Highland NHS Board 7 October 2014 Item 4.1

PROPOSED REDESIGN OF SERVICES IN BADENOCH AND STRATHSPEY

Report by Nigel Small, Director of Operations (South and Mid) and Maimie Thompson, Head of Public Relations and Engagement on behalf of Deborah Jones, Chief Operating Officer

The Board is asked to:

 Consider the detailed report on the feedback from three month public consultation into proposed major service change  Note the feedback from the Scottish Health Council endorsing the consultation process  Endorse the recommendation in support of the preferred option – to develop Community hospital and resource centre in a central location (Aviemore)  Note the next steps and the requirement for any decision on proposed major service change to be considered by the Cabinet Secretary for Health and Wellbeing

1. Background and Summary

This paper reflects the culmination of a huge amount of work which has taken place over the past five years as part of a comprehensive engagement exercises with communities in Badenoch and Strathspey (part of South and Mid Operational Unit). In particular it highlights the main findings from the three month public consultation exercise.

Within Badenoch and Strathspey some services are not strategically located or adequately resourced making them not as effective or efficient as they need to be to meet future demands. In addition the two local community hospitals are old, not in good physical condition and not designed to meet modern standards.

Work has been ongoing to look at these issues with a view to providing sustainable solutions for the future. Through an options appraisal process a local steering group agreed a short- list of three options:

Option 1 – Do minimum

Option 2 - Community hospital and resource centre in one town (‘hub’) and scaled-down services in the other (‘spoke’), based on existing hospital sites

Option 3 - Community hospital and resource centre in a central location (Aviemore)

Option 3 was identified as the steering group’s preferred option. If implemented this would mean building a new community hospital and resource centre in Aviemore, as part of a wider redesign and modernisation of health and social care services.

It would also include the re-location of Aviemore Health Centre, some other services located in Aviemore and the closure of both local hospitals - Ian Charles in Grantown-on-Spey and St Vincent’s in Kingussie. Any closures would be planned to take place after the new services were in place.

The board of NHS Highland considered these proposed changes to be ‘major’ and was therefore subject to a period of formal public consultation. The board approved the move to formal public consultation at a special meeting held in March 2014. The formal public consultation was launched on 21st April and ran for a total of 14 weeks until 21st July 2014. NHS Highland was consulting on the range of options including option three as the preferred option.

It is estimated that some 500 people took part during the consultation. Of those who completed NHS Highland’s consultation response survey (176) there was wide-spread support for the case for change with almost 80% selecting the preferred option.

Positive feedback on the consultation process and the preferred option was also received from staff, local GP Practices and partner agencies including Highland Council, Scottish Ambulance Service, Scottish Fire and Rescue Service, Highlands and Islands Enterprise and the Highland Hospice.

The Scottish Health Council has endorsed that the process has been in accordance with Scottish Government Guidance. This includes the options appraisal process (service model and sites), public consultation materials and the public consultation communications and engagement.

Taking everything into consideration the operational unit can demonstrate broad support from the wide range of stakeholders for the preferred option (option 3) and it is now being formally recommended to the board for endorsement.

As the preferred option represents major service change, should the board endorse the recommendation, the next step would be for the proposals to be considered by the Cabinet Secretary for a final decision.

It was also clear from some of the feedback NHS Highland received (written correspondence, personal contact with staff and at meetings) that there were some people who had some strong concerns about aspects of the proposed redesign (most notably but not exclusively in Grantown-on-Spey), and some topics of wider general concern (future services, transport, future use of buildings, bed requirements and care-at-home) requiring further consideration

The report, therefore also sets out some of the next steps in meeting the guidance and describes some of the further work that would be required should the preferred option move to implementation.

2. NHS Highland Report on the Public Consultation

2.1 Overview

The public consultation report specifically covers the three month public consultation into the proposed redesign of services across Badenoch and Strathspey.

It describes in detail how the consultation was managed and promoted, the range of ways that views were gathered, and an analysis of all the feedback.

It includes the findings from the feedback on the public consultation survey and the summary feedback from the independent review of the consultation process by the Scottish Health Council.

The write-up of the options appraisal process on site selection is also included. This work could only be completed after the consultation had closed.

Based on an assessment of all the supporting information a recommendation to the board is made on model of service, location and site.

2 The next steps in meeting the guidance are highlighted including some of the ongoing and additional work required.

2.2 Feedback on the Public Consultation Process

NHS Highland has embarked on an extensive and wide-ranging public consultation exercise. The approach appears to have been generally well received. The reasons for the changes to services being proposed have been understood and the majority of the feedback suggests that the case for major service change is accepted.

There was consistency in views received through the different routes and from partner agencies. By the end of the consultation no new themes or issues were being raised.

The feedback from the public meetings was fairly representative of the general feedback which emerged during the consultation. Areas of greatest concerns were raised from some residents in Grantown-on-Spey. This was also highlighted in the Highland Council response and further focussed work will be required should the proposed changes be implemented.

Overall the vast majority of people who took part in the consultation, and who fed-back, were positive about the opportunities to engage with NHS Highland and there was good awareness about the consultation and how to make views known

NHS Highland’s Health and Social Care Committee endorsed that the consultation process complied with Scottish Government major service change guidance. They also supported that the operational unit was in a position to present the full findings to NHS Board meeting to be held in October.

The Scottish Health Council carried out an independent review of the process and has also endorsed the process. They highlighted some areas of good practice as well as how the process could be improved in the future.

2.3 Feedback on the Service Model and Site

79% of people who responded to the consultation survey agreed with the proposal to develop a community hospital and resource centre in Aviemore supported with wider development of community services. This option also received backing from all four medical practices and partner organisations (The Highland Council, Scottish Ambulance Service, Scottish Fire and Rescue Service, Highlands and Islands Enterprise and the Highland Hospice).

People also had the opportunity to comment on aspects of the proposed changes. Over half the people who responded were positive about all elements. Closing in-patient beds in Ian Charles and St Vincent’s and moving the Glen day centre were the least well supported.

Both the public preference and the working group’s deliberations came up with the same conclusion on the favoured choice of site (Site C, Technology Park in Aviemore). This preference is based only on qualitative factors. Other important factors such as development costs, land purchase and the suitability of the land for construction also have to be considered. This work would be completed if there is a decision to progress to implement the preferred option.

2.4 Conclusion

There is broad support from the wide range of stakeholders for the preferred option (option 3) and this is now being formally recommended by the south and mid operational unit to the board for endorsement.

3 2.5 Next Steps and Decision Making Process

Should the board endorse the recommendation then an updated report will go to the Scottish Government for a final decision by the Cabinet Secretary.

Only if the Cabinet Secretary approves the preferred option would planning for the new facilities and services begin in earnest.

There would then be a requirement for the Business Case process to be followed, in accordance with the Scottish Capital Investment Manual Guidance. Once the next steps were completed an Initial Agreement document would need to be prepared and submitted for consideration by the Capital Investment Group.

Other specific work identified that would need to take place includes:

 Setting out how Primary Care and community services (delivered through the four Health Centres) will be maintained or improved  Explore opportunities for co-location of children and families staff in any new facility  Further engagement specific elements of some of the proposals  Clarification on consistent use of terminology to describe services such as minor injury/casualty/ A&E  Development of an Integrated Transport Plan  Strategic development and expansion of care-at-home services  Further detailed work to develop the final clinical specification for the hospital  Further modelling work on bed numbers  Carry out technical appraisal of preferred site  Collaboration with all concerned regarding the future use of any buildings no longer required by NHS Highland  On-going engagement with local communities and stakeholders throughout the development of the business case.

3 Contribution to Board Objectives

The service redesign, if successfully implemented would provide significant opportunities to implement better health, better care and better value and maximise the potential of integration.

The operational unit is fully aware of other strategic and operational considerations such as wider discussions relating to dental services, MSK review, transforming outpatients, older adult mental health services, strategic overview of radiology and diagnostic services and the Inverness Master Plan. Over the next two to three years other work may be identified.

Governance implications

 Staff Governance1 Staff are integral to the redesign and there is strong clinical, staff side representatives, and senior management leadership. Significant effort has been made to achieve a clinical consensus, and this has been supported through a series of clinical workshops and ongoing meetings with the local GPs, facilitated through the locality clinical lead and director of operations.

Going into the future there will be implications for some staff roles and responsibilities, including where staff will work from. Some of this is a continuum of the work already

1 In this context staff is used in the broadest term and includes GP and practice staff 4 underway linked to integration of health and social care and includes opportunities for staff co-location and professional and team development.

It is important that staff are provided with a safe and improved working environment as part of the staff governance standard, to enable them to provide high quality care for service users. The redesign work is consistent with meeting this standard.

Organisational Change Policy will underpin the approach to be taken supported by workforce planning and development strategies. There would need to be a clear read across with the Local Delivery Plan, Workforce Development Plan and Operational Unit Delivery Plans. There may be implications for staff travel which would be considered as part of the next steps including through the Impact Assessment and onwards through organisational change process.

Updates have been provided to Staff Governance Committee, Highland Partnership Forum, Area Clinical Forum, Highland Health and Social Care Committee, NHS Highland Senior Management Team, and Raigmore Senior Management Team.

Meanwhile service will continue to be staffed and developed, as appropriate to ensure ongoing quality of care. At this stage it is too early to implement a workforce plan.

 Clinical Governance Clinical governance issues were considered as part of the options appraisal process, development of the clinical brief and as part of the clinical workshops. Any model of service implemented would be required to be safe, effective and evidence-based. There is significant clinical engagement and consensus in both areas. Implementation of the preferred options would support delivery of NHS Highland’s strategic objectives.

There are significant governance implications to delivering healthcare in a hospital environment which is not conducive easily meeting standards. Recent hospital inspections relating to healthcare environment, disability access, hospital security, fire safety and healthcare associate infection have all highlighted current risks. Mitigation has been undertaken but the aged structures have made this challenging. In order to make sure facilities remain safe to deliver services last year NHS Highland invested over £100k for maintenance alone.

Furthermore, clinicians have raised concern about potential risks of patient harm caused by resources split over several sites in the present arrangements. Effective clinical governance and application of the Highland Quality Approach including systems redesign, mistake proofing, and reduction in unnecessary waste and ability to lower the risk of patient harm will be far more effective in a redesigned service.

These risks will continue to be managed until any new arrangements are in place. It is anticipated that there will also be day-to-day operational issues to be managed and short- term decisions to be taken relating to e.g. failures in equipment, ability to meet standards, recruitment difficulties and affordability, with the present arrangements.

It is anticipated that there will be issues to be managed and short-term decisions to be taken relating to e.g. failures in equipment, ability to meet standards. Any decision will need to take consideration of the range of governance issues, financial impact, management of any risks and business continuity.

 Financial Impact A high level financial appraisal has been carried out. At this early stage the purpose was to look at likely overall affordability and which option would provide best value for money. A more detailed appraisal of costs will be undertaken as the project progresses to the next phase.

5 The service redesign is part of Local Delivery Plan. One of the key sections within the Local Delivery Plan is the Financial Plans for NHS Highland for the next few years.

The redesign work would be closely monitored through the Improvement Committee, Highland Health and Social Care Committee and Operational Unit Management Teams.

4 Risk Assessment

The redesign of service has grown out of a number of risks which have been identified around the current model of service. The proposals, if implemented, would address the risks arising from the current conditions of the hospitals linked to Infection Control and Fire Safety.

There are also current challenges around the delivery of care-at-home; and issues around sustainability of Out-of-Hours (nurse and medical cover and inpatient management). These risks would be addressed as part of the new arrangements. Individual components of the service redesign may be required to have specific risk assessment.

Financial risks have been identified around maintaining the status quo and there are now some wider potentially significant reputational risks if this work is not taken through to completion in a reasonable time-scale.

A new facility would be required to be built and this would require a suitable site to be secured.

5 Planning for Fairness

The impact assessment has been updated and is available on the website. Further detailed work would be required as part of design of any proposed new buildings.

Further work is ongoing, including establishing a local access and transport group and carrying out a Transport Survey.

There was one request for an audio version, one request for large-print consultation document and one request for a home visit during the consultation period.

6 Engagement and Communication

As set out in the full report the public consultation has been a significant engagement and communications exercise led and delivered by the operational unit supported by a number of departments. The public consultation ran from 21st April to 21st July.

In discussion with the Scottish Health Council a wide range of approaches were identified for use to raise awareness with the public, partners and staff about the consultation; what was being proposed, promotion of meetings and how people could make their views known.

These activities were set out in a communications and engagement plan which was regularly reviewed. The process was designed to be a responsive with capacity built in to meet anticipated requests as they emerged during the consultation.

During the course of consultation period staff attended over 50 meetings with events starting on the 24th April and concluding on 9th of July.

6 A total of 8,207 summary documents were issued (homes = 7,703 and businesses =502) via a mail drop to all homes and business areas.

Close contact was maintained with all stakeholders throughout including local groups, councillors, community councils, partner agencies, MSPs, Scottish Government, Scottish Health Council, local GP practices and staff.

An after action review has been arranged for 5th November with the Scottish Health Council. A local access and transport group has been established and has already held its first meeting.

7 Conclusion The changes being proposed offer the opportunity to bring about major service improvement consistent with national strategy and the Highland Quality Approach. This would provide modern services and represent better value for money. Implementing the preferred option would help to accelerate transformational change and further support integration of adult health and social care in its widest sense.

This is a challenging but exciting modernisation programme which would impact on communities positively for many decades to come.

Nigel Small, Director of Operations (South and Mid)

Maimie Thompson, Head of Public Relations and Engagement

26 September 2014

7 Proposed modernisation of community and hospital services in Badenoch and Strathspey

Report on formal public consultation

21st April to 21st July 2014

Nigel Small (Director of Operations South and Mid Operational Unit)

Maimie Thompson (Head of Public Relations and Engagement)

September 2014

#strathchat

www.nhshighland.scot.nhs.uk Contents

Summary conclusion and recommendation

Executive Summary

1 Background

2 Management of the public consultation process

3 Raising awareness of the public consultation

4 Feedback from meetings and events

5 Feedback from the consultation survey

6 Feedback on the consultation process

7 Feedback on the service model options

8 Feedback on sites

9 Assurance of the consultation process

10 Conclusions and next steps

Appendices

Appendix 1 – Summary details on the short-list of options

Appendix 2 – Overview of the NHS service change process in Scotland

Appendix 3 – Events and stakeholder meetings including updates to committees etc

Appendix 4 – Summary of points raised at meetings and events

Appendix 5 – Further work identified to understand future bed numbers

Appendix 6 – Option appraisal process to support site selection

Appendix 7– Update on local care-at-home activities

Appendix 8 – A summary of what is included in district profiles

Appendix 9 – Feedback on aspects of the proposals

2 Summary conclusion and recommendation

There is broad support from the wide range of stakeholders for the preferred option (option 3) and it is now being formally recommended to the Board for endorsement.

In coming to this view, the operational unit has sought to satisfy itself that people were comfortable with the consultation process and that there was strong support for the preferred option.

79% of people who responded to the survey agreed with the proposal to develop a community hospital and resource centre in Aviemore supported with wider development of community services.

This option also received backing from all four medical practices and partner organisations (The Highland Council, Scottish Ambulance Service, Scottish Fire and Rescue Service, Highlands and Islands Enterprise and the Highland Hospice).

Both public preference and the option appraisal process identified Site C – Technology Park - as the preferred site at this stage to develop any new hospital in Aviemore.

The consultation process has been endorsed both internally via the Highland Health and Social Care Committee and independently by the Scottish Health Council.

3 Executive summary

1 Services throughout NHS Highland need to change to make sure they meet the future needs of the population.

2 Within Badenoch and Strathspey some services are not strategically located nor adequately resourced making them not as effective or efficient as they need to be. In addition the two local community hospitals are old, not in good physical condition and not designed to meet modern standards.

3 Work has been ongoing over the past few years to look at these issues with a view to providing sustainable solutions in the future.

4 A local steering group including community councilors, service users, partner agencies, representatives from local groups, elected members, GPs, other clinicians, NHS Highland staff and others went through an options appraisal process during 2013/14 and agreed a short-list of three options:

Option 1 – Do minimum

Option 2 - Community hospital and resource centre in one town (‘hub’) and scaled-down services in the other (‘spoke’), based on existing hospital sites

Option 3 - Community hospital and resource centre in a central location

5 Option 3 was identified as the steering group’s preferred option. If implemented this would mean building a new community hospital and resource centre in Aviemore as part of a wider redesign and modernisation of health and social care services.

6 It would also include the re-location of Aviemore Health Centre, some other services located in Aviemore and the closure of both local hospitals - Ian Charles in Grantown-on-Spey and St Vincent’s in Kingussie. Any closures would be planned to take place after the new services were in place.

7 The Board of NHS Highland considered these proposed changes to be ‘major’ and therefore were subject to a period of formal public consultation. The Board approved the move to consultation at their meeting in March 2014.

8 The formal public consultation was launched on 21st April and ran for a total of 14 weeks until 21st July 2014. NHS Highland was consulting on the range of options including option three as the preferred option.

9 During the consultation period over 50 meetings and events took place and a summary document was mailed to every house (7,703 copies). Throughout the consultation there was a regular flow of information available for the public. All requests for meetings during the consultation period were accommodated.

10 There was active engagement from community councils, local councillors and other key local groups such as Friends of Ian Charles, Friends of St Vincent’s, Badenoch & Strathspey Community Transport Scheme and Local Access Panel

4 to name but a few. There was also wider and ongoing engagement with partner agencies, MSPs, local MP and others.

11 It is estimated that 500 people took part during the consultation. Of those who completed NHS Highland’s consultation response survey (176) there was wide- spread support for the case for change with almost 80% selecting the preferred option.

12 Positive feed-back on the consultation process and the preferred model of service was also received from partner agencies including the Highland Council, Scottish Ambulance Service, Scottish Fire and Rescue, Highlands and Islands Enterprise and the Highland Hospice).

13 In their independent report of the consultation process the Scottish Health Council concluded:

“Based on our review and feedback from local people we are satisfied that NHS Highland has followed Scottish Government guidance on involving local people in the consultation.”

“Overall, feedback received indicated that the majority of people had understood the reasons for change, how the proposals had been developed, and felt listened to and that there has been sufficient opportunities to take part in the consultation.”

14 Taking everything into consideration the operational unit can demonstrate broad support from the wide range of stakeholders for the preferred option (option 3) and it is formally recommending this option to the Board for endorsement.

15 Should the Board endorse the recommendation the next step would be for the proposals to be considered by the Cabinet Secretary for a final decision.

16 It was also clear from some of the feedback NHS Highland received (written correspondence, personal contact with staff and at meetings) that there were some people who had strong opposition about aspects of the proposed re-design (most notably but not exclusively in Grantown-on-Spey), and some topics of wider general concern (future services, transport, bed numbers, future use of buildings, care-at-home) requiring further consideration.

17 Should the proposal get the necessary endorsements further work would be required, particularly around some of the detail relating to the new hospital, delivery of care-at-home, transport arrangements and what would happen to some of the buildings.

18 This would all form part of the work required for the Business Case Process and would require ongoing engagement with all stakeholders.

5 1 Background

Main points covered in this section:  Background to the public consultation process including what is covered in this consultation report  Brief description of strategic context, local services and the conclusion of the options appraisal process  Major service change process and why public consultation was required

1.1 Introduction

This report specifically covers the three month public consultation into the proposed re-design of services across Badenoch and Strathspey.

It describes how the consultation was promoted, the range of ways that views were gathered, and an analysis of all the feedback.

It includes a summary of the feedback from NHS Highland’s consultation survey and the independent review of the consultation process by the Scottish Health Council.

The write-up of the options appraisal process on site selection is included. This work could only be completed after the consultation had closed.

Based on an assessment of all the supporting information a recommendation to the Board is made on model of service, location and site.

The report also sets out some of the next steps in meeting the guidance and describes some of the further work that would be required should the preferred option be implemented.

There would be a requirement for the Business Case process to be followed, in accordance with the Scottish Capital Investment Manual Guidance, which would mean an Initial Agreement document would be required for consideration by the Capital Investment Group.

Other specific work identified to take place includes:

 Setting out how Primary Care and community services (delivered through the four Health Centres) will be maintained and improved  Explore opportunities for co-location of children and families staff in any new facility  Further engagement on aspects of some of the proposals  Development of an Integrated Transport Plan  Strategic development and expansion of care-at-home services  Further work on older adults with mental health  Further modelling work on bed numbers  Further detailed work to develop the final clinical specification for the hospital  Carry out technical appraisal of preferred site

6  Collaboration with all concerned regarding the future use of any buildings no longer required by NHS Highland  On-going engagement with local communities and stakeholders throughout the development of the business case

1.2 NHS Highland Strategic Context

NHS Highland’s strategic framework was endorsed by the Board at its meeting in October 2010. It was founded on the Healthcare Quality Strategy for Scotland and set out NHS Highland’s vision of Better Health, Better Care and Better Value.

It was recognized that to achieve this vision would require some modernisation and re-design of services, including around community hospitals, older adult mental health services, care-at-home, care homes, extended community care and integrated teams.

NHS Highland reported at their Board Meeting in June 2011 around £74m of repairs, maintenance and upgrading work to bring buildings up to minimum national requirements. The most recent report shows the figure at £80m reflecting the additional estate now owned by NHS Highland since integration in April 2012.

In terms of Badenoch and Strathspey the associated back-log maintenance costs are currently estimated at £5.2million. Notably, however, due to the changing needs of the service and physical layout and condition of the buildings they would never be able to evolve to facilitate modern integrated services.

Although the physical condition of the hospital buildings and some of the equipment has created some pressing urgency around the review, there are also a number of other important considerations to be addressed including: ensuring safe and sustainable nursing and medical rotas, especially during the out-of-hours period, the need to increase care-at-home capacity, as well as more generally modernizing services to meet future demands.

It is within this strategic context, that the local review and re-design proposals have emerged.

1.3 Description of Local Services

The services under review fall within the locality of Badenoch and Strathspey. There are 13,472 people registered with the three General Practices in the area: Grantown- on-Spey, Aviemore and Kingussie. The Kingussie Practice also runs a practice in Laggan. The Aviemore Health centre hosts the out-of-hours centre for the locality.

As well as a full range of services provided by the General Practice, the local communities are also served by two community hospitals:

Ian Charles in Grantown is a 13 bedded, GP led hospital which is co-located with the health centre and modular dental facility. The hospital is supported by 24 hour nursing cover. Minor Injury services are also available at the hospital. There are a very limited number of consultant outpatient clinics and x-ray service.

7 St Vincent’s in Kingussie is split into two units. The lower floor is 10 bed GP medical unit. Upstairs is an Old Age Psychiatry unit which has seven inpatient beds and us used for psychiatric assessment. Both units have 24 hour nursing cover.

Since integration, NHS Highland now manages two care homes (Grant House in Grantown-on-Spey and the Wade Centre in Kingussie). In addition there are two private homes in the district: Mains House Care Home in Newtonmore and Grandview House Nursing Home in Grantown-on-Spey.

The area is served by multi-disciplinary teams (social workers, care at home workers, physiotherapists, occupational therapists, speech and language therapists, dieticians, community nurses, community mental health teams etc), who work out of a number of different bases.

The location of the main NHS Highland run health and social care services in Badenoch and Strathspey are shown (see map below).

No change to the location of health centres or out-of-hours arrangements are being proposed as part of the consultation, other than the recommended re-location of the health centre in Aviemore.

1.4 Development of Options and Conclusion of Options Appraisal

Full details on the process to develop and appraise possible options for the future were presented to the Board in March 2014. Details are available on the NHS Highland website and were described in the public consultation materials.

8 Three options were short-listed and the scoring identified option 3 as the clear preferred option (see box below). Further details on each option are summarised (Appendix 1).

Summary of scoring of options appraisal (scored out of 1000) Capital Running Option Description Score Rank cost costs

1 Dominimum 250 3 £5.2m £3.2m

Community resource 2 centre and hospital hub 463 2 £9m £2.3m and spoke

Community resource 3 913 1 £12m £2m centre and hospital hub

1.5 Major Service Change and Public Consultation

At a special meeting held on 4th March 2014, the Board considered the changes being proposed to be major. A requirement of proposed ‘major’ service change is the need to carry out formal public consultation for a minimum period of three months (Appendix 2).

CEL 4 (2010)1 provides guidance on informing, engaging and consulting people in developing health and community care services including requirements for a public consultation. This document also clarifies the role of the Scottish Health Council during service change which is to quality assure the engagement process and produce a report on their findings for the Board to submit to the minister, alongside the final proposals.

NHS Highland worked closely with the Scottish Health Council on the communications and engagement plan, the public consultation materials and the consultation survey.

In April 2014 the Scottish Health Council confirmed that they were satisfied with the arrangements NHS Highland had in place allowing the formal consultation to take place.

1 http://www.sehd.scot.nhs.uk/mels/CEL2010_04.pdf 9 2 NHS Highland management of the public consultation process

Main point covered in this section:  Internal and external leadership, management support and advice to set up, manage and oversee the public consultation

2.1 Background

The formal consultation was launched on 21st April and ran for a total of 14 weeks until 21st July 2014. Responses were accepted up until 28th July 2014.

People were given an opportunity to feedback on the three short-listed options or to offer a view on any alternative option. Moreover, the feedback form also allowed people to comment on specific elements of the proposal including a short-list of sites.

The decision making process was also described in the consultation materials and at events, meetings, correspondence, media and with the Steering Group.

2.2 NHS Highland Leadership and Management Support

The public consultation was led by Nigel Small (director of operations) supported by a small core team (Box below). A member of the core team was present at all of the meetings or events. This was to provide consistency in approach. The core team were also responsible for providing responses to any correspondence.

Members of NHS Highland core team and their lead responsibilities Name Responsibilities Notes Nigel Small Senior management leadership Point of contact for Board, Overview of process Scottish Government, Signing-off responses and media Scottish Health Council and releases local steering group Boyd Peters Senior clinical leadership Lives in Grantown-on-Spey Clinical advice Responding to clinical queries Kenny Project management Lives in Grantown-on-Spey Rodgers Financial advice including Project manager for Nairn endowments and business case Town and County new build process Maimie Project management Point of contact for Board, Thompson Advice on service change process Scottish Government, overview of engagement Scottish Health Council and Overview of communications local steering group including media John Bogle Site selection and options appraisal Project manager for new Advice on business case process build of Migdale Hospital Sue Blackhurst Co-ordination of all administration Point of contact for local for events and meetings steering group

10 2.2.1 Other NHS Highland staff and GP Practice staff Other staff including Jean-Pierre Sieczkarek (area manager), Margaret Walker (district manager), Dan Fraser (charge nurse at Ian Charles) and Debbie Ennis (charge nurse at St Vincent’s), Eric Green (head of estates) and Michael Waters (capital support and project manager) made important contributions throughout the process including attending some of the meetings.

Margaret Macrae, local staff side representative was also an active member of the steering group.

Practice managers provided support with raising awareness of the consultation and the Transport Survey. GPs were in attendance at each of the three public meetings.

Each of the Practices was also represented on the steering group.

2.2.2 Communications Team All three members of the public relations and engagement team played an active part in supporting the process including: handling media inquiries, issuing media releases, promoting the consultation through social media, designing posters and flyers, and management of website. They also took part in walkabouts in Newtonmore, Kingussie, Grantown-on-Spey and Aviemore.

2.2.3 Clinical Governance Team Staff in the clinical governance team were responsible for advising with the design of the consultation questionnaire and transport survey (hard copy and on-line survey).

They also input the data from the hard copies of the forms, carried out the analysis and wrote up the report on the findings.

2.2.4 Executive and Non Executive input Executive leadership was provided by Elaine Mead (chief executive), Deborah Jones (chief operating officer) and Nick Kenton (director of finance). This included attendance at some of the meetings and events and liaison with Scottish Government.

The Nairn, Badenoch and Strathspey District Partnership is chaired by a non executive director of NHS Highland.

The Highland Health and Social Care Committee (a key committee of the Board) is chaired by a non executive. They were responsible for providing internal assurance to the Board on whether, in their opinion, the major service change process had been followed.

Non executive guidance was also provided from Robin Creelman and Elaine Wilkinson. They provided “outside-eyes” to support the process but were considered to be impartial as they did not sit on the Highland Health and Social Care Committee.

11 2.3 Other Advice and Support

2.3.1 Local Steering Group The make-up of the steering group and how they have been involved is described in the consultation materials and their names and contact details are available on the website2.

The group were kept in regular contact throughout the consultation period through group emails and direct contact. Many members attended one or more events and also brought queries to the attention of the core team throughout the consultation and continue to do so.

A well-attended mid-review meeting of the steering group was held on 5th June. This was to get feedback from members on the process and to allow time to incorporate their suggestions. This formed part of NHS Highland’s mid-consultation review write- up.

The public consultation was also discussed at the NHS Highland Annual Review which was held on 9th June in Fort William. Two members of the steering group attended the event.

The Steering Group was also re-convened on 27th August 2014 to complete the options appraisal exercise on the potential sites. This could only be completed after the consultation closed because public preference was one of the criteria being used on which to make a recommendation about the sites.

2.3.2 Community Councils and Local Groups There was ongoing liaison with the community councils and local groups to support organising of meetings, promoting events and public meetings.

All community councils were also contacted to get copies of minutes of any meetings NHS Highland attended. This was so that the information could be included on the NHS Highland website and also be used to validate NHS Highland’s notes from any meetings.

2.3.3 Scottish Government NHS Highland has kept in regular contact with the relevant departments of the Scottish Government during the consultation process. Carmel Sheriff (performance manager) visited Badenoch and Strathspey on 14th May. The director of operations showed her round each of the facilities under review. This was followed up with a wider discussion on the consultation process with the chief executive and head of public relations and engagement.

2 To support this work NHS Highland followed advice from the Scottish Health Council. Existing groups and community councils were approached and asked to send representatives. We were also open to include anyone who expressed an interest to get involved and to date all requests to get involved have been accommodated. This will continue to be an ongoing and evolving process.

As per set out in the guidance clinical staff and those who have management responsibility for its provision were also involved. There is no definitive guidance on the optimum number of people, or the proportion of the various stakeholders who should take part. The board is required to determine what is “reasonable and proportionate”. There is a general comment, however that the group should neither be too small or too large.

12 In July 2014 Steven Hanlon, capital finance and policy manager visited the current facilities in Badenoch & Strathspey and also met local clinicians.

More generally regular capital review meetings are held with Mike Baxter, deputy director (capital and facilities) and colleagues and these have included briefings on the Badenoch & Strathspey re-design proposal.

Update reports were considered by Highland Health and Social care Committee on 10th July 2014 and 11th September, and were also shared with Scottish Government colleagues.

2.3.4 Scottish Health Council NHS Highland has worked closely with the Scottish Health Council (SHC) service change team. This included meeting regularly during the consultation period.

SHC staff attended a number of meetings and conducted their own independent review of the process including holding a focus group.

13 3 Raising awareness of the public consultation

Main points covered in this section:  Actions taken to raise awareness of the public consultation  Details on planned communication and engagement activities which took place during the consultation  Evidence that the management of the consultation was a responsive process

3.1 Introduction and Summary

In discussion with the Scottish Health Council a wide range of approaches were identified for use to raise awareness with the public, partners and staff about the consultation; what was being proposed, promotion of meetings and how people could make their views known.

These activities were set out in a communications and engagement plan which was regularly reviewed. The process was designed to be a responsive with capacity built in to meet anticipated requests as they emerged during the consultation.

Describing the extent of the communications and engagement activities during the consultation is particularly important. It provides the context from which to interpret the number of attendances at the meetings and numbers responding to the consultation survey.

It is estimated that around 500 people actively took part in the consultation. It is difficult, to give an exact number, however, because some people attended more than one event, some members of the public and staff who attended events also submitted responses, wrote letters and so on.

3.1.1 Summary Headlines

 During the course of consultation period staff attended over 50 meetings with events starting on the 24th April and concluding on 9th of July

 Close contact was maintained with stakeholders ]including local groups, councillors, community councils, partner agencies, MSPs, Scottish Government, Scottish Health Council, local GP practices and staff

 A total of 8,207 summary documents were issued (homes = 7,703 and businesses =502) via a mail drop

 NHS Highland issued regular media releases about the consultation, and paid for three adverts to be placed in the local newspaper

 Hundreds of posters promoting dates of events were distributed, numerous articles issued for local and NHS Highland publications, and websites

14 Summary of the main initiatives Raising awareness  Mail drop of summary consultation document to all homes  Articles in local publications  Paid adverts in local newspaper  Posters and flyers  Walkabouts  Media and social media  Home page of website  Feedback questionnaire with freepost address and envelope  Collaboration with partner agencies

Engagement activities  Attendance at all community councils  Drop-in events  Public meetings  District Partnership meetings  Friends of Ian Charles and St Vincent’s hospitals  Other meetings and events  1:1 communications (letters, e-mails, phone-calls and face-to-face)

A responsive process In response to local feedback, or at request of the Scottish Health Council, additional activities were organised which were not in the original plan and included:

 Three public meetings (Kingussie, Aviemore and Grantonw-on-Spey)  Four requested meetings (Sunshine Club, Kingussie Lunch Club, Church of Scotland Presbytery meeting and committee of St Vincent’s Therapy Gardens  Requested drop-in event (Newtonmore)  1:1 meetings/ discussion including home visit  Attendance at dualling A9 public exhibition (Aviemore)  Walk-about in Newtonmore, Kingussie, Grantown and Aviemore  Social media #strathchat  Further promotion on all the ways people could feedback  Two further staff drop-in events  Meeting with head teacher in Kingussie (offer to meet was also made to head teacher of Grantown Grammar School)

3.2 Consultation Documents and Dissemination

A summary consultation document and a full consultation document were prepared in discussion with the Scottish Health Council. They confirmed that the documents complied with the guidance.

The documents set out the preferred option, the options appraisal process and advantages and disadvantages of the short-listed options.

15 They also highlighted how people could make their views known. The NHS Highland web address and named points of contact with email addresses, telephone numbers and postal address with free-post were included.

The intention of the documents was always to be generic and reasonably high level; hence all services and organisations were deliberately not listed. It was felt that had this been attempted then inevitably some would have been missed.

There was one request for an audio version and one request for a large print version.

3.2.1 Distribution of Consultation Materials A total of 8,207 summary documents were issued (homes = 7,703 and businesses =502) via a mail drop. This took place during the week beginning 19th May. It should be noted that this exercise is not a formal requirement, nor NHS Highland understands, is it usually carried out. The decision to take this step was to provide the best assurance that all homes and businesses in the area had the opportunity to be informed.

The documents were also widely distributed initially including:  Hospitals (St Vincent’s and Ian Charles)  GP Surgeries/Health Centres (Laggan, Newtonmore, Aviemore and Grantown on Spey)  Care Homes (Wade Centre in Kingussie and Grant House in Grantown-on-Spey)  Glen Day Care Centre in Aviemore)  Pharmacies (Aviemore, Grantown-on-Spey and Kingussie)  Dental units (Aviemore, Grantown-on-Spey and Kingussie),  Service Points (Aviemore, Kingussie and Grantown-on-Spey)  Outpatient department in Raigmore Hospital  All events and meetings.

Further distributions were carried out by NHS Highland staff during the process including as part of a walkabout, as well as being widely advertised, and more generally as and when opportunities presented, visits to the area

3.3 Partner Agencies

During the consultation the director of operations has met with Scottish Ambulance Service (21st May) and Cairngorms National Park Authority (CNPA) (30th May and 10th September). These have both been very positive with early engagement appreciated and clear opportunities for joint working. This dialogue has been ongoing and further meetings have taken place and are planned.

There have also been discussions with Transport Scotland including being informed on the plans for dualling of A9.

As well as local meetings, a letter was also sent from NHS Highland chief executive to a number of organisations including: The Highland Council, The Scottish Ambulance Service, Cairngorms National Park Authority, Highlands and Islands Enterprise, The Highland Hospice, Scottish Natural Heritage, Police Scotland, Fire Service and the Highland Third Sector Partnership.

16 3.4 Voluntary, Third and Independent Sector and Others

There has also been direct contact with a number of local groups including Badenoch and Strathspey Transport Group, Badenoch and Strathspey Access Panel, Friends of Ian Charles and St Vincent’s, Kingussie Therapy Garden Volunteers, Advocacy Highland, Age Concern, Badenoch Arthritis Support Group, Reshaping Care for Older People, Highland Third Sector Interface. Highland Home Carers, HUG, Mumsnet and Senior Citizen Network.

3.5 Direct e-Mailing and Mailing

A list of relevant local organisations and named contacts was drawn up and were emailed on 25th April, with links to the consultation materials and an offer to meet.

A further e-mailing was carried out to people who have relevant contracts with NHS Highland in Badenoch and Strathspey, and this was repeated towards the end of the consultation. This included Dachaidh Community Support Ltd, Deaf Action, Grandview House, Richmond Fellowship, Hanover (Scotland), Able Care, Carr Gomm and Speyside Trust.

Local presbyteries and dioceses were also contacted (through Derek Brown, Chaplain).

3.6 Advertising and Promotional Activities

Various posters and flyers were prepared and widely distributed throughout the area. These retained the same brand as the summary consultation document. The purposes of these were to (i) raise awareness of the consultation in general and (ii) promote the dates of the various consultation activities.

Small adverts (free) were also prepared and issued to local groups during the first two weeks with community newsletters, websites and social media (as detailed in the plan). All information carried the NHS Highland web address and contact details. These were issued early in the process and followed up with local media and social media as well as on the NHS Highland website.

In addition three paid adverts were placed in the Strathspey and Badenoch Herald (week beginning 5th May, week beginning 19th May and week beginning 16th June) and were also promoted in the various media releases.

Local groups and contacts also did their own awareness raising. As an example, for instance, in advance of the Carrbridge event (29th May) a local point of contact, confirmed on 20th May:

“Just to let you know that I have put up Notices in the Village Hall and outside our Village Hall about Carrbridge Consultation events.”

A further suite of posters were prepared to promote the public meetings. Members of the steering group, Friends of Ian Charles, community council members and a local councillor carried out the local distribution. These were also available on the website.

17 Following on from the mid-way review with the Steering Group (5th June 2014) further promotion was done on all the ways people can feedback including an advert in the local paper (19th June).

3.6.1 Walkabout On 27th May a member of the NHSH Highland communications team carried out a walkabout in Newtonmore, Kingussie, Aviemore and Grantown-on-Spey with the aim of providing a direct spot-check of levels of awareness of the consultation in these communities.

He spoke to around 50 people of wide age ranges and in a number of different community settings. A total of 26 full consultation documents and 43 posters were handed out including providing dates of consultation events.

Following feedback from the steering group a further walkabout was carried out in Grantown in June.

3.7 NHS Highland Website

The consultation was promoted on the NHS Highland website with all the background information, consultation materials and a calendar of events.

The links were also sent to others to display - GP Practices, local community websites, Highlife Highland, and other relevant organisations. Some examples of the links are provided below: http://www.aviemoremedical.co.uk/latest_news.htm http://www.grantownonspeymedicalpractice.co.uk/ http://carrbridgenews.co.uk/ http://highlifehighland.com/health-wellbeing

18 3.8 Media, Social Media and Other Publications

3.8.1 Media releases The following have been issued before, during and after the consultation:

1. New group targets improved transport links – 12th September 2014

2. Health Board completes Badenoch and Strathspey consultation - 28th July 2014

3. Feedback welcome on hospital sites - 20th June 2014

4. Public consultation reaches half way stage – 4th June 2014

5. Dates for three public meetings announced - 20 May 2014

6. Public urged to take part in consultation - 6 May 2014

7. Badenoch & Strathspey District Partnership meeting 24 April - 16 April 2014

8. Public to have their say on proposed new hospital - 15 April 2014

3.8.2 Letters Published in Strathspey and Badenoch Herald

At the time of writing the report 10 letters have been published since the public consultation got underway:

18th September 2014 Hospital future should also be put to the vote – Leonard Grassick (Grantown-on- Spey)

14th August Migdale a model hospital to imitate - Geoff Smith (Grantown-on-Spey)

(A visit to Migdale Hospital was arranged for Mr Smith to see the new facility)

31st July Making the case for keeping the hospital open – Leonard Grassick (Grantown-on- Spey)

Make sure you voice is heard – Cllr Bill Lobban (Aviemore), 2014

Cuts needs to be balanced against needs - Ian Maclean (Grantown-on-Spey)

Deflated after hazy answers – Geoff Smith (Grantown on Spey)

10th July Consultation period should be extended Leonard Grassick (Grantown-on-Spey)

19 26th June NHS chief’s comments worth considering - Leonard Grassick (Grantown-on-Spey)

19th June 2014 Cash bond could be way forward in building Aviemore hospital complex- Geoff Smith (Grantown-on-Spey)

Status quo for health centres – Dr Boyd Peters (Grantown-on-Spey)

3.8.3 Social Media (Twitter and Facebook)

Events and materials were promoted through NHS Highland twitter account (@NHSHighland) as well as through head of public relations and engagement (@nhshmt).

Twitter and Facebook accounts were identified for relevant local communities and these were also used to promote the consultation.

Events were scheduled into Twitter and promotion is ongoing through #strathchat

3.8.4 Other NHS Highland publications

The consultation process was also promoted through other publications including HighLights, GP Practice Newsletters and NHS Highland Annual Review (9th June 2014) and NHS Highland News.

3.8.5 Face to Face – Meetings, Events and Groups During the course of the consultation NHS Highland staff took part in around 50 events and meetings and included three public meetings (Appendix 3).

One request to meet a member of the public in their own home in Kingussie was also received and this took place during the consultation.

All requests for meetings during the consultation period were accommodated.

At least one member from the core team (Nigel Small, Boyd Peters, Kenny Rodgers and Maimie Thompson), has always been in attendance at each event.

Example of some Feedback

Kingussie Community Council Meeting,6th May 2015

“Thank you for coming down to Kingussie last night. The presentation and the question and answer session, from the "non-professional" viewpoint was excellent. Interestingly when I took round the posters and consultation documents people immediately opened them and starting reading - always a good sign! I also spoke to others there and the feedback was extremely positive.“ “Thank you for last night - thought the presentation was very good. It is not easy to

20 explain all the steps taken and decisions made and still reassure those who have not been involved that they have a voice and their views still count, but you did it admirably. Thought the discussion and suggestions made by the KCC were good.”

People attending the events had the opportunity to take away a consultation response form (and freepost envelope) and were encouraged to feedback their views and also to make contact with the Scottish Health Council.

They were also advised they could write to NHS Highland if they found that a more helpful way to make their views known.

3.9 MSPs and Local Elected Representatives

There has been regular contact with MSPs throughout the process via email and Face-to Face. All MSPs were sent an email on 25th April updating them on the consultation and asking for them to support people taking part with one responding:

“It’s great to see this level of community engagement” MSP, April 2014

A meeting was held on 28th May 2014 when the chair of NHS Highland provided an update; no concerns were raised at this stage.

They were also e-mailed a copy of the mid-way review report (6th July) and updates after the consultation closed (28th August and 17th September).

Dave Thompson MSP for Skye, Lochaber and Badenoch is also on the mailing list for the Steering Group. Fergus Ewing (MSP for Inverness and Nairn) and Minister for Energy, Enterprise and Tourism has a branch surgery in Grantown-on-Spey and has been involved in the discussions relating to transport.

A media release was also issued by Danny Alexander MP for Inverness, Nairn, Badenoch and Strathspey on 7th July encouraging residents to take part in the consultation.

Lib dem urge B&S residents to take part in consultation - 7th July 2014

All four local elected members are active participants on the Steering Group and Transport Group. They have been in regular contact with the core team to help facilitate engagement. They are on record as being positive about the process to date.

3.10 Staff/GPs and Practice staff

The formal consultation got underway with a series of drop in events at St Vincent’s and Ian Charles Hospital, Wade Centre (Care Home in Kingussie), Grant House (Care Home in Grantown-on-Spey) and Glen Centre (Day Centre in Aviemore). This was facilitated by the director of operations and around 40 staff attended the sessions. Further drop-in events were held during the consultation.

The head of public relations and engagement also visited all the NHS Highland facilities including GP Practices on 13th May. This was to discuss displays and dissemination of consultation documents, issuing travel surveys, posters and other

21 consultation materials. Charge nurses, practice managers, care home managers were all engaged and showed high level of awareness and support for the process.

In addition staff and staff side representatives are involved in the Steering Group and a range of other activities and staff have attended a number of the events. The re- design has been an agenda item on various operational unit meetings.

Two workshops for all clinicians have been held. These were facilitated by an independent health care planner. Further work is ongoing.

Dr Boyd Peters (Locality Clinical Lead) has also been liaising with all four Practices to look at how any new potential model of service might impact upon their ways of working. Several meetings have been held so far and more are planned.

22 4 Feedback from meetings and events

Main points covered in this section:  Method used to summarise feedback  Summary of feedback from public meetings  High-level summary of all feedback  NHS Highland response to feedback

4.1 Introduction

During the course of consultation some 50 meetings and events were attended, including 10 community council meetings; nine public drop-in events, three public meetings and various events for staff (Appendix 3).

The main purpose of these events was to allow further opportunities to present the case for change; the reasons the preferred option was selected and to answer any questions or understand any concerns.

It was not intended to “sell” the preferred option, nor to negotiate on possible changes to the model or options. Any new proposals or modification to proposals would come later once the analysis to all the feedback has been considered and debated.

4.2 Method: Process for Documenting Feedback

Hand-written notes were taken during each meeting and these were then typed up as bullet points. For the public meetings, and any other specifically arranged meetings, steps were taken to have the notes validated by a non NHS Highland participant.

Minutes of community council meetings were put onto NHS Highland website as they became available.

After the consultation closed the head of public relations and engagement and operational unit head of finance reviewed all the feedback. All comments were categorised to allow some high–level groupings.

4.3 Public Meetings

In discussion with the Scottish Health Council it was agreed to hold three public consultation meetings. These were arranged towards the end of the consultation period. A reporter from the Strathspey and Badenoch Herald was in attendance at the meetings in Kingussie and Grantown-on-Spey.

4.3.1 Kingussie The first public meeting was held in Kingussie on 25th June. Nine people attended including hospital staff, a GP and Scottish Ambulance Service. Two members from the Scottish Health Council were also present. There was full discussion on bed numbers, dementia, transport and what would happen to staff should the preferred option be implemented.

23 There was also a discussion on centralisation of services. The difference between centralisation within Badenoch and Strathspey as opposed to Inverness was discussed. In common with many other meetings and drop-in events, what would happen to the existing buildings was a source of some concern. There was also consideration of the Therapy Garden and Burrell Fund for St Vincent’s.

4.3.2 Aviemore 16 members of the public attended the Aviemore public meeting on 1st July. There was also a GP and practice manager. Topics discussed included sites, future services, future-proofing, transport and beds.

4.3.3 Grantown-on-Spey The public meeting in Grantown-on Spey was the best attended meeting of the consultation with around 80 people. Local GPs, NHS staff, Scottish Health Council staff were also in attendance at the meeting which took place on 2nd July 2014.

There was a range of views both in support of the proposal as well as some strong opposition to parts of the proposal. The main concern expressed was around the proposed closure of Ian Charles Hospital, and in particular loss of in-patient beds. The importance of developing care-at-home capacity was also discussed.

NHS Highland representatives provided responses to a range of other topics raised covering the service model, finance, single rooms, care-at-home, care home provision, end of life care as well as the overall need for change.

4.4 Findings: high-level summary of the feedback

Table Summary of responses by category and frequency Theme No Percent Additional services 31 16% Transport and access 23 12% Existing Services/buildings 22 11% Bed provision and numbers 21 11% Site proposal 19 10% Finance and endowments 16 8% Care Homes/Care at Home 14 7% Staffing 12 6% Population 9 5% Alternative proposals 8 4% Other (*) 8 4% Process 7 4% Palliative care 6 3% Grand Total 196 100% (*) other includes: respite, maternity, integration and housing

24 4.5 NHS Highland response to Feedback

All of the issues raised were summarised together with NHS Highland responses which were provided at the meetings (Appendix 4). These are analysed in this section of the report.

NHS Highland has been cautious about going too far to explore solutions to some of the issues raised. This is an important point to note. Neither the operational team, nor the steering group, wished to prejudice the outcome of the consultation.

In some cases, such as transport and access, there are already challenges being raised and so further work will be required regardless of the outcome of the consultation.

4.5.1 Additional Services While it was always made clear that the re-design was much wider than hospital services there was significant interest in what services would be in any new facility. It was raised at some meetings that there was not enough detail around the clinical model. This was acknowledged but it was also explained that further detailed work would be required to support the Business Cases.

There was general support to provide more services within Badenoch and Strathspey and the sorts of things being considered included chemotherapy, infusions, and out- patient clinics.

Some of the suggestions for additional services, for instance, Theatres, 24/7 A&E, maternity indicated a lack of understanding of the distinction between a community hospital and rural general hospital. The importance of explicitly considering children and young people’s services was also highlighted. These points were also raised in the Highland Council submission.

More generally NHS Highland needs to be clearer on using consistent terminology and understanding about the level of service being provided relating to casualty, minor injury and A&E services. Through the public consultation it has been highlighted that there needs to be clarity around the use of the term A&E (including from NHS Highland communications).

This is an issue which needs to be clarified across all parts of NHS Highland and will need to be followed-through with a review of all communications on this matter such as website, literature.

4.5.2 Transport & Access NHS Highland is not a transport provider but the opportunities to use the redesign of services to improve transport and access issues were recognised. Clearly people have to be able to access any facilities that exist or are developed. Any changes should take actions to reduce any inequality gaps that currently exist.

From the feedback the vast majority of people don’t currently use public transport to access services, arguably because the service is very limited. Further work will be required, however, to make an assessment as to whether patients, families, visitors and staff would use public transport were it more readily available. This would have

25 some bearing on, for instance, the number of car parking spaces required at proposed new facility.

More generally further steps need to be taken to reduce people having to travel in the first place. In the future more outpatient consultations will be replaced with alternative approaches such as with video-conferencing, or telephone and e-mail support.

Making sure the right community and home based service are in place will also mean people have to spend less time in hospital, further reducing the need for travel.

A transport and access plan will need to be developed to support the business case process and a group has already been set-up to lead and co-ordinate the work. They held their first meeting in September.

The group is made up of officers and elected members of The Highland Council, and representatives of NHS Highland, Cairngorms National Park Authority, the Scottish Ambulance Service, Badenoch & Strathspey Access Panel, Badenoch & Strathspey Transport Company and Voluntary Action Badenoch & Strathspey and community representatives. The Highland Council has recently submitted a proposal for additional investment to pilot new approaches to transport provision. A decision from Transport Scotland’s Business Development Fund on the bid is expected in the next few months.

4.5.3 Existing Services and Buildings

4.5.3.1 Services The consultation meetings and events provided further opportunities to clarify what services won’t be changing. For instance it was clarified that:

 GP services will remain in Grantown and Kingussie  Ambulance services will remain in Grantown and Kingussie  Physiotherapy services will be retained at Grantown and Kingussie  Dental services will remain in Grantown  Minor injury service will remain in Grantown  Out of hours services would be provided from the new hospital  Some staff providing children’s services will be located in the new building and some services will also be provided  The existing building, services and equipment will be maintained, as far as possible, until such time new arrangements are in place and subject to the caveat of being able to recruit staff and be affordable

4.5.3.2 Clinical Governance and Management of Risks Clinicians have raised concern about the potential risks of patient harm caused by resources split over several sites in the present arrangements. This is one of the drivers to support changes. Effective clinical governance and application of the Highland Quality Approach including systems redesign, mistake proofing, reducing waste and lowering the risk of patient harm will be far more effective in a re-designed service.

26 In the covering paper to be presented to the board in October the management of some of these risks will be briefly described.

Going forward it is also anticipated that there will be operational issues to be managed and short-term decisions to be taken relating to e.g. failures in equipment, ability to meet standards, recruitment difficulties and affordability, under the present arrangements.

Any decision will need to take consideration of the range of governance issues, wider re-design of services, pressures on Raigmore Hospital and general management of financial pressures.

The operational unit is fully aware of other strategic and operational considerations such as wider discussions relating to dental services, MSK review, transforming outpatients, older adult mental health services, strategic overview of radiology and diagnostic services and the Inverness Master Plan. Over the next two to three years other work may be identified.

The work to redesign services has had active input and support from local clinicians including GPs and their staff, hospital and community nursing staff and AHPs. An external healthcare planner has been involved and met with clinicians to help define the proposals. Local clinicians will continue to be consulted and involved as the project moves through its various stages to completion.

4.5.3.3 History There was significant interest in both the history and future use of the buildings, particularly both hospitals. During the consultation NHS Highland was able to confirm that the buildings are not listed.

There was recognition about the importance of honouring the past and making sure the heritage of the hospitals is safeguarded. NHS Highland set out their commitment to this in the consultation materials and this was reinforced during the consultation events, meetings and correspondence. There is ongoing contact with relevant stakeholders including authors of “History of Highland Hospitals”.

Moreover it was raised at the Grantown-on-Spey public meeting (and followed up by letter) that NHS Highland had not taken into account the different histories of both local hospitals.

4.5.3.4 Therapy Gardens Meetings have already taken place about the Therapy Garden at St Vincent’s and the key people who can support this work have been identified. There is commitment to look at providing Therapy Gardens both in Kingussie as well as in any new facility. From past experience the core team has identified the need to think about such facilities early in the process and not as an add-on. This approach has been welcomed by the local group.

4.5.4 Bed Provision and Numbers There were some concerns raised about the number of beds proposed and in general a feeling that more beds would be required to future-proof the service.

27 NHS Highland made it clear that the final number of beds had not yet been finalised but initial work to inform the public consultation suggested the requirement would be around 20-25 beds.

In coming to a final view important considerations would include:

 Further modelling work as set out in Appendix 5  Confidence in being able to increase care-at-home capacity;  Development of care home to include step-up/step-down beds  Agreement on preferred model for supporting people requiring adult mental health assessment and rehabilitation

Although there is a general perception that future-proofing must mean “more” in fact the review of historical data shows that over the years NHS Highland has reduced the length of stay and number of hospital beds (Charts below).

NHS HIGHLAND No. of hospital beds 1986 to 2010

3 500

3 000

2 500 s d e b

l 2 000 a t i p s o h

f 1 500 o

. o N 1 000

500

- 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year

28 Observed and expected bed days by type of admission and day case numbers; NHS Highland residents by financial year end period 2000 -2013*

Data source: SMR01 (Acute and General Hospital activity for inpatients and day cases) and NRS Mid- year population estimates, 2000 -2012 (revised series) * Expected activity calculated by applying age specific rates of bed day use and day case attendance of NHS Highland residents in 1999-2000 to mid-year population estimates

It was clarified that there are no proposals to include maternity beds due to their being insufficient demands to enable practitioners to maintain their skills.

4.5.5 Site Proposal There was interest in the sites, particularly around the size of sites and how were the sites short-listed. This was covered in the consultation materials with the final conclusion of the process set-out in section 8 and Appendix 6.

Further detailed work will be required in terms of design, access to the site and access in the building. This would involve engagement with all stakeholders

4.5.6 Finance including Endowments There were a number of queries relating to finance such as how much would the building costs and how developments would be funded.

It was explained that the final figures would not be known until the full extent of the accommodation is described, the site purchase and development costs are known and commercial negotiations concluded. However NHS Highland is working on a budget figure of £12million to £15million which is based on other similar facilities recently developed in Highland. NHS Highland is closely following the Scottish Government process for capital investment and funding options would be explored as part of the business case process.

29 In terms of endowments, The Theresa J Burrall legacy will continue to be used for the benefit of St Vincent’s hospital until such a time that the hospital becomes non- operational and the terms of the legacy cannot be met. NHS Highland Endowment Fund Trustees would then need to apply to the courts to determine the future use of the legacy.

The advice from NHS Scotland legal office confirms that the legacy could potentially be used for the benefit of a different hospital and/or the community where the services are currently provided to benefit local people in the future.

Any future decisions would be progressed by a local group from within the Kingussie area under the responsibility of NHS Highland and with close reference to NHS Endowment Fund regulations and the legal framework.

4.5.7 Care Homes and Care-at-Home There are no plans for NHS Highland to open new care homes in the area but there are ambitions to look at developing both existing care homes and more generally to work more collaboratively with the independent sector.

NHS Highland has been taking a number of steps to try and improve the immediate situation with care-at-home including advertising more posts, working with the independent sector and our own staff doing over-time, but the current situation remain challenging clearly highlighting that doing more of the same is not the answer (Appendix 7).

NHS Highland and others recognise the need to think differently by looking at new roles, developing apprenticeship schemes, offering better pay and conditions and improved career structures.

This is going to be a growing challenge and one which NHS Highland cannot fix on its own. We will continue to work with individuals, families, staff, local communities, independent and third sector organisations to see how together we can develop more effective and acceptable solutions.

Notably only option 3 would release funding to make significant investments into the care-at-home and wider community services.

4.5.8 Staffing Members of the public, community councils and others also expressed interest and some concern around future staffing arrangements. Throughout the consultation process there was consistent praise for the existing culture of care and a plea for that not to be lost.

Questions relating to redundancies, staff travel, who would provide medical cover in the new hospital and whether local builders were used were all answered by the consultation team (Appendix 4).

4.5.9 Alternative Proposals Some people felt strongly that both existing hospitals should be upgraded and were off the view that it would cost less.

30 As explained in the consultation materials the work carried out by NHS Highland estates and clinical colleagues highlighted that up-grading the existing buildings would never provide the standards required for modern healthcare. Modernising what currently exists would not bring the benefits of co-locating services nor enable the improvements in community care which are required.

Two people thought that there should have been an option to have a range of services available in all three main centres (Aviemore, Grantown-on-Spey and Kingussie.

4.5.10 Population People wanted to know whether projected population increases (An Camas Mor, seasonal visitors etc) had been considered and also had use of services by age- range been considered (*).

Public Health colleagues, service planners and experienced health care planners have all been considering this matter as part of planning for the future. This includes preparing district profiles (Appendix 8). These have been designed to assist services in the assessment of the health and social care needs of the populations. It will also be considered as part of the bed modelling work (Appendix 5).

There are variations between communities that need to be factored in. Aviemore has done the most expanding (20% rise in practice population in 10 years); yet the over 65-population has not significantly increased. The majority of the new housing tends to attract younger people, often families, therefore this has considerations for services for children’s and families (and of course schools). In terms of health, these services are usually delivered through health centres and were one of the arguments for building a new health centre in Aviemore as part of the proposals.

Equally people in Grantown-on-Spey wished to highlight that they have a higher percentage of older people and feel that losing in-patient facilities will compromise the needs of older people needing hospital care.

(*) – A statement on this matter was also raised at the Grantown-on-Spey public meeting and followed up by letter (dated 18th July). Letter was passed to public health colleagues (see also appendices 5 and 7). Detailed analysis has been completed by Public Health and confirmed that the profile of older populations is not unique to Grantown-on-Spey.

4.5.11 Other topics Palliative care, dementia, respite, supported housing were some of the other issues raised during events and meetings.

31 5 Public Consultation: Feedback from Survey

Main points covered in this section:  Summary of who responded to the consultation survey  Feedback on the consultation process, service model and possible sites

5.1 Introduction

As part of the public consultation a survey was designed to capture feedback on the consultation process, service model options, and possible sites. These are explored in more detail in sections six, seven and eight respectively.

A copy of the full report is available on the NHS Highland website and the key results are summarised below:

176 responses were received; 62 were online and 114 were paper based.

5.2 About the Respondents

 60% were aged between 60 and 80  60% were female  27% had a long term health condition or disability  13% indicated that they were carers  3% had stayed in St Vincent’s Hospital in the last 12 months  2% had stayed in Ian Charles Hospital in the last 12 months

5.3 Summary Findings

 Responses were received from residents from across the area, with Aviemore residents providing 35% of the overall (63 responses)  Responses were positive about the amount of consultation and associated materials

 In rating aspects of the proposed changes o ‘Improving community transport’ received the most support (94.2%) o ‘Closing in-patient beds in Ian Charles hospital’ received the least support (53.8%)

 Option 3 –the preferred service change option was supported by (78.5%)

32  If option 3 is implemented, the preferred site was the Technology Park (63%)

 88% of respondents have access to or own a car 6 Feedback on the Consultation Process

Main points covered in this section:  Summary of feedback on the consultation process collected from a number of different approaches:

6.1 Introduction

Feedback on the consultation process was captured by NHS Highland via a number of routes:

 consultation survey  events and meetings  correspondence from members of the public  Partner agencies, community councils and groups

The Scottish Health Council, however, also carried out their own independent survey (section 9).

6.2 Responses to NHS Highland survey on consultation process

NHS Highland’s consultation survey included a section on the consultation materials, events and how they were informed about the consultation. The main findings were:

 People said they had found out about the consultation through a number of ways including the mail-drop, local newspaper, direct from staff, website/social media and local councillors.

 Just under three quarters (73%) said they had received a copy of the summary consultation document; 17% and 10% said they had not or were unsure, respectively.

 Almost nine out of ten people who responded (89%) said they had read the summary document and over half (56%) said they had read the full document.

 Nine out of ten people responded that they felt that the consultation materials had given them enough information about the proposals and case for change.

 There were mixed views about which events were most helpful and more than half said they did not attend any events.

33  People had the opportunity to comment on whether NHS Highland had taken reasonable efforts to involve and inform local people about the proposed redesign of services (Box). Over eighty percent (82%) responded positively.

Do you feel NHS Highland had taken reasonable efforts to involve and inform local people about the proposed redesign of services:

Response Percent Number Toagreatextent 57 88 To some extent 25 42 Neutral 9 15 Not really 7 12 Not at all 2 3 100 160

6.2.1 Comments The following responses were taken from groups who responded to the consultation response survey in relation the question

“Do you feel NHS Highland has taken reasonable efforts to involve and inform local people about the proposed re-design of services?”

 Scottish Fire and Rescue Service, Highland area

Yes to a great extent

 Cairngorm Ski Patrol

Yes to some extent

 St Vincent’s Therapy Garden

Yes to a great extent.

“There have been meetings across B&S where people could attend and hear more. There have been articles in the local paper and telephone number and contact details for further information.”

 Community Councils

Responses to the survey were received from four community councils. All responded positively:

Yes to a great extent.

6.3 Feedback via letters from members of the public

34 Feedback from correspondence was themed and some points on the consultation process were highlighted:

 Should have been details on the options that were discounted  Don’t favour questionnaire for providing a response  Don’t like the use of age-bands  Critical of consultation form – too much on process  Disappointed that the consultation document didn’t say more about Independent Sector  Should have been public meetings three years ago, public meetings should have been at the start of the process, people are confused  Consultation was a waste of time and biased towards medical staff

6.3.1 Letters published in Strathspey & Badenoch Herald Several letters have been published which included issues relating to the consultation process:

18th September 2014 Hospital future should also be put to the vote – Leonard Grassick (Grantown-on- Spey)

26th June NHS chief’s comments worth considering - Leonard Grassick (Grantown-on-Spey)

In terms of the consultation process Mr Grassick includes the following comments in his letter:

“There has been a poor response to the drop-in sessions and correspondence to NHS Highland on the plans to redesign local healthcare services but this is understandable in the circumstances.

“Locals have been bulldozed into submission by all the literature provided, including asking which of the four preferred sites for a new hospital in Aviemore they prefer.”

“Residents across Badenoch and Strathspey should have been given the chance to discuss this option at a very early stage and there could have even been a vote on this inclusion.”

10th July Consultation period should be extended Leonard Grassick (Grantown-on-Spey)

“The consultation period on this crucial matter should be extended. NHS Highland needs to take a step back and figure out how they will cope with care in the community without the excellent facilities at Ian Charles.”

31st July Making the case for keeping the hospital open – Leonard Grassick (Grantown-on- Spey) 31st July 2014

This letter includes a comment about the make-up of the steering group:

35 “I have been looking through the contact list for the hospital development group and it looks top heavy with medical personnel and no sign of the ordinary working person being given a place on it.”

Make sure you voice is heard – Cllr Bill Lobban (Aviemore) Cllr Lobban’s letter includes the following comment:

“The NHS consultation process, has when compared to other consultations for example the Highland Council, been exemplary and is on-going but I would implore residents to please make your individual voice heard otherwise we may end up with something that none of us wants.”

6.4 Feedback received from participants at events

Some points specifically relating to the consultation process were raised at some of the meetings and events, as follows:

 The consultation outcome has already been decided “done deal”  What are the time-scales?  There should have been a fourth option (*)

(*) –Two people felt strongly that there should have been more detail covering why options had been excluded: what the options were and on what basis were they excluded (see also below). In their report the Scottish Health Council also suggested that it would have been helpful to have provided some information on all the issues considered.

More generally there were a number of queries around why sites were being considered at this stage. Some felt that this must mean that a decision had already been taken “done deal”.

It was explained that having identified a preferred option this was a requirement of the process. As NHS Highland had anticipated that this would be a query/concern it was included as part of the standard presentation.

6.5 Feedback comments from the survey

“The Group has a significant presence of Health Care professionals. It is therefore not surprising that Option 3 is preferred. It is the option proposed and developed by the Health Care Services for the Health Care Services

From outset I thought that the option of improving the services and facilities to the required level for now and the future at all three centres should have been included. Whether the Steering Group considered, discussed, explored, fully costed and then dismissed this option is not known. To state now that this option is not affordable or sustainable is not acceptable”.

(Further feedback on this matter was also received by the same respondent via email).

6.6 Feedback from partner agencies

36  Highland Council

“The Ward 21 Elected Members have been fully engaged in the consultation process which they feel has been carried out in a thorough, inclusive and comprehensive manner with a good level of community engagement. Members have a good track record of attendance at stakeholder meetings and consultation events.

“They have observed the consistent approach taken by NHS Highland Senior management and have said that the director of operations and his team should be congratulated for the exemplary manner in which they have conducted the work. There has also been recognition at a local level for the work done by Dr Boyd Peters.”

 Highlands and Islands Enterprise

“We acknowledge and welcome the extensive consultation and engagement processes undertaken by the NHS to secure community views such that communities affected by the future changes can inform and shape their service provision.”

 Highland Hospice

The Highland Hospice commented that it was “good to see such a wide and open consultation with local people”.

6.6 Feedback from NHS Highland local staff side representative

A Staff side representative was on the steering group and attended many of the meetings.

“I am certainly happy to endorse the process and feel that staff have been kept very well informed.”

37 7 Feedback on Service Model Options

Main points covered in this section:  Feedback on the short-list of options and aspects of the proposed changes from a range of sources:  Consultation survey  Open responses  Partner agencies  Local GP practices

7.1 Introduction

Throughout the process people were encouraged to make their views known after they had considered the relevant information and had responses to any queries.

7.2 Method

The consultation response form was agreed with the Scottish Health Council and included a section on the proposed changes and options.

Issues relating to the service model options were also raised at meetings, events and correspondence.

7.3 Results

7.3.1 Feedback on preferred option Over three quarters (78.5%) of people who responded supported the preferred option

Select your preferred option Number As a % Option 1 - Do minimum 10 5.8% Option 2 - Community resource centre and hospital in one town (Grantown or 8 4.7% Kingussie) and scaled-down services in other (e.g. no in-patient beds) Option 3 - Community resource centre and hospital (with ~20-25 in-patient 135 78.5% beds) in Aviemore supported by other services and developments Other – please provide suggestion 15 8.7% I have no preference 4 2.3% 176 100%

38 7.3.2 Feedback on other options Suggestions came forward on alternative proposals, summarised as follows:

 Upgrade hospital services in Grantown and Kingussie x4

 Increase patient bed numbers x3

 Option 3 but retaining some hospital services at Kingussie and Grantown x2

 Agree with option 3 but why Aviemore? I don't think that is fair on those from Laggan or Dalwhinnie

 Leave as it is. If Aviemore require more (new beds) look at the requirement.

 Three new modern efficient medical centres that are adequate to deal with the contemporary need of all 3 communities and smaller villages surrounding them. x2

 Agree with new hospital being at Aviemore -- BUT-- do not agree with the "Glen Centre" being relocated

 New facility should be in Grantown

7.3.3 Feedback on aspects of the proposals People also had the opportunity to comment on aspects of the proposed changes

Over half the people who responded were positive about all elements. Closing in- patient beds in Ian Charles and St Vincent’s and moving the Glen day centre were the least well supported (Appendix 9).

7.4 Open responses (e-mails and letters) **

7.4.1 Method The correspondence was categorised into themes and responses coded as to whether people were in support of the preferred option or otherwise and summarised.

7.3.2 Results Thirty-one people corresponded with NHS Highland about the consultation via letter or email.

Supportforpreferredoption Number Percent Yes 12 41.4 Yes-Qualified 2 6.9 No 9 31 Not clear 6 20.7 29

39 ** - Some people were in regular contact and in such cases meetings were offered. Communications were often wide ranging with many issues beyond the scope of the consultation, but nevertheless relevant.

One lady wrote a 25 page hand-written letter covering a range of topics including: general issues affecting the elderly, transport, training for family carers, housing, dementia care and what we need. A meeting has been arranged to discuss the feed- back.

Another gentleman has submitted detailed responses, also wide ranging covering topics as diverse as A9 dual carriageway, emergency response times, dental services, whether proposals meet with the National Park aims, happiness and local services and the Crichel Down rules

In terms of responses by community there was a range of views with eight people from Grantown-on-Spey not in support of the preferred option and four people in support.

Resident Support Don’t support Advie 2 Aviemore 2 BoatofGarten 1 Grantown-on-Spey 4 8 Kincraig 1 Kingussie 1 Laggan 1 Newtonmore 2 Total 13 9

7.5 Responses from Community Councils

Four community councils submitted responses via the survey and all selected Option 3 as their preferred choice.

One of the community council included an additional comment:

“Option 3 but with room for expansion and more beds to cope with expected 2000 new homes in the area.”

7.6 Response from local Medical Practices

The doctors who are partners in the medical practices of Kingussie, Aviemore and Grantown-on-Spey have considered the proposals in detail and are fully supportive.

7.7 Responses from Partners

7.7.1 The Highland Council In their formal letter of response the Council concluded as follows:

40 “The case for change has been well and clearly made through a wide range of consultation methods and documents. The Highland Council endorses the consultation process, is supportive of the move to modernise and reconfigure services and confirms that it is broadly supportive of Option 3 for a single hub community hospital and resource centre in Aviemore.

“The Highland Council looks forward to the detailed outcomes of the consultation and to working in partnership with NHS Highland on next and future stages.”

Highland Council comments/observations

Whilst the consultation process has been generally positive across Badenoch and Strathspey, it is recognised that some people do not want change. It is noted that the final public consultation meeting held in Grantown on Spey saw community concerns and objections raised specifically with regard to the Ian Charles Hospital. Further targeted consultation and community work may be required here by NHS Highland.

It is also noted that a greater distinction could have been drawn between what a community hospital offers and what a district general hospital provides. Perception is also that community hospitals are orientated toward elderly care, and whilst statistically there is no doubt that this will be the higher patient ratio, provision has to be made for children and young people and awareness raised on what can be provided in terms of local services.

Highland Council main areas of response:

1. Care and Learning. The Care and Learning Service would be broadly in support of Option 3 and the proposed location in Aviemore. Opportunities should be explored for co-location of Children and Families staff in any new facility and managers would be interested in being part of discussions about the proposed building and its facilities at an appropriate stage. Consideration should be given to early discussion on the provision of services for children and young people, on shared clinical space as well as space for permanent and visiting staff. Essentially how much space and how much would it cost are key factors for consideration.

As a result of the consultation process there is now discussion taking place with local schools around closer working with NHS Highland, and further opportunities will be sought to involve young people in the process. There are also opportunities to work with colleagues in High Life Highland on a range of health led initiatives.

2. Access and Transport. This has emerged as a key theme throughout the consultation. It is recognised that NHS Highland is not a transport provider and that a positive and proactive planning approach to the design of an effective transport system is required. The Highland Council is keen to work with in partnership with NHSH and others in developing access and transport solutions.

It is noted that a Transport Survey is currently being undertaken by NHS Highland. It is also noted that a date is being set to bring key stakeholders together with regard to forming an Access and Transport Group.

41 3. Care at Home. An obvious challenge is around providing care at home and it is clear that this requires new thinking and new ways of working. The Council would be keen to work with and support NHS Highland in this key area. Further consideration to be given to fully integrated approaches and how the Highland Council can support this.

4. Future Site Management. Whilst aware the NHS Highland would not want to prejudice the outcome of the consultation, it is recognised that should local hospitals close there could be a key role for both the Highland Council and the Cairngorm National Park Authority in providing assistance in considering the reuse or redevelopment of buildings and sites which may become redundant. The emotional attachment to sites and buildings in local communities has clearly emerged through the consultation process and is recognised. It is particularly relevant therefore, with regard to archive and heritage, to ensure that history is captured and artefacts safeguarded.

5. District Partnership. Future role for the District Partnership to be explored as a mechanism to update stakeholders and as a platform for public engagement.

(Reports have been tabled at the District Partnership including most recently an update on the consultation process at the meeting held on 25th September in Kingussie).

7.7.2 Scottish Ambulance Service Scottish Ambulance Service welcome and support the development of the proposed new model of care and would welcome the opportunity to work in partnership with NHS Highland as the development progresses. A meeting has been arranged with senior officials for the 3rd of October.

7.7.3 The Cairngorms National Park Authority The Park Authority has appreciated early involvement. As they have statutory and enabling roles they did not feel it was appropriate to comment on the options but have provided initial comments on potential sites and potential future use of existing sites.

7.7.4 Scottish Fire and Rescue (Highland area) “Recognise the challenges in health care provision and balancing competing financial demands. Therefore support the views of NHS Highland management to progress towards an improved service provision in the wider Badenoch & Strathspey area. Improved home care and partnership working with other CPP members will support the vision of safer communities and safer homes.”

7.7.5 The Highland Hospice Highland Hospice supports the broad aims of the proposal which they feel provides an opportunity to meet existing and future health and care needs for Badenoch and Strathspey.

42 They are also keen to work jointly to consider the palliative and end of life care improvements that could result from these proposals including how they can contribute.

7.6.6 Highlands and Islands Enterprise “From the investment values indicated in the consultation, development of modern facilities and associated infrastructure as proposed would be considered by HIE to be a welcome enhancement in service offer and the scale of the construction projects proposed will in themselves create valuable, through short term economic stimuli locally.

We would encourage the integration of community benefit clauses within the service tenders, including the requirement to source locally and via the third sector to maximise local social and economic benefits. The Government’s Procurement reform agenda is enabling in these respects.

We would be pleased to continue our dialogue with you, working together with third sector partners and social enterprises to further shape the routes through which effective avenues can be established (as an integral part of your service re design) to enable third sector led service delivery; where this brings opportunities to add value, bring tailoring to services, build community capacity and embed greater social outcomes through locally-led heath and social care service delivery.

The proposed service changes will affect some communities in terms of accessibility of services (where these change from current locations). We note your intention to work across strategic partnerships with stakeholders including public sector partners with direct responsibility for transportation. We would be pleased to contribute to such discussions, together with our local authority and other partners.”

43 8 Feedback on Possible Sites

Main points covered in this section:  Site preferred by the public  Further considerations and next steps

8.1 Introduction

An options appraisal was carried out to assess the possible site options in Aviemore. The details of the full process including a map showing the short-listed are described (Appendix 6).

This section of the report provides feedback on public views on the four sites. Public preference was identified as one of the five criteria on which to assess the different site options.

As public preference was one of the criteria the final decision on selecting a preferred site was completed after the consultation had closed.

Issues relating to the site proposal were also raised at the consultation events and meetings.

Box Summary description of shortlisted sites

Site A Grainish Farm On the eastern side of the B9152 travelling north leaving the village.

Site B Milton Beside the A9 underpass (north side) leading to Upper Burnside.

Site C Technology Park Land between the 2 rail lines beyond the closed call centre.

Site D Pony Field This is beside the Macdonald Aviemore Resort and lies between the A9 and new housing to the north of the Scandinavian Village

44 8.2 Public Preference

Results for this were determined from the feedback during the consultation process. 160 expressions of preference were noted through the consultation process including 51 “no preference” There were also seven responses which suggested ‘other’. For the purposes of determining the scoring “no preference” and “other” were excluded.

From the feedback provided as part of the public consultation the Technology Park (Site C) was the most favoured (Table below).

Site Name Votes % Rank A Grainish Farm 18 18 3 B Milton 1 1 4 C Technology Park 64 63 1 D Pony Field 19 19 2

8.3 Conclusion

Both the public preference and the working group’s deliberations came up with the same conclusion on the favoured choice of site (Site C, Technology Park).

8.4 Next Steps

This preference is based only on qualitative factors. Other important factors such as development costs, land purchase and the suitability of the land for construction also have to be considered. This work which will be carried out by technical advisors if there is a decision to progress to implement the preferred option.

45 9 Assurance of the Formal Consultation Process

Main points covered in this section:  Feedback from NHS Highland internal assurance  Feedback from Scottish Health Council independent review

9.1 Introduction

The process was assured both internally through the Highland Health and Social Care Committee and externally via the Scottish Health Council:

9.2 Highland Health and Social Care Committee

Committee members were kept regularly up-to-date with the consultation including two formal papers:

 11th September 2014 – Final report on process  12th July 2014 - Update report

A mid-way review paper was also circulated by email on 10th June 2014. All the papers are available on the NHS Highland website.

Issue raised on 11th September 2014 What is the latest position on the Public Consultation relating to Badenoch & Strathspey?

Assurance Circulated report indicated consultation exercise completed on 21 July 2014. Internal review concluded major service change guidance followed fully. The report gave an update on public consultation activities, in relation to an access and transport evaluation, the background to selection of a potential site for a new hospital at the Aviemore Technology Park and feedback on the public consultation process. It was intended that a full report would be provided to the NHS Board at their meeting on 7 October 2014.

9.2.1 Conclusion of Committee

At their meeting held on 11th September the committee members were satisfied that the major service change guidance had been fully followed. They commented on the number of responses received and in particular highlighted the number of younger people who had taken part.

Agreed to endorse that the process complied with Scottish Government major service change guidance

Agreed to endorse recommendation to present full findings to NHS Board on 7th October 2014.

46 9.3 Scottish Health Council (SHC)

The Scottish Health Council produced a detailed report on the process for involving and informing people and highlighting any issues raised by local people during the process. It was published on 26th September and on their website: http://www.scottishhealthcouncil.org/publications/major_service_change_reports.aspx

It is also available on NHS Highland website. In summary/conclusion the report states that:

“Based on our review and feedback from local people we are satisfied that NHS Highland has followed Scottish Government guidance on involving local people in the consultation.

“Overall, feedback received indicated that the majority of people had understood the reasons for change, how the proposals had been developed, and felt listened to and that there has been sufficient opportunities to take part in the consultation.”

47 10 Conclusions and Next Steps

Main points covered in this section:  Conclusion and recommendations based on feed-back on the consultation process, service proposals, options and sites

 Next steps and decision making process going forward from here

10.1 Summary conclusion and recommendation

This report brings together all the key elements of the public consultation: the background, consultation process, feedback on options and next steps.

Taking everything into consideration there is broad support from the wide range of stakeholders for option 3 - the preferred option (Box) and it is now being formally recommended to the Board for endorsement.

Option 3 - Community hospital and resource centre in a central location (Aviemore)

If implemented this would mean building a new community hospital and resource centre in Aviemore as part of a wider redesign and modernisation of health and social care services.

It would also include the re-location of Aviemore Health Centre, some other services located in Aviemore and the closure of both local hospitals - Ian Charles in Grantown-on-Spey and St Vincent’s in Kingussie. Any closures would be planned to take place after the new services were in place.

In coming to this view, the operational unit has sought to satisfy itself that people were comfortable with the consultation process and that there was strong support for the preferred option. The consultation process has been endorsed both internally via the NHS Highland Health and Social Care Committee and independently by the Scottish Health Council.

79% supported the preferred option and both public preference and the option appraisal process identified Site C – Technology Park as the preferred site to develop any new hospital.

As the preferred option represents major service change, should the Board endorse the proposal, the next step would be for the proposals to be considered by the Cabinet Secretary for a final decision.

Further detailed work would still be required as part of the business case process.

48 10.2 Feedback on Consultation Process

NHS Highland has embarked on an extensive and wide-ranging public consultation exercise. The communications and engagement activities were both pre-planned and responsive to requests made during the three month period.

The approach appears to have been generally well received. The reasons for the changes to services being proposed have been understood and the majority of the feedback suggests acceptance.

Although the queries raised were predominately addressed in the consultation materials, the events and discussions provided further opportunities to expand on some of the detail and really understand any ideas or concerns.

There was consistency in the feedback received through the different routes and from partner agencies. By the end of the consultation no new themes or issues were being raised.

The feedback from the public meetings was representative of the wider feedback which emerged during the consultation. Areas of greatest concerns were raised from residents in Grantown-on-Spey. This was also highlighted in the Highland Council response and further focussed work will be required should the proposed changes be implemented.

Overall the vast majority of people who took part in the consultation, and who fed- back, were positive about the opportunities to engage with NHS Highland and there was good awareness about the consultation and how to make views known

NHS Highland’s Health and Social Care Committee endorsed that the process complied with Scottish Government major service change guidance. They also supported that the operational unit was in a position to present the full findings to the NHS Board meeting to be held on 7th October 2014. This meeting is held in public.

The Scottish Health Council carried out an independent review of the process and has also endorsed the process. They highlighted some areas of good practice as well as how the process could be improved in the future.

10.3 Feedback on proposals, options and sites

78.5% of people who responded to the survey agreed with the proposal to develop a community hospital and resource centre in Aviemore supported with wider development of community services. This option also received backing from all four medical practices and partner organisations (The Highland Council, Scottish Ambulance Service, Scottish Fire and Rescue Service and the Highland Hospice).

There was also a consensus on a preferred site at this stage (Site C – Technology Park). Some felt it added bias to the consultation to have identified possible sites at this stage.

Some aspects of the proposals require further detailed work. Some of this relates to specific concerns raised during the consultation but for other issues, it was not appropriate to look in any detail prior to any decision being taken.

49 10.4 Next steps and Decision Making Process

The Board of NHS Highland will consider the report and the recommendation at their meeting to be held on 7th October 2014.

Should they endorse the recommendation then it will go to Scottish Government for a final decision by the Cabinet Secretary

Only if the Cabinet Secretary approves the preferred option would planning for the new facilities and services begin in earnest.

Significant work would still be required including to agree the specification, the design and purchase a site. Current estimates are that construction might start around summer 2017 with possible occupation of the new facilities in December 2018. But it is stressed this is a very tentative time-table at this stage.

50 APPENDIX 1 – Summary details on the short-list of options

Option 1 – Do minimum

Everything would stay the same but with some investment to address health and safety requirements around the hospitals.

Main Disadvantages Main Advantages  Missed opportunities to improve care-  It is what people know and like at-home and safety issues  Buildings will never be fit for modern  Keeps services in existing hospital services, even with investment locations  Not sustainable - may result in major  Easy to implement loss of services in the longer term

Costs The running costs for both hospitals alone are £3.2million per year. Capital costs would be £5.2million to bring the buildings up to minimum standard.

Summary This option scored 250 points. The low score reflects that this option would not address current or future problems. It would not improve access to medical cover during out of hours, allow investment in care-at-home, support integration or modernise the buildings.

Option 2 - Community hospital and resource centre in one town (‘hub’) and scaled-down services in the other (‘spoke’), based on existing hospital sites

Hub In either Grantown-on-Spey or Kingussie there would be a new facility which would provide in-patient beds, outpatient services, A&E, 24/7 nursing cover with a limited x- ray service. It would be very similar to the existing hospital services provided from Ian Charles with the main change being all the in-patient beds provided in one purpose-built facility.

Spoke Limited out-patient clinics and base for some community nurses and social care staff.

Other Continue to integrate services with some investment into care-at-home, service, community services and co-location of some staff.

Main Disadvantages Main Advantages  All in-patients beds on one site  Resources still split across three main allowing better use of staff and sites other resources  Does not address service issues such  Improves quality of accommodation as out-of-hours medical and nursing of in-patient and out-patient cover, limited access to x-ray  Won’t be sustainable in the future - may  Familiar - keeps some services in result in major loss of services in the existing locations longer term

51 Costs Running costs with this model would be around £2.3million. The capital costs to redevelop hospital sites would be around £9million

Summary Option 2 scored 463 points. This was seen as an improvement on current services but the low score reflects that this is not a good option. Having all the in-patient beds being located on one site would bring some benefits but overall it would not improve access. It would still mean money being heavily invested in buildings rather than in community services or care-at-home service. It does not tackle any of the staffing issues associated with out-of-hours or access to x-ray.

Option 3 – Community hospital and resource centre and spokes

Hub A new community hospital and resource centre in Aviemore with good access to public transport and the A9. This purpose-built facility would allow services to be fully integrated.

The centre would provide the full range of community hospital services, including in- patient beds, out-of-hours, accident and emergency, outpatient clinics. The local health centre, day care centre and NHS staff based in Aviemore would all move into the new building.

Other Development of care-at-home service, extended community care and community beds in care homes would all come as part of wider redesign to improve all services. Once these services were in place Ian Charles and St Vincent’s hospitals would close.

Main Disadvantages Main Advantages  Strong attachment to existing hospital  Improves quality of many services buildings and overall much safer, more effective and efficient  Culture change for communities and staff  Addresses service issues allowing to get used to better out-of-hours medical and nursing cover, access to x-ray plus investment in care-at-home and the community  Change of location of hospital for some  Integrated service designed to meet staff and communities the current and future needs of the population

Costs The running costs would be significantly lower at £2million and capital costs estimated at £12 to £15million.

Summary This option scored an extremely high 913. It would allow a fully integrated service to be set-up which would make better use of the resources to meet the needs of the local population.

52 APPENDIX 2 – Overview of the NHS service change process in Scotland

Identify strategic options and need for service change

Initial discussion with SGHD sponsor in cases of potential major change

Develop initial comms/stakeholder involvement plans in liaison with SHC

Undertake pre-engagement activity with key stakeholders

Options Appraisal in line with Green Book, SCIM and SHC guidance

Proposed change considered major? Confirm with SGHD sponsor

No Yes

Proceed with proportionate public NHS Highland board to engagement as agreed with SHC consider proposal and consultation materials

Approve formal consultation and materials

Yes No Revisit proposals

Undertake formal public Consultation

SHC assurance report to NHS Board

NHS Board Decision on Service Change

Non- Ministerial Approval Major Major

Yes No Revisit proposals

Commence Business Case process (SCIM) If infrastructure investment case

Proceed to implementation

Feedback and Evaluation

53 APPENDIX 3 – Events and stakeholder meetings including updates to committees etc (21st April to current)

Category Event Date Attendance District Kingussie 24th April + 4 members of public Partnership Nairn 11th June Kingussie 25th September

Community Nethy Bridge 1st May & 5th June +9 members of the Councils public meetings Kingussie 6th May + 6 members of public Aviemore 8th May + 6 Dulnain 14 May Grantown-on-Spey 20 May Carrbridge 29 May Boat of Garten 2nd June +1 Kincraig 10th June Newtonmore & Vicinity 7th July + councillor

Drop-in events Dulnain 14th May 4 + SHC Grantown-on-Spey 20th May 9 Carrbridge 29 May 2 Boat-of-Garten 2nd June 12 Nethy Bridge 5th June 9 Kincraig 10th June 4 Aviemore 11th and 12th June 30 Newtonmore 19th June 12 Laggan 19th June 8

Steering Group Mid-way review 5th June Post-consultation 27th August review and complete options appraisal on sites

Other Lunch Club, Kingussie 19 May 22 Walk-about 27 May 50 Friends of St. Vincent’s 28 May 8 Dalwhinnie Community 28 May 6 Group CoS Presbytry 17th June 35 Laggan Community 19th June 8 Association Friends of Ian Charles 23rd June 15 Sunshine Club 23rd June 42 Public meeting, 25th June 6 +x2 SHC Kingussie Public meeting, 1st July 16 Members of public + Aviemore x2 SHC Public meeting, 2nd July 82 Members of public + Grantown-on-Spey x2 SHC + Reporter St Vincent’s Therapy 7th July Committee members Garden Spey Valley Rotary 9th July 12

54 APPENDIX 3 (cont’d)

Attendance at public meeting, events and stakeholder meetings

Category Event Date Notes Partner Agencies Scottish Government 14th May + July Scottish Ambulance 21st May + 3rd October Cairngorm National 30th May, 10th Park Authority September Transport Scotland 11th June Kingussie High 24th June

NHS Highland Staff drop-in events w/b 21st April Staff also represented (various) at all meetings, 17th & 18th July steering group Consultant psychiatrist 3rd June Local GPs various ongoing Annual Review 9th June Local stakeholders met with the Minister South and mid 1st May, 23rd June Ongoing operational unit management team meetings/ Local Partnership Raigmore senior 16th July Ongoing management team NHS Highland senior 25th September Ongoing management team Highland health and 1st May, 10th July, Ongoing social care committee 11th September NHS Highland Board 3rd June, 12th 7th October August,

55 APPENDIX 4 Summary of points raised at meetings, events and drop-in. Themed and ranked based on the frequency of times raised at different events

Notes

After the consultation closed comments were categorised to allow some high–level groupings (Table). For instance additional services in the preferred option were mentioned at 31 of the 34 meetings and accounted for 16% of all the points raised at meetings and events. There was also a read across with the correspondence and survey responses.

Table Summary of responses by category

Categories No. % 1. Additional Services 31 16% 2.Transport 23 12% 3. Existing Services/Buildings 22 11% 4. Bed Provision 21 11% 5. Site Proposal 19 10% 6. Finance including endowments 16 8% 7.CareHomes/CareatHome 14 7% 8.Staffing 12 6% 9.Population 9 5% 10.Alternativeproposals 8 4% 11.Other 8 4% 12.Process 7 4% 13.Palliative Care 6 3% Grand Total 196 Category Points raised NHS Highland Response 1.1 Additional  Will there be additional Yes. But the detail will come later when the full clinical specification will be required to services services in the new hospital? be developed as part of the Full Business Case. Specialist outpatient clinics or input, chemotherapy and infusions are all things that were raised and will be considered (see also below) 1.2  Will there be greater use of The new facility will be fully equipped to take advantage of new and emerging new technology and tele- technologies including allowing for increased use of tele-medicine consultations with medicine consultations? consultants/specialist nurses. 1.3  Will the x-ray service be New more modern x-ray equipment will provide an overall improvement. While there enhanced? will no longer be an x-ray service in Grantown it will release radiographer travelling time to enable more examinations to be carried out in Aviemore. The current arrangements are not satisfactory and in particular for in-patients (see notes below). Moreover the equipment is at the end of life.

Notes Currently St Vincent's patients can't have an x-ray unless they are put in an ambulance and transported to Aviemore (and back). Ian Charles patients can have an x-ray (but machine is out of date, no spare parts available), if a radiographer is available. (Currently on-site one day per week). Otherwise to get an x-ay, the radiographer must close down the Aviemore service, travel through to Grantown, warm up the machine, take the x-ray, close down shop and travel back to Aviemore. Implementation of the preferred option would vastly improve this situation.

The equipment was installed in 2002 beginning to fail and no longer possible to cover it with a service contract as spare parts are no longer available. The equipment also does not have automatic exposure control devices, available on all other NHSH general X–ray equipment and considered as a standard feature for the optimisation of medical exposures.’ 1.4  We need a 24 A&E service. Local doctors say that the current service is more than adequate for current case mix Current out of hours cover is that they look after. It would not be appropriate to do more complex cases as staffing not enough? is by GPs not specialists. The level of activity does not warrant the necessary back-up required for more complex care such as theatre/anaesthetics, CT, MRI and 24/7 x-ray. Out of hour - In-patients The proposed arrangements will improve out-of-hours nursing and medical cover because all the inpatient care would be co-located.

57 Category Points raised NHS Highland Response Notes There are 50 hours (Mon - Fri 8am to 6pm) when a GP provides cover during the week in each hospital. In the evenings, weekends and overnight periods medical cover is provided from the Out of Hours service based in Aviemore. Local GPs provide this service. This means that our hospital in-patients are at a distance of either 10 or 15 miles from the doctor during these periods of time. Under the new arrangements all inpatients will be located in the same place (gets round the difficulty that arises when both hospitals need the doctor at the same time) and delays due to loading up plus journey time will be eliminated.

Terminology The re-design will also help to address a long-standing issue around terminology A&E, Casualty, Minor Injury Unit. A&E/ Emergency Department should only be used for consultant-led departments with all the necessary back-up; trauma teams; theatres and so on. Traditionally the term A&E/ casualty has been used for many of our community hospitals which really provide GP or Nurse led minor injury/ailment services. Adding to public confusion is that the sign outside the hospital says A&E. 1.5  Need an enhanced A&E As above plus the numbers don't justify this. service to better treat fractures 1.6  Will there be a pharmacy on- There will be a hospital pharmacy on site but there are no plans to relocate the current site? community pharmacy. 1.7  There is not enough detail in Agree. Further detail will be worked up, if and when the preferred option is approved. the clinical model The requirement to provide further detail comes later on as part of the Full Business Case. 1.8  Will there be a handyman The Handyman Schemes elsewhere in Highland involves Third Sector, Council service? services etc with very clear community roles for the Handyman in terms of care and repair, adaptations etc There is currently not a service like this in Badenoch and Strathspey but we will be looking to develop something along the above lines. 1.9  Will there be a hydrotherapy No. There are no plans for a hydrotherapy pool. pool? 1.10  Will there be an operating No. There will not be an operating theatre because there is not the demand. Theatre? However, there will be modern treatment rooms which will allow opportunities for more minor surgery to be carried out

58 Category Points raised NHS Highland Response 1.11  There should be an on-site A laundry could be provided but at a cost. This will need be considered alongside facilities for laundry? other priorities but local people will have an opportunity to influence these discussions/priorities. Other services like café/ dining facilities will be discussed. In these deliberations we will seek to balance patient/visitor requests with costs and impact on local providers. Notes: The context for this query was that it was raised at a meeting that there was no laundry in Migdale (Bonar Bridge) and the inconvenience this caused The policy is for patient’s relatives to take laundry home for washing. It is recognised, however, that this poses challenges where visitors may be infrequent or some patients may have no visitors/ relatives.

2.1 Transport and  Transport infrastructure must Transport is of paramount importance and needs to be developed. Access be in place to support While NHS Highland is not a transport provider, we believe the redesign is a catalyst to relocation of hospital services facilitate joint working across various partners. In terms of NHS Highland’s contribution, the proposals make provision for further investment into community transport. A working group on transport has been established and an initial Transport survey has been completed. Notes: From the survey we note that the majority of people don’t use public transport to come to hospital or for GP appointments. Arguably this is because the service is very limited. People who are visiting the hospitals generally come by car. Extremely few walk up the hill from Kingussie to St Vincent's and a very small number of people walk to the Ian Charles. Inpatients mostly arrive by ambulance and occasionally by private transport.

More generally further steps need to be taken to reduce people having to travel in the first place. In the future more outpatient consultations will be replaced with Video- conferencing, Skype, or telephone and e-mail. Making sure we have the right community and home based service in place will also mean people have to spend less time in hospital further reducing the need for travel. 2.2  Traffic flow/jams will affect This was raised as a concern and is something we will look into in collaboration with ability for ambulances to gain others including Police and Ambulance. However, busy towns and cities manage flow access to and from the of ambulance traffic. The steering group will consider when assessing sites. hospital?

59 Category Points raised NHS Highland Response 2.3  There is no taxi service in This was confirmed during the consultation process. It must have a number of Kingussie? implications for local people. In terms of NHS services it poses a problem with the current remote location of St Vincent's Hospital. It is intended that any retained services in Kingussie will be more centrally located and any wider access and transport issues will be improved. 2.4  Will dualling of the A9 impact We have met with Transport Scotland representatives, and believe one of the four on site selection? shortlisted sites could potentially be affected by A9 dualling. This will be noted during the site selection process. Moreover the dualling has not actually started and time- scales are somewhat uncertain. It is recognised that there will always be some uncertainties to contend with. 2.5  Will there be access to the A9 This is unlikely, two of the shortlisted sites lie adjacent to the A9 but Transport to the new hospital? Scotland has indicated that they are unlikely to approve any further junctions. The ambulance service have also indicated that this is not a requirement

3.1 Clarification on Will physiotherapy services be Yes that is our intention existing retained at Kingussie/Grantown? 3.2services and Will ambulance services remain in There are no plans to alter the current ambulance services apart from relocating the buildings Grantown and Kingussie? Aviemore Ambulance station 3.3 Will GP services remain in There are no plans to alter the current distribution of GP practices Kingussie/Grantown? 3.4 Will children’s services be co- Children's services staff might be, but the children's services themselves would located in the new building? continue to be delivered closer to home (schools, health centres, homes) 3.5 Can the existing buildings last the We are required to maintain our current buildings in a safe condition and will do this for five years until the new hospital is the remaining life of these properties built? 3.6 Will dental service remain in Yes there are no plans to remove dental services Grantown? 3.7 Will minor injury service remain in Yes the minor injury service will remain in Grantown Grantown 3.8 Will the out-of-hours (OOH) Yes OOH will be located in the new development in Aviemore services be located in the new building?

60 Category Points raised NHS Highland Response 3.9 What will happen to the existing There is no NHS use identified for buildings that might be vacated, Should this be a buildings requirement, NHS Highland will be asked to declare them surplus to requirements once vacated. NHSH will then follow the prescribed procedures for disposal this includes checking if there are any public sector uses for the buildings. Scottish Futures Trust and the Cairngorm National Park Authority have been consulted regarding possible community benefits which might be derived from the disposal of any properties and land. 3.10 Are the hospital buildings listed? No as far as we have been able to ascertain none of the buildings are listed 3.11 What will happen to the Therapy Some early discussions have been held with some of those involved with the Therapy Garden in St Vincent’s? Can it be Garden and it would be our intention to support the group to provide a therapy garden re-provided at the new hospital? at the new Aviemore facility and also at an alternative location within Kingussie. Discussions ongoing.

4.1 Bed numbers Are enough beds included in the The final number of beds has not yet been decided on though we have done some and provision proposal? initial work to inform the public consultation. Our Health Intelligence Unit will be carrying out further modelling work to assist in any final decision. Local medical experience; bed experts; service planners will work out the right number which will take into account flexibility and future requirements. The current stated estimated provision is between 20-25 beds. The number will be based on the optimum requirement; not the exceptions.

Notes: Identifying the right number of beds requires specialist expertise, modelling and is dependent on many factors. The number we have now is on the high side with beds occupied with patients who would be better served in other settings. This is due to a lack of home care. For instance recently 8 out of 23 beds in the valley had people in them who didn’t need to be in hospital at all. Currently it is not always possible to use all the beds because they are in bays of four or six. This may not always suit the mix of males and females. It can also mean whole bays have to be shut when there are infection outbreaks. The new hospital will have all single room; bringing a wider range of benefits including higher occupancy. 4.2 Will mental health/dementia beds We would want the building to be suitable for dementia patients in ways that the be included in the new hospital? current buildings are not. (As many as half of our GP inpatients have a degree of dementia, it co-exists with the physical conditions that affect older people.)

61 Category Points raised NHS Highland Response Discussions are ongoing with consultant colleagues from New Craigs who manage the bed to identify the clinical need and what is required going into the future. 4.3 Will the rooms in the ward be All beds in the new hospital will be in single rooms- this is Scottish Government policy. single rooms There are good clinical reasons, particularly regarding control of infection, for having all single rooms. In addition single rooms also help with bed management e.g. the gender of a patient does not matter when an admission is required, currently if there is only one bed available in a multi-bedded female ward then only a female patient can be admitted and vice versa. Space for patient socialising and dining (should they so wish) will also be provided.

Notes: With regard to single rooms, CEL48(2008) “Provision of Single Room Accommodation and Bed Spacing” refers. It states “For all new-build hospitals ….. there should be a presumption that all patients will be accommodated in single rooms, unless there are clinical reasons for multi-bedded rooms to be available.”

5.1 Site proposal Are the proposed sites big One of the short-listing criteria for the sites was that they had to be a minimum of three enough? acres in size or be capable of being made so. It takes into account the likely building size, parking, gardens and a 20% expansion capability. Further work will be required once it has been determined exactly what will be provided from the new facility including the number of staff likely to be working in the new facility 5.2 Will the site/building be The development will allows for 20% future expansion which is what is recommended expandable in the future? for NHS planning purposes. Over and above this there has been some discussion about what other support services might be beneficial to have co-located.

Notes: It is important to appreciate that future-proofing does not necessarily mean bigger. For instance the available evidence (including for Highland) show that we have needed far fewer in-patient beds over the last 20 years. Changes in technology, greater use of tele-medicine, advances in medicines and treatments will all mean people spend less time in hospital settings. What is of upper most importance is that any development is flexible and able to respond to changing circumstances – flexing up or down to suit local need.

62 Category Points raised NHS Highland Response 5.3 How were the sites short-listed? The long list of potential sites was drawn up after personal visits to the area by Board officers, by contact with architects and other public bodies in the area, by discussions with steering group members and by an advertisement in the local newspaper. This produced a long list of 10 sites which was reduced to a short list of four by applying two exclusion factors - 1) sites had to be a minimum of 3 acres in size or have the potential to be made so and 2) be within or immediately adjacent to the Aviemore settlement boundary. These exclusion factors were drawn up by the steering group and with advice from the Cairngorms National Park Authority. 5.4 Why is Aviemore selected as the Because of its central location and proximity to Inverness (Raigmore Hospital). preferred location? 5.5 Will there be a heli-pad close to No. Medical advice is that a heli-pad is not required, current arrangements for the use the new hospital? of helicopters will continue Note:

Those who need to be taken off the mountain to data have always need to go direct to Raigmore or further afield for diagnostic purposes and necessary medical and surgical expertise. Landing a casualty in Aviemore would only serve to cause delay and adding further risks. The same applies to those injured in for instance A9 causalities. 5.6 Co-location is not a significant Co-location means inpatients will have a doctor in the building with them almost all the advantage to justify a new build in time (as opposed to less than 1/3 the week which is the current situation. This brings Aviemore wider benefits for multi-disciplinary team working. Professional opinion is that co- location of all health and social care professionals greatly improves communication resulting in better and quicker outcomes for patients. Other benefits include more efficient use of buildings and staff time. 5.7 Will sites be compulsory It is not anticipated that this will be necessary, the owners of all four shortlisted sites purchased? have indicated a willingness to sell, subject of course to negotiations on price

6.1 Finance How much will the building cost? The final figures will not be known until the full extent of the accommodation is including described, the site purchase and development costs are known and commercial endowments negotiations are concluded. However we are working on a budget figure of £12million to £15million which is based on other similar facilities e.g. Migdale Hospital in Bonar Bridge and Nairn Town and County. This would include incorporating facilities for new Health Centre.

63 Category Points raised NHS Highland Response 6.2 How will the building be financed? NHS Highland is closely following the Scottish Government process for capital investment. The Business Case process will explore funding options but at this stage it seems likely that the building will be principally financed through the revenue route which will involve Hubco 6.3 The building should not be NHS Highland is closely following the Scottish Government process for capital financed by PFI or similar investment. The Business Case process will explore funding options but at this stage it seems likely that the building will be principally financed through the revenue route which will involve Hubco 6.4 Will there be savings as a result The principle aim of the project is to improve services to ensure they are safe, of the service re-design? sustainable and meet future needs. Any service must also be affordable. The current arrangements with are not efficient or cost effective and by re-designing services there are opportunities to free up resources. The proposal is to uses these resources to invest in community services, care-at-home and a contribution to community transport provision. 6.5 Are you being ambitious enough? Yes. We believe that the proposals will provide the best healthcare for the people of the valley which can be staffed and sustained. 6.6 Hubco finance offer is very There is a national shortage of capital funding and it is likely that the revenue model expensive – will cost £30k over available through hub will be the only viable option in the short to medium term. Any 25 years for a £12m hospital. attempt to upgrade the existing hospitals would result in a less than optimal solution Cheaper to upgrade Ian Charles and poorer services for patients than the preferred option. for £3m 6.7 What will happen to the Burrell The Theresa J Burall legacy will continue to be used for the benefit of St Vincent’s endowments at St Vincent’s hospital until such a time that the hospital becomes non-operational and the terms of the legacy cannot be met. NHS Highland Endowment Fund Trustees would then need to apply to the courts to determine the future use of the legacy.

The advice from NHS Scotland legal office confirms that the legacy could potentially be used for the benefit of a different hospital and/or the community where the services are currently provided to benefit local people in the future. Any future decisions progressed by a local group from within the Kingussie area under the responsibility of NHS Highland and with close reference to NHS Endowment Fund regulations and the legal framework.

64 Category Points raised NHS Highland Response 7.1 Care-at-home Can you recruit more care-at- This has been an on-going problem for many years now and we feel this is something and care home staff? that needs to change regardless of anything else. Whether we do or don't build a new homes hospital in B&S, we want to see greater recruitment and retention of people doing this kind of work locally. We understand this is a Highland wide problem, although this Locality may be worse than the average. 7.2 We need more care-at-home staff This is recognised and the preferred option was the only option to identify ways of investing further in community staff including care-at-home 7.3 Will there be a care home There are no plans for a care home to be built in Aviemore as part of this project attached to the new hospital ?

8.1 Staffing Existing excellent culture of care Agree. Staff will be fully consulted and involved in the proposals. must be maintained 8.2 Will local doctors be providing the Yes medical services at the new hospital? 8.3 Will local people be employed in Existing staff whose jobs will be affected by the proposals will be given the opportunity the new hospital? of moving to the new facilities, any posts remaining unfilled will be filled in the usual way, local people will be given the opportunity to apply 8.4 Will there be any redundancies? he NHS in Scotland has a policy of no compulsorily redundancies, staff will be given the opportunity to either work in the new facilities or be redeployed to other areas 8.5 Will there be enough staff? There is sufficient staff currently employed within B&S to operate the new facilities. It is generally accepted that modern facilities are an aid to recruitment 8.6 How will staff get to work? If and when the proposals are approved detailed discussions will be held with staff and their representatives to discuss employment issues such as travel to work and how the Board can assist them e.g. shift times that fit in with public transport. Staff travel to work will also be considered as part of the transport group. 8.7 Will local builders be contracted It is likely that the new facilities will be built by hubco under a design, build, finance and to build the hospital? maintain contract. hubco will tender at least 80% of the total work package value to local contractors. Hubco will hold local supply chain meetings or 'roadshows' where they can come along to hear about hub and what its role is and also meet the buyer events where they can meet the main contractor.

65 Category Points raised NHS Highland Response 9.1 Population Have you considered the Yes this is an important point and one which we have and will continue to consider projected population increases? pulling expertise in from our Public health colleagues, service planners and An Camus Mor, seasonal visitors experienced health care planners.

We know that Aviemore has done the most expanding (20% rise in practice population in 10 years; yet the over 65-population has not significantly increased (and this is the population that starts to use the hospital in patient facilities more). The majority of the new housing tends to attract younger people, often families, therefore this has considerations for services for children’s and families (and of course schools). In terms of health these services are usually delivered through health centres and are one of the strong arguments for building a new health centre in Aviemore as part of the proposals. Although there has been a lot of focus on the hospitals (and understandably so) we have been at pains to point out that this is a wide re-design and the primary care/ health centre element is very important.

10.1 Alternative The hospital should remain in Upgrading an existing old building will never provide the standards required for modern proposals Grantown and Ian Charles be healthcare, we are planning services for the next 50 years and we need a new modern upgraded facility for patients and staff which meet the highest health & safety, control of infection, patient dignity and energy efficiency standards as possible. 10.2 Both hospitals should be Modernising within the limited scope available would not bring the benefits of co- modernised and would cost less locating services or enable the improvements in community care which are required 10.3 Outpatient services should be Psychiatry and Medicine for the Elderly visit the three health centres. No changes are retained in Grantown being proposed although in line with other outpatient services if there are alternatives such as Video-conferencing. 10.4 There should be a 4th option – Clarify if this includes new build in Aviemore upgrade all sites to modern standards

11.1 Service The consultation outcome has The consultation process has been open and inclusive, it has been monitored change already been decided “done deal” throughout by the Scottish Health Council. They will be producing an independent process report. 11.2 What are the time-scales? The results of the public consultation are being analysed, a report will be considered at an NHS Highland Board meeting hopefully in October this year, if not in December.

66 Category Points raised NHS Highland Response Thereafter if the Board approves the preferred option it will go to Scottish Government for a final decision. Only if the SG approve the preferred option will planning for the new facilities and services begin in earnest Significant work would still be required and current estimates are that construction might start around Summer 2015 with possible occupation of the new facilities in December 2018. But it is stressed this is a very tentative time-table at this stage.

12.1 Palliative care Need increased Marie Curie to End of life care will be included in our review of services support people at end-of-life to die at home 12.2 Need to retain palliative care beds Notes at Kingussie and Grantown to End of life care will be included in our review of services allow people at end-of-life to die Hospice outreach = a consultant visiting (e.g. weekly or fortnightly.) Advice available in their own town for doctors too but not often required and is done by telephone in any case.

End of life care = someone doing the nursing/personal hygiene work so the patient gets drugs as needed plus dignity is maintained and relatives don't have it all to do. Community nurses do a bit of it in the day, OOH nurses now started doing a bit in the evening: both mainly doing the medication side of things. Marie Curie sit with folk overnight so family members can get some sleep. If family not available, not willing or not capable, admission is required.

13.1 Other (respite, Will respite provision be retained End of life care will be included in our review of services, we recognise that the maternity, in Grantown and Kingussie? voluntary sector have an important role to play in the delivery of health services housing, 13.2 Will there be maternity beds? No. There is no proposal to include maternity beds, there is insufficient demand to dementia and enable practitioners to maintain their skills. integration Notes There are national rules about how many deliveries a unit must be doing so that midwives and doctors maintain their skills and experiences. Back up facilities required would include emergency facilities, theatres, team of obstetric doctors, anaesthetists, theatre staff etc For these reasons a maternity unit would not be viable.

67 Category Points raised NHS Highland Response 13.3 We need cluster housing for Housing lies within the responsibility of the Local Authority and is outwith the remit of learning and physical disability this project but all four shortlisted sites provide the opportunity for supported housing patients. There is nothing in the by others Strath 13.4 Will there be supported housing Housing lies within the responsibility of the Local Authority and is outwith the remit of this project but all four shortlisted sites provide the opportunity for supported housing by others 13.5 Integration of health and social NHS Highland manages the entire adult health and social care budget for the locality care services are important providing far greater opportunities to make best of all resources, skills and talents. 13.6 How will people with dementia be Need a clinician to answer this one but presumably there will be mention of an cared for in the future? enhanced community service? Would it be worth quoting some stats about the home addresses of patients in that specialty at St Vincent’s?

68 APPENDIX 5 – Further work identified to understand future bed numbers

Ian Douglas, Health Intelligence Specialist (Directorate of Public Health) and Frances Matthewson, Senior Planning Analyst (Service Planning Team) were asked to develop ‘bed modelling’ to help the project team understand future bed requirements based upon drivers of service demand. This work will have five components:

I) Understanding baseline activity and capacity (bed numbers, trends in occupied bed days for patient groups/specialties, throughput and occupancy and blocked beds etc)

II) Estimating demand of catchment populations in 0, 5 and 10 year time horizons

III) Modelling care – estimating impact of possible changes in supporting community care arrangements, adjusting for other commissioning intentions (including repatriation of care from other sites / end of life care arrangements)

IV) Future utilisation of beds (occupancy and throughput)

V) Output – recommended bed numbers

Timescale:

To be completed by end of November 2014 APPENDIX 7 – Option appraisal process to support site selection

The preferred service model option included building a new community hospital in a central location (Aviemore). As part of the overall process NHS Highland was advised to identify possible sites in Aviemore to include as part of the consultation materials.

The process from identifying sites through to selection of a preferred site is described. This is based on quality factors which included access. Further work would still be required to consider any technical consideration should the decision be taken to progress with the preferred option.

Method

The Options Appraisal work followed a well established process recommended by Scottish Government in the Scottish Capital Investment Manual – Business Case Guide. Through this process four short-listed sites (see map) were assessed against a number of quality criteria. These had been agreed by the group in advance of the consultation, and without prior knowledge of the potential sites. The five quality criteria which were selected by the steering group were:

 Access/transport  Public preference  Environmental considerations  Proximity to other services and potential for expansion  Planning acceptability  The group also agreed that the final decision should weight the quality/cost factors as 60:40.

Phase I – Identification of potential sites

This involved undertaking a search of possible sites within or close to the Aviemore settlement boundary (as per Cairngorm National Park Authority plan).

Sites were suggested by members of the project group, visits around Aviemore by NHS Highland staff, contact with architects and liaison with partner agencies. From this process seven sites were identified. An advertisement was also placed in the Strathspey and Badenoch Herald which produced a further three sites. This meant there were 10 sites identified for initial consideration.

Phase II – Factors for assessing long list to produce shortlist

A workshop with steering group members and others was held in Aviemore on 3rd April. This involved 29 people, half of whom were community members and service users. The majority had participated in the earlier option appraisal events.

70 The purpose of this specific event was to agree high-level factors to allow a shortlist of sites to be agreed, and then to agree criteria and weighting (relative importance of each criterion) which would be applied to the shortlist of sites to allow NHS Highland to identify a preferred site(s). This was the same methodology used for previous option appraisal and so participants were familiar with the approach.

71 Process for agreeing criteria and weighting to be applied to the shortlist

The discussion to consider and agree criteria and weighting took place before any of the site locations were shared. This was to avoid any bias.

Participants at the workshop were asked to consider important factors for service users accessing the services. These were criteria that service users and public could reasonably have a view on and therefore could reasonably influence. After considerable discussion the following factors were agreed:

 Access / transport (such as proximity to A9, public transport, disabled access, traffic flow)  Public preference on the shortlist of sites (to be identified as part of the consultation)  Environmental considerations (outlook, location, green space, impact of development)  Proximity to other services/potential for expansion (current and future)  Planning acceptability (some sites will be more acceptable than others and more easily fit or be adapted to fit with the Park Plan)

Weighting

Although all these criteria were important, it was also agreed that they were not all of equal importance i.e. some were more important than others and therefore the criteria were weighted to reflect this. The process to do this was to first agree the most important criterion. The group decided that this was Access and it was ranked as 100. The group then agreed that the second most important criterion - Public Preference and gave it a ranking of 85 and so on. These rankings were then converted to percentages (Table below)

Assessment Criteria Ranking Weighting (%)

Access 100 27.03 Publicpreference 85 22.97 Environmentalfactors 75 20.27 Proximity to other services/ Potentialforexpansion 65 17.57 Planningacceptability 45 12.16

The weightings would be applied later to the scores for each site.

10.3.1 Process to determine short list

Participants first agreed on two high-level exclusion factors:

(i) sites have to be a minimum of three acres in size or the potential to be, and

(ii) within or immediately adjacent to Aviemore settlement boundary.

These were considered to be yes/no criteria and a no answer to either would exclude the site from further consideration.

72 Application of process to identify shortlist

From the 10 sites initially identified, six were excluded on the basis of not being big enough or were out with the Aviemore settlement boundary. The remaining four sites went forward as part of the public consultation to seek the views of the public (Box)

Summary description of shortlisted sites

Site A Grainish Farm On the eastern side of the B9152 travelling north leaving the village.

Site B Milton Beside the A9 underpass (north side) leading to Upper Burnside.

Site C Technology Park Land between the 2 rail lines beyond the closed call centre.

Site D Pony Field This is beside the Macdonald Aviemore Resort and lies between the A9 and new housing to the north of the Scandinavian Village

Please note A to D does NOT represent a ranking of the sites.

The following additional information on the sites together with a map was made available in the public consultation document.

Site Estimates of population within a 15 minute walk of each site

A 1,800 B 1,820 C 2,340 D 1,180

Phase III – Assessment of sites based on qualitative factors

As public preference was one of the criteria to assess the sites this work could only be completed after the consultation had closed.

The steering group held a further meeting on 27th August 2014 to complete the options qualitative appraisal process on potential sites. 29 attended the meeting and included local service users, councillors, community councillors, local access panel, Cairngorms National Park Authority, Ambulance Service, Friends of Ian Charles and St Vincent’s Hospital, Aviemore GP Practice, NHS Highland staff including partnership representative.

73 Quality versus Cost

It was recognised at the 3rd April meeting of the group that in addition to the qualitative criteria regarding site selection, cost would also need to be taken into account. These were described as technical or quantitative criteria and could include such things as, site purchase cost, cost of developing the site i.e. ground conditions, availability of utilities, access arrangements, etc This quantitative assessment and scoring would require to be completed by the Board’s technical advisors.

At the meeting on 27th August the group were also asked to make a determination on the balance between quality and cost. The group agreed that the final decision should weight the quality/cost factors as 60: 40

Assessment of sites against criteria

Each criterion was taken in turn to look at how the group thought each site performed relative to each other. In considering the options they were asked to consider the potential advantages for people travelling to Aviemore (i.e. hospital services) and those travelling to GP Practice.

This allowed each of the sites to be scored out of 10 for each of the criteria. The previously agreed weightings were then applied to these scores to arrive at a final qualitative score for each site:

Public preference

Results for this were determined from the feedback during the consultation process. These results did not require input from the group and were revealed at the end after the other criteria had been scored:

Site Name Votes % A Grainish Farm 18 18 B Milton 1 1 C Technology Park 64 63 D Pony Field 19 19

Notes 160 expressions of preference were noted through the consultation process including 51 “no preference” There were also 7 responses which suggested other unidentified sites but for the purposes of determining the scoring “no preference” and “other” were excluded.

74 Results from benefit weighting scenarios

Weighted benefit scores (see notes below)

Option Description Consensus Rank

A Grainish Farm 530.54 2 B Milton 340.14 4 C Technology Park 750.14 1 D Pony Field 467.97 3 Notes Scores are out of 1000

Sensitivity Analysis

In order to test the robustness of the decision, sensitivity analysis was carried out. This involved removing each of the selection criteria in turn to see if one particular criterion skewed the decision. Further analysis was carried out by scoring the preferred choice – Site C Technology Park at 0 for each of the criteria in turn. The Technology Park remained the highest scoring site in each of these scenarios.

The mechanics of the process are being independently audited by the Head of eHealth.

Conclusion

Both the public preference and the working group’s deliberations came up with the same conclusion (site C, Technology Park). The sensitivity analysis also showed that this was a robust choice.

Next Steps

This preference is based only on qualitative factors. Other important factors such as development costs, land purchase and the suitability of the land for construction also have to be considered. This work which will be carried out by technical advisors now needs to take place.

The reason that it is not carried out for all the short-listed sites is because it is costly and time consuming. It is only appropriate to carry out this level of work on one or two sites. This work will only be taken forward should there be a decision to progress with implementation of the preferred option. .

75 APPENDIX 7 Update on local care-at-home activities

NHS Highland is working with all sectors to coordinate and collaborate on recruitment and to make home visits work as well as possible. We have made progress and are starting to develop some innovative ways to address the issue of home carer recruitment.

This includes becoming the first Health Board in Scotland to achieve the living wage for carers in the independent sector. This means that through our contract we have increased the hourly rate and directed that this should be passed onto the carers.

In addition, NHS Highland is developing a modern apprenticeship scheme – in partnership with the Job Centre, Inverness College, Highland Council’s Education Department and Independent Care Providers - to promote caring as a career. It is proposed to train to SVQ Level 2 over the first two years and to use year three as an opportunity for each trainee to develop specific skills based on their experience of years’ one and two. The scheme would be modular and it is proposed that over years’ one and two, each trainee would undertake six, three month placements in a variety of care settings.

At the end of year three, trainees will be encouraged into mainstream posts, or make a choice about specialist training; e.g. Health or Social Work.

Our position is beginning to improve with the implementation of these ideas and we are also trialling different ways to managing runs with the independent sector – including a move away from 15 minute time slots.

76 APPENDIX 8 – A summary of what is included in public health district profiles

Adult and Children & Young People’s (CAYPs) health profiles of the Highland HSCP areas and the Argyll and Bute CHP

These were compiled by NHS Highlands Public Health Department and launched in December 2012 for adults and in June 2013 for CAYP.

They were designed to assist services in the assessment of the health and social care needs of the populations within the geographies of the Operational Units and within Argyll & Bute CHP. The measures used were selected to inform each of four aspects of health and social care:

 The wider determinants of health  The potential for health improvement  The protection of health  The need for health & social care

So for example, if rurality is particularly challenging or socio-economic deprivation, these measures will be found in the wider determinants of health category. Lifestyle related measures such as hospitalisation rates for alcohol-related conditions or the average life-expectancy will be amongst others in the potential for health improvement category. Relative uptake of screening programmes is an example of the protection of health category whilst the prevalence numbers with long-term conditions is in the need for health & social care.

These measures are available at different geographical levels from intermediate geographies, districts (localities in Argyll and Bute CHP), areas and Operational Units/CHP. They are also accompanied by comparator measures at National, Health Board; and Operational Unit/CHP level. To help users identify where strengths and weaknesses lie in their area, one page summaries were compiled which identified particular challenges, examples of good practice and areas for improvement across each operational unit. These together with the profiles themselves can be accessed both on the internet:

Adults: Adult_Profiles (internet)

CAYP: CAYP_Profiles (internet)

Notes

77 APPENDIX 9 – Feedback on aspects of the proposals

Table Feedback on aspects of changes being proposed as part of the service re-design Response group Number of Aspect responses Positive neutral Negative Improving community 94.2% 3.5% 2.3% 171 transport Improving out-of-hours 94.1% 4.7% 1.2% 170 inpatient medical cover More efficient use of 94% 2.4% 3.6% 168 resources Better joint working 93.4% 4.2% 2.4% 167 Improving public 93.4% 4.2% 2.4% 167 transport Developing care homes 89.4% 7.1% 3.5% 170 Providing more care-at- 88.4% 7.5% 4% 173 home (homecare) Retaining General Practice Health Centres 86.8% 13.2% - 174 at Grantown and Kingussie Providing services from 86% 7.6% 6.4% 171 modern buildings Developing new hospital and resource centre in 81.8% 5.9% 12.4% 170 Aviemore Retaining some outpatient services at 77.8% 18.1% 4.1% 171 Grantown and Kingussie Retaining NHS Dental 73.4% 24.9% 1.7% 173 Services at Grantown Moving Aviemore Health 68% 20.3% 11.6% 172 Centre into new facility Closing in-patient beds in 54.5% 24.6% 21% 167 St Vincent’s hospital Moving Glen day centre in Aviemore into new 54.4% 28.7% 17% 171 facility Closing in-patient beds in 53.8% 21.9% 24.3% 169 Ian Charles hospital

78 Making decisions

The Board of NHS Highland will consider the recommendation at their meeting to be held in Inverness on 7th October 2014.

This is a meeting held in public and papers for the meeting are available on the NHS Highland website, one week in advance of the meeting. http://www.nhshighland.scot.nhs.uk/Meetings/BoardsMeetings/Pages/W elcome.aspx

If you have any queries about the Board meeting, please contact [email protected] or [email protected]

NHS Highland Assynt House, Beechwood Park, Inverness, IV2 3BW

01463 717123 How to find out more

For any further information, please get in touch with:

Dr Boyd Peters Nigel Small Maimie Thompson clinical lead director of operations head of public relations

Tel 01479 811792 Tel 01463 704622 Tel 01463 704722 [email protected] [email protected] [email protected]

Local contacts

Contact details of the members of the steering group are also available on the NHS Highland website.

www.nhshighland.scot.nhs.uk

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