Mid Community Health Partnership Committee Meeting 28th October 2011

Item 17.0

Unscheduled Care in West , in particular, Emergency and Urgent Response

1. Introduction

Due to the imminent retiral of a District Nurse in who is currently undertaking first response duties on behalf on SAS, the development of safe and sustainable services in West Ardnamurchan has been the subject of considerable effort in partnership with Community representatives, SAS and Highlands and Islands Fire and Rescue Services. This paper will describe the challenges and work to date.

2. Geography

West Ardnamurchan is made up of 250 residents who live in Kilchoan, , Portuarik, Sanna and Kilmory at the end of a single track road on the Ardnamurchan Peninsula. The population increases during the summer months as it is a popular tourist destination. A ferry connects Kilchoan to the Island of Mull. West Ardnamurchan is one of the most isolated communities on the mainland of .

The main employment in West Ardnamurchan is a fish farm, crofting and tourism. Residents normally have at least 2 jobs to maintain a sustainable income.

The connects the Ardnamurchan Peninsula to the main arterial road to Fort William between the hours of 0630 and 2115. The Scottish Ambulance Service North Emergency Medical Dispatch Centre (EMDC) can request the ferry out of hours but there is no formal agreement in place and it depends on the availability of the ferry crew. If the ferry is not available it puts an additional 30 minutes to 1 hour onto the journey to Fort William.

3. Resources available to Communities in West Ardnamurchan

Scottish Ambulance Service Road Ambulance

The road ambulance is based in which has an average response time of 45 minutes to 1 hour to West Ardnamurchan. The nearest road ambulance response if it is out of area is Fort William which could take between 1hr 30 minutes and 2 hour 30 minutes. Strontian has 2 paramedics and 3 technicians and has increased its staffing in the last 12 months from 4 staff to 5 staff reducing single crewing and improving response times.

Scottish Ambulance Service Air Ambulance

The population of West Ardnamurchan have been advised that the SAS will use the air ambulance service to respond to serious and life threatening calls in

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Ardnamurchan when it is clinically appropriate and available. The air ambulance would be supported by other community responses and the road ambulance where this was required.

Inverness to Kilchoan – 45 mins based on still wind conditions Glasgow to Kilchoan – 35 mins based on still wind conditions

Wind dependant, flying time for the Glasgow and based SAS helicopters are similar. They can land 24/7 on a designated landing site in Kilchoan with HM Coastguard putting out landing lights during the hours of darkness on behalf of the SAS.

In cases of the SAS helicopters being unable to land in Ardnamurchan due to demand or weather, the SAS can call upon assistance from the HM Coastguard Helicopter (Stornoway) and the MOD SAR Helicopters (Lossiemouth and Prestwick). These need to be authorised by the on call air wing manager and will only be granted for life threatening conditions.

A specialist retrieval team may be involved in transfer of patients with a life threatening condition, and although Stornoway coastguard helicopter is closer, it is likely that rescue 177 based in Prestwick will be tasked as they will be able to pick up appropriate team from Glasgow en route. From time of call (including 15 minute scramble time and loading the team in Glasgow), they would be on the pad in Kilchoan in 1hr 10 mins (give or take for wind).

NHS Highland Primary Care and BASICS

At present, there is one full time and one part time nurse, both resident in West Ardnamurchan, providing services primarily to that area but are part of a wider West Integrated Team. The senior nurse ceased to deliver midwifery services several years ago due to low activity and clinical skills maintenance challenges. That service is delivered from Fort William. She continues to provide community nursing, health visiting and school nursing. The skills atrophy issue remains a matter of concern due to low volume and isolation of the Practitioner from direct peer support. The wider multidisciplinary team approach is therefore considered to be the most safe and sustainable model of care for the future.

There are 2 GPs based in which is around 45 minutes from West Ardnamurchan. NHS Highland has a 1 hour response time for urgent primary medical care out of hours, and therefore this obligation can be fulfilled.

These doctors are based in The Pines Medical Practice, and are independent contractors providing General Medical Services and dispensing services to a wide geographical area, and continue to provide a primary care out of hours service. Both of these GPs are BASICS trained, one being a Trainer, and are supported by the Mid Highland Community Health Partnership to respond to incidents on behalf of the SAS when available, which in reality is 24/7 unless on an emergency call elsewhere is their Practice area.

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The Senior Community Nurse who is resident in Kilchoan has provided an urgent and emergency response on a 24/7 basis in West Ardnamurchan for a number of years. She had undertaken additional training through BASIC (Scotland) to enable her to practice at an advanced level. Due to the distance, she also had an arrangement with the Practice that she would provide the first response for her part of the Practice area. Whilst some degree of flexibility is essential, modern governance requirements are more stringent and local arrangements need to seen within a framework of support, accountability and clinical governance.

The fragility of the situation based on one nurse with part time support, was explained to the community some 5 years ago. Due to the immense challenges, and the level of community concern, NHS Highland recommended the area for inclusion in the Remote Services Futures initiative in which many members of the local community were involved. Although concerned about the onerous on call commitment, NHS Highland agreed to allow the arrangement to continue until a more sustainable arrangement could be developed with SAS and the Community.

The nurse is retiring in February 2012 and in planning for the future, NHS Highland must take into account working time directives, agenda for change policies and clinical governance issues such as isolated practice, skills maintenance, knowledge and skills framework. It is acknowledged by SAS that this leaves a gap in urgent and emergency care in this area. There is 1 other community nurse who resides in West Ardnamurchan and there is no guarantee that new staff will live in the area, although NHS Highland is sympathetic to the community’s desire to see someone living in the community and will encourage new staff to consider living in West Ardnamurchan and to participate in a Co Responder scheme if that is achievable. The situation whereby a service is reliant on two people is inappropriate and unacceptable into the future.

There has been a considerable amount of joint working and planning between SAS and NHS Highland. For example, the majority of Community Nurses in Ardnamurchan have been trained to First Person on Scene (FPOS) Intermediate level by the SAS and have been issued with PPE and FPOS Equipment. Trackers will be issued to them shortly. There is an agreement with NHS Highland that the community nurses will respond to 999 calls as a first response during normal working hours. Community Nurses work in different parts of Ardnamurchan and may not always be in West Ardnamurchan when a 999 call comes in but, together with the GPs and Ambulance, they now provide a much wider coverage of appropriately trained and equipped FPOS responders.

HM Coastguard

A volunteer HM Coastguard team is located in Kilchoan.

Highlands and Islands Fire and Rescue Service

A retained Fire and Rescue Service is based in Kilchoan.

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Item 17.0 Community First Responder Scheme

During 2011, 10 people from West Ardnamurchan were trained by the SAS as Community First Responders but withdrew from providing this service in July 2011. The imminent retiral of the District Nurse and the loss of an immediate nursing response in the area has raised anxiety in the local community and placed a timeline on the need for statutory agencies to provide a safe, sustainable and affordable model of care for the future.

4. Strategic Options Framework (SOF) Guidance

The Strategic Options Framework (SOF) is clear in setting out the standards for emergency response which include the SAS Category A and Category B response targets but there is a clear recognition of the fact that in remote and rural areas this will be challenging for the SAS and as such, the SOF, suggests a range of models which can be introduced including Community First Responders (CFR), community paramedics, GP, etc.

The expectation on SAS is that it will normally try to ensure a response within 30 minutes but that the response can come from a member of a community emergency response team, which could be a Community First Responder or GP, not necessarily SAS, although they would automatically be backed up by an ambulance response.

Clearly, the people in West Ardnamurchan are unhappy about the Community First Responder being considered to be an acceptable response until Ambulance and/or BASICs GP can respond, hence the resignation of the First Responders. NHS Highland is working in partnership with the Scottish Ambulance service to ensure that community first responders can be appropriately backed up in order to provide a safe, sustainable and affordable model of care.

5. Agreed Actions

The following actions were agreed

• SAS Air Ambulance Service would provide a response to high acuity and / or life threatening calls in Ardnamurchan subject to this resource being available. HM Coastguard and the MOD can also be used where the SAS Air Ambulance Helicopter is not available due to being on another job or due to weather. The use of the air ambulance, where clinically appropriate, would be deemed a high priority for Ardnamurchan.

• SAS would continue to train Community Nurses in Ardnamurchan as FPOS Intermediate First Responders and would provide equipment and tracking to allow them to respond in hours to appropriate 999 calls. The Community Nurses would always be backed up by the road and or air ambulance where this was required but it is acknowledged that community staff and GPs may not be in West Ardnamurchan when an emergency call is received. This model does however provide greater coverage and potential for faster response when the Practitioners are on duty.

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Item 17.0 • NHS Highland would continue to resource and support and SAS would continue to use the BASICS GP where he was available to attend appropriate emergency calls in West Ardnamurchan

• The SAS and NHS Highland would work with the West Ardnamurchan Community to identify level 2 responders where they were available to explore the feasibility of being part of a co-responder model for urgent and emergency incidents.

• SAS, NHS Highland and HIFRS to explore the feasibility of establishing a co- responder model in West Ardnamurchan where their availability will be secured on a roster basis. Co-Responders would be trained up to First Person on Scene (FPOS) Intermediate level (see Appendix One for an outline of this training) and would also undertake a further period of training delivered by the Scottish Ambulance Service. The use of telemedicine kit by these responders will also be explored in future

• HM Coastguard outlined that the UK HM Coastguard position was not to participate in co-responder schemes although this was under review. There was still a willingness and enthusiasm to help out where appropriate. HM Coastguard in Kilchoan have previously transferred patients on a stretcher to the helicopter although it would be difficult to formalise these arrangements given the current guidance

• NHS Highland to consider encouraging new community nurses to reside in West Ardnamurchan although a note of caution was made about this and it was made clear that any nurses residing in the area could only take part in emergency response as part of a wider rota and then only if they are willing to do so, have the necessary skills and experience and are physically present at the time of the call.

• NHS Highland will continue to provide an on call nursing service for patients at the end of life. This will be covered by the wider West Lochaber team, with members not resident in the area staying in B&B accommodation whilst on call if necessary. This will ensure that the on call commitment is less onerous and the service more sustainable.

• NHS Highland will continue to use the Nurse’s base in Kilchoan and will continue to provide and further develop nursing services to the peninsula. In reality, this will mean that the area will be served by a team of nurses as the triple and quadruple post is no longer sustainable due to new training approaches and skills maintenance considerations. Any nurse based in Kilchoan will be given the opportunity to work in the wider area to ensure that skills and competencies are practised and maintained.

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• West Ardnamurchan Community Council representatives outlined that there was little interest in resurrecting the community first responder scheme. It wants urgent and emergency nursing cover on a 24/7 basis in West Ardnamurchan. As outlined above, this is not possible and it is hoped that the community will resume work with SAS in partnership with NHS Highland and other Partners, to develop a community resilience model that will support the community into the future.

6. Possible Safe, Sustainable and Affordable Solution

The Co-Responder Model would provide an urgent and emergency response at First Person on Scene Intermediate level in West Ardnamurchan on a 24/7 basis. In hours, Community Nurses would be tracked and would be available to respond to 999 calls when they were in West Ardnamurchan and indeed the rest of the Ardnamurchan Peninsula, but their presence in West Ardnamurchan itself cannot be guaranteed at all times. A First Person On Scene Intermediate Level Co-Response would be supported by the air ambulance for high acuity and life threatening calls, the road ambulance based in Strontian, the BASICs GP based in Acharacle or from home near Strontian (when available) and a primary care response (1 Hour) on a 24/7 basis through The Pines Practice in Acharacle . HM Coastguard is available to assist where this was deemed appropriate by their control room.

Subject to agreement the Co Responder Model could be operational by the end of December 2011 which would include training Co-Responders to First Person on Scene (FPOS) Intermediate level and would include an additional clinical skills course delivered to Co-Responders by the SAS which was specific to the Co- Responder Model, as described above.

The call volume is low in West Ardnamurchan i.e. 11 calls from January 2010 to present day. Primary Care calls will continue to be managed through a primary care response, triaged out of hours through NHS 24 and the co-responders would not be expected to manage cases of this nature. NHS Highland’s standard for an urgent medical primary care response is 1 hour.

West Ardnamurchan Community Council expectations are for nurses and or paramedics to be available for urgent and emergency response on a 24/7 basis in West Ardnamurchan. This is not a safe, sustainable or affordable solution and would require a minimum 1:3 rota which is neither affordable nor sustainable. The safety and clinical governance of such a model is also a key consideration due to the very low volume of activity and the high risk of skills atrophy.

NHS Highland has outlined that community nurses will not be available on a 24/7 basis in West Ardnamurchan. The replacement for the community nurse may not reside in West Ardnamurchan and due to the need to change the nursing model, the area will be covered by a wider team to ensure that public health nursing, school nursing, specialist nursing and midwifery services are also available to the community.

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7. Community Meetings

A further meeting with Community Representatives was held on 13th September. SAS and NHS Highland presented the joint solution outlined above. The West Ardnamurchan Community Council, following an adjournment, agreed to take the proposal to a public meeting later that evening but stated that they had concerns and invited SAS, NHS Highland and HIFRS to attend another public meeting on 27th September. This was agreed.

At the meeting on 27th September, a presentation of the proposal was given and a leaflet (copy attached) describing the model issued to all those in attendance. A full and frank discussion ensued, culminating in a rejection of the proposal by the community. In turn, the Community presented an alternative proposal in written form, to SAS and NHS Highland. It was agreed that this would be considered and that another public meeting would be held on 25th October.

8. Current Situation

SAS, NHS Highland and HIFRS are considering the Community Proposal and are also seeking to address the concerns raised in connection with a Co Responder model. It has been suggested to the Community Council that the meeting on the 25th October should be with the Representatives only to allow for further discussion on their proposal and that the Public meeting should be scheduled for a future date. Their response is awaited.

The Kilchoan fire fighters have written to the Chief Fire Officer declining to be involved in a Co Responder model. This is extremely disappointing but as the model is attracting national interest, and is thought to be a safe and workable solution in other remote communities, a request has been made to meet with the fire fighters in order to further explore their reasons for not being involved so that learning from that can be applied as other schemes are developed. It is hoped that the meeting will take place in the near future, but again a response is awaited.

Gill McVicar General Manager 18th October, 2011

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