SHETLAND HEALTH & SOCIAL CARE PARTNERSHIP IN CONJUNCTION WITH BRESSAY COMMUNITY COUNCIL ‘Caring for Bressay’ Engaging Communities in Developing Sustainable Service Models for the Future Bressay Lighthouse Introduction In December 2017 an initial meeting was held between representatives of the Bressay Community Council and the Chief Nurse (Community), Shetland Health and Social Care Partnership to discuss issues of concern with service provision on Bressay. This discussion led to the establishment of a jointly sponsored project between the Community Council and the Health and Social Care Partnership. Project Aims The aims of the project are to explore the health and care needs of residents on Bressay, and through working in partnership, create a sustainable, affordable, and clinically appropriate service model which meets the health & care needs of islanders for the future. This paper provides an overview of the work carried out by the Project Board and invites comments from the community on the proposed future service model. Membership of the Project Board can be seen in Appendix 1. All comments should be sent to Clinical Governance Support Team, NHS Shetland, Board Headquarters, Montfield in the SAE provided by 19 August 2019. Following review of all comments received, the Project Board will draft a paper for presentation to the Integration Joint Board (IJB) recommending a safe and sustainable service model for Bressay residents for the future. Background Shetland has 5 non-doctor islands – Fair Isle, Foula, Fetlar, Skerries and Bressay - where traditionally a resident nurse has been the first point of contact for all healthcare needs on a 24/7 basis. In addition to the resident nurse, the non- doctor islands - with the exception of Bressay - have regular scheduled visiting services from the General Practitioners based at the respective Health Centres with responsibility for each island. Some islands also have services provided by allied health professionals eg Podiatry, and Dental services, on a visiting basis. Strategic Context The development of integrated health and social care services takes account of national policy (‘Shifting the Balance of Care’) to move services out of hospitals 1 into community settings and from community based settings into people’s own homes. Local services perform well, albeit with higher unit costs than elsewhere in Scotland. Notwithstanding our successes, the rural care model, with its focus on residential care, is not consistent with the Older People’s Health and Wellbeing Strategy (2015) which identified that older people want to be cared for in their own home and where that is not possible in a community setting that is not institutional care. The Shetland Islands Health and Social Care Strategic Commissioning Plan 2019 -2022 approved by the Council, NHS Shetland and the IJB in March and April 2019 identified a significant imbalance between the current model of service delivery and the resources available to meet service demand. Moreover this will continue to increase as a result of an increasing aged population and a decreasing number of staff available to provide care and support services. Health Care Improvement Scotland (Living Well in Communities with Frailty. Evidence of what works. (June 2018)) have identified a significant number of interventions which have been demonstrated to improve outcomes for frail, older people. Many of these initiatives are preventative in nature and have already been implemented in Shetland. These include exercise interventions and physical activity; polypharmacy review; immunisation programmes; primary care interventions; community older people’s services; addressing lifestyle factors; nutritional interventions, hospital at home, re-enablement; bed based intermediate care and anticipatory care planning. In addition, increased integration of services (with comprehensive care provided along the entire pathway), improved care coordination and management can deliver significant benefits including 13% fewer hospital admissions, 27% fewer visits to A+E, care at home, rather than in a hospital setting, reducing care costs by 19%, (World Health Organisation Continuity and Coordination of Care 2018). While Care Inspectorate requirements reduce capacity to use the existing social care workforce to move the focus of care from residential to home based service provision we know that more people can be cared for in their own homes by fewer staff and a number of projects are being planned which will develop services to be delivered in people’s own homes through traditional care at home, district nursing services, intermediate care and an increased use of telehealth/telecare services. 2 Drivers for Change In addition to the overall strategic context of a shift to provide more services in the community, and thus closer to home, in relation to nursing posts, there are a number of drivers for change related to current Professional issues and challenges associated with working in non-doctor island posts. These issues are briefly outlined below; Changes in career structure/expectations – professional training is increasingly of a specialist nature and thus finding staff with a breadth of knowledge and experience to cover island settings is becoming increasingly difficult. Workload/ Re-registration issues – in order to work as a Registered Nurse, Nurses need to maintain a live Registration with the Nursing and Midwifery Council (NMC). On a 3 yearly basis a Registered Nurse has to demonstrate maintenance of their competence in a range of skills and procedures. The nursing caseload size on Bressay is very small which makes skill and competence retention difficult (if only undertaking the District Nursing role for Bressay). Professional Isolation – Professional support is crucial for any postholder to ensure that they feel supported in their role and also to provide an opportunity for peer support / supervision and development. Working in a single handed post limits the opportunity for peer support. Role? – The role of a non-doctor island nurse is different from the role of a District Nurse on mainland Shetland and the expectation from communities is different. Individual staff members may not be in a position to deliver the service that the community wants and thus it can prove challenging both to the professional and the community when the staff member appears unwilling to play the role that the community wants/needs. Living in remote communities/Work-life balance – It is a recognised challenge maintaining a professional role and also trying to have some private time whilst living in small communities amongst the people you serve. The posts, whilst not busy all the time, all have an oncall 24hr responsibility which limits personal “down time” and ultimately leads to stress and increasing the potential for burnout. Recruitment/retention issue – There is an increasing challenge in the sustainability of these posts/services due to the challenge of finding appropriately skilled staff, who wish to work in this role. 3 European Working Time Directive (EWTD) – The European Working Time Regulations prescribe a maximum working week of 48hours. The current Non- Doctor Island staffing model has a notional working week of 37.5hrs plus an oncall commitment of 128hrs per week. We have received a legal challenge to this model of working which means that this service model is not sustainable for the future. As well as the challenges experienced in the recruitment and retention of nursing staff, the demography of the Shetland working population, combined with the overall buoyancy in the local economy, means that recruitment to care work can be very challenging. There are significant difficulties encountered in trying to recruit individuals to the support at home service in particular. Health and Care Needs Analysis In 2016 NHS Shetland produced data on the health, care and wellbeing needs of local populations across the seven planning localities. The health needs assessment for Bressay is included in the report for Lerwick and Bressay. The full report can be accessed at http://www.shetland.gov.uk/Health_Social_Care_Integration/documents/Healthan dSocialCareIntegration-LerwickandBressayMASTERV6.pdf According to GP Registrations in September 2018, Bressay had a population size of 322 individuals, 162 of whom were female and 160 male. This was distributed across the following age ranges: 4 With the following being the percentage of individuals in the community aged over 50 Age % 50+ 53.4% 60+ 37.3% 70+ 20.8% The Health Needs profile identifies the following points in relation to the health needs of the population registered with the Lerwick Practice, which includes individuals living in Lerwick catchment area as well as on Bressay: • Below average rate of asthma and an average rate of COPD (Chronic Obstructive Pulmonary Disease), although the COPD rate is lower than a number of other practices in Shetland; • Average rate of CHD (Coronary Heart Disease); • Lower rate of Heart Failure; • Low level of Hypertension (high blood pressure); • Low level of Obesity and a lower rate of Diabetes than other areas in Shetland; • Above average rate of severe mental illness; • Average amount of cancers, but increasing in line with the population living longer; • Below average rate of Chronic Kidney Disease (CKD); • Average number of Strokes and Transient Ischaemic Attacks (TIAs). 5 In terms of actual numbers of individuals living with longterm conditions on Bressay, the following is the health profile Disease Patients Atrial Fibrillation 9 Asthma 22 Cancer 17 CHD 12 CKD 13 COPD <5 Dementia <5 Diabetes 26 Epilepsy <5 Heart Failure <5 Hypertension 66 Hypothyroidism 20 Mental Health <5 Peripheral Arterial Disease <5 Palliative <5 Rheum Arthritis 5 Stroke TIA 7 NB All numbers less than 5 are expressed as a <5 in order to protect anonymity Long Term Conditions per Patient Number of % of LTCs Number Population 0 197 61.2% 1 76 23.6% 2 23 7.1% 3 16 5.0% 4 5 1.6% 5 4 1.2% 6 1 0.3% Total 322 6 This table shows that almost two thirds of the Bressay residents have no longterm condition and that just over a fifth of the population has 1 longterm condition.