NHS GG&C Emergency Department review final report: March 2025

NHS Greater Glasgow and Clyde should improve waiting times in emergency departments. Where waits occur, communication with patients about waiting time length should be improved, both at initial arrival and through frequent updates during the wait. People should be appropriately supported during their wait.

NHS Greater Glasgow and Clyde should undertake specific engagement with people who are actively waiting in emergency departments to better understand the specific information and support people would find valuable while waiting.

NHS Greater Glasgow and Clyde should enable, expect and ensure that all staff involve patients in making decisions about their care.

NHS Greater Glasgow and Clyde should ensure patients are provided with information about their follow-up care, including who to contact if their condition worsens, before leaving the emergency departments.

NHS Greater Glasgow and Clyde should take action to reduce patients’ concerns about personal safety around other patients/visitors in emergency departments to create a safer, more secure environment.

NHS Greater Glasgow and Clyde should provide more opportunities to ask patients about their experience of using emergency departments and clearly demonstrate how this feedback is valued and used to continually drive improvements and shape services.

NHS Greater Glasgow and Clyde should enable and expect all staff to treat patients with dignity and respect and provide suitable surroundings for this to occur.

NHS Greater Glasgow and Clyde, and its six aligned Health and Social Care Partnerships, should strengthen their whole system unscheduled care plan to urgently reduce use of non-standard care areas, improve waiting times and reduce crowding by addressing:
• management of patient flow and redirection
• referral pathways to specialties from within and outwith the emergency departments
• delayed discharges, and
• models of care, same day delivery of care options and consideration of maximising 24/7 services including flow navigation.

NHS Greater Glasgow and Clyde should ensure its escalation and business continuity plans are practical and effective in addressing pressures at each hospital and are implemented across the whole system to ensure there is good awareness and ownership of them by teams across the hospitals. The effectiveness of the plans should be monitored and regularly reviewed through appropriate NHS board governance structures.

NHS Greater Glasgow and Clyde must demonstrate recognition of the low morale, poor wellbeing and moral distress among staff and take actions to address these. This should include engaging with staff in all three emergency departments to identify appropriate improvement actions needed beyond the other recommendations covered in this review.

NHS Greater Glasgow and Clyde must take action to protect the physical safety of staff from aggressive behaviour by patients.

NHS Greater Glasgow and Clyde should identify and make the necessary improvements to the physical environment in the emergency departments at Glasgow Royal Infirmary and the Royal Alexandra Hospital and to staff facilities, including spaces for teams to easily meet, across all three hospitals, to ensure the environment is as safe and supportive as possible for staff and patients.

NHS Greater Glasgow and Clyde must improve its systems for learning about safety concerns including the use of significant adverse event reviews, post-incident debriefs and incident reporting. It must enhance its processes for sharing learning and feedback with staff and making improvements in response to learning.

NHS Greater Glasgow and Clyde should review the risk management processes for emergency departments to ensure they provide an accurate and comprehensive assessment of current risks and steps being taken to mitigate these, with appropriate regular monitoring and oversight. The risks need to reflect the impact on quality and outcomes for patients rather than purely focusing on performance.

NHS Greater Glasgow and Clyde must undertake a comprehensive multi-disciplinary workforce review, utilising the Common Staffing Method, in line with the requirements of the Health and Care (Staffing) (Scotland) Act 2019.

NHS Greater Glasgow and Clyde should prioritise introducing robust systems and processes for the assessment of real time staffing and the escalation and monitoring of severe and recurrent risk, in line with the requirements of the Health and Care (Staffing) (Scotland) Act 2019.

NHS Greater Glasgow and Clyde should ensure that staff are given the time and resources to undertake required training to undertake their role, in line with the requirements of the Health and Care (Staffing) (Scotland) Act 2019.

NHS Greater Glasgow and Clyde’s board must ensure that compassion and respect are at the centre of the leadership culture demonstrated through behaviours that enable the values of NHS Scotland to be consistently upheld.

NHS Greater Glasgow and Clyde should take urgent action to collectively heal the relationships across and within staff groups and sector and corporate management levels. This is a critical step to establish shared responsibility for the delivery of safe urgent and unscheduled care with visible leadership from the corporate management team and strong clinical leadership at a local level. The aim should be to devolve authority and responsibility as much as possible to team leaders at the service level, supported by greater availability, visibility and responsive support from senior and sector leaders. The solutions and outcome should be jointly owned by all involved.

NHS Greater Glasgow and Clyde should commission urgent and credible external mediation within and between Queen Elizabeth University Hospital emergency department professional teams (medical and nursing) and separately for mediation between the professional teams and senior management (sector and corporate) in NHS Greater Glasgow and Clyde to support improved professionalism and team working amongst consultants, nursing staff and management.

NHS Greater Glasgow and Clyde should ensure sector management at the Glasgow Royal Infirmary are engaged and responsive to the needs of staff at the point of care to ensure that patient care and safety receive the necessary management attention and intelligent action.

NHS Greater Glasgow and Clyde should ensure sector management focus at the Royal Alexandra Hospital appropriately balances emergency department performance and flow in line with maintaining and managing the quality and safety of care.

NHS Greater Glasgow and Clyde should ensure job plans appropriately reflect the time and support required to undertake the clinical director, deputy clinical director and clinical lead roles across all three sites.

NHS Greater Glasgow and Clyde should review the appropriate use of the clinical and care governance framework for systematically and consistently escalating serious concerns.

NHS Greater Glasgow and Clyde should strengthen multi-disciplinary input to the clinical governance arrangements as these currently appear to be too reliant on the singular voice and participation of the medical profession.

NHS Greater Glasgow and Clyde should ensure that all staff feel able to speak up and their voices are consistently heard at all levels of management – especially in matters related to safety – and that there is confidence that individuals will be protected, and their concerns acted upon. Specifically, there is a need to ensure that the current NHS Greater Glasgow and Clyde whistleblowing procedures are known, understood, effective and trusted. This is particularly relevant for staff at the Queen Elizabeth University Hospital. It is vital that staff have confidence in the board’s commitment to the National Whistleblowing Standards and the Public Interest Disclosure Act 1998.

NHS Greater Glasgow and Clyde needs to enhance its governance of the operational management of urgent and unscheduled care. This includes ensuring robust documentation, transparency in decision-making, and greater involvement of clinicians in the design and delivery of care.

NHS Greater Glasgow and Clyde needs to adopt a balanced approach to sector leadership, ensuring that the quality and safety of care is not inappropriately overshadowed by other performance targets or financial considerations.

NHS Greater Glasgow and Clyde needs to ensure there is an active engagement and participation across the clinical leadership and wider community in the delivery of the Board’s recently approved quality strategy.

Scottish Government should commission Healthcare Improvement Scotland to lead the development of a national approach to improving the quality and safety of urgent and unscheduled care in NHS Scotland, consistent with the Quality Management System, including the development of national standards in partnership with a range of agencies including the Royal Colleges. This will build on work already commenced by The Centre for Sustainable Delivery and include urgent work needed to work towards eliminating the unacceptable use of non-standard care areas given the risks to patients and the impact on staff. This will require significant national focus and support.

Scottish Government should explore with Healthcare Improvement Scotland how best to gather patient views about experiences of accessing urgent and unscheduled care services and waiting in emergency departments to inform more detailed national recommendations on how to improve the patient experience and shape services for the future.

Scottish Government should engage with relevant national agencies to commission a review of the national guidance for specific health and care demand, capacity escalation and business continuity, which recognises the need to ensure a credible, robust and practical whole system response. This is essential and complementary to the current Multi Agency Major Incident Guidance.

Scottish Government should engage with relevant national agencies to commission a review of the professional advisory committee arrangements in NHS boards to ensure they have a transparent, independent and objective mechanism for the board to consider matters of safety and concern. There is an opportunity to refresh the previous national guidance and make these arrangements clearer and more open for all professions to understand.

Reliable and comparable whole-system datasets are essential to support improvement in urgent and unscheduled care and optimise flow through the health and social care system. Public Health Scotland should be commissioned by Scottish Government to work with other national and local partners with the aim of progressing existing work and further developing datasets that are designed with, and available to NHS boards to support continuous improvement.

The Centre for Sustainable Delivery should strengthen its collaboration with territorial and national NHS boards to engage in improvement activities aimed at:
• Reducing unwarranted variation in urgent and unscheduled care performance to enhance the quality and experience of care, as well as patient outcomes.
• Rethinking access to urgent and unscheduled care to ensure equity and that individuals are treated in the right place, the first time.
• Ensuring appropriate representation, including clinical leaders, in the recently formed Strategic Delivery Groups to drive improvement, set standards, and deliver change.
• Participating in the acute hospital site visit process to ensure that change is driven by clinical teams and tailored to meet the needs of local communities.

NHS Education for Scotland should strengthen and further develop structured development programmes to identify and support clinical and non-clinical leaders in NHS Scotland. These programmes will enable NHS boards to focus on developing whole system multidisciplinary working and relationships which foster innovation, improvement and inclusivity in decisions that explicitly benefit quality of care and patient safety.

NHS Education for Scotland should be supported by Scottish Government to explore the implications, and work towards the shift to whole time equivalent medical trainee recruitment in order to strengthen the learning experience, reduce gaps in service and build a more sustainable, effective medical workforce for the future.

The review has highlighted the critical role of effective and supportive leadership by the NHS Board. It is recommended that the Scottish Government commission NHS Education for Scotland to evaluate the current national and local induction and support arrangements for NHS Non-executive Board Members. This evaluation should aim to identify and implement any necessary improvements to ensure that Non-executive Board Members can perform their roles as effectively as possible, and consistent with the requirements set out in the NHS Scotland Blueprint for Good Governance.

The review has identified that the tools for appropriate staffing levels with regard to emergency departments are not sufficiently robust. Healthcare Improvement Scotland’s Healthcare Staffing Programme should prioritise the development of new tools which reflect the current operating context and multi-disciplinary working to ensure safe and effective care.

Healthcare Improvement Scotland should collaborate with the Independent National Whistleblowing Officer, and other relevant bodies, to develop clear and unambiguous guidance for staff in NHS boards on the national routes for staff to raise concerns under Whistleblowing and the Public Interest Disclosure Act. This will enable NHS boards to ensure that they have effective arrangements in place and improve staff awareness and understanding.