Item 4.4 PRINCIPLES for DELIVERING out of HOURS UNSCHEDULED CARE

Highland NHS Board 3 February 2015 Item 4.4 PRINCIPLES FOR DELIVERING OUT OF HOURS UNSCHEDULED CARE

Report by Gill McVicar, Director of Operations, Tracy Ligema, Area Manager, West and Evan Beswick, Project Manager on behalf of Deborah Jones, Chief Operating Officer

The Board is asked to:

• Note the outputs of the Steering Group workshops • Discuss and agree the key principles for a new model of care • Consider having a Non Executive Director on the Steering Group • Endorse the plan for the next steps including opportunistic changes based on the key principles

1 BACKGROUND AND SUMMARY

1.1 Introduction

The Out of Hours service in NHS Highland is a patchwork of local arrangements that have been successful in providing cover in this period but which are increasingly difficult to sustain due to staffing models, lack of GPs working in the system, high use of Locums and the current level of spend which is not affordable. The cost means that other important and urgent developments are not able to be progressed, thus creating an opportunity cost as well as an overspend. With the changing demographics and the need for more community based care, this is no longer acceptable.

At present, there is limited cooperation across boundaries which can lead to one area being extremely busy and staff stretched whilst another has very low activity. There are also different pay rates across area boundaries which can lead to quieter areas being more attractive to the workforce than those parts where activity and need is greater.

This paper will outline the current service, highlight the need for change, provide information on activity and performance and propose key principles to be used to redesign the service to make it more sustainable and affordable whilst also ensuring that it is safe, integrated to in- hours services and the Local Unscheduled Care Programme and with key Partners, in particular, Scottish Ambulance Service.

1.2 Background

The current Out of Hours [henceforth OOH] service has been in place since 2004. It was put in place very quickly to allow the opt out of GPs as agreed through the General Medical Services contract of that year. Of necessity, it was piecemeal, due to the fact that there were only two existing OOH cooperatives in Inverness and East Ross and most Practices had continued to provide out of hours services in the traditional way. Attempts to change since then have also been opportunistic, and in many cases, resisted, although some significant improvements have been made, especially in the larger centres such as Inverness, East and Mid Ross, Caithness and Fort William, where it has been possible to be better integrated with A&E departments, be more multi disciplinary, and cover larger areas.

In 2008, the responsibility for out of hours was devolved to localities to allow very local agreements to be put in place and this has been successful to some degree especially in maintaining service, but has led to a fragmented approach, lack of ability to cross cover and it is extremely expensive. In addition, it has been increasingly difficult to attract Doctors into the service and last minute arrangements are significantly more expensive. The different pay 1

rates also makes it inequitable. This is a national problem (see §3.4.3 Media Coverage), made particularly acute in Highland by the difficulty of attracting GPs to the more remote parts of the region.

Argyll and Bute CHP is involved in discussions and has intimated the need for change there as well. However, there are more business to business contracts in place and it will take some time to move to a new model, but the key principles will also apply there. A limited home visiting policy already applies in Argyll and Bute.

It is important to note that the OOH Primary Care service must be differentiated to an emergency care service of the likes provided by the Scottish Ambulance Service or by hospital-based Emergency (A&E) Departments. OOH in Primary Care is concerned with delivering urgent care of the sort that you would make an appointment to see your GP about as opposed to dire emergency care which should be through the ambulance service. The minimum NHS 24 disposition time of 1 hour in primary care (compared to an 8 minute ambulance response time for the most serious emergencies) is reflective of this. In rural areas, however, due to the distance that ambulances require to cover, communities still rely on having a doctor or nurse close at hand and this is not going to be possible or desirable in all communities in the future. There is a memorandum of understanding (Appendix 2) in place with SAS who accept the responsibility for emergency care and who have been working to develop more resilient models, working with communities on initiatives such as public access defibrillators, First and Emergency Responders. NHS Highland has been working closely with SAS on this.

Primary care is only one of a number of OOH care providers, including: NHS 24; Accident and Emergency Departments; Minor Injuries Units; Pharmacies, Emergency Ambulance Service; Emergency Dental Services; Social Work emergency services; Home care; Community Nursing; Mental Health services.

1.3 Work so far

Two very successful and well attended workshops have been held with clinicians and managers, where the current service was discussed and analysed and a potential future model described. There was unanimous agreement that a Highland wide networked approach is necessary to build sustainability for the future at a more affordable cost.

In reality, Highland comprises a city, several large towns, small towns and villages, and very rural communities. In the past, models have attempted to meet local demands more than local need and there now needs to be a more robust plan that reflects actual activity and recognises that with improved technology and travel times, a more networked approach is possible and that changes will be required to ensure that the available resource is better utilised both in and out of hours

Those attending the workshops have agreed to form the Steering Group and a smaller Taskforce has been established to develop the detail and to formulate the action plan for consideration.

2 CURRENT SERVICE

The Highland Hub provides a local call handling and support service for the system linking with NHS 24 and the local responders. The typical patient pathway begins with a patient calling NHS24 (‘111’). This call will be triaged and completed through the provision of advice for self care, or passed to the emergency services or the Highland Hub. At the Highland Hub, the call becomes the responsibility of NHS Highland. The Hub dispatch the call locally as appropriate. A flow diagram for this pathway is provided in Appendix 1.

In Highland, there are four main models for local processing of OOH calls:

a. Highland Hub triage to PCECs b. Highland Hub triage to GP areas (especially in remote and rural locations) c. Patient walks in to PCEC (may either be seen, or directed to a phone to call NHS24) d. GP areas provide initial call triage (Nairn, North-West Sutherland)

This variation is largely due to the arrangements in place since the 2004 GPs contract when practices (not individual GPs) were able to opt out of providing OOH care. The majority of practices did opt out, with responsibility for OOH provision allocated to the health board. Some practices remain opted in, retaining responsibility for ensuring OOH provision in their practice area (the board cannot mandate a practice to opt in or opt out). A number of these practices chose not to use the NHS24 triage, opting instead to give a phone number to their patients. It will be noted below that this causes problems for data collection. Where practices do not use NHS24 triage, activity data may be collected. This may, however, lack the detail provided by NHS24 (see §4.2.1 Data caveats).

Where GPs are opted in, they have responsibility for their own practice area (unless by agreement with neighbouring practice areas. A Primary Care Emergency Centre (PCEC) covers a number of practice areas. In Highland these are frequently co-located with an Emergency Department (A&E), or a Minor Injuries Unit. The locations of OOH Practices and PCECs are provided in Map 1. Map 2 shows the drive times for many of these locations. Map 3 illustrates the population densities across NHS Highland. Map 4 shows the locations of Scottish Ambulance Service vehicles and first responders.

Map 1: PCEC and GP Area locations

Map 2: Drive time extents from a number of OOH locations

Map 3: NHS Highland Population Distribution (as at 2008)

Map 4: Scottish Ambulance Service vehicle and First Responder locations

These maps illustrate the following:

i. That, in most instances, PCECs are concentrated around the areas of high population ii. That a number of areas of lower populations are well-served by PCECs (e.g. Skye, Alness/Golspie, some parts of Argyll &Bute) iii. That a number of PCECs are within an hour’s drive of each other (1 hour being the minimum NHS24 disposition at present) iv. That PCECs and GP locations are frequently positioned in line with drive times, rather than the shorter distances that could be accomplished using sea and air transport. This should be built into further modelling of transport times. v. That, even before changes in the service, populated areas of Highland are outwith areas that can be reached within a 1 hour primary care response time. This paper does not propose to distribute Primary Care OOH by travel times. Rather, what the present picture demonstrates is that the unique remoteness and rurality of Highland means there is a pressing need to respond differently using non-traditional methods – for instance drawing upon first responders, duty paramedics, BASICs responders or developing skills and assets within communities.

3 SERVICE PROVISION STATEMENT AND CURRENT STANDARDS

NHS Highland’s Out of Hours (OOH) service provides Primary Medical Services between 18:00 and 08:00 hours on weekdays, all weekends and public holidays. The services provided by the Board must provide access to health care professionals for primary (general) health care when the clinical condition of a patient means they cannot wait until the next day for this. In reality, many cases could have waited but are seen because a service exists.

There are no nationally mandated targets for OOH primary care. In 2004, Quality Improvement Scotland produced standards for The Provision of Safe and Effective Primary Medical Services Out-of-Hours, based around the following three requirements:

i) Accessibility and Availability at First Point of Contact ii) Safe and Effective Care iii) Audit, Monitoring and Reporting

While NHS Highland was evaluated well against the standards (i.e. we could show, for instance, that reporting processes were in place), QIS did not set any specific targets. More recently, Healthcare Improvement Scotland has been developing a suite of Quality Indicators for Primary Care Out of Hours Services, with reporting on the following measures to commence in Summer 2015:

Indicator Description

1: Response times Indicator 1.1 Proportion of calls to NHS 24 answered within 30 seconds by an NHS 24 call handler. Indicator 1.2 Proportion of home visit cases where a clinician arrives at the destination of care within the timescale recommended by triage Indicator 1.3 Volume and proportion of 1, 2 and 4-hour home visit referrals.

2: Appropriateness of triage for home visits Indicator 2.1 Proportion of clinically appropriate 1, 2 and 4-hour home visit referrals.

3: Effective information exchange Indicator 3.1 Proportion of primary care out-of-hours consultations during which the patient’s electronic care summary (ECS) is accessed by a clinician.

Indicator 3.2 Proportion of primary care out-of-hours consultations with patients registered with a GP within the same NHS board for which consultation information is provided to their GP by 8.30am the following working day. Indicator 3.3 Proportion of primary care out-of-hours consultations resulting in admission to acute care for which referral information is provided at the time of referral.

Indicator 4: Implementing national clinical standards and guidelines Indicator 4.1 Proportion of patients with a suspected or confirmed diagnosis of asthma assessed in line with current national standards and guidelines.

Indicator 5: Antimicrobial prescribing Indicator 5.1 Proportion of prescriptions of antimicrobial medications that are for high-risk antimicrobial medications (cephalosporins, quinolones, co-amoxiclav and clindamycin).

Indicator 6: Patient experience Indicator 6.1 Proportion of primary care out-of-hours service patients who report a positive experience. Indicator 6.2 Proportion of primary care out-of-hours service patients who say they got the outcome (or care/support) they expected and needed. Indicator 6.3 Proportion of complaints received from primary care out-of-hours service patients.

Clearly, these will require a mixture of data retrieval and assurance from our computerised systems, as well as manual audits of clinical effectiveness. As outlined below, one of the agreed principles for any new model of OOH provision is the establishment of a Clinical Governance Group. It is anticipated that reporting and monitoring against these standards will be a key responsibility of this group.

3.1 Activity data

The following information is intended to provide a clear picture of the activity across Highland during the OOH period.

3.1.1 Overall demand The chart below shows total activity directed from NHS 24 to NHS Highland since 2004. It is a useful starting point showing a clear pattern of activity (increased during winter), alongside relatively stable demand over the past three years.

Source, Healthcare Improvement Scotland

It is worth comparing this to some national data, as provided by Healthcare Improvement Scotland. The data are only provisional, but demonstrate that Highland sits below the national average, when standardized for age and sex, per 100,000 population.

Cases directly standardized per 100,000 population, October 2014

Source, Healthcare Improvement Scotland

All calls coming through NHS 24 are triaged as per the case types in the table below. As this illustrates, around 27% of calls do not reach the local Highland Hub – these patients have been provided with advice by NHS24, or dispatched straight to an emergency department or 999 response. Of the remaining calls, there are three main outcomes which place a demand on the Highland OOH service:

i) Appointments: patients will be invited to attend a PCEC or local practice for an appointment with a suitably-trained professional (within either 1, 2 or 4 hours) ii) Home Visit: a suitably-trained professional will visit the patient at home and treat them there (within either 1, 2 or 4 hours). Given the need for a clinician to travel, this is the most resource-intensive of our responses, particularly given the remoteness of some of our patients. iii) Advice: a professional will call the patient to advise upon actions for appropriate self- care.

Number and Percentage of Out of Hours Calls by Revised Disposition for 2013 and 2014

Revised Disposition Values by Year based on Case Type Number Percentage 2 Year Total and NHS24 Dispostion 2013 2014 2013 2014 No. % NHS24 Advice Only 7612 11946 13% 19% 19558 16% 27% of calls A&E / MIU 3168 4052 6% 6% 7220 6% do not reach the 999 Ambulance 2489 3361 4% 5% 5850 5% Highland Hub Appointment 27791 27291 48% 43% 55082 45% 3 case types Home Visit 9847 10156 17% 16% 20003 17% account for Advice 5966 5878 10% 9% 11844 10% 72% of calls

Information Only 303 472 1% 1% 775 1% Dual Response 240 236 0.4% 0.4% 476 0.4% District Nurse 128 134 0.2% 0.2% 262 0.2% CPN Advice 77 103 0.1% 0.2% 180 0.1% Untriaged Call ASAP 39 29 0.1% 0.0% 68 0.1% Flu Advice 2 1 0.0% 0.0% 3 0.0% Total 57662 63659 100% 100% 121321 100%

Source: NHS Highland Service Planning

An increase in overall calls between 2013 and 2014 was largely absorbed within the NHS24 Advice Only category (i.e. calls which did not reach the local Hub. The following chart shows that this comprised of increases in patient self management, as well as increases in 999 Ambulances, A&E calls and advice for the patient to contact their GP in-hours.

3.1.2 Overall demand by Hour

The graph below shows our three main categories of appointments, advice and home visits by hour of the day. What this demonstrates is a consistent and predictable pattern of demand, with increased activity around tea-time every week-day, and the majority of activity occurring in the middle of the day at the weekend.

It is worth comparing this to activity to ED admissions across Highland, in order to test the hypothesis that ED activity increases at times when patients cannot access their in-hours GP.

ED data is provided for 4 sites across Highland (Raigmore, Belford, Caithness, Lorn & Isles). It is difficult to draw conclusions around causation from this data. However, what the chart does demonstrate is a) that activity to EDs across Highland is has a relatively predictable profile and b) that there does not appear to be an inverse relationship between in-hours GP opening and increases in ED activity. In other words, there appear to be times of the day when people seek care, and times of the day when they are less likely to.

3.1.3 Activity by location Clearly, OOH activity is not distributed evenly across Highland, given the gradients of population density. In the table below, the location of activity is given as the PCEC or GP area to which it is sent by the Hub. Note, this may not always relate to the location of the patient’s registered GP: the Hub direct patients based on their current location, as well as taking into account patient preference. Data below are averages for 2013 & 2013 (unless otherwise stated.

Number of Out of Hours Appointment, Home Visit and Advice Calls by Location | Average per year over 2013 and 2014

Number of calls by Case Type Average number per week Rate per 1000 population Location Appt Home Visit Advice Appt Home Visit Advice Appt Home Visit Advice Population Raigmore (PCEC) 8193 2830 1728 158 54 33 Rates not calculated where Invergordon 2466 938 471 47 18 9 high level of activity cross-over Dingwall (PCEC) 2146 959 588 41 18 11 between locations Nairn* (PCEC) 1273 383 3458 24 7 67 87 26 238 14557 Aviemore (PCEC) 2366 735 573 46 14 11 173 54 42 13704 Fort William (PCEC) 1768 833 397 34 16 8 90 42 20 19719 Broadford (PCEC) 2820 53 112 54 1 2 467 9 18 6035 Oban (PCEC) 1576 719 413 30 14 8 92 42 24 17049 Portree (PCEC) 2097 76 75 40 1 1 296 11 11 7071 Golspie (PCEC) 973 668 363 19 13 7 131 90 49 7429 Wick (PCEC) 712 465 239 14 9 5 51 33 17 14067 Dunoon (PCEC) 630 486 198 12 9 4 45 35 14 13875 Thurso 456 264 166 9 5 3 31 18 11 14644 Lochgilphead (PCEC) 324 71 19 6 1 0 39 8 2 8319 Rothesay (PCEC) 185 177 24 4 3 0 29 28 4 6430 Ullapool 115 145 94 2 3 2 46 59 38 2473 Gairloch 95 145 91 2 3 2 43 66 41 2200 Scourie/Kinlochbervie* 97 84 43 2 2 1 152 131 67 640 Mull 88 61 59 2 1 1 35 24 23 2509 Islay (PCEC) 70 56 37 1 1 1 21 17 11 3297 Lochcarron/Torridon 42 66 37 1 1 1 31 49 28 1338 Campbeltown (PCEC) 100 25 12 2 0 0 16 4 2 6345 Tighnabruich 51 51 31 1 1 1 49 49 29 1038 Acharacle 39 36 35 1 1 1 31 28 28 1247 Inveraray 45 29 16 1 1 0 13 9 5 3388 Carradale 20 19 10 0 0 0 592 Morvern 9 9 8 0 0 0 317 Glenelg 7 10 7 0 0 0 280 Rates not calculated where Muasdale 8 5 4 0 0 0 1175 fewer than one call a week on

Port Appin 8 1 1 0 0 0 average 844 Applecross 2 2 2 0 0 0 248 Coll 1 1 1 0 0 0 238 Highland Hub 9 6 49 0 0 1

* Figures sourced from practices: Nairn FYE 2013/14|Sc ourie/Kinlochbervie 2014 Source: NHS Highland Service Planning Incomplete data excluded for Tongue/Armadale, Jura and Colonsay

14 Highland NHS Board 3 February 2015 Item 4.4

As the chart above demonstrates, the vast majority of this activity occurs at Raigmore PCEC. Activity occurs mainly at PCECs, with low levels of activity occuring at other staffed locations. This is significant given the limited flexibility of staffing to meet demand. Staff numbers may be flexed up in PCECs and elswhere, but where we have GP bases with low activity levels there is a minimum provision (1800-0800 7 days per week, plus 0800-1800 Sat-Sun) which in the current system cannot be reduced. Changes to this will require increased coordination across areas and a more multi-professional approach. Concern for professional isolation, very low activity and cost will mean that smaller communities will no longer have a dedidated presence and will be served from busier areas supported by community resilience and technology as well as the emergency services.

3.1.4 Highand Hub Activity against the “Highland Hub” location denotes a specific arrangement in place on public holidays in order to cope with the combination of increased demand and reduced staffing. During these times, a GP with be placed on shift within the Highland Hub to provide clinical support for triage and to conduct advice calls. This demonstrates that, in practice, it is indeed possible to enhance the role of the Hub in providing coordinated clinical support across the Highland region.

3.1.5 Outcome type The data also illustrates a degree of inconsistency in terms of whether the triaging clinician opts for a home visit, appointment or telephone advice. This may be due to local policy (so, for instance, Broadford and Kintyre have opted not to provide many home visits) or by custom and practice (e.g. Ullapool)). It is clear, however, that there is scope for a Highland- wide policy around home visits.

This may be set in the context of the national picture. From the provisional HIS data it can be seen that Highland delivers a slightly higher percentage of home visits than the Scottish Average – though is by no means among the highest:

Source, Healthcare Improvement Scotland

3.2 Response times for home visits and PCEC visits

In addition to a case type, calls requiring primary care treatment are provided with a “disposition” of either 1hr, 2hr or 4hr. The overall proportions and proportion by location of these dispositions given at the point of triage are illustrated below. The charts illustrate a degree of variation between locations, but with 4 hr dispositions making up around 50% of the total (appointments and home visits). It should be noted that the national target for A&E waits for emergency care, is based on 4 hours.

Overall, NHS Highland is roughly in line with the Scottish Average in terms of the split of dispositions:

Proportion of 1, 2 and 4 hour Home Visit Referrals, October 2014

Source, Healthcare Improvement Scotland

Data may also be provided regarding the response times to these dispositions (i.e. whether or not the disposition given at triage is met). Of particular relevance here are response times to home visits: can a clinician reach a patient in a timely fashion in the event of a need for urgent care:

Percentage of 1, 2 and 4 Hour Priorities which are ‘On Time’ (Home Visits Only)

Source, Healthcare Improvement Scotland

This illustrates that Highland performs poorly against the 1hr response time, though much better against the 2hr and 4hr dispositions. This is predictable given the distances required to travel by, at times, a single practitioner on shift. A key principle for future models, therefore, must be around co-coordinating across patches and multi-disciplinary teams to identify improved ways of reaching patients within an urgent time frame. This may include first responders, BASICs trained practitioners or local community members.

3.2.1 SAS response times

The table below, taken from the Scottish Ambulance Service Annual Report shows average response times for Scotland. As expected, Highland Category A call performance is slightly above the Scottish Average, though within the 8 minute window. Also of note is the significantly higher number of Air Ambulance Missions in Highland, reflective of the fact that SAS is already using non-road responses to overcome the unique geography of the Highlands.

3.2.2 Data caveats There are a number of caveats to the data expressed above. i. Several practices do not use NHS24. The activity data from Nairn/Ardersier is provided by the practice. Only the small proportion of activity which goes through NHS24 includes data on response times/dispositions/case types. NHS24 figures for the five North-West Sutherland practices under-report activity (though some local data is reported manually). NHS24 is used in Scourie/Kinlochbervie, Durness, Tongue and Armadale only on Friday-Sunday (where locums are in place). The practices provide their own GPs Monday-Thursday and do not use NHS24. Data has been provided by the Kinlochbervie/Scourie practice only. Lochinver do not use NHS24 at all. ii. Broadford and Portree use the Adastra software for all emergency activity, including in-hours A&E activity. In-hours activity has been excluded. However, the activity reported over-states OOH activity. It has been impossible to distinguish emergency department and PCEC activity and so ED activity which occurs within the normal OOH period is included in total activity for Portree and Broadford. iii. Data provided by Nairn includes some double-counting. For instance, where a patient receives a nurse advice call and a GP advice call, each call will be noted. This does not occur in NHS24 data, for which items have only one case type. Nairn data may be over-stated by up to 28%. iv. No data is available for locations in Helensburgh & Lomond. OOH care in this area is delivered entirely by NHS Greater Glasgow & Clyde via an SLA. We have not yet been able to obtain the data for this service.

3.3 Costs and Staffing profile

A number of factors make providing a direct cost for OOH care a difficult exercise. In particular, the degree of integration between several PCECs and A&Es/MIUs, where staff work across both departments. In addition, where locums are employed to cover both in- hours and OOH at a single-handed practice, there is not a uniform method for apportioning their costs across centres. The following costs are full year forecasts for the financial year 2014-15, in order to show the full cost of the OOH service: Unit/CHP District 2014-15 forecast Argyll & Bute Oban, Lorn & Isles £ 614,000.00 Mid Argyll, Kintyre & Islay £ 1,176,000.00 Cowal & Bute £ 2,169,000.00 Helensburgh & Lomond (SLA with Glasgow) £ 684,000.00

North Caithness £ 619,000.00 Sutherland £ 807,000.00

West Lochaber £ 639,000.00 Skye, Lochalsh & Wester Ross £ 1,369,000.00

Raigmore Raigmore £ 1,177,916.00

South Nairn & Ardersier £ 228,006.00 Badenoch & Strathspey £ 682,442.00 Mid & Easter Ross £ 880,162.00

Highland Highland Hub £ 95,000.00

Total £ 11,140,526.00

In order to ascertain an indicative cost per unit activity, costs are provided below for 2013-14 up to Month 8 (these are the latest figures available) with activity apportioned accordingly to provide an indicative cost per unit activity. Helensburgh & Lomond has been excluded since 21 this is delivered entirely via an SLA with NHS GG&C (and for which we currently have no data available).

Unit/CHP District Cost at Month 8 Activity (8 Indicative months) cost/unit activity Argyll & Bute Oban, Lorn & Isles £ 390,000.00 1858 £ 209.90 Mid Argyll, Kintyre & Islay £1,195,000.00 554 £ 2,157.04 Cowal & Bute £1,445,000.00 1240 £ 1,165.32

North Caithness £ 420,000.00 1471 £ 285.46 Sutherland £ 522,000.00 1555 £ 335.62

West Lochaber £ 384,000.00 2111 £ 181.93 Skye, Lochalsh & Wester Ross £ 933,000.00 4122 £ 226.35

Raigmore Raigmore £ 732,386.00 8567 £ 85.49

South Nairn & Ardersier £ 151,369.00 3557 £ 42.55 Badenoch & Strathspey £ 460,213.00 2345 £ 196.28 Mid & Easter Ross £ 587,119.00 5021 £ 116.92

Highland Highland Hub £ 61,000.00

Overall £7,281,087.00 32402 £ 224.71

Clearly, this shows a great variation reflective of the higher costs incurred in more remote and rural parts of the highland. Costs are also greater in areas with numerous opted-in practices, rather than combined PCECs. This is particularly evident where OOH is provided by a single practice. Take, for instance, the following examples:

Unit/CHP Practice Area Cost at Month Activity (8 Indicative 8 months) cost/unit activity

West Lochaline £ 22,663 23 £ 985 Applecross £ 19,200 2 £ 9,600 Gairloch/Aultbea £ 202,307 210 £ 963 Fort William (PCEC) £ 372,219 2018 £ 184 Activity data is based on 2014 data. Worked example: Total year activity in Gairloch/Aultbea = 316. 8/12 of this is 210. Expenditure at M08 = £202,307. Cost/unit activity based on simple calculation of cost/activity. Note that this calculation is extremely sensitive to small denominators. Where activity is low, the cost/unit activity will vary significantly subject to small changes in activity. The cost/unit activity is therefore indicative, and should be used for comparative purposes only.

Examples have been provided for the West operational unit purely because detailed financial information for OOH is available on a practice-by-practice basis.

Aside from the expense of delivering OOH services in these locations, of note here is the difference in cost of providing OOH cover in Lochaline and Applecross, despite the similarity of their staffing model (1 GP covering OOH). While the opt-out meant that practices lost a proportion of their contract funding (£6000 per GP), there is now far greater scope for GPs to negotiate a rate for the cover of out of hours primary care – particularly in locations where it is already difficult to recruit GPs. Where locums must be brought in to cover OOH periods, the cost is vastly more expensive – hence the difference in cost between Gairloch/Aultbea

22 and Applecross GP areas, where roughly the same level of cover (i.e. one GP at all times) is provided. Clearly, this funding model is not sustainable.

Further factors for variations in cost include the staffing profile, and the ability to staff shifts at normal vs. enhanced/locum rates. A wide variation in pay rates exists across Highland. A sessional GP may work in Wick for £60/hr, but if this shift is not filled it may be offered at £120/hr – occasionally a GP has been able to negotiate this up to £180/hr. A GP working additional sessions in Scourie may do so at £18/hr, but with an additional piece rate of £40 per call out. A GP doing a weekend overnight shift in Inverness on double time may receive £156/hr – while working alongside a salaried Emergency Practitioner colleague receiving £49/hr.

A summary of some of the pay rates is provided below:

Role Hourly rate Salaried GP, working OOH £5 (based on the agreement with the Applecross GP. This is an on-call rate which sees the GP almost permanently on-call)

Sessional GP From £55 - £156, depending on area/time/enhanced rates

Contracted GP This is a specific rate negotiated with an external provider to deliver set periods of OOH cover. E.g. £53/hr in Fort William; £60/hr in Wick

Locum GP £126.89 (based on the most used agency)

Emergency Practitioner (Raigmore) £48.95

Unscheduled Care £21 (based on Band 7, top point to reflect Practitioner/Unscheduled Care Nurse experience) (Raigmore/Ross)

Hospital Nurse (Nairn PCEC) £18 (based on Band 6, top point to reflect experience)

The last available national comparison is found in a 2007 Audit Scotland report on OOH Primary care services. The following chart shows costs per head of GP population, and reflects the uniquely high spend in Argyll & Bute, as well as high costs to deliver OOH services in the rest of Highland.

3.3.1 Staffing models

The greatest proportion of expenditure is on medical staffing pay, reflecting that the traditional model of GP out of hours cover is still the most common practice in most areas of Highland – whether by salaried GPs, sessional GPs or Locums. However, as shown in §4.2, a number of multi-disciplinary staffing models are already in place across Highland. Of note are Raigmore and Mid/Easter Ross, where models of Unscheduled Care Practitioners/Unscheduled Care Nurses working alongside GPs or autonomously are already in place. The chart below shows the number of patients seen by these unscheduled care specialists (alongside other non-medical staff, e.g. district nurses):

Location Total Doctor UCP/UCN Other Percentage Percentage activity Consultations non- non-medical clinical pay medical consultations cost Raigmore 25696 17245 8357 94 33% 36%

Dingwall/Invergordon 16048 12601 3268 179 21% 17%

3.3.2 Unfilled shifts

It is worth noting as part of the staffing that these costs exclude a number of unfilled shifts (i.e. shifts where no cover has been able to be sourced from the GP cohort or from external locums). Data is only available for those shifts covered using the Hub’s online rota management software. It also does not reveal the number of shifts filled at the last minute by expensive locum cover or enhanced rates for NHS Highland sessional GPs. The chart below shows data for the past 12 months, and demonstrates the difficulty in sourcing robust GP cover for two areas of high volume activity:

Location No. available shifts No. unfilled shifts in Percentage unfilled in past year past year Inverness 780 35 4.5% East Highland 936 25 2.7%

3.3.3 Other partners and supporting services The above costs/activity do not include that associated with the numerous partner and supporting services for OOH care. NHS Highland works very closely with key partners, in particular, NHS 24 and Scottish Ambulance Service. One key development was the establishment of the Highland satellite of NHS 24, which is based in Inverness and is co located with SAS and the Highland Hub, providing the local call handling and support service. This has facilitated closer working with all key partners and the linking of systems. An example of this is that the Out of Hours vehicles have vehicle tracking devices, supported. Some GP vehicles also have these tracking devices.

Scottish Ambulance Service

The Scottish Ambulance Service serves all of Scotland and is a Special Health Board funded directly by the Health Department of the Scottish Government.

The ambulance service is regarded as the frontline of the NHS in Scotland and covers the largest geographic area of any ambulance service in the UK. Services are delivered locally across Scotland in six divisions.

The SAS has two main functions:

1. The provision of an Accident and Emergency service to respond to 999 calls. 2. The provision of a Non-Emergency Service, which performs an essential role in taking patients to and from their hospital appointments.

An Air Wing, consisting of two helicopters and four fixed wing aircraft, provides emergency response and invaluable hospital transfer for remote areas.

First Responders

A Community First Responder is a member of the public who volunteers to help their community by responding to medical emergencies while the ambulance is on its way. The administration and continuous management of these volunteer schemes is onerous and labour intensive, however, the benefits to the community make it a necessity. Several first responder co-ordinators (Volunteers) have received training (SVQ level 3) so that they can contribute to their own team’s self learning and refresher training requirements. The collaboration between the SAS, NHSH and Heartstart (British Heart Foundation) to develop first responder volunteers as Heartstart trainers in their community is also being progressed; local responder schemes will be affiliated to the local Heartstart group and issue certificates on behalf of Heartstart.

Immediate Care – BASICs

Through the Enhanced Services element of the new GMS Contract, there is a network of GPs who provide an immediate care service for life threatening situations. Some rural nurses are also trained in BASICs. Some Doctors have vehicle-tracking devices to facilitate response planning.

Dual Response

The SAS has the ability to call a local GP if they suspect that it would be advantageous to the patient to have the services of a doctor as well as an ambulance crew.

Fire Service

The Fire Service has, in recent years, carried out a comprehensive review of their service and positioning of crews and tenders. As a result of this, emergency tenders are situated in the areas of highest need, in particular at road junctions where the most road traffic accidents occur. The Fire Service is keen to work with us to further enhance that service and in some areas; the retained Fire Crews have been trained as First Responders.

3.4 Other quality indicators

We do not routinely audit the quality of care provided Out of Hours, other than by exception where complaints or serious incidents occur. Given the importance of the principle of clinical governance (outlined below) it will be important to consider auditing against standards as central to any proposed redesign of services.

It is worth noting that HIS standards 4.1, 5.1, 6.1, 6.2 and 6.3 will require us to develop reporting mechanisms for quality. A useful point of comparison may be made to NHS Grampian: the introduction of Advanced Nurse Practitioners in the seven GMED cells across the region included clinical audit of OOH practitioners – initially only covering the advanced nurse practitioners, but now extended to all GPs working OOH. A similar audit of cases has been built into the implementation of Unscheduled Care Practitioners in Portree and lessons from this must be taken forward as work progresses.

3.4.1 DATIX/Complaints From January – December 2014 there were a total of 92 Datix incidents and 13 complaints relating to the Out of Hours primary care service across Highland (though noting that some of these intersect with hospital-based emergency care or tele-medicine provision at the Highland Hub, where software and protocols are provided at a national level).

The majority of the small number of complaints related to patient’s dissatisfaction with their treatment. Only one of these was categorised as high risk:

Issue type Number Poor medical treatment 4 Clinical Treatment 3 Lack of pain management 1 Lack of a clear explanation 1 Attitude & Behaviour 1 Wrong diagnosis 1 Abruptness 1 Face to face 1 Grand Total 13

Of the 92 Datix complaints, 33 of these related to workplace environmental issues within the Hub workplace. Of the remainder, 83% were categorized as minor or insignificant:

Rating Percentage Insignificant 59% Minor 24% Moderate 17%

3.4.2 NHS24 Quarterly Reporting NHS24 provide all partners with a quarterly quality report. In addition to providing activity data (similar to those provided above), the report closes the loop on all issues raised by users in the previous month. The majority of issues relate to the appropriateness of the patient triage or disposition by NHS24 call handlers. From July – September 2014, 12 issues were raised and investigated, none of which resulted in patient harm.

Comments are investigated, reviewed at the multi-disciplinary regional Clinical Governance meetings and appropriate corrective action taken at organisational and individual level with frontline staff. It is not anticipated that this useful learning tool will cease – indeed, HIS Quality Indicator 2.1 will require that this continue.

3.4.3 Media Coverage On a number of occasions, both locally and nationally, OOH services have appeared in the media. In particular, a number of themes are commonplace:

a) There is a severe shortage of GPs in Scotland, with newer GPs also less willing to take on responsibilities for Out of Hours Care (e.g. Sunday Times Scotland, 18/01/15, ‘GP Shortage Feared as Applications Hit Record Low’) b) Nationally, results of the 2013/14 Health and Care Experience Survey show a decrease in respondents’ satisfaction with OOH Primary care (though increased satisfaction with OOH Ambulance services) c) Much media coverage focuses on NHS24, services, particularly during service disruption as such as occurred in November 2014 (e.g. BBC News, 22/11/14, ‘Non- emergency calls to 101 and NHS 24 restored after glitch’). d) However, coverage has also focussed on campaigns such as ‘Be Health-Wise’. The Medical Director of NHS24 encouraged patients to ensure they were aware of their GP opening times over the Christmas period and to prepare accordingly (e.g. Glasgow Evening Times, 18/12/14, ‘Advice on GP opening hours this winter’. This is demonstrative of a national message around patient and community resilience, particularly during the OOH period. e) In Highland there has also been coverage of community concerns when there are proposed changes to the OOH service, especially anxiety about emergency care. This must not be underestimated and public comfort in the new model will take time to achieve (see, for instance, STV, 14/11/11, ‘Rural west coast GP stops out of hours provision’). Note, however, that not all coverage has been negative, with some reporting reflecting a degree of openness towards new models of care (see, for instance, Ross-shire Journal, 25/05/14, ‘Could 'telehealth' be cure for Ross out-of- hours GP crisis?’)

4 VISION FOR THE FUTURE

4.1 National principles and evidence from elsewhere

Theme Source Summary Multi-disciplinary BMA GPC (2013) Position paper from the BMA GP teams Developing out-of-hours Committee arguing against changes to the care in England GP contract. States OOH provision should be “GP-led” but that “There is a role for greater use of extended multi-professional and integrated teams led and or organised by GPs.” Also notes that OOH care may be improved by providing better access to electronic clinical records.

NHS Grampian (2013) Clearly demonstrates appropriateness Clinical audit of Nurse and safety of triage, diagnosis and triage Practitioners working OOH from the UCP team working from Grampian’s GMED teams. Extended this year to cover all practitioners, including GPs. Scores both sets of practitioners using an adapted version of the Royal College of GPs Urgent and emergency care clinical audit toolkit. In some instances, UCPs scored higher than their GP colleagues.

Scottish Ambulance Paper discusses NHS Forth Valley’s use Service (2009) Potential of community paramedics based within impact on preventing communities and up-skilled to deal with avoidable A&E minor illness/injury. Attends all 999 calls attendances and all calls transferred to SAS from NHS24. Review of cases shows paramedic managing between 64&-84% (dependent on 999 disposition: Red/Amber/Green) at home or within primary care. Notes important change within SAS whereby calls can be seen & treated or transferred to NHS24, rather than a routine A&E pathway. Accompanying presentation also shows evidence of high patient satisfaction with community paramedic service.

Skills for Health (2007) Examines a number of measures Measuring the Benefits of regarding Emergency Care Practitioners Emergency Care (i.e. para-medical professionals trained to Practitioners degree level) working in a number of settings including in unscheduled care. Shows strong evidence for clinical effectiveness & safety; a return on investment for ECPs of around 1 year (a similar figure is cited by NHS Grampian); high levels of public trust and satisfaction with ECPs.

NHS GG&C (2007) A Audit of OOH presentations retrospective analysis of retrospectively mapped onto Nurse ooh presentations which Practitioners competencies. Excluded can be holistically sudden death, professional referrals, managed by OOH nurse obs/gynae calls & acute mental illness. practitioners Used competencies outlined in the NHS Education for Scotland Competency Framework for Unscheduled practice. Suggested that 81% of eligible calls were within the competency of an experienced Unscheduled Care Nurse.

Skills for Health (2006) Submission following consultation on the The Competence and ECP role. Outlines standards and a Curriculum Framework for competency framework for the training the Emergency Care and practice of para-medical practitioners Practitioner working in (among other settings) unscheduled care.

OOH workforce ISD (2013) Primary care This is an “experimental report” i.e. one Workforce Survey, OOH for which data was not considered robust GP services Strand, enough for full publication. What it does Experimental report illustrate is a) the variation in staff mix in OOH across Scotland, b) the difficulty face by a number of boards in filling GP shifts to required levels, c) the significant proportion of OOH GP shifts filled nationally by sessional GPs or locums, as well as salaried GPs, d) better success in filling Nurse Practitioner shifts.

Health and Sport Accepts the unsustainability of providing Committee (2010) Report OOH services which depend on the on out-of-hours healthcare expensive purchasing of GP time at an provision in rural areas, ad-hoc hourly rate. Encourages boards to HC/S3/10/R4 develop “specific, sustainable, and often innovative arrangements whereby out of hours services meet the needs of individual communities. This should be delivered in consultation with those communities”.

ED/OOH NHS Borders Clinical Describes consolidation of peripheral integration Strategy (2014) Case OOH service into one combined Study: Borders emergency service within the Borders Emergency Care Service General Hospital. Home visits are mostly (BECS) delivered by OOH nursing staff. GP based in the Hospital. Combined triage nurses triage all patients arriving into the building (whether walk-in, ambulance or NHS24) and direct to either the OOH service or ED. Notes the important link between in- hours and OOH, with anticipatory care plans and self management forming a key part of the strategy.

4.2 New models of care: local progress to date

It is not necessary in this context, to provide a detailed description of the various models in action in each of the locations across Highland. A detailed summary on a practice-by- practice basis is provided in Appendix 3. However, it is useful to note some of the developments which already show new ways of providing OOH care.

Area Model Inverness For a number of years, OOH care has been provided by a combination of salaried and sessional GPs, Emergency Practitioners (based in the hospital) and Unscheduled Care Practitioners. These UCPs are highly- trained advanced nurse practitioners with the ability to work autonomously, conducting home visits and dealing with all minor injuries/ailments. They always work on shift with either a GP or EP who they can phone for advice. The EP works across the PCEC and Emergency department, though OOH GPs do not. No GPs are employed overnight – this is covered by an EP in the Emergency Department and a UCP.

Mid Ross Similar to the model above, Mid Ross employ Unscheduled Care Nurses to work autonomously delivering OOH care. These band 7 nurses work alone during the day, but must be backed-up by an on-call GP overnight.

NHS Grampian By way of comparison, Grampian’s seven GMED cells also use a combination of GPs and nurses and, now, trained paramedics to deliver OOH care. These emergency care practitioners take the MSc in Advanced Clinical Practice, as well as an extended (circa 6 month) in- house training scheme. They are also BASICs trained in life preservation. They can work alone and have telephone and telemedicine back-up, usually from Dr Gray’s in Elgin.

Nairn In Nairn, a multi-professional model consists of a GP and a band 6 nurse. The GP does home visits while the nurse remains at base and runs the PCEC/A&E, calling upon the GP for advice or input.

Small Isles Given recruitment difficulties there is now no permanent GP on the Small Isles. Accordingly, this has required an adjustment in the provision of OOH services. OOH care is now provided from Skye. Clearly, a 1 hour disposition is not possible by road, therefore an informal arrangement is in place whereby a 999 call will be raised should a patient need to be seen by a clinician, though this may not be clinically appropriate.

Acharacle (in Acharacle OOH will be provided by Nurse/Paramedic Practitioners development) working closely with local support structures such as Emergency Responders and First Responders. Initially they will be supported by GP on call cover locally however once confidence and local knowledge is built GP support will be provided remotely from Fort William PCEC. Telemedicine facilities are in place in Acharacle practice and in the village of Kilchoan (to support Emergency Responder team as well as local NHSH clinicians.

At the heart of this model is the Rural Support Team. The Rural Support Team will consist of GPs, Advance Nurse Practitioners, Unscheduled Care Practitioners and Paramedic Practitioners working

together in a team that is a virtual network. This means that although they may be geographically distributed across a large area and working in different parts of that area they are all part of the same team and link with each other daily (by VC etc) for professional support. Individuals within the team may have a main base and work in other areas as required or they may be fully rotational i.e. routinely working across a number of different areas/bases.

A summary table of the skills, competencies and training of several non-doctor OOH practitioners is provided in Appendix 4. Of particular note is the legal requirement for a doctor to attend in case of either a) an acute mental health emergency requiring use of the Mental Health Act and b) an unexpected death. While there is currently no alternative to the acute mental health requirement, Police Scotland protocol around unexpected death has recently changed to permit certification of an unexpected death by “authorised personnel from the Scottish Ambulance Service” (Police Scotland, December 2014, ‘Forensic Physician attendance at sudden deaths and expert opinion’). Further discussions will need to be held to ascertain whether other authorised non-medical practitioners may be able to certify unexpected death. Nonetheless, a key consideration here is the ability to work across boundaries to ensure the most appropriate professional can attend in these situations.

4.3 Principles agreed at workshops

• Multi professional teams • Use of technology to support clinical decisions • Telebooths for use by patients to speak to a healthcare professional • Fewer ‘manned’ sites • Increased coordination through the Hub • Strong functional relationships across PCECs • Improved transport including use of maritime and air wing solutions • Strengthened retrieval services, Flying Squads, including mental health • Improved responses in terms of Care at Home and Community Nursing • Larger centres support rural areas • ED (A&E) and Primary Care integration in the larger centres • Use of ‘oilrig’ model of support to more remote communities • Routine surgeries at weekends run by peripatetic staff in rural areas • Limited home visiting apart from end of life care, frailty, mental health crises • Remove the one hour primary care response triage option in favour of emergency response. This requires national negotiation and agreement • Strong links to in hours anticipatory care with more patients having anticipatory care plans and holding ‘rescue’ medication packs • Community resilience such as First and Emergency Responder schemes and Community Health Assistants • High quality, standards based but ‘good enough’ not gold plated • Robust and timely information for service management • Robust and integrated IT systems

This will mean considerable change to the way the service is currently delivered and it is likely to lead to community concern, especially where there will be a sense of loss when traditional approaches are changed. Strong clinical leadership and programme management support is required to progress all aspects of the plan.

The new approach is to formally network and strengthen coordination of local models and would see the following changes to the existing distribution of emergency centres (note, the following table does not propose a model for Argyll & Bute):

Current locations Type Proposed Type Locations Aviemore PCEC Aviemore PCEC Broadford PCEC Broadford PCEC Dingwall PCEC Dingwall Sub-Base Fort William PCEC Fort William PCEC Golspie PCEC Golspie PCEC Invergordon PCEC Invergordon PCEC Nairn PCEC Nairn PCEC Portree PCEC Portree Sub-Base Raigmore PCEC Raigmore PCEC Thurso PCEC Wick PCEC Wick PCEC Acharacle GP area 1 location in Sub-Base Lochaber, possibly Acharacle Applecross GP area Durness GP area Gairloch/Aultbea GP area 1 PCEC in Wester PCEC Ross, possibly Gairloch Glenelg GP area Lochcarron/Torridon GP area 1 sub-base in Sub-Base Wester Ross, possibly Lochcarron Morven GP area Scourie/Kinlochbervie GP area 1 location in North Sub-Base West Sutherland Tongue/Armadale GP area Ullapool GP area

Some of these bases will be manned by GPs, Advanced Nurse Practitioners, Unscheduled Care Practitioners, Nurse and Paramedics with robust technology links and effective clinical decision support systems.

4.4 eHealth implications

Any development in OOH delivery requires practitioners to be able to quickly access relevant information on a patient, often while mobile/not at base. As a minimum, practitioners will need to consult:

i) Adastra ii) Vision iii) Emergency Care Summary iv) Key Information Summary v) SciStore vi) Care First vii) Hospital-based information (Trak)

Discussions with colleagues in eHealth indicate that this requirement sits comfortably in line with current eHealth strategy around the provision of a clinical portal. This will enable

32 clinicians to access multiple sources of information from within a single interface, greatly assisting ability to make quick, safe decisions based on all relevant information. We will continue to work within this strategy to ensure the unique needs of OOH primary care are met within this work stream.

4.5 Risks of change, and action required to mitigate

Risk Description Next steps Acute Mental Health and Any new model must ensure It is necessary to understand Unexpected Death that a doctor can attend in the extent to which this the case of acute mental constitutes ‘routine’ work. As health emergencies or yet, the volumes and unexpected death. frequency of this work is not understood.

Disparity of As multi-disciplinary teams Clinical/nursing leadership training/banding of non- have begun to develop, for OOH care is required to doctor practitioners doing some divergence in terms of develop clinical standards, OOH work the skills, training and pay job descriptions and training have emerged. requirements for non-medical practitioners delivering OOH care.

Emergency care provision There is a risk in Ensure continued implementing new models in involvement of Scottish areas (e.g. Portree) which Ambulance Service in this have traditionally also work stream (as per delivered self selected walk memorandum of in service (not just urgent) understanding). We need to care. be able to show that an emergency response can be A related risk concerns more delivered robustly to all areas remote areas of Highland of Highland. This work must (e.g. Glenelg) where an OOH also be cognisant of ongoing GP has traditionally been the discussions around major only medical support within trauma centres. the area. There will be understandable concern Update modeling data on around losing what is response and travel times perceived to be the only (first conducted in 2008) to available response in the evidence the impact of case of an emergency. proposed models on access to care.

Ensuring safe care There is an understandable Evidence from elsewhere concern that a move to multi- (e.g. Grampian) disciplinary models of OOH demonstrates a positive care will compromise patient impact on patient safety safety, or result in more following a move to multi- admissions into secondary disciplinary models of OOH care. care. This must now be supplemented with a robust audit of the available evidence base in Highland where nurse-led care has already been implemented in some areas.

Negative media Changes to models of care Agree principles on a coverage/public reaction will result in dissatisfaction Highland-wide basis to from some groups concerned ensure parity of approach about losing doctor coverage across the board area. of a certain geographical areas. Develop consultation/communication strategy.

Financial pressures New models of care must Develop local models based see a reduction in overall on the agreed principles. cost. Multi-disciplinary teams Proposed changes in each can be shown to reduce cost locality must be supported by in principle by reducing strong business cases reliance on locums/enhanced rates. Training/contingency arrangements may reduce these savings initially, and there will be costs associated with a strengthened Hub and leadership, but overall and through time it is anticipated that significant savings can be made.

5 THE WAY FORWARD

It is recommended that the Steering Group be augmented to include all key stakeholders, in particular, patient and public representatives and hopefully a Board Non Executive Director. The Steering Group and smaller Task Force should be charged with further developing the new model and should bring a detailed and paper with outlining the model including costs, to the meeting of the Board in June.

In the meantime, however, it is recommended that the key principles can be applied as the opportunity arises, especially in these areas that work is already ongoing such as in East and Mid Ross, Inverness, Wester Ross, Ardnamuchan, Skye and Lochalsh.

6 CONTRIBUTION TO BOARD OBJECTIVES

Implementing our Vision and Strategy – This proposal will provide a clear strategic direction and strategy for care and treatment in the out of hours period. It will further the ambition of the Board for integrated health and social care and will follow key principles of the Highland Quality Approach by driving out waste, harm and variation and by delivering better health, better care and better value.

Improving Population Health and Reducing Inequalities – By improving links between in hours and out of hours care, better anticipatory care, supporting and encouraging self care and individual responsibility, the out of hours service will play a role in improving health and reducing inequalities.

Creating a Caring, Person-centred Experience - Better integration of health and social care services out of hours and better anticipatory care planning involving individuals and families, to include steps to be taken in deterioration of conditions, rescue medication packs and red flagging.

Providing Safe and Effective Care - Better coordinated service, reduction in isolated and lone working, improved clinical governance, implementation of HIS standards

Transforming our Services – This proposal will lead to transformational change that will build in sustainability for the future. It will follow lean principles and will be subject to continuous quality improvement.

Designing Integrated Care – It is proposed that the service will integrate health and social care and will also be integrated across Highland to ensure best use of resource. Working with key partners, in particular, Scottish Ambulance Service will be essential. Links to voluntary organisations working out of hours will also be further developed.

Engaging our People – This proposed model is based on teamwork, excellence, integrity and caring and will engage all key stakeholders.

Promoting Creativity, Innovation and Research – Through staff and skills development, and the use of available and emerging technologies, the new model will demonstrate innovation.

Ensuring Value and Sustainability – By developing the multi professional approach, creating a better coordinated model and reducing cost, the new model will be both more sustainable and more cost effective.

Delivering our Targets – the final model will be designed to meet key targets and standards and will assist with meeting other key targets such as four hour Accident and Emergency waits.

7 GOVERNANCE IMPLICATIONS

• Staff Governance

Staff working in the out of hours period have been involved in discussion about the new model. It is fair to say that some, especially doctors, have some concerns about reduction in their numbers and potential changes to their contracts. There will be no redundancies although some salaried staff may be required to work in different locations. As mentioned above, learning and development to ensure that all staff have the skills and consequences required to undertake their roles, is one of the key planks of the proposal

• Patient and Public Involvement

There has been local involvement in discussions in respect of potential changes to out of hours services with Small Isles being an example. However, patient and public representatives will be invited to be part of the Steering Group planning for changes required in the new model and in implementation. A robust communications and engagement plan will be developed as part of the action plan should the Board agree the principles.

• Clinical Governance

A Highland wide Clinical Governance Group will be established to ensure compliance with Health Improvement Scotland (HIS) Standards, to review complaints and incidents and to oversee the learning and development plan. In addition, a Clinical Development Manager will be appointed whose key responsibility will be to ensure that nursing and paramedic staff are well supported and have and maintain the skills and competencies to carry out their role and to facilitate service development. In addition, it is recommended that a Clinical Lead be appointed for the Highland wide service.

• Financial Impact

The current spend on out of hours service in north Highland and in Argyll and Bute is unsustainable and there are opportunity costs for other essential services. It is therefore necessary to reduce these costs whilst ensuring clinical safety and reasonable access. There will however, be a need to invest in the supporting infrastructure to ensure that the service is well coordinated and is safe and sustainable. It is envisaged that this investment will be covered by reduction in costs in the service as well as releasing savings. These costs are likely to be in leadership and in a strengthened role for the Highland Hub. Learning and development costs will also be built in to the new financial model.

8 RISK ASSESSMENT

A risk assessment will be carried out on the overall model and the local implementation of that.

9 PLANNING FOR FAIRNESS

A full impact assessment will be carried out both at Highland and at local levels

10 ENGAGEMENT AND COMMUNICATION

As part of the action planning and robust engagement and communication plan will be developed and implemented.

Gill McVicar, Director of Operations, North and West Highland

Tracy Ligema, Area Manager (West)

Evan Beswick, Project Manager

January, 2015

APPENDIX 1

OOH Patient and Information pathway

Patient (or relative, carer “3rd party”) calls NHS24 on 111

NHS24 call handler takes demographic details and initial information Demographic details taken link to national systems to ensure correct patient identified and confirmed Follows algorithm to guide passing to clinician

Dispositions NHS24 clinician (e.g. nurse practitioner) triages patient by Send to A&E phone. Advise patient to attend A&E Sets ‘disposition’, ie who the patient needs to see, where, within GP to call patient to what timescale give advice May also stop at advice, or send to A&E (pt advised to attend or PCEC appointment 999 call raised) Home Visit Consultation is recorded in Adastra & clinician ‘sends’ case to Hub 1hr – 2hr – 4 hr

time frames

Case is passed electronically to Highland Hub, via Adastra; sending virtually instant Case appears on Hub Controller’s screen

Hub controller passes call to screen at PCEC nearest patient’s location; may also phone GP to alert that a call has been sent to him. Phone used for rural areas Hub Controller calls patient to advise where/when to attend (for appointment only)

GP (or other clinician) sees patient and records summary and outcome in Adastra and closes the case. Where there is no Adastra access, Dr faxes/phones summary to Hub for typing up The case remains visible on the Hub screen until it is closed – this guards against cases being missed or notes not being completed and closed Clinician can look up KIS (Key Information about patient, maintained by own GP) via portal in Adastra for clinical information and alerts previously added by GP practice Adastra now has a complete record of the patient episode Adastra records are in ‘real’ time and cannot be edited/overwritten

Adastra automatically generates a ‘post event message’ and sends a fax or email to the patient’s own GP practice Hub can see summary of faxes sent, monitor for failures and resend manually if necessary

APPENDIX 2

APPENDIX 3

Summary of OOH provision by GP practice

PCEC GP practice Area Locality OOH provision Activity to Setup

Princes Street Surgery, North Caithness Opted out - service Wick/Thurso PCEC Thurso outsourced by Board

Riverbank, Thurso North Caithness Opted out - service Wick/Thurso PCEC outsourced by Board

Canisbay & Castletown Joint North Caithness Opted out - service Wick/Thurso PCEC Medical Practice, Canisbay outsourced by Board

Dunbeath Health Centre, North Caithness Opted out - service Wick/Thurso PCEC Dunbeath outsourced by Board

Medical Centre, Lybster North Caithness Opted out - service Wick/Thurso PCEC outsourced by Board

Riverview Practice, Wick North Caithness Opted out - service Wick/Thurso PCEC outsourced by Board

Wick Medical Centre, Wick North Caithness Opted out - service Wick/Thurso PCEC outsourced by Board

Wick North Caithness 1 GP 1800-0800, 7 days (M-F on contract) 1 GPs 0800-1800, SS (sessional) Thurso North Caithness Not a PCEC, but GPs work across Wick/Thurso. Nurse at Dunbar takes calls and manages ward/MIU when no GP

Creich Surgery, Cherry Grove, North East Sutherland OOH provided by Golspie Bonar Bridge IV24 3EP Consortium of local GPs on rota Helmsdale/Brora Medical North East Sutherland OOH provided by Golspie Practice, Brora Health Centre, Consortium of local GPs Station Square, Brora KW9 on rota 6QJ & Health Centre, Rockview Place, Helmsdale KW8 6LF Golspie Medical Practice, North East Sutherland OOH provided by Golspie Golspie Health Centre, Consortium of local GPs Fountain Road, Golspie KW10 on rota 6TH Lairg Medical Practice, The North East Sutherland OOH provided by Golspie Health Centre, Main Street, Consortium of local GPs Lairg IV27 4DD on rota Dornoch Medical Practice, North East Sutherland OOH provided by Golspie Shore Road, Dornoch IV25 Consortium of local GPs 3LS on rota Golspie North East Sutherland TBC

Armadale Medical Practice, North West Sutherland Opted out - OOH Tongue/Armadale Own GP from M-T (non-NHS24). Armadale, Thurso KW14 7SA provided by Practice Locum Fri-Sun shared across GPs contracted with Tongue/Armadale (NHS24) Board and Locums The Health Centre, St North West Sutherland Opted out - OOH Tongue/Armadale Own GP from M-T (non-NHS24). Andrew's Glebe, Tongue IV27 provided by Practice Locum Fri-Sun shared across 4XB GPs contracted with Tongue/Armadale (NHS24) Board and Locums The Surgery, Durness IV27 North West Sutherland Opted out - OOH Own GP from M-T (non-NHS24). 4PH provided by Practice Locum Fri-Sun shared across GPs contracted with Scourie/KLB/Durness (NHS24) Board and Locums Scourie & Kinlochbervie North West Sutherland Opted out - OOH Own GP from M-T (non-NHS24). Medical Practice, Health provided by Practice Locum Fri-Sun shared across Centre, Kinlochbervie IV27 GPs contracted with Scourie/KLB/Durness (NHS24) 4RP Board and Locums Assynt Medical Practice, 6 North West Sutherland Opted in Lochinver Practice GPs cover. Data not through Main Street, Lochinver IV27 NHS24 4JZ

The Surgery, Birchburn, West Wester Ross Opted out - OOH Gairloch/Altbea Own GP from M-T. Locum Fri-Sun. Aultbea IV22 2HU & Gairloch provided by salaried All NHS24. Health Centre, Auchtercairn, GPs, some sessional Gairloch IV21 2BH locums. Unscheduled Care Nurses also providing cover Ullapool Health Centre, North West Wester Ross Opted out - OOH Ullapool Own GP from M-T. Locum Fri-Sun. Road, Ullapool IV26 2XL provided by practice All NHS24. GPs, salaried GP and sessional locums. The Surgery, Applecross IV54 West Wester Ross Opted out - OOH Applecross Own GP from M-T. Locum Fri-Sun. 8LS provided by practice All NHS24. GPs, salaried GP and sessional locums. Lochcarron Medical West Wester Ross Opted out - OOH Lochcarron/Torridon Shared across Lochcarron/Torridon. Partnership, The Ferguson provided by practice Own GP M-T. Locum Fri-Sun. All Medical Centre, Lochcarron GPs, salaried GP and NHS 24 IV54 8YD sessional locums. Torridon Medical Practice, West Wester Ross Opted out - OOH Lochcarron/Torridon Shared across Lochcarron/Torridon. Fassaig, Torridon IV22 2EZ provided by practice Own GP M-T. Locum Fri-Sun. All GPs, salaried GP and NHS 25 sessional locums. Broadford Medical Practice, West Skye & Lochalsh Broadford High Road, Broadford IV49 Opted out - salaried 9AA OOH service - Rural Practitioners Carbost Medical Practice, The West Skye & Lochalsh Broadford Surgery, Carbost IV47 8ST Opted out - salaried OOH service - Rural Practitioners Sleat Medical Practice, Sleat West Skye & Lochalsh Broadford Medical Centre, Kilmore, Sleat Opted out - salaried OOH service - Rural IV44 8RF Practitioners Broadford West Skye & Lochalsh All PCEC activity dealt with in ED. 1 RP on for the full OOH period evening & weekends. Looks after whole hospital. Dunvegan Medical Practice, West Skye & Lochalsh Portree Dunvegan Health Centre, Opted out - salaried Dunvegan IV55 8GU OOH service - Rural Practitioners Portree Medical Centre, West Skye & Lochalsh Portree Portree, Isle of Skye IV51 9BZ Opted out - salaried OOH service - Rural Practitioners plus

practice GPs

Portree West Skye & Lochalsh All emergency activity dealt with in PCEC. 1 RP on 18:00-23:00 weekdays, 08:00 - 23:00 weekends, then Broadford doc goes on-call 23:00-08:00.

Glenelg Health Centre, Allt West Skye & Lochalsh Opted out - OOH Glenelg 1 GP, evenings and weekends Ruadh, Glenelg IV40 8JD provided by Practice GPs contracted with Board and Locums Kyle Medical Practice, West Skye & Lochalsh Opted out - salaried Broadford Lochalsh Healthcare Centre, OOH service Station Road, Kyle of Lochalsh IV40 8AE Ballachulish Medical Practice, West Lochaber Opted out - service Fort William East Laroch, Ballachulish outsourced by Board PH49 4JB local GP input at weekends Craig Nevis Surgery, Fort West Lochaber Opted out - service Fort William William Health Centre, outsourced by Board Camaghael, Fort William local GP input at PH33 7AQ weekends Glen Mor Medical Practice, West Lochaber Opted out - service Fort William Fort William Health Centre, outsourced by Board Camaghael, Fort William local GP input at PH33 7AQ weekends Tweeddale Medical Practice, West Lochaber Opted out - service Fort William Fort William Health Centre, outsourced by Board Camaghael, Fort William local GP input at PH33 7AQ weekends Doctor's Surgery, Kearan West Lochaber Opted out - service Fort William Road, Kinlochleven PH40 outsourced by Board 4QU local GP input at weekends Mallaig & Arisaig Medical West Lochaber Opted out - GP provides Fort William Practice, Mallaig Health practice cover Centre, Victoria Road, Mallaig contracted to Board & Arisaig Medical Practice, Rhu Road, Arisaig PH39 4NU

Cill Chuimein Medical Centre, West Lochaber Opted out - service Fort William Fort Augustus PH32 4BH outsourced by Board local GP input at weekends Fort William West Lochaber 1 GP 1800-0800, 7 days (M-F on contract) 2 GPs 0800-1800, SS (sessional) Morvern Medical Centre, West Lochaber Opted out - service Morvern 1 GP evenings and weekends Rowanbank, Lochaline, Oban outsourced by Board PA34 5XT local GP input at weekends Acharacle Medical Practice, West Lochaber Opted out - GP provides Acharacle 1 GP evenings and weekends The Pines Medical Centre, practice cover Acharacle PH36 4JU contracted to Board Small Isles Medical Practice, West Lochaber Opted out - GP provides Broadford Grianan, Isle of Eigg PH42 practice cover 4RL contracted to Board Alness/Invergordon Medical Mid Ross & Cromarty Opted out - OOH Invergordon Group, Robertson Health provided by salaried Centre, Dalmore Road, GPs, some sessional Alness IV17 0UN & The locums. Unscheduled Health Centre, County Care Nurses also Community Hospital, Saltburn providing cover Road, Invergordon IV18 0JR Tain & District Medical Mid Ross & Cromarty Opted out - OOH Invergordon Practice, The Health Centre, provided by salaried Scotsburn Road, Tain IV19 GPs, some sessional 1PR locums. Unscheduled Care Nurses also providing cover Tain & Fearn Area Medical Mid Ross & Cromarty Opted out - OOH Invergordon Practice, The Health Centre, provided by salaried Scotsburn Road, Tain IV19 GPs, some sessional 1PR locums. Unscheduled Care Nurses also providing cover Cromarty Medical Practice, Mid Ross & Cromarty Opted out - OOH Invergordon Allan Square, Cromarty IV11 provided by salaried 8YF GPs, some sessional locums. Unscheduled Care Nurses also providing cover

Dingwall Medical Group, The Mid Ross & Cromarty Opted out - OOH Dingwall Health Centre, Ferry Road, provided by salaried Dingwall IV15 9QS GPs, some sessional locums. Unscheduled Care Nurses also providing cover Fortrose Medical Practice, Mid Ross & Cromarty Opted out - OOH Dingwall Station Road, Fortrose IV10 provided by salaried 8SY GPs, some sessional locums. Unscheduled Care Nurses also providing cover The Surgery, Brae Terrace, Mid Ross & Cromarty Opted out - OOH Dingwall Munlochy IV18 8NG provided by salaried GPs, some sessional locums. Unscheduled Care Nurses also providing cover Strathpeffer Medical Centre, Mid Ross & Cromarty Opted out - OOH Dingwall The Surgery, Strathpeffer provided by salaried IV14 9AG GPs, some sessional locums. Unscheduled Care Nurses also providing cover Dingwall Mid Ross & Cromarty Modal varies. But typical model: M-F 1800-2300 - 1 GP M-F 2300-0800 - 1 UCN with GP on- call

SS 0800-1600 (UCN) 1600-2200 (GP) 1000-2200 (UCN) 2100-0800 (UCN plus GP on-call)

Aird Medical Practice, Ferry Mid West Ness Opted out - OOH Raigmore Road, Beauly IV4 7EA provided by salaried GPs, some sessional locums. Unscheduled Care Nurses also providing cover

The Surgery, Croyard Road, Mid West Ness Opted out - OOH Raigmore Beauly IV4 7DJ provided by salaried GPs, some sessional locums. Unscheduled Care Nurses also providing cover The Surgery, Balmacaan Mid West Ness Opted out - OOH Raigmore Road, Drumnadrochit IV63 provided by salaried 6UR GPs, some sessional locums. Unscheduled Care Nurses also providing cover Culloden Surgery, Keppoch South Inverness Opted out - OOH Raigmore Road, Culloden IV2 7LL provided by sessional locums, Unscheduled Care Nurses and Emergency Practitioners Culloden Medical Practice, South Inverness Opted out - OOH Raigmore Keppoch Road, Culloden IV2 provided by sessional 7LL locums, Unscheduled Care Nurses and Emergency Practitioners Cairn Medical Practice, 15 South Inverness Opted out - OOH Raigmore Culduthel Road, Inverness provided by sessional IV2 4AG locums, Unscheduled Care Nurses and Emergency Practitioners Kingsmills Medical Practice, South Inverness Opted out - OOH Raigmore 18 Southside Road, Inverness provided by sessional IV2 3BG locums, Unscheduled Care Nurses and Emergency Practitioners Fairfield Medical Practice, 22a South Inverness Opted out - OOH Raigmore Abban Street, Inverness IV3 provided by sessional 8HH locums, Unscheduled Care Nurses and Emergency Practitioners Riverside Medical Practice, South Inverness Opted out - OOH Raigmore Ballifeary Lane, Ness Walk, provided by sessional Inverness IV3 5PW locums, Unscheduled Care Nurses and Emergency Practitioners

Dunedin Medical Practice, South Inverness Opted out - OOH Raigmore Hilton Clinic, Temple provided by sessional Crescent, Inverness IV2 4TP locums, Unscheduled Care Nurses and Emergency Practitioners Kinmylies Medical Practice, South Inverness Opted out - OOH Raigmore Assynt Road, Inverness IV3 provided by sessional 8PB locums, Unscheduled Care Nurses and Emergency Practitioners 43 Southside Road, Inverness South Inverness Opted out - OOH Raigmore IV2 4XA provided by sessional locums, Unscheduled Care Nurses and Emergency Practitioners Burnfield Medical Practice, South Inverness Opted out - OOH Raigmore Harris Road, Inverness IV2 provided by sessional 3PF locums, Unscheduled Care Nurses and Emergency Practitioners Crown Medical Practice, 12 South Inverness Opted out - OOH Raigmore Crown Avenue, Inverness IV2 provided by sessional 3NF locums, Unscheduled Care Nurses and Emergency Practitioners The Medical Centre, Foyers South Inverness Opted out - OOH Raigmore IV2 6YB provided by sessional locums, Unscheduled Care Nurses and Emergency Practitioners Raigmore South Inverness Mix of GPs/UCPs/Eps during evening. No GP on from 24:00-08:00. Overnight covered by 1 EP and 1 UCP. EPs cover across ED and PCEC (GPs do not) and provide senior medical support within department. UCPs home visit. EPs and UCPs are salaried (some sessions). GPs some salaried and mostly sessional. Detail in next sheet.

Ardersier Medical Practice, South Nairn & Ardersier Opted in Nairn 142B Manse Road, Ardersier IV2 7SR Lodgehill Clinic, Lodgehill South Nairn & Ardersier Opted in Nairn Road, Nairn IV12 4RF

Nairn South Nairn & Ardersier 1 GP evenings and weekends for home visits, plus 1 nurse (band 6) who stays at PCEC, manages ward & A&E Aviemore Medical Practice, South Badenoch & Opted out - OOH Aviemore The Health Centre, Aviemore Strathspey provided by local PH22 1SY Consortium of GPs contracted with Board The Health Centre, Grantown South Badenoch & Opted out - OOH Aviemore on Spey PH26 3HR Strathspey provided by local Consortium of GPs contracted with Board Kingussie Medical Practice, South Badenoch & Opted out - OOH Aviemore Old Distillery Surgery, Strathspey provided by local Ardvonie Park, Kingussie Consortium of GPs PH21 1ET contracted with Board Gergask Surgery, Laggan, by South Badenoch & Opted out - OOH Aviemore Newtonmore PH20 1AH Strathspey provided by local Consortium of GPs contracted with Board Aviemore South Badenoch & 1 GP, evening (1800-0800) and Strathspey weekends (plus 0800-1800) (40h salaried, plus sessional) Port Appin Surgery, Port Argyll & Bute Oban, Lorn & Isles Opted in Appin (<10 NHS24 Data) Appin PA38 4DE

Coll Medical Practice, Argyll & Bute Oban, Lorn & Isles Opted in Coll (<10 NHS24 Data) Arinagour, Isle of Coll PA78 6SY Colonsay Surgery, Scalasaig, Argyll & Bute Oban, Lorn & Isles Opted in Colonsay (No NHS24 Data) Isle of Colonsay PA61 7YW

Taynuilt Medical Practice, The Argyll & Bute Oban, Lorn & Isles Opted out - salaried GPs Oban Surgery, Connel PA37 1PH provide OOH from LIH

Easdale Medical Practice, Argyll & Bute Oban, Lorn & Isles Opted out - salaried GPs Oban Clachan Seil, Isle of Seil PA34 provide OOH from LIH 4TL Lorn Medical Centre, Soroba Argyll & Bute Oban, Lorn & Isles Opted out - salaried GPs Oban Road, Oban PA34 4HE provide OOH from LIH

Oban Argyll & Bute Oban, Lorn & Isles 1 GP 1800-0800, 7 days, covers casualty and PCEC. 1 GP Sat-Sun 0800-1800 just covers PCEC

The Surgery, Salen, Isle of Argyll & Bute Oban, Lorn & Isles Opted in Mull? Mull PA72 6JL

Tobermory Medical Practice, Argyll & Bute Oban, Lorn & Isles Opted in Mull? The Surgery, Rockfield Road, Tobermory, Isle of Mull PA75 6PN Ross, Mull & Iona Medical Argyll & Bute Oban, Lorn & Isles Opted in Mull? Services, The Surgery, Bunessan, Isle of Mull PA67 6DG Tiree Medical Practice, Baugh Argyll & Bute Oban, Lorn & Isles Opted in Tiree Surgery, Isle of Tiree PA77 6UN The Health Centre, Stewart Argyll & Bute Mid Argyll, Kintyre & Opted in -B2B contract Campbeltown Road, Campbeltown PA28 Islay with Board - local GPs 6AT cover OOH & community hospital A&E Campbeltown Argyll & Bute Mid Argyll, Kintyre & 2 GPs 1800-0800 7 days, and 0800- Islay 1800 weekends. Supported by nursing staff in community hospital & A&E. 3 salaried GPs

The Carradale Surgery, Argyll & Bute Mid Argyll, Kintyre & Opted out - covered by Carradale Carradale, Argyll PA28 6QG Islay Salaried GP Kintyre Medical group

The Furnace/Inverary Argyll & Bute Mid Argyll, Kintyre & Opted in- currently Inverary Surgery, Inverary PA32 8XN Islay covered by locums- practice vacancy advertised Bowmore Medical Practice, Argyll & Bute Mid Argyll, Kintyre & Opted in -B2B contract Islay Windsor, The Surgery, Main Islay with Board - local GPs Street, Bowmore, Isle of Islay cover OOH & community PA43 7JH hospital A&E Port Ellen Practice, The Argyll & Bute Mid Argyll, Kintyre & Opted in -B2B contract Islay Surgery, Geirhilda, Back Islay with Board - local GPs Road, Port Ellen, Isle of Islay cover OOH & community PA42 7DR hospital A&E Rhinns Medical Centre, Port Argyll & Bute Mid Argyll, Kintyre & Opted in -B2B contract Islay Charlotte, Isle of Islay PA48 Islay with Board - local GPs 7UD cover OOH & community hospital A&E Islay Argyll & Bute 1 GP 1800-0800 7 days, and 0800- 1800 weekends. Supported by nursing staff in community hospital & A&E Jura Medical Practice, Argyll & Bute Mid Argyll, Kintyre & Opted in Jura (No NHS 24 Data) Glencairn Surgery, Islay Craighouse, Isle of Jura PA60 7XG Lochgilphead Medical Centre, Argyll & Bute Mid Argyll, Kintyre & Opted in -B2B contract Lochgilphead Mid Argyll Community Islay with Board - local GPs Hospital & Integrated Care cover OOH Centre, Hospital Road, (Lochgilphead & Tarbert) Lochgilphead PA31 8JZ & community hospital A&E Kintyre Medical Group Argyll & Bute Mid Argyll, Kintyre & Opted out -Practice now Lochgilphead (Southend Practice, Teapot Islay merged and OOHs Lane, Southend PA28 6RW & (including Carradale) Muasdale Practice) covered by Salaried GP Tarbert Medical Practice, Argyll & Bute Mid Argyll, Kintyre & Opted out - Lochgilphead Campbeltown Road, Tarbert Islay Lochgilphead practice PA29 6TY cover see above Lochgilphead 1 GP 1800-0800 7 days, and 0800- 1800 weekends. Supported by nursing staff in community hospital & A&E

246 Argyll Street, Dunoon Argyll & Bute Cowal & Bute Opted out - salaried Dunoon PA23 7HW OOH GPs based in Cowal Community hospital 30 Church Street, Dunoon Argyll & Bute Cowal & Bute Opted out - salaried Dunoon PA23 8BG OOH GPs based in Cowal Community hospital 246 Argyll Street, Dunoon Argyll & Bute Cowal & Bute Opted out - salaried Dunoon PA23 7HW OOH GPs based in Cowal Community hospital Dunoon 1 GP 1800-0800, 7 days, covers casualty and PCEC. 1 GP Sat-Sun 0800-1800 just covers PCEC

The Lochgoilhead Medical Argyll & Bute Cowal & Bute Opted out - provided by Centre, Lochgoilhead PA24 Greater Glasgow & 8AA Clyde The Bute Practice, The Health Argyll & Bute Cowal & Bute Opted in -B2B contract Rothesay Centre, High Street, Rothesay with Board - local GPs PA20 9JL cover OOH (lochgilphead & Tarbert) & community hospital A&E Strachur Medical Practice, Argyll & Bute Cowal & Bute Opted out - OOH cover ??? Dalnacraig, Strachur, contracted to salaried Cairndow PA27 8BX GPs Riverbank Surgery, Kilmun Argyll & Bute Cowal & Bute Opted out - OOH cover ??? PA23 8SE contracted to salaried GPs Kyles Medical Centre, Argyll & Bute Cowal & Bute Opted out - OOH cover Tighnabruaich Tighnabruaich PA21 2BE contracted to salaried GPs Arrochar Surgery, Kirkfield Argyll & Bute Helensburgh & OOH provided via SLA Place, Arrochar G83 7AE Lomond with Greater Glasgow & Clyde

Garelochhead Medical Argyll & Bute Helensburgh & OOH provided via SLA Centre, McAuley Place, Lomond with Greater Glasgow & Garelochhead, Helensburgh Clyde G84 0SL The Medical Centre, 12 East Argyll & Bute Helensburgh & OOH provided via SLA King Street, Helensburgh G84 Lomond with Greater Glasgow & 7QL Clyde Dr MacLeod & Partners, Argyll & Bute Helensburgh & OOH provided via SLA Medical Centre, 12 East King Lomond with Greater Glasgow & Street, Helensburgh G84 7QL Clyde Kilcreggan Health Centre, Argyll & Bute Helensburgh & OOH provided via SLA Kilcreggan G84 0JL Lomond with Greater Glasgow & Clyde

APPENDIX 4

Summary of non-doctor OOH practitioners currently in action Title Area Band Triage? Home Works Injuries? Ailments? Acute mental Support from Training visit? autonom health & doctor ously? unexpected death

Unscheduled Care Raigmore 7 Always on shift Minimum Practitioner       with EP or GP advanced for support. clinical Generally does assessment home visits while (ACE) skills EP/GP remains and non- at PCEC. medical prescribing. Most have also done minor injury/illness module

Unscheduled Care Mid 7 Can work Nurse Highland       independently on daytime shifts. On call doctor for advice overnight.

Hospital Nurse Nairn & 6 Work in wards Nurse Thurso       and A&E and run prescribing, the PCEC. GP university does home paeds visits. Nurses module, assess, treat and unscheduled discharge care without Medical practitioner input course, first responder

training.

Advanced Nurse Grampian 7 Can work MSc in Practitioner/Advanc       independently Advanced ed Paramedic day or night. Clinical Often no GP in Practice. area. Telephone BASICs and telemedicine training. In- support from house Aberdeen training for circa 6 months, inc. 4 months shadowing.

Rural Support team Wester 6/7 Will be able to Minimum (Proposed) Ross       work advanced independently clinical day or night. assessment Telephone and (ACE) skills telemedicine and non- support from medical Portree/Fort prescribing. William PCEC Most have also done minor injury/illness module. BASICs trained, Advanced Life Support, Pre-Hospital Emergency Care, Paediatric Immediate Life Support