Shaping the Future

The Clinical Strategy for NHS Argyll & Clyde

Paper for Public Consultation 14 June – 17 September 2004

NHS Argyll & Clyde Consultation paper

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Executive Summary

1. This document contains proposals for the future provision of health services for the people of Argyll and Clyde. It is based on a set of seven key principles – safety, sustainability, quality, affordability, integration, access and timeliness.

2. A clear plan for health services in NHS Argyll & Clyde is necessary to help tackle both the pressures that health services across Scotland and the UK are experiencing generally and those that apply to the particular circumstances of Argyll and Clyde. These pressures mean that we are unable to sustain the current way in which we provide health services in Argyll and Clyde. If we do not address these pressures effectively, there is a real danger that services will fail and that a poorer quality of service with much diminished access will result.

3. As part of this process of developing a clear plan for the future, we have talked with, and listened to, a great many people from across Argyll and Clyde. These have included patients, carers, people in local communities, our partners and our staff. The proposals contained in this consultation paper are based on these discussions and on the work that took place in the many workshops and meetings across Argyll and Clyde over a period of eight months. We have also looked carefully at professional standards and advice and taken these into account in our proposals.

4. Five overall themes emerged in our discussions, reflecting the views of public, patients and staff about the health services we should provide. These included the wish of patients and carers to be treated as equal partners in the healthcare process, the importance of better access to care and how these, and other improvements, could be achieved through building on the patient pathway approach. Maximising care in local communities and making sure of continued access to high quality acute services were also highlighted. This paper contains proposals for service redesign to deliver the improved services that people told us they wanted to see.

5. We need to change the way in which our health services are provided to meet the aspirations of patients and public. We believe we can do this through developing primary care, introducing intermediate care models more widely and building a healthcare network across Argyll and Clyde. But before we can do this, we must make sure our services are stable.

6. This paper contains our proposals to provide services that are safe, sustainable and of high quality. In some cases this means significant change to the current pattern of services. We propose to maintain our main acute hospital sites although we will have to change some services to do this. We intend to provide additional services as we shift the emphasis of care from institutional to community-based care for older people, people with a mental health problem or with a learning disability.

7. We propose to develop services at the Royal Alexandra Hospital as the major acute hospital for Argyll and Clyde. This will include the major accident and emergency department networked to other emergency services across the area. We have outlined the options for the provision of services in the Inverclyde and Lomond areas to provide as many services as possible locally. We will work with NHS Argyll & Clyde Consultation paper

local communities in Argyll and Bute to develop health services for remote and rural services.

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Contents

1. Introduction

2. The need for change

3. Redesign of services and working practice

4. Modernisation and reform of services and infrastructure

5. How to give us your views

Glossary

References NHS Argyll & Clyde Consultation paper

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1. Introduction

This paper describes NHS Argyll & Clyde’s plans for future health services in our area. When making these plans we need to consider the geography of Argyll and Clyde, the kind of communities we live in, and projected changes to the population of Argyll and Clyde. We also need to take into account the views of the 418,000 people in Argyll and Clyde whom we serve, and the staff who provide the services. In doing this, we must have a view to the future and our responsibilities to the next generation of service users, to local communities and to our staff.

Since October 2003 we have been talking with people across Argyll and Clyde to hear their views about the development of our NHS. These discussions have been with members of the public, politicians (MSPs and MPs) and local councillors, as well as many of our staff, patients, carers, advocacy groups and other organisations, both statutory and independent. More than 4000 people have been directly involved so far in these discussions.

We have listened carefully to what we have been told over the last eight months by patients, the public, staff and partners. People want healthcare services that work better together to meet their needs as fully as possible. They want assurance that the healthcare services they use are consistently of high quality. They want to be able to rely on their services, and be reassured that the services they require will be available to them when they need them. This paper describes, therefore, not simply an acute services strategy but covers all healthcare services for the people of Argyll and Clyde. Neither does it suggest short term or quick “fixes” that would only mask underlying challenges and problems. Instead, we have outlined the tough decisions that need to be made both now and into the future.

1.1 Key principles

It was also clear from the discussions we have had over the past eight months that some principles must shape the future design of services. Taken together, these principles provide us with a robust framework within which to develop the Clinical Strategy. They are:

Safe services

A service is safe when we can be confident that the care provided by our staff compares well against national standards and that, for most people, the expected health outcomes will be achieved. We are confident that all the proposals in this plan are consistent with this view on safety.

Sustainable services

We have a duty to ensure that our plans serve communities in Argyll and Clyde well into the future. We believe this is a duty shared equally by the community at large. This means we will only invest in services that are sustainable. This strategy describes developments that are realistic and robust enough to be enduring, but also flexible enough to adapt to changing needs and new opportunities.

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Quality services

The services that we provide must be fit for the purpose intended. Each service in itself must demonstrate a commitment to continuously improving the quality and standards of care. This view of quality accepts that we will provide services in a variety of ways to meet local needs but each service must be able to demonstrate that it is fit for purpose.

Affordable services

On behalf of the 418,000 people living in our area, we have a duty to live within the budget given to us by the Scottish Executive. We cannot spend money we do not have. This means only spending the money on our strategy for health services that has been allocated as our fair share of the Scottish health budget.

Integrated services

We must make sure that our services are designed and delivered with the individual needs of patients as the focus. This means that service providers work together, involving patients and carers, to break down any artificial boundaries and deliver seamless care to patients and carers. One of our key aims in this strategy will be integrating primary, secondary and social care pathways and, in this way, creating new opportunities to redesign local services.

Access to services

We must make sure people have good access to the services they need. This is not just access on a geographical basis, in other words, how far and with what difficulty patients must travel. Improving access means we must play our role, along with our partners, in dealing with transport issues. But access is also about how easy it is to take up services, including waiting times, bureaucracy, staff attitudes, deprivation and disability. It is only by providing services in new ways, by re-defining the nature of services and recognising new types of healthcare practitioners that we will be able to develop and support sustainable access to services.

Achieving change over time

This strategy proposes change over a time period from two to fifteen years. Stability for acute services will mean that changes to acute hospital services must be completed within two years. Developments in primary care, which are significant and transformational, will be put in place over the whole period of this strategy, from two to fifteen years and beyond.

1.2 Choice

Whatever the final decisions following the conclusion to this consultation, NHS Argyll & Clyde fully recognise the right of individual patients to exercise choice when referred from their GP or other healthcare practitioner to hospital services for planned care. This means that, in discussion with their GP or healthcare practitioner, all patients will have the right to be treated in any appropriate NHS hospital which can meet their care needs. This includes hospitals outside NHS Argyll & Clyde.

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1.3 What is this public consultation about?

We are proposing radical change to many services across Argyll and Clyde, and we would like you to comment on our proposals. These changes will affect the way in which we develop primary care, acute services, services for older people and mental health services. Wherever possible, we will listen to, and take account of, all constructive views on our proposals. For some of our proposals we have set out some options, and we would appreciate your views about the choices we should make.

Where we can see only one option that meets the principles we have set out for the Clinical Strategy, then we have said so. Nevertheless, we still welcome your views on the proposed option to help refine our thinking further and enhance what we have proposed, if this is possible. We are particularly interested in comments that would ensure that the implementation of the option is firmly centred around the patient experience. We expect a range of views and opinion from this consultation. However, where these have taken account of the issues described in the next chapter, The Need for Change, and are consistent with the above principles, we will be able to afford them more consideration.

The way in which we provide health services at present will not sustain safe or quality services, so we cannot continue as we are now. We need to plan ahead in a way that avoids sudden or unpredictable service failures, and that builds a sustainable model of service delivery that will meet the needs of our population both now and into the future.

Our experience over the past year or so has already taught us much of significance about the actions required to sustain safe, quality specialist consultant services, and alternative options where a consultant-delivered service is no longer sustainable. For example, The Need for Change highlights why consultant maternity services have been consolidated within NHS Argyll & Clyde, and in many other NHS systems across Scotland.

We would, therefore, like respondents to focus on contributing to the debate about services for the future that maintain or improve the quantity and range of services that can be provided safely and sustained in the long term in local communities. Focussing on the desire for services to remain unchanged cannot take us forward in this major work that we need to do to make sure the people of Argyll and Clyde continue to have access in the future to safe, quality services.

1.4 The consultation process

This consultation will run for a three month period from 14th June to 17th September 2004. Following this, the outcomes of the consultation will be reported to the NHS Board, along with any amendments to our initial proposals arising from the consultation. We will then be seeking permission from the Minister for Health and Community Care to put in place the changes we have outlined in our Clinical Strategy. Many of these changes will happen over the following two to fifteen years, with some of the major changes happening within the first two to four years.

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1.5 Independent evaluation

Given the magnitude of the changes we are proposing and the degree of community interest in this consultation, we are commissioning an independent evaluation that will run in parallel with the consultation. It will report directly to the NHS Board at the conclusion of the consultation so that it can be taken into account in final decision making. The NHS Board will, therefore, have available the report of the independent evaluation before any final decisions are made. The evaluation will be led by Dr Andrew Walker of Glasgow University.

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2. The Need for Change

2.1 Background

This chapter of the Clinical Strategy explains why services in NHS Argyll & Clyde must change if the people of Argyll and Clyde are to continue to have access to safe, high quality healthcare services.

Most of these reasons are not unique to Argyll and Clyde, or even to the NHS, but reflect much broader changes in:

• the population

• people’s health needs

• clinical practice (the way health professionals treat different health problems)

• the way NHS staff work.

Information on each of these, and their implications for NHS Argyll & Clyde, is set out in the sections that follow. However, whilst we describe how we cannot continue to provide the current pattern of services for all these reasons, it is important to acknowledge the impact of finance and affordability, and the geography of Argyll and Clyde. These are covered at the end of the chapter.

2.2 Changes in the population

In the future in Argyll and Clyde, and Scotland as a whole, there will be more older people needing care and there will be fewer people of working age to provide that care:

Ageing population

People in Argyll and Clyde are living longer than ever before. As people live longer they are more likely to have health problems that need on-going help and support from the NHS and others. Over the next ten years, it is estimated that there will be a 10% increase in people aged between 85 and 89, and a 36% increase in people aged 90 and older.

People aged 85 and over in Argyll and Clyde

10000

9000

8000

7000

6000

5000

4000 Number of people

3000

2000

1000

0 1984 1994 2004 2014 Year Estimates Source: General Register Office for Scotland 1984 & 1994 uses mid year population estimates that have been revised using the results of the 2001 national census Projections 2004 & 2014 uses 2002 based population projections that have been revised. 5 NHS Argyll & Clyde Consultation paper

These are the people who need most care, as shown in the graph showing bed days required by emergency patients below1.

Bed days used by emergency inpatients by broad age group. Argyll and Clyde. 1981 to 2001.

400

350

300

Bed 80 and over days 250 per annum 200 (’000) 150 65 to 79

100 45 to 64 50 Under 45 0 1981 1985 1990 1995 2001

Admission year

Falling birthrate

The number of births in Argyll and Clyde has fallen from 5,003 in 1997 to 4,236 in 2002/03 and is projected to fall further to 3,954 in 2010/11. The birth rate is falling faster in some areas than in others. Overall, this means that in some areas there are not enough babies being born to allow doctors to maintain their skills to the standards set by their professional organisations.

There will be fewer young people in Argyll and Clyde. The number of young people and of working age (15 to 64 years) will drop by 5% and the number of children aged 14 years and under will drop by 18% between 1999 and 2014.

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Children aged 0 - 14 years of age in Argyll and Clyde

100000

90000

80000

70000

60000

50000

40000 Number of children of Number

30000

20000

10000

0 1984 1994 2004 2014 Year Estimates Source: General Register Office for Scotland 1984 & 1994 uses mid year population estimates that have been revised using the results of the 2001 national census Projections 2004 & 2014 uses 2002 based population projections that have been revised

Declining population

The total number of people in Argyll and Clyde has fallen from 425,600 in 1999 to 418,400 in 2002, and is expected to fall further to 405,923 in 2014. Altogether, the population of Argyll and Clyde will drop overall by 5% over 15 yearsi. In some areas, such as Inverclyde, the population is declining more rapidly than in others.

We must make sure that our services develop to meet the specific requirements of our changing population. If not, then some vulnerable sections of our community, such as the growing numbers of elderly people, will not receive the services they need.

2.3 Addressing health needs

The healthcare services that we provide must meet the health needs of the people of Argyll and Clyde. Health needs change over time, reflecting changes in the make-up of the population, how people live, and the opportunities open to them, such as employment, housing and education. A full picture of the health needs of the people of Argyll and Clyde, with the information to support it, is contained in the Annual Reports of the Director of Public Health2.

People’s health in Argyll and Clyde is improving in many ways, but is still poor compared to most other Western European countries. In Scotland, Argyll and Clyde is one of the areas where people are likely to die younger and suffer poor health at a young age3. In particular, rates of cancer, coronary heart disease, stroke and a range of other health problems are higher among people in Argyll and Clyde than in many other parts of Scotland.

• In Argyll and Clyde, cancer remains the most common cause of death in those aged under 65. Lung cancer remains, overall, the most common cancer although this is very largely a preventable disease, with smoking accounting for some 90%

i 1999-2014.

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of cases. The incidence of other forms of cancer, such as skin cancer and bowel cancer, is on the increase and many of these cases could also be prevented4.

• In Argyll and Clyde, 41% of all deaths are due to strokes, or coronary heart disease such as heart attacks. This is the second-worst level of deaths from stroke and coronary heart disease in Scotland. Many of these are people who die prematurely (that is, before the age of 65). Often people leave behind dependent relatives. Many of those who survive have continuing major problems with their health that affect their families and their work5.

• Lung disease is the third biggest killer in Argyll and Clyde and, if lung cancer is included , is the largest cause of death. Smoking is a major cause of lung disease with the UK death rate twice the European Union average.

• Diabetes has been described as “Scotland’s epidemic for the 21st Century”. Health statistics indicate that the number of people with diabetes is doubling every decade6. Diabetes is a major cause of premature death from heart disease, as well as significant disability such as blindness, kidney disease and other health problems.

• In Argyll and Clyde, deaths from alcoholic liver disease/cirrhosis are higher than the rest of Scotland and have increased markedly over the past decade. Alcohol misuse also causes other illnesses and is a major factor in attendance at Accident and Emergency Departments. Figures show a serious and growing problem of alcohol misuse in Argyll and Clyde. Similarly, drug misuse is associated with many types of ill-health and is a key cause of increases in the transmission of blood borne viruses such as Hepatitis C which can lead to serious liver disease7.

• One in four people will need care and support from mental health services at some point in their lives. Depression was the most common condition recorded at GP consultations in Scotland in 20008. Use of general health services by people with depressive disorders is 50-100% higher than by those without depressive disorders9. People with a mental health problem are much less likely to be in a job, though almost all want to work10.

These are just some of the healthcare needs of the population of Argyll and Clyde. The NHS has the lead role in providing accurate diagnosis, assessment, treatment and care for those with health problems. Over time we must adapt our services and the way we provide them. If we do not do this, the healthcare services we offer will soon be out-of-date and will not be of the quality that we know we could provide.

We know that people who are unemployed or live in over-crowded or damp houses have poorer health than those living in better-off areas. For example, rates of cancer, coronary heart disease and mental ill-health are certainly much higher in poorer areas and people are more likely to die from their illnesses than those who live in areas where most people are in work and have comfortable homes and living conditions11. This happens for a number of reasons, but people coming forward to talk to their doctor at a later stage in their illness is one of them.

The NHS can’t do everything to help people live healthier and happier lives but we can work with other agencies that can help change things by improving housing, creating opportunities for education and work, and making sure children have

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somewhere safe and clean to play. The NHS must make explicit links with these agencies and local communities, so that health becomes everyone’s business12.

2.4 Changing clinical practice

Clinical practice is how healthcare professionals (such as doctors, nurses and allied health professionals) treat patients. What might have been best clinical practice in the past is unlikely to be the best that we can do today. Clinical practice changes over time to reflect a number of things, such as:

• changing patterns of disease

• the introduction of new techniques, treatments and drugs

• the introduction of new equipment and new technologies

• increased knowledge and evidence about what gives the best results for patients

• responding to better informed and more knowledgeable patients and public

• meeting quality standards and requirements

• changes in regulation and training and accreditation requirements

• staff availability.

What we can do for patients and those suffering from poor health has also changed. Improved understanding of illnesses, better ways of finding out what is wrong with a patient and a greater range of treatments allow us to provide higher quality care today than ever before. Research-based evidence shows what treatments and drugs will give the best result for most patients.

We know more about how best to use medicines to treat common problems such as heart attacks. New surgical techniques, such as keyhole surgery, have been developed that lead to faster recovery times and shorter hospital stays13. Modern technology allows us to link up remote and rural areas with specialist centres, and new equipment such as MRI (Magnetic Resonance Imaging) and PET (Positron Emission Tomography) scanners allow much more sophisticated diagnosis and understanding of health problems than ever before.

As they learn more about new and more effective treatments, health professionals are constantly changing the ways in which they care for patients. But providing better care has a number of knock-on effects. Some of these are outlined in the sections that follow.

New techniques, treatments and drugs

With new techniques, treatments and drugs, the time people stay in hospital has been greatly reduced. Many treatments are now carried out on a day case basis, allowing people to return home the same day rather than having to remain overnight in hospital. For example, the number of day cases in ophthalmology has risen from 909 to 1750 over the past seven years. This is a rise from 41% to 70% of all planned ophthalmology treatments being carried out as day cases.

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Another example of change arising from the introduction of new techniquesii is that now far fewer patients have to have a hysterectomy, a major operation normally requiring the patient to stay up to a week in hospital and usually followed by at least eight weeks off work. In 1996/97, 692 hysterectomies were carried out in Argyll and Clyde but this reduced to 404 in 2001/0214. Modern surgical techniques can now be used for other previously major operations e.g. for gallstones and knee operations, making the time spent in hospital and the time it takes to recover afterwards much shorter. The number of days that most people spend in hospital is therefore much shorter, as shown in the graph.

We need to make sure that we are not keeping hospital beds unnecessarily, based on old ways of working rather than the modern techniques clinicians are using. We must avoid money being tied up in maintaining beds we don’t need instead of putting money into providing the health services that people need.

Argyll & Clyde Residents - Average length of stay in general hospitals per inpatient record

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12

10

8

6

4

Average length of stay (days) of length Average 2

0

6 9 0 01 992 002 1 /20 2 1/ 1/ 92/1993 93/1994 96/1997 99 9 9 995/199 9 998/199 999/200 000 00 1 1 1 1994/19951 1 1997/19981 1 2 2 Year of discharge

New drugs are being developed that have a significant impact in tackling disease and improving health. Although they are very effective, they can also be very costly. Significant amounts are being spent on new drugs that have shown to be very effective in dealing with specific health problems, such as statins for coronary heart disease. If we are to continue to afford these new drugs, we must find additional money to pay for them.

New technologies and equipment

The introduction of new technologies and equipment allows us to improve diagnosis and treatment. Some highly specialised equipment will always be provided only in regional centres, for example, the radiotherapy machines at the Beatson Oncology Centre, but many others, such as CT (Computerised Tomography) and MRI scanners, become standard as technology develops. New technologies, such as telemedicine and near-patient testing, can also allow healthcare to be provided in more local settings.

New technologies are usually expensive, more expensive than the ways of working they replace. They can, sometimes, also require higher levels of skill and team ii such as endometrial ablation and levonorgestral-containing intrauterine system (Mirena)

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working amongst staff. We need to make sure that we can access such technology in order to provide the best possible diagnosis, treatment and care for patients.

Quality standards and requirements

There are increasing numbers of quality standards that the NHS is required to meet. Some of these are recommendations only, but others are essential requirements that must be met to allow a service to continue to be provided. These standards can be set by the Scottish Executive, normally through NHS Quality Improvement Scotland, an umbrella organisation that has been set up to cover a range of previously separate quality bodies, but also by professional organisations such as the Royal Colleges.

One example of changes impacting on healthcare provision is the fall in the number of births. With fewer babies now being born, it has not been possible to give clinicians in some areas enough experience of babies being born to meet the standards laid down by their professional organisations. This has meant changes to maternity services in Argyll and Clyde such that, in future, many babies will be born in local midwife-led units unless it is predicted that mother or baby may need specialist care. Consultant-led care is available for patients who need it or choose it but some of these patients will have to travel further than previously. This pattern of services is being set up in many other areas of Scotland for exactly the same reasons15.

New ways of working

We know that, for those people who are most seriously ill, we can provide better treatment than we could in the past. For some people we can now provide treatment when before there was little we could do, and for people with chronic (long lasting) conditions we can provide more support throughout their lives. We can do this by developing both our specialist and primary care services and making sure they are better co-ordinated.

This means helping clinicians – doctors, nurses, physiotherapists, radiographers, and many others – to develop their skills and expertise so that they can provide better treatment for patients. This is achieved by making sure that clinicians have the right skills through specialist training, through working in teams16, by sharing knowledge with other clinicians and by treating lots of patients with the same illness on a regular basis.

For some services, we must work more closely with specialist centres elsewhere in the West of Scotland, notably in Glasgow, to help provide the right circumstances for improved results for patients. 17

Patient and carer choice

We know from our work that patients - and their families and carers - would prefer to receive treatment and care as close to home as possible. 18 Sometimes this is to avoid unnecessary travel or disruption to normal family life. Sometimes this is because they would prefer to be cared for by healthcare professionals they already know and trust in their local communities. Increasingly, services are being designed to reflect this and to prevent people being admitted to hospital when there are alternatives to this. This has resulted in developments such as rapid response teams that work to prevent unnecessary admissions to hospital, or hospital at home schemes that provide care to help people remain in their own homes. Sometimes,

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this has resulted in the closure of hospital accommodation as people choose to live their lives being cared for in ordinary communities, supported by teams of professionals in health and social care.

There are many more opportunities in Argyll and Clyde for treatment and care to be given in people’s homes or in local communities rather than being admitted to a hospital. Healthcare professionals are keen to see this happen and to allow patients, their families and carers the chance to live as normal a life as possible.

For example, the numbers of psychiatric beds in Scotland has halved over the last decade as care and treatment for people with mental health problems has increasingly been provided in their own homes and local communities. NHS Argyll & Clyde has failed to keep up with such change with the result that much mental health care is still provided in institutions, contrary to national policy and to the wishes of staff and to the detriment of patients and their families19.

Specialisation in training and skills

Increased knowledge about what makes a difference to health has led to changes in the way doctors are trained and work. Fewer hospital doctors than in the past are now trained to deal with a wide range of problems. Instead, they now specialise, or concentrate, on treating a smaller number of conditions20. This is based on evidence that such specialisation results in more skilled and experienced staff with improved results for patients21 22. However, this often requires services to be brought together in one place to enable essential skills to be shared and maintained. This means that some specialist services can no longer be sustained locally. Instead, such services must be concentrated in a smaller number of locations23 24.

For this reason, we have had to concentrate the urology service in Argyll and Clyde (urology covers diseases of the kidneys, bladder and prostate). Some patients have to travel further to a new urology service, but the waiting time to get to that service has been reduced to 2-3 weeks. This is significantly less than the 75 week wait that was average for the same service previously provided in Glasgow.

The next part of this chapter looks in detail at the many factors affecting health service staff and how these are impacting on NHS Argyll & Clyde.

2.5 A changing workforce

NHS Argyll & Clyde currently employs more than 11,000 people. It has employed increasing numbers of staff over recent years to provide more services. We have almost 20% more medical staff than we had ten years ago and 12% more nurses25.

There are substantial pressures on the workforce26 27. These include:

• their age profile

• shortages of staff

• pay modernisation

• the impact of employment legislation

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• professional training and development.

Age profile of the workforce

As the general population is ageing, so is our workforce:

• The average age of hospital consultants in Scotland was slightly higher in 2000 than in 1990, which means that there is an increase in the number of doctors approaching retirement28. There are clusters of consultants in parts of NHS Argyll & Clyde very near to retirement. Replacing these consultants and sustaining services as they are now presents a real challenge, given the shortage of consultants across Scotland and the UK.

• The average age of GPs in Scotland is rising. This is particularly the case in more rural areas29 30. NHS Argyll & Clyde faces this situation, notably in Argyll and Bute as illustrated in this graph:

Principal GP age profile (Argyll and Bute LHCC 2001)

18 16 16

14

12 Number 10 10 9 9 9 of GPs 8 (Total 62) 6 5 4 4

2

0 30-34 35-39 40-44 45-49 50-54 55-59 60-79 Age in years (Average age 48yrs)

The age distribution of nurses in Scotland includes a large number of nurses who joined the profession between 1985 and 1990. Although not imminent, this age structure poses a potential challenge in ten years time if not addressed now31. This would not necessarily present a problem, except that fewer young people in the overall population means fewer available to train and work for the NHS.

Shortages of staff

In Scotland we are, along with the rest of the UK, facing overall shortages of clinical staff and serious shortages in some areas such as radiology, pathology and psychiatry32. Unfilled posts, especially hospital consultant posts, disrupt services and increase waiting times. Despite running a series of initiatives, such as the Return to Work programme to persuade staff to return to work in the NHS, there remain many areas with staff shortages. The shortage of qualified nursing staff, most notably in specialist areas like intensive care nursing, has meant using temporary and agency

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staff to fill gaps. This is expensive and, by disrupting the continuity of care, risks compromising the quality of care.

Changes in medical training and the way in which doctors provide treatments for patients sometimes make it difficult to attract and keep staff to provide certain services locally. Retaining good local access to services and maintaining quality may involve local clinicians working more closely with specialists from other hospitals to continue to provide services, but in a different way. This may change local provision and is a pattern of change being repeated in hospitals across the UK.

Many of our staff in NHS Argyll & Clyde will be retiring within the next ten years. There will not be enough new staff qualifying to replace them on a one-to-one basis. This mirrors the various changes set out at the beginning of this chapter and is a significant issue for the whole of the NHS across Scotland and beyond. It means we will have to find new ways to deliver the health services needed by the population of Argyll and Clyde.

In NHS Argyll & Clyde we have had difficulty recruiting to some more specialised areas and have already had to look at different approaches to providing services in order to retain access. Given the changes to medical training in recent years, this trend is forecast to continue and we must, therefore, plan for it. This problem is not confined, however, to specialist posts; it is also difficult to attract applicants to some GP posts. This is particularly true of rural areas where the numbers applying for posts, especially for vacant single-handed practices, has declined steadily over the last 20 years (a single-handed practice is where a GP works on his own rather than with a group of GPs, and is more common in rural and remote areas).

The trend, which continues, was highlighted in a recent study33:

Number of Applicants per Single-Handed Practice Vacancy

35 30 25 20 15 10 5 0 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998

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The impact of employment legislation

The NHS is a 24 hour, 7 day a week service in which many NHS staff have worked excessive hours and unsocial working patterns. The UK had no restrictions on working hours until the implementation of the European Working Time Directive in 1998. These regulations place an obligation on employers to reduce the number of hours staff are allowed to work and to introduce safe working patterns. All clinical staff are affected by the Working Time Regulations, particularly those involved in out- of-hours emergency care, but our most immediate concern is about junior doctors.

Historically, the NHS has relied very heavily on junior doctors in training. Medical care for patients in hospital at night has been provided by junior doctors who stay resident in the hospital while the consultant is on-call from home. In the past, some junior doctors could be available to work more than 100 hours per week. The "New Deal" and the European Working Time Regulations were introduced as health and safety measures for junior doctors as it was recognised that excessive working hours, as well as being unsafe for the individual, could lead to a lower quality of patient care provided by doctors who were tired. As we plan for the future we can only plan on the basis of junior doctors working a maximum of 48 hours a week in accordance with the Regulations.

To compensate for the reduced time our existing junior doctors will work, NHS Argyll & Clyde would require to recruit an additional 59 junior doctors at a cost of £2.6 million. This number of junior doctors is simply not available. In any case, given current levels of clinical activity in Argyll and Clyde, we could not justify the training opportunities, educational content and clinical experience to gain the necessary approval from the training authorities to employ these additional staff. So we need to look at different ways of filling the gap through redesigning our services.

The weekly 48-hour limit on working hours is also a problem for services provided by senior hospital doctors. A British Medical Association survey of consultants in January 2003 showed that 77% of consultants currently work more than 50 hours per week and that 46% work more than 60 hours per week. In NHS Argyll & Clyde, we would require an additional 23 Consultants to meet the requirements of the Working Time regulations. These numbers of additional consultants are not available. Even if they were, the levels of clinical activity available to them in Argyll and Clyde would mean that the individuals could not remain appropriately skilled and therefore accredited to practice.

These changes in employment legislation will mean that doctors will be less likely to work excessive hours which is good for patient care. However, it also means that the NHS will not be allowed to continue to provide many health services in the way that it has done in the past or is currently doing. The way in which services are provided must, therefore, change. Amalgamating doctors' rotas will help to meet the requirements of the regulations. This involves concentrating out- of-hours commitments in fewer but more intensive shifts and requires services to be centralised in fewer, larger hospitals.

All this is a significant challenge for hospitals across the UK and will result in considerable changes to the services that can be offered in particular locations and the hours they can be accessed.

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Pay modernisation

New UK-wide employment contracts are being implemented for all staff to help encourage people to join and stay in health professions and overcome the staff shortages already being experienced in Argyll and Clyde and across the UK. The new pay arrangements replace obsolete terms and conditions which have remained broadly unchanged since 1948 and have not been updated to take account of changing clinical practice, modern employment legislation and best practice.

Whilst these new employment contracts mean considerable change in the way services are currently provided, they also present many opportunities to improve services and the way staff deliver them. The main changes throughout the whole of the UK are the Consultant’s contract, the General Medical Services contract for GPs, the new contract for pharmacists and Agenda for Change for all other staff.

A new contract is being introduced for the most senior specialist doctors. The Consultant’s contract specifies more precisely the clinical work that they will do within their normal working hours and emergency on-call. For the first time, the additional hours worked by consultants will be recognised. The intention is to focus more on direct patient care and introduce more flexibility to enable service development. This has an implication for the workload of an individual consultant and means significant changes for most consultants in the hours they work and what work they do. Services will require to be redesigned accordingly.

NHS Scotland is also introducing changes to the care patients receive from their GPs as part of the new General Medical Services contract. The contract is based on a new quality framework, setting out standards of care based on the latest evidence. Family doctors will be paid according to the quality of care they provide. It also allows doctors increased flexibility to organise services to meet local needs and provides more scope for a wider range of services in local communities. The contract allows GPs to choose not to provide services out-of-hours, and arrangements will have to be made to provide alternative medical cover for patients at nights and at weekends.

A new contract for pharmacists is also being introduced. This will better represent the widening range of services that some community pharmacists have already started to provide and will encourage the development of additional services to benefit patients, such as extended opening hours34.

Agenda for Change is a modern pay system for the majority of NHS staff (except doctors and dentists). It seeks to harmonise the conditions of service for NHS staff, provide a more transparent system of fair reward, more flexible working, and helps to create the conditions for newly designed jobs.

An important aim of pay modernisation is to make it more attractive for people to train for, join and remain in the NHS. The new pay agreements will improve the rewards available to staff and, in return, improvements to patient care and to services will be achieved.

Professional training and development

Everyone should expect to be treated by competent clinicians. Competence depends on on-going experience, professional development and adequate supervision. Professional development and training are, therefore, essential requirements for healthcare professionals and underpin the quality of the healthcare they provide. This

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can be compromised when patient numbers fall below the standards set for training purposes and important skills can be lost.

New arrangements are being introduced to improve the training and development of middle grade doctors (the level between junior doctor and consultant)35. This will make clearer the commitments of doctors in training and the responsibilities of those GPs and consultants who undertake such teaching. There will be a greater emphasis on training at service level and on spending training time in all parts of the service. This will improve training overall but will mean significant reduction in the time that middle grade doctors have traditionally spent in hospitals. This will have to be met through new ways of working as there are insufficient doctors available to make up the shortfall arising from these changes.

Increasingly, with changes in population and in the standards we are required to meet, we must review how to provide the right circumstances for our staff to access the continuing training and experience that enables them to provide high quality care. As we have found over the past few years, it is also difficult to recruit and keep clinicians where patient numbers are low as such lack of exposure to workload limits their ability for on-going learning and keeping up-to-date.

2.6 Finance and affordability

From a financial perspective alone, NHS Argyll & Clyde simply cannot afford to continue as it is. We currently spend around £40 million each year more than we receive from the Scottish Executive. A significant part of this is the high cost involved in providing services from a wide number of relatively small sites across a large geographical area. In addition, many of the buildings from which we provide our services are now unsuitable for the provision of modern 21st century healthcare and are increasingly expensive to maintain to reasonable standards.

Significant additional funding has been allocated to the NHS over recent years and this has helped us to develop services in some areas. But annual inflation is greater in the health service than in the rest of the economy, partly as a result of advances in medical science, technology and new drugs, and this means that the cost of providing services is exceeding the money we receive to pay for them.

We also spend much more than the national average on some services. This inevitably means less money available for other important things that we want to do to meet the needs of our local population. There will never be enough money to do everything that we would like to and could do, but we must look seriously at areas where we are not getting best value for money and see if there are better ways to use the money available to us. It is important that we make best use of what we receive and use our resources to best effect.

Even if we had unlimited financial resources, we would still need to change the current pattern of services and the ways in which they are delivered to address the broader pressures for change that are set out in the remainder of this chapter. But a key concern for NHS Argyll & Clyde in looking at how to provide and sustain safe, high quality services must be how we can afford them. It is our legal duty to spend only the funding allocated to us by the Scottish Executive. We must, therefore, develop a clinical strategy that allows us to make best use of that allocation and meet our legal duty of matching our expenditure to our income.

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We believe that the proposals set out in this Clinical Strategy will enable us to get back into financial balance over time. Perhaps more importantly, we think these proposals represent a better use of our funds than at present and will enable us to provide high quality services that meet the needs of the people in Argyll and Clyde within budget.

2.7 The impact of geography

In addition to the key forces and drivers already listed, we have to recognise the unique geography of Argyll and Clyde as this has a major influence on the way in which we are able to provide services, especially in rural and remote areas.

The geography of Argyll and Clyde is one of the most diverse in Scotland. Making sure that health services are safe and sustainable across Argyll and Clyde presents particular challenges. Four out of five people in Argyll and Clyde live in the areas of Paisley and Renfrew, Gourock, Greenock and Port Glasgow, and Dumbarton and Helensburgh and other towns. The remaining population live in remote and rural communities, including 26 inhabited islands, of which only three (Islay, Mull and Bute) have populations of over 1,000. The urban areas of Argyll and Clyde include areas of poverty and deprivation arising largely from the decline of traditional heavy industries. New industries have developed in some areas but there are still significant problems of unemployment. Poverty and deprivation also exist within rural areas.

Local Authority area Population Argyll and Bute 91,030 East Renfrewshire* 24,298 Inverclyde 83,600 Renfrewshire 171,940 West Dunbartonshire* 47,563 Total 418,431

Source: 2002 mid year estimates GRO (S)

*includes only those parts of the Local Authority that lie within NHS Argyll & Clyde’s boundaries.

Issues around social deprivation and transport are very much important factors in accessing healthcare and related services across Argyll and Clyde. These must be addressed when we consider how best to provide healthcare services for the future to meet the requirements of safety, sustainability and quality.

2.8 Conclusion

This chapter has set out the reasons why we need to change. If we fail to respond to the need for change, services will be subject to uncontrolled change. This could be not having enough staff or staff with the right skills to keep providing a service.

This means, in blunt terms, that some services will collapse and will have to be withdrawn. While alternative arrangements will have to be found to enable continuing access in some form, these are likely to be less than satisfactory for some parts of Argyll and Clyde. Services may, for example, only be provided on the basis of restricted availability or may involve extended waiting times. Staff will not wish to work in circumstances where uncontrolled change is a real possibility or where they

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feel they cannot provide the appropriate quality of service. In such circumstances they will choose to look for alternative employment, in the NHS or in another field, thus worsening the staff shortages we already have.

We believe that we can respond to the need for change to provide safe and sustainable services. Our proposals to do this are set out in the remainder of this document. We believe that we can take advantage of the opportunities for change to provide improved services that reflect the needs of our population.

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3. Redesign of services and working practice

3.1 Background

This chapter outlines the views we have heard during our eight months of discussions with patients, carers, staff, local communities and partner organisations about NHS Argyll & Clyde’s Clinical Strategy. It explains how we propose to incorporate them into future service redesign.

Our main priority is to maximise the amount of diagnosis, treatment and management of both chronic and specific health problems in local communities without compromising the quality of care or the results for patients. To do this, over time, we will invest in the development of primary care and put in place intermediate models of care. This will help to keep services locally, will improve the joint working between different parts of our service and also with partners such as social work and housing. In these ways, such changes will also greatly improve the experience of patients. Some of these changes will take between five and fifteen years to complete but much redesign can happen sooner and, in some areas, is already taking place.

In developing this Clinical Strategy, we have been clear from the outset that it needed to be based on the input of many different parties - patients, service users, carers, local communities, staff and our partners. We have taken time to go out and discuss issues with staff, with local communities and groups, to listen to their concerns and to note their many useful suggestions for improvement. We have also had the opportunity to speak with many groups and individuals about the difficulties the NHS, locally and nationally, is facing in dealing with a range of different pressures.

These discussions, whilst difficult on some occasions, have been extremely productive in drawing out views and concerns and in achieving much better understanding all round. They have also been useful in developing shared solutions to some very difficult issues. The significant involvement of our clinicians, and the clear lead they have taken in discussions with other staff, with patients, public and partners throughout the pre-consultation, has been key to the process.

We are committed to using the outputs from this work over the long term, and making sure that they form a core part of our business.

3.2 Key findings

Eight months of discussions with the public, patients and staff about the sort of health services they want have provided a clear view of the future for healthcare services that we want to achieve. These findings are described here within the overall framework stated in Partnership for Care. This is the Scottish Executive’s blueprint for health service provision in Scotland, reflecting national policy and direction across a whole range of healthcare services.

Patients and carers attending workshops and other events told us they were generally satisfied with the care they were receiving from NHS Argyll & Clyde. They want as many high quality services available locally as possible but recognise that they may have to travel for some specialist care. Patients and carers could, of course, see scope for improvement. These improvements were largely related to issues such as communication, information, access and waiting times.

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Staff concerns were also focussed around the issues and challenges they faced in providing what they considered to be an acceptable level of care. This covered such issues as recruiting and retaining staff, meeting quality standards, delivering care in poor environments, and workload.

Clinicians and managers were also concerned about levels of funding, both to run existing services and to modernise them, while also balancing the many priorities, standards and targets set by the Scottish Executive, professional bodies and other organisations. These particular concerns are set against the ever-increasing expectations that staff, public, patients and our partners have of the NHS.

Five overall main themes emerged in our discussions with patients, carers, staff, local communities and partner organisations. These are:

• Patients as partners

• Widening access to care

• Making pathways of care work

• Promoting local services

• Improving acute care

In the remainder of this chapter, each of these themes is described in summary.

3.3 Patients as partners

People told us that they, their families and carers wished to be treated as equal partners in the healthcare process. This requires us to make sure they have the information they need to play this equal part and for us to respect their wider needs as carers, parents, employees, etc. They also told us that they felt this should be matched by responsibility on their part to try and lead a healthy lifestyle and to use healthcare services in a responsible way. These views were strongly echoed by staff.

We will commit to the following:

• Setting up patient information groups in each division, involving patients, carers, staff and partners to consider local information needs and review and revise, as appropriate, written information provided for patients and carers. These groups will prioritise cancer, coronary heart disease, stroke, diabetes and mental health and access to services as the initial focus for improving information

• Providing comprehensive information on maintaining good health, symptom awareness and assessment, accessing services, patient choice, understanding treatment, access to support, self-management and lifestyle

• Using information technology to support the provision of relevant, comprehensive and up-to-date information

• Exploring how increased support can be given to families and carers, working closely with the voluntary sector and other partners. We will in this way improve

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links with voluntary organisations to give a wider range of information and support beyond the statutory sector

• Working with NHS 24 to make sure information for patients is up-to-date, relevant and easily accessible

• Developing the role of community pharmacies in providing information matched to patient needs

• Developing a network of “expert patients” with various conditions to support and inform voluntary or statutory groups.

3.4 Widening access to care

People told us that they wanted access to healthcare made easier and faster for all. Transport is a big issue in Argyll and Clyde, not just in remote and rural areas but in urban areas as well. It affects patients especially but also their families and friends, just as it affects our staff. Easier and quicker access could be achieved through clear points of entry to the healthcare system, through helping patients to help themselves more in meeting their specific needs, and removing barriers to access, such as restricted opening times.

The time that people sometimes had to wait for services was also a cause for concern. But people also told us that they understood the reasons why on occasions they might have to travel to receive the healthcare they needed. Staff were also keen to make sure that patients were seen by the appropriate person based on effective systems of access and assessment.

To those we talked with and listened to over the past eight months, perhaps the most important issues were access to health services generally, and transport in particular. For example, amongst the transport issues raised were the distances people sometimes had to travel, the lack of public transport in some areas and the importance of taking into account people’s specific travel needs when arranging appointments or booking transport by ambulance. Other issues raised included the lack of integration between different bus routes and transport services, and limited provision for car parking at certain hospital sites. This level of interest requires us to pay specific attention on how to make improvements in these areas.

We intend, therefore, to identify, on an Argyll and Clyde basis, an access co- ordinator with a specific remit for improving access to health services and health related transport. This senior post will be given high level responsibility to take action across Argyll and Clyde to achieve this. The access co-ordinator will work closely with the divisional redesign teams to carry out redesign work as required. The person will report to the NHS Board on access issues and the actions to address them. The co-ordinator will also be the health service lead to organise action with our local authority colleagues and with other relevant transport bodies.

We will commit to the following:

• Developing simpler patient pathways into secondary care by putting in place clear referral protocols

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• Accelerating our Electronic Clinical Communications Integration (ECCI) programme to improve the sharing of information on patients being jointly managed in primary and secondary care and to improve processes for communication between clinicians for referrals, booking of appointments, discharge letters, test results reporting etc

• Extending easier access to diagnostic and therapeutic services through fast track and direct access arrangements to the appropriate level of treatment and care

• Introducing extended opening hours for healthcare services at both primary and secondary care levels

• Taking account of the needs of patients, especially in rural and remote areas, through the booking of appointments to reflect their transport arrangements

• Introducing new staff roles and extended skills to give improved and wider access to appropriate specialist care at local level

• Increasing the number of one-stop clinics, thus reducing the number of times patients have to attend for diagnosis and treatment, and making the best use of specialist staff input

• Rolling out new appointment booking schemes based more on the needs of patients and building on the current pilot scheme to cover all appropriate specialties

• Making sure that transport issues are addressed in all future service developments to facilitate access to services

• Working with all relevant agencies, such as the Scottish Ambulance Service, Local Authorities, Strathclyde Passenger Transport Authority, commerical and voluntary organisations, to integrate transport resources to better meet the needs of people travelling to specialist services.

3.5 Making pathways of care work

People, patients, staff and partners, were very enthusiastic about the patient pathway approach. They wanted to see patient-focussed care supported through staff working in, through and across networks, through training to support new ways of working, and minimising boundaries between professional groups, primary and secondary care services, health and other sectors, and geographical locations. Staff wished to see increased support to establish and run networks through shifting existing resources to these areas. They were also keen to explore new roles and enhanced skills and saw this as a real opportunity to keep current staff and attract new staff to NHS Argyll & Clyde.

The Clinical Strategy has been built around pathways of patient care. Pathways best reflect the experience of patients, service users, their families and carers as they seek and receive healthcare. Pathways also support an approach based on care and treatment of the whole person. Eleven pathways were selected to support the development of the strategy:

Cancer Children

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Stroke Chronic disease Coronary Heart Disease Addictions Diabetes Planned treatment Mental Health Emergency care Older People

We also took into account the significant work that had been carried out over the past few years on maternity and associated services in Argyll and Clyde.

We will commit to the following:

• Implementing a phased and structured programme of development and roll-out of Managed Clinical Networks for major conditions, starting with those networks currently under development

• Working with partners to develop Managed Care Networks in those areas where significant joint working is required or already underway, such as older people, mental health, and learning disabilities

• Prioritising management resources to work closely with clinicians and patients to develop and maintain effective clinical networks as a key mechanism for the planning and delivery of services

• Drawing up local referral and discharge protocols and guidelines, disease registers and clinical audit plans as initial priorities within the development of Managed Clinical Networks

• Extending and supporting better use of IT and video-conferencing facilities to enable better network links with staff in rural and remote areas

3.6 Promoting local services

People told us that they wanted to continue to receive most of their healthcare in their local communities. Patients and staff were keen to look at new roles and approaches in the delivery of care to achieve this and there was particular interest in the intermediate care model. They were supportive of closer integration between clinicians working in local communities and those working in specialist areas. They also understood that in some instances access to services would have to change to maintain services and guarantee quality.

One of the key ways to maximise local provision of healthcare services is through on- going development of primary care and the introduction of intermediate models of care. We will, therefore, sponsor models of intermediate care in which we will support clinicians from both primary and secondary care to maximise the amount of diagnosis, treatment and management of both chronic and specific health problems in local communities without compromising the quality of care or results for patients.

This will be achieved by enhancing the role of GPs, nurses, allied health professionals and pharmacists etc. The traditional allocation of responsibilities between primary and secondary care clinicians will be revised with clinicians from both sectors working more closely together.

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This model will apply differently in different parts of Argyll and Clyde depending on a variety of factors such as geography, local pressures for change, and the preparedness of local partners and communities to embrace redesign. The scale of change in certain areas will, thus, vary and will take differing times to prepare and implement.

The establishment of community health partnerships, a key strand of the Scottish Executive’s approach to local healthcare provision, will facilitate the development of this community-focussed model. Similarly, the opportunities presented by the new GMS contract will allow different ways of working that before would have been almost impossible to achieve.

We will commit to the following:

• Encouraging and supporting the development of intermediate models of care across the various local communities of Argyll and Clyde, refining existing plans and considering future proposals and plans against this model of care

• Commissioning the new Mid-Argyll Hospital to provide intermediate care. We will draw upon and develop the existing evidence base as a resource for NHS Argyll & Clyde

• Continuing to develop out-of-hours services across Argyll and Clyde to ensure consistency with on-going service redesign and the application of intermediate models of care

• Making the most of opportunities to provide care on an ambulatory basis, including increased rates of day case surgery, avoiding the need for patients to stay overnight in hospital36

• Accelerating community-based models of care for mental health, older people and learning disabilities in collaboration with local authorities, through the shift of healthcare service provision from institutional care to the development of community teams and associated support, including crisis intervention and rapid response

• Developing local care for older people with enhanced community based services and the consolidation of existing provision to provide an improved and integrated range of services

• Introducing therapist-led outpatient clinics in local areas to maximise access to treatment and rehabilitation services provided by Allied Health Professionals

• Implementing training schemes for extended medical, nursing and allied health professionals’ skills and new ways of working to enable new models of care to be implemented successfully, with the potential to serve as national pilots

3.7 Improving acute care

Many participants were already aware of the difficulties being experienced in sustaining high quality specialist services in some parts of Argyll and Clyde. In some areas people have had to face up to some difficult realities, one of the hardest being the tension between what can and cannot now be provided locally. Many people find

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it hard to accept that some services cannot continue to be provided locally. People told us that they were prepared to travel for care if necessary and we must ensure that the transport needs of vulnerable people are met. We have described earlier our commitment to play our part with our partners to address transport and access issues.

People told us of the importance to them of 24-hour access to emergency care. The public need to know that emergency help will also be available. For many cases this will be calling NHS24 for advice or receiving treatment from a member of the primary care team. More serious cases will require access to a fully equipped and staffed accident and emergency department backed by a comprehensive range of diagnostic and treatment services.

Staff expressed a keenness to develop new roles and ways of working to support what they saw as necessary changes in the provision of specialist and emergency services.

We will commit to the following:

• Providing 24 hour 7 day a week access to a comprehensive range of services within Argyll and Clyde in a major acute hospital

• Developing agreed referral protocols for specialist services provided in Argyll and Clyde, including improved access to specialist advice and guidance for primary care colleagues over the full 24 hour period

• Developing services and ways of working in Argyll and Clyde that support community hospitals and other intermediate care centres

• Developing clinical teams to ensure the best possible clinical practice through the sharing of expertise, skills and knowledge

• Safeguarding high standards of care and continuously improving the range and quality of services provided

• Ensuring the integration of specialist services with healthcare professionals in other sectors to provide seamless care for patients

• Providing safe and rapid patient transfer between services as required.

3.8 Conclusion

Patients, public, staff and partners have, through the five themes listed here, set out a clear direction for the future of NHS Argyll & Clyde. We intend to strengthen the patient-centred approach and redesign our services based on pathways of patient care. Our main priority will be to develop primary care and improve the joint working between primary care, social care and secondary care to improve the patient experience – developing intermediate models of care accordingly. We think these goals are ambitious, but achievable.

All service redesign must be sustainable in the context of the many pressures for change described in the first chapter. The next chapter describes how we believe services must change in the near future if they are to be safe and sustainable. This

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will allow us to build on stability to provide the quality of service that we believe is possible, and that people have told us they want.

To demonstrate our commitment to making these changes happen, each of our three divisions (Inverclyde, Lomond and Argyll, and Renfrewshire) will set up redesign teams. The purpose of these teams will be to produce plans for all the action points listed throughout this document. These redesign teams will be led by clinicians and will have community involvement. They will be accountable for making sure that the changes agreed actually happen and that such changes deliver all the benefits to patients, staff, partners and local communities that we anticipate.

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4. Modernisation and Reform of Services and Infrastructure

4.1 Background

We have explained why we cannot continue the way we are now. We have set out the sort of changes and improvements that we want to see in the future. This chapter sets out the model of service that we intend to develop and the steps we will take to do this.

Changing our health services in Argyll and Clyde is about the transformation of primary care. At present, these services account for more than 90% of the healthcare needs of local communities37. We wish to build on this and to work more closely with other health and social care providers in a more integrated and networked way. Only in this way can we provide sustainable, safe, affordable and quality provision for local communities.

If we are to do this, we must make sure that our major acute services are stable. There are many reasons for this. We must make sure that services are safe and sustainable in the face of the many pressures we face. We must be able to continue to improve the quality of healthcare we provide. We also want to enable our staff working in acute services to play a full part in the transformation of our healthcare services as a whole.

Significant change will be required to achieve this. Some of this will be controversial for some people but we believe, through discussion with patients, public and staff, that these changes are necessary and overall will benefit the people of Argyll and Clyde.

This chapter describes how we intend to provide our services in the future, based on a network of linked healthcare services. It sets out the opportunities to deliver improved services. It reflects new models of primary care and the development of intermediate care in local communities. It also sets out changes in the provision of major acute services and improvements to services for older people, those with mental health problems and learning disabilities.

4.2 Elements of a healthcare network

By a healthcare network we mean the way in which staff work together to provide services for people rather than buildings or hospital beds. We have a tremendous range of skills and expertise in our staff in NHS Argyll & Clyde, together with extensive medical technology and substantial resources in the local authority and voluntary sectors. The challenge is to bring these resources together in the best way to meet patient needs.

All the resources across Argyll and Clyde will need to work together in ways that support each other. Through networking in this way we will be better able to provide safe and sustainable services in local communities. We will continue to have hospitals, health centres and practice premises across Argyll and Clyde but it will be the range of services and how we provide them that will be most important. For example, in a networked service specialists will be more accessible to clinical colleagues and patients in local communities. Another example is the way in which

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professional colleagues will work across the whole of Argyll and Clyde rather than in separate geographical areas.

The following sections describe elements of the healthcare network:

• Primary and intermediate care • Care in the community • Acute care.

4.3 Primary care

Primary care is those services provided locally by the Primary Care Team. This has traditionally been the team directly attached to the GP practice (GP, practice nurse, community nurses) but this is now expanding to include other professionals, including pharmacists, opticians and allied health professionals such as physiotherapists and dieticians. There are many opportunities to deliver real improvements to services that will benefit patients, carers and local communities. These include:

• Providing extended services • Introducing new technologies • Working more closely with specialists • Developing intermediate care.

Providing extended services

The introduction of the new General Medical Services Contract presents a significant opportunity to make improvements in service. A key intention of the Contract is to improve quality and provide better access for patients to the services they need. Of course, many parts of primary care in NHS Argyll & Clyde already provide high quality services. The new General Medical Services Contract provides the opportunity to extend and build on this to enhance the range and quality of patient care that can be provided locally.

Introducing new technologies

The on-going development of new technology presents opportunities to do things differently. New equipment and methods of carrying out certain laboratory tests mean that some tests can be carried out by a GP, or other member of the primary care team, rather than a patient having to travel to a hospital. It also means that results can be available on the spot, avoiding the need for the patient to have to return to get test results and often allows appropriate treatment to start earlier. Near-patient testing is already in use in some parts of Argyll and Clyde and offers considerable scope to be extended to benefit patients throughout the area, especially in the more rural and remote localities.

The extension and better use of telemedicine is another area where improvements in patient care can be achieved. For example, using teleradiology, GPs in Argyll and Bute can make digital images of x-rays and send them over the internet to a specialist Radiology Department. This allows someone who is expert at reading x-ray images to advise the doctors back in Argyll and Bute what the problem is. Under this arrangement, routine reports on x-rays are available much sooner, greatly reducing the time that patients have to wait for results. For more immediate or urgent problems, sending x-ray images in this way can give GPs immediate access to specialist clinical advice and support.

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Working more closely with specialists

Improved knowledge and treatments help clinicians to provide healthcare in different ways. Many GPs are developing additional skills and ways of working, supported by specialists to provide people with high quality treatment and care in their local community rather than having to travel to receive treatment38.

This is of particular importance in allowing services to be maintained and developed locally. There are many opportunities to carry out a wider range of treatments in primary care, thus enabling specialists to focus on the more complex cases that need their specialist skills. For example, people with chronic conditions, such as asthma and diabetes, now receive most of their care close to home by experienced professionals who know them well, with referral to a specialist only when their condition requiresiii. This is a pattern of treatment that patients tell us they prefer.39 There are real opportunities to extend this much further to other chronic health conditions that affect many of our population, such as coronary heart disease, stroke, and chronic obstructive pulmonary disease (breathing problems).

Developing intermediate care

Intermediate care is an approach to healthcare that maximises the amount of diagnosis, treatment and management of both acute and chronic health problems in local communities, without compromising the quality of care or the outcomes of treatment. Developing intermediate care is an important part of our clinical strategy. It involves enhancing the skills of members of the primary care team (doctors, nurses and allied health professionals) through training and on-going professional development. It makes the best use of new technologies, such as near-patient testing and teleradiology, for example. It also involves the use of guidelines and protocols, agreed with specialists, to support enhanced roles.

Under intermediate models of care, a wider range of services is provided locally by the enhanced primary care team. This means that specialists should see only those patients whose health problems cannot be dealt with locally. This model of care is already being practised in some parts of NHS Argyll & Clyde but the potential is there for this to be much extended to the benefit of patients and their families. It is also an attractive way of working for NHS staff.

Intermediate care is a relatively new model of working in Scotland but is practised elsewhere including North America, Australia, in the European Community. It is a model of care supported by evidence that we will further explore with our clinicians.

An intermediate model of care

In Lochgilphead, for example, an intermediate model of care has been in place for a number of years. Local GPs have trained in extended skills and provide a variety of services in addition to their traditional role in primary care. This includes providing cover for accidents and emergencies, and managing hospital beds where patients are admitted for a broad range of medical problems. They are supported by specialists based in other hospitals who provide advice and agree protocols for the treatment and onward referral of patients as required. This has allowed many more people to be cared for in their local community instead of having to travel for healthcare. Data gathered over a number of years has shown that the results for iii Evidenced by the emerging results of the Scottish Primary Care Collaborative.

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patients are extremely good and compare well with much larger hospitals. The current development of the new Mid-Argyll Hospital in Lochgilphead will result in greatly improved facilities in which to provide care.

The other important aspect of this model of care is the integration with social care services provided by Argyll and Bute Council. This will also be greatly enhanced with the new Mid-Argyll Hospital that has been designed around joint working and sharing of premises with a range of partners.

The way in which intermediate care is being practised in mid-Argyll may not be appropriate in every location but it serves as a useful model for others to explore in their specific circumstances. In many other areas across Argyll and Clyde, members of the primary care team are already working to improve the integration of services, that is, services that work together well and are focussed on the needs of patients. We want to support the better integration of services and the development of intermediate care as important elements of the healthcare network in NHS Argyll and Clyde.

4.4 Care in the community

We still have significant work to do with our partners to replace outdated institutionalised care for vulnerable patient groups with more appropriate community based models of care in line with national strategy. The key areas are:

• Services for older people • Mental health services • Services for people with a learning disability.

Services for older people

Providing for an ageing population was one of the principal challenges set out in The Need for Change. We therefore highlight this patient group as one of the important elements in the healthcare network and as part of our future plans.

Our services for older people are based too heavily on care that takes place in hospitals. Working with our Local Authority partners, we want to shift the emphasis to increased care provided in local communities and in people’s own homes. In order to do this, we must consolidate our healthcare services for older people. We should not continue to provide those services that could be better and more appropriately provided by others. Instead, we should be focussing on meeting the specific healthcare needs of older people. The Joint Future initiative introduced across NHS Argyll & Clyde in collaboration with our Local Authorities is helping to create the conditions for more integrated services for older people and our plans must build on this.

Our proposals include developing a care management and prevention system across the whole of Argyll and Clyde. We will develop local rehabilitation and recuperation services and will cease the inappropriate use of continuing care beds in hospitals. In conjunction with our Local Authority partners, we will work to ensure a range of supporting services in the community.

Mental health services

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Too much of our mental health service is based in hospitals rather than in local communities. We are keen to change this in line with agreed national policy. This will require us to close our excess hospital beds for mental health and transfer services into local communities. This process of change has already been achieved successfully in many other areas across Scotland and our staff and partners are keen that services in Argyll and Clyde develop similarly to match the best of those elsewhere.

We have already started working to introduce more community-based healthcare integrated with social care services provided by Local Authorities. Extending the Joint Future initiative to cover mental health will allow the particular advantages of closer working (such as single joint assessment of needs replacing previous multiple assessments) to be realised.

We want to achieve better integration with primary care (including co-location of “primary care Mental Health teams” in redeveloped Health Centres) alongside the development of specialist services for specific disorders. We will agree with our local authority partners what kind of care is best provided by the NHS, and what can be better provided by local authorities, retaining only those in-patient beds that we need.

Services for people with a learning disability

We have already made significant improvements in our services for people with a learning disability. As part of our programme to help people with a learning disability lead more normal lives, we have invested in providing more community-based services. This has enabled us to move people from long term care into community settings to give them the opportunity to have the same quality of life that other people take for granted. We intend to complete our reprovision programme and re-settle remaining patients into the community, making sure that appropriate services are in place for patients who have challenging behaviours and complex needs.

4.5 Acute Care

The vast majority of healthcare is provided in local communities and, under these proposals, will continue to be. However, it is not possible to provide all services in every community. The reasons for this have been set out earlier.

If we adopt the service models set out here, not only can we address the pressures for change but we believe that we can deliver real improvements in acute services that will benefit patients, carers and local communities. These service improvements include:

• Increasing day surgery and other acute activity in local settings • Developing specialist acute in-patient services • Providing accident and emergency services • Developing an integrated regional network.

Increasing day surgery and other acute activity in local settings

Most acute services will continue to be delivered locally. We will do more day case surgery and more procedures on an outpatient basis. Outpatient consultations will continue to be provided locally, either as they are at present or as part of one-stop clinics. We will provide local minor injuries services. As the model of intermediate

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care is developed we will provide acute medical in-patient care as appropriate. The potential for short stay surgery40 will also be explored.

Specialist acute in-patient services

In exploring pathways of care and what evidence tells us is best practice, and in light of our current experience in trying to sustain services, we have concluded that certain hospital services – principally specialist acute in-patient services - can only be maintained by locating them in one hospital within Argyll and Clyde. This will have the advantage of ensuring 24 hour 7 day a week access to a comprehensive range of services for everyone. The development of intermediate care in local communities, networked with specialists will reduce the number of patients that need the level of care that this major acute hospital will be able to provide.

Developing specialist acute in-patient services in one hospital will enable improved provision of care for all. Many aspects of care currently lacking in our acute hospitals across Argyll and Clyde will be greatly enhanced within a single centre. For example, by centralising specialist cardiology care (matched by the linked development of cardiology services in the community) we will in future be able to provide 24 hour specialist cardiology advice to all healthcare professionals across the area. It will also mean that anyone attending the major acute hospital with suspected heart problems will be seen by a specialist cardiologist. This is not always possible in our hospitals at present. This would be a significant improvement in service provision, given that heart problems is one of the major causes of ill health and premature death amongst those living in Argyll and Clyde.

In the specialty of cancer, the development of a major acute hospital will facilitate the establishment of a regionalised multi-disciplinary meeting in all cancer specialties including physicians, surgeons, radiologists, pathologists and oncologists. This will enable improved decision making and treatment planning for patients. Within the healthcare network, this arrangement will provide advice and support to clinicians providing cancer treatment locally in intermediate or primary care settings. The major acute hospital will have a range of acute in-patient specialties on site with supporting services, including radiology and laboratories. It will have intensive and high dependency facilities to support medical and surgical specialties. This environment will provide staff with the opportunity to become part of a single clinical network, working in multi-professional teams and developing skills to provide a high standard of service and an ever-improving quality of care.

This model of care, with the major acute hospital supporting a wide network of services in the community, is already evident in a number of planned or recently developed services.

In developing our options for the future we have considered building a single new hospital to provide acute services for the whole population of Argyll and Clyde. We are not proposing this as an option, for the following reasons:

• This strategy is about the development of new models for the provision of local services. It would be very difficult to achieve this aspiration if we committed to a new hospital.

• A single new build hospital would cost upwards of £300 million, would take a minimum of ten years to realise, and would take between £30 to £40 million per year for the next thirty years out of direct patient care budgets to service the loan.

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This would mean that we would not have the money to do all the many improvements that people have told us they would like to see. The alternative, to reconfigure existing hospitals in line with our proposals, would cost less than £50 million.

• There is not a single location for a new hospital in Argyll and Clyde that would attract and be used by the total population. As the majority of the population (about two-thirds) live south of the River Clyde, any new build would most probably be south of the river. We do not see this as a realistic development. We believe a new hospital would simply mean that the sustainability challenges we face now would be replicated in the new hospital and we would have no flexibility to respond to these or to develop local services.

• While we acknowledge that modern services need facilities fit for purpose, the whole focus of our clinical strategy is about investing our allocated budget in services rather than in buildings or institutions. Every additional pound spent on loans for large-scale new buildings takes away from the money available to invest in direct patient care, staffing, equipment, drugs and new technology to support new and improved ways of working. We must make sure all of the estate we have, now and in the future, is necessary, fit for purpose and used to best effect.

We recognise that a key issue for many people will be where the major acute hospital will be located in NHS Argyll & Clyde. We have looked carefully at the existing sites and have concluded, using the principles set out at the beginning of this document, that the Royal Alexandra Hospital is the only feasible location for the major acute hospital.

At no other site is there a large enough local population to provide the basis to sustain a single major acute hospital. The site has the greatest potential to provide the additional capacity required in a reasonable timeframe and with least cost. While acknowledging the need to address access issues for many people, selection of this site minimises disruption to access in overall terms. The location also offers the best opportunity to maximise the integration of services, both within Argyll and Clyde and on a regional basis.

Linked to this is the location of the major Accident and Emergency Department. Such a department requires a range of supporting specialist services to be adjacent if it is to function effectively. This includes intensive and critical care facilities, operating theatres and a full range of laboratory services. It is not possible to have a major accident and emergency unit standing alone or separate from such important support services. The location of the major acute hospital, therefore, effectively determines where the major accident and emergency department will be.

Providing accident and emergency services

Guidance on the provision of major Accident and Emergency services including trauma is that, to be sustainable and provide the best possible clinical outcomes, they should serve a population of around 450,00041. There will, therefore, be a single major accident and emergency department to serve Argyll and Clyde, based in the major acute hospital and located alongside other specialist diagnostic and treatment services. Accident & Emergency consultants will be on hand to provide specialised advice to other staff across Argyll and Clyde. There will be a comprehensive accident and emergency service across Argyll and Clyde, including specially trained nurses providing telephone advice as part of NHS 24, local first responders, ambulance service paramedics, GP surgeries and out-of-hours services, emergency nurse

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practitioner run minor injuries units and GPs with specialist accident and emergency training. Working together, this service will provide a local response to emergencies and ensure that patients are provided with an appropriate level of care to meet their needs.

This part of the network will be connected by rapid and safe patient transfer arrangements. The Scottish Ambulance Service and other agencies such as the Ministry of Defence will provide safe and rapid transfer of accident and emergency patients to the main centre in Argyll and Clyde or beyond, to the Southern General Hospital for example, if the patient’s condition warrants. We will set up a rapid retrieval service, which will involve an expert team led by an Accident & Emergency consultant, collecting and transferring seriously injured or unwell patients.

Developing an integrated regional network

Many patients already receive more specialised healthcare outside Argyll and Clyde, notably in Glasgow. We intend to work more closely with specialist providers to improve communications and service provision for Argyll and Clyde patients. This is already evident with the development of Managed Clinical Networks across traditional health board boundaries. Increasingly, we will develop clinical links and ways of working with colleagues in other areas. This will also allow more aspects of care to be provided locally under protocol, for example, chemotherapy

The remainder of this chapter sets out how the models of care we have described will look.

4.6 Summary of key proposals

• The development of advanced and comprehensive diagnostic and treatment centres in Inverclyde, Lomond, and Renfrewshire. These centres will provide local access to a range of services that are safe, of high quality that can be sustained into the future.

• The development of intermediate care in Lomond, Renfrewshire and Inverclyde, including in-patient beds as appropriate. This will allow the retention of as many services as possible locally without compromising safety or quality. It will also promote the greater integration of services to the benefit of patient care.

• Consolidated assessment and treatment services for older people in Inverclyde, Renfrewshire and Lomond. As part of this, the Victoria Infirmary in Helensburgh (29 Geriatric long stay and 6 GP beds) and Dumbarton Joint Hospital (29 geriatric long stay and 12 dementia beds) will close and the services will be transferred to the community and/or to the Vale of Leven Hospital, as appropriate. The 51 long stay care of the elderly beds at Ravenscraig Hospital will also close and supporting services will be provided in the community. This will promote a model of community care for older people, reducing unnecessary admission to hospital, and minimising the amount of time those who are admitted need to remain in hospital. It will allow increased rehabilitation and enable faster discharge home.

• Integrated community mental health services across all localities in Argyll and Clyde, supported with in-patient provision as appropriate. This will require the acceleration of existing plans, in line with national policy, for community-based

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models of care for mental health. Work will take place to further determine the future use of Blythswood House in Renfrew as a community support for mental health and other services. Argyll and Bute Hospital (108 general psychiatry and 72 dementia beds, and including the Alcohol Treatment Unit) in Lochgilphead and Ravenscraig Hospital (58 general psychiatry beds, and 80 dementia beds) in Inverclyde will close and services will be transferred into the community and other locations, as appropriate. These changes will allow resources to be focussed on the provision of improved services, rather than tied up in old and obsolete buildings. These changes will allow people to receive care closer to home, with minimal disruption, thus improving the quality of their lives. It will also enable closer integration with social care services, recognising the importance of the wider needs of patients, their families and carers.

• Integrated learning disability services across all localities in Argyll and Clyde, supported with in-patient provision as appropriate. This will require the completion of current plans, in line with national policy, for the re-settlement of long stay patients into community settings. This will free up resources to allocate to improved community-based provision where people wish to receive care. The remaining 55 learning disability beds at Merchiston Hospital will close and the services will be provided in the community. The in-patient provision for young physically disabled people at Merchiston Hospital (21 beds) will transfer to more appropriate accommodation and Merchiston Hospital will close.

• The new maternity services at the Vale of Leven, the Royal Alexandra Hospital and Inverclyde Royal Hospital will continue under these proposals, as will the existing renal dialysis service in Inverclyde and the new renal dialysis service at the Vale of Leven Hospital. This will ensure continued local access to safe, quality services.

• A single 24 hour 7 day major acute hospital for NHS A&C will be developed at the existing Royal Alexandra Hospital. This will become the main in-patient centre in Argyll and Clyde for critical care and acute specialist medical, surgical and orthopaedic services with the associated supporting facilities, including diagnostics, ITU/HDU, laboratories etc. This will enable the continued provision of acute in-patient and critical care services for those who need then to a high level of care. It will also address issues of recruitment and retention of staff and meet professional training and accreditation requirements. Locating specialist services together in this way also enables improved standards of care and better outcomes for patients.

• The new Mid-Argyll Hospital in Lochgilphead will be completed and opened on an intermediate model of care basis. This will provide the opportunity to further develop intermediate care training and accreditation programmes for the wider application of intermediate care.

• In Argyll and Bute, we are proposing a community development programme, involving people from across the communities, to redesign services within the principles outlined in this strategy, including safety, sustainability, quality, affordability and integration between primary and secondary care and other agencies as appropriate. Subject to the conclusion of the community development process, we currently envisage consultant delivered services at the Lorn and Islands Hospital. These would be within an intermediate model of care, integrated with primary care services and networked with services in Argyll and

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Clyde and Glasgow. This process will also take account of the work of the Solutions Group of the West Highland Health Services project.

• In Campbeltown, Islay, Dunoon, Rothesay and Mull, we will use the community development process to determine services that we can provide locally. This approach will address the particular problems of access in remote and rural areas and will be informed by work already taking place in relation to Cowal development and the proposed Progressive Care Centre on Mull. Without addressing the specific issues of rural and remote areas in this way, it would be most likely that services would begin to fail and contingency measures would have to be taken to provide health services to these communities from other centres within Argyll and Clyde.

All these proposed changes will take place within the development of the overall healthcare network described earlier in this chapter, and will enable the further development of primary care.

The remainder of this chapter outlines the specific proposals for each of the three divisions in NHS Argyll & Clyde – Inverclyde, Lomond and Argyll, and Renfrewshire.

4.7 Inverclyde

We are proposing two broad options for future services in Inverclyde, both based at Inverclyde Royal Hospital :

Option A - an ambulatory hospital

Develop an ambulatory hospital that will contain, in a single facility, all services except acute in-patient provision. Acute in-patient services will be provided in the Royal Alexandra Hospital in Paisley. There will be a nurse-led minor injuries unit with more serious emergencies going to the Royal Alexandra Hospital.

Option B - an intermediate hospital

Develop an intermediate care hospital in Inverclyde, integrating ambulatory care with intermediate care beds and services (including a 24 hour minor injuries unit). Patients requiring major acute in-patient care only will be transferred to the Royal Alexandra Hospital, Paisley.

Under both options, the midwifery–led maternity service and local renal dialysis services will remain. The major acute in-patient services at the Royal Alexandra Hospital will include surgical in-patient services, medical in-patient services requiring access to critical care, and accident and emergency services.

As part of the restructuring of mental health and older people’s services in line with national policy, Ravenscraig Hospital will close. This will include, in conjunction with local authorities, the appropriate provision of services to meet the needs of these client groups, building on those provided at the recently opened Larkfield Unit. This will enable resources currently used in keeping open old and unsuitable buildings to be used instead to provide improved services, both at Inverclyde Royal and in the community. The in-patient provision (eight beds) for Young Physically Disabled people, currently at Ravenscraig, will transfer to more appropriate accommodation.

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Comparison of proposed options with current activity

Service Current Option A Option B (2003/4) Ambulatory Intermediate Hospital Hospital Day Treatment Centre: Theatre Suite and Total day 110-115% of 110-115% of Interventional Imaging cases 6,605 current current Medical treatment Endoscopy + 300 cases + 300 cases Chemotherapy treatment Increase TBA Increase TBA Haematology – oncology Diagnostic imaging 41,693 100 – 110 % of 100-110% of outpatient current current 18,477 outpatient outpatient inpatient 20% of current 40% of current inpatient inpatient Outpatient attendances for all 81,287 At least 100% At least 100% specialties and visiting of current of current specialists, including nurse and AHP led clinics Renal dialysis unit Planned Planned increase increase Allied Health Professionals 60,943 100 – 110% of 100 – 110% of outpatient current current 43,395 outpatient outpatient inpatient 20% of current At least 40% of inpatient current inpatient

Clinical support During working Local service day only 24/7

Older People Unit including day Larkfield & Integrated Unit, Integrated Unit, hospital, assessment and long Ravenscraig Larkfield Larkfield stay Hospitals

Child and Family Centre Site change Site change Midwife led maternity services As in Maternity As in Maternity Strategy Strategy Emergency nurse practitioner led 25-30% of minor injuries unit 34,208 current A 24 hour 7 day a week GP led 50% of current minor injuries unit (replacing the emergency nurse practitioner led minor injuries unit) In-patient admissions - Emergency Emergency Emergency emergency/ elective 13,338 0% 20 - 25% Elective Elective Elective 3,942 0% 20 - 25% At the RAH In-patient services Emergency Emergency 100% 75-80% Elective Elective 75-80% 45-55%

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Critical care medical in-patient Yes Yes services Accident and emergency services 25,000 17,000

Assumptions

60% of current elective patients stay 2 days or less. One third of these (i.e. 20%) will become day cases Endoscopy capacity increased by waiting times capacity in 2003/4 i.e. 300 cases 25% of current A&E attendances can be treated by ENP led minor injuries unit 50% of current A&E attendances can be treated by 24/7 GP led minor injuries unit 42% of current emergency admissions stay 2 days or less. Half of these will be suitable for intermediate care bed admission. 60% of current elective patients stay 2 days or less. One third of these (i.e. 20%) will be suitable for short stay intermediate care) in addition to the day case shift described above

The key differences between the two options are shown in the table below:

Key differences Option A Option B Ambulatory Hospital Intermediate hospital Minor injuries unit Staffed by emergency nurse Staffed by GPs and emergency practitioners on extended day nurse practitioners 24 hours, 7 basis but not overnight days In-patient beds None, other than in mental Intermediate care beds managed health, care of the elderly and by GPs for non-critical medical midwife-led maternity and surgical care (as per protocols agreed with secondary clinicians)

4.8 Lomond and Argyll

The new Mid-Argyll Hospital in Lochgilphead will be completed and commissioned on an intermediate model of care basis. This will provide the opportunity to further develop intermediate care training and accreditation programmes for the wider application of intermediate care.

For other areas of Argyll and Bute, we propose an alternative approach to bring about the modernisation of services. This is for a community development programme, involving people from across the communities, to redesign services within the principles outlined in this strategy including safety, sustainability, quality, affordability and integration between primary and secondary care and other agencies as appropriate. We expect a conclusion to this process, with locally agreed solutions meeting the principles outlined, by the end of 2005.

For the Oban area we currently envisage developing a way to sustain the Lorn and Islands Hospital. This will be based on an appropriate intermediate model of care that would also include consultant delivered services within the healthcare network, including outreach. This approach will be considered as part of the proposed community development process.

As part of the restructuring of mental health services in line with national policy, Argyll and Bute Hospital, including the Alcohol Treatment Unit, will close and

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appropriate services provided to meet the needs of the population. This will release the resources tied up in the continued provision of old and out-of-date buildings and allow improved services to be provided in the community, closer to home.

As part of the proposal to develop services to better meet the needs of older people, we will consolidate services in the Lomond and Argyll area. This will include the closures of the Victoria Infirmary in Helensburgh and the Dumbarton Joint Hospital and, in conjunction with local authorities, the development of appropriate services to meet the needs of this client group.

There are two broad options for future services in Lomond, both based on the Vale of Leven site or an appropriate alternative local site:

Option A - an ambulatory care and diagnostic centre provided by NHS Greater Glasgow

All acute services will be provided by NHS Greater Glasgow. NHS Greater Glasgow will provide an Ambulatory Care and Diagnostic Centre (ACAD) in a single facility in Lomond for non in-patient activity. This will include a nurse-led minor injuries service on an extended day basis. All in-patient services will be in Glasgow, networked with the Royal Infirmary and/or the Southern General Hospital. Services provided locally in Lomond will be on a day or extended day basis.

Option B - an intermediate hospital provided by NHS Argyll & Clyde

NHS Argyll & Clyde will develop an intermediate hospital in Lomond, integrating ambulatory care with intermediate care beds and services (including a 24 hour GP led minor injuries unit). Patients requiring major acute in-patient care only will be transferred to the Royal Alexandra Hospital in Paisley.

Under both options, NHS Argyll & Clyde will continue to develop plans jointly with NHS Greater Glasgow to provide mental health services. A midwifery-led maternity service will also continue to be provided under either option.

Comparison of proposed options with current activity

Service Current Option A Option B ACAD Intermediate provided by Hospital NHS Greater provided by Glasgow NHS A&C In Lomond Day Treatment Centre: Theatre Suite and Total day 105-110% of 105-110% of Interventional Imaging cases 6,212 current current Medical treatment Endoscopy +80 + 80 Chemotherapy treatment Increase TBA Increase TBA Haematology – oncology Diagnostic imaging 19,587 100-110% of 100-110% of outpatient current current 5,745 outpatient outpatient inpatient 20% of current 40% of current inpatient inpatient

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Outpatient attendances for all 52,443 At least 100% At least 100% specialties and visiting of current of current specialists, including nurse and AHP led clinics Renal dialysis unit Planned Planned increase increase Allied Health Professionals 73,500 100–110% of 100–110% of outpatient current current 48,000 outpatient outpatient inpatient 20% of current 40% of current inpatient inpatient

Clinical support: Pathology During working Local service Pharmacy day only 24/7 Older People Unit, including day Vale, D’ton Day Hospital Integrated older hospital, assessment and long Joint, only. people’s unit stay H’burgh Vic Assessment in NHSGG Child and Family Centre No change No change Midwife led maternity services As in Maternity As in Maternity Strategy Strategy 24hour 7 day a week GP led 21,829 50% of current minor injuries unit Emergency nurse practitioner led 30% of current minor injuries unit In-patient admissions, Emergency Emergency Emergency 20- emergency/ elective 2,730iv 0% 25% Elective Elective Elective 20- 976 0% 25% ELSEWHERE: In NHS GG At RAH In-patient services Emergency Emergency 75- 100% 80% Elective Elective 45- 75-80% 55% Critical care medical in-patient Yes Yes services Accident and emergency services 11,000 11,000 Overnight Minor Injuries 4,500

Assumptions

69% of current elective inpatients stay 2 days or less. One third of these (i.e. 23%) will become day cases Endoscopy capacity increased by waiting times capacity 2003/4 i.e. 80 cases 50% of current A&E attendances can be treated by 24/7 GP led minor injuries unit 30% of current A&E attendances can be treated by extended day minor injuries unit 20% of current A&E attendances can be treated in overnight minor injuries

iv Of these, 499 were admitted to CCU (Coronary Care Unit) and 132 to ITU (Intensive Care Unit).

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43% of current emergency admissions stay 2 days or less. Half of these will be suitable for intermediate care bed admission. 69% of current elective patients stay 2 days or less. One third of these (i.e. 23%) will be suitable for short stay intermediate care in addition to the day case shift described above

The key differences between the two options are shown in the table below:

Key differences Option A – ACAD Option B – intermediate provided by NHS Greater hospital provided by Glasgow NHS Argyll & Clyde In-patient beds No provision on site for in- Acute in-patient services patient services: all acute with critical care provided in-patient services to be at the Royal Alexandra provided within NHS Hospital: other surgical/ Greater Glasgow. medical conditions requiring in-patient admission (as agreed under protocol) managed locally by GPs in intermediate care unit. Minor injuries unit Minor injuries unit staffed GP led minor injuries unit by emergency nurse open 24 hours, 7days practitioners on an extended day basis, but not overnight Child and Family No provision on site; Yes (as at present) Centre services accessed in NHS Greater Glasgow. Older people Day hospital for older Local unit with extended people range of day and in-patient services linked to the intermediate care unit

In discussions with NHS Greater Glasgow we have been advised that they cannot provide this service for a number of years, until perhaps as late as 2012. However, if this is the preferred option, NHS Argyll & Clyde will recognise this as the long-term plan for this service. It does not mean that we will be able to maintain existing services until this date. Under these circumstances, interim arrangements to sustain services will be consistent with option B and which will make it possible in time to implement the Glasgow option (A).

4.9 Renfrewshire

The main proposal is to reconfigure the Royal Alexandra Hospital as the major acute hospital in Argyll and Clyde. This will involve redevelopment of the site to provide sufficient critical and acute in-patient capacity for those cases that cannot be treated more locally elsewhere in Argyll and Clyde. The Royal Alexandra Hospital will remain the site for the consultant-led maternity unit for NHS Argyll & Clyde as in the agreed Maternity Strategy. Intensive care facilities for newborn babies and all in-patient services for children will be located at the Royal Alexandra Hospital.

The reconfiguration will also include work to establish adequate facilities for the main accident and emergency department for Argyll and Clyde. As in other areas in Argyll

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and Clyde, we will maximise local diagnostic and treatment services, including outpatient and day case activity.

The Royal Alexandra Hospital will work as part of the wider West of Scotland network, developing links with specialist centres in Glasgow, notably the Royal infirmary and the Southern General Hospital.

We also intend to reconfigure the Dykebar Hospital site, in line with national policy, reducing the current number of in-patient mental health beds (currently 182 general beds and 125 dementia beds). Work will take place to further determine the future of Blythswood House in Renfrew as a community support for mental health and other services. The remaining 55 learning disability beds at Merchiston Hospital will close in accordance with previously agreed plans and the services will be provided in the community. The in-patient provision for young physically disabled people at Merchiston Hospital (21 beds) will transfer to more appropriate accommodation and Merchiston Hospital will close.

4.10 The process of change

What we propose in this clinical strategy represents a significant change programme. The sooner we implement these changes, the sooner we will achieve stable services that we can then focus on developing and improving. It is proposed to substantially complete the reconfiguration of services by the end of April 2007. All changes will take place under NHS Argyll & Clyde’s organisational change policy.

Each of our three Divisions will establish a redesign team to develop the detailed operational plans for the proposed models of service set out. These plans will need to ensure adequate facilities and resources are put in place to make a success of the changes proposed. The redesign teams will have significant clinical involvement, building on the models of change used to put in place the contingency arrangements over the last year at the Vale of Leven and Inverclyde Hospitals. The teams will also have significant input from patients, carers and our partners.

The redesign teams will work closely with Community Health Partnerships. These are local management structures which are being established to assess local health needs and manage local service provision. They will directly manage and provide some services, lead the co-ordination and direct the delivery of some services and co-ordinate the delivery of other services as part of a managed network.

The improvements we envisage cannot be achieved without the support and commitment of our staff. The prospect of the changes outlined in this document has enthused many of our staff but may also concern some others. We will work hard to make sure that we retain the goodwill and continuing commitment of staff and that any concerns are addressed through the consultation process and beyond. We have an extremely high quality workforce and we will work hard to keep these staff and attract others to help secure the future of NHS Argyll & Clyde.

The successful delivery of change will depend on many factors, such as strong clinical leadership and the empowerment of front line staff in designing and implementing change. Part of our change process will be to develop and support clinical leaders and equip our staff with the necessary skills that will better enable them to play a full part in this process. We will design our training and development

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plans around the redesign and modernisation agenda set out in this document, and provide training and support to staff as they face change.

We will work closely with our partners, particularly Local Authorities, the Scottish Ambulance Service and neighbouring health areas to carry out agreed changes and make the most of resources available to us. Arrangements will be put in place to assure the NHS Board that all agreed changes take place as planned and that the outcomes and benefits expected from the changes are fully delivered in an agreed timescale.

4.11 Conclusion

This chapter has set out the changes that require to take place to modernise healthcare services in NHS Argyll & Clyde and ensure that they are safe, sustainable and of high quality. These changes also present significant opportunities to improve the way healthcare services are organised and provided to the benefit of patients. We have set out options where we think these exist. We hope that readers will take the opportunity to comment on our proposals. How to do this is outlined on the following page.

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5. How to give us your views

Thank you for taking the time to read this document. We welcome your views.

You can give us your views in many ways:

Write to John Mullin Chairman, Argyll and Clyde NHS Board FREEPOST PA 191 Ross House, Hawkhead Road, PAISLEY, PA2 7BR

Email us at: [email protected]

Free phone us on 0800 525034 and leave your views

Log on to our website at www.show.scot.nhs.uk/achb

To ensure openness, details of the views and comments received will be available for public scrutiny, including on our clinical strategy website, unless you indicate that all or any part of your comments are confidential.

THE CONSULTATION WILL END ON FRIDAY, 17TH SEPTEMBER 2004.

Please let us have your views by then.

At the end of the consultation period, the responses received will be considered by the NHS Board, along with any amendments to the initial proposals arising from the consultation. The NHS Board will then make recommendations to the Minister for Health and Community Care.

We will be holding local events across Argyll and Clyde during the consultation period. We hope that you will come along to these and contribute to the debate about future services. Details of these events will be publicised in advance.

This consultation document can also be made available, on request, on audio cassette tape, in braille, on disk, in large print and in other languages.

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Glossary

Accident and Hospital department that receives, diagnoses and treats Emergency Department patients who have suffered an accident or a health emergency, often brought to the hospital by blue light ambulance. Normally 24 hour, 7 days a week and staffed by specialist medical and nursing staff

Accreditation The quality based inspection process which assesses if staff (or a facility) is considered able to perform a function

Acute services Normally hospital based services including medical and surgical specialties but excluding Care of the Elderly, Mental Health, Learning Disabilities and Maternity

Advocacy groups Community based groups, often voluntary, who are prepared to speak on behalf of local communities and or people with particular health problems

Agenda for Change National policy to harmonise pay for the majority of health service staff except doctors and dentists

Allied Health Includes physiotherapy, occupational therapy, speech Professionals and language therapy, radiology, audiology, dietetics

Ambulatory A service where patients “walk in and walk out” on the same day

Ambulatory Care and An facility where patients attend, during the day, for Diagnostic Centre diagnosis and treatment of their condition. No overnight (ACAD) beds are provided

Anticholinesterases A group of drugs that have been shown to slow the deterioration associated with dementia in some patients

Blood borne viruses A group of diseases that can be transmitted through (BBV) blood contact. These include hepatitis, HIV/AIDS

Cancer A general term for more than 100 diseases characterised by uncontrolled, abnormal growth of cells. Cancer cells can spread locally or through the bloodstream and lymphatic system (tissue and organs producing and storing cells that fight infection) to other parts of the body42

Cardiology Medicine of the heart and associated blood vessels

Chemotherapy Treatment, usually of cancer, using toxic drugs to kill cancer cells. Usually involves a series of treatments

Chronic A condition that is life long and, although its symptoms can be addressed, cannot be cured

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Clinical audit A process of information gathering and analysis that measures the effects of treatments and care

Clinical practice The ways in which clinicians work

Clinical Strategy A process for identifying the future shape of health services

Clinician A professional healthcare provider including doctors, dentists, pharmacists, opticians, nurses and allied health professionals

Community Care Care provided by the NHS in partnership with local authorities to help vulnerable people, such as the elderly or people with disabilities, to live in their own homes rather than in institutions43

Community Health A management structure, aligned with Local Authorities Partnership/ CHP and with public representation, with the responsibility for assessing local health needs and managing services to address these needs

Community Hospital A local hospital, unit or centre providing an appropriate range and format of accessible healthcare facilities and resources. These will include inpatient and may include outpatient, diagnostic, day care, primary care and outreach services for patients provided by multidisciplinary teams. Medical care is normally led by general practitioners in liaison with consultants, nursing and allied health professional colleagues, as necessary. Consultant long-stay beds, primary care nurse-led and midwifery services may also be incorporated44

Consultant Contract The contract of employment between the NHS and Consultants which defines the hours of work, the duties undertaken and the salary

Consultant delivered Patient care is provided by the Consultant

Consultant-led care/unit The care of patients is provided under the direction of a Consultant by a range of staff

Coronary Care Unit/CCU Specialist unit to provide intensive care to people who have suffered heart attacks or similar conditions

Coronary heart disease Diseases of the heart and the associated blood vessels

Crisis intervention A readily available service that responds quickly to people in the community experiencing problems with the aim of preventing unnecessary admission to hospital

Critical care Highly specialised, heavily staffed and equipped facility for the most seriously ill. Includes Intensive Treatment, High Dependency, Coronary Care and similar units

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Dementia Irreversible brain degeneration leading to loss of memory

Deprivation/ social Poor conditions (housing, employment, income, health deprivation etc)

Diagnostic Tests to identify what is wrong

Diagnostic imaging Includes x-ray, CT, MRI and ultrasound scanning

Disease register A list of people with particular health conditions e.g. diabetes, that is used to ensure regular review and follow up of their condition

District General Hospital/ A major acute hospital normally serving a population of DGH 400 – 500,000 population, functioning 24 hours a day with A&E, outpatient, inpatient and diagnostic facilities

Elective A procedure that is planned

Emergency An event that is unplanned and requires immediate attention

Emergency on call Arrangement where staff, who are not present on site, attend a patient in an emergency

Emergency nurse A nurse with additional training who can assess and treat practitioner patients within a set of protocols

Emergency patients Patients who have an urgent need for care

Endoscopy A series of procedures that involve the insertion of telescopes or cameras to diagnose and treat conditions without the need for surgery

Estate Buildings and land

European Working Time A series of requirements that restrict the hours that Directive/ Working Time people can work Regulations

Extended day Longer than 9am to 5pm. Often 7am to 9pm

Financial balance The position where income and expenditure are equal

First responder The trained individual who first attends some-one on an emergency. This could include ambulance paramedics, other emergency service, GPs, first aiders or other trained members of the community

General Medical Services provided by family doctors and the legal terms Services/ GMS Contract under which they provide services and receive payment

General practitioner/ GP Family doctor

Haematology Diseases of the blood

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HDU High dependency unit – a facility with high levels of nursing and equipment for people who require close observation, often after surgery

Health outcomes The effect on an individual’s health as a result of treatment

Healthcare practitioners/ Trained staff who provide health care. Includes doctors, professionals nurses, allied health professionals

Hospital at Home A way of providing care for people in their own home as scheme an alternative to hospital admission

Information technology/ Electronic equipment and systems that support working IT practices including computers, videoconferencing, telephones and communications systems

Integrated Care Pathway A way of providing care that makes sure that all the services required by a patient are available in the most effective way

Intermediate Care/ A range of services for patients who require more than model primary care but less than acute hospital care. These could range from additional services provided by the family doctor or the primary care team in the GP surgery or Health Centre to hospital beds and services that are managed by non-Consultant medical staff

Interventional imaging Treatments given whilst the patient is being examined using ultrasound, x-ray or similar techniques

ITU Intensive Therapy Unit – highly specialised, staffed and equipped facility for the care of the most seriously ill

Managed Clinical An arrangement whereby all those involved in the care of Network a particular condition e.g. certain cancers, work together within a series of protocols to make best use of their specialist skills to achieve the best health outcome for the patient

Medical Non-surgical care and treatment

Midwife led units/care Care of the mother and baby provided in a facility that is staffed by midwives within a series of protocols

Minor Injuries Unit/ A facility that provides assessment and care for a limited services range of non-serious injuries and conditions

Model of service/ care A description of how services can be provided

National standards/ Quality standards that are set to provide safety and a standards of care good health outcome for patients and staff

Near-patient testing Equipment that allows a diagnosis to be given without test

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samples having to be sent off and the patient having to return for the results

New Deal An agreement that requires the reduction in hours worked by junior doctors

New technologies New equipment and instruments that mean that we can improve diagnosis and treatment e.g. CT and MRI scanners

NHS National Health Service (in Scotland)

NHS24 A national organisation that is being developed across Scotland that will provide information and advice to patients and carers over the telephone 24 hours a day

Oncology Medical treatment of cancers

One-stop clinic A service where the patient receives a consultation, diagnostic tests and a treatment plan at one visit. In some instances, the treatment will be given at the same visit.

Operating Division The organisation of the management and delivery of health services based on a geographic area. In NHSA&C, this comprises the Lomond and Argyll, Inverclyde and Greater Renfrewshire Divisions

Orthopaedics Treatment of bones and bone related conditions

Out of hours Outwith the normal working day i.e other than 9-5 Monday to Friday

Overnight minor injuries A unit where patients with minor injuries can be kept in overnight for observation under the care of a nurse

Pathology Laboratory based diagnostic specialties including biochemistry, haematology, histology, bacteriology and virology

Pathway of Patient Care/ An approach to organising and delivering care that patient pathway follows how a patient moves through the healthcare system from presentation to diagnosis to treatment to aftercare

Pay modernisation The various initiatives and changes to how we reward staff.

Planned care Treatment that is booked in advance

Primary Care/Primary Services provided by health professionals, either in clinics Care Team and practices, or at home. The category includes GPs, nurses, health visitors, dentists, optometrists, pharmacists and other specialists. Primary care is normally the first point of contact with the NHS and primary care professionals are considered the gatekeepers of

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secondary and tertiary services. Approximately 90% of patient contact is handled at this level. Within primary care there are 4 general practitioner services: medical, dental, pharmaceutical and optical. All general practitioners are independent and are contracted by local NHS boards to provide their particular service. On average most people will consult their GP over 3 times a year45

Progressive Care Centre An integrated facility for people requiring care (often the elderly) which provides a wide range of services ranging from sheltered housing to nursing care in a way that prevents people having to move as their need for care increases

Quality standards A set of statements that define how a service should be provided

Rapid response team A team of care staff (nursing, home care etc) that provides a fast response to prevent some-one being admitted to hospital or to allow earlier discharge from hospital

Referral and discharge Guidelines and rules agreed between professionals that protocols set out what should happen to patients under a range of circumstances

Renal dialysis Use of specialised equipment to filter waste products from the blood for patients with impaired kidney function. Can be hospital or home based

Research based Results of good, valid investigations that show the effects evidence of treatment

Seamless care A way of working where the person receiving care is unaware of the boundaries between the various departments and organisations providing that care

Secondary Care mainly hospital-based health care provision. Services range from emergency care (via Accident & Emergency) to non-emergency treatment (usually through outpatient departments and referrals from GPs)46

Service failure Where, because of staffing or quality problems, a service can no longer be provided

Short stay surgery Surgical treatment where the patient requires a day or two in hospital for observation and/or follow-up procedures but does not require critical care

Single-handed Working on his/her own rather than in a group practice

Social care Non-NHS care provided by local authorities, residential homes and voluntary organisations

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Solutions Group of the A group jointly established by NHS Argyll and Clyde and West Highland Health NHS Highland with clinical and public representation to Services Project identify possible ways of providing health services in North Argyll and Lochaber

Specialist acute services Acute (see above) hospital services with required levels of specialist staffing to provide a 24 hours consultant led service

Specialist consultant Healthcare services provided by Consultants Services

Statins A group of drugs used to control blood pressure

Surgical Invasive procedures normally requiring cutting

Sustainable Will continue to be viable in the longer term

TBA To be assessed/agreed

Telemedicine Use of videoconferencing and similar equipment to allow patient consultations with the patient and healthcare professional in different locations

Teleradiology Use of computer systems to transfer x-ray and other diagnostic images from one location to another

Tertiary Care refers mainly to the provision of highly specialised services which require high levels of expertise and support services. An example of this would be oncology services such as those provided at the Beatson Oncology Centre in Glasgow47

Therapist-led A service provided by an Allied Health Professional (see above) within protocols without the need to be seen first by a consultant

Urology Conditions affecting the kidneys, bladder and prostate

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References

1 Information Services Division. (2003) Whole System Project. 2 NHS Argyll and Clyde. (2000-2003) Director of Public Health’s Annual Reports. http://www.show.scot.nhs.uk/achb/public/publichealth.htm 3 Healthy Life Expectancy Steering Group. (2004) Healthy Life Expectancy in Scotland. http://www.isdscotland.org/isd/info3.jsp?pContentID=2860&p_applic=CCC&p_service=Conten t.show& 4 NHS Argyll and Clyde. (2000-2003) Director of Public Health’s Annual Reports. http://www.show.scot.nhs.uk/achb/public/publichealth.htm 5 NHS Argyll and Clyde. (2000-2003) Director of Public Health’s Annual Reports. http://www.show.scot.nhs.uk/achb/public/publichealth.htm 6 NHS Quality Improvement Scotland. (2004) Diabetes, National Overview. http://www.nhshealthquality.org/nhsqis/qis_NewsArchivePage.jsp;jsessionid=8C967E342989 E4D15F86FAD6A9EB1191?pContentID=1286&p_applic=CCC&p_service=Content.show& 7 NHS Argyll and Clyde. (2000-2003) Director of Public Health’s Annual Reports. http://www.show.scot.nhs.uk/achb/public/publichealth.htm 8 ISD Scotland. (2002) Mental Health in Scotland: Information sources and selected insights. Mental Health Information Programme. http://www.show.scot.nhs.uk/isd/mental_health/sources_insights2002.pdf 9 Wells KB, Sturm R, Sherbourne CD, et al. (1996) Caring for Depression. Massachusetts: Harvard University Press. 10 Scottish Development Centre for Mental Health, Durie S. (2003) Mental Health and Employment Policy for Scotland. 11 Graham B, Normand C and Goodall Y. (2002) The Cost of Cancer Care in Scotland. 12 Scottish Executive. (2003) Improving Health in Scotland – The Challenge. http://www.scotland.gov.uk/library5/health/ihis-00.asp 13 Recent advances in minimal access BMJ Vol 324 5 Jan 02; Intervention for Tubal Ectopic Pregnancy Cochrane Review, Cochrane Library Issue 1/2004. 14 NHS Argyll & Clyde. (2003) Annual Statistical Report. http://www.show.scot.nhs.uk/achb/reports/asr2002/2002sections.htm 15 Scottish Executive Expert Group on Acute Maternity Services. (2002) Reference Report. http://www.show.scot.nhs.uk/sehd/publications/egas/egas-00.htm 16 The Royal College of Surgeons of England. (2000) The Provision of Elective Surgical Services. http://www.rcseng.ac.uk/services/publications/publications/pdf/elecss.pdf 17 Scottish Executive. (2003) Partnership for Care. http://www.show.scot.nhs.uk/sehd/viewpublication.asp?publicationid=789 18 Argyll & Clyde Local Health Council and Argyll and Clyde Health Board. (1999) Strategic Review of NHS Services - Summary Report on Public Questionnaire. 19 NHS Argyll & Clyde. (2003) Annual Statistical Report. http://www.show.scot.nhs.uk/achb/reports/asr2002/2002sections.htm 20 Department of Health. (2003) Modernising Medical Careers The response of the four UK health ministers to the consultation on Unfinished Business: Proposals for Reform of the Senior House Grade. http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/ PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4010460&chk=SGJ%2Bvb Department of Health. (2004) Modernising Medical Careers The next steps The future shape of Foundation, Specialist and General Practice Training Programmes. http://www.dh.gov.uk/assetRoot/04/07/95/32/04079532.pdf 21 Gillis CR, Hole DJ. Survival outcome of care by specialist surgeons in breast cancer: a study of 3786 patients in the west of Scotland. BMJ. 1996 Jan 20;312(7024):145-8. 22 Junor EJ, Hole DJ, Gillis CR. Management of ovarian cancer: referral to a multidisciplinary team matters. Br J Cancer. 1994 Aug;70(2):363-70. 23 Scottish Executive Health Department. (2003) Partnership for Care. http://www.show.scot.nhs.uk/sehd/publications/PartnershipforCareHWP.pdf

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24 Senate of Surgery of Great Britain and Ireland. (2003) Reconfiguration of Surgical, Accident and Emergency and Trauma Services in the UK. http://www.baps.co.uk/documents/senate.report.3.pdf 25 Information Services Division. NHSScotland Workforce Statistics. http://www.isdscotland.org/isd/info3.jsp?p_applic=CCC&p_service=Content.show&pContentI D=796 26 Scottish Executive Health Department National Workforce Unit. (2004) Scottish Health Workforce Plan 2004 Baseline. http://www.scotland.gov.uk/library5/health/shwp04b-00.asp 27 Advisory group commissioned by the Scottish Executive to review the medical workforce. (2002) Future Practice, A Review of the Scottish Medical Workforce 2002. http://www.scotland.gov.uk/library5/health/fpmr-00.asp 28 Health Economics Research Unit. (2002) NHS Labour Market in Scotland. http://www.abdn.ac.uk/heru/pdfs/NHS%20Labour%20Markets%20Executive%20Summary.pd f 29 Health Economics Research Unit. (2002) NHS Labour Market in Scotland. http://www.abdn.ac.uk/heru/pdfs/NHS%20Labour%20Markets%20Executive%20Summary.pd f 30 Information Services Division. NHSScotland Workforce Statistics. http://www.isdscotland.org/isd/info3.jsp?p_applic=CCC&p_service=Content.show&pContentI D=796 31 Health Economics Research Unit. (2002) NHS Labour Market in Scotland. http://www.abdn.ac.uk/heru/pdfs/NHS%20Labour%20Markets%20Executive%20Summary.pd f 32 Advisory group commissioned by the Scottish Executive to review the medical workforce. (2002) Future Practice, A Review of the Scottish Medical Workforce 2002. http://www.scotland.gov.uk/library5/health/fpmr-00.asp 33 Argyll and Bute LHCC. (2001) Integrating Primary and Community Emergency Care Services. 34 Scottish Executive Health Department. Primary Care Division. Letter dated 31st July 2003. 35 Department of Health. (2004) Modernising Medical Careers The next steps The future shape of Foundation, Specialist and General Practice Training Programmes. http://www.dh.gov.uk/assetRoot/04/07/95/32/04079532.pdf 36 Audit Scotland. (2004) Day surgery in Scotland – reviewing progress. http://www.audit-scotland.gov.uk/publications/pdf/2004/04pf04ag.pdf 37 Scottish Executive Health Department. (2003) Partnership for Care. http://www.show.scot.nhs.uk/sehd/publications/PartnershipforCareHWP.pdf 38 Enhanced skills for immediate care are outlined on the British Association for Immediate Care at http://www.basics.org.uk/index.htm. 39 Output from NHS Argyll & Clyde patient pathway workshops. (2004) http://argyllnhs.org.uk/clin_strat/pathways.shtml 40 Senate of Surgery of Great Britain and Ireland. (2003) Reconfiguration of Surgical, Accident and Emergency and Trauma Services in the UK. http://www.baps.co.uk/documents/senate.report.3.pdf 41 Senate of Surgery of Great Britain and Ireland. (1997) 42 The Scottish Parliament Information Centre, Research Note RN 01/69 26 June 2001. http://www.scottish.parliament.uk/S1/whats_happening/whisp-01/wh84-09.htm 43 The Scottish Parliament Information Centre e briefing 04 June 2003 03/47. http://www.scottish.parliament.uk/research/briefings-03/sb03-47.pdf 44 LD Ritchie. (1996) Community Hospitals in Scotland: promoting progress. University of Aberdeen. 45 The Scottish Parliament Information Centre e briefing 04 June 2003 03/47. http://www.scottish.parliament.uk/research/briefings-03/sb03-47.pdf The Scottish Parliament Information Centre e briefing 04 June 2003 03/47. 46 Ibid. 47 Ibid.

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