An assessment of the impacts of the proposed redesign of inpatient health service provision on transport to health for Skye, Lochalsh and South West Ross
Dr Richard Mounce1 and Dr Steve Wright2 Centre for Transport Research3 University of Aberdeen
January 2018
1 E-mail: [email protected] 2 E-mail: [email protected] 3 http://www.abdn.ac.uk/ctr Contents Executive Summary ...... 4 1 Background...... 6 1.1 Geography and demography of Skye, Lochalsh and South West Ross...... 6 1.2 Health service provision in Skye, Lochalsh and South West Ross ...... 8 1.2.1 Existing health service provision ...... 8 1.2.2 Redesign of health service provision...... 10 1.3 Methodology ...... 11 1.4 Transport services available for accessing hospitals in Skye, Lochalsh and South West Ross...... 12 1.4.1 Car ownership and access...... 12 1.4.2 Public transport and taxis...... 12 1.4.3 Scottish Ambulance Service ...... 16 1.4.4 Community transport and voluntary services...... 16 1.4.5 Distance and travel times matrices ...... 18 1.5 Barriers to transport to health...... 20 2 Establishing demand for transport to access hospital in Skye, Lochalsh and South West Ross ...... 20 2.1 Introduction...... 20 2.2 Inpatient admissions ...... 21 2.3 Inpatient discharges...... 22 2.4 Inpatient visitors...... 27 2.5 Outpatient appointments...... 31 3 Overcoming gaps in transport provision through a new specialist door-to-door service 32 3.1 Estimated level of demand for a dedicated door-to-door service...... 32 3.2 Service Timings ...... 34 3.3 Service Operating Characteristics...... 35 3.3.1 Service Licensing...... 35 3.3.2 Service Design...... 35 3.3.3 Competition ...... 36 3.3.4 Vehicle...... 36 3.3.5 Driver Regulations ...... 36 3.3.6 Depot...... 37 3.3.7 Fares ...... 37 3.4 Estimated Costs and Revenues...... 37 3.4.1 Capital costs...... 37 3.4.2 Staff costs...... 37 3.4.3 Fuel costs ...... 38 3.4.4 Vehicle Maintenance/Servicing, License, Insurance and other costs ...... 38 3.5 Revenues ...... 39 3.5.1 Fare Revenues ...... 39 3.5.2 BSOG grant...... 39 3.6 Summary of Costs and Revenues and annual subsidy required from NHS Highland to support the service...... 40 4 Future transport needs assessment...... 40 5 Summary of specific recommendations...... 41 Acknowledgements...... 41 References ...... 41 Executive Summary This is a report on the study carried out by the Centre for Transport Research (University of Aberdeen) for NHS Highland, who commissioned the study. The study was an independent assessment of the implications for transport to health of the proposed redesign of inpatient health service provision for Skye, Lochalsh and South West Ross (SLSWR). Part of the proposed redesign involves building a new hospital in Broadford and providing all inpatient facilities from there whilst removing inpatient facilities from Portree. A condition of implementing the redesign is to ensure that transport and access needs are met. The assessment sought to:
1. Identify the implications for patient, carer and visitor travel of closing inpatient facilities at Portree; 2. Identify and quantify the potential benefits for transport to health provision that may be realised through greater use of technology, more care at home and increased care home placements 3. Any additional implications for transport to health that may not have been considered; 4. Make recommendations on how to best accommodate the resulting transport to health demands, e.g. identifying the need for additional investment in transport or the modification of existing services to best accommodate these demands.
It is important to note that this is an assessment of the implications for transport to health of the proposed service redesign, and not an assessment of the proposed service redesign per se. Section 1 contains background information that is relevant to the assessment, including the geography and demography of the area; current and planned health services provision; and current transport service provision. Section 2 establishes the demand for transport to access hospital in Skye, Lochalsh and South West Ross, taking into account the proposed redesign of inpatient health service provision. Section 3 looks at how the gaps in transport service provision might be overcome. Section 4 summarises the specific recommendations that have come out of the study, which include:
1. Consideration of the feasibility of establishing a dedicated door-to-door minibus service to cover the North of Skye in facilitating trips to the new hospital in Broadford. This would be an on-demand but semi-fixed-route service covering the North West of Skye to Portree and onward to Broadford Hospital on Monday, Wednesday, Friday and Sunday; and the North East of Skye to Portree and onward to Broadford Hospital on Tuesday, Thursday and Saturday. The service would be primarily aimed at visitors to inpatients in Broadford, but could also be potentially used for inpatient discharges as well as other purposes such as shopping trips in Portree. The service would generate some revenue but would need to be subsidised. 2. In addition, it is recommended that the Transport and Access Sub Group with all key Partners, consider establishing a volunteer car service in the SLSWR area for access to outpatient appointments and GP appointments for those with no car access and who find it difficult to access their appointment by other means, such as newly introduced Attend Anywhere: NHS Near Me. 3. Scottish Ambulance Service may need to consider a review of the emergency ambulance cover situation and to assess the impact of a single inpatient site. Additional demands may be placed on the ambulances and crews in the North of Skye, when providing transport for inpatient admissions due to the relocation of inpatient services to Broadford. This may result in additional time when these ambulances and their crews are not available to respond to emergency call outs. 4. Complementary components of the service redesign, such as greater level of care at home, telemedicine, have the potential to mitigate a considerable proportion of the transport demands identified in this report. However, consideration should be given to the actions identified in points 1 to 3 above should the community infrastructure not be sufficiently well developed immediately following the closure of the inpatient ward at Portree Hospital.
Finally, it is important to note that although transport to health in the South of Skye will not be directly affected by the service redesign, there are existing transport issues for people accessing the hospital in Broadford. 1 Background 1.1 Geography and demography of Skye, Lochalsh and South West Ross The geographical area considered in this transport to health assessment consists of Skye, Lochalsh and South West Ross, and is shown in Figure 1.
Figure 1. The study area: Skye, Lochalsh and South West Ross (from NHS Highland (2016))
The population of Skye, Lochalsh and South West Ross has been growing steadily over the last ten years, with an increase in the population from 13,747 in 2003 to 14,510 in 2013 (a rise of 5.6%). This is projected to remain relatively stable into the future with only a slight increase (0.4%) by 2025. Portree is the largest and most densely populated settlement with a resident population of 2318 (in the 2011 census). Figure 2 shows the population distribution and density in Skye and Lochalsh.
Skye, Lochalsh and South West Ross has a much older population than average for the Highlands (NHS Highland, 2016) and this is set to become more pronounced since there is predicted to be a further shift in the demographic towards the older age groups (shown in Figure 3): the proportion of people aged over 65 is predicted to increase from 22% currently to 40% in 2037. Figure 2: Skye and Lochalsh population distribution and density 2013 (from NHS Highland (2016))
Figure 3 Trend in population estimates (2003 to 2013) and projections to 2037 by age band, Skye, Lochalsh and South West Ross (from NHS Highland (2016)) Skye has a large influx of tourists, particularly during the summer months (in common with other parts of the Highlands). These tourists place additional demands on services on the island including the hospitals and emergency ambulance crews.
1.2 Health service provision in Skye, Lochalsh and South West Ross 1.2.1 Existing health service provision There were 14680 registered patients in 2016 in Skye, Lochalsh and South West Ross, but there is a significant increase in temporary patients (particularly in the summer months) due to the popularity of the area with tourists and outdoor sports enthusiasts. In terms of delivery of health and social care in the community the area is split into three Integrated Community Teams: West Ross, South Skye and Lochalsh, and North Skye and Raasay (see Figure 1). These integrated teams include social workers, care at home workers, physiotherapists, occupational therapists, community nurses, and community mental health teams, working out of different locations.
Figure 4 Location of health services within Skye, Lochalsh and South West Ross locality
The facilities in the area (shown in Figure 4) include:
1. Two community hospitals: Dr MacKinnon Memorial Hospital (Broadford) and Portree Hospital (these are detailed below). 2. Ten GP practices: Portree (which has branch locations at Uig, Staffin and Raasay), Broadford, Dunvegan, Carbost, Sleat, Glenelg, Kyle, Lochcarron, Torridon and Applecross. 3. NHS care facilities: a. one NHS Highland care home (An Acarsaid in Broadford); b. NHS Highland day care services (Tigh na Drochaid in Portree, and Airdferry in Dornie). 4. Private care homes: a. Budh Mhor in Portree; b. Home Farm in Portree (nursing home); c. The Howard Doris Unit in Lochcarron (residential and day-care services).
Dr McKinnon Memorial Hospital, Broadford
The Dr McKinnon Memorial Hospital in Broadford is a community hospital with 20 inpatient beds providing intermediate care encompassing assessment, resuscitation and stabilisation of acutely ill patients. It is supported by a small team of Rural Practitioners (RPs), who are GPs with enhanced skills in emergency, resuscitation and anaesthetics; this allows the hospital to function at a higher level than all community hospitals in the Highland Health and Social Care Partnership area (= Highland Council area). RPs have particular advantages in small hospital settings when the volume of work, especially out of hours is low and variable. RPs are capable of assessing and stabilising patients who come to A&E with trauma, medical or surgical condition; as well as providing inpatient care. RPs work shifts and so are in the hospital 24/7 providing senior medical cover (with additional cover on call in case of major trauma). The hospital is supported by 24 hour on-site medical and nursing cover providing the Urgent Care Centre. Radiology services (ultrasound and x-ray) are available on site and a range of visiting specialist outpatient services is also provided. Palliative care is provided for those patients with a terminal illness who are no longer able to be cared for at home. There is a midwifery-led community maternity unit at the Dr MacKinnon Memorial Hospital, where pregnant women considered to be at low risk generally give birth. Pregnant women in the area who are not considered to be at low risk generally elect for a planned birth at Raigmore Hospital in Inverness.
Portree Hospital
Portree Hospital is a community hospital with 12 inpatient beds and is located adjacent to Portree Medical Centre. It is supported by 24-hour nursing cover and access to 24-hour clinical cover. The inpatient medical cover is provided by GPs from Portree Medical Centre from 0800 to 1800, Monday to Friday. Out-of-hours cover is provided by Advanced Practitioners triaged through the RPs in Broadford, supported by a North Skye on-call service after 2300 hours. A minor injury/urgent care service is available from 0800 to 2300, provided by GPs from Portree Practice 0800-1800 Monday to Friday and by Advanced Practitioners (Nursing and Paramedic) from 1800-2300 Monday to Friday and 0800-2300 at weekends and bank holidays. There are part time x-ray facilities (five days per week between 1000 and 1500), care of the elderly physician input and a community midwife base. A small range of visiting specialist outpatient services are also available. Portree hospital beds are typically used for end of life care, palliative care, and care of elderly people who may not be able to return home due to insufficient care in the community and lack of care home beds to discharge to. Due to staffing issues including for catering and cleaning staff, since July 17, the hospital has been working with a reduced bed complement of two to four beds.
Scottish Ambulance Service
The Scottish Ambulance Service is responsible for the immediate treatment and delivery of transport in the case of medical emergencies. Patients are treated at the scene where appropriate by paramedics or first responders. The Dr MacKinnon Memorial Hospital in Broadford is a non-bypass hospital where patients who are acutely ill will be taken to be stabilised. Patients will be treated or transferred to Raigmore Hospital in Inverness (90 miles and more than a two-hour drive from Broadford) or by air to a tertiary centre, in cases where there are not the necessary facilities or medical professionals present.
1.2.2 Redesign of health service provision The focus for the proposed redesign is on having strong primary care and community services; more care being delivered at home or in a homely environment; and having less reliance on hospital beds. The new model of care will encompass Scottish Ambulance Service, third sector and independent service providers, building on existing close working relationships but allowing co-location and shared working where possible, to further enhance this. The community services will be expanded and developed.
The service model for the proposed redesign is for a ‘hub’ facility at Broadford and a ‘spoke’ facility at Portree, with this option being the preferred option in the public consultation in 2014 (NHS Highland, 2014a, 2014b). The hub facility at Broadford will be a new hospital which will be built close to the existing Dr MacKinnon Memorial Hospital. The hub will have 24 beds, which is based on a bed-modelling exercise that took into account current use, future demand and the future model of service delivery (NHS Highland, 2016). The spoke facility in Portree will be the existing Portree Hospital, but without any inpatient facilities (all inpatient services will be located in Broadford). There will however be some beds commissioned in one or more care homes in the Portree area for the purposes of step up/ step down care and end of life care (NHS Highland, 2016).
Outpatient clinics will be provided from the Hub or Spoke as appropriate with an aim to improve access (NHS Highland, 2016), including through the increased use of tele-medicine. Fracture clinics will be provided by the local rural practitioner team supported by an improved radiology service in the Hub and links to Orthopaedic specialists in Raigmore. Further discussions will be undertaken to identify whether additional consultant-led outpatient activity could be reasonably delivered. In addition, discussions are required to identify clinics that can be provided by specialist nurses including diabetes, heart failure and COPD. Clinical space will be designed to allow each consulting room to be used flexibility. Tele-health clinics are being introduced as a way of reducing the need to travel, which is particularly important for more remote locations. This will form part of wider roll out across NHS Highland as part of Attend Anywhere: NHS Near Me.
In addition, there is a new approach for diagnostic endoscopy investigations currently being piloted, including on Skye.
The pathways to treatment identified above for emergency cases will essentially be unchanged. 1.3 Methodology Utilising data on inpatient bed use at both Portree and Broadford hospitals and combining this with data from the 2014 public consultation surveys (completed by 19% of the adult population of SLSWR), assessment is made of the inpatient demands and visitor demands for transport to Broadford hospital (following the redesign of inpatient facilities) by different mode according to age group and residential location.
The assessment is undertaken over a short-term time horizon (up to 2020). The purpose is to establish gaps in current transport provision related to changes to inpatient services and estimate the likely need for additional transport provision to Broadford hospital immediately after the planned inpatient bed changes take effect. This demand assessment is based on existing levels of inpatient admissions and current demographics, with assumptions informed through consultations with experts from NHS and transport providers as well as representatives from local organisations.
Data for the assessment was collated from a variety of sources, and these have been acknowledged where appropriate. These sources include freely available information such as census data and information about public transport services, etc. NHS reports relating to the service redesign provided substantial information for the assessment to be based on, including results from a large public consultation survey on proposed changes to SLSWR Health Services conducted in 2014 which had 2273 responses (these are referenced in the text). Surveys were also conducted in order to provide specific information regarding particular aspects of the assessment. These surveys included a survey of transport providers (including community and voluntary services and taxi providers) in the SLSWR area, which were developed by the University of Aberdeen and delivery coordinated by Maimie Thompson (NHS Highland). Additional information was provided through discussions and meetings with numerous individuals representing a range of organisations. Chrisann O’Halloran (Senior Charge Nurse at the Dr MacKinnon Memorial Hospital and Portree Hospital) helped us gain an overview of the current inpatient provision, inpatient and visitor characteristics and transport provisions for patients travelling to the two hospitals. Dr Kirsty Shaw (General Practitioner Principal at Dunvegan Medical Practice) gave us valuable insights into the difficulties faced in accessing health services by the rural communities on Skye. Hamish Fraser (Councillor for Skye and Raasay) discussed with us the decisions around, and impacts of, the service redesign. Steven Gorman and Alan Knox (Scottish Ambulance Service) helped us understand the Scottish Ambulance’s role in transport to health in the SLSWR area. Jennifer Francis (Glenachulish Preservation Trust) contacted us with relevant information from a related study. Ray Shields (Red Cross) provided valuable information about the role of the Red Cross in facilitating transport to the hospitals in the SLSWR area. Sarah Marshall (Save our Services, North Skye) helped us understand the concerns that many people in the North of Skye have in relation to the service redesign. Dr Caroline Gould (Skye and Lochalsh Access Panel) gave us valuable insights into the transport difficulties faced by disabled people on the Isle of Skye. 1.4 Transport services available for accessing hospitals in Skye, Lochalsh and South West Ross 1.4.1 Car ownership and access Table 1 shows car access rates for Skye, Lochalsh and South West Ross, based on survey responses from the public consultation in 2014. This survey provided responses from 19% of the population aged over 16 in the SLSWR area. Around 84% of the respondents said that they had access to a car.
Table 1. Car ownership and access in Skye, Lochalsh and South West Ross
Car owner / have access to a car
Consultation Area NumberofRespondents PercentageofRespondents Not Not Yes No Yes No stated stated Skye North 397 43 18 86.7 9.4 3.9 Skye Central 334 52 14 83.5 13.0 3.5 Skye South 486 46 14 89.0 8.4 2.6 Lochalsh 331 50 8 85.1 12.9 2.1 South West Ross 101 13 4 85.6 11.0 3.4 Total SL&SWR 1,649 204 58 86.3 10.7 3.0 Unknown/Other (1) 267 63 32 73.8 17.4 8.8 Total Responses 1,916 267 90 84.3 11.7 4.0 (1) Unknown/other - includes 344 blanks, 15 prefer not to answer and 3 locations outwith the consultation area
1.4.2 Public transport and taxis Stagecoach is the main bus operator in SLSWR. Figure 5 shows the routes for the Stagecoach services. Whilst this appears to provide a reasonable geographic coverage for much of the area, it is important to recognise that many services only operate on schooldays to tie in with school start and end times; and in any case most services are infrequent when compared to those operating in more urban areas. Figure 5. Fixed-route bus services operated by Stagecoach on the Isle of Skye
Table 2 gives a summary of the Stagecoach services operating on the Isle of Skye4. In addition, there is a lack of direct services between some locations, e.g. from Dunvegan to Broadford. Stagecoach offer adult dayrider tickets which allows travel on their services
4 Note that this table has been based on the summer timetable (not during the school holidays). Full timetables for these services can be viewed online at https://www.stagecoachbus.com/timetables. Note that services 58 and 158 are services operate within Portree only and so have been omitted. throughout the Isle of Skye for a single day for £8.85. Concessionary pass holders travel for free. Stagecoach now only operate services as far as Kyle of Lochalsh (whereas previously they had operated service 164 from Kyle to Lochcarron.
Table 2. Summary of Stagecoach services on the Isle of Skye
Service Route Travel time Services Sat and Sun services / number per day Notes 50 Portree – Broadford - 1 hour (38 mins 2 outward, None Kyle to Broadford) 3 return 51 Armadale – 50 mins (25 1 outward, None Broadford - Kyle mins to 1 return Broadford) 52 Portree – Broadford - 1h08m (38 mins 2 outward, Both. 3/day out and Armadale to Broadford) 2 return return 54 Portree – Fiscavaig 52 mins 3 outward, None 3 return 56 Portree – Dunvegan 50 mins (Portree 6 outward, Sat only- 3/day – Lonmore -> – Lonmore) 5 return Glendale 57A Portree – North End 1h48m (1h17m 4 Sat: 4/day. Sun 2/day (east circular through to Uig) Uig) 57C Portree – North End 1h44m (31 mins 4 Sat: 4/day. Sun 1/day (west circular to Uig) through Uig) 152 Portree – Broadford - 1h26m (41 mins 1 outward, High school days only Ardvasar to Broadford) 1 return 155 Portree – Broadford - 1h03m (37 mins 1 outward, High school days only Torrin to Broadford) 1 return 917 (City Inverness – 3h17m (2h31m 3 outward, Both (same service Link) Broadford - Portree to Broadford) 3 return daily). Links with services to Uig 2/day
The bus stops in the vicinity of the hospitals in Portree and Broadford are shown in Figure 6 and Figure 7 respectively. Figure 6. Bus stops within 10 minutes’ walk of Portree Hospital
Figure 7. Bus stops within 10 minutes’ walk of the Dr Mackinnon Memorial Hospital in Broadford
There are three taxi services in the study area: Kyle Taxis, based in Kyle and covering Skye, Lochalsh, Inverness and Lochaber; Donal Nicolson, based in Sleat and covering the Highland Council area; and Don’s taxis, based in Portree and covering Skye and Lochalsh. Only one of these taxi companies (Kyle Taxis) is accessible to both wheelchair users and disabled passengers. 1.4.3 Scottish Ambulance Service 1.4.3.1 Emergency Service Emergency ambulances are used in the case of medical emergencies and are provided by the Scottish Ambulance Service. There is an emergency ambulance and crew at each of the two hospitals, i.e. one in Broadford and one in Portree, as well as ambulances and crews located in Dunvegan, Kyle and Lochcarron. However, the Dunvegan crew does not have a trained paramedic. All inpatient admissions from home to Broadford and Portree are classed as emergency admissions and so are entitled to be conveyed by emergency ambulance, however, some choose to be driven by friends or family members rather than call and wait for an emergency ambulance. Note that there are no non-emergency inpatient admissions to Broadford or Portree other than inter-hospital transfers as all non-emergency planned medical procedures requiring overnight admission are carried out at the General Hospitals of Raigmore in Inverness, Fort William, or further afield.
1.4.3.2 Non-Emergency Patient Transport Service Non-emergency patient transport services (PTS) provide free transport to and from hospital for people who have a medical need for it, i.e. for people who:
1. Require assistance from skilled ambulance staff, e.g. they require access to oxygen whilst travelling; 2. Have a medical condition that would prevent them from travelling to hospital by any other means; 3. Have a medical condition that might put them at risk from harm if they were to travel independently; 4. Are receiving treatment with side effects that requires support from skilled ambulance staff.
PTS vehicles can carry all types of passenger including disabled and wheelchair users. They les are available during the daytime (0900-1700) on weekdays, although in effect this is more limited because, unless patients appointments have finished by 2pm, they are not eligible to be transported since it will take the Care Assistants in to overtime which is unfunded and provides no guarantee of service to patients. PTS vehicles can be booked in advance. In the past PTS was cancelled regularly due to the prioritisation rating applied by the service. However, Scottish Ambulance Service now implements a capacity management system which they say is reducing cancellations and providing more guarantee of a PTS ambulance will be available.
In a typical month, the Patient Transport Service facilitates around 125 trips per month in the study area, with 19 to/from Broadford Hospital and 11 to/from Portree Hospital.
1.4.4 Community transport and voluntary services The community transport and voluntary services operating in Skye, Lochalsh and South West Ross are as shown in Table 3.
Table 3. Community transport and voluntary services operating in Skye, Lochalsh and South West Ross Service Area Availability Vehicle Eligibility Fare Funding Red Cross Generally Anytime Modified Users are None Contract Skye and Ford authorised with NHS Lochalsh, Connect by the NHS. Highland but can be van, which Service is further is mainly to fill afield wheelchair gaps, e.g. to accessible perform hospital discharges Sleat Based in Operating Same as Taxis can Company Subsidised Community and covers times are the taxi be hired for pays half, by Highland Trust in and the same as operators, shopping, customer Council subsidised around the taxi since they transport pays half Rural taxis Sleat providers, are in effect links, Community but booking an hospital Transport system is intermediary appointment only . One taxi s, etc Monday- company’s Saturday vehicles are accessible to wheelchairs /disabled Broadford Covers Operates 7 Volunteer The service Patients pay The service Patient Broadford days per drivers use is only open 25p per mile is heavily Participation area and as week as their own to patients subsidised Group far as required cars to registered by the PPG (PPG) Portree and transport at South who Dornie patients to Skye fundraise and from Practice. for it local Mainly used medical for GP and appointment Outpatient s appts. North West North West Vehicle is Wheelchair- Used to N/A None Skye Skye available for accessible transport Minibus group hire minibus. groups of Association Not door-to- people. door. Minginish Skye Only 14-seater Local use, Pensioners Bus Service Community available 2 wheelchair- plus private shopping Operators Minibus days per accessible hire for any and lunch Grant from Group week minibus individual or club is a flat Scottish group on rate per Government Skye person. The cost for all other groups is 45p per mile or 65p per mile if not refuelled South West South West Operates 7 Volunteers’ Open to all Passenger Receives Ross Ross i.e. days per own cars residents is charged £27,555 Community encompassi week, and their 20 pence p.a. funding Car ng the area usually associates per mile up from Scheme between 0600-2200 who, for to a Highland Gairloch to subject to whatever maximum of Council the north, volunteer reason, are £8 for any Community Kyle of driver unable to one journey Transport Lochalsh to availability use public Grants the south. transport for Applecross their journey to the west and have no and means of Achnashee private n to the transport east.
It is clear from Table 3 how few trips to and from both of the hospitals (in Portree and Broadford) are currently facilitated by community transport providers. The availability of trained minibus drivers is an issue confronting community transport groups seeking to make more use of their minibuses and operate community bus services.
1.4.5 Distance and travel times matrices Table 4 gives the proportions of the population of Skye and Lochalsh who live within 30 and 60 minute drive times of the community hospitals in Portree and Broadford. This is illustrated on a map for Portree in Figure 8 and for Broadford in Figure 9. It is important to note that the table and figures are from a report that focussed on Skye and Lochalsh only, and so exclude any potential catchment population living in the South West Ross area.
Table 4. Community Health Index Practice list population of Skye and Lochalsh who live within 30 and 60 minute drive times of the community hospitals in Portree and Broadford5
Hospital Location % population within % population within % population over 60 30 minute drive 60 minute drive minute drive Portree 41.9 86.0 14.0 Broadford 33.4 87.4 12.6
5 Data source: Community Health Index Population 2014 (April) Figure 8. 30 and 60 minute travel time catchment to Portree Hospital
Figure 9. 30 and 60 minute travel time catchment to Broadford Hospital6
6 Data source: Community Health Index Population 2014 (April) It can be seen from Figure 9 that it is the residents from the far North of Skye who will be most impacted by the inpatient service redesign.
1.5 Barriers to transport to health The cost of travel to access health services may be a barrier for some, particularly those without their own vehicle. People on low incomes can claim travel expenses via the Healthcare Travel Costs Scheme (HTCS), but the journey itself may be difficult to undertake, particularly for elderly or disabled people. Barriers that disabled people may experience include: 1. Requiring a vehicle and/or trained staff that can accommodate them. This usually requires a booking to be made ahead of time, which is generally done on a first-come first-served basis; this can cause problems if the return trip disabled place is unavailable. 2. Different operators have different requirements for disabled people and this can cause issues when trips involve multiple legs using different operators. 3. Lack of information at locations such as bus stops that is accessible to disabled people, e.g. displays and signs may not be accessible to the visually impaired.
These barriers are particularly relevant as there is a higher proportion of disabled people in Skye and Lochalsh than average.
Making provisions for carer and partner access (including transport) is important because the patient may need their assistance, as well as being important for the comfort and wellbeing of the patient. Partners can generally travel along in the ambulance, but in the case where the partner is disabled this can be problematic especially for users of motorised wheelchairs. The return trip back from the hospital after a partner travels along in the ambulance can also be problematic.
2 Establishing demand for transport to access hospital in Skye, Lochalsh and South West Ross 2.1 Introduction This Section examines the demand for transport, following the proposed service redesign, from inpatient admissions and inpatient discharges to/from Broadford hospital as well as the demand for transport from visitors to inpatients at Broadford hospital.
This demand assessment, based on existing levels of inpatient admissions and current demographics, is undertaken over a short-term time horizon (up to 2020). The purpose is to establish gaps in current transport provision and estimate the likely need for additional transport provision to Broadford hospital immediately after the planned inpatient bed changes take effect (suggested new transport service outlined in Section 3).
It is recognised that levels of inpatient admissions are likely to change in the medium to longer term as a result of: a. The introduction of planned supporting measures including improved care home/care at home/care in community provision. These supporting measures are likely to reduce the need for inpatient admissions as well as reducing the delays to inpatient discharges for those patients well enough to leave hospital but who still require significant levels of help and care either in care homes or at home. b. The growth in elderly population (over 65) from current level of 22% to 40% by 2037. The demand for inpatient transport that this generates is likely to increase gradually over time, all things being equal. c. Advances in telemedicine over the medium to long term time horizon are expected to decrease the need for travel to hospital for some patients. However, at this stage the exact benefits of telemedicine advances are uncertain in relation to reducing inpatient admissions.
These medium to long term changes to inpatient admissions and their impacts on demand for transport to hospital are discussed in Section 4.
2.2 Inpatient admissions There is currently a small amount of planned day case surgery carried out at MacKinnon Memorial Hospital in Broadford and none at Portree Hospital. All planned medical or surgical procedures requiring overnight admission are carried out at the General Hospitals of Raigmore in Inverness, Fort William, or further afield. Hence, all inpatient admissions to Broadford and Portree hospitals that are not inter-hospital transfers are classified as emergency admissions of acutely ill patients. As a result, these patients are eligible to be transported to hospital by emergency ambulance. Despite this, some choose to be driven by friends or family members rather than call and wait for an emergency ambulance. However, due to their acute condition, these patients do not drive themselves or travel by public transport, community transport or other means to get to hospital.
For the 5-year period from 1st April 2008 to 31st March 20137: . 69% of admissions to Portree Hospital were from patient’s homes and 10% were from temporary residences or care homes. 21% of admissions were transfers from other hospitals; . 75% of Portree hospital inpatients are admitted by Portree Medical Centre and 15% from Dunvegan Medical Practice and 3.5% from Carbost (the remaining are: unknown 3%, Kyle 1%, Broadford 0.5% and other 2%); . There is an average of 362 inpatient admissions patients per annum to Portree hospital, with 271 from the Portree Medical Centre catchment area, 54 from the Dunvegan Medical Practice catchment area and 13 from the Carbost Practice catchment area (see Table 5).
If these patient admissions were to Broadford rather than Portree then this would require an additional 40-minute drive time each way for the Portree Medical Centre patients and an additional 20 minutes each way for the Dunvegan Medical Practice patients. Assuming all admissions from temporary residences and care homes are by emergency ambulance (10%
7 From ‘Appendix 2 - Skye Hospital Services Review’ of the “Skye, Lochalsh and South West Ross Initial Agreement v26 10th October 2016” of all admissions) and half the admissions from patients’ homes were by private car with the other half by emergency ambulance (0.5 x 69% of all admissions) then 44.5% of all admissions will require emergency ambulance transport from home or temporary residential addresses. This places an additional time demand of 0.445 x 271 x 80 mins = 160.8 hours per annum on the Portree emergency ambulance crew and an additional time demand of 0.445 x 54 x 40 mins = 16 hours per annum on the Dunvegan emergency ambulance crew, totalling 176.8 hours per annum.
Given that 21% of admissions are transfers from other hospitals, reducing the need to transfer from Broadford to Portree (i.e. for patients currently transferring to Portree from Broadford) or removing the additional travel time between Broadford and Portree (i.e. for transfers from hospitals further afield) will save 0.21 x 80mins x 362 = 101 hours per annum. If these transfers are being made by emergency ambulance then this constitutes a saving in emergency ambulance demand. It is likely that these transfers are shared between the Broadford and Portree ambulance crews.
In total there will be an additional demand on emergency ambulance crews of 176.8- 101 = 75.8 hours per annum. However, the additional demand on the crews in the North of the Island are likely to total 176.8-101/2 = 126.3 hours per annum, while the Broadford crews will benefit from a 50.5 hours per annum reduction in demand. This is 126.3 hours when these ambulances and their crews in the North of the Island are not available to respond to emergency call outs.
2.3 Inpatient discharges The number of annual admissions to both Portree and Broadford hospitals from the different areas of North Skye is presented in
Area Population Annual admissions to Annual admissions to Total admissions Portree hospital Broadford hospital to Skye hospitals Number % of Number % of as % of population population population Portree and 5139 271 5.3% 265 5.1% 10.4% North East Skye North West 1477 54 3.7% 95 6.4% 10.1% Skye Table 5. The areas included in
Table 5 are depicted on the map in Figure 10. The age distribution of hospital inpatients at each of the Skye Area Population Annual admissions to Annual admissions to Total admissions Portree hospital Broadford hospital to Skye hospitals Number % of Number % of as % of population population population Portree and 5139 271 5.3% 265 5.1% 10.4% North East Skye North West 1477 54 3.7% 95 6.4% 10.1% Skye hospitals is given in
Table 6. Table 5 shows that there are similar numbers of admissions to both Portree and Broadford hospitals from the Area Population Annual admissions to Annual admissions to Total admissions Portree hospital Broadford hospital to Skye hospitals Number % of Number % of as % of population population population Portree and 5139 271 5.3% 265 5.1% 10.4% North East Skye North West 1477 54 3.7% 95 6.4% 10.1% Skye ‘Portree & NE Skye’ area. Admissions from the ‘NW Skye’ area are lower in number due to the lower population with almost two thirds to Broadford and just over a third to Portree hospital.
Table 6 shows that 70% of inpatient admissions to Portree hospital are over 70 years old with 46% being over 80 years old and only 17% aged under 60. Broadford hospital has a larger cohort of younger admissions with 40% aged under 60, although there are still 42% over 70 and 24% over 80.
Table 5. Annual admission to Skye Hospitals as % of population8 Area Population Annual admissions to Annual admissions to Total admissions Portree hospital Broadford hospital to Skye hospitals Number % of Number % of as % of population population population Portree and 5139 271 5.3% 265 5.1% 10.4% North East Skye North West 1477 54 3.7% 95 6.4% 10.1% Skye
Table 6. Age distribution of hospital inpatients Age Range Portree Hospital Broadford Hospital Under 60 17% 40% 60-69 13% 17% 70-79 24% 18% Over 80 46% 24%
8 Data derived from ‘Appendix 2 - Skye Hospital Services Review’ of the “Skye, Lochalsh and South West Ross Initial Agreement v26 10th October 2016” Figure 10. Subareas within the SLSWR catchment area
On discharge inpatients are not eligible for transport by the Scottish Ambulance Service in either emergency or non-emergency transport, unless there is a clinical need to be transported by an ambulance (see Section 1.4.4 for non-emergency eligibility criteria). The majority of patients are driven home by friends or family members in private cars. However, a sizeable minority have no access to a car to get home and so are reliant on public transport, community transport, taxi or specialist transport services often provided by voluntary organisations.
The proportion of patients without access to private transport increases with age. Across the whole SLSWR area, 43% of those over 80 have no access to a car but this drops to 14% for those aged 70-79, 9% for those aged 60-69 and 8% for those under 60 years old. For the breakdown by sub-area see Table 7 9 . This data relates to access to a car in normal circumstances, however upon discharge from hospital patients will not have access to their own car at the hospital: some who normally have access to a car will have partners who pick them up; some will have friends or family who are able to pick them up for a one-off trip; but others will not have access to private transport for the journey home. Equally some who normally have no access to a car will have friends or family who are able to pick them up for a one-off trip home from the hospital. On balance, the proportion without access to private transport for the journey home from hospital is assumed to be reasonably reflected by the data in Table 7.
Table 8 summarises, for those who have no access to private transport, the percentage from each sub-area who state that it is ‘not at all’ or ‘not really’ easy to access public transport to get to and from Broadford. This shows the majority of those from the North of Skye, without access to private transport, find it difficult to access Broadford by PT regardless of age.
9 Based on Skye, Lochalsh and South West Ross (SLSWR) public consultation survey on proposed changes to Health Services (2014) which had 2273 responses, equivalent to 195 of population over 16 years of age. Table 7. Proportion of population with no access to car by age and area Population10 % No access to car Over 80 70-79 60-69 Under 60 Portree Area 2850 73% 23% 11% 9% North East Skye 2289 50% 27% 9% 6% North West Skye 1477 25% 14% 8% 6% Rest of SLSWR 3393 40% 9% 7% 8% Location not indicated 4135 44% 19% 14% 14% Entire SLSWR area 14144 43% 14% 9% 8%
Table 8. Percentage of those without access to private transport stating difficulty accessing Broadford by public transport % of those with no access to car who state it is ‘not at all’ or ‘not really’ easy to access PT to get to and from Broadford Over 80 70-79 60-69 Under 60 Portree 73% 50% 71% 87% North East Skye 100% 75% 75% 86% North West Skye 75% 100% 100% 83% Rest of SLSWR 72% 63% 36% 44% Location not indicated 73% 47% 35% 48% SLSWR area 75% 59% 48% 57%
Table 9 provides a similar breakdown for ease of accessing community transport services. This shows that community transport is less available in the North East and North West areas of Skye (about 70% of those without access to private transport stating it to be ‘not at all’ or ‘not really’ easy to access community transport services, compared to about 50% in Portree and the rest of Skye, Lochalsh & South West Ross). It is also less available for younger residents (80-90% of under 60s across the entire SLSWR region stating it to be ‘not at all’ or ‘not really’ easy to access community transport services), most likely due to limitations on use of these services for specific purposes or restrictions on use according to age or mobility status. These services, where they do exist, generally provide for social and shopping trips and not trips to access hospital.
Table 9. Percentage of those without access to private transport stating difficulty accessing community transport services % of those with no access to car who state it is ‘not at all’ or ‘not really’ easy to access community transport services Geographical area Over 80 70-79 60-69 Under 60 Portree 50% 50% 80% 85% North East Skye 71% 67% 67% 83% North West Skye 67% 100% 100% 80% Rest of SLSWR 48% 60% 75% 85% Location not indicated 73% 57% 67% 92% SLSWR area 58% 63% 77% 86%
The proposed service redesign involves the removal of inpatient beds from Portree Hospital, with all future admissions previously made to Portree going directly to Broadford. As a result, there will be no inpatient transfers to Portree Hospital and patients currently discharged from
10 Populations derived from 2011 Census data: http://www.scotlandscensus.gov.uk/news/census-2011- population-and-household-estimates-scotland-release-1c Portree will be discharged from Broadford instead. For those living in the Portree area and the North of the Island this will involve a longer journey home. Analysis combining the data contained in Tables 1 to 4 enables estimates of the annual number of inpatients that will be immediately affected by the service redesign and the changes they will experience to their journey home upon discharge. This is presented in Table 10.
In summary, the direct impacts of the changes associated with inpatient beds in the service redesign on inpatient discharge will be (per annum):
. 191 patients (from the Portree and NE Skye areas) will require to travel an additional 40 minutes by private car on discharge and their friends or family will be required to travel an additional 2 x 40 minutes to collect them additional 362 person hours per annum. . 66.5 patients (from the NW Skye area) will require to travel an additional 40 minutes by private car on discharge and their friends or family will be required to travel an additional 2 x 40 minutes to collect them additional 66.5 person hours per annum. . 56.5 patients (from the Portree and NE Skye areas) will require to travel an additional 45 minutes by specialist transport on discharge . 7.5 patients (from the NW Skye area) will require to travel an additional 25 minutes by specialist transport on discharge . 17 additional patients (from the Portree and NE Skye areas) will require specialist transport taking 45 - 75 minutes per trip . 7 additional patients (from the NW Skye area) will require specialist transport taking 60 - 80 minutes per trip . 0.5 patients (from the Rest of SLSWR area) no longer need specialist transport removing 40 - 60 minutes per trip
Based on a similar analysis conducted on patients currently admitted to Broadford Hospital it is estimated that each year 120 patients currently require specialist transport on discharge from Broadford hospital: 28 of these to the Portree area, 22 to North East Skye, 10 to North West Skye and 58 to other locations in SLSWR.
Following redesign, the total number of specialist transport discharge trips required to Portree area will be 72 per annum, 58.5 discharge trips to NE Skye per annum and 17.5 discharge trips per annum to North West Skye. Table 10. Inpatient discharge trips impacted by the service redesign
Travel opportunities Current Redesign inpatient inpatient Home location of Annual admissions % of those withno % of those withno discharge discharge Age group inpatient to Portree Hospital % with no car number with car access who find car access who find door to door door to door access no car access it difficulttouse PT itdifficultto use PT transport trips transport trips to access Portree to access Broadford required required
149 under 60 17% 25.3 9% 2.3 47% 87% 1.1 2.0 Portree Area 60-69 13% 19.4 11% 2.1 71% 71% 1.5 1.5 70-79 24% 35.8 23% 8.2 25% 50% 2.1 4.1 over 80 46% 68.5 73% 50.0 45% 73% 22.5 36.5 Area sub-total 27.2 44.1 Total 122 under 60 17% 20.7 6% 1.2 71% 86% 0.9 1.1 North East Skye 60-69 13% 15.9 9% 1.4 25% 75% 0.4 1.1 70-79 24% 29.3 27% 7.9 50% 75% 4.0 5.9 over 80 46% 56.1 50% 28.1 86% 100% 24.1 28.1 Areasub-total 29.3 36.1 Total 54 under 60 17% 9.2 6% 0.6 67% 83% 0.4 0.5 North West Skye 60-69 13% 7.0 8% 0.6 75% 100% 0.4 0.6 70-79 24% 13.0 14% 1.8 100% 100% 1.8 1.8 over 80 46% 24.8 25% 6.2 75% 75% 4.7 4.7 Areasub-total 7.3 7.5 Rest of SLSWR Total 20 under 60 17% 3.4 8% 0.3 71% 44% 0.2 0.1 60-69 13% 2.6 7% 0.2 59% 36% 0.1 0.1 70-79 24% 4.8 9% 0.4 88% 63% 0.4 0.3 over 80 46% 9.2 40% 3.7 78% 72% 2.9 2.6 Areasub-total 3.6 3.1 GRAND TOTAL 67.3 90.9 2.4 Inpatient visitors The number of inpatient visitor trips per week for each inpatient can vary widely from patient to patient based on various factors including the patient’s age, whether they have family members living in the area, how close their circle of friends lives to the hospital, etc. During an interview with the Senior Charge Nurse for Portree and Broadford hospitals, it was established that most inpatients in Portree will receive a visitor on most days, with some patients receiving more than one visitor per day. However, it is unlikely that all these visitors would be able and willing to visit as frequently if the journey involved at least an extra 40 minutes travel time in each direction to and from Broadford hospital rather than Portree hospital. As a result, two scenarios for the demand for inpatient visitor trips have been considered: 1) one visit per day and 2) one visit every other day for each inpatient.
The proportion of visitors without their own means of getting to the hospital depends on the age of the visitor and the locations they are travelling from. Of course, not all visitors will be of a similar age to the inpatient or reside in the same location as the inpatient. In the absence of better data, we assume that half the visitors are likely to be friends or partners of similar age to the inpatient and the other half are likely to be family members under 60 years old. We also assume that they all reside in the same sub-area as the inpatient they are visiting.
The number of visits per annum then depends on the number of inpatient admissions and the average length of stay in hospital of the inpatient. Figure 11 shows that the average length of stay as an inpatient at MacKinnon Memorial Hospital Broadford has remained at just under 4 days for each of the years between 2008/2009 and 2012/2013. The average length of stay at Portree Hospital has increased from 7.6 days in 2008/2009 to 11.5 in 2012/2013. Discharges can be delayed due to lack of capacity in care homes. Table 11 gives the breakdown by age for length of stay for the most recent year of data (2012/2013). Table 12 presents the estimated number of visitor trips per patient to both hospitals based on each of the ‘1 visitor per day’ and ‘one visitor every other day’ scenarios.
Figure 11. Average Length of Stay at Skye Hospitals, Year ending 31st March 2009 to 2013, GP beds only. Source: SMR01, NHS Highland Service Planning Table 11 Average length of inpatient stay by age11
Portree Broadford Age Range Hospital Hospital
Under 60 3.4 1.8 60-69 9.8 2.9 70-79 11.1 3.6 Over 80 15.3 7.3 Average 11.5 3.6
Table 12. Estimated number of visitor trips per patient12
Age Range Portree Hospital Broadford Hospital Every Every Every Every day other day day other day Under 60 4 2 2 1 60-69 10 5 3 2 70-79 12 6 4 2 16 8 8 4 Over 80 12 6 4 2 Average
Table 13 presents annual estimates of the demand for inpatient visitor transport and the modes of travel used to access hospital combining the data contained in
Area Population Annual admissions to Annual admissions to Total admissions Portree hospital Broadford hospital to Skye hospitals Number % of Number % of as % of population population population Portree and 5139 271 5.3% 265 5.1% 10.4% North East Skye North West 1477 54 3.7% 95 6.4% 10.1% Skye Table 5,
Table 6, Table 7, Table 8 and Table 12; and applying the assumptions mentioned earlier regarding age and home location of visitors and assuming ‘one visit every other day’. In summary, the direct impacts of the service redesign on inpatient visitor trips is estimated to be (per annum):
. 1219 visitors trips per annum (from the Portree and NE Skye areas) will be required to travel an additional 40 minutes by private car each way additional 1625 person hours per annum. . 288 visitors trips (from the NW Skye area) will require to travel an additional 20 minutes by private car each way additional 192 person hours per annum. . 101 visitors trips (from the rest of Skye, Lochalsh and South West Ross area) will save 40 minutes travel time by private car each way saving of 135 person hours per
11 Data derived from ‘Appendix 2 - Skye Hospital Services Review’ of the “Skye, Lochalsh and South West Ross Initial Agreement v26 10th October 2016” 12 ensuring the possibility of patients receiving a visitor every other day annum. . 92 visitor trips by public transport (from the Portree and NE Skye areas) will be required to travel an additional 45 - 75 minutes each way. . 278 visitor trips (from the Portree and NE Skye areas) will be required to travel an additional 45 minute journey time by specialist transport services each way. . 17 visitor trips (from the NW Skye area) will require to travel an additional 25 minutes by specialist transport services each way. . 105 additional visitor trips (from the Portree, NE Skye and NW Skye areas) will require specialist transport taking 45 - 75 minutes per trip each way.
Based on a similar analysis conducted on visitors to patients currently admitted to Broadford Hospital, it is estimated that each year 587 return trips per annum from North Skye currently require specialist transport to visit inpatients at Broadford hospital: 220 of these from the Portree area, 179 from the North East Skye, and 168 from North West Skye.
Following redesign, the total number of specialist transport trips required by visitors will be: . 220 (current) + 200 (new) = 420 return trips per annum from the Portree area; . 179 (current) + 153 (new) = 332 return trips per annum from the North East Skye area; . 168 (current) + 34 (new) = 202 return trips per annum from the North West Skye area.
This forms the basis of the demand for a new door to door service from the North of the Island to Broadford Hospital proposed in Section 3. Table 13. Inpatient visitor trips impacted by the service redesign
Travel opportunities Current: Redesign: Average Redesign: Redesign: Number of Number of Number of Visitor number of Number of Number of Home location of Annual admissions return Number of %of those withno %of those withno visitor trips visitor trips Age group profile by visitor visitor trips visitor trips inpatient to Portree Hospital visitor trips % with no return visitor car access who find car access who find requiring door requiring door age trips per using private using Public by age car access trips with no it difficulttouse PT it difficulttouse PT to door to door patient car Transport car access to access Portree to access Broadford transport transport
149 under 60 17% 25.3 59% 2.0 480.5 9% 43.2 47% 87% 20.3 37.6 437.3 5.6 Portree Area 60-69 13% 19.4 7% 5.0 48.4 11% 5.3 71% 71% 3.8 3.8 43.1 1.5 70-79 24% 35.8 12% 6.0 107.3 23% 24.7 25% 50% 6.2 12.3 82.6 12.3 over 80 46% 68.5 23% 8.0 274.2 73% 200.1 45% 73% 90.1 146.1 74.0 54.0 Area sub-total 120.3 199.8 637.0 73.5 Total 122 under 60 17% 20.7 59% 2.0 393.5 6% 23.6 71% 86% 16.8 20.3 369.8 3.3 North East Skye 60-69 13% 15.9 7% 5.0 39.7 9% 3.6 25% 75% 0.9 2.7 36.1 0.9 70-79 24% 29.3 12% 6.0 87.8 27% 23.7 50% 75% 11.9 17.8 64.1 5.9 over 80 46% 56.1 23% 8.0 224.5 50% 112.2 86% 100% 96.5 112.2 112.2 0.0 Area sub-total 126.0 153.0 582.3 10.1 Total 54 under 60 17% 9.2 59% 2.0 174.2 6% 10.4 67% 83% 7.0 8.7 163.7 1.8 North West Skye 60-69 13% 7.0 7% 5.0 17.6 8% 1.4 75% 100% 1.1 1.4 16.1 0.0 70-79 24% 13.0 12% 6.0 38.9 14% 5.4 100% 100% 5.4 5.4 33.4 0.0 over 80 46% 24.8 23% 8.0 99.4 25% 24.8 75% 75% 18.6 18.6 74.5 6.2 Area sub-total 32.1 34.1 287.8 8.0 Total 20 under 60 17% 3.4 59% 2.0 64.5 8% 5.2 71% 44% 3.7 2.3 59.3 2.9 Rest of SLSWR 60-69 13% 2.6 7% 5.0 6.5 7% 0.5 59% 36% 0.3 0.2 6.0 0.3 70-79 24% 4.8 12% 6.0 14.4 9% 1.3 88% 63% 1.1 0.8 13.1 0.5 over 80 46% 9.2 23% 8.0 36.8 40% 14.7 78% 72% 11.5 10.6 22.1 4.1 Area sub-total 16.6 13.8 100.6 7.8 GRAND TOTAL 295.1 400.8 1607.7 99.4 Transport to Health Assessment for Skye, Lochalsh and South West Ross January 2018
2.5 Outpatient appointments The presence of suitable transport options for outpatients is important in facilitating travel for outpatients to get to their appointments. It is also important because a proportion of missed appointments can be attributed to there being a lack of suitable transport options in some cases, and these missed appointments are a significant cost to the NHS. Table 14 shows the number of missed appointments at the community hospitals in Broadford and Portree between April 2015 and March 2016.
Table 14. Number of missed appointments at community hospitals in Broadford and Portree: April 2015 - March 2016
Hospital location Total number of Number of missed % of appointments appointments appointments missed Broadford 2774 211 7.6 Portree 1889 212 11.2
Although there is the opportunity in the future to deliver more outpatient appointments through advances in telemedicine, in the short term there are no significant changes resulting from the proposed service redesign to the location and delivery of outpatient appointments. Nevertheless, it is still worth examining the demand for door-to-door services to access outpatient appointments at Portree and Broadford and to assess whether they could be linked to the new inpatient and visitor travel demand.
Outpatient appointments can be scheduled for any time of day (0800 to 1700) or any day of the week (Monday – Friday). They are planned according to the availability of the clinical professionals and not based on the transport availability of patients.
Over 75% of outpatient appointments attended by residents of SLSWR are to Inverness or other Highland Hospitals and not to Broadford or Portree. Only 9.6% of outpatient appointments for SLSWR residents are seen at Portree and 13.6% at Broadford. Of these, over 85% access their appointment by private car.
So, taking account of residential location; age of patient; access to private car; and difficulty using PT, it is estimated that only just over 6 return trips per week for the entire SLSWR area require door-to-door transport (or 10 trips per week if we assume that no one can use public transport) to access their outpatient appointment. Table 15 shows the geographical distribution of these door-to-door trips to each hospital (refer to Figure 1 for the area locations).
This suggests that on average less than 1 trip per week would be expected from each sub- area with the exception of Portree and NE Skye areas where up to 1.5 trips per week could be expected from outpatients requiring door-to-door transport. As these trips could be at any time of day when outpatient clinics are seeing patients and potentially any day of week (Mon – Fri) it would be impossible to coordinate these trips into any planned transport service. However, a volunteer car service could be a very feasible and flexible solution to provide this transport without the need for many volunteers from each area (see last column of Table 15).
32 Transport to Health Assessment for Skye, Lochalsh and South West Ross January 2018
It is recognised that there will always be passengers with very special needs who can’t use such a service. In such cases non-emergency PTS or wheelchair accessible taxis should be considered as an alternative option.
Table 15. Outpatient return trips per week requiring door-to-door transport
To To TOTAL Volunteer PORTREE BROADFORD trips per drivers needed if hospital hospital week each provides 1 trip per month Portree Area 0.88 0.59 1.47 6 NE Skye 0.79 0.52 1.31 5 NW Skye 0.49 0.34 0.83 4 Skye Central: West, East & 0.17 0.47 0.64 3 Raasay
Broadford and South Skye 0.27 0.68 0.95 4 Lochaber 0.07 0.73 0.8 4 South West Ross 0.01 0.07 0.08 1
3 Overcoming gaps in transport provision through a new specialist door-to-door service 3.1 Estimated level of demand for a dedicated door-to-door service Section 2 has utilised data on inpatient bed use at both Portree and Broadford hospitals and combined this with data from the 2014 public consultation surveys (completed by 19% of the adult population of SLSWR) to establish the inpatient demands and visitor demands for transport to Broadford hospital (following the redesign of inpatient facilities) by different mode according to age group and residential location.
This has established the demand for post-service redesign door-to-door transport provision for both inpatient discharges from Broadford hospital and for visitor access to and from Broadford hospital. Table 16 summarises these demands for inpatient discharges.
Table 16. Estimated discharged inpatient demand for dedicated door-to-door transport to/from Broadford hospital to North Skye following service redesign
Inpatient discharge dedicated transport service demand Portree Area North East North West Skye Area Skye Annual trip demand 72 58.5 17.5 Weekly trip demand 1.4 1.1 0.34
It is clear from Table 16, that following the redesign of inpatient services, the demand for a dedicated door-to-door service for transporting discharged inpatients from Broadford to the Portree area and the rest of the North of the Island is likely to be very low. Taken in
33 Transport to Health Assessment for Skye, Lochalsh and South West Ross January 2018 isolation, this level of demand could be met with a relatively low cost through the use of subsidised taxis or existing community bus and volunteer car services which currently operate on the Island (see Section 1.4.4).
However, the demand for a dedicated door-to-door service for visitor transport is likely to be more significant, as illustrated in Table 17. This shows the estimated level of demand for a dedicated door-to-door service generated from each inpatient in the two scenarios (i.e. each inpatient receiving a visit every day or every other day). It assumes the level of visitor access to private transport and their ability to use public transport is based on their age and home location as indicated in Section 0. One visit every other day is likely to reflect a minimum level of demand for such a service while one visit every day is likely to reflect a maximum level of demand from inpatient visitors.
Table 17. Estimated visitor demand for dedicated door-to-door transport to/from Broadford hospital to North Skye following service redesign
Inpatient visitor dedicated transport service demand Portree Area North East North West Total Skye Area Skye 1 visit 1 visit 1 visit 1 visit 1 visit 1 visit 1 visit 1 visit every per every per every per every per other day other day other day other day day day day day Annual trip demand 420 840 332 664 202 404 954 1908 Weekly trip demand 8.1 16.2 6.4 12.8 3.9 7.8 18.4 36.8
If inpatients received one visit per day, the demand for a dedicated door-to-door service from the North of the Island to Broadford would total 36.8/7 = 5.25 return journeys per day (since visiting is 7 days per week). The existing community and voluntary bus and car services operating on the Island, in particular in the North of the Island (see Section 1.4.4), do not have sufficient capacity, resources or coordination capability to respond to such demands.
However, the level of estimated demand (Table 17) suggests that a new dedicated door-to- door bus service could be considered as an option to serve the North of the Island and Portree in providing visitor access to Broadford hospital.
Given the geography of the North of the Island and the distances and roads in between settlements, it would not be feasible to serve the entire area with a single bus, since travel times would be intolerable; e.g. travel from Lower Milovaig in the North West via Uig and Staffin in the North East to Broadford would take close to 3 hours each way by minibus even without any deviations for pickups off the direct route. To limit travel times to reasonable levels, it is necessary to split the North West and the North East areas into two separate operating areas, however the estimated level of demand does not justify running two separate dedicated door-to-door bus services on a daily basis A suggested service outline would be to operate in the North East and Portree area on Mondays, Wednesdays, Fridays and Sundays, and the North West and Portree area on Tuesdays, Thursdays and Saturdays. This provides door-to-door access to Broadford hospital every other day from the North West and North East areas and door-to-door access to Broadford hospital every day from the Portree area. With carefully planned timetabling, this service can double up as a door-to-door shopper bus, for residents from the North West and North East areas, dropping off shopping
34 Transport to Health Assessment for Skye, Lochalsh and South West Ross January 2018
passengers in Portree before carrying on to Broadford hospital. GP appointments could also be coordinated to coincide with the drop-offs and pickups from either Dunvegan or Portree medical practices. There are no set inpatient visiting times at Broadford hospital but advice from the Ward Manager is that the time immediately after lunch is best as patients have been fed and are most likely to be awake and receptive to visitors. Therefore, an arrival time at Broadford hospital of around 1pm to 1.30pm can be considered optimal. A visiting time of around 1.5 hours is recommended, since it allows visitors ample time with their friends or relatives, and also gives time for the driver to have a lunch break. This layover time at Broadford could also be put to good use to take discharged patients from Broadford hospital to the area south of Broadford as and when needed, or pick up severely mobility-impaired visitors from the Broadford area for a shorter visiting period. Visitors from the North return on bus to Portree, picking up shoppers, then onwards to the North East or North West depending on which day of the week it is. Assuming the Portree area demand is spread evenly across the week, then the estimated level of demand would be 5.51 return visitor trips each Monday, Wednesday, Friday and Sunday; and 4.91 return visitor trips each Tuesday, Thursday and Saturday. Discharged inpatients may also be transported home by the vehicle if the discharge days and timings coincide with the bus service operation.
3.2 Service Timings Suggested timings for the proposed door-to-door bus service are given below. Note that the bus must be pre-booked and will only operate if bookings are received in advance. The timings and locations below only depict the core route, passengers can book to be picked- up/dropped-off from any location surrounding the core route. Monday/Wednesday/Friday/Sunday Timings (core service with shorter 1 hour advance booking requirements highlighted in blue, other stops, identified in grey, require pre-booking at least 2 hours in advance of travel):
o 11.00 a.m. in Staffin if booked at least 2 hours in advance (travel anticlockwise); o 11.15 a.m. in Kilmaluag; o 11.35 a.m. in Uig; o 12.00 (to 12.30) p.m. arrive in Portree depending on number/location of pickups; o 12.45 (to 1.15) p.m. arrive in Broadford; . 1.5 to 2 hours visiting . Driver lunch + possible local pick-ups/drop-offs around Broadford area o 2.45 p.m. depart Broadford; o 3.30 p.m. arrive Portree o 4.00 p.m. arrive Uig; o 4.20 p.m. arrive Kilmaluag; o 4.35 (to 5.00) p.m. arrive Staffin depending on number/location of drop-offs.
Tuesday/Thursday/Saturday Timings (core service with shorter 1 hour advance booking requirements highlighted in blue, other stops require pre-booking at least 2 hours in advance of travel): o 11.00 a.m. in Lower Milovaig if booked at least 2 hours in advance; o 11.30 a.m. in Dunvegan;
35 Transport to Health Assessment for Skye, Lochalsh and South West Ross January 2018
o 12.00 (to 12.30) p.m. arrive in Portree depending on number/location of pickups; o 12.45 (to 1.15) p.m. arrive in Broadford; . 1.5 to 2 hours visiting . Driver lunch + possible local pick-ups/drop-offs around Broadford area o 2.45 p.m. depart Broadford; o 3.30 p.m. arrive Portree o 4.00 (to 4.15) p.m. arrive Dunvegan o 4.30 (to 5.00) p.m. arrive Lower Milovaig depending on number/location of drop-offs.
The above suggested timings would also allow for connection for pre-booked passengers at Sconser to and from the Raasay ferry on a Monday to Saturday, allowing foot passengers the option to use the service to visit patients in Broadford.
3.3 Service Operating Characteristics 3.3.1 Service Licensing It is recommended that the service be registered as a Section 22 service, using paid drivers and operated through a community transport company who would coordinate the bookings, scheduling of the service and handle the day-to-day operations management. The Section 22 Permit allows for the carriage of members of the public in return for a fare on a ‘not for profit’ basis. It also allows for the hiring out of the transport services using the vehicle, outwith the registered route, on a commercial basis to give access to other revenue streams to help support the local bus service. This could be possible in the evenings for use by clubs and societies in the Portree area and the North of the Island. The definition of a Section 22 permit is given below.
Definition of a Section 22 Permit - The scheme is mandated for local bus services to be run on the basis of need and to service the welfare and social requirements of a local community. It is not designed for commercial bus operators. There is however no compulsion to simply ‘break even’. It is permissible to achieve a surplus of revenue over expenditure through the popularity of the service or close financial management. The regulations allow for this providing the excess is retained for service improvements or a contingency fund. The over-riding principle is that these revenues must not be used for any other purpose.
3.3.2 Service Design The service should operate based around the routes and timings as outlined in the previous section. However, the service will only operate when booked in advance. Passengers whose home address is along or near the core service (in blue) require pre-booking at least 1 hour in advance of travel. Pick-up from home addresses beyond the core service route (i.e. the stops in grey) requires pre-booking at least 2 hours in advance of travel. It is important to keep this pre-booking requirement as short as possible since patients do not plan in advance when they take ill and so visiting family and friends may not know until the day of travel that
36 Transport to Health Assessment for Skye, Lochalsh and South West Ross January 2018 they need to go to the hospital. It is suggested that the administration of the service, and the service booking and scheduling be provided by staff from a suitable community transport group (to be identified).
3.3.3 Competition In order to avoid conflict with the commercial service Stagecoach #52 between Portree and Broadford, this section of the journey will only allow pick-up in Portree of residents who live more than 400 metres from the existing Stagecoach Service 52 bus stops or who have mobility difficulties preventing them from using the #52 Stagecoach Service. Drop-off of passengers from Portree will only be to Broadford hospital and not to anywhere else in Broadford.
3.3.4 Vehicle There is a requirement of the Section 22 permit that the vehicle must carry at least 9 passengers otherwise it falls within Taxi legislation. If the vehicle has a capacity of more than 12 passengers then it must adhere to the more stringent Public Service Vehicle regulations. If the vehicle carries between 9 and 12 passengers these rules are simplified and the vehicle can be driven without the need for a PCV licence. The requirement of the driver also holding a CPC (Certificate of Professional Competence13) is also removed. This would have the effect of easing any recruitment problems with relation to the driver. The vehicle can be driven on an ordinary car licence providing the driver passed their driving test prior to 1st January 1997. Before that time a category D (Minibus) authorisation was automatically given. If the test was passed after that date the driver can still drive the vehicle but cannot be paid for their services until they have upgraded the licence to the D (Minibus) category. This upgrade can be obtained through the satisfactory completion of a short course.
It is suggested that the vehicle used should be a wheelchair accessible bus with a hydraulic tail lift. A standard long wheelbase 15-seat Ford Transit minibus converted to remove the rear 4 or 5 seats14 should provide the necessary space for an electric wheelchair at the rear of the vehicle and provide extra space for shopping.
3.3.5 Driver Regulations The timings depicted above fall within the restrictions for PCV driving hours15 as long as a 30 minute lunch break is taken while in Broadford. This is the case even if 1hour empty running is required to and from the Depot at the start and end of each day.
13 https://www.gov.uk/driver-cpc-training/how-much-training-you-need-to-do 14 For example: http://minibus-online.co.uk/vehicle-details.php?productid=2500 15 https://www.gov.uk/drivers-hours/gb-domestic-rules
37 Transport to Health Assessment for Skye, Lochalsh and South West Ross January 2018
3.3.6 Depot Due to the pre-booking requirements, the vehicle could be based anywhere in the North of the Island including Portree, as it would be possible to get to any pickup point within the 1 or 2 hour notice period.
3.3.7 Fares Fares charged will need to be set at a similar level to those charged by other public bus services on the Island. Stagecoach dayrider tickets which offer all day travel and cover the entire island are £8.85 for adults. A similar adult fare will need to be charged for this dedicated door-to-door service. Concessionary pass holders travel for free and based on the analysis presented in Table 9 it is estimated that 83% of visitor trip demand for the dedicated door-to-door service are over 60 and therefore entitled to free travel. Of the remaining 17% it is probable that a significant proportion will be registered disabled and therefore also entitled to free travel.
3.4 Estimated Costs and Revenues 3.4.1 Capital costs16 The estimated capital costs for the service are as follows:
Initial capital costs for vehicle purchase = £30,000 Interest payments on loan @ 5% APR Value after 5 years = £5000 Total purchase cost including interest depreciated over 5 years = £6657 per annum.
3.4.2 Staff costs The core service operating times amount to approximately 4.5 hours per day. However, there is the possibility that they will be extended by up to 45 minutes either side of this to accommodate bookings outside of the core route. It is also the case that empty running time at the start and end of the day between the depot and the first pick-up or last drop-off may amount to another 45 minutes at either end of the day. As a result, a driver would need to be contracted for a 7.5 hour day, seven days per week. It is more realistic that two part-time drivers would need to be employed, working 4 days and 3 days respectively. This would allow for holiday and sickness cover as well.
Without the need for additional driving qualifications it is expected that the National Living Wage of £8.45 per hour would attract suitable drivers. With an hourly rate of pay of £8.45 per hour, this would cost £23,068 per annum.
Building in 4 weeks holiday for each employee would require an additional £1,922 per annum.
16 See for example: http://minibus-online.co.uk/vehicle-details.php?productid=2500
38 Transport to Health Assessment for Skye, Lochalsh and South West Ross January 2018
Total driver costs = £24,990 per annum
It is suggested that the administration of the service and the service booking and scheduling be provided by staff from a suitable community transport group (to be identified). While this may benefit from the use of volunteers for some of the week and utilise available capacity of existing staff, it is likely that costs will be incurred to secure staff for weekend shifts and to provide 40% resource for existing paid staff time during the week. As result it is estimated that paid administration staff are required for 7.5 hours per day on both Saturdays and Sundays and for 40% of 7.5 hour days Monday to Friday. If they are also paid at the Living Wage of £8.45 per hour, this would result in additional staff costs of £13,182 per annum.
Total administration staff costs = £13,182 per annum
3.4.3 Fuel costs The suggested service is an on-demand service which requires pre-booking. As a result, it will only operate when a booking has been made. Whilst it is not known where and when bookings will actually occur, the demand analysis conducted above suggests a likely demand of an average of 7 passengers per day. The furthest possible journey to Broadford (i.e. from Lower Milovaig on Tuesday, Thursday or Saturday; or from Staffin or Kilmaluag on Monday, Wednesday, Friday or Sunday) would be under 50 miles each way. Whilst bookings from these furthest points are not likely to be common, deviations from the most direct route are probable and so it is not unreasonable to assume a daily distance of 50 miles each way on each day. It is also unknown where the bus would be located overnight and therefore 20 miles each way empty running at the start and end of the day should be assumed.
This would result in a total daily mileage of 140 miles.
At the time of writing (3rd July 2017) the price of diesel in Portree was 116.9p per litre and in Uig it was 120p per litre. Taking an average of 118p per litre and applying a fuel consumption rate of 5.53 miles per litre (8.9km per litre) for a typical 15 seat Ford Transit minibus, the service would require 140 / 5.53 = 25.3 litres of diesel per day.
At a price of 118p per litre this would cost £29.85 per day or £10,865 per annum.
Total fuel costs = £10,865 per annum
3.4.4 Vehicle Maintenance/Servicing, License, Insurance and other costs Servicing, inspections and repairs are likely to cost no more than £2000 per annum.
Insurance costs are likely to be around £2000 per annum with other licensing costs and admin costs amounting to no more than £500 per annum.
Total other costs = £4,500 per annum
39 Transport to Health Assessment for Skye, Lochalsh and South West Ross January 2018
3.5 Revenues 3.5.1 Fare Revenues The concessionary travel scheme pays a total of 60% of the adult fare for each concessionary entitled journey. Assuming an adult fare of £8.85 and 90% of visitor trip passengers are entitled to concessionary fares, then fare revenues from visitor trips are estimated to be:
Mon, Wed, Fri and Sun; (£8.85 x 5.51 trips per day x 90% x 0.6) + (£8.85 x 5.51 trips per day x 10%) = £31.21 per day
Tues, Thurs, Sat; (£8.85 x 4.91 trips per day x 90% x 0.6) + (£8.85 x 4.91 trips per day x 10%) = £27.81 per day
Visitor fares = £10,830 per annum
It is also likely that a significant number of passengers will use the service to access Portree from the North of the Island for shopping and other purposes (e.g. GP appointments). The demand for this is less certain but is likely to be, on average at least 2 passengers per day. If a lower return fair was charged for these journeys of £6.50 and 80% of travellers were concessionary entitled, then the fare revenues expected from these trips are estimated to be:
Mon, Wed, Fri and Sun; (£6.50 x 2 trips per day x 80% x 0.6) + (£6.50 x 2 trips per day x 20%) = £8.84 per day
Tues, Thurs, Sat; (£6.50 x 2 trips per day x 80% x 0.6) + (£6.50 x 2 trips per day x 20%) = £8.84 per day
Shopping fares = £3,218 per annum
3.5.2 BSOG grant Bus Service Operators Grant is a rebate on the fuel duty for local bus service mileage paid by the Scottish Executive. The rate of reimbursement is 14.4p per km for all registered service miles. For on-demand services this includes mileage recorded between pre-booked passengers. Assuming a service mileage of 160 km per day (50 miles each way per day as outlined in the fuel costs section), the BSOG grant would amount to 160km x 14.4p/km = £23.04 per day or £8387 per annum.
BSOG grant = £8,387 per annum
40 Transport to Health Assessment for Skye, Lochalsh and South West Ross January 2018
3.6 Summary of Costs and Revenues and annual subsidy required from NHS Highland to support the service. Table 18 summarises the estimated costs and revenues for the proposed new service. This includes the cost of a loan for the initial vehicle purchase depreciated over 5 years. With no upfront capital costs, the annual subsidy requirements would be £37,759.
Alternatively, a one-off capital payment of £30,000 could be provided for vehicle purchase (grants may be available from Scottish Government for this17) and an annual subsidy for service operation of £31,102 would be required. After 5 years the minibus would have a second-hand resale value of approximately £5000.
Table 18. Annual Costs and Revenues for proposed new bus service Costs (per annum) Revenues (per annum)
Driver costs £24,990 Visitor fares £10,830 Admin staff costs £13,182 Shopping fares £3,218 Fuel costs £10,865 BSOG grant £8,387 Other costs £4,500 Vehicle purchase £6,657 TOTAL £60,194 TOTAL £22,435
4 Future transport needs assessment There are various factors affecting hospital admissions in the SLSWR area in the future. It has already been noted in Section 1.1 that Skye, Lochalsh and South West Ross has a much older population than average for the Highlands, and that this is set to become more pronounced in the future. An older population will naturally require a greater level of medical provision.
It is predicted that the proportion of the population over 65 is set to increase from 22% up to 40% by 2037. The proportion of inpatients over 65 accounts for around 75% of all current admissions. The growth in elderly population is likely to result in a doubling of inpatient admissions by 2037, with over 87% of admission being those over 65. Since this group of the population are the least likely to have access to car and also find using public transport most difficult, the demand for emergency ambulance transport for admissions and for door- to-door transport on discharge, outlined in Section 2, will more than double if all other conditions remain constant. However, there are several measures planned as part of the service redesign which should lessen the need for transport to hospital. There is the opportunity in the future to deliver more outpatient appointments through advances in telemedicine. There are planned improvements in care at home and community-based delivery, which should help to reduce hospital admissions. Improved coordination between hospitals and care homes has the potential to avoid delayed discharges and reduce lengths of stay in hospitals.
17 See, for example, Transport Scotland’s Bus Investment Fund: https://www.transport.gov.scot/public-transport/buses/bus-investment-fund/#45522
41 Transport to Health Assessment for Skye, Lochalsh and South West Ross January 2018
In order to offset the increased admissions resulting from an increasingly aged population, these measures would need to mitigate over 50% of hospital admissions going forward. Without more detailed plans and better data on the provision of these services it is not possible to judge whether this level of inpatient admission mitigation is realistic.
5 Summary of specific recommendations The measures that have been recommended to be put in place to best accommodate the changes to transport to health in Skye, Lochalsh and South West Ross are as follows:
1. Consideration of the feasibility of establishing a dedicated door-to-door minibus service to cover the North of Skye in facilitating trips to the new hospital in Broadford. This would be an on-demand but semi-fixed-route service covering the North West of Skye to Portree and onward to Broadford Hospital on Monday, Wednesday, Friday and Sunday; and the North East of Skye to Portree and onward to Broadford Hospital on Tuesday, Thursday and Saturday. The service would be primarily aimed at visitors to inpatients in Broadford, but could also be potentially used for inpatient discharges as well as other purposes such as shopping trips in Portree. The service would generate some revenue but would need to be subsidised. 2. In addition, it is recommended that the Transport and Access Sub Group with all key Partners, consider establishing a volunteer car service in the SLSWR area for access to outpatient appointments and GP appointments for those with no car access and who find it difficult to access their appointment by other means, such as newly introduced Attend Anywhere: NHS Near Me. 3. Scottish Ambulance Service may need to consider a review of the emergency ambulance cover situation and to assess the impact of a single inpatient site. Additional demands may be placed on the ambulances and crews in the North of Skye, when providing transport for inpatient admissions due to the relocation of inpatient services to Broadford. This may result in additional time when these ambulances and their crews are not available to respond to emergency call outs. 4. Complementary components of the service redesign, such as greater level of care at home, telemedicine, have the potential to mitigate a considerable proportion of the transport demands identified in this report. However, consideration should be given to the actions identified in points 1 to 3 above should the community infrastructure not be sufficiently well developed immediately following the closure of the inpatient ward at Portree Hospital.
Acknowledgements We would like to thank all the people who contributed to this work, in particular those mentioned in Section 1.3.
References
NHS Highland (2014a) Proposed major service change in Skye, Lochalsh and South West Ross: Analysis of the responses to the public consultation survey. November 2014
42 Transport to Health Assessment for Skye, Lochalsh and South West Ross January 2018
NHS Highland (2014b) Proposed redesign of services in Skye, Lochalsh and South West Ross. Highland NHS Board, 2nd December 2014, Item 4.1 NHS Highland (2016) Skye, Lochalsh and South West Ross Initial Agreement v26, 10th October 2016
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