDT approach. They offer listening, advice, and can connect individuals with a range of both NHS and charity organizations for further help. Common reasons for contacting the Hub include thinking about suicide, feelings of despair, anxiety, low mood, depression, psychosis, and self-harm.

Critically, the development of the award-winning Enhanced Mental Health Pathway has formalized integration with frontline emergency services, allowing Police Scotland and the Scottish Ambulance Service (SAS) call centres to direct non-life-threatening mental-health-related calls directly to the Hub. This highly effective de-escalation mechanism ensures that vulnerable individuals receive the most appropriate care from the right professional, avoiding unnecessary transportation to A&E, which is often ill-equipped to provide immediate specialized psychiatric assessment. The Hub model, which combines centralized triage with dedicated 24/7 specialized MDT support, provides a blueprint for building system resilience against complex, non-physical health presentations.

4.2 Urgent Dental and Accessibility Services

Similar centralization efforts have been applied to urgent dental care. If a patient is registered, they should contact their own Dentist during normal working hours (Monday to Friday, 9:00 am to 6:00 pm). However, outside these hours, urgent dental issues are managed by calling NHS 24 on 111. This centralized process also caters to unregistered patients who develop severe pain or swelling, though they may need to contact specific centres in hours and rely on 111 out of hours. The service provided in these urgent dental pathways is limited strictly to immediately necessary treatment.

Additionally, equitable access to UUC is maintained through robust accessibility provisions via NHS 24. These include the use of the free interpretation service Language Line for non-English speakers, the BSL interpreting video relay service Contact Scotland BSL, and options for textphone users.

Performance Analysis: The Crisis in A&E Waiting Times

The effectiveness of the RUC pathway in protecting acute services must be measured against the prevailing statistical data on A&E performance, which reveals a system under chronic and intensifying strain.

5.1 Analysis of the 4-Hour Access Standard

The cornerstone of NHS performance monitoring is the 4-hour access standard, established in 2007, which requires that 95% of patients are seen and subsequently admitted, discharged, or transferred within four hours across all A&E sites.

Persistent Failure

Statistical evidence confirms a protracted and systemic failure to meet this target. Compliance has remained below 80% since summer 2021. The latest monthly figures highlight the severity of this deficit: out of 141,865 A&E attendances, only 67.8% (96,226 patients) achieved the 4-hour target. This recent compliance rate (67.8%) marks a slight decrease from the preceding month (68.9%) and is consistent with the monthly average for the reporting year (68.4%).

The trend indicates that, despite the strategic intent of the RUC to divert non-critical patients, the acute system has been unable to absorb the remaining critical demand efficiently, leading to a long-term decline in performance against the access standard.

5.2 Quantifying Severe System Strain: 8-Hour and 12-Hour Breaches

While the 4-hour target measures efficiency, the metrics for 8-hour and 12-hour breaches quantify patient harm exposure and severe system strain. Prolonged stays in Emergency Departments are strongly correlated with increased morbidity and mortality risks.

Breach Data: All A&E Sites (Type 1 and Type 3)

Across all A&E sites, the number of prolonged waiting times remains critically high:

• Over 8 Hours: 15,821 patients (11.4%) spent more than 8 hours in A&E.

• Over 12 Hours: 6,609 patients (4.8%) spent more than 12 hours in A&E.

Acuity Concentration in Type 1 Emergency Departments

The performance metrics are significantly worse within the 30 core Type 1 Emergency Departments, which manage the highest acuity and most complex patients. In a recent weekly period, only 61.5% of attendances met the 4-hour target. The breaches for critical stays were alarming:

• Over 8 Hours (Type 1): 4,273 patients, representing 15.9% of total attendances, spent more than 8 hours in a Type 1 Department.

• Over 12 Hours (Type 1): 2,007 patients, equating to 7.5% of total attendances, spent more than 12 hours in a Type 1 Department.

The analysis of these severe breach metrics demonstrates a fundamental issue within the acute system flow. If the RUC pathway is successful in filtering out low-acuity demand, the patient cohort remaining in Type 1 EDs should overwhelmingly require admission or complex intervention. The fact that 7.5% of these high-acuity patients are enduring delays exceeding 12 hours proves that the primary failure is not at the front door (triage), but rather in the acute hospital's capacity to admit and process these critical patients. This outflow congestion, where admitted patients cannot move to wards due to a lack of available beds or timely social care packages, acts as a severe impediment to emergency flow, rendering the ED a holding space for acute system failure.

Conclusions and Recommendations

The expert analysis confirms that NHS Scotland has designed a sophisticated unscheduled care pathway intended to divert non-critical demand away from strained acute services. However, the system faces critical challenges arising from coordination failures and, most significantly, a profound deficit in acute and intermediate capacity, which is preventing successful patient flow. The failure to meet the 4-hour A&E standard (compliance below 80% since mid-2021) and the unacceptably high rate of 12-hour breaches in core EDs (7.5%) necessitate immediate, structural policy responses focused on capacity and integration.

6.1 Strengthening Triage Integrity and Service Availability

The centralized triage mechanism must operate with guaranteed operational integrity to maintain public trust and prevent the regression to A&E self-presentation.

1. Mandatory Real-Time Capacity Management: To eliminate the dangerous scenario where patients are directed to services that are unavailable , a mandatory system of real-time capacity and appointment slot availability feedback must be implemented, linking all downstream services (MIUs, OOH centres, specialized hubs) directly to the NHS 24 111 system.

2. Professional Development for Triage Staff: Given the significant clinical complexity and risk associated with initial assessment and prioritization decisions , dedicated and compulsory professional development programs must be established to elevate the clinical decision-making skills of staff performing triaging roles.

3. Data Harmonization: Efforts to standardize the definitions and recording methodologies for 'cases' and 'consultations' across all NHS boards must be accelerated to ensure that performance metrics and trend analyses (such as those for Primary Care Out of Hours) are reliable for future resource allocation.

6.2 Investment in Acute Avoidance and Flow Mechanisms

Addressing the severe outflow congestion driving 12-hour A&E breaches requires strategic investment outside the Emergency Department itself, focusing on expanding acute avoidance capacity.

1. Scaling Hospital at Home (H@H) Services: The H@H model must be significantly scaled across all specialities (including OPAT, respiratory, and frailty) to rapidly create functional bed capacity in the community, thereby alleviating the acute admission pressure that leads to exit block and A&E delays.

2. Formal Implementation of Regional Urgent Care Hubs: The analysis suggests the high-resilience model of dedicated, specialized MDT hubs , similar to the successful Mental Health Hub , should be formalized. These regional centres, drawing on paramedics, pharmacists, and physiotherapists, are necessary to manage fluctuating regional demand and provide the structural resilience lacking in fragmented, local services.

3. Maximizing Multidisciplinary Workforce Deployment: The effectiveness of the UUC system is intrinsically linked to the specialist MDT workforce (nurses, paramedics, physiotherapists) utilized in MIUs and triage. Strategic workforce planning must ensure sufficient supply and deployment of these practitioners to maximize the filtration effect and reduce the reliance on physician-led acute care for manageable urgent conditions.

6.3 Strategic Policy Shift

The current performance metrics demonstrate that policy focus must expand beyond front-door triage to encompass system-wide flow.

1. Revising Performance Metrics: While the 4-hour target remains important, future policy assessment must place equivalent, measurable weight on reducing 8-hour and 12-hour breaches. The persistent failure at these higher breach levels indicates that the challenge is now one of acute hospital management and discharge pathways, requiring a shift in policy intervention away from solely demand management.

2. Replicating Specialized Success: The structural success of the 24/7 Mental Health Hub provides a clear model for managing other high-volume, complex patient cohorts that inappropriately consume ED time. The establishment of dedicated, specialized frailty assessment or ambulatory emergency care pathways, separate from Type 1 EDs but integrated via the 111 gateway, is essential for filtering complex demand.

FAQ Section

Q: What is unplanned care? A: Unplanned care refers to unexpected medical services, often due to accidents, sudden illnesses, or exacerbations of chronic conditions.

Q: What is urgent care? A: Urgent care addresses medical needs requiring prompt attention but not immediately life-threatening.

Q: How has the demand for unplanned and urgent care services changed? A: The demand for unplanned and urgent care services has significantly increased recently, with notable rises in GP appointments and A&E attendance.

Q: What challenges does the NHS face in delivering unplanned and urgent care services? A: Challenges include increasing demand, record hospital bed occupancy rates, delays in discharging patients, and variations in service performance across regions.

Q: What innovations is the NHS implementing to improve unplanned and urgent care services? A: Innovations include technological advancements like AI tools, workforce and capacity building, and implementing Integrated Care Systems (ICSs).

Q: What is the role of Integrated Care Systems (ICSs) in unplanned and urgent care? A: ICSs coordinate and deliver unplanned and urgent care services by bringing together the NHS, local councils, and other partners to improve health and care services in their area.

Q: How is the NHS using data tools to predict urgent medical needs? A: The NHS uses data tools to understand and predict people’s urgent medical and care needs, allowing for proactive support and targeted interventions.

Q: What is the impact of the COVID-19 pandemic on unplanned and urgent care services? A: The COVID-19 pandemic has exacerbated challenges in unplanned and urgent care services, leading to increased demand and decreased productivity and patient satisfaction.

Q: What steps is the NHS taking to improve patient experiences in urgent and emergency care? A: The NHS has implemented a two-year plan with funding to improve patient experiences by increasing capacity, growing the workforce, improving discharge processes, and joining up care outside of hospitals.

Q: How can digital solutions enhance access to NHS services? A: Digital solutions like video calls and other technologies can enhance access to NHS services, particularly during increased demand or restricted mobility.