Public Health Statistical Appendix out of Hours Care in Skye, Lochalsh and South West Ross

Public Health Statistical Appendix Out of Hours Care in Skye, Lochalsh and South West Ross

Hugo van Woerden, Director of Public Health and Policy, NHS Highland

Andrew Rideout, Public Health Speciality Registrar, NHS Dumfries and Galloway

April 2018

Executive Summary

The aim of the briefing is to present epidemiological information that will inform the recommendations that the panel will make, whilst minimising any overlaps with sources of epidemiological information that are provided by other reports to the panel.

The briefing considers: who receives care, who delivers care, what care is delivered, where is the care delivered and when is care utilised?

The population of Skye is scattered with relatively long travel distances. It is an aging population, with a falling proportion of working age, who can provide care services, although the elderly in Skye place relatively low demands on Out of Hours services. There are areas of rural deprivation, which may result in greater levels of Out of Hours care.

Out of Hours care has historically been provided by GPs and hospital based facilities including units in both Portree and Broadford that did not fall into a typical description of emergency departments or minor injury units. Unscheduled care is increasingly being provided by nurses, paramedics, NHS 24, other emergency services and first responders. Care is also provided for island populations on Raasay and Eigg.

The delivery of care draws on community services, primary care, local intermediate care, NHS 24, a general hospital in Fort William and a large general hospital1 in Inverness, which is the main source of visiting outpatient services to the island. Service redesign plans around facilities in Broadford and Portree are underway, with a new hospital planned in Broadford.

Out of Hours services display expected diurnal variation and an annual seasonal pattern associated with the very large influx of tourists each summer. It is anticipated that complementary data on ambulance and NHS 24 services will be provided by these services.

In conclusion, the Isle of Skye is a challenging environment in which to provide Out of Hours care, given its geography. There is a need to build on emerging models of care to make Skye a place which is internationally recognised as leading the way in providing solutions that work in such a context. This is likely to require cross organisational working and increasing use of technology to link local services with specialist input.

1 ISD Hospital classification: http://www.isdscotland.org/Health-Topics/Finance/Costs/Reference-Information.asp

Table of Contents

1. Introduction 7 1.1 Defining Out of Hours Care 7 2. Who receives care? 8 2.1 Demography 8 2.2 Deprivation 11 2.3 Patients with Long Term Limiting Illness 19 2.4 End of Life Care 19 3. Who delivers care? 24 3.1 NHS staff 24 3.2 Unpaid carers 27 4. What care is delivered? 30 4.1 Historic changes to services 30 4.2 Out of Hours Services 34 4.3 Unscheduled care contact outcomes 36 4.4 Admission to hospital after unscheduled care contact 37 4.5 Outpatient Care 39 4.6 District Nursing 43 4.7 Allied Health Professionals 44 4.8 Hospital services 48 4.9 Midwifery Care 60 4.10 Ambulance Services 61 5. Where is the care delivered? 66 5.1 Travel 70 5.2 Care Homes 74 5.3 Projections of future need 76 6. When is care utilised? 78 7. Conclusion 85 7.1 Limitations 85 7.2 Main findings 85 8. Acknowledgements 86 9. References 87

Tables

Table 1: Income deprivation in Skye, Lochalsh and South West Ross by data zone 17 Table 2: Proportion of deaths by Locality and District geographies and place of death, 2010-2012 (NHS Highland residents only) 20 Table 3: Number of deaths by Locality and District geographies and place of death, 2010-2012 (NHS Highland residents only / 3 year number of events) 21 Table 4: Unscheduled care contacts at Broadford and Portree by outcome, 2013- 2017 36 Table 5: Unscheduled care contacts at Broadford and Portree resulting in hospital admission, 2015- 2017 37 Table 6: Admission to hospital in the Out of Hours period after contact with the Out of Hours service 2017 38 Table 7: Summary of outpatient services at Portree Hospital and the MacKinnon Memorial Hospital 39 Table 8: Allied Health Professional Appointments, Portree Hospital 45 Table 9: Allied Health Professional Appointments, Mackinnon Memorial Hospital 46 Table 10: Allied Health Professional Appointments, other Skye and Lochalsh locations 47 Table 11: Summary of services in Portree Hospital and the Mackinnon Memorial Hospital, Broadford 48 Table 12: Mean and Median length of stay for Skye Hospitals, 2008/9 to 2012/13 55 Table 13: Pattern of delayed discharges by length of delay, Skye, Lochalsh and South West Ross, 2011-14 58 Table 14: Age specific delayed discharge rates per 1000 population, Skye, Lochalsh and South West Ross, 2011- 14 59 Table 15: Annual rates of SAS call-out attendances during 2014 by Ambulance station 61 Table 16: Annual rates and numbers of SAS call-out attendances during 2014 by area of attendance 62 Table 17: Patients transferred by ambulance from Portree Hospital/Medical Centre to Broadford Hospital during 2014 by emergency status 62 Table 18: Community Health Index Practice list population of Skye and Lochalsh (excluding South West Ross) within 60 minutes drive time from Portree and Broadford 71 Table 19: Summary of bus services to and from Broadford or Portree 73 Table 20: Summary of Ferry Services for Raasay-Sconser 74 Table 21: Number of unscheduled care patient contacts at Broadford and Portree by calendar year by time of day 79 Table 22: Number of unscheduled care patient contacts at Broadford and Portree combined, by calendar year by time of day 82 Table 23: Number of contacts with unscheduled care services at Broadford and Portree by Data Zone of residence by time of contact, during 2017 82 Table 24: Percentage of contacts by type and time at Portree, 2017 83 Table 25: Percentage of contacts by type and time at Broadford, 2017 83 Table 26: Service access to unscheduled care services at both Broadford and Portree by time period for residents of SLsWR and non-residents by method of contact, 2017 84

Figures

Figure 1: Trend in population estimates (2003 to 2013) and projections to 2037 by age band, Skye, Lochalsh and South West Ross 8 Figure 2: Population over time – Skye, Lochalsh & West Ross 9 Figure 3: Community Health Index population distribution in the Skye, Lochalsh and South West Ross area 10 Figure 4: Population pyramid for Skye and Lochalsh, 2013 and 2026 11 Figure 5: Overview of the NHS Highland Board 1st and 2nd Quintiles of deprivation using SIMD 2012 12 Figure 6: Model of potentially fragile areas in Scotland 14 Figure 7: Economically fragile areas in Scotland 16 Figure 8: Distribution of income deprivation by data zone area in Skye, Lochalsh and South West Ross 18 Figure 9: Age and sex specific rates of Long Term Limiting Illness, Skye and Lochalsh, 2001 & 2012 19 Figure 10: Place of death by data zone, combined years 2013-17 (hospital deaths) 22 Figure 11: Place of death by data zone, combined years 2013-17 (deaths at home) 23 Figure 12: Proportion of Out of Hours cases seen by different professionals, Skye, 2013 to 2017 24 Figure 13: Summary of current Whole Time Equivalent (WTE) establishments in Skye, Lochalsh and South West Ross Workforce Plan 25 Figure 14: Provision of unpaid care by category by Highland geography 2011 27 Figure 15: Unpaid care and formal care provision in Highland at 2011 Census 28 Figure 16: Estimated and projected number of older people in Highland receiving informal care 29 Figure 17: Location of Out of Hours Care, Skye and Lochalsh, 2018 34 Figure 18: Percentage of unscheduled care activity at Portree and Broadford (combined) by age group and residence, Jan-Dec 2017 34 Figure 19: Directly age standardised rate per 1000 population of unscheduled care at Broadford and Portree by Data Zone of residence in SLsWR, 2017 35 Figure 20: Directly age standardised outpatient attendance rates by data zone of residence in SLsWR, all specialties and all locations, 2010-2011 – 2012-2013 40 Figure 21: Directly age standardised outpatient attendance rates by data zone of residence in SLsWR, all specialties at MacKinnon Hospital, 2010-2011 – 2012-2013 41 Figure 22: Directly age standardised outpatient attendance rates by data zone of residence in SLsWR, all specialties at Portree Hospital, 2010-2011 – 2012-2013 42 Figure 23: Directly age standardised outpatient attendance rates by data zone of residence in SLsWR, all specialties at Raigmore Hospital, 2010-2011 – 2012-2013 43 Figure 24: Number of inpatient admissions and available beds at Portree Hospital, 2011-18 49 Figure 25: Number of inpatient discharges and length of stay at Portree Hospital, 2011-18 49 Figure 26: Percentage occupancy and available beds at Portree Hospital, 2011-18 50 Figure 27: Number of inpatient admissions and available beds, MacKinnon Memorial Hospital, 2012-18 51 Figure 28: Number of inpatient discharges and length of stay, MacKinnon Memorial Hospital, 2012-18 51 Figure 29: Occupancy and number of available beds, MacKinnon Memorial Hospital, 2012-18 52 Figure 30: Trends in admissions and bed day rates for Skye hospitals, 2003 - 13 53 Figure 31: Summary of bed changes identified in the Mackinnon Memorial Hospital, Broadford, 2006/07 to 2013/14 54 Figure 32: Summary of bed changes identified in the Portree Hospital, 2006/07 to 2013/14 54 Figure 33: Monthly percentage bed occupancy at Skye Hospitals, 2009/10 to 2013/14 55 Figure 34: Length of stay in Skye Hospitals, including inter-quartile data, maximum and minimum data, 2008/09 to 2012/13 (GP beds only) 56 Figure 35: Trends in admission rates per 1000 population by GP practice, Skye Hospitals, 2009-13 57 Figure 36: Top 25 primary diagnoses for admissions to Skye Hospitals, 2009-13 58 Figure 37: Reasons for delayed discharges, Skye, Lochalsh and South West Ross, 2011-14 60

Figure 38: Births to mothers resident in Skye and Lochalsh in calendar years 2006 - 2016 60 Figure 39: Number of patients conveyed from Skye and Lochalsh in 2017 by receiving hospital 63 Figure 40: Average time spent conveying patients to Raigmore Hospital, 2017 64 Figure 41: Average time spent on incidents in Inverness, when ambulances were detained in Inverness, by home despatch point, 2017 65 Figure 42: Health Services across NHS Highland 66 Figure 43: Health care facilities in Skye and Lochalsh and South West Ross 67 Figure 44: Geography covered by Integrated Care teams (nursing and social care) 68 Figure 45: GP practices in Skye and Lochalsh 69 Figure 46: Population registered with General Practices in April 2014 and October 2017 70 Figure 47: Area within 30 and 60 minutes drive from Portree Hospital 71 Figure 48: Area within 30 and 60 minutes drive from MacKinnon Memorial Hospital 72 Figure 49: Care home places in Skye, Lochalsh and South West Ross 75 Figure 50: Care Home places and Hospital beds per 1000 population aged 75+, NHS Highland 76 Figure 51: Summary of bed models using Skye, Lochalsh and South West Ross population projections and 85% bed occupancy 77 Figure 52: Cumulative number of Out of Hours cases seen per hour over a week, totalled over 12 months 78 Figure 53: Percentage of unscheduled care patient contacts at Broadford and Portree combined by calendar year by time of day 78 Figure 54: Percentage of unscheduled care patient contacts at Broadford and Portree by calendar year by time of day 79 Figure 55: Unscheduled care activity at Portree and Broadford (combined), Jan 2013 to Dec 2017 80 Figure 56: Unscheduled care activity at Broadford from January 2013 to December 2017 81 Figure 57: Unscheduled care activity at Portree from January 2013 to December 2017 81 Figure 58: Out of Hours contacts at both Broadford and Portree and Highland by method of contact, 2013- 2017 84

1. Introduction The terms of reference for the Out of Hours work being led by Sir Lewis Ritchie state that, “The specific remit is to assess the resilience of urgent primary care out-of-hours provision” and “to provide an external professional view of the urgent care services in the area”2 . This briefing is designed to support that review and provide epidemiological information for consideration by the Panel who are supporting the review.

The aim of the briefing is, therefore, to present epidemiological information that will inform the recommendations that the panel will make, whilst minimising any overlaps with sources of information that are provided by other reports to the panel. It is anticipated that any recommendations that the panel may make may wish to take into consideration: who receives care?; who delivers care?; what care is delivered?; where is the care delivered?, and when is care utilised? Available evidence which addresses these questions is provided below.

The primary focus of this briefing is the Isle of Skye. Data related to Lochalsh & South West Ross is also provided where it is thought that this may be relevant and is easily available. Given the tight timescale, the briefing draws primarily on available data, as opposed to undertaking fresh analyses.

This briefing has not been underpinned by a literature review, as relevant literature on Out of Hours services and models of care are available as part of the recent Scottish Government National Review on Out of Hours care published in 2015 by Sir Lewis Ritchie, ‘Pulling together: transforming urgent care for the people of Scotland. The Report of the Independent Review of Primary Care Out of Hours Services’.3

1.1 Defining Out of Hours Care Out of Hours care can be defined in a recent review as “care provided between 18.30 and 08.00 on weekdays, all weekend and Bank Holidays”4. The review goes on to say, “Care provided in the OOH time period is unscheduled, i.e. there has been no forward planning (either by patient or professional) or appointment made in advance. However, such care may or may not be regarded as urgent care.” The report also states that, “in practice, out-of-hours care provision often starts at 6pm.” This is the standard hand over time in NHS Highland.

2 NHS Highland, 2018. Terms of Reference, External view of arrangements for Unscheduled Care (urgent primary care out- of-hours provision) in Skye, Lochalsh and South West Ross. Available online: http://www.nhshighland.scot.nhs.uk/News/PublicConsultation/Skye/Documents/1%20OOHs%202018/SkyeNHS%20HighlandReviewTOR160118_Final.pdf 3 Ritchie, L., 2015. Pulling together: Transforming Urgent Care for the People of Scotland. The Report of the Independent Review of Primary Care Out of Hours Services. Edinburgh: Scottish Government. Available online: http://www.gov.scot/Resource/0049/00490526.pdf 4 O’Donnell, C., Foster, H., Macdonald, S., Burns, N. & Gannon, M., 2015. Out-of-Hours Primary Medical Care: What Can Research Tell Us? Findings From a Rapid Systematic Review and Qualitative Study. University of Glasgow. Available online: http://www.gov.scot/Resource/0049/00492082.pdf [Accessed 9 April 2018].

2. Who receives care? A range of information describing the population of Skye is provided below in relation to demography, deprivation, long term limiting illness and end of life care.

In summary, although the total population numbers in Skye are expected to be stable over the next twenty years (Figure 1), the proportion of older people has increased since 2001 (Figure 4) and this trend is expected to continue (Figures 1 & 2). People across Skye also experience significant deprivation (Figures 5 and 8), with just over 1,000 individuals (10%) being regarded as ‘income deprived’. Both increasing age and greater deprivation are also associated with having one or more long term limiting illnesses (Figure 9).

2.1 Demography The trend in population by age is shown below.

Figure 1: Trend in population estimates (2003 to 2013) and projections to 2037 by age band, Skye, Lochalsh and South West Ross

Source: NHS Highland and Highland Health and Social Care Partnership, 2016. Modernisation of community and hospital services for communities in Skye, Lochalsh and South West Ross - Initial Agreement - Version 26. p.25. Figure 2. Available online: http://www.nhshighland.scot.nhs.uk/News/PublicConsultation/Skye/Documents/SLWR%20IA%20V26%2010Oct16.pdf

Slightly older data is provided below, which is useful in that it demonstrates the percentage changes in different age groups.

Figure 2: Population over time – Skye, Lochalsh & West Ross

Source: NHS Highland Public Health Intelligence, 2017. Highland Community Partnership Profile – Skye, Lochalsh & Wester Ross. Data source: National Records of Scotland Small Area Population Estimates; Best fit of data zones 2001 and 2011 to Highland Community Partnership area.

The graph above demonstrates that the population between birth and 15 years fell by 17% between 2001 and 2015, whereas the population aged 65 years and over rose by 40.2% within the same timeframe. An aging population is likely to place additional pressure on Out of Hours services over the medium to long term.

Figure 3: Community Health Index population distribution in the Skye, Lochalsh and South West Ross area

Source: Douglas, I., 2013. Population drive time access to Community Hospitals in Skye & Lochalsh and South West Ross, NHS Highland, Public Health Intelligence and Knowledge Team. p.6. Available online: http://www.nhshighland.scot.nhs.uk/News/PublicConsultation/Skye/Documents/Drive%20time%20access%20SLSWR%20Nov%202013.pdf

Also included in: NHS Highland and Highland Health and Social Care Partnership, 2016. Modernisation of community and hospital services for communities in Skye, Lochalsh and South West Ross - Initial Agreement - Version 26. p.19, map2. Available online: http://www.nhshighland.scot.nhs.uk/News/PublicConsultation/Skye/Documents/SLWR%20IA%20V26%2010Oct16.pdf

The map demonstrates that the greatest population density is around Portree, Broadford, and Kyle of Lochalsh, although there are significant clusters of population elsewhere.

A population pyramid is provided below for 2013 and 2026. The predicted trend is a significant growth in the very old and a fall, in particular, in the female population around their twenties and thirties.

Figure 4: Population pyramid for Skye and Lochalsh, 2013 and 2026

Source: Marshall, A., 2017. Projections of health care usage for Skye and Lochalsh. University of St Andrews. p.11, figure 6.

Figure 4 should be interpreted with caution, as the date labelling in the source document is unclear. However, the key message from the population pyramid is that there are relatively few individuals of working age, compared to the population of very elderly who are may require care.

2.2 Deprivation Deprivation is known to affect Out of Hours service utilisation.

Deprivation within communities not only relates to income (Table 1), but also factors such as population density and access to services, and using these indices the population in parts of Skye, along with other parts of Highland Region, experiences the highest levels of community ‘fragility’ (Figure 6).

The figure below provides information using the standard deprivation measure used in Scotland.

Figure 5: Overview of the NHS Highland Board 1st and 2nd Quintiles of deprivation using SIMD 2012

Data source: NHS Highland, Public Health Intelligence, Scottish Government SIMD 2012 indicators. Available online: http://www.gov.scot/Topics/Statistics/SIMD/DataAnalysis/Background-Data-2012/Background2SIMD2012

The map above indicates that a number of data zones in the Skye, Lochalsh and South West Ross area are in the 40% of most deprived areas within NHS Highland. One data zone, representing Skye North East, is in the 20% of most deprived areas in the study area. If the national rather than health board ranks of deprivation are considered, no areas in Skye, Lochalsh and South West Ross are ranked in the 20% of most deprived areas.

Deprivation in remote and rural areas is poorly reflected in standard deprivation indices and, therefore, two models which use alternative approaches5 are shown below, based on the concept of fragility. In rough outline the first model included the following factors:

1. Depopulation related to young working age adults 2. Population density 3. Rates of claim for Department of Work and Pensions benefits 4. Estimated median gross total household income £ per week 5. Access to nine core services 6. Drive time to a major retail centre

5 Douglas, I. and Thomas, C., 2015. Supporting the Highland Community Planning Partnership to identify areas of rural population need. NHS Highland and Highland Council. Published within: Highland Community Planning Partnership (CPP) Board meeting 3 June 2015 – Item 8: Deprivation and Inequalities – Rural Analysis; Annex 2. Available online: https://www.highland.gov.uk/meetings/meeting/3466/highland_community_planning_partnership_board

Figure 6: Model of potentially fragile areas in Scotland

Source: Douglas, I. and Thomas, C., 2015. Supporting the Highland Community Planning Partnership to identify areas of rural population need. NHS Highland and Highland Council. Published within: Highland Community Planning Partnership (CPP) Board meeting 3 June 2015 – Item 8: Deprivation and Inequalities – Rural Analysis; Annex 2, .p6. Available online: https://www.highland.gov.uk/meetings/meeting/3466/highland_community_planning_partnership_board

Fragile areas were “characterized by a number of factors including weakening of communities through population loss; low incomes; limited employment opportunities; poor infrastructure; inadequate housing and remoteness”, based on four indicators:

1. Population decline 2001 to 2005, three bands identified (Small Area Population Estimates) 2. Population density 2005, two bands identified (Small Area Population Estimates) 3. Drive time to a mid-sized service centre, three bands identified (SNS, Google Maps 4. Income per household, two bands identified (CACI Paycheck).

Although the map above and map below produce quite distinct patterns, both maps indicate that parts of Skye, Lochalsh and South West Ross include economically fragile areas.

Figure 7: Economically fragile areas in Scotland

Source: Douglas, I. and Thomas, C., 2015. Supporting the Highland Community Planning Partnership to identify areas of rural population need. NHS Highland and Highland Council. Published within: Highland Community Planning Partnership (CPP) Board meeting 3 June 2015 – Item 8: Deprivation and Inequalities – Rural Analysis; Annex 2, p.6. Available online: https://www.highland.gov.uk/meetings/meeting/3466/highland_community_planning_partnership_board

The map above indicates that the whole of the north-west coastline of the north of Scotland is economically fragile. If it is assumed that this is potentially associated with an aspect of rural deprivation, it would confirm the fact that north Skye is an area which would be of importance in terms of public sector planning.

The data below relate to income deprivation, which is arguably the single domain that is most generalisable as a marker of deprivation.

Table 1: Income deprivation in Skye, Lochalsh and South West Ross by data zone

Source: Douglas, I., 2014. Income deprivation in Skye, Lochalsh and West Ross. NHS Highland Public Health Intelligence and Knowledge Team. p.6. Available online: http://www.nhshighland.scot.nhs.uk/News/PublicConsultation/Skye/Documents/Skye_incomedep.pdf

There are clearly areas of low income in Skye, which are likely to impact on the need for Out of Hours services. The most deprived areas by this metric are Portree North and Portree West.

The map below provides a graphical description of income, which is one of the indices included in many assessments of deprivation.

Figure 8: Distribution of income deprivation by data zone area in Skye, Lochalsh and South West Ross

Source: Douglas, I., 2014. Income deprivation in Skye, Lochalsh and West Ross. NHS Highland Public Health Intelligence and Knowledge Team. p.7. Available online: http://www.nhshighland.scot.nhs.uk/News/PublicConsultation/Skye/Documents/Skye_incomedep.pdf

The map above indicates that north east Skye is the area with the highest level of deprivation on the island, using this particular metric; although Table 1 indicates greater proportions in Portree West and Portree North, and greater numbers of deprived individuals in Portree West, Portree North, Uig, Broadford, and Skye South East, which may have an impact on service use.

2.3 Patients with Long Term Limiting Illness There is a clear relationship between age and long term limiting illness and between both of these factors and the use of Out of Hours services6. Age specific rates of Long Term Limiting Illness prevalence in this area is therefore shown below.

Figure 9: Age and sex specific rates of Long Term Limiting Illness, Skye and Lochalsh, 2001 & 2012

Source: Marshall, A., 2017. Projections of health care usage for Skye and Lochalsh. University of St Andrews. p.9.

There is a strong relationship between age and Long Term Limiting Illness in both men and women. This is relevant to Out of Hours services, where the population is aging, as is the case in Skye, as it is likely to affect need for health services.

2.4 End of Life Care End of life care can have a significant impact on Out of Hours services. Some information on the pattern of death across NHS Highland is therefore provided below.

In West Highland area a larger proportion of people die in settings where they may require Out of Hours care (at home or in care homes) compared to Highland Region as a whole (Table 2). In Skye, Lochalsh and West Ross over a three year period this meant that every week an average of between 1 and 2 people (74 people per year) died at home, with a significant proportion presumably dying in the Out of Hours period.

6 Ritchie, L., 2015. Pulling together: Transforming Urgent Care for the People of Scotland. The Report of the Independent Review of Primary Care Out of Hours Services. Edinburgh: Scottish Government. Available online: http://www.gov.scot/Resource/0049/00490526.pdf

Table 2: Proportion of deaths by Locality and District geographies and place of death, 2010-2012 (NHS Highland residents only)

Source: Douglas, I., 2013. Place of death in NHS Highland. NHS Highland, Public Health Intelligence & Knowledge Team. p.20, Figure 15

The proportion of deaths in hospital for Skye, Lochalsh and West Ross, at 43.4%, is higher than some comparable areas.

Table 3: Number of deaths by Locality and District geographies and place of death, 2010-2012 (NHS Highland residents only / 3 year number of events)

Source: Douglas, I., 2013. Place of death in NHS Highland. NHS Highland, Public Health Intelligence & Knowledge Team. p.19, Figure 14

The above table gives the numbers of deaths, to give an indication of the size of the end of life population requiring end of life care and comparisons with other areas in NHS Highland. There were 664 deaths over the three year period, 2010-12 in Skye, Lochalsh and West Ross (SLWR). From Table 3 this indicates an annual average of 96 deaths in hospital, 2 deaths in a hospice, 74 deaths at home, and 49 deaths in care homes in SLWR during this period.

The two maps below provide blue and pink shading of data zones to indicate two and three standard deviations from the mean. The aim of these maps is to help identify areas that have unusual patterns of place of death. The southern half of Skye is an area that relies heavily on hospital beds as the place of death, and presumably end of life care, compared to NHS Highland as a whole.

Figure 10: Place of death by data zone, combined years 2013-17 (hospital deaths)

Source: NHS Highland, 2017. The Annual Report of the Director of Public Health – Realistic Medicine. p32. Available online: http://www.nhshighland.scot.nhs.uk/Publications/Documents/DPH-Annual-Report-2017_(web-version).pdf

The map below examines the same topic but from the point of view of areas where a high proportion of residents die at home. The Isle of Skye is not somewhere which stands out as a place where a high proportion of patients die at home.

Figure 11: Place of death by data zone, combined years 2013-17 (deaths at home)

3. Who delivers care? This section provides information on the workforce who deliver care. Some information is also provided around informal carers.

3.1 NHS staff In recent decades Out of Hours patients have been seen by GPs. However, parts of NHS Highland are increasingly using a range of health professionals as is shown in the graph below.

Figure 12: Proportion of Out of Hours cases seen by different professionals, Skye, 2013 to 2017

Source: NHS Highland, 2017. Urgent Care – Data Summary for Skye. p.7.Prepared by Project Lead, Out of Hours and Acting Primary Care Manager North & West (GMS) from ADASTRA patient management system.

The graph demonstrates the increasing use of nurses and paramedics to provide Out of Hours services, with 40% of cases being seen by a professional other than a doctor by mid-2017. It is anticipated that this trend will continue.

Several tables are provided below, which present available data on staff groups.

Figure 13: Summary of current Whole Time Equivalent (WTE) establishments in Skye, Lochalsh and South West Ross Workforce Plan

Data source: Extracted from Skye, Lochalsh and South West Ross Workforce Plan: version 8 within NHS Highland, 2017. OUTLINE BUSINESS CASE, The Modernisation of Community and Hospital Services in Badenoch & Strathspey (B&S) and Skye, Lochalsh and South West Ross (SLSWR). Appendix 11, pp 155-168. Available online:http://www.nhshighland.scot.nhs.uk/Meetings/BoardsMeetings/Documents/November%202017/4.5%20Outline%20Business%20C ase%20BS%20and%20SLSWR.pdf.

Figure (cont): Summary of current Whole Time Equivalent (WTE) establishments in Skye, Lochalsh and South West Ross Workforce Plan

Some of these teams appear to be relying on small numbers of staff and are probably fragile, as recruitment in this area is known to be challenging. Teams such as those providing radiography and MacMillan nurses have some of the smallest whole time equivalent numbers (WTE).

3.2 Unpaid carers The 2011 Census indicated that there were 2,054 people living in Skye, Lochalsh and West Ross (SLWR) who were involved in providing unpaid care and support to a family member, friend or neighbour to enable that person to continue to live in their own community.

The provision of unpaid care makes a vital contribution to the supply of care and this will be increasingly important factor as the Highland population continues to age. The number providing unpaid care in SLWR has grown by 3.6 percent between 2001 and 2011.

Figure 14: Provision of unpaid care by category by Highland geography 2011

Source: NHS Highland Public Health Intelligence. Census 2011 Snapshots: Unpaid care in Highland. Data source: Census 2011: KS301SCA

The above graphic shows a higher percentage of the population providing unpaid care in Skye, Lochalsh and West Ross compared to other areas in Highland.

Figure 15: Unpaid care and formal care provision in Highland at 2011 Census

Source: NHS Highland Public Health Intelligence. Census 2011 Snapshots: Unpaid care in Highland. Data source: Census 2011: KS301SCA

The above figure suggests that there is relatively little relationship between inpatient and care establishment places, per 1000 population, and unpaid care at local level across Highland.

The sustainability of long-term care to older people relies heavily on the supply of informal care. As the number of older people increases in future years, demand for informal care is also likely to increase. Most informal care for older people is provided either by spouses or adult children.

The trends in population ageing and changes in the structure of families have led to forecasters projecting a “tipping point” for care, where the numbers of older people needing care will begin to exceed the numbers of family members available to provide the care7.

The following figure illustrates the projected increase in provision of unpaid, informal care over the next 20 years in Highland.

7 Carers UK, 2010. Tipping point for care: time for a new social contract. Available from: http://www.carersuk.org/professionals/resources/research-library/item/495-tipping-point-for-care-time-for-a-new-social-contract. Accessed 11 April 18.

Figure 16: Estimated and projected number of older people in Highland receiving informal care

Source: NHS Highland Public Health Intelligence, 2018. Appendix 1: Assessing the needs of individuals with high levels of dependency in NHS Highland. Data source: Family Resource Survey (2017) and NRS population estimate for Highland 2016.

As has previously been demonstrated, the growth in numbers is particularly marked in those aged 85 years and over.

4. What care is delivered? A number of aspects around what care is delivered is provided below including: historic aspects of services, Out of Hours services, outpatient services, services delivered by Allied Health Professionals in the community, and hospital services.

4.1 Historic changes to services Some of the key changes to services that have happened in Skye are provided in box 1 and 2 below. These are taken from the Full Public Consultation document for service redesign and provide a snapshot of the services around 2014.

Box 1 Local context

 The opening of the Skye Bridge in 1995, and removal of tolls in 2004, eased access onto and off the island.

 Development of the Rural Practitioner Team based in Dr MacKinnon’s Memorial Hospital in Broadford. Rural Practitioners are mostly GPs with enhanced training in emergency care for rural settings. The team was established in 2004 to meet community needs following the withdrawal of local surgical consultant and anaesthesia cover (for safety reasons) plus the need to provide out-of-hours medical cover.

 In May 2006, Gesto Hospital in Edinbane was closed.

 New health centres were opened in Sleat in 2005, Kyle in 2008, and Broadford in 2012. Broadford Health Centre replaced the existing Broadford Medical Practice and serves patients from communities in Broadford, Strath, Kyleakin and Kyle Rhea communities. It is co-located with Dr MacKinnon’s Memorial Hospital.

 There have been Care home closures – Staffin, Hilton (Broadford) and Graham House (Dornie).

 An Acarsaid Care Home in Broadford was re-developed in 2010/11. There has been new supported housing in Dornie.

 Teleneurology clinics, Telediabetes clinics and Telecardiac rehabilitation clinics got underway in both Portree and Broadford in 2011.

 Various developments to community teams include redesign of community nursing team, community midwifery team and community midwifery Unit in Dr MacKinnon Memorial Hospital in Broadford.

 A new dental clinic opened in Portree in 2012.

 NHS Highland took on responsibility for adult social care (care-at-home, care homes, day care services) in April 2012, as part of integration.

 The Broadford Ambulance station closed in 2013 and was re-located to Dr MacKinnon Memorial Hospital

 Development of South Skye Practice (Broadford/Sleat/Carbost) – ongoing

Source: NHS Highland, 2014. Full public consultation document - Proposed modernisation of community and hospital services in Skye, Lochalsh and South West Ross. p.14. Available online: http://www.nhshighland.scot.nhs.uk/News/PublicConsultation/Skye/Documents/SLWR%20%20FINAL%20FULL%2019%20May%2014.pdf

A description of services, as included in the Public Consultation document, is provided below.

Box 2 Summary of some of the current services Local GPs, nurses, allied health professionals8, community staff and others have been working with an independent health care planner. They have been looking at current services which are summarised below:

GP Practice There are 14,680 registered patients in the area who are served by ten GP Practices

District General Hospital The nearest district general hospital is Raigmore Hospital which is 120 miles away from Portree, approximately three hours by road ambulance.

Dr MacKinnon Memorial Hospital, Broadford

This is a 20-bedded, intermediate care community hospital providing assessment, resuscitation and stabilisation of acutely ill patients, supported by a small team of salaried Rural Practitioners (RPs).

RPs are like GPs but with additional emergency training, allowing the hospital to function at a higher level than most community hospitals. The hospital has 24-hour on-site medical and nursing cover and 24 hour A&E and Primary Care Emergency Services (PCEC).

A small amount of planned day case surgery is carried out.

Radiology services, including ultrasound, are also on site.

There are a range of visiting specialist out-patient services from Raigmore (Inverness), New Craigs Hospital (Inverness) and Belford Hospital (Fort William).

Portree Community Hospital

12-bedded community Hospital is located adjacent to the Portree Medical Centre. It is supported by 24-hour nursing cover and access to 24-hour medical cover. The medical cover is provided by GPs from the Portree Medical Centre from 0800-2300 every day, delivered by GPs and during the out-of-hours period by Rural Practitioners; after 2300 there is no on-site medical cover but is provided from Broadford RPs supported by a North Skye second on call doctor.

8 Allied Health Professionals or AHPs include a number of health care workers such as physiotherapists, occupational therapists, podiatrists, dieticians, speech & language therapists and radiographers.

Box 2 Summary of services (contd.) Portree Hospital (contd.) Radiology services are available four days per week to support out-patient clinics which include Orthopaedics, Ear, Nose and Throat, Ophthalmology, General Medicine, Renal, Chest, Rehabilitation and Psychiatry.

Other services

Midwifery services cover Skye and Lochalsh with a base in both hospitals and one community bed in Dr MacKinnon Memorial Hospital supporting 15-25 births per year.

Multi-disciplinary teams (social workers, care-at-home workers, physiotherapists, occupational therapists, community nurses, and community mental health teams), currently work out of a number of different bases.

Adult social care provided by NHS Highland includes care-at-home service, one Care Home (An Acarsaid) in Broadford, Day Care Services (Tigh na Drochaidh) in Portree and (Airdferry) in Dornie.

There are also two privately run Care Homes (Budh Mhor) in Portree and (The Haven) in Idrigill, Uig. There is one private Nursing Home (Home Farm) in Portree.

The Howard Doris Unit in Lochcarron is a privately run facility, providing residential and day services. Source: NHS Highland, 2014. Full public consultation document - Proposed modernisation of community and hospital services in Skye, Lochalsh and South West Ross. pp15-16. Available online: http://www.nhshighland.scot.nhs.uk/News/PublicConsultation/Skye/Documents/SLWR%20%20FINAL%20FULL%2019%20May%2014.pdf

4.2 Out of Hours Services A variety of analyses of Out of Hours data is provided below. The first map shows the locations of different types of Out of Hours care.

Figure 17: Location of Out of Hours Care, Skye and Lochalsh, 2018

Source: NHS Highland, 2018. Urgent care on Skye: a summary from routine patient management data. p.3. Available on request from Project Lead, Out of Hours and Acting Primary Care Manager North & West (GMS)

A number of first responder and community response units locations are shown, as well as urgent care facilities in Broadford and Portree. The age profile of unscheduled care activity is provided below.

Figure 18: Percentage of unscheduled care activity at Portree and Broadford (combined) by age group and residence, Jan-Dec 2017

Source: NHS Highland, 2018. Urgent care on Skye: a summary from routine patient management data. p.7. Available on request from Project Lead, Out of Hours and Acting Primary Care Manager North & West (GMS)

There is a notable difference in the age profile of those with out of area postcodes using unscheduled care services at Broadford and Portree compared to those with resident postcodes. The largest numbers of users in both groups are aged between 25 and 64. This activity makes up 60% of the overall volume of the out of area group contacts compared with 42% of those with resident postcodes in Skye, Lochalsh and South West Ross (SLsWR). The SLsWR resident activity has a younger and older age profile. Utilisation by the very elderly is lower than might be expected. A more detailed analysis of utilisation by area is provided below. A datazone is the key small area statistical geography that is used in Scotland. They were introduced in 2004, to provide stable and consistent small area geography, as other metrics, such as postcode or electoral ward can change over time. There are 6,505 datazones covering the whole of Scotland.

Figure 19: Directly age standardised rate per 1000 population of unscheduled care at Broadford and Portree by Data Zone of residence in SLsWR, 2017

Source: NHS Highland, 2018. Urgent care on Skye: a summary from routine patient management data. p.10. Available on request from Project Lead, Out of Hours and Acting Primary Care Manager North & West (GMS)

After adjusting for population age, the highest rates of unscheduled care contacts with services are found in Data Zones that are geographically close to service locations. In particular, the populations of Broadford and Portree have the highest rates of service use. The rate in the Portree East & Rural Data Zone is nearly twice as high as the overall rate.

There are very few contacts with patients who have home postcodes in South West Ross. Resident of Lochalsh and the South of Skye almost exclusively use services only at Broadford. Residents of the north of Skye access services at both Portree and Broadford. From the data extract used for this analysis, it is not possible to understand the nature of the injury or illness involved in individual

35 contacts. However, the pattern of use of Broadford by residents of the north Skye data zones may reflect prioritisation of care to a location with an urgent care facility.

4.3 Unscheduled care contact outcomes The outcome for unscheduled care contacts is provided below for the two main Skye hospitals.

Table 4: Unscheduled care contacts at Broadford and Portree by outcome, 2013- 2017 Broadford Contacts Portree Contacts 2013 2014 2015 2016 2017 2013 2014 2015 2016 Patient to Contact Surgery 971 1169 1205 1570 1840 1078 1201 1099 922 No Follow Up 2174 1950 1745 1587 1293 1392 1338 1157 1465 Surgery Follow Up in Morning 117 117 126 150 111 164 149 121 141 Admitted to Hospital 289 300 169 175 300 60 61 22 12 Refer to Ward 933 961 1115 1050 886 223 255 192 75 Outpatient Review Arranged 653 609 575 672 635 213 273 220 228 Refer to A&E 119 102 109 113 121 212 266 232 212 Transfer 12 5 18 26 48 14 19 16 19 Patient to Contact Dental Helpline 13 19 17 19 12 10 14 12 17 District Nurse Attended 7 10 9 14 10 8 11 14 5 Other 21 5 7 5 7 23 9 11 10 Total 5309 5247 5095 5381 5263 3397 3596 3096 3106 Source: NHS Highland, 2018. Urgent care on Skye: a summary from routine patient management data. p.23. Available on request from Project Lead, Out of Hours and Acting Primary Care Manager North & West (GMS)

The available Adastra data extract provided no indication of the acuity of the patient workload. However, an outcome field has been used to illustrate what happens to patients contacting unscheduled care services. At Broadford in 2017, 25% of activity results in no follow up. As a proportion of all activity the no follow up outcome has decreased in every year since 2013 with more patients being instructed to contact their General Practice.

In 2017 6% of activity resulted in admission to hospital. However, the category ‘refer to ward’ also appears to be used to capture admission related activity and 6 percent will be an underestimate of admission. Very few consultations at the location are formerly recorded as resulting in a transfer and again ‘refer to ward’ appears to be used to capture some of this activity.

The data suggests that 60-65% of unscheduled care contacts at Broadford end either with no follow up or potential for a further contact with Primary Care and that 12% go on to an outpatient review. About a quarter of all the contacts result in further direct engagement with hospital based services either as an admission or a ward referral.

The pattern of patient care is very different at Portree. 40 percent of activity ends in no follow up. A further 33-40 percent of activity results in a potential contact with Primary Care. Seven percent of activity is referred to A&E and a further 7 percent results in an outpatient review. Very few people are recorded as being admitted directly to hospital through unscheduled care services at Portree.

4.4 Admission to hospital after unscheduled care contact It is useful to consider the proportion of cases that are admitted after contact with Out of Hours services. The number of contacts with an associated hospital admission has been calculated by linking Adastra data and an extract of hospital admission data from the local TrakCare patient management system. The first hospital admission within a day of the recorded Adastra contact was included in the table below.

Table 5: Unscheduled care contacts at Broadford and Portree resulting in hospital admission, 2015- 2017 Broadford Contacts No. per year 2015 2016 2017 Belford Hospital 2 5 2 Mackinnon Memorial Hospital 325 267 355 New Craigs Hospital 6 1 - Portree Hospital 2 - - Raigmore Hospital 127 161 137 Total 462 434 494 Portree Contacts No. per year 2015 2016 2017 Mackinnon Memorial Hospital 140 106 105 New Craigs Hospital 4 2 - Portree Hospital 36 6 - Raigmore Hospital 45 49 45 Total 225 163 150 Source: NHS Highland, 2018. Urgent care on Skye: a summary from routine patient management data. p.24. Available on request from Project Lead, Out of Hours and Acting Primary Care Manager North & West (GMS)

At Broadford the data linkage suggests that 9 percent of contacts result in an admission. The majority of these occur at the location. The analysis of the informational outcome data in the section above suggested that about 6% of activity at Broadford resulted in further direct engagement with hospital care.

From the data linkage there was an average of 141 direct admissions to Raigmore from Broadford a year.

The data linkage suggests that about 6 percent of unscheduled care contacts at Portree result in an admission to hospital. This is a larger proportion than identified in the admitted category of the ‘informational outcomes’. The majority of the admissions identified by the data linkage were recorded as being ‘referred to A&E’ or ‘referred to ward’ in the informational outcomes recorded on Adastra.

Information on admission to hospital, by Out of Hours period, is shown below.

Table 6: Admission to hospital in the Out of Hours period after contact with the Out of Hours service 2017 Out of Hours locations Number of admissions* Number of admissions as a % of all contacts at the location Tongue/Armadale 32 17.7 Lochcarron/Torridon 22 13.3 Wick 131 11.3 Thurso 108 10.1 Islay 10 9.6 Broadford 305 9.5 Fort William 237 8.8 Oban 232 8.4 Raigmore 1058 8.2 Dingwall 209 7.8 West Lochaber 11 7.8 Ullapool 27 7.3 Golspie 162 7.2 Invergordon 313 7 West Sutherland 10 7 Mull - Tobermory and Salen 13 6.6 Aviemore 220 6.3 Gairloch/Aultbea 20 6.3 Campbeltown 13 6.2 Portree 107 5.7 Cowal Rural 11 5.4 Rothesay 16 4.7 Lochgilphead 21 4.2 Dunoon 31 2.8 Nairn1 25 0.7 Total 3360 7.2 *table excludes sites with less than 10 admissions; Activity between 6pm - 8am Monday to Friday, weekends and Bank Holidays recorded on Adastra. Source: NHS Highland, 2018. Urgent care on Skye: a summary from routine patient management data. p.26. 1 Activity at Nairn is only very partially captured on Adastra. Available on request from Project Lead, Out of Hours and Acting Primary Care Manager North & West (GMS).

The above table is based upon the first hospital admission within a day of an Out of Hours contact at a location recorded on Adastra.

The percentage of admissions at Broadford is higher than the Highland average; whereas the rate at Portree is lower than average. 224 of the 305 (73%) admissions from Out of Hours contacts which were at Broadford Hospital were to the Broadford Hospital and 80 (26%) to Raigmore Hospital. 84 of the 107 (79%) admissions from Out of Hours contacts at Portree were to the Broadford Hospital and 23 (21%) to the Raigmore Hospital.

4.5 Outpatient Care The two hospitals in Skye have a number of outpatient services. Many of these are provided by visiting Consultants, primarily from Raigmore Hospital. Although outpatient care is less relevant to Out of Hours care, the review has requested as full information as possible on local services and details have therefore been provided. Much of the information presented below is from the Service Redesign Outline Business Case and related Public Consultation documents.

Table 7: Summary of outpatient services at Portree Hospital and the MacKinnon Memorial Hospital

Source: McVicar, G., 2014. Summary presentation used at public meetings – Skye hospitals, summary of current and possible future arrangements. NHS Highland. p.4. Available online: http://www.nhshighland.scot.nhs.uk/News/PublicConsultation/Skye/Documents/Skye%20Hospitals%20- %20Summary%20of%20current%20and%20future.pdf

Local clinics are also run in both locations, although only shown on the left of the above table.

The pattern of outpatient care is summarised in the following maps, in relation to both hospitals in Skye and Raigmore Hospital, Inverness.

Figure 20: Directly age standardised outpatient attendance rates by data zone of residence in SLsWR, all specialties and all locations, 2010-2011 – 2012-2013

Source: Douglas, I., 2014. Outpatient activity in Skye, Lochalsh and South West Ross, 2011-2013. NHS Highland Public Health Intelligence and Knowledge Team. p.13. Available online: http://www.nhshighland.scot.nhs.uk/News/PublicConsultation/Skye/Documents/Outpatient%20activity%20in%20Skye.pdf

The map above indicates that the north west of Skye appears to have a relatively low rate of use of outpatients.

Figure 21: Directly age standardised outpatient attendance rates by data zone of residence in SLsWR, all specialties at MacKinnon Hospital, 2010-2011 – 2012-2013

Source: Douglas, I., 2014. Outpatient activity in Skye, Lochalsh and South West Ross, 2011-2013. NHS Highland Public Health Intelligence and Knowledge Team. p.16. Available online: http://www.nhshighland.scot.nhs.uk/News/PublicConsultation/Skye/Documents/Outpatient%20activity%20in%20Skye.pdf

The map above indicates that, as expected the highest users of services in the hospital in Broadford live in the south of Skye and in the vicinity of the hospital.

Figure 22: Directly age standardised outpatient attendance rates by data zone of residence in SLsWR, all specialties at Portree Hospital, 2010-2011 – 2012-2013

Source: Douglas, I., 2014. Outpatient activity in Skye, Lochalsh and South West Ross, 2011-2013. NHS Highland Public Health Intelligence and Knowledge Team. p.19. Available online: http://www.nhshighland.scot.nhs.uk/News/PublicConsultation/Skye/Documents/Outpatient%20activity%20in%20Skye.pdf

The map above indicates that, as expected, the population that make the most use of the hospital in Portree live north of that hospital, or in the vicinity of Portree.

Figure 23: Directly age standardised outpatient attendance rates by data zone of residence in SLsWR, all specialties at Raigmore Hospital, 2010-2011 – 2012-2013

Source: Douglas, I., 2014. Outpatient activity in Skye, Lochalsh and South West Ross, 2011-2013. NHS Highland Public Health Intelligence and Knowledge Team. p.22. Available online: http://www.nhshighland.scot.nhs.uk/News/PublicConsultation/Skye/Documents/Outpatient%20activity%20in%20Skye.pdf

The map above appears to indicate that utilisation of outpatient appointments at Raigmore Hospital falls progressively as the travel distance increases, with residents of Skye making less use than residents in Lochalsh. This pattern may also be related to a higher proportion of appointments being delivered locally.

4.6 District Nursing The level of community care and the hours that service is available can impact on more formal Out of Hours services.

The District Nursing teams for Skye, Lochalsh and West Ross do not routinely provide a 24 hour per day service, but arrangements are in place via an overnight on call service for End of Life care, by the day team, as and when this is possible and as it is required. This service can be accessed through NHS 24 or the Out of Hours team.

NHS Highland is piloting the principles developed by the Buurtzorg model in Holland across a number of sites and is increasingly recognising the need to consider the optimal level of provision of Out of Hours district nursing and community care services, within available funding envelopes9. There may be the possibility of extending some district nursing services into the evening in the

9 https://buurtzorg.org.uk/ Accessed 11 April 18.

43 future10. The ongoing review of district nursing services in the north and west operational unit builds on the Scottish Government report, ‘Transforming Nursing, Midwifery and Health Professionals Roles – Paper 3 - The district nursing role in integrated community nursing teams,11‘ published in December 2017, and on the ‘The Report of the Independent Review of Primary Care Out of Hours Services’.12 Both of these documents highlight the challenges and opportunities for District Nursing and Advanced Nurse Practitioners in remote and rural areas.

Virtual community wards are planned for Integrated Health and Social Care Teams in the North & West NHS Highland unit. The aim of such virtual wards is to provide a high level of care in people’s own homes for those most at risk from unscheduled hospital admissions. Work is also underway to integrate Care at Home staff into such arrangements13.

4.7 Allied Health Professionals Data on community services is generally poorly collected in Scotland and should be interpreted with caution. Available data on Allied Health Professionals is provided below.

10 NHS Highland, 2017. Draft North Highland District Nursing Service Review. 11 http://www.gov.scot/Resource/0052/00529738.pdf 12 http://www.gov.scot/Resource/0049/00490526.pdf 13 North & West Operational Unit, Service Description, Virtual Community Ward (personal communication from Director of Transformation and Quality Improvement to DPH 9/4/18)

Table 8: Allied Health Professional Appointments, Portree Hospital

2013/2014 2014/2015 2015/2016 2016/2017

onal Therapy onal

Profession Profession Profession Profession

Total Total Total Total Total

- - - -

Podiatry Podiatry Podiatry Podiatry

Dietetics Dietetics Dietetics Dietetics

Physiotherapy Physiotherapy Physiotherapy Physiotherapy

Multi Multi Multi Multi

Speech & Language Language & Speech Language & Speech Language & Speech Language & Speech

Occupational Therapy Occupational Occupati Therapy Occupational Month Therapy Occupational APR 49 24 241 85 12 411 14 13 250 75 4 356 30 15 319 91 9 1 465 74 272 107 453 MAY 42 30 268 69 11 420 33 23 250 103 14 423 41 12 207 88 4 3 355 77 1 220 79 377 JUN 51 40 226 108 19 1 445 46 29 246 132 17 470 13 13 216 89 1 332 79 12 182 104 1 1 379 JUL 58 19 277 103 16 1 474 40 12 230 72 11 365 22 14 232 110 2 3 386 80 1 112 72 265 AUG 25 16 189 82 9 321 21 19 223 121 1 385 50 6 272 114 442 67 138 102 307 SEP 81 15 151 97 3 347 47 11 296 82 5 441 50 8 287 49 1 10 405 52 76 104 232 OCT 40 27 257 41 12 4 381 39 2 307 104 3 2 457 61 13 209 109 8 400 63 190 113 366 NOV 43 25 200 118 21 407 34 12 305 105 3 2 461 42 4 228 113 1 7 395 56 1 129 113 299 DEC 35 15 151 59 4 264 33 15 319 88 4 459 50 8 202 93 3 356 53 137 93 283 JAN 44 12 270 106 7 439 40 8 265 89 1 403 47 6 249 116 1 1 420 25 169 80 274 FEB 39 14 277 86 4 420 52 7 245 118 3 425 80 5 219 143 1 448 46 138 79 263 MAR 33 34 220 79 14 380 11 244 112 10 10 387 66 1 198 108 373 44 204 96 344 TOTAL 540 271 2727 1033 132 6 4709 399 162 3180 1201 73 17 5032 552 105 2838 1223 19 37 4777 716 15 1967 1142 1 1 3842 Source: NHS Highland Planning & Performance, 2017. Requested by Project Lead, Skye & Lochalsh Service Redesign Project

The numbers suggest a well utilised service in this population. There is marked variation in physiotherapy appointments over time. Relatively little of the activity is multi-profession. The numbers seen are generally higher than in Broadford (see below). This suggests that future provision of this nature should be considered in any future model of care for north Skye residents.

Table 9: Allied Health Professional Appointments, Mackinnon Memorial Hospital

2013/2014 2014/2015 2015/2016 2016/2017

Profession Profession Profession Profession

Total Total Total Total Total

- - - -

Podiatry Podiatry Podiatry Podiatry

Dietetics Dietetics Dietetics Dietetics

pational Therapy pational

Physiotherapy Physiotherapy Physiotherapy Physiotherapy

Multi Multi Mul Multi

Speech & Language Language & Speech Language & Speech Language & Speech

Month Language & Speech

Occu Therapy Occupational Therapy Occupational Therapy Occupational APR 18 4 111 3 23 159 8 3 129 2 27 169 7 42 22 71 13 59 30 102 MAY 16 10 128 4 43 201 9 15 74 23 121 3 2 45 9 59 16 1 91 1 24 133 JUN 6 13 110 3 51 183 8 10 120 1 16 155 1 18 37 1 24 81 35 4 98 1 38 176 JUL 11 36 106 2 1 29 185 5 9 85 16 115 20 3 48 15 86 12 94 17 123 AUG 14 7 88 2 33 144 6 81 2 12 101 6 3 38 15 62 10 118 5 32 165 SEP 10 5 94 13 122 7 6 71 31 115 13 6 74 26 119 10 41 1 8 60 OCT 4 4 108 5 121 2 2 58 22 84 9 7 53 8 77 7 90 34 131 NOV 8 5 89 11 11 124 6 1 48 5 16 76 10 6 57 13 86 9 101 2 32 144 DEC 11 4 92 1 4 10 122 7 6 74 3 17 107 22 3 67 6 98 7 96 1 32 136 JAN 9 14 140 2 29 194 1 9 57 3 2 72 2 6 73 34 115 2 102 40 144 FEB 8 12 107 4 17 148 1 6 27 10 44 12 5 77 25 119 9 84 2 12 107 MAR 6 10 75 4 22 117 1 14 36 13 64 23 67 8 98 13 1 63 18 95 TOTAL 121 124 1248 3 38 286 1820 55 87 860 0 16 205 1223 121 66 678 1 0 205 1071 143 6 1037 13 317 1516 Source: NHS Highland Planning & Performance, 2017. Requested by Project Lead, Skye & Lochalsh Service Redesign Project

The information on ‘other locations’ in the table below indicate that a proportion of the residents in Skye, Lochalsh and South West Ross are seen in very local facilities across the area. This suggests a very accessible service.

Table 10: Allied Health Professional Appointments, other14 Skye and Lochalsh locations

2013/2014 2014/2015 2015/2016 2016/2017

Profession Profession Profession Profession

Total Total Total Total Total

- - - -

Podiatry Podiatry Podiatry Podiatry

Dietetics Dietetics Dietetics Dietetics

ational Therapy ational

Physiotherapy Physiotherapy Physiotherapy Physiotherapy

Multi Multi Multi Mult

Speech & Language Language & Speech Language & Speech Language & Speech Language & Speech

Occup Therapy Occupational Therapy Occupational Month Therapy Occupational APR 43 68 102 172 23 18 426 21 24 85 193 26 5 354 4 26 88 103 6 17 244 47 22 82 205 19 375 MAY 51 70 106 220 49 53 549 45 34 75 200 20 17 391 2 10 69 164 6 13 264 38 16 70 288 1 9 422 JUN 53 31 68 205 43 5 405 29 27 56 214 42 10 378 5 13 72 188 3 20 301 57 12 80 263 1 9 422 JUL 41 66 106 195 25 4 437 24 45 68 198 25 1 361 20 33 63 189 12 11 328 44 3 64 182 2 295 AUG 56 31 111 203 27 8 436 14 46 52 171 10 39 332 49 28 58 171 1 27 334 61 79 178 318 SEP 42 45 85 201 29 3 405 35 58 84 241 27 93 538 63 39 78 208 5 33 426 46 73 232 1 352 OCT 27 48 135 143 31 4 388 47 34 64 177 25 62 409 43 34 62 207 2 19 367 64 104 180 348 NOV 77 68 92 217 42 1 497 31 26 76 185 16 55 389 28 36 69 271 1 27 432 29 129 201 359 DEC 27 37 70 167 24 1 326 42 19 63 181 8 35 348 42 19 65 219 2 16 363 41 85 178 304 JAN 57 52 76 69 34 21 309 39 36 84 136 15 34 344 25 43 54 218 2 7 349 39 111 162 312 FEB 27 27 56 240 35 21 406 42 29 63 107 8 52 301 23 18 64 183 12 300 44 108 168 320 MAR 40 37 71 225 29 11 413 1 35 80 111 13 28 268 52 32 86 286 15 471 76 88 138 302 TOTAL 541 580 1078 2257 391 150 4997 370 413 850 2114 235 431 4413 356 331 828 2407 40 217 4179 586 53 1073 2375 3 39 4129 Source: NHS Highland Planning & Performance, 2017. Requested by Project Lead, Skye & Lochalsh Service Redesign Project

14 NB: Other centres included: An Acarsaid Community Care Centre, Applecross Primary School, Applecross Surgery, Auchtertyre Nursery, Auchtertyre Primary School, Broadford Medical Centre, Broadford Nursery, Broadford Primary School, Budmhor House, Carbost Medical Practice, Carbost Nursery, Carbost Surgery, Domiciliary Visit, Dundonnell Community Clinic, Dunvegan Health Centre, Dunvegan Nursery (Gaelic), Dunvegan Primary School, Ferguson Medical Centre, Gairloch Health Centre, Glenelg Primary School, Glenelg Heath Centre, Glenelg Surgery, Graham House, Home Farm Nursing Home, Howard Doris Centre, Kilmuir Primary School, Kyle Church Rd Surgery, Kyle Nursery, Kyle Primary School, Kyleakin Clinic, Kyleakin Primary School, Loch Duich Primary School, Lochalsh Healthcare Centre, Lochcarron Playgroup, Lochcarron Primary School, Lochcarron Surgery, MacDiarmid Nursery, Macdiarmid Primary School, None, Nurses Cottage, Raasay, Other Community Setting, Plockton High School, Plockton Primary School, Portree High School, Portree Medical Centre, Portree Primary School, Raasay Nursery, Raasay Primary School, Sleat Medical Practice, Sleat Primary School, Staffin Nurse Base, The Haven Care Home, To Be Confirmed, Torridon Surgery, Uig Surgery, Ullapool Health Centre.

4.8 Hospital services The availability of hospital services may have some impact on the pattern of use of Out of Hours services. The services provided at the two hospitals are summarised below. The pattern of service provision at these sites has varied over time and this should be seen as a snap shot of what was provided at the time that the business case for service redesign was being developed for the Scottish Government during 2014.

Table 11: Summary of services in Portree Hospital and the Mackinnon Memorial Hospital, Broadford

Source: McVicar, G., 2014. Summary presentation used at public meetings – Skye hospitals, summary of current and possible future arrangements. NHS Highland. p.3. Available online: http://www.nhshighland.scot.nhs.uk/News/PublicConsultation/Skye/Documents/Skye%20Hospitals%20- %20Summary%20of%20current%20and%20future.pdf

4.8.1 Current inpatient activity at Portree and MacKinnon Memorial Hospitals The figures below are based upon summary data from the NHS Highland Bed Occupancy Statistics Tool. The accuracy of this is dependent on submissions of local units. The data that has been used from March 2014 onwards has been taken from the TrakCare Computer Database.

Currently, Portree Hospital has four open General Practice led beds. These have been almost continually occupied in the quarter Jan-Mar 2018. The number of days with beds unavailable or designated as ‘closed’ was first noted in the period Jul-Sep 2017. However, the reduction in the number of admissions and discharges from Jan-Mar 2016 (Figure 24 Figure 25) predates this period. Non recording of ‘closed beds’ may have impacted on the summary of occupancy in Figure 26 during the period Oct-Dec 2016 to Apr-Jun 2017.

The volume and pattern of care at the hospital has changed over the last two years. The current pattern is one of a very low volume throughput of patients, but with very long lengths of stay.

Figure 24: Number of inpatient admissions and available beds at Portree Hospital, 2011-18