Argyll and Bute CHP

SERVICE OPTIONS For the 24/7 REVIEW OF GP OUT OF HOURS AND GP HOSPITAL SERVICES

Cowal 24/7 Review 1 Version 10 (23/03/12)

Contents Page No.

1 Background 3-4 2 Project Objectives and boundaries 4 3 What is the Out of Hours GP Service? 5-6 4 What core services should be provided in a community hospital? 9

5 What is the current workforce in Cowal Community Hospital (Medical & Nurse Practitioner) and for Out of Hours services 10-12

6 Options or ways of providing these services across Cowal 13-50 Three Centres

Option 1 page 15 & 16 Option 2 page 16 & 17

Two Centres

Option 3 page 20 & 21 Option 4 page 22 & 23 Option 5 page 24 & 25 Option 6 page 26 & 27 Option 7 page 28 & 29 Option 8 page 30 & 31

One Centre Option 9 page 33 & 34 Option 10 page 35 & 36 Option 11 page 37 & 38 Option 12 page 39 & 40 Option 13 page 41 & 42 Option 14 page 43 & 44 Option 15 page 45 & 46 Option 16 page 47 & 48 Option 17 page 49 & 50 7 Comment Log - Comments to date on the Options 51-53 9 What Happens Next? 54 10 Glossary 55-57 11 Further Information 58

Cowal 24/7 Review 2 Version 10 (23/03/12) NHS Highland’s Vision

VISION

 Provide quality care at all times Option 3  OptionSupport people4 and communities to maximise their own health  Develop precision driven services so that when people need our care they experience timely, focussed, effective services that minimise the duration and frequency of contact

 Ensure that every health pound spent delivers maximum health gain

BETTER HEALTH, BETTER VALUE, BETTER CARE

Argyll and Bute CHP is putting in place a Better Health Better Care Better Value plan. This means our services are being redesigned to meet a range of challenges while at the same time ensuring they remain safe and sustainable.

OVER THE NEXT 5 YEARS WE WILL:

1. Promote good health, self care and independence

2. Provide services that are high quality, integrated, equitable, needs and evidence-based, and cost-effective

3. Become more community based with hospital beds preserved for the most acutely ill and those with specialist needs

4. Integrate with, and complement local authority, voluntary and independent sector care

5. Be run by healthy, flexible, well-motivated and well-trained staff working to their maximum potential and capability

6. Use modern, flexible, efficient, green assets to maximum effect with zero waste and inefficiency across all services and reduce overheads

Cowal 24/7 Review 3 Version 10 (23/03/12) 1 Background

Rural GPs have been making changes over the past few years to the way they provide services once their surgeries are closed -‘Out of Hours’ (OOH).

The GP who provided the Strachur Out of Hours service decided to not to do this any more – to ‘opt out’. The contract was not renewed. As a result, throughout 2010, the Community Health Partnership (CHP) looked at ways of establishing a GP out of hours service for the Tighnabruaich and Strachur GP practices to replace that contract. This had to be done quickly. So a temporary contract was put in place for 12 months until a comprehensive review could be done.

Now we are reviewing all GP Out of Hours Services for Cowal to see how a safe and sustainable service can continue for the future. This is better than undertaking the task each time there is a change. We are also reviewing the medical cover within Cowal Community Hospital. The review runs until September 2012

The 24/7 Review will look into;

 the Out of Hours service provided from Cowal Community Hospital and the OOH service provided to Tighnabruaich and Strachur

 the OOH service provided from the Vale of Leven District General Hospital to Lochgoilhead

 medical staffing in Cowal Community Hospital covering Casualty, Inpatient and Palliative Care

 the role of the Scottish Ambulance Service ( SAS) , Nurse Practitioners (NP), other agencies, voluntary sector and the community in providing emergency and first aid responses

 the type and level of activity, need and demand for these services

 comparing (or benchmarking) the service with other models

 identifying the size of the resources involved and the cost of the services

 engaging with the community, stakeholders and service providers to obtain their views on the current services

 developing alternative options and doing a formal appraisal. This includes consultation and engagement with local communities

 identifying a preferred option to recommend to Argyll and Bute Community Health Partnership

Cowal 24/7 Review 4 Version 10 (23/03/12) 2 Cowal 24/7 Project Objectives and Boundaries

The Cowal 24/7 service review has the following service objectives and boundaries:

Table 1 Cowal 24/7 Medical Practitioner Service Objectives

Objective Description

1 To provide a safe and responsive service in and out of hours that meets patients needs, service standard and performance targets.

‘The right service in the right place at the right time’

2 To provide a sustainable service that can meet the forecast demand in the next 3 years

3 To provide services that are flexible, and meet the requirements for in and out of hours Medical services  Cope with peaks and troughs in demand  Respond to rural areas to the standards set

4 To acknowledge the constraints rural geography places on the services.

As far as possible and practical, ensure services are accessible to patients, to accepted performance standards

5 To provide ‘fit for purpose’ services for use by staff so that staff have the resources they need to deliver the standards that are expected

6 To attract and retain high quality staff

7 To ensure the efficient and cost effective use of resources

Cowal 24/7 Review 5 Version 10 (23/03/12) Table 2 Cowal 24/7 Medical Practitioner Service Boundaries

Constraint Description

1 Options must be compatible with existing service strategies and principles

2 Options must be flexible enough to meet the future needs of the service

3 Options must make best use of existing resources (staff, skills and capacity) as there are no new financial resources.

4 Options must meet agreed and defined service needs and performance standards

5 Options must offer value for money

6 Service exclusions.  Not to address current day to day operational issues.  Not to address General Medical Services for Primary Care  Scottish Ambulance Service 999, Transport and Emergency response role

Cowal 24/7 Review 6 Version 10 (23/03/12) 3 What is the Out of Hours GP Service?

What General Medical Service (GMS) GP out of hours service can we expect (Mon-Fri 6pm-8am & Weekends & public holidays 24 hours)

Note not all of these services may be in this area

NHS 24 Call Management & Nurse Triage

Cowal 24/7 Review 7 Version 10 (23/03/12) Calls made to NHS 24 are put into the following categories

. Immediate life threatening conditions Calls must pass to the ambulance service within 3 minutes

. Urgent calls All Serious or urgent calls - clinical assessment must start within 20 minutes of the call being answered

. All other calls Patients with routine or minor symptoms, calls prioritised and NHS 24 call back 1-3 hours

If a GP is called they must respond within these times (Note new standards are being developed by Health Improvement Scotland)

When the NHS 24 clinical assessment indicates a response by a doctor is required the doctor must respond as follows:

. Urgent: Within 1 hour.

. Less Urgent: Within 2 hours.

. Routine: Within 4 hours

Cowal 24/7 Review 8 Version 10 (23/03/12) 4 What Core services should be provided in a community hospital?

Table 3 As a minimum a Community Hospital should support these services

‘Unscheduled’ Care (unexpected by the patient/doctor)  Unscheduled Care o Trauma o Acute medical conditions o Nurse led Urgent Care service managing minor injury and minor illness o Clear and appropriate retrieval and transfer arrangements.  Paediatric Services o Common paediatric conditions o Short stay assessment o Emergency care for ill and injured children  Midwifery led maternity service o Short stay assessment during antenatal period, prior to transfer or discharge o Labour and childbirth  Mental Health o Alcohol Detoxification o Place of Safety for 24- 48 hours  Capability to manage patients requiring a higher dependency of care before transfer

Planned Care  Preadmission assessment for elective procedures  Older People o 24 hour observation and alteration to treatment o Exacerbation of chronic condition o Rehabilitation o Treatment of Acute episodes occurring in person with dementia o Interim care o Additional assessment of challenging community patients  Palliative Care o Short term observation and monitoring for symptom management o Supported care o End of life care o Supportive therapies o Chemotherapy  Rehabilitation and ‘step-down’ – care provided once a treatment or procedure has finished  Post-op step down, rehabilitation and follow-up treatment  Visiting specialist clinic services

Diagnostic Services  Local diagnosis and treatment- including blood tests, ultrasound, radiography, physiological measurements

Reference: The Remote and Rural Steering Group Report 30.11.07

Cowal 24/7 Review 9 Version 10 (23/03/12) 5 What is the current workforce in Cowal Community Hospital (Medical & Nurse Practitioner) and for Out of Hours Services

GPs have their own practices and are self employed. Doctors who work in the hospital may or may not also be GPs as some do not have their own GP practices. GPs and Doctors provide services to the NHS Community Health Partnership (CHP) under different contracts. In Lochgoilhead another health board is contracted to provide Out of Hours services rather than direct contracts with GPs or Doctors employed by the CHP.

GP and Doctor services

Community Health Partnership ( CHP) employed Doctors based in Cowal Community Hospital (CCH) provide the following in the Hospital; Casualty, cover for patients (inpatients) after 6pm (i.e., Out of Hours) and weekends/bank holidays. They provide the Out of Hours service for Dunoon and South Cowal from CCH.

The 3 GP practices based in Dunoon cover inpatients during the day Mon-Fri 8am to 6pm.

Rural GPs provide Out of Hours services in rural Cowal.

A separate arrangement with NHS Greater Glasgow &Clyde ( NHS GG&C) provides a service to Lochgoilhead from the Vale of Leven Hospital ( VoL).

Cowal 24/7 Review 10 Version 10 (23/03/12)

Table 4 Cowal Community Hospital & OOHs Service Medical Staffing

This table shows what staff work in which areas over a period of 24 hours. The table is divided into;  Shifts e.g. 8 am to 6 pm  Departments e.g. Casualty  Location - where the work takes place e.g. Lochgoilhead.

The colour coded key tells you what kind of medical staff are working in a department or geographical area. Below the table there is an explanation of the colour coding and some abbreviations.

Monday to Friday

11pm - Hospital Department 8am -6pm 6pm -11pm 8am Description of Activity Casualty 1 Admissions, A&E patients Admissions + Reviews + Wards Ward Rounds 1 1 Primary Care Primary Care Emergency Emergency Centre Centre (PCEC) patients + ( PCEC) Home Visits 3 GPs various times during Admissions + Reviews + Wards each day ward rounds

Location

Strachur/Tighnabruaich 1 Surgery + Home Visits

Primary Care Emergency Centre (PCEC)+ Home Lochgoilhead 1 Visits

Key Community Health Partnership (CHP) employed Doctors GP = 3 town surgeries, 1 GP from each = 3 GPs Rural GPs Strachur & Tighnabruaich Lochgoilhead OOH (NHS Greater Glasgow &Clyde ) 1 No. of Drs on duty in a session

Cowal 24/7 Review 11 Version 10 (23/03/12) Table 6 Cowal Community Hospital & OOHs Service Medical Staffing

Weekends & Bank holidays

Hospital Department 8am -6pm 6pm -11pm 11pm -8am Description of Activity Admissions + Reviews + Casualty & Wards Ward Rounds Primary Care 2 2 1 Emergency Centre PCEC patients + Home (PCEC) Visits

Location Strachur/Tighnabruaich 1 PCEC + Home Visits

Lochgoilhead 1 PCEC + Home Visits

Key CHP employed Doctors GP = 3 town surgeries, one doctor from each = 3 GPs Rural GPs Strachur & Tighnabruaich Lochgoilhead (NHS Greater Glasgow &Clyde ) 1 No. of Drs on duty in a session

PCEC - Primary Care Emergency Centre NP - Nurse Practitioner

Table 7 Cowal Community Hospital Casualty Department Nurse Staffing

Monday- Sunday

07:00am – 3.00pm 1.30pm- 9.15pm 9.15pm to 7.30pm Nurse Practioner ( NP) Band 6 Nurse Practitioner Band 6 minor injuries etc minor injuries etc Registered Nurse Band 5 Registered Nurse Band 5 supports the Dr supports the Dr Nurse Practitioner Band 6

Nursing staff also support theatre & outpatient clinics -orthopaedics in Casualty

Cowal 24/7 Review 12 Version 10 (23/03/12) 6 Options or ways of providing these services across Cowal

On the following pages is a list of 17 options or ways of providing the following services;

 Out of Hours  Casualty  Primary Care Emergency Centre  In Patient Hospital Beds

These options are presented in diagram form and in words. Some of the key advantages and disadvantages of each option are highlighted.

These options are listed to enable discussion and debate between professionals and also the public. There are a lot of them to encourage a broad look at what is possible.

There are very many ways the services could be arranged. These options do not cover them all and comments are welcome. For instance Lochgoilhead area could be within Cowal or still with the Vale of Leven for many of the options.

The options have been clustered according to whether the service is provided from three centres as now,, ( Cowal Community Hospital, Rural Cowal and Vale of Leven) two centres or one.

Feedback from the public as well as discussions at the 24/7 Review will be used to make the decision about which options will be put forward for careful scoring. The scoring will result in a decision about which would be the best option for Cowal. The scoring process scores each of the following

 Benefits ( not financial but to patients etc)

 Risks

 Value for Money

 Affordability

More information about this process and timescale is available in section 9.

Descriptions of options 1 – 17 follow.

Cowal 24/7 Review 13 Version 10 (23/03/12) Options Based in three Centres

 Cowal Community Hospital Primary Care Emergency Centre

 Rural Primary Care Emergency Centre

 Vale of Leven (VoL) Primary Care Emergency Centre (Greater Glasgow and Clyde Health Board)

Primary Care Emergency Care Centre VALE OF LEVEN DISTRICT GENERAL HOSPITAL

Cowal Community Hospital

Cowal 24/7 Review 14 Version 10 (23/03/12) Option 1 Existing Service

GPs and Doctors provide services under different contracts.

Community Health Partnership ( CHP) employed Doctors based in Cowal Community Hospital (CCH) provide the following in the Hospital; Casualty, cover for patients (in patients) after 6pm (i.e., Out of Hours) and weekends/bank holidays. They provide the Out of Hours service for Dunoon and South Cowal from CHH.

The 3 GP practices based in Dunoon cover inpatients during the day Mon-Fri 8am to 6pm.

Rural GPs provide Out of Hours services in rural Cowal.

A contract with NHS Greater Glasgow &Clyde ( NHS GG&C) provides a service to Lochgoilhead from the Vale of Leven Hospital ( VoL).

Description:  CHP employed Doctors provide casualty 24/7 out of hours service for Dunoon and Kilmun practices and weekend hospital inpatient service based in Cowal Community Hospital  Dunoon GPs admit and take the lead for the care of their own practice patients Mon-Fri 8am to 6pm. Two of the Dunoon practices cover patients from other practices  Rural Cowal GPs cover OOH in rest of Cowal (except for 1 day a week cover provided by CHP employed doctors). Strachur is the service base called the Primary Care Emergency Centre (PCEC).  Lochgoilhead community have service provided by GG&C from VoL Hospital.

Advantages  Existing service- known and familiar  Dunoon GPs know and look after patients from their own practice Mon-Fri 8:am to 6pm  2 of the Dunoon practices look after rural practice patients who are admitted to hospital  Dunoon GPs involvement support continuity of care from community to hospital for their patients  Rural Cowal OOH service designed to meet rural need and easily meets demand  Meets General Medical Service performance standards  Meets Casualty performance standards

Cowal 24/7 Review 15 Version 10 (23/03/12) Disadvantages  Number of Doctors working in the hospital during day, 1 doctor in casualty. 3 GPs looking after their ward patients.  The varying number of patients can result in medical and nursing staff not being fully utilised on direct patient care  3 practices are not the ideal way to ensure integrated and multidisciplinary working  Rural Cowal OOH activity is currently very low.

Option 1 Existing Service

Monday to Friday

Hospital Department 8-6. 6-11. 11-8. Description of Activity Casualty 1 Admissions , A&E patients Admissions + Reviews + Wards ward rounds 1 1 Primary Care Emergency Centre PCEC patients + Home (PCEC) Visits 3 Drs various times during Admissions + Reviews + Wards each day ward rounds

Location Strachur/Tighnabruaich 1 Surgery + Home Visits

Lochgoilhead 1 PCEC + Home Visits

Weekends & Bank holidays

Hospital Department 8-6. 6-11. 11-8. Description of Activity Admissions + Reviews + Casualty & Wards ward rounds 2 2 1 Primary Care Emergency Centre (PCEC PCEC patients + Visits

Location Strachur/Tighnabruaich 1 Home Visits

Lochgoilhead 1 PCEC + Home Visits Key CHP employed Medical Staff GP = 3 town surgeries, one GP from each Rural GPs Strachur & Tighnabruaich Lochgoilhead (NHS GG&C) 1 No. of Drs on duty in a session

Cowal 24/7 Review 16 Version 10 (23/03/12) Option 2

CHP employed Doctors based in CCH provide the following in the Hospital; Casualty, in patients during Out of Hours and weekends/bank holidays. They provide the Out of Hours service for Dunoon and South Cowal from CCH

GPs contracted to cover inpatients during the day Mon-Fri 8am to 6pm.

Rural GPs provide Out of Hours services in rural Cowal - Tighnabruaich, Strachur and extend the coverage to Ardentinny (currently covered by CCH OOH)

Contract with NHS Greater Glasgow &Clyde providing OOH service to Lochgoilhead from the Vale of Leven Hospital

Description-  A contract with GPs providing an on-call doctor covering rural Cowal. 24/7 based in Strachur or Tighnabruaich  A contract with GPs covering wards Mon – Fri 0800 – 1800.  Doctors employed in CCH and travel from hospital if necessary for home visits and/or patients attend casualty to be seen by relevant practitioner in Dunoon catchment area  Patients who are able to travel by their own transport or NHS 24 arranges a taxi

Advantages  Similar to existing service- known and familiar  If local town GPs opt to submit a tender and win contract,- provides service continuity between hospital and community for their patients  Rural Cowal out of hours service designed to meet rural need and easily meets demand  Meets GP out of hours performance standards  Increased area of responsibility of rural GPs covering a wider area up to 30 minutes from Dunoon

Disadvantages  May be to many Doctors on duty in hospital then level of activity requires  Rural Cowal out of hours service activity is very low

Cowal 24/7 Review 17 Version 10 (23/03/12) Option 2

Monday to Friday

Hospital 8-6 6-11 11-8 Description of Activity Department/Location Casualty & Wards out of 1 1 1 Dr Workload admissions + hours A&E Patients. Admissions + Reviews + Ward Rounds Wards 1 Admissions + Reviews + Ward Rounds PCEC in Hospital 1 1 PCEC Patients + Home covering Dunoon Visits PCEC in rural area 1 1 Surgery + Home Visits covering Strachur/Tighnabruaich VOLDGH PCEC for 1 1 PCEC + Home Visits Lochgoilhead

Weekends and Bank holidays

Hospital 8-6 6-11 11-8 Description of Activity Department/Location Casualty & Wards & 1 1 1 Dr Workload admissions + PCEC 11-8 AE Patients., Reviews + Ward Rounds & out of hours cover after 11pm

PCEC in Hospital 1 1 PCEC Patients covering Dunoon PCEC in rural area 1 1 1 Visits + “Surgery” covering Strachur/Tighnabruaich VOLDGH PCEC for 1 1 1 Visits + PCEC Lochgoilhead

Key CHP employed Doctors Contract for Rural Cowal (T&S) Contract with GPs for wards Contract NHS GG&C Lochgoilhead

Cowal 24/7 Review 18 Version 10 (23/03/12) Options Based in 2 Centres

 Cowal Community Hospital Primary Care Emergency Centre

 Rural Primary Care Emergency Centre

Primary Care Emergency Care Centre

Cowal Community Hospital

Cowal 24/7 Review 19 Version 10 (23/03/12) Option 3

CHP employed Doctors providing Casualty, Inpatient and Out of hours service in based in the hospital.

Contract for GPs to provide out of hours service for Strachur, Tighnabruaich and Lochgoilhead

Description-  2 Doctors providing out of hours service  Dedicated Team of Rural GPs provide out of hours service to Strachur, Tighnabruaich and Lochgoilhead on a call out basis  CHP employed Doctors providing all hospital, and out of hours service based at the hospital for Dunoon catchment area  Drs travel from hospital if necessary for home visits and/or patients attend casualty to be seen by relevant practitioner in Dunoon catchment area  Patient who are able to travel by their own transport or NHS 24 arranges a taxi

Advantages  Doctors employed by the CHP may provide greater opportunity to co- ordinate and improve continuity of hospital, casualty and out of hours care  Offers a financial advantage by improving the efficiency of workforce (matching patient demand/activity across hospital, out of hours and casualty 24/7- potentially less Drs on duty)  Patients who are able to travel to hospital out of hours can benefit from assessment and access to other diagnostic and treatment services  Would meet response times in rural areas for GP service

Disadvantages  Patients who are not able to travel will not benefit from assessment and access to other diagnostic and treatment services  Possible loss of continuity of care between the hospital and GP practices for e.g. as GP are no longer responsible for hospital beds  Could increase calls to the Scottish Ambulance Service  Could be an increase in complaints regarding the service  Rural Cowal OOH service activity is very low  There may be too many doctors on duty for service demand

Cowal 24/7 Review 20 Version 10 (23/03/12) Option 3

Monday to Friday

Hospital 8-6 6-11 11-8 Description of Activity Department/Location Casualty & Wards 1 1 1 Dr Workload admissions + A&E Patients. Admissions + Reviews + Ward Rounds

PCEC in Hospital 1 1 PCEC Patients covering Dunoon PCEC in rural area 1 1 covering Strachur/Tighnabruaich /Lochgoilhead

Weekends & Bank Holidays

Hospital 8-6 6-11 11-8 Description of Activity Department/Location Casualty & Wards 1 1 1 Dr Workload admissions + AE Patients. Admissions + Reviews + Ward Rounds

PCEC in Hospital 1 1 1 PCEC+ Home Visits covering Dunoon PCEC in rural area 1 1 PCEC + Home Visits covering Strachur/Tighnabruaich /Lochgoilhead

Key CHP employed Doctors Contract GPs Strachur/Tighnabruaich /Lochgoilhead

Cowal 24/7 Review 21 Version 10 (23/03/12) Option 4

CHP employed Doctors based in CCH provide the following in the Hospital; Casualty, inpatients during Out of Hours and weekends/bank holidays. They provide the Out of Hours service for Dunoon and South Cowal from CCH.

The 3 GP practices based in Dunoon cover inpatients during the day Mon-Fri 8am to 6pm.

Rural GPs provide Out of Hours services in rural Cowal, Tighnabruaich, Strachur and Lochgoilhead

Description:  CHP employed Doctors covering casualty 24/7 and Dunoon out of hours service 24/7  A contract with rural GPs providing an on-call doctor covering rural Cowal. 24/7 based in Strachur, Tighnabruaich or Lochgoilhead  A contract with Dunoon GPs covering wards Mon – Fri 8am – 6pm  Doctors travel from hospital if necessary for home visits and/or patients attend casualty to be seen by relevant practitioner in Dunoon catchment area  Patient who are able to travel by their own transport or NHS 24 arranges a taxi

Advantages:  Offers a service with a minimum 1 duty doctor and 1 on-call doctor out of hours  Provides a Doctor in Casualty and GPs covering wards Monday to Friday  If local town GPs opt to submit a tender and win contract- provides service continuity between hospital and community for that practices patients.  Provides a designated GP rural out of hours rota  Increased area of responsibility of rural GPs covering a wider area up to 30 minutes from Dunoon

Disadvantages:  Rural Cowal out of hours service activity is very low -  May be to many Doctors on duty then level of activity requires

Cowal 24/7 Review 22 Version 10 (23/03/12) Option 4

Monday to Friday

Hospital 8-6 6-11 11-8 Description of Activity Department/Location Casualty & Wards out of 1 1 1 Dr Workload admissions + hours AE Patients. Admissions + Reviews + Ward Rounds Wards 1 Admissions + Reviews + Ward Rounds PCEC in Hospital 1 1 PCEC Patients + Home covering Dunoon Visits PCEC in rural area 1 1 Surgery + Home Visits covering Strachur/Tighnabruaich /Lochgoilhead

Weekends

Hospital 8-6 6-11 11-8 Description of Activity Department/Location Casualty & Wards & 1 1 1 Admissions + A&E PCEC 11-8 Patients. + Reviews + Ward Rounds Dr Workload admissions +

A&E Patients. Admissions + Reviews + Ward Rounds & OOHs from 11am PCEC in Hospital 1 1 PCEC Patients + Home covering Dunoon Visits PCEC in rural area 1 1 1 Surgery + Home Visits covering Strachur/Tighnabruaich /Lochgoilhead

Key CHP employed Doctors Contract with GPs for wards and out of hours Rural Cowal

Cowal 24/7 Review 23 Version 10 (23/03/12) Option 5

In rural Cowal Saturday & bank holiday ‘drop in’ out of hours GP surgery in either of Strachur/Tighnabruaich/Lochgoilhead

Description-  1-2 CHP employed Doctors provide all hospital, and out of hours service based at the hospital for the whole of Cowal except for Saturday mornings and bank holidays- see below  When 2 Drs are on, travel from hospital if necessary for home visits and/or patients attend casualty/PCEC to be seen by relevant practitioner  No routine home visits when single Doctor on duty  Patients who are able travel by own transport or NHS 24 arranges a taxi  Saturday morning /bank holiday out of hours drop in “GP Surgery” for Strachur/ Lochgoilhead/ Tighnabruaich

Advantages  Offers a financial advantage by improving the efficiency of workforce (matching patient demand/activity across hospital, out of hours and casualty 24/7- potentially less Doctors on duty)  Drs may travel from hospital if necessary for home visits and/or patients attend casualty to be seen by relevant practitioner  Patient who are able to travel by own transport or NHS 24 arranges a taxi  Patients who are able to travel to hospital can benefit from assessment and access to other diagnostic and treatment services  Majority of rural Cowal can be reached within 1 hour from Dunoon if there are no delays  Saturday and bank holiday out of hours drop in GP session/s in either Strachur/Lochgoilhead/Tighnabruaich meets highest peak of out of hours weekend and Bank holiday demand to see GP

Disadvantages  Patients may have to travel or be brought to hospital who live beyond 30 minutes travel time  Service may not be able to meet home visit service standard if delayed on another call or delayed with other patients  Service would not meet response times in rural areas due to higher priority of the hospital service  Could increase calls to the Scottish Ambulance Service  Could be an increase in complaints regarding the service  Risk to emergency response at Casualty when a single hospital doctor is covering out of hours service also

Cowal 24/7 Review 24 Version 10 (23/03/12) Option 5

Monday to Friday

Hospital Department/Location 8-6 6-11 11-8 Description of Activity Casualty & Wards & PCEC after 1 1 1 Dr Workload 11pm admissions, ward round, reviews + A&E Patients.

PCEC in Hospital covering 1 Post 11pm patients Dunoon and rural Cowal attend PCEC if need see Dr

Weekends and Bank holidays

Hospital Department/Location 8-6 6-11 11-8 Description of Activity Casualty & Wards & PCEC after 11pm 1 1 1 Dr Workload admissions, ward round, reviews + AE Patients.

PCEC in Hospital covering Dunoon and 1 1 Post 11pm patients rural Cowal attend PCEC if need see Dr Located in Sat + BH am Emergency GP out of Strachur/Tighnabruaich/Lochgoilhead GP Session hours surgery in Strachur

Key CHP employed Doctors GP contract for out of hours “surgery” session

Cowal 24/7 Review 25 Version 10 (23/03/12) Option 6

Contract with GPs to provide inpatient hospital service Monday to Friday 8am – 6pm.

In rural Cowal Saturday & bank holiday ‘drop in’ out of hours GP surgery in either of Strachur/Tighnabruaich/Lochgoilhead

Description-  Contract with GPs to provide day time medical cover Monday to Friday  2 CHP employed doctors provide all hospital and out of hours service based at the hospital for the whole of Cowal  Drs travel from hospital if necessary for home visits and/or patients attend casualty/PCEC to be seen by relevant practitioner  Patients who are able to travel by own transport or NHS 24 arranges a taxi  Saturday morning out of hours “GP Surgery” in rural Cowal

Advantages  If local town GPs opt to submit a tender and win contract - provides service continuity between hospital and GP for their practice patients.  Doctors may travel from hospital if necessary for home visits and/or patients attend casualty to be seen by relevant practitioner  Patients who are able to travel by own transport or NHS 24 arranges a taxi  Patients who travel to hospital can benefit from assessment and access to other diagnostic and treatment services  Majority of rural Cowal can be reached within 1 hour from Dunoon if there are no delays  Saturday and bank holiday out of hours drop in GP session/s in either Strachur/Lochgoilhead/Tighnabruaich meets highest peak of out of hours weekend and Bank holiday demand to see GP

Disadvantages  When single handed Doctor would not travel beyond 30 minutes from hospital so patients may have to travel to hospital  Service may not be able to meet home visit service standard if delayed on another call or at certain times  Service would not meet response times in rural areas due to higher priority of the hospital service  Could increase inappropriate calls to the Scottish Ambulance Service  Could be an increase in complaints regarding the service

Cowal 24/7 Review 26 Version 10 (23/03/12)  Potentially more Drs on duty at times than patient activity requires  Could increase calls to the Scottish Ambulance Service  Could be an increase in complaints regarding the service  Risk to emergency response at casualty when a single hospital doctor is covering out of hours service also

Option 6

Monday to Friday

Hospital Department/Location 8-6 6-11 11-8 Description of Activity Casualty & Wards & PCEC after 1 1 1 Dr Workload 11pm admissions, ward round, reviews + AE Patients.

Wards 1 Dr Workload admissions, ward round, reviews PCEC in Hospital covering 1 SAS response Dunoon and rural Cowal patients attend PCEC if needed see DR

Weekends and Bank holidays

Hospital Department/Location 8-6 6-11 11-8 Description of Activity Casualty & Wards & PCEC after 11pm 1 1 1 Dr Workload admissions, ward round, reviews + AE Patients. & OOH

PCEC in Hospital covering Dunoon and 1 1 SAS response rural Cowal patients attend PCEC if needed see DR Located in Sat + BH am Emergency GP out of Strachur/Tighnabruaich/Lochgoilhead GP Session hours surgery in Strachur

Key Salaried Medical Staff GP contract for out of hours “drop in surgery” session GP contract

Cowal 24/7 Review 27 Version 10 (23/03/12) Option 7

CHP employed Doctors to provide hospital inpatient and casualty service

GP practices form consortium to provide GP Out of Hours service via a contract for the whole of Cowal

Description-  Doctors employed by the CHP for all hospital and casualty service  Consortium GP out of hours services for Cowal could be based at the hospital, in a rural base or both  Consortium GPs travel if necessary for home visits across Cowal and/or patients attend casualty to be seen by relevant practitioner  Patients who are able to travel by own transport or NHS 24 arranges a taxi to hospital or rural out of hours base if needed

Advantages  Patients who are able to travel to hospital can benefit from assessment and access to other diagnostic and treatment services  Majority of rural Cowal can be reached within 1 hour from Dunoon if there are no delays  Service expected to be responsive for out of hours and hospital/casualty

Disadvantages  Loss of GP cover for in-patient beds  Could increase Casualty attendance if Out of hours GP not in Dunoon  Risk of an increase in locum doctor use for out of hours service

Cowal 24/7 Review 28 Version 10 (23/03/12) Option 7

Monday to Friday

Hospital Department/Location 8-6 6-11 11-8 Description of Activity Casualty and wards 1 1 1 Dr Workload admissions Reviews + Ward Rounds + A&E Patients.

Cowal wide PCEC service based in 1 1 Patients attend PCEC Dunoon or rural area if need see Dr or home visit if required

Weekends and Bank holidays

Hospital Department/Location 8-6 6-11 11-8 Description of Activity Casualty and wards 1 1 1 Dr Workload admissions + A&E Patients. Also Nurse workload

Cowal wide PCEC service based in 1 1 1 Patients attend PCEC Dunoon or rural area if need see Dr or home visit if required

Key Contract GP practices Salaried Medical Staff

Cowal 24/7 Review 29 Version 10 (23/03/12) Option 8

CHP employ Doctors to provide hospital inpatient (out of hours, weekends & bank holidays) and casualty service

GP practices form consortium to provide hospital inpatient service Monday to Friday Mon-Fri 8am to 6pm

GP practices form consortium to provide GP out of hours service via a contract for the whole of Cowal

Description-  CHP employed Doctors provide hospital and casualty service  Contract for day time medical input by GPs Monday to Friday  Consortium GP out of hours services for Cowal could be based at the hospital in a rural base or both  Consortium GPs travel if necessary for home visits across Cowal and/or patients attend casualty to be seen by relevant practitioner  Patients able to travel by own transport or NHS 24 arranges a taxi to the hospital or to the rural out of hours base if needed

Advantages  If local town GPs opt to submit a tender and win contract/s provides service continuity between hospital and community for their patients.  Patients who are able to travel to hospital can benefit from assessment and access to other diagnostic and treatment services  Majority of rural Cowal can be reached within 1 hour from Dunoon if there are no delays  Responsive service for out of hours and hospital/casualty  May be more attractive to recruit GPs/Drs for designated service areas - casualty, GP out of hours & Hospital ward.

Disadvantages  The varying number of patients in the day and out of hours can result in medical and nursing staff not being fully utilised on direct patient care  Risk of an increase in locum doctor use

Cowal 24/7 Review 30 Version 10 (23/03/12) Option 8:

Monday to Friday

Hospital Department/Location 8-6 6-11 11-8 Description of Activity Casualty and wards from 6pm 1 1 1 Dr Workload admissions, reviews & ward rounds + A&E Patients. Wards 1 Admissions + Reviews + Ward Rounds Cowal wide PCEC service based in 1 1 Patients attend PCEC Dunoon or rural area if need see Dr or home visit if required

Weekends and Bank holidays

Hospital Department/Location 8-6 6-11 11-8 Description of Activity Casualty and wards 1 1 1 Dr Workload admissions + A&E Patients. Also Nurse workload

Cowal wide PCEC service based in 1 1 1 Patients attend PCEC Dunoon or rural area if need see Dr or home visit if required

Key Contract GP practices Salaried Medical Staff

Cowal 24/7 Review 31 Version 10 (23/03/12) Options Based in 1 Centre

 Cowal Community Hospital

Cowal Community Hospital

Cowal 24/7 Review 32 Version 10 (23/03/12)

Option 9

CHP employed Doctors based in the hospital providing all casualty, inpatient (out of hours & weekends/bank holidays) and out of hours service for the whole of Cowal

Contract with GPs to provide day time medical input Monday to Friday

Nurse practitioner provides initial response to patient home if necessary

Description-  2 CHP employed doctors on duty providing all hospital (out of hours & weekends/Bank holidays), and GP out of hours service based at the hospital  Contract with GPs to provide day time medical input Monday to Friday  Doctors travel from hospital for home visits or patients attend casualty to be seen by relevant practitioner  Patient able to travel come to the hospital by own transport or hospital arranges a taxi  Additional nurse practitioner provides initial response out of hours

Advantages  If Dunoon GPs submit a tender and win contract- provides service continuity between hospital and community for their patients  Nurse practitioners are expected to respond quickly, see and treat patient. If clinically necessary will arrange transport of patient to hospital by ambulance or contract taxi  Develop role of nurse practitioner care  Patients who are able to travel to hospital out of hours can benefit from assessment and access to other diagnostic and treatment services  Majority of rural Cowal can be reached within 1 hour from Dunoon if there are no delays

Disadvantages  Patients have to travel to hospital. No home visits except in specific cases e.g. sudden death, mental health etc.  Would not meet GP out of hours service response times in rural areas due to higher priority of the hospital service  No practice GPs involved in the inpatient service  Could increase calls to the Scottish Ambulance Service  Could be an increase in complaints regarding the service  Nurse practitioner cannot provide same service as GP  Nurse practitioner Training and development time lag could be a problem to starting service

Cowal 24/7 Review 33 Version 10 (23/03/12)  Lone worker issues may occur  Recruitment may be difficult  Risk to emergency response at Casualty when a single hospital doctor is covering out of hours service also

Option 9

Monday to Friday

Hospital 8-6 6-11 11-8 Description of Activity Department/Location Casualty and wards and 1 1 1 Dr Workload admissions + PCEC after 11pm, A&E Patients. Also Nurse workload Wards 1 Admissions + Reviews + Ward Rounds PCEC in Hospital 1 SAS response patients covering Dunoon and attend PCEC if need see rural Cowal Dr Nurse Practitioner 1 1 Nurse response patients response attend PCEC if need see Dr

Weekends and Bank holidays

Hospital 8-6 6-11 11-8 Description of Activity Department/Location Casualty and wards & 1 1 1 Dr Workload admissions + PCEC after 11pm A&E Patients. Also Nurse workload

PCEC in Hospital 1 SAS response patients covering Dunoon and attend PCEC if need see rural Cowal Dr Nurse Practitioner 1 1 1 Nurse response patients response attend PCEC if need see Dr

Key CHP employed Doctors Nurse Practitioner response Contract with GPs

Cowal 24/7 Review 34 Version 10 (23/03/12) Option 10

Consultant led service with CHP employed Doctors based in Cowal Community Hospital providing the Casualty, Inpatient and Out of hours service for the whole of Cowal

Description-  CHP employed Doctors provide all hospital, and out of hours service based at the hospital  CHP employed Doctors travel from hospital if necessary for home visits and/or patients attend casualty/PCEC to be seen by relevant practitioner- not routinely after 11pm  Patient who are able to travel by own transport or NHS 24 arranges a taxi  Consultant led service for inpatient care  Cowal Community Hospital remains a blue light receiving hospital i.e. It has an emergency department

Advantages  Medical Specialty consultant input provides greater level of “expert” care day time  Patients who are able travel to hospital out of hours can benefit from assessment and access to other diagnostic and treatment services  Centralises workforce. Greater efficiency as matching supply to demand and maximising capacity of service  Majority of rural Cowal can be reached within 1 hour from Dunoon if there are no delays

Disadvantages  Patients have to travel or be taken to hospital after 11pm who live beyond 30 minutes travel time  Service may not be able to meet home visit service standard if delayed on another call or delayed with other patients  Service would not meet response times in rural areas due to higher priority of the hospital service  Could increase calls to the Scottish Ambulance Service  Could be an increase in complaints regarding the service  Additional consultant input expensive (7 days a week)is not required for a Community Hospital  May be difficult to recruit Consultants to service and unlikely Greater Glasgow &Clyde NHS would support service as outreach due to low activity  Risk to emergency response at casualty when a single hospital doctor is covering out of hours service also

Cowal 24/7 Review 35 Version 10 (23/03/12) Option 10

Monday to Friday

Hospital Department/Location 8-6 6-11 11-8 Description of Activity Casualty and wards & PCEC post 11pm 1 1 1 Dr Workload admissions, reviews, ward rounds + A&E Patients. Wards 1 Medical specialty consultant input PCEC in Hospital covering Dunoon and 1 PCEC patients + visits rural Cowal

Weekends and Bank holidays

Hospital Department/Location 8-6 6-11 11-8 Description of Activity Casualty and wards & PCEC 1 1 1 Dr Workload admissions + A&E Patients. Also Nurse workload Wards 1 Medical specialty consultant input PCEC in Hospital covering Dunoon and 1 1 PCEC patients + visits rural Cowal

Key CHP employed Doctors Consultant

Cowal 24/7 Review 36 Version 10 (23/03/12)

Cowal 24/7 Review 37 Version 10 (23/03/12) Option 11

CHP employed Medical Staff based in Cowal Community Hospital cover the Casualty, Inpatient and Out of Hours service for the whole of Cowal from the hospital

Description  2 CHP employed Doctors providing all hospital, and out of hours service based at the hospital for the whole of Cowal  Drs travel from hospital if necessary for home visits and/or patients attend Casualty/PCEC to be seen by relevant practitioner  Patient who are able to travel by their own transport or NHS 24 arranges a taxi

Advantages  Doctors employed by the CHP may provide greater opportunity to co- ordinate and improve continuity of hospital, casualty and out of hours care  Offers a financial advantage by improving the efficiency of workforce (matching patient demand/activity across hospital, out of hours and casualty 24/7- potentially less Drs on duty)  Patients who are able to travel to hospital out of hours can benefit from assessment and access to other diagnostic and treatment services  Majority of rural Cowal can be reached within 1 hour from Dunoon

Disadvantages  Patients who are not able to travel will not benefit from assessment and access to other diagnostic and treatment services  May not meet out of hours response times particularly in rural areas due to higher priority of the hospital service  Could increase calls to the Scottish Ambulance Service  May be more complaints due to dissatisfaction with the service  1 Doctor covering the whole of Cowal out of hours  Possible loss of continuity of care between the hospital and GP practices for e.g. as GPs are no longer responsible for hospital beds

Cowal 24/7 Review 38 Version 10 (23/03/12) Option 11

Monday to Friday

Hospital Department/ 8-6 6-11 11-8 Description of Activity Location Casualty & Wards 1 1 1 Dr Workload admissions + AE Patients. Admissions + Reviews + Ward Rounds

PCEC in Hospital 1 1 PCEC Patients covering Dunoon Strachur/Tighnabruaich /Lochgoilhead

Weekends & Bank Holidays

Hospital Department/ 8-6 6-11 11-8 Description of Activity Location Casualty & Wards 1 1 1 Dr Workload admissions + AE Patients. Admissions + Reviews + Ward Rounds

PCEC in Hospital 1 1 1 PCEC Patients covering Dunoon Strachur/Tighnabruaich /Lochgoilhead

Key CHP employed Doctors

Cowal 24/7 Review 39 Version 10 (23/03/12) Option 12

CHP employed Medical staff based in the hospital providing all Casualty, inpatient and OOH service for the whole of Cowal

Scottish Ambulance Service (SAS) Paramedic Practitioner provides initial response to patient home if necessary

Description-  Single Doctor on duty providing all hospital, and out of hours service based at the hospital  Routine home visits to patients would cease  Patient who are able to travel by their own transport or NHS 24 arranges a taxi  Additional SAS paramedic practitioner provides initial response out of hours

Advantages  Offers a financial advantage by improving the efficiency of workforce (matching patient demand/activity across hospital, out of hours and casualty 24/7- potentially less Doctors on duty)  Patients who are able to travel to hospital out of hours can benefit from assessment and access to other diagnostic and treatment services  Majority of rural Cowal can be reached within 1 hour from Dunoon if there are no delays  SAS are expected to respond quickly, see and treat the patient. If clinically necessary transport of the patient will be arranged to hospital by ambulance or hospital contract taxi  Augments SAS service improving response times

Disadvantages  Patients may not be able to travel to hospital  No home visits except in specific cases e.g. sudden death, mental health, care home  May not meet GP out of hours service response times in rural areas due to higher priority of the hospital service  No practice GPs involved in the inpatient service  Could increase calls to the Scottish Ambulance Service  Could be an increase in complaints regarding the service  SAS Paramedic practitioner cannot provide same service as GP  Recruitment, Training and development time lag could be a problem for SAS to commence service  Risk to emergency response at Casualty when a single hospital doctor is covering out of hours service also

Cowal 24/7 Review 40 Version 10 (23/03/12) Option 12

Monday to Friday

Hospital 8-6 6-11 11-8 Description of Activity Department/Location Casualty, and Wards and 1 1 1 Dr Workload admissions + PCEC after 11pm? A&E Patients. Admissions + Reviews + Ward Rounds

PCEC in Hospital 1 SAS response patients covering Dunoon and attend PCEC if need see rural Cowal Dr SAS Paramedic 1 1 SAS response patients response attend PCEC if need see Dr

Weekends and Bank Holidays

Hospital 8-6 6-11 11-8 Description of Activity Department/Location Casualty and wards & 1 1 1 Dr Workload admissions + PCEC after 11pm AE Patients. Also Nurse workload PCEC 1 1 Admissions + Reviews + Ward Rounds

SAS Paramedic SAS response patients response attend PCEC if need see Dr

Key CHP employed Doctors SAS paramedic response

Cowal 24/7 Review 41 Version 10 (23/03/12) Option 13

Contract with GPS to cover inpatients during the day Mon-Fri 8am to 6pm.

SAS paramedic practitioner provides initial response to patient home if necessary

Description-  Single Doctor on duty providing all hospital (out of hours & Weekends/Bank holidays), and out of hours service based at the hospital  Contract with GPs to provide day time medical input Monday to Friday  Doctors do not travel from hospital for home visits patients attend casualty to be seen by relevant practitioner  Patients who are able to travel by own transport or NHS 24 arranges a taxi  Additional SAS paramedic practitioner provides initial response OOH

Advantages  If local town GPs opt to submit a tender and win contract provides service continuity between hospital and community for their patients.  Patients who travel to hospital out of hours can benefit from assessment and access to other diagnostic and treatment services  Majority of rural Cowal can be reached within 1 hour from Dunoon if there are no delays  SAS will respond quickly, see and treat patient. If clinically necessary will arrange transport of patient to hospital by ambulance or hospital contract taxi  Augments SAS service improving response times

Disadvantages  Patients have to travel to hospital no home visits except in specific cases e.g. sudden death, mental health  Would not meet GP out of hours service response times in rural areas due to higher priority of the hospital service  Could increase calls to the Scottish Ambulance Service  Could be an increase in complaints regarding the service  SAS Paramedic practitioner cannot provide same service as GP  SAS Recruitment, Training and development time lag could be a problem for SAS to commence service  Risk to emergency response at casualty when a single hospital doctor is covering out of hours service also

Cowal 24/7 Review 42 Version 10 (23/03/12) Option 13

Monday to Friday

Hospital 8-6 6-11 11-8 Description of Activity Department/Location Casualty and wards and 1 1 1 Dr Workload admissions + PCEC after 11pm, AE Patients. Also Nurse workload Wards 1 Admissions + Reviews + Ward Rounds PCEC in Hospital 1 SAS response patients covering Dunoon and attend PCEC if need see rural Cowal Dr SAS Paramedic SAS response patients response attend PCEC if need see Dr

Weekends and Bank holidays

Hospital 8-6 6-11 11-8 Description of Activity Department/Location Casualty and wards & 1 1 1 Dr Workload admissions + PCEC after 11pm A&E Patients. etc

PCEC in Hospital 1 SAS response patients covering Dunoon and attend PCEC if need see rural Cowal Dr SAS Paramedic 1 1 1 SAS response patients response attend PCEC if need see Dr

Key Hospital Staff SAS paramedic response Contract with GPs

Cowal 24/7 Review 43 Version 10 (23/03/12) Option 14

GP Out of Hours service for the whole of Cowal based in the hospital

Nurse Practitioner providing nurse led care in the hospital and a minor injuries unit

SAS paramedic practitioner provides initial response to patient home if necessary

Description-  Nurse Practitioners provide nurse led care in hospital – Casualty becomes a minor injuries unit  GP out of hours service provided Cowal wide based in hospital  Specialist medical services brought in as needed e.g. palliative care  SAS ‘bypass protocol’ in place for major trauma, specialist medical care ensures those patients are not brought to CCH but go to an appropriate one  Additional SAS community paramedic practitioner provides initial response  Doctors do not travel from hospital for home visits patients attend PCEC to be seen by relevant practitioner

Advantages  GP out of hours service responsive to demand  SAS are expected to respond quickly, see and treat patient. If clinically necessary will arrange transport of patient to hospital by ambulance or hospital contract taxi  Augments SAS service improving response times  Develops the role of nurse practitioner care

Disadvantages  Patients have to travel to GG&C hospitals instead of local unit – reduced local access to services  No practice GPs involved in the inpatient service  Could increase calls to the Scottish Ambulance Service  Could be an increase in complaints regarding the service  SAS Community Paramedic practitioner cannot provide same service as GP  SAS Recruitment, Training and development time lag could be a problem to starting the service  Closure of Casualty department and downgrading to minor injuries unit  Political and public concern re downgrading of service profile of local hospital

Cowal 24/7 Review 44 Version 10 (23/03/12) Option 14

Monday to Friday

Hospital 8-6 6-11 11-8 Description of Activity Department/Location Casualty Nurses admissions + A&E Nurse staffing for Casualty Patients. Also Nurse workload Wards Nurse led Admissions + Nurse staffing for wards Reviews + Ward Rounds PCEC in Hospital 1 1 GPs based in Dunoon covering Dunoon and rural Cowal SAS Paramedic 1 1 SAS response response

Weekends

Hospital 8-6 6-11 11-8 Description of Activity Department/Location Casualty Dr Workload admissions + Nurse staffing for Casualty AE Patients. Also Nurse workload Wards Admissions + Reviews + Nurse staffing for wards Ward Rounds PCEC in Hospital 1 1 1 GMS Dr based in Dunoon covering Dunoon and rural Cowal Cowal SAS 1 1 1 SAS response

Key Nurse led service by Nurse Practitioners SAS paramedic response Contract with GP OOHs

Cowal 24/7 Review 45 Version 10 (23/03/12)

Option 15

GP practices form consortium of some practices to provide integrated Hospital, Casualty and GP Out of Hours service for the whole of Cowal

Description  GPs under one contract provide medical services for all hospital, and out of hours services based at the hospital to a service specification  GPs travel from hospital if necessary for home visits across Cowal and/or patients attend casualty to be seen by relevant practitioner  Patients who are able to travel by own transport or NHS 24 arranges a taxi

Advantages  Offers GP practices the opportunity to provide an integrated primary care and hospital services making best use of all resources  Patients who travel to hospital out of hours can benefit from assessment and access to other diagnostic and treatment services  Simplifies medical staff arrangements and responsibilities  Majority of rural Cowal can be reached within 1 hour from Dunoon if there are no delays

Disadvantages  As Cowal practices have opted out of on-call in 2006 most GPs do not have the skills/competency to deal with a range of casualty work, and so they currently cannot provide this service.  Could be a reliance on locum Doctors  Service may not be able to meet service standard if delayed on another call  Service may not meet response times in rural areas due to higher priority of the hospital service  Could increase calls to the Scottish Ambulance Service  Could be an increase in complaints regarding the service  May not be sustainable

Cowal 24/7 Review 46 Version 10 (23/03/12) Option 15

Monday to Friday

Hospital Department/Location 8-6 6-11 11-8 Description of Activity Casualty Dr Workload admissions + A&E Patients. Also Nurse workload Wards Admissions + Reviews + Ward Rounds PCEC Patients attend PCEC if need see Dr or home visit if required Strachur/Tighnabruaich/Lochgoilhead Patients attend PCEC if need see Dr or home visit if required

Weekends and Bank holidays

visit if required

Key Contract GP practices

Cowal 24/7 Review 47 Version 10 (23/03/12)

Option 16

CHP employed Doctors based in the hospital provide all casualty, inpatient and out of hours service for the whole of Cowal

Nurse practitioner provides initial response to patient home if necessary

Description-  Single doctor on duty based at the hospital providing all hospital and GP out of hours service  Doctors travel from hospital for home visits patients attend casualty to be seen by relevant practitioner  Patients who are able to travel by own transport or NHS24 arranges a taxi  Additional Nurse practitioner provides initial response out of hours – would require driver etc

Advantages  GP out of hours service responsive to demand  Nurse practitioners are expected to respond quickly, see and treat patient. If clinically necessary will arrange transport of patient to hospital by ambulance or contract taxi  Develop role of nurse practitioner care  Patients who are able to travel to hospital out of hours can benefit from assessment and access to other diagnostic and treatment services  Majority of rural Cowal can be reached within 1 hour from Dunoon if there are no delays

Disadvantages  Patients have to travel to hospital, no home visits except in specific cases e.g. sudden death, mental health etc.  Would not meet GP out of hours service response times in rural areas due to higher priority of the hospital service  No Dunoon GPs involved in the inpatient service  Could increase calls to the Scottish Ambulance Service  Could be an increase in complaints regarding the service  Nurse practitioner cannot provide same service as GP  Nurse practitioner training and development time lag could be a problem to starting the service  Lone worker issues may be occur  Loss of local GP input into inpatient care in the hospital  Recruitment may be difficult  Risk to emergency response at casualty when a single hospital doctor is covering out of hours service also

Cowal 24/7 Review 48 Version 10 (23/03/12)

Option 16

Monday to Friday

Hospital 8-6 6-11 11-8 Description of Activity Department/Location Casualty, and Wards and 1 1 1 Dr Workload admissions + PCEC after 11pm A&E Patients. Admissions + Reviews + Ward Rounds

PCEC in Hospital 1 SAS response patients covering Dunoon and attend PCEC if need see rural Cowal Dr Nurse Practitioner 1 1 Nurse response patients response attend PCEC if need see Dr

Weekends and Bank Holidays

Hospital 8-6 6-11 11-8 Description of Activity Department/Location Casualty and wards & 1 1 1 Dr Workload admissions + PCEC after 11pm A&E Patients. Also Nurse workload PCEC 1 1 Admissions + Reviews + Ward Rounds

Nurse Practitioner 1 1 1 Nurse response patients response attend PCEC if need see Dr

Key CHP employed Doctors Nurse Practitioner response

Cowal 24/7 Review 49 Version 10 (23/03/12) Option 17

Consultant led service with CHP employed Doctors based in Cowal Community Hospital providing the Casualty, Inpatient (out of hours, weekends/bank holidays) and all Out of Hours services for the whole of Cowal

Contract with GPs to provide in patient cover Mon-Fri 8 am – 6pm

Description-  CHP employed Doctors providing all hospital, and out of hours service based at the hospital  CHP employed Doctors travel from hospital if necessary for home visits and/or patients attend casualty/PCEC to be seen by relevant practitioner but not routinely after 11pm  Patient who are able to travel by own transport or NHS 24 arranges a taxi  Consultant led service for inpatient care  Cowal Community Hospital remains a blue light receiving hospital for emergencies

Advantages  Consultant input provides greater level of “expert” care day time  Patients who are able travel to hospital out of hours can benefit from assessment and access to other diagnostic and treatment services  Centralises workforce, greater efficiency as matching supply to demand and maximising capacity of service  Majority of rural Cowal can be reached within 1 hour from Dunoon if there are no delays

Disadvantages  Patients have to travel or be taken to hospital after 11pm who live beyond 30 minutes travel time  Service may not be able to meet home visit service standard if delayed on another call or delayed with other patients  Service would not meet response times in rural areas due to higher priority of the hospital service  Could increase calls to the Scottish Ambulance Service  Could be an increase in complaints regarding the service  Additional consultant input expensive (7 days a week)is not required for a Community Hospital  May be difficult to recruit Consultants  Risk to emergency response at casualty when a single hospital doctor is covering out of hours service also

Cowal 24/7 Review 50 Version 10 (23/03/12) Option 17

Monday to Friday

Hospital Department/Location 8-6 6-11 11-8 Description of Activity Casualty and wards & PCEC post 11pm 1 1 1 Dr Workload admissions, reviews, ward rounds + A&E Patients. 1 Wards 1 Medical specialty consultant input PCEC in Hospital covering Dunoon and 1 PCEC patients + visits rural Cowal

Weekends and Bank holidays

Key CHP employed Doctors Consultant GPs

Cowal 24/7 Review 51 Version 10 (23/03/12) 7 Comments Log – Comments to date of the Options

Comment/ Question Answer

GP beds - concept patients to be looked after by own GP's – Importance of this? – does it happen in practice, is it significant.

Are there GP beds in hospital or not –if not then would the hospital change . Depends on to just a casualty department and a casualty ward: caliber of Dr . ? IRH would not use hospital as step down/ rehab recruited . Would the Drs recruited be able to undertake the role of local GPs regarding the profile of medical care provided? – . Would status of hospital affect use of it by local GPs and other clinicians . Community hospital service run by local GPs (as in rest of CHP) works as integrated whole primary care, community and casualty- maintain skills & competencies and supports consistent practice and continuity of care

Could hospital have a visiting consultant from IRH - like the Vale of Leven Model

Service Quality/issues . Brevity of clerking in patients and access to patients notes from GP practices . Ensuring time for handover period of patients to ensure quality of care between day time Drs (GPs, CHP employed and out of hours) . Drs Attendance at Multidisciplinary meetings on ward . Single ward round reduce disruption on ward . If Dr does not know patient history from own practice- ward round will take longer

Primary Care Activity undertaken in Casualty – continuity of care, tourists, role of ENP & Dr, redirection of patients

Balance of service- need more community nursing overnight- redirected to 24/7 service

Specialist medical input e.g. Palliative care so need almost a sub specialty etc- group of GPs –diploma in palliative care – so to try and provide more specialized and consistent PC.

Are there difficulties in recruitment and retention of medical staff? – Can the service continue in its current form (3-5 years) . Should we include a mixed option with ENP’s and Paramedics? . ENP skills and ability- study in Stornaway ENPs dealt with 80% of minor injury etc in thee DGH . Can we recruit people with the appropriate range of skills to provide the full range of medical services required- individual Drs find attractive for short periods?

Cowal 24/7 Review 52 Version 10 (23/03/12)

Comment/ Question Answer

Should we consider options where the GP’s or a group of GP’s opting back in?

Ambulance service: Current response & performance have matters improved?

 Current surgery boundaries… should that be a consideration?  How fixed is the 30 min boundary  Are there patients currently registered with practices outside their “normal” practice boundary e.g. Strachur with a town GP

In the OOH there is an expectation of home visits… where do they fit or do they?

Elderly populations -Travel distances and times and methods of transport

Urban vs. Rural - Consider the differences between the town and country and can one size fit all?

How many CHP employed doctors would we need to take over the GP inpatient role and the OOH’s cover?

Should there be an option with the existing GMS GP’s putting in a consortium proposal on a rota basis a similar set up as current for inpatient care and OOH’s cover? . Does this give too much control to GP’s not under control of the locality?

Is having the control and management of the inpatient care and OOH together important?

Should we consider hospital based staff but for OOH cover based elsewhere as an option?  On-call Dr – lower pay rate and on-call fee if called out  On-call cover unexpected peaks in activity or call out beyond the 30 min elastic band  Medical input to support timeliness of reviewing hospital patients for admission and prompt discharge  NPs with the right training, consolidated experience and confidence in their autonomy working to their full capability/capacity can assess, diagnose treat and or refer without medical input. NHS Legislation demands that all inpatients in a hospital must be under the care of a named Consultant or Principal in General Practice.  Does this invalidate some of the long list of options drafted  Are there hospitals in the UK where hospital care is provided by medical staff who are not in this category

Cowal 24/7 Review 53 Version 10 (23/03/12)

Comment/ Question Answer

81% of the inpatients in Cowal Community Hospital during 2011 (749) benefited from being looked after by their own GP day time Monday to Friday  Patients who are looked after by their own doctor - who knows them well - value this service immensely.  The qualities and additional care that the patients own GP bring to patient’s hospital stay is fundamental to holistic continuity of care and we are uniquely able to bridge the gap between secondary care and home and manage long term ongoing conditions with our extensive knowledge of our patients. 19% of the inpatients in Cowal Community Hospital during 2011 (165) were not looked after by their own GP The 3 large town practices have declined any form of business to business contract that involves taking responsibility for casualty and OOH, and all the staff that the CHP currently employs to run them, away from the CHP to the practices themselves - and that we have no plans to form a consortium. The public and wider review group must be made aware that the 9 GP principals provide daytime ward cover during the working week - but outwith these times the rest of the service model is little to do with us - and is run extremely effectively by Dr Paterson and his team – with whom we have close and strong working relationships Local concern voiced over the long term future of emergency department at Inverclyde on • Would NHSGG&C agree to additional load? Compensatory costs. • Would SAS agree to additional load? Compensatory costs. • Would ferry service continue 2300 – 0800? Continuity of care on the wards -? is there is true continuity of care when they are doing ward rounds with different GPs every day. Weekends and bank holidays more continuity issues as designated lead Dr not available

Concern that OOH, at weekends etc. there are more 'inappropriate' admissions than in hours and that may be a consequence of the 2 team system currently used. – single team offers better hospital continuity of care

Delayed discharges have not been a significant issue of late and certainly most delays are not related to lack of provision of care.

Cowal 24/7 Review 54 Version 10 (23/03/12) 10 What Happens next

. Options “long list” is presented to staff, the public and stakeholders at a variety of events to obtain feedback and comments on the option in March 2012

. Feedback informs Cowal 24/7 Project group selection of the short listed options to go forward for formal option appraisal- April 2012

. Short list of options are then taken out for a further period of staff, the public and stakeholders consultation to obtain feedback and comments on the options - Mid April to Mid May

. Cowal 24/7 Project Group conduct a formal Option appraisal process in May and June on the short listed options considering feedback and assessing the options against the following criteria:

 Non financial benefits  Risk Assessment  Affordability  Value for money

. Cowal 24/7 Project Group Review outcome of the appraisal and identify a preferred option –end of June 2012

. Preferred option is taken out to staff, the public and stakeholders to obtain their comments and feedback on the option- July 2012

. Cowal 24/7 Project Group review feedback and make recommendation/s on their preferred Option- August 2012

. Argyll and Bute CHP Management Team and CHP Committee consider the Option Appraisal report and make a decision on which option to implement- September 2012

OPTION APPRASIAL PROCESS

Long List of O p t io n s

T o d a y ’ s e v e n t S h o r t - L is t e d O p t io n s

N o n - F in a n c ia l V a lu e f o r R is k s Affordability B e n e f it s M o n e y

P r e f e r r e d O p t io n Cowal 24/7 Review 55 Version 10 (23/03/12) 11 Glossary

Acute - Used to describe a disorder or symptom that comes on suddenly and needs urgent treatment. It is not necessarily severe and is often of short duration. Acute is also used to describe hospitals where treatment for such conditions is available.

Argyll and Bute Community Health Partnership (CHP) - provides a range of primary, community and mental health services across Argyll and Bute. It delivers these services from a network of facilities including a rural general hospital, community hospitals, day hospitals, health centres, medical centres, and mental health facilities. It also contracts with other Health Boards for specialist services e.g. Orthopaedics

Business to Business Contract - a legal contract between NHS Boards and GP practices to provide services.

Casualty Department - is a medical treatment facility specialising in the acute care of patients who present without prior appointment. The department provides initial treatment for a broad spectrum of illnesses and injuries, some of which may be life- threatening and require immediate attention. It operates 24 hours a day

Chronic illness - a disease that is long-lasting and reoccurring e.g. asthma, diabetes. The opposite of acute

Community Health Partnerships (CHPs) - are organisations which have been set up by Health Boards across Scotland to manage a wide range of community-based health services.

Community Hospital - is a locally based centre which provides a bridge between home and specialist hospital care and provides planned care, unplanned care and diagnostic services

Consultant - is the title of a senior doctor who has completed a specialist training and been placed on the specialist register in their chosen speciality. Consultants accept ultimate responsibility for the care of all the patients referred to them. A consultant typically leads a team of doctors training to work in the consultant's speciality.

Continuity of Care - Users experience services arranged or provided by different agencies without encountering difficulties arising from organisational or professional boundaries

Elective care - is pre-arranged, non-emergency care

General Medical Services – medical services provided in primary care. It also refers to the national contract introduced across the UK for General Practitioners (GPs) to operate in the NHS.

Health Board (HB) - The Organisation which plans and provides health and healthcare services for the people of the region acting on behalf of the Scottish Government locally

Independent Sector Organisations which provide health and social care on a private not for profit or voluntary basis.

Cowal 24/7 Review 56 Version 10 (23/03/12) Locum doctor - is a doctor who works in the place of the regular doctor when that doctor is absent, or when a hospital/practice is short-staffed. Often provided by an agency.

Minor Injuries Unit (MIU) - is a hospital department staffed by emergency nurse practitioners (ENPs) working autonomously who look after minor injuries such as lacerations and fractures, and have access to X-ray facilities. No appointment is needed.

NHS 24—National Health Service 24 - Confidential 24 hour telephone health service, which coordinates out of hours care and provides advice, support and information

Patient Focus - This term is often used interchangeably with 'patient centred' or 'people centred' which means that services or care delivered should be responsive to the individual's unique preferences, values and needs, identified and agreed in partnership with the patient.

Nurse Practitioner (NP) - an Advanced Practice Registered Nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice for example Emergency Care

OOH – Out of Hours –services that are provided outside normal working hours and at weekends and bank holidays

Palliative Care - work designed to improve the quality of life of patients who have a life threatening illness.

Primary Care - Primary care is health care at the first point of contact (your GP, Dentist, pharmacy, optician) with the Health Service, addressing physical, social and psychological problems, but also providing continuity of care if you have had specialist treatment.

Primary Care Emergency Centres (PCEC) - are well equipped clinics where doctors and/or nurses will be able to give you the treatment you need. They are not Accident and Emergency Units and are not walk-in facilities. Patients will only be seen when directed there by NHS24

Rehabilitation - is a treatment or treatments designed to facilitate the process of recovery from injury, illness, or disease to as normal a condition as possible.

Rural Medical Practitioner - A term used to describe a Doctor employed by the Health Board to provide medical services in a hospital. This doctor is GP trained and also may have or be undergoing additional training to provide hospital casualty and inpatient services. Referred to as CHP employed Doctors in this report.

Salaried Medical staff - A GP or Doctor who is employed by a GP practice or by the NHS Board on a salaried basis

Scottish Ambulance Service (SAS) The emergency service used to transport people to hospital

Scottish Health Council SHC — National organisation with local offices to oversee public involvement in healthcare. SHC became part of Healthcare Improvement Scotland formed in 2011.

Cowal 24/7 Review 57 Version 10 (23/03/12) Secondary care - The second stage of treatment when you are ill and usually provided by a hospital. See also primary care and tertiary care.

Service Level Agreement - SLA: a contract between NHS Boards

Stakeholders - People with a shared interest in services, either as a provider or user or partner in delivering services e.g. the council or voluntary sector

Step-down care - intermediate between that of an intensive care unit and a normally-staffed ward.

Tertiary care - The third and highly specialised stage of treatment, usually provided in a specialist hospital centre. See also primary care and secondary care.

Cowal 24/7 Review 58 Version 10 (23/03/12) 11 Further Information

Further information on the review can be found at

http://www.nhshighland.scot.nhs.uk/CHP/ArgyllandBute/PPF/Pages/CowalGPS ervices.aspx

THE CLOSING DATE FOR FEEDBACK ON THE LONG LIST OF OPTIONS IS FRIDAY 5TH APRIL 2012

The feedback form can also be found at the web site address

Cowal 24/7 Review 59 Version 10 (23/03/12)