An Approach to Building Sustainability of Health and Care Services in Remote and Rural Areas
Proposal to Cabinet Secretary for Health and Wellbeing
Contents
Executive Summary 3 1 Introduction 4 2 Background 5 3 The Need for Change 13 4 Elements of Success 20 5 The Proposal 23 6 Governance Arrangements 26
Appendices Appendix 1 – Initiatives, cost and funding source and timelines Appendix 2 – Dewar 2012 Mind Map
2 Executive Summary
On December 11 th 2012 NHS Highland received a letter from the Cabinet Secretary for Health and Social Care inviting it to develop and test of models for remote health and care services in Scotland, with outline estimates of:
• Governance arrangements • Expected timelines • Resource requirements
It was also agreed that any recommendations resulting from this work would be expected to:
• Have relevance to all remote areas of Scotland • Reflect the new context of integrated health and social care • Be suitable for testing in rural and urban areas of Scotland
The proposals developed and submitted for consideration by NHS Highland take account of the historical context in establishing and providing services, the extensive research and work undertaken to date re:
• Policy and principles informing and guiding service provision • Rural community viability, resilience, participation and ownership • Partnership arrangements across the public and voluntary sector • Current status of service – issues, resourcing, challenges and solutions • Service proposals with resource implications and timelines • Evaluation methodology and reporting process • Governance arrangements
The proposals developed and submitted for consideration are derived from the acute need to put in place robust and sustainable arrangements that communities, users and stakeholder can “see, feel and touch”. This ensures that there is reassurance about security of service provision within a context of bench testing and implementing redesigned services over the set timescale.
It must be stressed that there will be no single model of service, the proposal will set out principles and key elements for success rather than a blueprint as successful solutions will be grown from local need and local resilience.
The proposals submitted are underpinned by NHS Highland Quality Approach principles and combine a mixture of NHS Highland funded and non recurring funding as detailed. The final selection of initiatives to proceed will be determined once a response has been received from the Scottish Government Health and Care Directorate.
3 1. Introduction
The challenges of delivering safe and sustainable services in remote and rural areas have long been recognised and there is a plethora of reports going back to the Dewar Report of 1912 and more recently, Delivering for Remote and Rural Healthcare in 2007. A fifth of the Scottish population lives in a rural area and of these a significant number live in very remote areas, which necessitate different models of service delivery at a higher proportionate cost to those in more populated areas.
Highland has seventy percent of communities deemed to be part of ‘rural’ Scotland and since 1912 has been the subject of much interest due to the enormity of the challenge of providing public services in a safe and equitable way. Given the history and experience Highland is therefore a good place to explore options for future sustainability. In many respects there has been tremendous success through the Highlands and Islands Medical Service, but that success has brought with it its own challenges in that communities and individuals have become reliant on their very local service, be it doctor, nurse, policeman, fire and rescue , small school or post office. A dependency has therefore been created and it is little wonder that some of these communities find change difficult.
Expectations of communities that have been in receipt of these local services, specifically, those delivered through the NHS are understandably high but for many reasons, including training, revalidation, governance and importantly, personal, recruitment and retention is challenging and even where recruitment is possible, single handed, isolated practice is no longer deemed to be desirable or safe.
This paper will briefly provide a background drawing both on previous reports and on present intelligence from the current operational reality in NHS Highland, and then outline a proposal for action research into an approach that will assist communities and providers to plan and develop safe and sustainable models for health and care. The proposal will therefore not describe a model or single solution, it is clear that one size fits all does not apply to community resilience in remote and rural areas.
It is clear that there is a substantial depth of knowledge on the issues and that over the years several solutions have been put forward, but not all of the intended actions have been followed through and there is an urgent need to make changes which will be sustainable and affordable for the future. The current models of Doctor and Nurse dependent services in all small communities are clearly significantly challenged and need to change but in such a way as to ensure that local communities feel safe and feel involved with and an active part of any
Different parts of Highland are at different stages, and it is also clear that there are similar challenges in other remote and rural areas and so this proposal will set out an action research approach to developing a menu of possible solutions that will be tested as the opportunities arise. Action Research is described by Hart and Bond as “A method of understanding a system while simultaneously trying to change it. ” By adopting this approach, changes can be made as and when necessary but within an evaluation framework that promotes learning and transferability. It is clear that there will be no single successful model and that this needs to take a partnership route to include all public services working in the area and the communities themselves. The work needs to build on that already happening on community resilience, the definition of which in this context is a ‘collective and collaborative response within communities to promote independence .’ This also
4 chimes with the Christie Report (2011) into the future delivery of public services which called for communities to be more involved in the design and delivery of services and for all public sector agencies to work together to avoid duplication and to maximise the use of all available resources.
This proposal, then, is not to duplicate the immense efforts invested in previous reports, but to take the key recommendations and ideas from them and test them in the here and now. Action is urgently required if services are to be maintained and communities supported. Health and Care services need to be viewed in the wider social and economic context of remote and rural life and community involvement in building capacity and strengthening resilience is seen as being key to the sustainability of public services in these communities. This proposal is aimed at supporting communities and the professionals working in them, to find local solutions that meet a set of principles and that are robust and sustainable. There will inevitably require to be a change from much loved historical models and it is recognised that independent facilitation may be required in some areas.
NHS Highland is working with members of the Dewar Group, to ensure that historical lessons are used to help shape the future.
2. Background
2.1 History
There have been many reports and pieces of work focused on remote and rural health services spanning many years. This is not intended to be a literature review but it may be helpful to the set the current proposal in the context of previous work as there are common threads and many of the issues raised over a hundred years ago are pertinent to our deliberations in the present.
2.1.1
The Highlands and Islands Medical Committee (1912), chaired by Sir John Dewar, was established to review the challenges of providing good care in the Highlands and Islands and travelled the length and breadth of the country, speaking to local professionals and communities. They found that there were substantial shortcomings in the system including significant disease and high mortality rates, lack of death certification, poor maternity care, poor quality, insufficient qualified personnel, lack of education and ongoing training, lack of technology (telephone and motor car) and lack of any supportive structure. The wider determinants included the vast geography and sparsity, rural deprivation, lack of transport, lack of employment and poverty. Whilst some of these are greatly improved in the Highlands and Islands, some of the challenges remain the same. The geography, sparsity and rural deprivation are the same and the issues pertaining to education, training, support and the need for team working are all cited by professionals working in rural areas today as considerations when they decide whether to apply for posts and indeed whether or not to stay in remote and rural areas. Recruitment and retention is increasingly problematic. The Dewar Group (2012) which comprised Health Care professionals and Historians, believe that there is much to be learned from the way in which the Dewar Committee carried out its work and indeed in their recommendations, albeit that some of the clinical challenges have changed. They are keen to see the success of the Dewar Committee being used as an icon for modernisation of services to ensure
5 sustainability for the next 100 years and have called for a systematic political plan and leadership, empowered and responsible communities, recognition that the cost of providing safe and sustainable services in remote areas is costly and that a subsidy should be considered and that the wider aspects of community resilience should be taken into account.
2.1.2
In 1964, the then Secretary of State for Scotland in the Scottish Home and Health Department commissioned a report into General Medical Services in the Highlands and Islands, chaired by the Honourable Lord Birsay, which was reported to Parliament in 1967. This Committee also went on the road and met in several locations across the Highlands and islands, taking evidence from interested local groups and organisations, including voluntary sector, and visiting many rural General Practitioners. They also visited Norway and included some recommendations from their learning in that country.
Interestingly, this Committee found similar issues to those articulated by the Dewar Committee, and they grouped these into four main themes:- transport and communications (including the unpopular automatic telephone exchanges that obviated the need for operators who could triage calls); integration of services; conditions of service, including ability to be released for training, and expense involved with that, together with professional isolation; and remuneration, highlighting the additional cost involved in living and working in remote and rural areas.
The Committee’s report also highlights the fact that the public often judges the quality of service on the proximity of a Doctor and that any attempt to reduce the number of small isolated practices would be unpopular, a fact that has been borne out over the years when change has been attempted. Nevertheless, Lord Birsay recommends that the number of small isolated practices should be kept to a minimum and that those remaining should be kept under close scrutiny. There is a suggestion that small practices could be ‘grouped’ together, that better transport, including the use of boats and aircraft, could support the service more effectively and that Doctors should not be encouraged to stay in small practices for long periods of time. The report also notes that issues associated with health services cannot be examined in isolation from the wider aspects of life in remote and rural communities, including making best use of all local resources and the need for economic development. Interestingly for NHS Highland and The Highland Council, the report also explores the potential for more integrated and co located services.
Although written over forty five years ago, this report resonates with the challenges of today and also makes recommendations that were not followed through and it could be said that this lack of action has contributed to the problems facing health and care services in remote and rural areas at the present time.
2.1.3
In 2001, the Remote and Rural Area Resource Initiative (RARARI), established The Solutions Group with a remit to explore and facilitate the introduction of innovative methods of delivering care in remote and rural areas of Scotland. The Group’s report makes reference to another, the Thomson report, from 1995, written following a review of services in remote and island communities, and the fact that few of the recommendations were acted upon. The Solutions Group, themselves, made several recommendations, including contract reviews, better team working, mobile health units,
6 telemedicine, training schemes, career structures, twinning of practices, better transport, including an ambulance boat, and greater patient involvement. Some of these recommendations have been enacted but others are worthy of further consideration.
2.1.4
In 2004 a Rural Action Team was set up under the auspices of the National Framework for Service Change in NHS Scotland after Professor David Kerr and the National Framework Advisory Group identified access to health services in rural areas as a key concern. The Action Team considered five distinct aspects:- out of hours care; maximising services provided locally; The role of remote Rural General Hospitals; the skilled and competent workforce; and creating an integrated transport system.
2.1.5
Delivering for Remote and Rural Healthcare (2007) was the final report of the Remote and Rural Steering Group, established to develop a policy for remote and rural healthcare services and provided a framework intended to help services to orientate themselves towards the changing needs of communities and to make best use of available resource.
This report again covered the same themes of staffing models, training, support and crucially, transport. One of the key successful outputs has been the retention and expansion of the Helicopter Emergency Retrieval Service (HEMRS). This now means that much of rural Scotland has access to specialist medical care and fast evacuation to places of definitive care.
The report describes a triangular hierarchy of care including self care, extended primary care, community hospitals, rural general hospitals, district general hospitals and tertiary care. It helpfully separates anticipatory, planned, emergency and out of hours care and there are some key recommendations, some of which have been implemented, others are more challenging due to workforce, recruitment and retention issues and funding shortfalls. The staffing models in Rural General Hospitals for example were challenging at the time and have proven to be extremely difficult to sustain. Even in the few years since the report was published, the environment has changed in terms of availability of suitably qualified staff and in training of junior doctors. Maintaining rotas in these hospitals has been difficult and it is increasingly challenging to deliver the aspirations of the report. A review of some aspects may be required to take account of changes since 2007.
There was a considerable amount of work done on emergency response and a Strategic Options Framework and Memorandum of Understanding with the Scottish Ambulance Service was drawn up. SAS accepted their responsibility for emergency response in areas where doctors and/or nurses historically were retained due to a lack in emergency cover, but it is taking time for that to happen and the recruitment problems are highlighting the need for faster implementation of different models. However, capacity required to develop community resilience and the cost of this is prohibitive. The fear of change articulated strongly by some communities, is another limiting factor. SAS is also challenged by the need for their staff to maintain skills and activity in remote areas is such that they require to be rotated regularly into busier areas which can be problematic both for the individual and for maintenance of service. It has therefore been difficult for SAS to assume the responsibility described in the SOF in many parts of Highland.
7 2.1.6
There are several other reports and pieces of research that can be drawn on to assist with implementation of this current proposal, including the West Highland Solutions Group, Health and Rurality Digest, Technical Annex for Delivering for Remote and Rural Healthcare, Rural Peripheries Project, Recruit and Retain an EU Approach and many others and therefore no new reports are necessary , but there is a need to pull the key strands of all of this work together, to analyse the recommendations and supporting information and to identify outstanding actions that are relevant today.
2.1.7
There are also ongoing educational initiatives and international research with which links require to be made, most recent one being the SGHD direction “Community Hospital Strategy Refresh” April 2012, with the SGHD Primary Care department convening a short life working group for community hospitals with a remit to look at the challenges of delivering medical cover, in and out-of-hours within community hospitals. NES progressing the development of education and training packages for practitioners and NHS Boards to review and re-new the core service provision of hospitals
2.1.8
It should be acknowledged that from 1912 until 2004, the GPs were responsible for provision of care of their patients 24/7, 365. This was part of their contract and was clearly good value for money. In some more populated areas, GPs had already established consortia or cooperatives to deliver out of hours care, examples being GDocs and Ness Docs. In 2004, the new GMS Contract allowed the opt out of GPs from the provision of out of hours services, that is for 118 out of 168 hours per week. This became the responsibility of the Health Board. In the more urban areas, it was relatively easy and cost effective to build on the existing cooperatives and Boards simply took over the running of these. In more rural areas, this was much more difficult to achieve, particularly in the face of public angst and clinical concerns that their communities should receive the same cover as when practices were contracted to provide it. It should be noted that the safety and governance of these arrangements had had little scrutiny and anecdotal evidence suggests that, due to onerous on call commitments and isolation, the services were in fact extremely fragile. The cost of establishing out of hours services in NHS Highland, as detailed by Audit Scotland in 2007, is far greater than in other parts of Scotland, and the opportunity cost is great due to very low activity in some areas and possibilities for change that have not been able to be enacted due to community concerns about lack of emergency cover from ambulance services, which may be based up to an hour away. The Boards were able to claw back 6% of Practice funding but this was nowhere close to being sufficient to provide these services, especially in rural areas.
2.2 Current Challenges
There are many situations in NHS Highland area at present that are giving cause for concern. Other remote and rural areas of Scotland are experiencing similar challenges.
Although the focus here is on general practice, there are similar recruitment difficulties in other professions e.g. radiography and in Consultants in Rural General Hospitals.
8 2.2.1 Recruitment of Rural General Practitioners
Vulnerable small Rural Medical Practices across Highland: Glenelg, Applecross, Small Isles, Acharacle, Broadford, Lochinver, Armadale, Isle of Jura, Isle of Islay, Inveraray, Southend and Carradale have in the last year alone experienced recruitment difficulties and required NHS Highland’s assistance.
This is not only an issue in small practices, the Riverbank Practice in Thurso with approximately 6000 patients has failed with dissolution of the GMS practice and NHSH requirement to step in. Thurso, while a small town, is considered remote for medical recruitment purposes.
This issue has also become more prevalent in practices which provide a “triple duty” role of day time GMS, Out of hours and 999 non-bypass Community Hospital services for localities (population served circa 8-9,000). Vacancies in establishment, maternity and sick leave cover have meant Lochgilphead , Campbeltown, Bute and Isle of Islay have operated these services on a 1 in 5 or 1 in 4 on-call rota. Recruitment to these posts has been unsuccessful due to unattractiveness of the on-call commitment and the limited availability of suitably competent medical staff with the specialist skills to support the acute A&E and casualty work.
2.2.2 Health and Wellbeing of Rural General Practitioners
People have told us that isolation, on-call, no readily available support, lack of career progression, community pressure, professional pressure and new regulatory requirements plus social and family expectations have led to decline in job satisfaction and fulfilment, illness (depression, anxiety, suicide) and movement away to a more populous area.
Health and Care Practitioners report that the ‘goldfish bowl’ effect of living and working in small communities can become overwhelming and the feeling of being ‘owned’ by those communities, whilst initially welcoming, can become stifling and unbearable not only for the practitioner, but also their families, whose normal day to day life is often disrupted whether or not the member of staff is actually officially on duty. Communities feel able to contact professionals at any time of the day or night. These pressures must be acknowledged as younger professionals grow up in a totally different environment. They work in teams and on shifts and expect to have their time off and a sensible work life balance. The days of any professional being responsibility 24/7, 365 have gone. It is an outmoded, unsafe model and this level of commitment cannot be expected of professionals any longer. Better support and time away from their responsibilities will be essential in recruiting and retaining high calibre professionals in the future.
2.2.3 Professional Skills Maintenance
This is essential in low volume clinical areas. Such learning is most useful via exposure based scenarios and working in busier units. Releasing time for Rural GP’s and wider healthcare team staff to achieve this is difficult. Without a rigorous supported and resourced approach to ongoing learning the quality of work will fall and avoidable harm will result.
In remote and rural areas in particular, but certainly not exclusively, the benefits of having highly skilled practitioners require to be maximised and in some areas, patients could be brought to professionals. The team approach is also crucial and it is clear that we should be more interested in the level of skills and competencies that are available rather than the individual discipline of the
9 provider. For example, nurses and therapists have developed additional skills over the years and they are now able to provide a lot of care traditionally expected of doctors. Similarly, if there is a doctor in attendance, we should expect that they could carry out tasks that might have traditionally been done by other healthcare professionals. The integration agenda provides further opportunity to develop this multi professional approach to care.
2.2.4 Lone Working and Safety
For all working in the rural healthcare environment there are increased risks of lone working and a poor communications infrastructure. Patient expectation may not be met when a sole GP or nurse is confronted with complex needs remote from assistance. This clearly places additional pressure on the healthcare worker. Lone working in Rural Areas is also inherently dangerous due to the environment, geography and distance from support.
2.2.5 Sustaining the Support and Local Healthcare Capacity
All healthcare is interconnected. In Rural Areas the community hospital or Rural General Hospital is a crucial support as a hub, centre for advice, educational opportunity and diagnostic centre. There are significant challenges in sustaining such units, particularly around recruitment, cost and buildings regulations. NHSH faces a constant struggle to ensure the viability of such units.
2.2.6
It is clear that health and care, indeed all public services, both contribute to and require a vibrant local economy as described in the Scottish Government’s aspiration for a Flourishing Scotland. The health and care contribution to the sustainability of rural communities cannot be underestimated and that social and economic responsibility is strongly felt by NHS Highland. However, in order to continue to deliver that contribution effectively, new ways of working, patterns of delivery and finance which reflect the true value of and cost require to be developed as a matter of urgency.
2.3 Funding Models
The Arbuthnott formula did recognise the additional cost of providing services in remote and rural areas; however, this was seen as disadvantaging the more urban areas, particularly those with public health challenges in areas of high deprivation. The National Resource and Allocation Committee (NRAC) The National Resource and Allocation Committee (NRAC) therefore made a series of recommendations that were accepted by the Cabinet Secretary. The current NRAC formula includes a weighting for the unavoidable excess costs of supply. The definition of ‘excess costs’ is vital and it is acknowledged that it is a real challenge to differentiate between costs that can be avoided and those that are unavoidable. In addition, the Morbidity and Life Circumstances Index, may not fully recognise remote and rural issues. These are crucial issues for remote and rural areas and together with the ongoing work of TAGRA on assessing the impact of the formula on delivering services in remote and rural areas – in particular the recognition of the excess cost of delivering out of hours services in remote and rural areas, it is suggested that some specific health economic work is undertaken on sparsity and peripherality.
The cost of provision of services has increased in remote and rural areas, particularly where there is an out of hours commitment and also where there is acute service provision such as that provided in
10 Rural General Hospitals, which is Consultant led, and where Rural Practitioners and up skilled GPs in Community hospitals in Skye, Campbeltown and Bute provide a higher level of acute and trauma care than that provided in other community hospitals. The cost of 24/7 medical cover in community hospitals is also an issue as GPs who traditionally provided this service, are no longer trained or interested in working out of hours
The additional cost of providing rural Primary Care Out of Hours services has not hitherto been specifically acknowledged in any funding mechanism even though the difference was evidenced in the Audit Scotland report in 2006 which stated:.
“The cost is directly linked to remoteness, with higher costs in more remote or rural areas. ”
The recent recommendation by the Technical Advisory Group on Allocation (TAGRA) in this regard, is therefore to be welcomed.
The current number of vacancies has necessitated NHS Highland taking over the running of the Practices. It costs more to run on a Locum basis and even salaried options are more costly than the traditional Independent Contractor model. There are non obvious costs involved as well such as the cost of premises, buying out leases and third party commitments.
The map below shows the immense geographical challenges and the lack of opportunity through economies of scale, to provide services at reduced cost. A Home Carer, for example, in a town may be able to support up to 8 clients in a small radius. In a remote and rural area, the clients can be spread over many miles and the same level of care can only be delivered to one or two clients. In Rural General Hospitals, if a key member of staff in a one in two or three rota, is off, it is necessary to employ Locums at a very high cost in order to sustain the service. Absence can often be absorbed in busier areas but that is not possible when teams are already very small. Sustaining this level of care has excess costs attached.
11 Location of Isolated GP practices and Non-Bypass 999 RGH & Community hospitals
2.4 General Medical Services Contract (GMS)
The new contract initiated in 2004, allowed GPs to opt out of providing 24/7 care. In remote and rural areas, this is particularly challenging and extremely costly. For example, in West Ross, where there is a population of approximately 6,500 and a very low activity level, the cost is almost £700, 000 In East and Mid Ross, covering a population of approximately 53,100 and where a cooperative, multi disciplinary team approach is adopted, the cost is approximately £670,000 therefore the cost per head of population in West Ross is approx. £1,134 and in East and Mid Ross is approx. £91.
The contract does not allow for 24/7 GP cover in Community Hospitals and as previously mentioned, this has added additional strain in that out of hours cover requires to be provided through a small
12 number of Practitioners who are undertaking a “triple duty role” (A&E, Acute inpatient and GMS OOHs), this allows the local management of patients thus preventing patient travel to secondary care hospitals a key component in managing unscheduled care demand and speeding discharge from specialist care as part of an integrated pathway of care which could be emulated in urban areas.
The relatively low activity in small remote Practices does not fit comfortably with the needs of the Quality & Outcomes Framework (QOF) nor do small numbers easily fit the needs of Enhanced Services requirements. While there is no suggestion of designing another “remote” specific contract (as was previously the case with the Inducement Scheme) there is a need to consider carefully how the small remote Practices whose patient population is restricted by geography can receive sufficient recompense to allow a full range of General Medical Services to be provided.
The recent negotiations around a more sensitive and relevant Scottish GMS Contract will be helpful here. Indeed developing a contract that is indeed rural proofed and rural sensitive will ensure sustained medical input in every part of Scotland into the future.
Regarding models of care, it’s well accepted that approaches adopted in rural settings can usually be transferred to more urban areas, but there is plenty evidence that urban centric initiatives rarely translate neatly if at all into the country settings.
3. The need for change
Building on the historical and current information and the intelligence gathered, it is clear that the status quo is no longer an option and that perpetuating old models is both unsustainable and undesirable and would be repeating the mistakes of the past, whereby short term fixes were adopted. It is suggested that this approach over many years, as demonstrated by the historical background, has been unhelpful in that change is now having to be wrought in the face of crises. Meaningful mature engagement with communities on this basis is extremely difficult.
Fewer healthcare professionals, especially doctors, are applying to work in remote and rural areas and those that are interested are not willing to provide 24/7 cover in an onerous 1 in 2 or 3 rota. There is considerable anxiety about single handed practice due to professional isolation, lack of peer challenge and peer support ,difficulty in achieving the necessary education and training to maintain fitness to practice and indeed interest. The pressures and impact on professionals and their families also require to be acknowledged and addressed.
3.1 Demographics - Scottish picture
The population of Scotland has been, and is expected to continue to grow in recent years due mainly to in-migration, increased birth rate and increased life expectancy, although there are geographical variations. The population is continuing to age with a predicted increase in the number of over 60s by 2033. There is a strong urban/rural dimension with 17% of the population in urban areas being over 60 and in some rural areas that rises to 21%. The dependency rate is due to increase from 60 per 100 to 68 per hundred by 2033 and rural areas show a net migration increase in older people as people move to these locations to retire.
13 Whilst the population of Highland and Islands is projected to grow by 2% by 2024, this is likely to be in the more urban more densely populated areas such as Inverness and Nairn. The remote and rural areas are likely to be more fragile and depopulation, particularly by younger people is possible. The population is ageing, in Sutherland for example, 25% of the population us elderly. This presents challenges both in terms of the number of people who will require care and in the numbers of carers available to deliver that care.
3.2. Health profile
There are variations across the different remote and rural areas and therefore flexibility is required in order to address the specific health needs of rural communities. Although the general pattern of disease is similar in remote and urban communities, access to appropriate care is more difficult. There are however some notable differences:-
• Higher suicide rates • Higher incidence of alcohol related disease • Higher number of accidents • Palliative care workload is proportionately higher • Seasonal fluctuations in population
(Delivering for Remote and Rural Healthcare, 2007)
3.3 Education and Training
Experience has shown that rural doctors require a broader, more practical skill set than urban doctors. They also require experience of isolated decision making where transport and communications are difficult. Exposure to this environment is crucial both to inform doctors of this type of work and to prepare them. This is also true of other health and care practitioners, and as previously indicated, solutions will lie in a multi professional approach with adequately trained and supported professionals with the relevant skills and competencies that are regularly updated.
In general terms health care professional training is urban and necessarily so. How do we then bridge this gap to prepare doctors for the challenges of rural healthcare? There have been many attempts in the past and the Rural Fellow scheme for doctors has been one notable success. This should be considered for other key professionals. In past years the retention rate to remote and rural posts has been high (70%) but recent application rates are worryingly lower than before. It should be noted that recruitment to General Practice training (GPST) nationally is lower and remote and rural areas are competing with those that can provide a more supportive and balanced lifestyle. It is clear from feedback from GP training practices that the calibre of trainees being put forward for placement is not of the required standard and that vacancies and competency issues arise as a result.
One suggestion is to base a “rural health and care school or college” or a department of a larger university actually in a rural area. Such immersion and commitment to rural healthcare will allow a true rural focus, but this is clearly a medium term goal.
14 There are some other existing initiatives aimed at future recruitment. A scheme in Lochaber, for example supports a mentoring model for High School pupils who are considering a career in medicine. These types of initiatives need to be strengthened and supported.
Local initiatives including developing specific training skills or modules e.g. early work by the Lochgilphead GP practice and latterly the clinical lead at the MacKinnon hospital on Skye have proved exactly that, with wider take up and ownership by NES and GP Deanery patchy or absent.
3.4. Clinical Standards and Governance
Clearly, there is a need to ensure that services in remote and rural areas are of a high standard and that pathways are understood and followed. Previous reports and current experience point to communities being more concerned by the presence of a doctor than the clinical governance aspects of provision. The tension here is about managing expectation versus the actual risk, helping communities to understand that the situation whereby they are reliant on single isolated professionals may not be as safe as they believe.
One of the recommendations from the Dewar Group is that a framework to support bench testing and risk management of remote practice models could be helpful both for prospective candidates and in working with communities on what service is required.
Monitoring, mentoring and site visits must be carried out on a regular basis to allow open, constructive discussion around clinical, social and educational difficulties. Such outreach quality control and rigorous attention is often missing when viewing quality from a database or outcome focused viewpoint.
Proposals to change existing models of service delivery for Remote Primary Care are known to cause considerable concern in remote communities and for professionals delivering existing models of care. It is evident from discussions with communities that there is more of a focus on emergency care, more associated with the ambulance service in more urban areas, than on the breadth and depth of primary care and the modern role of the GP.
In order to facilitate professional and public discussion, there is a need to ‘bench test’ and ‘stress test’ proposed models for remote medical primary care with current practitioners and community groups, to gauge the consensus on risk management. ‘Stress testing could include variables such as weather, professional illness and limited prior knowledge of the patient together with the resilience level of other emergency services, fire, coastguard, life boat etc.
Risk management requires an understanding of the impact and likelihood of clinical events with particular reference to a ‘delayed response’.
Accurate prevalence data is available from group practices. The Practice Team Information scheme run by Information Services Division can supply reliable prevalence data for bench testing.
The overriding principle of modern primary care is ‘caring with science’ from ‘cradle to grave’ with particular attention to holism for individuals. Broadly primary medical care splits into three main categories: episodic medical care; long term condition management; emergency and urgent care. It is proposed that emerging models should explore standard approaches for these and risk assessment including impact, likelihood and mitigation.
15 3.5. Community Resilience
In ‘Towards a More Successful Scotland (2009) ’, the Scottish Government laid out its approach to Government with the ambition to pass on to the next generation a nation that is flourishing. They state that they will promote “...a culture of independence, culture of responsibility to ensure that communities and individuals are playing their part in efforts to deal with some of the most pressing challenges facing our nation, from the current economic downturn to the longer term problems associated with alcohol.” In ‘Renewing Scotland’ (2011) the Government encourages an asset based approach to sustainability and states their vision as being “.....one which builds on assets – the strengths, abilities and connections held by our people, communities and businesses. We will help our individuals, families and communities flourish through social partnership.” In ‘Working for Scotland (2012), the Scottish Government describes their approach as being “....built around working in collaboration and partnership and focusing on prevention...”
These ambitions and principles are highly pertinent to this work with rural communities. The provision of health and care services cannot be viewed in isolation, particularly in remote and rural areas. As described above recruitment and retention is reliant on the vibrancy of communities, employment and leisure opportunities for families and ability to have protected time off. Often health provision is viewed as a last vestige of public service as, over the years, Police, Fire and Rescue, Post Offices and sometimes Schools have withdrawn. It is little wonder then, that communities are anxious when there is any threat to the status quo in health service delivery potentially fatally damaging the viability of remote rural communities. Health and Care services need to be viewed in context of wider public services.
There are many definitions of the term ‘community resilience’. Delivering for Remote and Rural Health Care uses the definition ‘... a collective and collaborative response within communities to promote independence. ’ In ‘Exploring Community Resilience in times of rapid change (Carnegie trust, 2009) it is suggested that the actual definition is less important than the driving force behind using resilience approaches, which is that it helps people to future proof their communities on the basis of agreed values. This is about a sense of personal and community wellbeing and the ability to cope with and adjust to changing circumstances. There is an analogy here with personal health and the promotion of self care and anticipatory care. Some communities are already self reliant and have coping abilities, whilst others are more dependent.
The Christie Report (2011) states that reforms must aim to empower individuals and communities by involving them in design and delivery and also that there must be integrated service provision in order to improve efficiency by ensuring that all public sector resource is used to best effect, duplication is reduced and that services are shared. One of the key messages in the report is ‘maximising scarce resources by utilising all available resources from the public, private and third sectors, individuals, groups and communities. ’
Ownership of personal health and a community awareness and responsibility for health issues is crucial. Priorities, standards, needs and expectations all vary from community to community. Allowing community views to drive the healthcare agenda gives back the ownership and shared responsibility that is required for constructive dialogue with the NHS and other public bodies. When making rural decisions a wide view of community capability is required. This will bring in all other
16 available services and crossover of resources between council, healthcare, voluntary sectors and so on.
The Scottish Government’s policies on mutuality and localism promote the concept of rights and responsibilities of communities and individuals, responsible, equal partners who are involved with and take ownership of service planning and difficult decision making. The Chief Medical Officer calls for co production and asset based approached to health and wellbeing in his annual reports.
Meaningful and effective engagement with communities is therefore extremely important. In some cases, this will be more difficult than others. Public sector organisations require to build trust and relationship. NHS Highland has been exploring the possibility of receiving coaching and mentoring on ‘live adaptive’ work from Irwin Turbitt. One meeting has taken place and it is hoped that Irwin’s support can be utilised as part of the work on new models of delivering health and care services in remote and rural areas. It may be that in some communities, Irwin would be able to act as an ‘honest broker’. Clearly there is a need to develop strong and effective facilitation networks and it is hoped that some community members will be able to develop the expertise to support conversations in other communities. The ‘Inspiring Scotland’ work with areas of multiple deprivation has had success with this approach.
There are community resilience factors that require to be borne in mind when thinking about recruitment and retention. Past and present staff have indicated that family considerations are important to them. They are concerned with employment for Partners, housing, education, culture and leisure opportunities and a sensible work/life balance.
The Dewar Group (2012) produced a Mind map – Dewar 2012 “Being Here” (appendix 2) which provides a clear picture of the key factors that make remote and Rural General Practice a rewarding and satisfying career choice. This is an extremely helpful was of thinking about sustainability and building resilience and capacity in remote and rural areas
3.6 Scottish Ambulance Service
SAS is a key Partner in sustaining services in remote and rural areas. Emergency and Urgent care is cited most frequently when working with communities. SAS has been working to develop a range of services highlighted in the Strategic Options Framework, developed through ‘Delivering for remote and Rural Healthcare’. Community First Responder schemes and most recently Emergency Responders in West Ardnamurchan are key planks of this work.
The Scottish Ambulance Service works closely with partners across boundaries in primary, secondary and tertiary care through a range of clinical networks. Emerging technologies and their adoption across Scotland will better support this work with our partners to assess, monitor and manage patients in the community without the necessity of hospital attendance. Advances in monitoring, decision support and other enabling technology solutions will support the clinical workforce to manage patients with the aim of maximising clinical effectiveness, supporting improved patient safety and improving outcomes.
Over the next five years, the Scottish Ambulance Service key aims are to systematically enhance the provision of pre hospital care and referral pathways. In terms of their clinical strategy, the priorities will be focussed on improving the patient journey and in particular:
17
• Initial telephone triage and first clinical assessment through the introduction of the Single Triage Tool in partnership with NHS24;
• Getting the right response to patients first time, every time, extending and enhancing the alternatives to hospital attendance, for example ‘hear and treat’, providing self care advice, referral to a member of the primary care team i.e. pharmacy, community nursing, GPs, community psychiatric nursing teams, social care etc
• Working collaboratively with primary care to better manage patients with long term conditions;
• Working with primary and secondary care to reduce avoidable and unnecessary attendance at hospital
• Sharing information with primary care, contributing to anticipatory care plans to enable paramedic practitioners to contribute effectively to the case-management of high risk patients or frequent users of emergency services
• In conjunction with all providers (primary and secondary) agree consistent care pathways for a range of long term conditions that can effectively deal with exacerbations of the patient’s condition, for example, breathlessness, heart failure, falls, frailty in older people, drug and alcohol misuse and mental health
• Increasing the range of primary care we can deliver in the pre-hospital environment, increasing the see and treat protocols for minor illness and injuries
• Enhancing specialist skills within our paramedic practitioner workforce to support:
o The management of major trauma o The delivery of more bespoke and specialist care for paediatrics o The care of vulnerable adults o Greater awareness of developments and best practice in child protection o The delivery of specialist retrieval services
• Electronic transfer of our patient record form to GPs and hospital clinicians to ensure patient follow up, continuity of care and better case management
• Optimising the use of e-health and telehealth technology to provide remote and rural communities where the transfer is often only undertaken to facilitate as face to face assessment or undertake a routine diagnostic procedure
• Explore opportunities for enhancing the diagnostic capability within the service i.e. near patient testing, sonography etc
The Scottish Ambulance Service Community Resilience Strategy recognises that the needs of individual communities will differ and our role will be to work with partners and communities to understand those needs and support them in strengthening their healthcare capacity and resilience.
18 CEL 21 (2010) issued in June 2010 sets out the framework through which the Scottish Ambulance Service and NHS territorial Boards can ensure that there are robust and responsive systems in place within remote and rural communities to respond in emergency or urgent situations.
The Scottish Ambulance Service and NHS Boards seek to deliver the best outcome for patients by working collectively and collaboratively with partners and local communities:
• To clearly define appropriate emergency and urgent responses; • To make the best use of existing resources; and • To explore opportunities for enhancing skills and sharing resources.
This work is underpinned by NHS Scotland’s Quality Strategy which puts the patient, patient safety and clinical excellence at the heart of healthcare delivery.
The final report of the Remote and Rural Implementation Group outlines that
‘delivering for remote and rural healthcare extends across the continuum of care, from the need for community resilience and integration between health and social care through to the role of hospitals, workforce, transport and technological solutions that are required to sustain appropriate local access to care’.
For many years the Scottish Ambulance Service has been working with partners to enable sustainable community resilience. They now support over 130 Community First responder schemes and more than 1,000 trained volunteers throughout Scotland, supported by local Community Resuscitation Development Officers who recruit and train community members to provide emergency care support. They have established new roles and services including community paramedics, a retained service and the involvement of the Scottish Ambulance Service in preventative initiatives for example anticipatory care, ‘Heartstart’ UK Resuscitation training in Schools and ‘Safe Drive’. We also continue to work closely with the third sector to deliver services and support to communities such as the placement of public access defibrillators.
Across Scotland, more than 1 in 10 people attended by 999 crews last year were treated in their homes under the SAS See and Treat Initiative. Epilepsy sufferers recovering from seizures, diabetic patients recovering from low blood sugar episodes, people with minor nose bleeds are among those who no longer need to be taken to hospital.
It is important that 999 crews respond to ‘appropriate’ emergency and urgent incidents as this will improve the patient experience and ensure that accident and emergency vehicles are not taken out of remote and rural communities when a hospital admission is unnecessary . This requires joint working between the SAS, primary and social care teams and local communities to provide the most appropriate response for the patient.
Working with health and social care teams across Scotland, Paramedic Practitioners have evidenced a 30% to 40% reduction in hospital admissions through utilising extended clinical skills and decision support. There are significant opportunities to role this model out across Scotland particularly in remote and rural areas where paramedic practitioners could help to assess, monitor and manage patients in the community with decision support from other healthcare professionals who may be
19 working remotely but are accessible through satellite links. Successful models in operation in Killin and the Western Isles need to be applied as they provide great opportunities to enhance local access to service but also support redesign and rationalisation of on-call and core GMS services.
The Scottish Ambulance Service has been working closely with the Scottish Centre for Telehealth, NHS Boards and local communities to test out new models of care using telehealth and decision support. This is enabling our clinical workforce to manage patients with the aim of maximising clinical effectiveness, supporting improved patient safety and improving outcomes. The key drivers are to ensure there are:
• Suitably qualified staff working in an integrated system designed to deliver appropriate care in the appropriate place. • Clinical advice and back up available through professional to professional support • Robust audit
We all know that the demands for healthcare and the way in which it will be delivered will be very different in the future. We are also committed to achieving our Quality Ambitions of providing safe, effective and person-centered care. In order to meet these challenges, we will need staff to do different things, in different ways, and to develop new skills.
4. Elements of Success
Firstly it is important to restate that there will be no single solution and there will require to be a range of models that can be considered. This section therefore describes principles and what have been found to be key elements for successful change in remote and rural communities.
The reports mentioned above, and many others, back up recent focus groups and discussions with present and past health and care professionals. Sustainability of rural services depends on wider aspects of life in rural communities. There is no one size fits all solution but there requires to be some common principles and high level agreement on the need for change. Local areas then need to use a ‘menu’ of possibilities and standards to grow their own solutions as the opportunity arises. There therefore requires to be a flexible approach that will allow for local variation but there are essential criteria that require to be met in order to both build sustainability and help communities to feel safe.
The key essential principles are:-
In order for any models to be successful, there requires to be meaningful and extensive community engagement, hearing all the voices, ownership and participation, also involving all key public and voluntary agencies working with and in the community in an integrated and collaborative way and the facilitation of community development approaches to enhance community resilience.
20 As part of building community confidence, it is suggested that a ‘bench and stress test’ being developed through the Dewar Group, be used to scenario plan and to develop and test contingencies and alternatives, utilising a risk management approach.
Any model will require to be multi disciplinary team based to ensure best use of all available skills, talents and resources. The team will require clear coordination and clear lines of accountability and will require to have access to ongoing and relevant continuing professional development and will require to be able to work in busier areas to maintain skills and competencies. Single handed practice and long periods of lone working should be phased out as the opportunity arises.
Transport and travel are often barriers to change, from routine daily journeys to emergency and urgent response and these aspects are an essential part of any new model of service. Consideration needs to be given particularly to fast access in emergency situations and may in future involve ambulance boats as well as helicopters.
4.1 Key enabling factors
The team could use anticipatory care assessment, planning and management as a means of limiting the need for unscheduled care, and they will require access to technological solutions both for team communication and learning and also for patient contact as appropriate. This has been tried elsewhere with success.
Innovative ways of creating interesting posts, including rotational opportunities, portfolio careers and opportunities to develop special interests should be considered. This within the context of a rationalised locality wide service, enhancing rural community access to something as simple as a male or female GP, sexual health or dermatology specialist services.
Capability frameworks and specific training packages require to be developed. Piloting specific initiatives as part of identified redesign processes to develop “community confidence” in service alternatives
The Dewar Group held a successful multi stakeholder conference on the 19 th April to explore the key factors to promote recruitment and retention as highlighted in the mind map contained in the appendix. It is proposed that this type of event should become a regular means of bringing together those working to bring about change in their communities, key partners and those able to support such as the Scottish Government, Local Politicians, Educational Organisations, Transport Providers and international colleagues working with similar challenges.
4.2 Stakeholders
The stakeholders will vary in the different areas and different aspects that are being explored but core involvement to develop resilience will be from communities involved in any potential change, all public, voluntary and independent service providers including Health, Local Authority, Police, Fire and Rescue, Scottish Ambulance Service, Culture and Leisure, Housing, Care Homes, Care at Home. For emergency support, key players will be Coastguard and RNLI and external providers such as NHS 24 and Scottish Centre for Telehealth will b required.
21 For economic development, local businesses and agencies such as Forestry Commission and Scottish Natural Heritage will have important roles to play.
For educational aspects, local and national further education providers and the Royal Colleges will be key.
4.3. Rural General Hospitals, Community Hospitals and Care Homes
Rural services rely on access to relatively local beds in community hospitals and care homes. It is important that any models for primary and community care, takes cognisance of the wider infrastructure and that hospitals and care homes may act as ‘hubs’ for unscheduled care services including out of hours and A&E.
Staffing of these facilities with suitably qualified staff is an additional challenge. In particular medical consultant and independent GP vacancies are a serious cause for concern in all RGH and non-bypass community hospitals.
22 The NHS Highland Proposal
Building on the above, NHS Highland is pleased to submit the following proposal at the request of the Scottish Government Health and Care Directorate.
5. The Proposal
NHS Highland proposes to use Action Research and Learning to develop and test the approach to developing new models of service. It is clear that the most sustainable solutions will be those that are locally grown with the involvement of all key stakeholders and with the involvement of the communities served. In recognition that there will be no single model that will suit all areas, our proposal is to allow a range of models to be developed and tested but with some agreed key principles.
Meaningful and effective engagement takes a significant amount of time and effort. Capacity to deliver this requires to be developed and it should be recognised that there will be no quick fixes which raises the urgency factor to embark on this work to avert further crises.
Ensuring maintenance of existing services via resourcing backfill arrangements to ensure local clinical leads participate, own and publicly support/demonstrate the service model.
Effective and thorough evaluation will be required to promote learning and to gauge transferability and therefore a Research Partner will be required.
5.1. Resources/ Assistance Required a) Assistance with public awareness raising b) Action Researcher to support evaluation of local initiatives c) Literature Review and Analysis d) Higher Education awareness and change to reflect rural educational need, consider a Rural College based in the Highlands and Islands. e) Programme Management to oversee initiatives and to make the links and share the learning f) Support for Community Engagement and ownership g) Funding to support Conferences h) Pump priming resource to test new models i) Consideration of ongoing additional rural funding in recognition of the costs of providing services such as out of hours, emergency care, Rural General and 999 non bypass community hospitals and care homes j) Making the links across Government to assist with the wider issues, for example, housing, negotiation with lenders on ‘rural mortgages’.
23 Annual Costs for a 3 year period
Item Estimated Cost Estimated cost years Year 1 2 and 3
Research partner £50,000 £50,000
Literature Review and Analysis £10,000
Programme Manager £50,000 £50,000
Conferences and engagement events £10,000 £10,000
Health Economist (sparsity work) £30,000
Pump priming for Key Initiatives £570,000 £570,000
See appendix 1
TOTAL £720,000 £680,000
5.2 Examples of Initiatives
5.2.1
One example of a new model that is about to be tested is in West Lochaber. There are two vacant Practices, one brought about by the tragic death of the resident GP on Eigg, covering the Small Isles and the other by the resignation of both GPs and the Practice Manager in Acharcle after less than three years in post. NHS Highland had for some time been considering the need for a different way of thinking about configuring these small practices and a local GP made an approach to establish whether or not a multi practice would be considered. This was encouraged and, following considerable community engagement, the two Practices were advertised inviting creative and innovative solutions. Although there was reasonable interest, only four applications were received. Two were for the Small Isles only and the other two were for a multi practice, collaborative approach. The two for Eigg were withdrawn in advance of the interview. The preferred model would incorporate the two Practices with Mallaig and Arisaig Practice on the basis of a single Practice but with two teams operating from the two main centres and providing out of hours cover for the Acharacle Practice area where the previous GPs had not opted out but cited the onerous nature of on call as one of the reasons for leaving. The in hours service could be covered by five full time or six part time GPs, within budget, but to operate 24/7 and allow a sensible work/life balance as well as supporting education and training, it is estimated that eight GPs will be required. This model is over budget, even after Board Administered Funds have been added for all three existing Practices. It is however, believed to be a sustainable solution and sources of additional funding are being sought.
Significant public engagement has already been undertaken and is ongoing. The Mallaig and Arisaig Practice has been involved in the discussions at all stages.
24
5.2.2
Another example is rationalisation of mainland small rural single handed practices with larger ones in Kintyre and Mid Argyll.
The practices in Campbeltown and Lochgilphead deliver the “triple duty role” previously outlined with the local community hospital acting as the hub. The practices cover extensive geographical areas within which are a number of smaller practices and their status and profile is detailed in the appendix.
The issues outlined in 15.1 apply equally within these localities and are accentuated by the “triple duty” role required of the medical staff. Once again NHS Highland has for some time been considering the need for a different way of thinking about configuring the smaller practices, integrating and merging them with the larger practices. Progress has been very much on and off with both Lochgilphead and Campbeltown interested and willing to merge practices, develop locality wide service and enhance service sustainability and increase pool of staff to provide the service. Inevitably progress has ground to a halt due to staff vacancy, inability to recruit, risks to practice income and absence of supporting infrastructure out of hours to triage and support all pathway aspects of the unscheduled demand, aligned with community and political concern re perceived loss or reduction in local service without the confidence of seeing the alternative service operate in practice.
It is clear the solution comprises:
• Exploring the opportunities within the GMS contract re section 17C, or a salaried service or a hybrid of both to support the rationalisation of practices in each locality.
• Enhancing the remuneration levels to match urban only GMS activity.
• Providing and resourcing training and placement programmes for skills development and retention.
• Enhancing the SAS capability and capacity to see and treat with supporting infrastructure (similar to the model developed on the Western Isles).
The expectation is that there would be an establishment of at least 8 staff to provide the triple duty medical input. Alongside this is an enhanced SAS service to provide see and treat out of hours capability pan-locality.
This is facilitated by a GMS service/practice rationalisation to establish a single locality multidisciplinary service delivered by a “hub and branch” surgery model. This will offer opportunities to enhance and develop locality services and at the same time drive out service and organisational efficiencies, from which it is expected to offset some of the increased cost of the “triple duty” rural practitioner.
25 Meetings with the Practices to explore these possibilities were held in April and May and there was support for further exploration of the model. The potential benefits from the training programme development, increased use of telemedicine and multi professional approach was acknowledged.
Indicative costs and timing of these initiatives are detailed in Appendix 1.
5.2.3
Similar to 5.2.2 another example is the rationalisation of Island Practices.
The Isle of Islay faces the same situation all be it at a much smaller scale. There are 3 practices on the island serving a population of 3,000 and over the last 2 years there has been a crisis in staffing the GMS service and Community hospital with locums propping up the service. NHS Highland has now agreed with the 3 GP principals to provide additional resources for one year to stabilise the service whilst a formal review is conducted supported by an independent expert Dr Gordon Peterkin of Kithstone consulting.
This review will look to merge and rationalise the practices, define and implement the core service provision of the non-bypass 999 hospital and explore and implement the remote support from stakeholders to further enhance community viability and resilience. The intention is to put this in place on Islay and then to look to build on the work done to merge with the adjoining practice on the Isle of Jura (population 194), which has been suspended.
6. Governance Arrangements
NHS Highland recommends that there should be a formal programme process to take forward the “Approach to Building Sustainability of Health and Care Services in Remote and Rural Areas”. A Programme Board should be established to oversee and govern the initiatives and act as a research advisory group.
If this proposal is agreed, NHS Highland will also establish a governance structure and underpinning the Programme Board the relevant NHS Highland Operational Unit will establish as part of its management team, an operational programme group tasked with progressing the initiatives with appropriate representation and general/programme management support. The Programme Groups will oversee the day to day operation of the initiatives utilising the Highland Quality Approach Charter system , with monitoring and control process to ensure the programme delivers against is aims and objectives to the timelines specified.
The programme groups will be supported by short life working sub groups addressing specific pieces of work as required. The indicative programme organisational structure is outlined in Figure 1 below.
Conclusion
From a brief review of the literature and from local and anecdotal evidence, it is clear that the current health and care service models for remote and rural areas are under extreme pressure and that many are unsustainable even in the short term. There is a wealth of information and previous
26 recommendations going back over a hundred years which can be drawn on to assist with building safe and sustainable solutions for the future. There is much work to be done with communities, some of which are anxious about any change, particularly where a diminution of service is perceived, and their sense of being ‘safe’ is challenged. One of the key elements of success then, is to ensure that communities are involved in exploring options for the future and play a part in building solutions for sustainability of those communities in a wider sense. Mainly for that reason, a ‘one size fits all’ model will not succeed and therefore, it is suggested that as action research approach is adopted to explore and test models with communities as opportunities arise. This approach could be transferred to other areas facing recruitment and retention issues in remote and rural areas but also to more populated areas. In this way, a ‘menu’ of possible solutions could be developed for others to consider and test for themselves. It is suggested, though, that there are some key element s of success and principles that will be common to all change initiatives.
NHS Highland was requested to submit a proposal to Scottish Government to develop and test models of care for remote and rural areas. This paper has described more of an approach to building sustainability through involvement of key stakeholders and supporting community resilience. There are some immediate challenges in parts of NHS highland and it is proposed that the approach described be utilised in those areas utilising action learning that can be captured through working with a research partner, evaluated and shared.
A summary of recommendations are:-
• There is no single model that will address the challenges and fragility in remote and rural health and care services and therefore an action research approach is being proposed.
• Solutions lie is the combined efforts of public service providers and communities themselves and therefore an inclusive, mutual approach is recommended, skilled facilitation may be required to assist this process.
• For clinical governance reasons, single handed practice should no longer be supported and a where possible a locality wide model of service provision, delivered under a multi professional team based approach, based on key skills and competencies should be adopted.
• Risk management, including bench and stress testing should be integral to the development of any solution.
• Community ownership and confidence in new service models is essential, “see and touch” alternatives underpinned by transitional or pilot arrangements demonstrate commitment to the programme.
• There should be exploration of cross portfolio enabling factors in Scottish Government, examples being Education, Finance, Transport and Infrastructure
27 Appendix 1 - provides a breakdown of potential initiatives, cost and timeline
Argyll and Bute example
Kintyre – Current situation GMS OOHs/Comm 24/7 Triple Budget £ Hospital/A&E duty or Budget £ GMS OOHs hourly rate £
Campbeltown Medical 6 partner practice - (current 874,672 Practice vacancy 1 partner) 600,600 69 GP Pop 6316 24/7 GMS OOHs A&E & Inpatient CH med cover
Kintyre Medical Group 2.3 wte Salaried practice 530,200 (Southend & Muasdale (includes (Current 1 vacancy & second 0 53* GP retires in June 2013) Isle of Gigha Provides GMS out of hours GP Pop 1169
Kintyre – Proposal GMS OOHs/Comm 24/7 Triple Budget £ Hospital/A&E duty or Budget £ GMS OOHs hourly rate £
South Kintyre Medical GMS 8.3 wte partner 1,404,872 Group GP practice (Campbeltown 810, 600 93 Southend & Muasdale 1. 5 wte salaried or partner - 24/7 GMS OOHs A&E & includes Isle of Gigha ) Pop 7485 Inpatient CH med cover Total complement 9.8 wte
28 Mid Argyll – Current situation GMS OOHs/Comm 24/7 Triple Budget £ Hospital/A&E duty or Budget £ GMS OOHs hourly rate £
Lochgilphead Medical 6 partner practice 1013,362 656,100 75 practice 24/7 GMS OOHs A&E & GP Pop 6668 Inpatient CH med cover
5 partners providing GMS on-call, A&E, Inpatient & CH Med Cover
Inveraray Vacant practices- locum 338,803 20,880 3 cover – recruitment process not attractive as OOHs GP Pop 1196 commitment is 1 in 2- expressions of interest in post advise they will opt out
Mid Argyll – Proposal GMS OOHs/Comm 24/7 Triple Budget £ Hospital/A&E duty or Budget £ GMS OOHs hourly rate £
Lochgilphead & GMS 8 partner practice 1,352,165 886,120 99 Inveraray Medical 1.5 wte salaried or practice partner GP Pop 7864 24/7 GMS OOHs A&E & Inpatient CH med cover
Total complement 10.0 wte
Note:
• GMS Out of Hours Activity Overnight Mon-Fri 6pm-8.00am & 24/7 weekends and bank holidays • Community hospital inpatient and casualty 24/7 • Based on salaried cost
29 Advertised hourly rates for GMS OOHs activity work only e.g. Leeds & Yorkshire Up to £110 per hour for regular/ad hoc immediate start in Out of Hours (OOH), GP Practice and Walk in Centres:
GENERAL PRACTICE - GPs (Hourly Rate) SURGERY - Monday to Friday £70.00 to £100.00 SURGERY - Night and Weekend £80.00 to £125.00 SURGERY - Bank Holiday £140.00 to £200.00 SURGERY - Out of hours £70.00 to £110.00 SURGERY - Paperwork £35.00
No Action Indicative Funding source Timeline cost £000 £000
1 Rationalisation of mainland rural small single £300 SGHD - £150 12-18 months handed practices with larger ones circa 8-9000 population that provide integrated GMS, CHP- £150 community hospital, A&E and social care service Pilot localities Kintyre & Mid Argyll either:
o GP model with business to business contract o GMS 17c contract (Arran model) o Salaried model - o Hybrid of GP/salaried model
2 Rationalisation of Island 3 small GP practices £220 CHP £220 12 months into larger ones providing integrated GMS, community hospital, A&E and social care service. Pilot locality Isle of Islay circa 3000 population GP model with business to business contract
o GMS 17c contract (Arran model) o Salaried model o Hybrid of GP/salaried model
Apply outcome to Isles of Mull and Bute
30 3 Identify and commission training programmes Backfill Staff CHP £30 for those working within remote and rural costs Community Hospital settings e.g. GPs in Included in SGHD £10 MACHICC were commissioned by to develop a salaried training curriculum for GPs joining community staffing hospital teams which were never implemented. model in AND/OR Skye training model to be rolled out to proposal 1 action areas 1 and 2 Travel etc £42
4 Implementing Intermediate Care Capability TBI CHP Framework for nurses working within Community Hospitals to support the education 24 months and skills development within nursing teams merging the community nursing workforce with the community hospital staff
5 Team approach to OOHs use of DNs, RCOP 24 months intermediate care teams and to assess patients in community and engagement with NHS 24 re appropriate triage- enhancing anticipatory care focus.
6 Enhancing the use and application of £50 Delayed 12 months telemedicine to support service e.g. Grampian and Orkney model of service delivery and support of ENPs in Community hospitals via telemedicine.
7 Establishing a critical mass of SAS see and treat £50 Reduced look 18-24 months practitioners in Argyll and Bute localities as a at fast (roll out by viable supplement to GMS on-call thus responder locality) facilitating a rationalisation of existing GMS vehicle cover provision into community hospital hubs and Mid Argyll & enhancing quality of patient service in three north end of areas - Cowal, Mid Argyll and Kintyre Kintyre in peak out of hours period- Needs further development so that SAS provides practitioner see & treat as core business
31 CHP /SGHD
8 Review of GP remuneration levels to accurately Hourly rate SGHD/NHS ? reflect the “triple duty” market rate of service TBI Highland – provision to enhance recruitment rural primary attractiveness and retention (links to Action 1) care funding review
9 GMS contract and budget management £34 CHP/SGHD 12 months support to negotiate and put in place new contract arrangements (section 17C) – accessing SGHD support
Summary of recurring and non recurring costs 2013/14 ** & 14/15
No. Initiative CHP SGHD
1 Additional GPs – Mainland (3 wte) 210,000 210,000
2 Additional GPs – Island Islay (2 wte) 216,000 0
3 Backfill training costs 30,000 10,000
7 SAS First responder 25,000 25,000
9 GMS specialist contract project 22,000 22,000 management
503,000 267,000
Note ** This is full year effect – in essence for 13/14 would probably be 50%
32 North Highland example
No Action Indicative Funding Timeline Additional source cost £'000 £'000 1 Linking mainland Mallaig/Arisaig and Acharacle NHS H NHS H 3 years to fully Practices with Small Isles establish
WLMP Additional Costs: £422K NHS Highland funds BAF and Sea Transport £222K SGHD - Shortfall £200K
Proposal: Develop two GP sub teams Develop multi professional approach Community resilience – First Responders etc Improve sea transport options Develop Emergency response
Summary of Recurring and Non Recurring 2013/14 to 2015/16
No Initiative NHS SGHD Highland £ £ 1. West Lochaber medical practice 222,000 200,000 Mallaig Team of 3.5 GPs, North WLMP including small isles. Ardnamurchen Peninsula Team of 3 GPs, South WLMP including OOH’s
33 Appendix 2 – Mind Map
34