Highland NHS Board 2 December 2014 Item 4.1

PROPOSED REDESIGN OF SERVICES IN SKYE, LOCHALSH AND SOUTH WEST ROSS

Report by Gill McVicar, Director of Operations (North and West) 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 the three month public consultation into proposed major service change.  Note the feedback from the Scottish Health Council endorsing the options appraisal and consultation process.  Endorse the recommendation in support of the preferred option – to develop a Community ‘Hub’ in Broadford and a ‘Spoke’ in Portree.  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 Skye, Lochalsh and South West Ross (part of North and West Operational Unit). In particular it highlights the main findings from the formal three month public consultation exercise but touches on the earlier options appraisal process.

Within Skye, Lochalsh and South West Ross, some services are not adequately resourced making them not as safe, effective or efficient as they need to be to meet future demands. In addition the two local community hospitals are not in good physical condition and not designed to meet modern standards.

It is increasingly difficult to maintain and sustain the current hospital services due to the condition of the facilities, availability of staff and the cost. While it is the intention to do so for as long as possible, as demonstrated by the recent suspension of endoscopy services from Dr MacKinnon Memorial, this is increasingly challenging.

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 for potential future models of service:

Option 1 – Do minimum

Option 2 – Community hospital and resource centre in one town (‘Hub’) and scaled-down services in the other (‘Spoke’).

Option 2a – ‘Hub’ in Broadford, ‘Spoke’ in Portree Option 2b – ‘Hub’ in Portree, ‘Spoke’ in Broadford

Option 3 – Community Hospital and resource centre ‘Hub’ in a central location

Do minimum scored very lowly confirming that there was significant support for a change with option 2 identified as the preferred model of service. Further work by the steering group via the options appraisal process determined that the preferred location, at this stage, would be to have the ‘Hub’ in Broadford and ‘Spoke’ in Portree. If implemented this would mean building a new community hospital and resource centre in Broadford. This would be part of a wider redesign, as well as investment and modernisation of health and social care services across the areas of Skye, Lochalsh and South West Ross. This work is already underway in the community and the plan would be for new community arrangements to be fully tested and up and running before any changes were made.

The Board of NHS Highland considered these proposed changes to be ‘major’ and therefore subject to a period of formal public consultation. The Board approved the move to consultation at their meeting in April 2014 and in May 2014 the Scottish Health Council confirmed that NHS Highland was in a position to get the public consultation underway.

The formal public consultation was launched on 19th May and ran for a total of 15 weeks until 31st August. NHS Highland was consulting on the range of options including option 2a as the preferred option.

During the consultation period over 50 meetings and events took place and a survey response form (with free-post envelope) was delivered to every home and business.

Of those who completed NHS Highland’s consultation response survey (2,273) there was wide-spread support for the case for change with only 1% of the population who responded supporting the do minimum option, and almost 86% supporting the preferred model of service. In terms of location, overall, the majority, 57%, favoured the preferred option 2a, ‘Hub in Broadford and ‘Spoke’ in Portree, whereas 29% supported Portree as the ‘Hub’ (option 2b).

Positive feedback on the consultation process and the preferred option was also received from many 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 and the Highland Health and Social Care Committee has endorsed that the process has been in accordance with Scottish Government Guidance. This includes the options appraisal process (service model, location and sites), public consultation materials and the public consultation communications and engagement plan.

Taking everything into consideration the Operational Unit can demonstrate broad support from the wide range of stakeholders for the preferred option (option 2a) 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 that there were some people who had some strong concerns about aspects of the proposed redesign (most notably in the North and Central parts of Skye), and some topics of wider general concern (for instance future services, transport, future use of buildings, bed requirements, care homes and care-at-home) requiring further consideration.

The full report, therefore also sets out some of these concerns, responses and assurances as well as the next steps in meeting the guidance. It describes some of the further work that would be required should the preferred option move to implementation.

Although the board and the Scottish Health Council has already endorsed the Options Appraisal process to determine the service model and location this was challenged during the public consultation including a late submission and is touched on in this paper (Section 2.4) and covered in more detail in the full report.

2 2 NHS Highland Report on the Public Consultation

2.1 Overview

The full public consultation report specifically covers the three month public consultation into the proposed redesign of services across Skye, Lochalsh and South West Ross. It does, however, provide some background information to allow the findings to be understood in the wider context of the work that has taken place over the past few years including the options appraisal process.

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

It also includes a summary of the feedback from the independent review of the consultation process by the Scottish Health Council.

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

Early work on a potential site to support the preferred option has also been carried out by the Steering Group with appraisal criteria and weighting having been agreed. This work would be completed if there is a decision to progress to implement the preferred option in the preferred location (Broadford).

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.

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 that 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 December.

The Scottish Health Council carried out an independent review of the process and has also endorsed the process. A link to their report is here

In coming to a conclusion as to whether NHS Highland had followed the guidance, the Scottish Health Council reported:

“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 about the ’Proposed Modernisation of Health and Social Care Services in Skye, Lochalsh and South West Ross’.

3 “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. Where people have requested further meetings or information NHS Highland has been responsive.”

2.3 Feedback on the Service Model and Location

2,2,73 people took the opportunity to complete the consultation survey. Of these 86% agreed with the proposal to develop a ‘Hub’ and ‘Spoke’ model with a new build community hospital and resource centre with wider development of community services. The remaining 14% comprised not given (8%), option 3 (2%), no preference (2%), option 1 (1%) and other (1%).

57% favoured the preferred option (Option 2a) the ‘Hub’ in Broadford and Spoke in Portree, 29% favoured the ‘Hub’ being in Portree (Option 2b),

The feed-back from the public survey, therefore, shows two to one in favour of the preferred option. This option also received backing from the clinical community, 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 11 of the 12 elements (ranging from 59% to 91%) apart from closing in-patient beds in Portree where 53% did not support this proposal.

In addition there is some anxiety in the North about possible loss of ‘A&E’ facilities. At present, Portree Community Hospital provides minor injury and ailment care (and is not A&E) and also does not run 24/7. Concerns were also expressed that there would be a loss of out of hours care.

During the consultation NHS Highland was able to confirm that there are no proposed changes to level of service or access to these services in Portree Community Hospital. The current pathways, which have been in place for the last ten years, will remain unchanged.

2.3.1 Site

Although four possible sites have been identified in Broadford, one being in the ownership of NHS Highland, further feasibility work would be required on determining a final site proposal. The Steering Group has undertaken the initial step in the site option appraisal and will complete that should this recommendation be approved. A majority of those responding during the consultation process had no preference for site. Early discussion with the Planning Department did not reveal any potential difficulties with any of the sites.

2.4 Feedback on Options Appraisal Process

During the consultation, and following the consultation, some feed-back was received regarding the Options Appraisal process which made a determination on the proposed location of the ‘Hub’ and ‘Spoke’. This was responded to in the report to the Highland and Health and Social Care Committee

Although the Scottish Health Council had already endorsed the options appraisal process to determine both the model and location (Appendix 3, of the full report), in their recent report, they further considered some of the concerns raised by some members of communities on these matters.

4 “Feedback from the north of Skye indicated some strong resistance to the proposed location of the ‘Hub’ in Broadford. This was partly linked to criticism of the membership of the steering group and the process used to identify the proposed location.”

“We evaluated the model and location option appraisal workshops by sharing a survey with the community and public representatives. We received 13 responses.1 The evaluation indicated that the majority of the public participants understood the option appraisal process and how the preferred option was reached. They also felt their views were listened to and that they had the opportunity to ask questions.

People attending the focus group in August 2014 reflected on their involvement and said they felt they had been encouraged to discuss what was happening at the meetings with their groups and communities. They also suggested that the process had started with a ‘blank sheet’ and the outcome of the option appraisal was the consensus view of the group.

After the report was considered by the Health and Social care Committee NHS Highland was made aware of an action group which had formed. It was confirmed on 18th November that the group is chaired by Sarah Marshall. A paper was initially submitted on behalf of the group to NHS Highland on 10th November 2014 and then re-submitted on 18th November when the chair of the group was confirmed. It is understood that the author of the report is not a member of the group. Their submission has been included in the full report (Appendix 10).

The group was unhappy with the Options Appraisal process on location and carried out their own analysis based on the documents available in the public domain. A version of this was first presented at the Public Meeting in Portree on 14th August.

Their report has been considered by the authors of the board paper and also shared with the steering group.

Some of comments as set out in critique appear to be anecdotal, personal opinion, some are not factual while others are not supported with any evidence.

In addition, as part of our own internal scrutiny, a review of the Options Appraisal review was carried out by an internal option appraisal expert, and an external analyst. This included carrying out a range of sensitivity analysis. Two of the points that the external analysis sought clarification on were:

 evidence of who took part and whether geographic spread could be evidenced, and  did participants understand the definitions

Both these points have already been covered in the Independent Report from the Scottish Health Council and are further covered in the main report including name, designation and representation of people who took part in the options appraisal exercise into model and location. This information has been in the public domain for some time. Members of the steering group, who were part of a lengthy process, were also quite clear that they were fully informed and had access to any information they deemed necessary, before or during the workshops.

NHS Highland also considered whether there was any merit in asking for an opinion of another board. This was discounted because it would not add anything extra to the additional internal and external technical scrutiny which has already taken place. Only the people who took part can explain their rationale behind agreeing criteria and weights but did so in the context of a length process that was independently facilitated.

1 From community and public representatives who were members of the steering group and took part in the options appraisal

5 The key benefit of an option appraisal exercises are that they are done by a representative group which has the opportunity to agree key principles, ground rules and to debate each criterion at length and in depth. The process brings objectivity to the subjectivity of individual opinions and potential bias. For these reason, it is suggested that the exercise carried out by the Steering Group following extensive debate with a representative group (Appendix 9 of full report), facilitated by an independent facilitator, and endorsed by the Scottish Health Council is robust and there is no place for it to be challenged simply via a desk top exercise, however well undertaken.

It was important to check the arithmetic and to be challenged on our underpinning evidence and assumptions and this work has now been completed.

Notably, while the option appraisal provides useful evidence to inform the decision-making process, it is clear from the guidance that the views of wider local communities must also be taken into account. This is why the public consultation was so important and the evidence of an extensive engagement exercise also endorsed by the Scottish Health Council. By sending a survey form to every home and business the exercise undertaken by the operational unit could not have been more inclusive.

2.5 Conclusion

The options appraisal process and public consultation process has already been endorsed both internally via the Highland Health and Social Care Committee and independently by the Scottish Health Council. Parts of the process have been further scrutinised by internal and external technical experts.

NHS Highland can evidence a comprehensive engagement exercise with two to one also supporting the preferred option as determined by the steering group and is now being formally recommended to the Board for endorsement.

In coming to this view, the Operational Unit has sought to satisfy itself that the majority of people were comfortable with the consultation process, understood the case for change and that there was a majority favouring the preferred option and location.

2.6 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 and location 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 will be maintained or improved  Explore opportunities for co-location of children and families staff in any new facility  Further engagement on specific elements of some of the proposals  Clarification on consistent use of terminology to describe services such as minor injury/ailment, casualty (i.e. not A&E) so that people fully understand what would be delivered from the ‘Spoke’  Development of an Integrated Transport Plan  Strategic development and expansion of care-at-home services

6  Engagement with care homes with a view to integrated working and development of step up step down and end of life care beds  Further work with Highland Hospice in respect of Palliative Care and Virtual Hospice  Further detailed work to develop the final clinical specification for the hospital and resource centre  Further modelling work on bed numbers  Further development of telehealth care options  Carry out technical appraisal of preferred site  On-going engagement with local communities and stakeholders throughout the development of the business case.

Changes will only be made when there are tried and tested alternative arrangements are in place.

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.

This proposal is in line with the NHS Highland Care Strategy and the NHS Scotland 20:20 vision.

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.

4 Governance Implications

 Staff Governance2 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 and discussions with the local GPs, facilitated through the Clinical Director 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 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.

2 In this context staff is used in the broadest term and includes GP and practice staff

7 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 good clinical engagement and consensus.

There are some significant governance implications to delivering healthcare in a hospital environment which is not conducive to easily meeting standards . 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 £105,000 maintenance alone.

Furthermore, clinicians have raised concern about potential risks of patient harm caused by inpatient resources split over two sites as 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.

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. However, the plan would be for the new arrangements to be tested and up and running before any changes were made.

 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.

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.

Funding in principle for the proposals in Skye, Lochalsh and South West Ross was announced by the Scottish Government on 2nd November 2014. The exact level of funding has still to be confirmed and how long the funding will be available for is not clear.

It is likely to be beneficial if this proposal could progress in parallel with the proposed service re-design in Badenoch & Strathspey, already agreed by the Board in October 2014.

8 5 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 and issues with having in-patient services across two sites.

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.

Additional scrutiny has taken place to review the technical aspects of the options appraisal work on location which showed consistency in results.

6 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.

As part of the survey data on equality and diversity were collected. These are presented in the full consultation report to the board but are summarised below:

 Overall response rate of 19%, highest in Skye South (23%)

 The female response rate (22%) was higher than that of males (14%) with the greatest disparity in Skye Central and Skye North with nearly a 2:1 ratio

 Higher response rates were in older age groups ( 60y&over), particularly for Skye South and Lochalsh

 Older age groups were over-represented; particularly males aged 60-69 years (30% versus 20% in the population). The 16-29y age group was the least represented in the responses.

 The majority of responders considered themselves as patient/service user/carer (61%) and as a member of the community (71%).

 In the last 12 months, 12% and 4% of overall responders had been an inpatient in the MacKinnon Memorial or Portree Community hospitals respectively.

 Amongst the areas, the highest percentage in relation to MacKinnon was 16% in Lochalsh whilst the highest percentage in relation to Portree hospital was 9% in both Skye South and Skye Central

 Three quarters (75%) of responders indicated they were not living on their own, whilst over one fifth (21%) were living on their own. 4% either did not answer or preferred not to answer.

9  Most of the responders (83%) stated they were not carers, 12% stated they were carers and of these 60% were part-time and 40% full-time

 Approximately 40% (n = 851) stated they had a long-term condition or disability. Of these, nearly 60% indicated a long-term illness, just under 30% a physical disability and nearly 9% indicated a mental health problem. These proportions are not mutually exclusive.

Specifically in terms of the consultation process a wide range of approaches were used to inform and involve local people. There was one request for large print and audio version of the consultation materials.

Detailed work has been carried out on travel times, deprivation and service profiles. Further work is ongoing. An access and transport group has been established and a Transport Survey and needs assessment will be carried out.

7 Engagement and Communication

As set out in the full report and the report to the Health and Social care Committee the public consultation has been a comprehensive engagement and communications exercise led and delivered by the Operational Unit supported by a number of departments.

An after action review between NHS Highland and Scottish Health Council has been arranged for 10th December. . A local access and transport group has been established and has already held its first meeting. The Group is chaired by a local Councillor.

8 Conclusion There is no ideal solution to where a new community hospital ‘Hub’ and associated services are located for the communities of Skye, Lochalsh and South West Ross. However, the management team can demonstrate broad and strong support for the service model ‘Hub’ and ‘Spoke’ with only one percent supporting the status quo, and 2:1 in favour of the Broadford as the preferred location.

The changes being proposed offer the opportunity to bring about sustainable services which will be safer and consistent with national strategy and the Highland Quality Approach. The changes if implemented 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. Scrutiny by the Health and Social Committee, together with the independent report from the Scottish Health Council, internal and external technical experts should provide further assurances to the Board that service change guidance has been fully followed.

Gill McVicar Maimie Thompson Director of Operations (North and West) Head of Public Relations and Engagement

21 November 2014

10 Proposed Modernisation of Community and Hospital services in Skye, Lochalsh and South West Ross

Report on formal Public Consultation 19th May to 29th August 2014

20th November 2014

Gill McVicar Director of Operations North and West Operational Unit

&

Maimie Thompson Head of Public Relations and Engagement

November 2014

#skyechat

www.nhshighland.scot.nhs.uk

1 Contents

Recommendation and Conclusion Executive Summary

1 Overview

2 Major service change and public consultation process

3 Assurance of the options appraisal and public consultation process

4 Feedback on issues from events and open letters

5 Who responded to the consultation survey?

6 Feedback on service model options, location and aspects of the proposal

7 Recommendation and next steps

Appendices

Appendix 1 Overview of the NHS service change process in Scotland Appendix 2 Summary of key milestones and timeline Appendix 3 Email from Scottish Health Council confirming NHS Highland in a position to move to public consultation Appendix 4 Summary of the main initiatives to raise awareness Appendix 5 Events and stakeholder meetings including updates to committees Appendix 6 Overview of services provided from Dr MacKinnon Memorial Hospital and Portree Community Hospital Appendix 7 Advantages and disadvantages of short-list of service model options Appendix 8 Development of options and conclusion of options appraisal on location Appendix 9 List of participants at the options appraisal workshop on location, 11th March 2014 Appendix 10 Options appraisal workshop (11th March) a North Skye Action Group Critique, 8th November 2014 Appendix 11 Points raised at meetings, events and correspondence Appendix 12 Outline of services to likely to be provided from Hub and Spoke Appendix 13 Skye & Lochalsh population within estimated drive times of selected sites Appendix 14 Further work identified to understand future bed numbers and a summary of district profiles

2 Supporting Information

The Options appraisal work, public consultation and write-up of the full report is underpinned by a number of other reports

 North Skye Action Group Critique into the options appraisal workshop held on 11th March 2014 (November 2014)

 A report on NHS Highland’s consultation on the proposed modernisation of community and hospital services in Skye, Lochalsh and South West Ross (October 2014), Scottish Health Council

 Skye and Lochalsh population within estimated drive times of selected sites (October 2014), Ian Douglas Health Intelligence Specialist

 Income deprivation in Skye, Lochalsh and West Ross (August 2014), Ian Douglas Health Intelligence Specialist

 Outpatient activity in Skye, Lochalsh and West Ross (August 2014), Ian Douglas Health Intelligence Specialist

 Inpatient activity in Skye, Lochalsh and West Ross (November 2013) Ian Douglas Health Intelligence Specialist

 Population drive time access to community hospitals in Skye, Lochalsh and South West Ross (November 2013), Ian Douglas Health Intelligence Specialist

 Summary of hospital service provision on Skye (November 2013), Frances Matthewson Service Planning Analyst and Ian Douglas Health Intelligence Specialist

 Adult health and well-being profiles - September 2012 (September 2013), Epidemiology & Health Science, Public Health

 Place of death in NHS Highland (August 2013), Ian Douglas Health Intelligence Specialist

 Proposed major service change in Skye, Lochalsh and South West Ross: Analysis of responses to the public consultation survey, November 2014

 Proposed major service change in Skye, Lochalsh and South West Ross: Additional Analysis of responses to the public consultation survey

3 Recommendation and Conclusions

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

There is broad support from a wide range of stakeholders for the preferred option (option 2a) and this is now being formally recommended to the Board for endorsement.

In coming to this view, the operational unit has sought to satisfy itself that the majority of people were comfortable with the consultation process, understood the case for change and that there was a majority favouring the preferred option. By the end of the consultation (and following the consultation) no new concerns were being expressed and all the evidence gave a consistent picture.

2,273 people completed a consultation survey response form. From these one percent of people who responded were in favour of the ‘do minimum option’ while 86% supported the preferred model of service - ‘Hub and Spoke’. The remaining 14% were ‘not given’ (8%), ‘no preference’ 2%, ‘option 3’ 2% and ‘other’ 1%.

Although the re-design of services is much wider than hospital facilities, it was always anticipated that deciding on the location of the main hospital and resource centre ‘Hub’ would be the most contentious element, even though it represents the smallest element of health and social care provision that most people will be in contact with.

In terms of location, overall the majority (57%) favoured the preferred option (Option 2a) Broadford for the ‘Hub’ and Portree for the ‘Spoke’; whereas 29% supported Portree (Option 2b). It should be noted, however that support for option 2a did vary by geography. While communities in Skye South, Lochalsh and South West Ross were all strongly in favour of Broadford being the Hub (80% or higher), in Skye North and Skye Central it was lower 19% and 23% respectively.

The majority of responders were in support of most of the components of the proposed changes ranging from 59% to 91% but with one exception. 53% of all responders did not support the closing of in-patient beds in Portree Community Hospital.

Option 2a also received the backing from partner organisations (The Highland Council, Scottish Ambulance Service, Scottish Fire and Rescue Service, Highlands and Islands Enterprise and the Highland Hospice).

Although the survey was the main way that public feedback was considered, other information and feedback was also considered. This included feedback from events, open letters and emails. All of this information reflected the wider feedback with overall support for Option 2a but with some strong opposition in Skye North and Skye Central, and some general concerns around the ‘Spoke’.

4 Executive Summary

1 Services provided by the NHS need to change to make sure they meet the future needs of the population due to demographic changes, particularly the increasing ageing population of Scotland and the number of people with long-term health conditions. The increasing financial challenges provide a further significant catalyst for major change.

2 There are additional challenges facing NHS Highland linked to geography, recruitment, retention and in some cases history. In addition there is a pressing need to develop more community services, facilitate greater community resilience and modernise and rationalise our estate.

3 Specifically on Skye there are two local community hospitals that are not in good physical condition and are not designed to meet modern standards.

4 Historically there has been heated debate over many decades particularly around the location of any new proposed main hospital. It was anticipated from the outset that this would again be a significant challenge and there may be a struggle to reach a consensus that will be accepted and not contested.

5 Work has been ongoing over the past few years to look at the issues with a view to providing sustainable solutions in the future. A local steering group was established to identify possible models of service. During 2013/14 the group went through an options appraisal process and agreed a short-list of three options for a proposed model of service:

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

6 Do minimum scored very lowly confirming that there was significant support for change with option 2 identified as the preferred model.

7 Further work by the steering group via the options appraisal process determined that the preferred location, at this stage, would be to have the ‘Hub’ in Broadford and ‘Spoke’ in Portree. The process through which this was determined has since been challenged by a North Skye Action Group which has recently been set-up. Their submissions was considered but discounted and the reasons are explained in the report.

8 If implemented this would mean building a new community hospital and resource centre in Broadford. This would be part of a wider redesign, as well as investment and modernisation of health and social care services across the areas of Skye, Lochalsh and South West Ross.

9 The Board of NHS Highland considered these proposed changes to be ‘major’ and therefore subject to a period of formal public consultation. The Board approved the

5 move to consultation at their meeting in April 2014 and in May the Scottish Health Council confirmed that NHS Highland was in a position to get the public consultation underway.

10 The formal public consultation was launched on 19th May and ran until 29th August 2014.

11 While option appraisal provides useful evidence to inform the decision-making process, the views of local communities must also be taken into account. This is why the public consultation is so important.

12 NHS Highland consulted on the range of options including Option 2a as the preferred option but it was also made clear that people could highlight any other option or variations on options.

13 During the consultation period over 50 meetings and events took place. A summary document was mailed to every home and business (9,126, homes =8,405 and businesses= 721 copies) during the early part of the consultation (week beginning 9th June). A survey response form was also delivered to every home and business towards the end of the consultation (week beginning 11th August).

14 Throughout the consultation there was a regular flow of information available for the public. All requests for meetings during the consultation period were accommodated.

15 There was active engagement from most community councils, local councillors, and other key local groups such as Access Panel, Public Partnership Forum, Friends of Portree Community Hospital, Young Carers, and League of Friends Dr Mackinnon Memorial Hospital. There was also wider and ongoing engagement with partner agencies, MSPs, local MP and others.

16 In their independent report of the consultation process published in October 2014, 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.”

17 The Highland Health and Social Care Committee also considered a detailed report from the North and West Operational Unit on the consultation process. This included the full report provided by the Scottish Health Council.

18 In their assurance report to the Board the Committee acknowledged that a thorough consultation process had been conducted, with evidence of a high level of engagement. They endorsed that the process complied with Scottish Government major service change guidance and agreed that the full findings and recommendation should be presented to the NHS Board on 2nd December 2014.

6 19 During the consultation NHS Highland received 2,273 full or partially completed survey responses. One percent of responders supported ‘do minimum’ while 86% supported the preferred model of service - ‘Hub and Spoke’ (Option2). This strong endorsement was consistent with the conclusions of the options appraisal.

20 In terms of location, overall the majority (57%) favoured the preferred option (Option 2a) Broadford for the ‘Hub’ and Portree for the ‘Spoke’; whereas 29% supported Portree (Option 2b). This shows 2:1 in favour of the preferred option, again adding confidence to the conclusions from the options appraisal.

21 It should be noted, however, that support for Option 2a did vary by geography. While communities in Skye South, Lochalsh and South West Ross were all strongly in favour of Broadford (80% or higher) only 19% and 23% of those in Skye North and Skye Central respectively were in favour of Broadford.

22 The majority of responders were in support of the components of the proposed changes ranging from 59% to 91% but with one exception; 53% of responders did not support the closing of in-patient beds in Portree, although the do minimum only received the support of one percent.

23 Although the survey was the main way that public feedback was considered other information was reviewed. All of the information reflected the wider feedback with overall support for option 2a but there was some strong opposition in the Skye North and Skye Central.

24 Positive feedback on the consultation process and the preferred model 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.

25 The specific opposition from some areas (North Skye and Central Skye) and the general concern over the lack of in-patient beds in Portree is recognized but it needs to be set in the context of the overwhelming support for Option 2 –which clearly stated that inpatient beds would only be on one site.

26 Taking everything into consideration the Operational Unit can demonstrate broad support for the preferred option (Option 2a) and it is, therefore, formally recommending this option to the Board for endorsement. 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.

27 Clearly further work would still be required to ensure that there is confidence in the new model of service. This would include further work on Access and Transport and developing community and adult social care services. This would all form part of the work required for the Business Case process and would require ongoing engagement with all stakeholders.

28 Developing community infrastructure work is ongoing and the plan would be for new arrangements to be tried and tested before any changes were made.

7 1. Overview

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 provides an overview of the three month public consultation into the proposed re-design of services across Skye, Lochalsh and South West Ross.

It also briefly describes some of the background including how a preferred option for consultation was arrived at.

An overview of how the consultation was promoted, the range of ways that views were gathered, and a summary of all the feedback is set out. Although this was the subject of a more detailed report already in the public domain.

It includes the findings of the independent review by the Scottish Health Council endorsing the consultation process and the conclusions and endorsement from the Highland Health and Social care Committee concerning whether the necessary guidance has been followed. Again these reports are already in the public domain.

A summary of the analysis of the feedback from NHS Highland’s consultation survey is provided including a link to the full report. This was the main way of gauging public opinion but other feedback is also described.

Based on an assessment of all the supporting information at this stage a recommendation is made to the Board on the model of service and location of ‘Hub’ and ‘Spoke’. Some provisional work has taken place on potential sites.

The report also sets out some of the next steps in meeting the guidance including the proposal to be considered by the Cabinet Secretary. Considerable further work would be required should the preferred option be implemented. This would include preparing an Initial Agreement document to be considered by the NHS Highland Board and then the SG Capital Investment Group before progressing through the Business Case process. The plan would be for new arrangements to be in place before any changes were made.

Without prejudice to any Board decision the operational unit has identified that some further work will be required regardless of location of Hub and Spoke, including:

 Further detailed work to develop the clinical specification for the ‘Hub’ and ‘Spoke’  Setting out how Primary Care, community services and adult social care services will be maintained and improved including through community resilience and co- production  Explore opportunities for co-location of children and families staff in any new facility  Complete work on site

8  Further engagement on some aspects of the proposals  Development of an Integrated Transport Plan  Strategic development and expansion of care-at-home services  Further modelling work on bed numbers  Complete site selection and carry out technical appraisal of preferred site  On-going engagement with local communities, staff and other stakeholders throughout the development of clinical services, community services and development of the business case process

1.2 NHS Highland Strategic Context and case for Change

Services provided by the NHS need to change to make sure they meet the future needs of the population. This is due to a number of reasons including demographic changes, particularly the increasing ageing population of Scotland and the number of people with long-term health conditions. But they also need to change to reflect changing times: models of care, technology, recruitment challenges, expectations and increasing financial challenges.

Major changes to services are therefore required with additional challenges facing NHS Highland linked to geography, recruitment and retention. There is a general need to develop more community services, facilitate greater community resilience and modernise and rationalise our estate.

There have already been lots of changes to modernize and improve services, with less need for hospital beds (Charts below) and a greater desire from the public to be cared for at home (as opposed to hospital or care home). It’s clear, however, that more radical change is required if services are to cope in the future.

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

9 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

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.

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. Although significant and ongoing progress is being made the increased figure reflecting the additional estate now owned by NHS Highland since integration in April 2012.

Integration of adult health and social care in April 2012 provides further opportunities to significantly re-design services. It should provide greater confidence and opportunities and move away from hospital care for people who don’t need medical care.

NHS in Scotland 2013/14, published on 30th October 2014 by Audit Scotland is the most recent publication to highlight “growing pressures” and the need for boards to “to deliver major changes to meet the future needs of patients.”

Funding in principle for the proposals in Skye, Lochalsh and South West Ross was announced by the Scottish Government on 2nd November 2014.

It is within this strategic context in Highland that the re-design proposals have emerged.

10 1.2.1 Local Context

There has been considerable debate and discussion over many decades around how best to re-design services across the Island of Skye. Previous attempts highlighted some contentious issues and in particular, the potential location of any proposed new main hospital and little progress was made.

It is also the case that some of the changes in more recent times such as the closure of Gesto Hospital in 2006 and general reduction in beds were strongly opposed and for some, these past changes, have the potential to influence the current consultation.

Nevertheless the rationale behind the need to make changes not only remains but is strengthened. It is clear that the status quo is no longer an option and the step-change needed will require resources to be used quite differently. This means less reliance on hospital beds and doctors and more care being provided by multi-professional teams and out of hospital.

Specifically for the communities of Skye, Lochalsh and South West Ross, in terms of health and social care the need to change includes:

 Community services and care-at-home to support needs to be developed to support the delivery of the Scottish Governments 20:20 vision and people’s expectation to be able to stay in their own home if at all possible. It may also need to test what people would really prioritise if they had to choose over more community resources or shorter waiting times for specialist care.

 To reflect the local changes in recent years such as the Skye Bridge which has changed access to services on and off the island.

 Splitting services across two hospitals (Dr MacKinnon Memorial Hospital in Broadford and Portree Community Hospital) is making it increasingly difficult to provide a safe level of medical and nursing cover, especially during the out-of-hours period. It is also duplicating some services. Increasingly to be affordable and sustainable hospitals need to have at least 20 plus in-patient beds due to economies of scale and value for money.

 Dr MacKinnon Memorial Hospital is 100 years old and is not designed to provide modern services. Parts of Portree Hospital have been modernised but other areas require further upgrading. The current site would allow only very limited opportunities for expansion.

 Associated back-log maintenance costs for both hospitals are currently estimated at £5.5million.

 Hospitals must meet various standards, such as infection, prevention and control, privacy and dignity and fire safety. It is now increasingly difficult for staff to meet some of these standards in both hospitals. Due to the physical layout and condition of the buildings they would never be able to evolve to facilitate modern integrated services

Notably, the physical condition of the hospital buildings and some of the equipment has created some pressing urgency around aspects of the review and re-design. This has

11 been further highlighted by the recent suspension of endoscopy services from Dr MacKinnon Memorial Hospital.

 Health and Social Care Profiles

Access to services in the North and West Operational Unit are generally far more challenging compared to many other parts of Highland. In Skye, Lochalsh & Wester Ross over half the population is in the most access deprived in NHS Highland.

While it might initially lead one to conclude that this should set the scene to develop hospital services on both existing areas on Skye, the steering group did not short-list this option. The group recognised the challenges of trying to staff and fund two facilities while at the same time requiring to develop more local community solutions.

The Steering Group took a wider view of service development and supported as local access as possible to a wider range of community services but with less reliance and focus on hospital beds.

Access needs to be considered both within the area of Skye, Lochalsh and South West Ross as well as the wider health board area. There is a balance to be struck between retaining services as locally as possible while making sure they are safe, sustainable and affordable. Getting the overall strategy right will help to safe-guard as many local services possible and prevent further centralisation to e.g. Inverness and Fort William.

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

12 2. Major Service Change and the Public Consultation process

Main points covered in this section:  Overview of major service change guidance  How the public consultation process was managed  Summary of how the consultation was promoted  Feedback from the steering group as part of mid-way consultation review

2.1 Introduction

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 1).

The Board of NHS Highland endorsed the preferred model of service (4th March 2014) and preferred location of Hub (1st April 2014) and ratified the major service change process thus far, at their meeting on 1st April 2014. This included approving the public consultation materials subject to further work being completed to identify sites in Broadford. This work on sites was completed on 30th April (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.

NHS Highland closely followed the guidance provided by the Scottish Health Council on the communications and engagement plan, the public consultation materials and the consultation survey.

The Scottish Health Council signed off the public consultation materials, and on 15th May 2014 confirmed that: “We feel that NHS Highland are now in a position to move to formal public consultation” (Appendix 3).

2.2 Management of the public consultation process

The formal consultation was launched on 19th May and ran for a total of 14 weeks until 29th August. This included a two week extension to provide further time to respond to the additional mail drop to every home and business which took place week beginning 11th August 2014.

The public consultation was led by Gill McVicar (Director of Operations) and Dr Paul Davidson (Clinical Director) supported by a small core team. 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 or queries.

1 http://www.sehd.scot.nhs.uk/mels/CEL2010_04.pdf 13 Other staff and NHS departments were actively involved in advising and supporting the consultation including: estates, communications, clinical governance, public health as well as executive and non executive leadership support.

A local staff side representative was also an active member of the steering group.

Other advice and support was provided by the local steering group, community councils, local groups, Scottish Health Council and Scottish Government officials, MSPs as detailed in the reports to Highland Health and Social Care Committee meetings held on 6th November 2014, 11th September, 10th July 2014 and 1st May 2014.

Specifically in relation to MSPs there has been ongoing contact throughout the process. All MSPs were sent an email updating on the consultation and asking for their support to promote the consultation.

They have also been sent regular updates including at the close of the consultation. Since then they have received further updates including on the specific issues of the suspension of endoscopy services. Most recently the chair of NHS Highland met with MSPs on 19th November 2014 and provided an update on the consultation.

There are also scheduled meetings with elected members and officials and these are ongoing. The Ward 6 & 11 councillors are members of the Skye, Lochalsh and South West Ross steering group. In the Highland Council’s response to the consultation it included the following:

2.3 Raising Awareness of the Public Consultation

In discussion with the Scottish Health Council a wide range of approaches were identified 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 detailed communications and engagement plan which was regularly reviewed and available on the NHS Highland website. The process was designed to be responsive with management capacity built in to meet anticipated requests or to address queries as they emerged during the consultation.

The decision making process and likely timeline was also described in the consultation materials and at events, at meetings, through correspondence, in media releases and with the Steering Group. The likely time-line as set out in the consultation materials is the one still being followed. Some of the key initiatives are noted below and summarised (Appendix 4).

 Consultation materials were available from 19th May and the full document included the dates for meeting and events which had been agreed in advance of the consultation – which at that stage numbered 40.

 A total of 9,126 summary documents were issued (homes = 8,405 and businesses = 721) via a mail drop during the week beginning 9th June 2014.

 During the course of the consultation period staff attended over 50 meetings and events and got underway on 19th May (Ross-shire Ward Forum) and concluding with a public meeting in Portree on 14th August (Appendix 5).

14  Activities included four public meetings, 20 drop-in events, 9 meetings with community councils (or grouping of Community Councils), attendance at Public Partnership Forum (Skye and Lochalsh and Wester Ross), District Partnerships, Friends of Portree and Friends of Dr MacKinnon Memorial Hospital, a walkabout, Young Carers and meeting with pupils in Portree High School.

 Hard copies of the consultation response form (with envelope and free post address) were handed out at various events and meetings. It was also made clear that people could write or email to NHS Highland or the Scottish Health Councils with their views.

 NHS Highland issued regular media releases and answered media inquiries about the consultation including paid for adverts (w/b 9th June; w/b 29th June and w/b 28th July) placed in local newspapers (West Highland Free Press and Ross-Shire Journal).

 Posters promoting dates of events were distributed and articles issued for local and NHS Highland publications and websites.

 At the Skye & Lochalsh Public Partnership Forum meeting held in Portree on 1st July it was requested that every household be sent a hard copy of the survey to ensure that everyone gets a chance to respond with members saying:

“This would mean that the consultation truly is a consultation”.

 A mid-review meeting was held with the Steering Group on 9th July 2014. This was to discuss progress with the consultation and to agree any further actions if required (Box 1).

Box 1 – Feedback from mid-review meeting held on 9th July 2014

Issue Resolution Status  Need to continue to Agreed – ongoing promotion Ongoing promote that it’s not just about hospitals but wider re-design

 Steering group has been Agreed – ongoing promotion Actioned through robust weighting process but public feedback important

 Some concern over poor Yes – Further advert and media Actioned attendance at meetings and release. Mail drop of form to all number of responses. Can homes. more be done?  Should consultation Agreed – additional mail drop Actioned response be delivered to all carried out homes?

 Extend consultation period Agreed – extended to 29th August Actioned

15 2.4 Feedback from Meetings, Events and Correspondence

Notes were taken at all meetings and events and the feedback themed. Similarly comments from correspondence letters and emails from 48 individuals or groups were also summarised. Feedback was categorised as relating to: i) Consultation process or public consultation materials and ii) Service model and aspects of the proposals (there was some overlap).

Comments specifically relating to the public consultation process were considered and responded to in the full report presented to the Highland Health and Social Care Committee and are not repeated here in any detail.

The options appraisal process and activities up to the point of moving to the public consultation had already been endorsed by NHS Highland Board, Highland Health and Social Care Committee and the Scottish Health Council.

Aspects relating to the service model are considered under section four of this report.

2.5 Feedback from partner agencies on the consultation process

 Scottish Ambulance Service “Scottish Ambulance Service welcome and support the development of this proposed new model of care and would welcome the opportunity to work in partnership with NHS Highland and the locality management team as this development progresses.”

 Highland Council “The Ward 6 & 11 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 Head of Operations North and West, Gill McVicar, and her team should be congratulated for the exemplary manner in which they have conducted the work.”

In conclusion they commented:

“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 health & social services.”

 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 “Good to see such a wide and open consultation with local people”.

16 3. Assurance of the Options Appraisal and Public Consultation process

Main points covered in this section:  Feedback from Scottish Health Council’s independent review  Feedback from NHS Highland internal assurance process via the Highland Health and Social Care Committee  Endorsement that Scottish Government guidance on major service change process has been followed

3.1 Introduction

The major service change process including the public consultation has been considered both externally through the Scottish Health Council, and internally through the NHS Highland Health and Social Care Committee.

3.2 Scottish Health Council (SHC)

One of the duties of the Scottish Health Council is to monitor the process and to provide an Independent Assurance Report to the Board of NHS Highland and feedback to the Scottish Government.

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 24th October and is available on their website: http://www.scottishhealthcouncil.org/publications/major_service_change_reports.aspx

Although the Scottish Health Council had already endorsed the options appraisal process to determine both the model and location (Appendix 3), in their recent report, they further considered some of the concerns raised by some communities on these matters.

“Feedback from the north of Skye indicated some strong resistance to the proposed location of the ‘Hub’ in Broadford. This was partly linked to criticism of the membership of the steering group and the process used to identify the proposed location.”

“We evaluated the model and location option appraisal workshops by sharing a survey with the community and public representatives. We received 13 responses.2 The evaluation indicated that the majority of the public participants understood the option appraisal process and how the preferred option was reached. They also felt their views were listened to and that they had the opportunity to ask questions.

People attending the focus group in August 2014 reflected on their involvement and said they felt they had been encouraged to discuss what was happening at the meetings with their groups and communities. They also suggested that the process had started with a ‘blank sheet’ and the outcome of the option appraisal was the consensus view of the group.

2 From community and public representatives who were members of the steering group and took part in the options appraisal 17 “However, they suggested that the option appraisal process could have been better explained to the wider community.“

In coming to a conclusion as to whether NHS Highland had followed the guidance, Scottish Health Council reported:

“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 about the “Proposed Modernisation of Health and Social Care Services in Skye, Lochalsh and South West Ross.

“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. Where people have requested further meetings or information NHS Highland has been responsive.”

3.3 Highland Health and Social Care Committee

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

 6th November 2014 – Final report on consultation process  11th September 2014 – Update  10th 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.

The chair of the committee was also in attendance at a number of meetings including the public meetings in Portree.

A draft paper was circulated to steering group members in advance of the most recent meeting and a number of minor amendments incorporated to the final committee paper.

3.3.1 Conclusion of Committee

At their meeting held on 6th November 2014 the committee members considered all the feedback and were satisfied that the major service change guidance had been followed.

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

They agreed to endorse recommendation and to present the full findings to NHS Board on 2nd December 2014.

18 Extract from Highland Health and Social Care Assurance Report from the meeting held on 6th November 2014

TOPIC: Redesign of Services in Skye, Lochalsh and South West Ross Public 4.1 Consultation: Update on the Consultation Process – Director of Operations (North and West) and Head of Public Relations and Engagement Issues Assurance Actions What is the latest Circulated report indicated consultation Action: position on the Public exercise completed on 19 August  Agreed to endorse that Consultation relating to 2014. A review by the Scottish Health the process complied Skye, Lochalsh and Council concluded that NHSH had with Scottish South West Ross? followed Scottish Government Government major guidance on involving local people in service change the consultation. The report gave an guidance – Dir of Ops update on the management of the (North & West)/Head public consultation process and of Public Relations activities, survey responses, comments and Engagement received in relation to the consultation process, background on the potential  Agreed to endorse location for a ‘Hub’ and ‘Spoke’ and a recommendation to brief description of the development present full findings to and conclusion of the relevant options NHS Board on 2 appraisal, and an access and transport December 2014 - Dir of evaluation. It was intended that a full Ops (North & report would be provided to the NHS West)/Head of Public Board at their meeting on 2 December Relations and 2014. Engagement

The Committee acknowledged a thorough consultation process had been conducted, with a high level of engagement having been evidenced. The Committee asked that there be clarity on some minor points of detail including confirming that one form was sent per household. There was also an opportunity for people to complete the form on behalf of family or a group. The Committee was assured of the process.

19 4. Feedback on Service Model Options, location and aspects of the proposal

Main points covered in this section:  Brief description of local services  Re-cap on options appraisal and selection of preferred model and location  Feedback on the short-list of options and aspects of the proposed changes from a range of sources:  Events  Open responses  Partner agencies

4. Background

Full details on the description of local services and the process to develop and appraise possible options were presented to the Board in April 2014. Details are available on the NHS Highland website and were described in the public consultation materials. For convenience a brief overview of services is included.

4.1 Brief description of local services

There are 14,680 people registered with CHI with General Practices in the area (April 2013. The populations of Skye, Lochalsh and South West Ross are served by ten GP Practices. As well as a full range of services provided by General Practice, the local communities are also served by two community hospitals: an overview of services currently provided from both hospitals are summarised (Appendix 6).

Dr MacKinnon Memorial Hospital, Broadford is a 20 bedded, hospital with medical cover provided by a small team of Rural Practitioners, who are doctors with additional training in acute immediate care. It has 24 hour on site medical and nursing cover and 24 hour A&E (casualty service). A small amount of elective day case surgery is carried out including until very recently endoscopy. Radiology services including ultrasound are on site. There are a range of visiting outpatient services from Raigmore Hospital (Inverness), New Craigs Hospital (Inverness) and Belford Hospital (Fort William).

Portree Hospital is a 12 bedded GP-led Hospital which is located adjacent to the Portree Medical Centre. It is supported by 24 hour nursing cover. The medical cover is provided by Portree Medical Centre (8am – 6pm), where a doctor is on site for most of that period. Minor Injury/ Ailment and out of hours cover is provided by a combination of local GPs, Rural Practitioners and nurses on site from 8am to 11pm, thereafter cover is provided from Broadford supported by a North Skye 2nd on call Doctor.

Radiology services are available three days per week to support outpatient clinics which include Orthopaedics, Ear Nose and Throat, Ophthalmology, General Medicine, Renal, Chest, Rehabilitation and Psychiatry.

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

20 More generally the area is served by multi-disciplinary teams (social workers, care at home workers, physiotherapists, occupational therapists, community nurses, community mental health teams), who work out of a number of different bases.

NHS Highland manages one Care Home (An Acarsaid) in Broadford. There are three privately run Care Homes: Budh Mhor in Portree, The Haven in Idrigill, Uig and Home Farm in Portree.

NHS Highland manages Day Care Services in Portree (Tigh na Drochaidh) and Dornie (Airdferry). Howard Doris Unit in Lochcarron is a privately run facility.

4.2 Brief description of development and conclusion of options appraisal

During 2013/14 the group went through an options appraisal process - which was independently facilitated – and arrived at a short-list of three options for a proposed model of service. Three service model options were short-listed:

 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

Some of the advantages and disadvantages of each were described (Appendix 7). Scoring at this stage identified option 2 as the preferred model of service (Appendix 8).  A further option appraisal exercise was undertaken to identify where the ‘Hub’ and ‘Spoke’ could be located. Both Portree and Broadford were considered feasible from a location point of view:

Option 2 (a) ‘Hub’ new-build in Broadford with ‘Spoke’ in Portree Option 2 (b) ‘Hub’ new-build in Portree with ‘Spoke’ in Broadford

The two options were scored using the same methodology as the previous workshops and again were independently facilitated. This was to maintain consistency. Members of the steering group identified and agreed the weighting and scoring of criteria relevant to the location. Through this process Option 2 (a) scored the highest (Appendix 8). The scoring of both options was close, however, highlighting that both locations would perform well as a ‘Hub’ or ‘Spoke’.

4.2.1 Sensitivity Analysis

 Steering Group and NHS Highland

Sensitivity analysis is where key quantitative assumptions are changed systematically to assess their effect on the final outcome. The process involves various ways of changing input values of the model to see the effect on the output value. To test the robustness of the option appraisal process sensitivity analysis was carried out at the workshop. One of the criteria ‘land acquisition’ was debated by the participants and it was felt that there was merit in re-running the analysis this time excluding the criteria. While it reduced the scoring advantage to Broadford, option 2a still scored higher.

21 After the consultation closed, as part of wider analysis and preparation of full report, further ‘sensitivity analysis’ and scrutiny was carried out. This was to consider some of the points raised during the consultation including formal objections from Kilmuir CC and Portree CC. In addition, a presentation at the Portree Public Meeting was given by a member of the public highlighting that revised weightings and scoring can obviously affect the results.

An internal expert for NHS Highland carried out the following sensitivity analysis:

1. Each of the 7 criteria was scored 0 in turn but the weightings were not changed. In each case the result remained the same, option 2a was the preferred option 2. Each of the 7 criteria was removed in turn and the weightings of the remaining criteria were recalculated to total 100, the previous scores were then applied. In each case the result remained the same, option 2a was the preferred option 3. All criteria were given equal weighting, option 2a was the preferred option 4. Criteria 2 and 7 which arguably have an element of cost associated with them were both scored 0, option 2a was the preferred option 5. Criteria 2 and 7 were removed and weightings recalculated, option 2a was the preferred option

The analysis further supported that the process was robust and stood up to the various tests that were applied. Option 2a remained the preferred option in each scenario. The detailed analysis is available on request.

The weighting and scoring emerge as a result of the stakeholder’s discussion at the workshop. The participants at the workshop (Appendix 9) carried out considerable debate on every criterion and every weighting score. It was an open and intensive process, independently facilitated and took the time necessary to arrive at decisions. Had further time been required then future meetings would have been arranged. In addition to those who participated, the wider list of stakeholders was sent all communications throughout the process (Appendix 9).

Nevertheless not everyone had confidence in the process (see below) despite independent assurance from the Scottish Health Council (Section 3).

 North Skye Action Group

The recently formed North Skye Action Group state that they are a “group that consists of representatives from communities throughout Skye - mostly North Skye currently but it is open, inclusive and growing - and it believes that the current NHS proposals will be damaging to health outcomes and economic viability of the entire area in the long term and constitutes a genuine, avoidable risk to patient safety. The group is made up of Highland Councillors, Community Councillors, NHS employees and interested and concerned members of the public. Although it is a new group it has very broad appeal and we believe has the support of the majority of the people in Skye.”

It is understood that their aims are as follows

 A group pushing for better health service for everybody in Skye and Lochalsh  A group that believes that the location of the new 'hub' should be based on sound statistical evidence  A group that believes that the decision making process should be transparent and thorough and engage all stakeholders equally

22 In their most recent correspondence (18th November) they further state they wish to “ engage constructively with the Health Board to ensure that all the necessary information is used to reach decisions on the future siting and configuration of health services in Skye.”

The paper states that: “Whilst acknowledging this may well be a biased outcome, we would argue that it does produce the result that the preferred option should be Portree. Over 60% of the GP Registered population depend on North Skye practices, and the invariable principle that the main hospital should be established as near as possible to the main population centre reinforces the argument.

“We submit that the Location Options Appraisal must be the subject, at the very least, of an Independent Review, carried out by a qualified practitioner.

“Without such a review this deeply flawed exercise and its perverse, not to say irrational outcome, will result in our much needed and most welcome new hospital being located away from the majority of those stakeholders who will depend upon its services for the next 100 or more years.” The Group fundamentally believe that any new facility should be in Portree, concluding in their report:

“The above critique provides overwhelming support for our conviction that this 11th March Options Appraisal Workshop was deeply flawed at every stage, with one exception: the terms of engagement were very clear. As a consequence the outcome in favour of Broadford as the “preferred option” for location of the hub is both perverse and irrational. Invariably a regional hospital should be built as near as possible to the main centre of population. Any other outcome is illogical and offends against natural justice. The hub must be located in Portree with the spoke in Broadford.”

After the report was considered by the Health and Social care Committee NHS Highland was made aware of an action group which had formed. It was confirmed on 18th November that the group is chaired by Sarah Marshall. A paper was initially submitted on behalf of the group to NHS Highland on 10th November 2014 and then re-submitted on 18th November when the chair of the group was confirmed. It is understood that the author of the report is not a member of the group. Their submission has been included in the full report (Appendix 10).

The group was unhappy with the Options Appraisal process on location and carried out their own analysis based on the documents available in the public domain. A version of this was first presented at the Public Meeting in Portree on 14th August.

Their report has been considered by the authors of the report and also shared with the steering group. The report has a number of factual inaccuracies and it further makes some statements, which have not been substantiated, and can be countered by the findings from the public consultation. . In addition, as well as our own internal scrutiny, a review of the Options Appraisal review was carried out an external analyst. This included carrying out a range of sensitivity analysis. Two of the points that the external analysis sought clarification on were:

23  evidence of who took part and whether geographic spread could be evidenced, and  did participants understand the definitions

Both these points have already been covered in the Independent Report from the Scottish Health Council and included in this report (as noted above) including name, designation and representation of people who took part in the options appraisal exercise into model and location (Appendix 9). This information has been in the public domain for some time. Members of the steering group, who were part of a lengthy process, were also quite clear that they were fully informed and had access to any information they deemed necessary, before or during the workshops.

NHS Highland also considered whether there was any merit in asking for an opinion of another board. This was discounted because it would not add anything extra to the additional internal and external technical scrutiny which has already taken place.

It should be emphasised that sensitivity analysis is just that. It is not appropriate to carry out whole-scale change to the criteria, weighting and scoring in isolation of the process. It is not a desk-top exercise. The options location workshop was facilitated by an Independent Consultant and an Independent review has been carried out by the Scottish Health Council.

The key benefit of an option appraisal exercises are that they are done by a representative group which has the opportunity to agree key principles, ground rules and to debate each criterion at length and in depth. Only the people who took part can explain their rationale behind agreeing criteria and weights but did so in the context of a lengthy process that was independently facilitated.

The process brings objectivity to the subjectivity of individual opinions and potential bias. For these reason, it is suggested that the exercise carried out by the Steering Group following extensive debate with a representative group (Appendix 9 of full report), facilitated by an independent facilitator, and endorsed by the Scottish Health Council is robust and there is no place for it to be challenged simply via a desk top exercise, however well undertaken.

It was important to check the arithmetic and to be challenged on our underpinning evidence and assumptions and this work has now been completed.

Notably, while the option appraisal provides useful evidence to inform the decision-making process, it is clear from the guidance that the views of wider local communities must also be taken into account. This is why the public consultation was so important and the evidence of an extensive engagement exercise also endorsed by the Scottish Health Council. By sending a survey form to every home and business the exercise undertaken by the operational was inclusive.

4.3 Feedback from meetings, events and correspondence

All of the issues linked to service model options, location or aspects of the proposal were summarised together with NHS Highland responses (Appendix 11). An outline of proposed services to be provided from the ‘Hub’ and ‘Spoke’ are also summarised (Appendix 12).

24 4.3.1 Service Model: ‘Hub’ and ‘Spoke’ During the consultation a range of queries were raised about the service model including service provision. Some people wanted to explore the possibility of getting two new hospitals and the need to maintain a full range of services. Various permutations were suggested about what new facilities to build. It was explained that under the preferred option the new build would be in Broadford and Portree Community Hospital would be re- configured as the ‘Spoke’.

It was clear during the consultation (and from the consultation responses) that the need for change was understood and accepted by the vast majority. The contentious element was around the location of the ‘Hub’ and the process that has been gone though to arrive at the preferred option.

This has already been considered by the Scottish Health Council and the Highland Health and Social Care Committee. Nevertheless some further sensitivity analysis was carried out to address the specific points raised, as described above (Section 4.2.1). The feedback from the consultation process has highlighted how important it was to try and reach a consensus on the location.

4.3.2 Service Model: other There were some general queries concerning the level of detail in the clinical model both in terms of the ‘Hub’ and ‘Spoke’. This is a fair point but reflects the current stage in the process. It became obvious that many people did not fully understand what was currently provided at each site, mistakenly believing that the two hospitals carried out the same role. In particular the difference between the minor injury/ailment and opening times provided in Portree and Casualty service in Broadford was not fully understood.

Further detailed work will be required as part of the business case process. The key elements that people have been concerned about, however, were clear from the outset: i) where there would be inpatient beds (i.e. Hub but not spoke), and that there would be the same access to Minor Injury/ Illness and Primary Care Emergency Centre in ‘spoke’.

The benefit of the preferred model is that it would allow additional investment in community services such as: community nursing, long term care options, intermediate care, respite care, care at home.

An outline of services to be provided in the Hub and Spoke is provided (Appendix 12). While this was available at the outset not everyone found it easy to see at a glance and so this was addressed during the consultation.

It will be necessary to describe in more detail some of the community services, community resilience and plans for managing patients where there is any change to the number of in- patient beds. The detail for the clinical specification and facilities will also need ongoing engagement and it is clear there is significant interest in these elements.

During the consultation it provided an opportunity to explain that there would be no planned changes to mental health services. Currently the psychiatrist holds clinics in Portree and Kyle and these will continue along with currently sited CPN teams in North and South Skye.

25 Other considerations were around what specialist services would be provided. It was suggested that it would “make more sense for consultants to travel to the patients rather than patients to the consultant”.

NHS Highland’s first commitment is to try to significantly reduce anyone having to travel unless they really need to do. During the consultation people have fed-back at their frustration of travelling for “five minute appointments.” A lot more can be done by consultants/specialists supporting GPs to manage patients locally with appropriate support and advice and by better use of telephone, email and tele-medicine consultations with consultants/specialist nurses.

The reality is that during 2013/14 NHS Highland spent £1million for consultants to simply be in a car with no clinical benefit to anyone. The more time consultants spend travelling then the fewer patients they are able to ‘see’ and who are therefore able to benefit from specialist input.

NHS Highland has, however, invested in greater consultant input to care of the elderly which will bring a wide range of benefits. A care of the elderly physician has recently been appointed with a specific remit for Skye, Lochalsh and South West Ross.

4.3.3 Patient Flow Patient flow is a term commonly used by health care professionals to describe ease of timely access to the right level of care and services and in the most appropriate care setting. One example is when patients end up having to stay in an acute hospital bed even after they have no medical need to be there. This can be due to the fact that they can’t be discharged to a community hospital because they have no beds or no beds for the gender of the patient – a problem with multi-bedded wards. The reason that this might happen is poor discharge planning, professional mindset, lack of care-at-home services, delays to make housing adaptations or no transport. Each of these issues can mean that patients are not cared for in the most appropriate setting.

Another example is the pathway for emergency referrals and admissions and the current flow between hospitals: Portree, Broadford and Raigmore. This was given the strongest weighting in the options appraisal. In the view of senior local clinicians who took part in the options appraisal or fed into the process that the current arrangements can be confusing with patients sometimes being initially taken to the wrong hospital. In terms of the location if the ‘Hub’ was in Portree it would have the effect of taking significant numbers of patients in potentially the opposite direction from necessary transfer to higher levels of secondary care which they may later need to access (in a short-time frame). Currently a large part of the role of Dr MacKinnon Memorial Hospital in Broadford is the ability to stabilize seriously ill and injured patients prior to onward transfer to other secondary or tertiary care. Most of these transfers are by road ambulance but will also include air ambulance.

It was argued, at some of the public meetings and responses however, that the same could be said for populations in Lochalsh and South West Ross who might come north to Broadford and then have to be transferred south to Raigmore. While this is true in this regard this would be exacerbated if they had to travel to Portree, and in effect would probably not happen. This would carry a different risk to patients then having to occupying a bed in Raigmore possibly inappropriately.

26 In terms of patient pathways in reality it is more complex. Clinical colleagues explained that it generally makes more sense for acutely unwell patients to be moving in the direction of definitive care (South). However, patients will also be directed dependant on need and where that need can be best met. A more central geographical location holds benefits here, and in this regard explains both why it was weighted the highest and why Broadford scored higher on this criterion than Portree.

More generally in the view of the clinicians and SAS, greatest pathway benefit is in removing the confusion that the two centres create. A better flow results from a single central model, closest to secondary care that can be staffed and safely run 24/7 and with greatest impact on harm reduction.

People from the South West Ross and Lochalsh said that if the new facility was not in Broadford it would not make sense to go to Portree (comment from South West Ross Community) and supported by GPs from these communities. While others claimed that if you live in the North you have no choice where to go to stating that “if you live in South Skye, Lochalsh or South West Ross there is an option to go to Raigmore”.

This, however, fails to explain that if the new hospital was in Broadford, it would provide local access for all communities. The distances that people feel are reasonable for communities to travel to Raigmore (e.g. Kyle or Lochcarron to Inverness) are longer than for instance those in Uig to travel to Broadford.

Others commented that they didn’t mind where the Hub was so long as the infrastructure was in place to respond to emergencies. In effect this was in support of Option 3 – single site model and which also scored very highly as a model of service in the options appraisal process.

It is important to state that patient flow and place of care is determined by the needs of the individual and the skills and facilities available at each hospital and the proximity to secondary care. The catchment area included in the proposal would optimise the number of people who could be cared for in a community setting.

This has two important benefits. Firstly, it means high cost specialist acute care is available for those who need it and not occupied by those who don’t. Second, assessments for discharging people home are more successful and realistic if done in a community setting and by community staff. This can often be the reason that patients end up being a delayed discharged in Raigmore. Small numbers of patients with long lengths of stay are one of the main problems impacting on patient flow and Raigmore should not be used as a community hospital.

4.3.4 Future Service and Service Specification Questions and comments were wide-ranging on this theme. One view was that there was a need to agree on what diagnostics would be provided and not raise expectations (e.g. CT). On the other hand another response was that there should be a full range of surgical, radiological and ultrasound services in order to reduce travel. Another also stated that just putting existing facilities in a new building would be a missed opportunity.

Some people felt that there should be a hospital in both areas with beds and 24/7 A&E. This was not a widely held view; however, it was not a short-listed option and did not emerge as gaining support during the consultation.

27 The critical thing in this regard is around having a sustainable model that can be staffed, and avoids the issues of having resources split across two sites.

With the suspension of endoscopy services in October 2014, on the grounds of safety, this posed further queries and concerns post-consultation. NHS Highland confirmed, however, that it is planned to have endoscopy services in the new hospital.

There was a general feeling that it would be helpful to describe more clearly what would be in the ‘Hub’ and ‘Spoke and this was responded to during the consultation (Appendix 12). The important point here is to describe what services need to be provided and then identify the appropriate infrastructure and staffing. This will be progressed in collaboration with primary and secondary care colleagues.

The importance of explicitly considering children and young people’s services was also highlighted. These points were also raised in the Highland Council submission.

While it was continually reinforced that the re-design was much wider than hospital services the main focus for the majority was what would be in the Hub and Spoke. This is of more general concern given the clear need to move to develop more community based services and have less reliance on hospital services.

4.3.5 Existing Services There appeared to be a lack of clarity about what exists currently specifically relating to Out-of-hours, A&E in the north of the Island with differences in opinion as to when Portree Hospital can be accessed during the out of hours period.

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. 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, signs and clear definitions.

4.3.6 Emergency Provision and Response (including SAS) Some concerns were raised about the proposed changes for Portree Community Hospital in terms of emergency care, the golden hour and whether there would be increased risk of harm.

It is not possible to have centres equipped to deliver the necessary treatment within the 'golden hour' all over Scotland and so SAS Paramedics and others, are trained to deliver the treatment under the guidance of Specialists. SAS has technology on board ambulances that link Electro Cardio Graph and other recordings directly to Specialists. In addition, NHS Scotland has invested in increased capacity for Emergency Medical Retrieval Services, helicopters that bring Specialists to patients and the SAS is increasing its air wing capacity, and therefore the ability to take patients to definitive places of care more quickly.

Having said all that the only difference being proposed is the removal of in-patient beds. Appropriate clinical risk management will continue to be in place. The model will be safer because it will reduce confusion and allow more sustainable staffing levels.

28 Development of new specialist paramedics, First Responder Teams and role of SAS as partners with NHSH to deliver emergency treatment and response are all part of emergency response. Currently emergency patients in the North are (or should) be taken directly to Broadford. This has been the pathway for the last ten years. Stopping en route at Portree is not the recommended pathway as it can delay definitive treatment. The protocol (memorandum of understanding) between SAS and NHS Highland re hospital transfers, admissions has recently been updated. This clearly identifies which patient presentations should and should not go to Portree.

When these points were explained some people then stated that they did not think current arrangements were satisfactory and indeed this was the starting point of the Kilmuir Community Council response.

A number of queries were raised by the public in relation to Scottish Ambulance Service. SAS has confirmed that they will continue to deploy their ambulance resources in accordance with their patterns of demand and existing bases. It was suggested that the Portree ambulance is called out more often than any others in the district and therefore must be greater need for A & E cover in the North of the Island. In fact Portree and Broadford are equally busy and Kyle is busier than Dunvegan.

NHS Highland is working closely with SAS at both local and National level. They are supportive of the model and preferred option.

4.3.7 GP/Primary Care There were very few queries in relation to GP services and primary care. This is an important point. 95% of activity is currently provided out of hospital by GP, Primary care and community teams.

4.3.8 Care-at -home/Care homes There are no plans for NHS Highland to open new care homes in the area but there is a need and commitment to developing step-up/step-down beds in Portree.

NHS Highland has taken 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 remains challenging clearly highlighting that doing more of the same is not the answer

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, and local communities, independent and third sector organisations to see how together we can develop more effective and acceptable solutions. Greater use of Self Directed Support and establishing local social enterprise initiatives need to be considered.

4.3.9 Respite/palliative/end of life care General concerns were raised about current capacity how will it be increased. Respite, palliative and end of life care will be included as part of the review of services. The re- design offers the opportunity to invest in and re-design community services which will support more people to die at home where this is their choice.

29 Palliative care is the management of symptoms and promotion of quality of life for people living with life threatening and long term conditions. This type of care is delivered every day by primary and community teams and only rarely do patients have to be admitted to hospital for pain and or symptom control. NHS Highland works closely with Highland Hospice in this regard.

Respite care is available in the district but the feedback is that it is not meeting the aspirations of individuals and families and so alternatives are currently being explored.

4.3.10 Staff and 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 were all answered by the consultation team.

4.3.11 Hospital buildings What would happen to existing hospital buildings was posed at a number of the meetings. In terms of Dr MacKinnon Memorial Hospital, should this be a requirement the existing 100 year old building would be disposed of in accordance with NHS Scotland/Scottish Government regulations for property surplus to requirements

Parts of Portree Community Hospital are in good condition and are suitable for a ‘Spoke’ facility but not a main ‘Hub’.

4.3.12 Travel times and Pathways This was raised at a number of meetings and in correspondence both from the perspective of the north and the south. There were a range of queries including the methodology for calculating travel times and taking account of winter weather among other things.

The report prepared by Ian Douglas in November 2013 detailed both 30 and 60 minute travel times and this was available as part of the Options Appraisal work. If the whole of the catchment area (or indeed just Skye and Lochalsh) was to be served by the hospital then it was considered reasonable to use 60 minutes travel times to both Portree and Bradford. This is because parts of the area are more than 30 minutes drive from either location. Some are also more than 60 minutes but overall 60 minutes covers a larger proportion of the population. Due to the geography in Highland people travel in excess of 60 minutes for care and treatment. This is why it is so important to minimise travel for routine care and appointments.

Kilmuir Community Council (KCC) challenge the basis for using one hour travel times (rather than 30 minutes) and questioned the whole basis of including South West Ross as part of the catchment. In their view this skewed the central point (one of the criteria) in favour of Broadford.

In the KCC response they also state that there was a lack of weighting given to travel times in the Options Appraisal.

It was made clear in the full consultation report that travel times and distance underpinned one of the criteria “geographic centre”. Detailed work was carried out on travel times and looking at different catchments was available as part of the options appraisal was available on the website during the consultation.

30 Given the issue was raised; however, travel times were re-calculated excluding the communities of South West Ross, as part of sensitivity analysis (Appendix 13). This showed that there were still more people within one hour of Broadford (87.4%) than Portree (86%) but less within 30 minutes.

The reality is there is not an ideal solution whether South West Ross is included or not. Wherever the Hub is located means some communities will inevitably have longer travelling times but that is consistent with other parts of Highland.

The additional distance north to Portree has further disadvantages with respect to general travel times and costs associated with transporting goods and services from central locations.

Regarding the winter travel question, in the original work provided to the local steering group it was noted that:

It is recognised that actual journey times over the same roads may result in very different experiences and will be influenced by factors that include the behaviour of the individual driver, the vehicle, and the volume of traffic and the incidence of road works. Driving conditions and journey times can obviously be affected by the weather. The travel times estimated by a GIS provide a representation of likely journey times and the distance that it may be possible to travel within a timescale. In attempting to model access to services this picture is more useful than the range of possible extremes that may be recalled from individual experience. Other studies have shown GIS estimates of travel time to be closely correlated with actual journey times[1]. If poor road conditions prevail, all journey times would be expected to increase.

4.3.13 Transport and 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.

From the feedback the vast majority of people don’t currently use public transport to access services, arguably because the service is very limited.

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 be developed to support the business case process and a group has already been set-up to lead and co-ordinate the work. The inaugural meeting was held on 16th October. The Steering Group has decided that, as transport and access issues were wider than simply access to healthcare buildings, they will take a wider partnership approach to finding solutions. This remit includes the development of a transport and access plan for the Hub and Spoke.

[1] Haynes, R, Jones A, Sauerzapf V and Zhao H: Validation of travel times to hospital estimated by GIS. International Journal of Health Geographics 2006, 5(40): [http://www.ij-healthgeographics.com/content/5/1/40] 31 4.3.14 Bed numbers and Bed modelling Concerns were expressed about bed numbers in general and the prospect of no beds at all in any ‘spoke’ facility. 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 28-32 beds. In coming to a final view important considerations would include:

 Further modelling work as set out in Appendix 14  Confidence in being able to increase care-at-home capacity;  Ability to develop step-up/step-down beds

4.3.15 Young Carers Two meetings were held with young carers (Kyle and Portree). These were wide-ranging discussions and touched on many general issues as well as issues specific to young carers. One strong theme from was that the priority needs to be the quality and diversity of the services provided. Reducing the need to travel to Inverness was very high on their list of priorities and having the option to travel to Broadford or Portree instead was a no brainer.

“It’s not where it is on Skye; it’s what it is and what it does that’s really important.”

Many of the points related to person-centred care and interaction with professionals. They also raised issues with what should be in the new facility including the need for single rooms, separate areas for children and babies, over-night accommodation, lounge area, quiet room, café area, water coolers, pictures on the wall and TVs in bedrooms. It is clear that this will be a very important group to include in any discussions about the design and facilities for any building.

4.3.16 Other Portree and Braes Community Council and Kilmuir Community Council raised a number of issues, many of which were similar, including whether due consideration was taken of the number of people on cruise ships, visiting yachts, proximity to High School/ West Highland College, local facilities, closer to the Cullin and housing. In their view these matters further contribute to why the Hub should be in Portree. They were also of a view that any new facility should go in Portree because it is the most populated area. These points have been responded (Appendix 11).

32 5. Who responded to the Consultation Survey?

Main points covered in this section:  Summary of who responded to the public consultation survey including total number of responses, response rate, gender, age and area

5.1 Introduction

As part of the public consultation a survey was designed to capture feedback on the service model options, components of the re-design proposal and possible sites. These are explored in more detail in section six.

The survey also included some standard questions to capture information about who responded to support equality and diversity monitoring and sensitivity analysis such as where people lived.

It did not include anything on the consultation process as it was agreed that this would be facilitated through the Scottish Health Council.

A copy of the full report of the analysis of the survey is available on the NHS Highland website and the key results are summarised below and in section 6:

5.2 Number of responses

2,273 full or partially completed survey forms were returned. There were 1581 hard- copies provided, and 692 online responses.

96% of all the responses were from individuals (i.e. not on behalf of other individuals or groups/families). 43 of the responses were submitted either on behalf of another individual or on behalf of more than one person (e.g. families, groups, community councils). Of these, 23 indicated that they were responding on behalf of families, whilst others were on behalf of the following groups:

 Applecross Community Council  Broadford and Strath Community Council  Kilmuir Community Council  Uig Community Council  Friends of Portree Hospital  SGM Cars

In some cases (n=14) a group name was not provided.

5.3 Response rate

Overall, just under one fifth (19%) of the population aged 16 years and over responded to the survey (Table 1). The highest response rate was Skye South with a 23% response;

33 Table 1: Response rate by geographical area of responders’ residence

Number of Population Response Consultation Area Responses aged 16+ (1) Rate (%) Skye North 458 3,358 13.6 Skye Central 400 2,962 13.5 Skye South 546 2,391 22.8 Lochalsh 389 2,217 17.5 South West Ross 118 1,300 9.1 Total SL&SWR 1,911 12,228 15.6 Unknown/Other (2) 362 -- Total Responses 2,273 12,228 18.6

(1) NRS Small Area (data zone) populations 2013 (2) Unknown/other - includes 344 blanks, 15 prefer not to answer and 3 locations outwith the consultation area SL&SWR - Skye, Lochalsh and South West Ross

In addition it was known that there were 8,405 homes in the area, thus giving a response rate of 27% per house-hold. This response rate is believed to be higher when compared with other proposed major service changes in Scotland. Notably the recent public consultation in Badenoch and Strathspey 176 responses were received (176/7,703 house- holds =2.3%).

5.4 Self declared category of responder

Most of the responders indicated they were members of the community (71%) and 61% as a patient, carer or service user (Table 2). Around nine percent stated that they were from NHS Highland ‘staff’ including GP, or GP Practice staff.

It should be noted that responders were given the opportunity to tick all that applied and so responses are not mutually exclusive.

Table 2: Q8, what categories best describe you?

Number of % of Category Respondents Respondents Patient/carer/service user 1,384 60.9 Member of the community 1,611 70.9 Community council 70 3.1 Councillor/elected representative 8 0.4 Voluntary organisation 79 3.5 Community Group 12 0.5 NHS Highland staff 178 7.8 GP or GP Practice staff 29 1.3 Other 54 2.4

*Note: responders could select more than one category, and were not mutually exclusive and so% will not add up to 100% Note although people identified themselves of NHS Highland staff or GP – they may also have been responding in their personal capacity

34 5.5 Response rates by gender, age and by area

Localities were grouped into five areas to support aspects of the analysis, particularly around views on location of Hub and Spoke. The location of people who responded was plotted (Map 1, next page).

Relatively greater response rates in all areas were by females. This disparity was highest in Skye North and Skye Central (Chart 1).

Chart 1: Response rate by area and gender

Total Responses

Total SL&SWR

Skye South

Lochalsh

Skye North All SkyeCentral Females Males South West Ross

0.0 5.0 10.0 15.0 20.0 25.0 30.0 Response Rate (%)

Generally, the highest response rates were in the older age groups, particularly in Skye South and Skye North where the highest response rate was in the 80 years and over age group (Chart 2).

Chart 2 Survey response rate by age-band within each area

40.0 Skye North 35.0 Skye Central Skye South 30.0 Lochalsh )

% South West Ross

( 25.0

e t Total SL&SWR a R

e 20.0 Total Responses s n o p s

e 15.0 R

10.0

5.0

0.0 16 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80 + Age Group

35 Map 1 Showing number of responses to the consultation within each area

36 5.6 Representativeness of responses by Gender and Age

Disproportionate to the underlying population profile, older age groups responded more, the highest percentage of total responses was by those aged 60-69 years and this was the highest in males where over 30% of male responders were aged 60-69 years compared to around 20% in the population (Chart 3).

Chart 3: Response profile by age group and gender compared to the underlying population profile

Total responses (Males) Total responses (Females) 35.0 30.0 Responses 30.0 Responses 25.0 Population Population 25.0 20.0 l l a a t t o o 20.0 t t

f f 15.0 o o

% % 15.0 10.0 10.0

5.0 5.0

0.0 0.0

Age Group Age Group

5.7 Other

 Three quarters (75%) of responders indicated they were not living on their own, whilst over one fifth (21%) were living on their own. 4% either did not answer or preferred not to answer.

 Most of the responders (83%) stated they were not carers, 12% stated they were carers and of these 60% were part-time and 40% full-time

 Approximately 40% (n = 851) stated they had a long-term condition or disability.

 Overall 84% had access to or ownership of a car. The highest percentage was in Skye South (89%) and Skye North (87%) and the least in Skye Central (84%) and Lochalsh (85%).

5.8 Conclusion

The pattern of responses is consistent with other surveys carried out by NHS Highland where response rates were higher by females and older people. It is also a recognised characteristic of responses to larger health related surveys such as the Health Survey for Scotland.

37 There was no sampling undertaken in this survey i.e. all residents in the areas were potential responders (regardless of whether their characteristics made them more or less likely to actually respond). In this situation, it would, therefore, not be appropriate to adjust to the total population by weighting responses The analysts did compare the profile of the responders by each geographic area with the underlying area population profile

95% confidence intervals were calculated for the responses to the options to indicate any overlap in the responses. In this case it showed that the overall percentage preferring option 2a was distinct from the percentage opting for 2b or any of the other options. Analysis is available on request.

38 6. Feedback on Service Model options, location and aspects of the proposal

6.1 Introduction

The consultation response form was agreed with the Scottish Health Council. People were given an opportunity to feedback on the options and aspects of the proposal. There were 22 questions. As appropriate, reference is made to the Question number as included in the form mailed to all homes.

Forms were available throughout the consultation and in addition one form was mailed to all homes and businesses in the area with a freepost envelope. It was made clear that people could request further forms, complete their forms on behalf of individuals, families or groups and/or submit their feedback in any other way.

6.2 Feedback on model of service

Just under nine out of every ten people who responded (86%) supported the model of service with only 1% preferring the ‘do minimum’ option. Eight percent did not tick a response (Table 1 and Chart 1).

Table 1 – Feedback on model of service

Option Description No % 1 Do minimum 16 1 2 Community resource centre and hospital ‘Hub’ and 1,956 86 ‘Spoke’ 3 Communityresourcecentreandhospital‘Hub’ 44 2 No No preference 46 2 preference Other Respondent could suggest a different option 34 1 Not given Respondent did not tick an option 177 8

Chart 1 Feedback on model of service

39 6.3 Feedback on options including location of ‘Hub’ and ‘Spoke’

Overall the majority (57%) selected the Community Resource Centre and Hospital ‘Hub’ to be located in Broadford with a ‘Spoke’ in Portree (Option 2a); 29% supported Portree as the location of the ‘Hub’ (Option 2b) (Table 2 and Chart 2).

Table 2 – Feedback on model of service including location of ‘Hub’ and ‘Spoke’

Option Description No % 1 Do minimum 16 1 2a Community resource centre and hospital ‘Hub’ in 1,294 57 Broadford and ‘Spoke’ in Portree 2b Community resource centre and hospital ‘Hub’ in 662 29 Portree and ‘Spoke’ in Broadford 3 Communityresourcecentreandhospital‘Hub’ 44 2 No No preference 46 2 preference Other Respondent could suggest a different option 34 1 Not given Respondent did not tick an option 177 8

Chart 2: Percentage preferred option (as per Q2) of all survey respondents1

Not Given 8% Option 1 Other* 1% Nopreference 1% 2%

Option 3 2%

Option 2b 29%

Option 2a 57%

1 Includes all responders to the survey whether question 2 (preferred option) of the survey was answered or not (n=2,273)

6.3.1 Variation by Area

40 Option 2a was also selected by the majority (i.e. >50%) of those from Skye South (92%), Lochalsh (91%) and South West Ross (80%). In contrast, for Skye Central and Skye North, the majority selection (60% & 66% respectively), was for Option 2b in which the Community Resource Centre and Hospital ‘Hub’ would be in Portree and the ‘Spoke’ in Broadford (table 3).

Table 3: Percentage preferred option (as per Q2) of all survey respondents: overall and by area of residence Preferred Option (% of responses) Total Consultation Area No Number of Option 1 Option 2a Option 2b Option 3 Other* Not Given preference Responses

Skye North 0.7 18.8 65.5 2.6 2.0 2.6 7.9 458 Skye Central 1.0 23.0 60.0 4.0 3.3 1.8 7.0 400 Skye South 0.4 91.8 1.3 1.1 0.9 0.4 4.2 546 Lochalsh 0.3 90.5 1.5 0.5 0.5 1.5 5.1 389 South West Ross 1.7 79.7 3.4 0.8 5.1 0.8 8.5 118 Total SL&SWR 0.6 58.9 29.1 1.9 1.8 1.5 6.1 1,911 Unknown/Other (1) 1.1 46.7 29.0 1.9 3.0 1.7 16.6 362 Total Responses 0.7 56.9 29.1 1.9 2.0 1.5 7.8 2,273 (1) Unknown/other - includes 344 blanks, 15 prefer not to answer and 3 locations outwith the consultation area

6.3.2 Data handling

Although 2,273 people responded to the survey not everyone answered all questions. The analysis of survey question 2 was therefore repeated including only those who responded to the specific question on option (i.e. excluded those who did not provide an answer). This had the effect of strengthening the support in favour of Option 2a (from 57% to 62%) and to a lesser degree for option 2b (from 29% to 31%).

Chart 3: Percentage preferred option (as per Q2) of survey respondents who gave an answer 1

No preference Other* 2% 2% Option 1 1% Option 3 1 2% Includes only responders to the survey who gave an answer to question 2 (preferred option) of the survey (n=2,096)

Option 2b 31%

Option 2a 62%

6.4 Feedback ratings of aspects regarding the proposed changes

41 The responders were asked to rate each of twelve different aspects in relation to proposed changes relating to the preferred model. The majority of respondents were in support of all elements with one exception, ranging from 59% to 91% (table 2)

The only aspect not associated with a majority in support was the ‘closing in-patient beds’ in Portree Community Hospital’. In this case the majority (53%) of respondents did not support this aspect of the proposed change (table 4).

Table 4: Percentage ratings of aspects relating to proposed changes for all survey respondents

Rating (percentage of respondents n=2,273) Aspect of proposed change Don't Not Support 1 Neutral support 2 answered

Improving in-patient medical cover 90.6 4.3 0.9 4.2

Providing services from modern 90.6 4.2 0.7 4.5 hospitals Better joint working across professions 89.7 4.9 0.7 4.7 and services More efficient use of resources (e.g. 86.7 6.9 1.5 4.9 staff, buildings) Developing a new hospital 'Hub' and 65.6 5.1 25.9 3.4 resource centre in Broadford Closing in-patient beds in Portree 22.7 20.5 52.5 4.2 Community Hospital Retaining Minor Injury Unit & Primary 79.5 8.3 8.0 4.2 Care Emergency Centre in Portree

Developing local care homes 86.4 7.6 1.8 4.2

Providing more care-at-home 87.2 6.7 1.8 4.2 Developing telehealth services for 58.7 23.5 11.6 6.1 home and hospital Improving community transport to and 90.5 4.9 1.2 3.3 from healthcare Keeping some out-patient services in 79.3 11.0 4.9 4.8 Portree 1 Support includes those answering 'Support to great extent'and 'Support to some extent' 2 Don't support includes those answering 'Don't really support' and 'Do not support at all'

42 6.4 Other responses

Although the consultation survey was the main way that public feedback was considered other information and feedback was also considered and is described below. There is some overlap as some people/groups were known to submit a consultation form and a letter.

6.4.1 Open responses (e-mails, letters and petition)

The correspondence was categorised into themes and responses coded as to whether people were in support of the preferred option or otherwise. The wider comments are included in Appendix 11 & Section 4. In this section only responses to the options are considered.

48 people or groups corresponded with NHS Highland about the consultation via letter or email (see below):

Option supported Number Percent Option 1 0 0 Option 2 1 2.1 Option 2a 17 35.4 Option 2b 13 27.1 Option 3 2 4.1 Other 2 4.1 Not specified 13 27.1 48 100

Those writing in favour of Option 2b were from Dunvegan, Kilmuir, Portree, Sleat, and Uig including a 65 signature petition from Uig.

While those in support of option 2a identified themselves as from Inverinate, Isleoronsay, Kyle, Plockton, Portree, Sleat, Staffin, Stein and Torrin.

More people were motivated to write in favour of option 2a compared to the other options. Some people were looking for further information or were raising general comments.

6.4.2 Responses from Community Councils & Groups: survey form or letter: A number of detailed and considered responses were received from community councils and other groups. Extracts from their responses are highlighted below. Full responses are available either from the groups or NHS Highland on request. Responses are categorised as SUPPORT for or OBJECT to the preferred option.

 Applecross Community Council

SUPPORT – An upgraded hospital at Broadford would be very useful for residents of Wester Ross. Portree would be too far away and we would prefer to be sent to Raigmore. Applecross is over two hour’s drive from Portree.

43  Broadford and Strath Community Council

SUPPORT – “In reading all the supporting consultation documents we fully support the view that a major change in the provision of appropriate, safe and up to date health and community services is an absolute necessity to enable a sustainable service to be delivered and future-proof healthcare provision in the locality for generations to come in Skye, Lochalsh and South West Ross. “WE are also aware of the geographical spread of the SLSWR area and the difficulties users of the service would have accessing a Hub based in North Skye, if travelling from South West Ross, Lochcarron, Glenelg and South Skye communities.

“We accept that users from North and West Skye may contend that a ‘Hub’ in South Skye might present similar difficulties. While acknowledging that a view regarding the location of the ‘Hub’ may be raised B&SCC is concerned that any debate that focussed mainly on this outcome would seriously detract from the main proposal to re-design the provision of health services throughout the area.

In view of the above and many excellent proposals contained within the preferred option, B&SCC fully support option 2 (a).

 Broadford Patient Participation Group

“I know that there is great concern within Skye, Lochalsh and Wester Ross, concerning the siting of the main hospital and its satellite(s). I believe that if patients were assured that a proper transport service would be put in place ahead of the roll- out of the new design, then many of the fears about geographical location of services would be reduced.

“As to the scope of the service, I would strongly suggest that the transport service should not be limited just to transporting named patients to appointments in one or other of the medical facilities, but should be made available also to those who accompany the patient, or wish to visit a patient in hospital. If the NHS is serious about wanting to enable older people to remain in their homes for as long as possible, then the transport service should to broad enough in its scope to include journeys necessary for social welfare, such as shopping trips, and trips to attend social activities such as lunch clubs, leisure centres, activity groups. Now is the ideal opportunity to plan for this, and to budget for it within the budget for the redesign of facilities.”

 Dunvegan Community Council

SUPPORT FOR MODEL – The Dunvegan Community Council would like to offer their support to the proposal of the new hospital and a spoke.

We are not so concerned where the hub is situated either in Portree or Broadford as long as there are improved facilities in the hub and a CT scanner in the new hospital , or at least room made for a scanner that could be installed at a later date.

It would also be important that there would still be an A&E facility in the spoke and one call doctor that could attend any emergencies.

44 That any new hospital is built in a place with lots of room to both increase the building size and the car park size in the future and has scope for a helipad close to the hospital.

 Kilmuir Community Council

OBJECT – Kilmuir Community Council (KCC) formally objects to the ‘preferred option’ of having the ‘hub’ in Broadford.

“We consider that the ‘hub’ should be in Portree, with the ‘spoke’ in Broadford.”

“We believe that the starting point for considerations should be that the current range of facilities available in Portree is inadequate.

“This response is based on the genuine concern that current service levels provided by NHS Highland are simply not adequate to make communities like Kilmuir viable in the long term and a belief that the proposals contained in the consultation document will make things considerably worse

“The proposals as they stand will have a drastic effect on the North of the island and be instrumental in causing greater poverty and greater social exclusion among a population that already suffers in this regard.

“We feel it would be grossly irresponsible and perhaps dangerous to site the so far from the majority of those who would have to use its services.

Note – Detailed response letter with 13 specific points raised.

 Portree & Braes Community Council

OBJECT – “There are numerous reasons why Portree should have the Hub rather than Broadford and I enclose a list of some of these reasons in the hope that they may have some influence in the final decision. It has been said that if the there is dispute over the two possible sites we may not get a new hospital at all. I sincerely hope that this is not true as the Chair of Kilmuir CC said that he had David Thompson MSPs assurance that a new facility would definitely be provided for the area. Sadly this apparent ‘red herring’ has been much repeated with the inevitable result that many people have feared that it was the truth and have therefore decided not to press for the site to be Portree. If, as we have been told, the present hospitals are ‘not fit for purpose’ surely a new facility will have to be built despite any disagreements regarding the site?

We realise that the people of South Skye, Lochalsh and SW Ross are also your concern but hope that you can see the reasons for those of us in North Skye to press for the ‘Hub’ to be in Portree. If we are left with only the ‘spoke’, with no inpatient beds, it will be the first time since Gesto Hospital was built in 1878 that North Skye will be without any hospital beds – surely this is unacceptable?”

Note - Detailed response with 16 specific points raised.

45  Uig Community Council OBJECT – Portree is the 'Hub' of Skye and Lochalsh, it's the capital of Skye and has a central location so is therefore the obvious preferred location for a new 'Hub' hospital.

 Friends of Portree Hospital

OBJECT – There need to be hospital beds in Portree because the A87 suffers from severe winter conditions between Sconser and Luib (with no alternative route) which might prevent transport to Broadford from the north of Skye. For patients in the south of Skye, it is possible to travel to Inverness or Fort William if need be. In addition, there is a lot of growth in the Portree population and more ambulances will be needed in Portree if patients are always having to be transported from the north of Skye to Broadford. We are not opposed to an improvement at Broadford, but beds must not be removed from Portree. If all the main services are based at Broadford, it will be impossible for staff there to visit the north end of Skye if the A87 is closed (e.g. after an accident or in severe weather as outlined above) north of Luib.

We believe that demography, rather than geography, should play a major part of the decision-making process. We would wish to have a meeting with the 'powers that be' to discuss matters further.”

 SGM Cars Achmore, Achmore, Stromeferry, Dornie and Kyle

SUPPORT

 Sleat Community Council

SUPPORT – In their letter they concluded: “Sleat Community Council is strongly of the view that Broadford is the correct location for the new hub facility. This location has served the area well in the past, it is centrally situated for the entire catchment area to be served.”

 West Ross Community Council

SUPPORT – At their meeting with NHS Highland on 9th July asked for it to be minuted that “everyone in the rook endorses the preferred option.”

 North Skye Action Group

OBJECT Late response but accepted. An interim committee of people in North Skye was formed in Portree on 17th November to express concern about aspects of the proposed health services changes in Skye. They are preparing a short note of the meeting outlining the purpose and objectives of the group and will be forward to NHS Highland in due course.

The chair of the group is Sarah Marshall, Secretary (Catriona MacDonald) and the name of ten others has been forwarded to NHS Highland. Further details are awaited.

46 6.4.3 Responses from Partner Agencies

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

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 health & social services and confirms that it is broadly supportive of Option 2 (a) ‘Hub’ new build in Broadford, with ‘Spoke’ in Portree.

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 of the redesign process.

Comments/Observations Whilst the consultation process has been generally positive across Skye, Lochalsh and South West Ross, it is recognised that some communities are not in favour of Option 2 (a) and would prefer Option 2 (b). It is noted that the Public meetings held in Kilmuir on the 12th August and Portree on the 14th August raised community concerns and objections to the preferred Option 2 (a) in terms of the proposed location of the Hub and Spoke model. Highland Council main areas of response: 1. Care and Learning. The Care and Learning Service would be broadly in support of Option 2. 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 any discussions about the proposals and its facilities at an appropriate stage. Consideration should be given to early discussions 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 what this would cost are key factors for consideration.

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 whatever Option is finally approved. The Highland Council is keen to work in partnership with NHS Highland 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 has been set for the 16th October 2014 to bring key stakeholders together with regard to forming an Access and Transport Group.

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.

47 4. District Partnership. Future role for the District Partnership to be explored as a mechanism to update stakeholders and as a platform for public engagement in relation to the integrated approach in work relating to Highland Council and NHS Highland.

 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. Since their response a meeting took place with senior officials on 3rd of October.

 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.

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.

 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.”

 Skye and Lochalsh CAB

OPTION 3 would allow greater co-location of professionals and third sector involvement with integrated health and social care, including the voluntary and independent sector.

Currently Skye & Lochalsh Citizens Advice Bureau are able to offer an Advice Outreach one day a week at the Kyle Health Centre. Evidence suggests that there

48 would be a real benefit for us to be able to offer similar model in Broadford, noting also that Broadford health centre has a population of 1865.

Healthcare professionals often spend time talking to patients about non-medical problems such as benefits, housing problems and relationship difficulties. Having a fully-trained adviser or caseworker on-site frees up time that can be better spent on medical matters. CAB work on health and social care issues is now a substantial part of bureau workloads.

49 7. Recommendation and Next Steps

Main points covered in this section:  Recommendation based on options appraisal, feedback on the consultation process, service proposals, options and sites  Next steps and decision making process going forward

7. Introduction

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

7.1 Recommendation

Taking everything into consideration there is broad support from the wide range of stakeholders for option 2a - the preferred option and this is now being formally recommended to the Board for endorsement.

7.2 Supporting Points

In coming to this view, the operational unit has sought to satisfy itself that majority of people were comfortable with the consultation process and that there was strong support for the service model and clear consensus regarding the location.

2,273 people completed a consultation survey response form. From these one percent of people who responded were in favour of the ‘do minimum option’ while 86% supported the preferred model of service - ‘Hub and Spoke’.

For the preferred option, 2:1 were in favour of Broadford (2a) as opposed to Portree (2b).

The majority of responders were in support of most of the components of the proposed changes ranging from 59% to 91% further providing confidence in the model. One component, however, closing in-patient beds did receive the support of the majority.

Overall more people in communities Skye South, Lochalsh and South West Ross felt more strongly about supporting the preferred option than communities in the North did about supporting option 2b. Notably, however, those in the north were much more vociferous.

Option 2a also received the backing from partner organisations.

Some sensitivity analysis was carried out by the steering and NHS Highland to see if anything significantly influenced the findings. In this analysis only marginal differences were found which did not change the scoring in favour of Option 2b. It is noted that North Skye Action Group submitted a critique of the weighting and scoring and they did conclude in favour of Option 2b. Their analysis and conclusions were rejected for the reasons provided under section4.2.1

50 All of the evidence together should provide confidence in the work of the steering group who, through the options appraisal model, arrived at a preferred option and location, now supported by the majority of those who participated in the consultation.

During the consultation and post consultation period, however, it was raised by some that progressing with the preferred option may be challenged with the suggestion of Judicial Review.

The plan would be for new arrangements to be tried and tested before any changes were made.

7.3 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 2nd December 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 of a site if necessary. In addition wider work on Transport and Access and developing community services would be required.

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.

51 APPENDIX 1 – 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

52 APPENDIX 2 – Summary of high level milestone and indicative time-line

Time High level milestones and dates of Board meetings Dec 14  NHS Highland Board meeting (2nd December) Nov 14  Highland Health and Social Care Committee - endorsement (6th November) Oct 14  Scottish Health Council – Publish Report endorsing process 24th October)  NHS Highland Board meeting – update (7th October) Sep 14  Highland Health and Social Care Committee update (11th September) Aug 14  NHS Highland Board meeting (12th August) Aug 14  Consultation closes (29th August)  Mail drop of consultation form to all homes (w/b 11th August) Jul 14  Highland Health & Social Care Committee – Mid-way update (10th July) Jun 14  Mid-way review meetings and report Jun 14  NHS Highland Board meeting (3rd June) May 14  Confirmation from Scottish Health Council OK to move to public consultation  Verbal update and email to HHSC, 1st May Apr 14  Workshop on criteria and weighting for site selection (30th April) Apr 14  NHS Highland Board meeting endorse preferred option Apr 14  Complete options appraisal on location and site Mar 14  Highland Health and Social Care Committee (20th March) Mar 14  Workshop on options appraisal on location (11th March) Mar 14  Special Board meeting to approve draft public consultation material and agree further work (4th March) Feb 14  Preparation of draft consultation materials Feb 14  Discuss with SGHD sponsor to confirm major service change and next steps Jan 14  Scottish Health Council endorsement of process to date Jan 14  Preparation of consultation documents and engagement plan Jan 14  Update Report to Highland Health and Social Care Committee (9th Jan) Jan 14  Hold further workshop events to support options appraisal process if required (7th and 10th January) Dec 13  Hold further workshops on options appraisal to develop preferred option(s) Dec 13  Update NHS Highland Board on process, progress and next steps Dec 13  Prepare draft forward communication and engagement action plan Nov 13  Further work to develop and describe in more detail the short list of options Nov 13  Update local communities on process and likely next steps Nov 13  Update Highland Health and Social Care Committee Nov 13  Agree plan for evaluation of initial engagement activities Oct 13  Communicate feedback from Workshop to: i) Scottish Government, ii) Scottish Health Council, iii) Steering Groups Oct 13  Update Asset Management Strategy to Board Oct 13  NHS Highland News distributed to all homes Jun - Jan  Hold Workshops to identify long and short list of options and make recommendation on preferred option May 13  Include re-design as part of Local Delivery Plan and Publish on Web Apr 13  Appoint Project Staff to support Operational Unit with the options appraisal process and building the strategic case for change Dec 12  Set-up Steering Group Jun 12  Board approval Property and Assessment Strategy (2012 -2017) Jan 12  Informal engagement underway about the case for change

53 APPENDIX 3 – Email from Scottish Health Council confirming NHS Highland in a position to move to public consultation

From: Marie McIlwraith [mailto:[email protected]] Sent: 15 May 2014 18:36 To: Thompson Maimie (NHS HIGHLAND) Cc: Connelly Daniel (HEALTHCARE IMPROVEMENT SCOTLAND - SD039); Ashman Emma (HEALTHCARE IMPROVEMENT SCOTLAND - SD039); McVicar Gill (NHS HIGHLAND) Subject: RE: Skye, Lochalsh and South West Ross consultation

Dear Maimie

I am writing in relation to the Skye, Lochalsh and South West Ross service redesign.

We feel that NHS Highland is now in a position to move to formal public consultation.

In our letter dated 27th January 2014, we suggested that NHS Highland should undertake further engagement work in relation to the development and selection of locations for any proposed new development to be fully in line with CEL 4 guidance.

As the proposal outlined a new build hospital (hub) in a one location and a day/outpatient hospital facility (spoke) in a different location in the Skye, Lochalsh or South West Ross area, we highlighted that further work would be required to identify where these services could potentially be provided.

This specifically included work to ensure local people are engaged and consulted in the identification of the possible locations/towns where the proposed services would be delivered from, as well identification of potential site locations within these places. We are pleased that through our discussions and attendance we can confirm that this work was undertaken.

In preparation for public consultation we are satisfied that NHS Highland;

 Have undertaken an exercise to determine the locations for the proposed hub and spoke service model, highlighting Broadford as the location of the proposed new hospital (Hub) and Portree for the proposed (spoke) facility.  Have identified potential sites within Broadford and Portree and undertook an exercise to short list the Broadford sites, with patients and community representatives  Have provided opportunity for the steering group to comment and contribute towards the development of consultation materials  Have undertaken an initial snapshot travel survey with patients and visitors who use the current hospital services and have provided information relating to travel and access from different locations across Skye, Lochalsh and South West Ross area in the consultation document  Will provide sufficient information and opportunity for the general public to give their views on the on the proposals

Added to this we understand that NHS Highland are forming a travel group to assist with the wider travel and access analysis work. We ask that this work is fed into the consultation process as it is developed and available for discussion.

54 We would expect information identified in the revisited impact assessment to be available to the public during the consultation. Any requirement for further targeted engagement as a result of this should be undertaken during the consultation.

As the consultation period is going to take place over the busier holiday period, we would expect information about consultation events or meetings that are taking place, to be available and visible to patients and members of the public as early as possible.

If NHS Highland plan to go to the December Board meeting with their final proposals it should be clear in the feedback report to the public what the timescales are for the decision being made. It would also be an opportune time to highlight to people, the further engagement that will be done on the site, development of the business case and implementation of the proposal.

The Scottish Health Council has a formal quality assurance role within this work and we will be undertaking a number of quality assurance exercises during the course of the consultation. As with the Badenoch and Strathspey redesign, it would be helpful to meet throughout this time to address any points as they arise, Lynn the administrator for the local office is currently looking at organising these.

We look forward to working with you over the coming months.

55 APPENDIX 4 – Summary of the main initiatives to raise awareness

A full update was included in the report to Highland Health and Social Care Committee on 6th November 2014

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  MSPs and other elected members

Engagement activities  Meeting with community councils  Drop-in events  Public meetings  District Partnership meetings  Friends hospitals  Other meetings and events  1:1 communications (letters, e-mails, phone-calls and face-to-face)  Responding to correspondence

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:

 Two additional public meetings  1:1 meetings/ discussion including home visit  Walk-about 8th and 9th July  Social media #skyechat  Additional media and adverts  Further promotion on all the ways people could feedback  Meeting with pupils and staff in Portree High School  Providing information as requested:  Establishment of a Access & Transport Group

56 APPENDIX 5 – Public meeting, events and stakeholder meetings

Category Event Date Notes/Attendance Community Portree CC 21st May Dr McCabe – Councils arranged before meetings consultation announced Staffin CC 5th June 9 North East Skye CC 19th June 8 (Portree & Braes, Staffin, Kilmuir, Uig and Minginish) South Skye CC 26th June 5 (Broadford & Strath, Kyleakin & Kylerhea, Sleat and Sconser) Applecross CC 30th June 4 North West CC 1st July 10 (Dunvegan, Skeabost & 2nd July Edinbane, Waternish, Glendale and Struan Raasay CC 3rd July ? Lochalsh CC 9th July 12 (Glenelg, Inverinate, Dornie, Kyle, Plockton and Achmore) South West Ross CC 10th July 0 (Lochcarron, Torridon, Kinlochewe, Sheildaig, Achnasheen)

Drop-in events Aird Ferry, Dornie 4th June 7 Howard Doris Centre, 11th June 17 An Acarsaid Care Home 13th June 3 Broadford Hospital 13th June 3 + 8 Broadford Hotel 25th June 9 Portree Hospital 26th June 14 Tigh na Drochaid 26th June 7 Glenelg 30th June 28 Applecross 30th June 14 Dunvegan 1st July 12 Carbost 1st July 4 Torridon 2nd July 8 Portree 2nd July 10 Sleat 3rd July 7 Broadford 3rd July 9 Raasay 3rd July 4 Kyle 4th July 12 Lochcarron 4th July 9 Lochcarron 8th July 20 Portree 24th July 1

57 APPENDIX 5 – Attendance at public meeting, events and stakeholder meetings (cont’d)

Category Event Date Attendance

Public Meetings Broadford 25th June 8 + SHC Lochcarron 8th July 3 + SHC Portree 24th July 20 + SHC Kilmuir 12th August 100 Portree 14th August 70

Other Wester Ross Public April Partnership Forum Alzheimer Scotland 4th June (Portree) Young Carers (Kyle 10th and 18th June 16 and Portree) League of Friends 12th June 12 MMH Portree High School 17th June Skye & Lochalsh 1st July, 11th Public Partnership November Forum Walkabout 8th & 9th July Friends of Portree 15th July 6 Wester Ross Public 10th July Partnership Forum

Steering Group Mid-way Review 9th July 18 Update meeting 29th October

District Partnership Tign na Sgire, 12th May 2014 Portree Lochcarron Hall 18th August 2014

Highland Council Ross-shire Ward 19th May Forum Skye Ward Forum 2nd June Elected Members 2nd June, 7th July and 7th August Health and Social 3rd June Care (Care and Learning) meeting Health & Social Care 5th June Forum (Portree) Health and Social 10th June Care (Care and Learning) meeting Business Meeting 7th July, 4th August with elected members

Scottish SAS rep in 12th August, 3rd Ambulance attendance at public October meeting

58 APPENDIX 5 – Attendance at public meeting, events and stakeholder meetings (cont’d)

Category Event Date Attendance

Scottish 1 May &July Government

MSPs Visit to Dr 23rdMay MacKinnon by Jean Urquhart Chair and CEO meet 28th May with MSPs

NHS Highland Integrated Team 20th May Meeting (Skye & Lochalsh) Extended Senior 21st May Management Team Portree Operational 29th May Meeting with GPs NHS Highland 9th June Annual Review Health & Social Care 10th June Meeting District Core Team 24th June Portree Hospital Ops 26th June Meeting Care Home Steering 27th June Group Drop-in events at GP 30th June to 4th July Practices / Health Centres North West Senior 16th July Management Team Raigmore Senior 16th July Management Team District Management 22nd July Core Team Meeting Hospital Operational 31st July Group Meeting North West Senior 13th August Management Team NHS Highland Senior 25th September Management Team Highland Health & 1st May, 10th July and Social Care 11th September Committee NHS Highland Board 3rd June, 12th August & 7th October

59 APPENDIX 6 – Services currently provided from Dr MacKinnon Memorial (Broadford) and Portree Community Hospital

Dr MacKinnon Memorial Hospital (Broadford Portree Community Hospital • Out-patient consultant led clinics (see next slide) • Out-patient consultant led clinics (see next table), • 12 In-patient beds with 24/7 nursing cover • 20 In-patient beds with 24/7 nursing cover • GP cover 08.00-1800 RP /GP / NP cover 1800-2300 • RP cover 24/7 • Minor Injury/illness Centre – 8am – 2300 (7 days) • Community Casualty Unit with 24/7 on-site medical and • Primary Care Emergency Centre – until 2300 nursing cover • Part time X-ray (4 days per week, 10-3) • Primary Care Emergency Centre 24/7 • Care of the elderly physician input • X-ray 24/7 (via on-call) • Community midwife unit base • Care of the elderly physician input • Health Centre located nearby • Radiology services (24/7 cover) with Ultrasound elective capability • Emergency/resuscitation room • Endoscopy (currently suspended) • Planned day case surgery, lumps and bumps, vasectomies • GA assessments • Bladder scanning • Chemotherapy suite (Macmillan supported) • Fracture clinic • Midwife led maternity unit (2 beds) • Place of safety • Health Centre located nearby

60 APPENDIX 6 (Cont’d)– Consultant-led Out Patients

Dr MacKinnon Memorial Hospital (Broadford) Portree Community Hospital • AA Screening • AA Screening • Audiology • Audiology • Diabetic • Diabetic • Ear, Nose and Throat • Ear, Nose and Throat • General Medicine • General Medicine • Medicine for the Elderly • Medicine for the Elderly, • Occupational Health • Ophthalmology • Ophthalmology • Orthopaedics • Pace maker • Orthoptics • Paediatrics • Orthotics • Psychiatry • Paediatrics • Rehabilitation • Paediatric diabetics • Renal, • Paediatric hip screening • Retinal Screening • Psychiatry • SleepApnoea • Rehabilitation • Stoma • Renal, • + Local run clinics • Retinal Screening • SleepApnoea • Stoma • Surgical, Obs & Gynae • Urology + local run clinics

61 APPENDIX 7 – Short-list of options including advantages and disadvantages

Option 1 – Do minimum

Everything would stay the same but with some investment to look to address regulatory and statutory requirements around Portree Hospital and Dr MacKinnon Memorial Hospital. There would be limited opportunities for minor improvements in community based care. Work would continue to integrate services while accepting limitations imposed by the current facilities, IT infrastructure and locations of services and staff.

Main disadvantages Main advantages 1. Buildings will never be fit for modern 1. It is what people are familiar integrated healthcare services, even with with significant investment

2. Missed opportunities to improve 2. Keeps the full range of services care-at-home and address safety in existing hospital locations issues and standards 3. Not sustainable - may result in 3. No major service change major loss of services from the required locality in the longer term

4. Inefficient use of resources 4. Continues excellent culture of care

5. Buildings difficult to adapt and so can’t make best use of new technology or expertise

Costs The running costs for both hospitals alone are £4million per year. Capital costs would be £5.5million to bring the buildings up to minimum standard.

Summary This option scored 400 points (out of a possible maximum of 1000, see page 31). The low score reflects that this option would not address current or future problems. Clinicians have raised concerns around patient safety linked to resources split over both sites, additional transport for acutely unwell patients, and at times, confusing pathways. This option would also not allow investment in care-at-home, support joint working or modernise the hospitals.

62 APPENDIX 7 (cont’d)

Option 2 - Community resource centre and hospital ‘Hub’ and hospital ‘Spoke’

‘Hub’ – In either Broadford or Portree, a full range of services would be delivered through a new modern purpose-built ‘Hub’. It would have in-patient beds enhanced diagnostic services (including X-ray and Ultrasound), A&E, out-patient and day-case facilities. Other features would include co-location of staff, spaces for third sector organisations and it would be the main base for Scottish Ambulance Service.

‘Spoke’ – This facility would be in the other location and would support Primary Care Emergency Centre (GP and nurse cover for community casualty/minor ailments and injuries), out-patient clinics and co-location of some staff. There would be no in-patient beds.

Main disadvantages Main advantages 1. Requires agreement on location of 1. Provide services in new modern ‘Hub’ and ‘Spoke’ facilities with enhanced diagnostics 2. Loss of some services (e.g. in-patient 2. Pathways clearer with better beds) in the area with the ‘Spoke’ medical cover for in-patients with greater clinical governance, especially out-of-hours 3. Still would require investment in two 3. Greater opportunities for integration hospital buildings and staff co-location 4. Potential closure of some buildings 4. Potential to reduce occupied bed days in hospitals and look after more people at home 5. Some staff would be required to 5. Provides a stronger foundation to change base safeguard services in the locality going into the future

Costs The running costs are estimated to reduce from around £4million to £3.5million. The capital costs would be around £14million with unitary charge costs of approximately £1.4million.

Summary Option 2 scored 800 points (out of 1000) representing a significant improvement on the ‘Do minimum’ option. It would deliver safer, modern and more sustainable services. The new arrangements would provide greater opportunities for joint working. It would mean a reduction in immediate access to some services, for some people, and would require transport and access issues to be addressed. It could be designed in a way to allow further developments in the future.

63 APPENDIX 7 (cont’d)

Option 3 – Community resource centre and hospital ‘Hub’

A new service model that would be provided from a new modern purpose-built community resource centre and hospital ‘Hub’ in either Portree or Broadford.

It would involve the closure of Portree Hospital and Dr MacKinnon Memorial Hospital and a re-organisation of some of the GP Practices, care homes and day care services with many of the services being based at the ‘Hub’. There would be opportunities for others to be based in the ‘Hub’ including Scottish Ambulance Service and third sector. This would be the only hospital on the island.

Main disadvantages Main advantages 1. Level of redesign unprecedented 1. Provide services in new modern in Highland facility with enhanced diagnostics 2. Significant culture change for 2. Pathways much clearer and improved communities, staff, GPs and medical cover for in-patients and others greater clinical governance 3. Requires land of sufficient size 3. Unlocks resources across many and agreement on location of facilities allowing for alternative ‘Hub’ investment and overall better use of resources 4. Could make access for some 4. Increased “one-stop” shop services more frequently used services poorer (e.g. services provided from GP Practices/health centres) 5. Base of many NHS staff and GP 5. Could increase the range of services Practice staff would change provided on the island 6. Model not familiar, would take 6. Far greater co-location of time to implement and could be professionals, partners and third disruptive during the transition sector

Costs The running costs are estimated at £3.1million (£400k less than option 2). The capital costs would be around £15million to build the new centre with unitary charges of £1.5 million.

Summary This option also scored very highly at 788 points (out of 1000). It would address safety and quality issues, allow services to be provided from modern facilities and provide greater sustainability on the island going into the future. It would mean a potential reduction in immediate access to some services, for some people, and would require significant transport and access issues to be addressed

64 APPENDIX 8 – Development of Options and Conclusion of Options Appraisal

Full details on the process to develop and appraise possible options for the future model of service were presented to the Board at the special meeting held in March and were described in the public consultation materials.

Three service model options were short-listed (Appendix 1) and option 2 scored highest albeit by a small margin.

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

1 Dominimum 400 3 £5.5m £4m

Community resource 2 centre and hospital 800 1 £14m £3.5m ‘Hub’ and Spoke Community resource 3 centre and hospital 788 2 £15m £3.1m ‘Hub’

(*) The consensus score is summarised above. This is a score agreed by the group following debate and challenge. It is not an average. If people feel it is too high or too low then this captured via optimistic and pessimistic scores. These were all presented to the Board in earlier papers and were included in the full public consultation document.

The Board endorsed the recommendation on the preferred model of service (option 2a) and also approved that a further option appraisal exercise should take place to determine the location of ‘Hub’ and ‘Spoke’ on Skye

Option 2 (a) ‘Hub’ new-build in Broadford with ‘Spoke’ in Portree Option 2 (b) ‘Hub’ new-build in Portree with ‘Spoke’ in Broadford

Benefits criteria and weighting of criteria

A further workshop was held and included representatives and contributions from a range of stakeholders.

At the workshop participants agreed seven criteria as being the most important on which to base a decision to determine the best location for the ‘Hub’. The flow of patients i.e. going from home to the hospital on the island and potentially onto Secondary care was ranked the highest (most important = rank 1) and purchasing land for the ‘Hub’ (the least important = rank 6). In ranking and scoring the participants were asked to consider each criterion relative to Broadford vs. Portree 65 APPENDIX 8 (Cont'd)

Benefit Criteria Rank Weight 1. Patient Flow – Home to GP premises/Hospital 1 17 ‘Hub’/Raigmore 2. Suitabilityfordevelopmentof‘Spoke’ 2 16 3. Demographic Centre- where people live taking 3 15 into account age, illness profiles etc. 4. Geographic Centre - travel times/distance for patients, family, visitors, staff and potential 3 15 economic impact on local rural communities 5. Recruitment and retention of staff 4 14 6. Travel time and infrastructure for visiting 5 12 consultants/services 7. Ease of acquisition for land– current ownership, 6 11 acquisition timescales Total Weight 100

The scoring identified that the preference for the ‘Hub’ was the Broadford locality (Option 2a) leaving the ‘Spoke’ to be in the Portree locality. Option 2a ranked highest in all three scoring scenarios. Notably both options scored highly indicating that the group felt both locations would perform reasonably well in terms of satisfying the criteria for the ‘Hub’

Overall Weighted Benefits Score (Workshop Group’s weights applied)

Optio Description Optimistic Consensus Pessimistic Rank n No

‘Hub’ based in Broadford – ‘Spoke’ 2a 780 766 751 1 based in Portree

‘Hub’ based in 2b Portree – ‘Spoke’ 743 717 702 2 based in Broadford

66 APPENDIX 9 – List of participants at options appraisal workshop re location 11th March 2014

Name Designation Area representing Audrey Sinclair Councillor Main base Kyle covers Wester Ross and Lochalsh Caroline Gould Access Panel Covers Skye & Lochalsh, lives Broadford Catriona Leslie Community Council Portree Paul Davidson Rural Practitioner Skye Hospitals Clinical Lead N&W Operational Unit Jonathan Hanson Rural Practitioner Skye Hospitals including out- of-hours cover in Portree Hospital. Lives South Skye Isabelle MacDonald Community Council Staffin Isobel MacLeod Skeabost Community Council Skeabost Tracey MacRitchie Learning Disabilities Covers Skye, Lochalsh and Community Charge Wester Ross Nurse/Staff-side Representative RCN Stephen McCabe GP Portree Medical Practice and Community Hospital Meg Gillies S&L CVO Covers Skye & Lochalsh, lives Staffin Will Nel Rural Practitioner Skye Hospitals including out- of-hours cover in Portree Hospital Chrisann O’Halloran Charge Nurse MMH/Acting Skye Hospitals Charge Nurse Portree Hospital Julia Rudram Senior Occupational Therapist Covers Skye, lives Dunvegan Joan Turkington Access Panel Covers Skye & Lochalsh, based Struan Lesley Unwin GP Kyle Willie MacKinnon Highland Council Ward Main base Portree Manager Kevin Lawley Alzheimer’s Scotland Main base Portree covers Skye & Raasay Alistair McPherson Community Council Broadford & Strath Hamish Fraser Councillor Covers Skye & Raasay, main base Breakish Biz Campbell Councillor Wester Ross, Strathpeffer & Lochalsh Kirsty Shaw GP Dunvegan Mary MacBeth Community Council Achmore & Stromeferry

Pre meeting contributions received from: Dave Murray – GP Lochcarron Angus Venters – GP Sleat, Charlie Crichton - GP Portree

67 APPENDIX 9 (cont'd)

NHS Highland advisers at event but who did not score

Gill McVicar Direct of Operations Tracy Ligema Area Manager West NHS Highland Michael Waters Capital Support & Project Manager NHS Highland

Scottish Health Council

Marie McIlwraith Service Change Adviser

NOTE: Skye, Lochalsh and South West Ross Redesign Invite list

This is the full distribution list of people invited to attend the workshops. NHS Highland did not select who attended

Name Designation AlanKnox SAS,AreaManager Alex Jones Skye & Lochalsh Mental Health Association Alistair Innes Rural Practitioner Alistair McPherson Breakish CC AlysonRoberts PAtoAreaManager(NHS) Andrew Maclean Red Cross AngusVenters GP,Sleat Ann Eadie Red Cross Anna Adderley Social Work, Highland Council Audrey Sinclair Councillor, Ward 6 Breda McCarthy Social Work, Highland Council Broadford &Strath CC Callum MacDonald Unison/Business Officer NHS Campbell Dreghorn Staff side Rep, UNISON Caroline Gould Advisor to Access Panel Catherine Holmes NHS Human Resources Catriona Leslie Secretary, Portree & Braes CC Charles Crichton GP, Portree Chrisann O’Halloran Senior Charge Nurse, Skye Christine Barwick C/N Theatre, MacKinnon Memorial Hospital David Hearn Chair Portree& Braes CC David Murray GP, Lochcarron Drew Millar Councillor, Ward 11 Fay MacRae Admin , Highland Council Fiona McGeachan NHS Highland Frances Matthewson NHS Service Planning Gill McVicar Director of Operations, North & West Glenda MacKinnon PA to District Manager, Skye Gordon MacKay Waternish CC Hamish Fraser Councillor, Ward 11 Ian Renwick Councillor, Ward 11

68 APPENDIX 9 (cont'd)

Name Designation Isabelle Campbell Councillor, Ward 6 Isobel MacLeod Secretary, Skeabost & District CC Jim Towers Minginish Community Council Joan Turkington Secretary, Skye & Lochalsh Access Panel John Bogle Capital Planning Manager John Gordon Councillor, Ward 11 JonathanHanson RuralPractitioner Julia Rudram Occupational Therapy K Lawton Carrgomm Kate Earnshaw NHS District Manager, Skye Lochalsh & South West Ross KennyMacLean Chair,WesterRossPPF Kevin Lawley Alzheimer’s Scotland Kirsty Shaw GP Dunvegan Medical Practice Lachie MacDonald Chief Executive, Lochalsh & Skye Housing Association Leo Murray Rural Practitioner, MacKinnon Memorial Hospital Lesley Unwin GP, Kyle Liz MacDonald Scottish Health Council Liz Williams Housing Manager, Highland Council Maimie Thompson Head of Communications NHS Marie McIlwraith Scottish Health Council Marie Noble Social Work Dept, NHS Marjory Jagger Young Carers Mary MacBeth Stromeferry & Achmore Community Council Meg Gillies Chief Development Manager, Skye & Lochalsh Community Voluntary Organisation Michael Francis Deputy Chair, Skye & Lochalsh PPF Michael Maclennan Finance, NHS Highland Michael Waters Project Manger Capital Planning NHS Nick Shone Practice Manager, Dunvegan PatMatheson NHS,IntegratedTeamLead Paul Davidson Clinical Lead/GP PaulYoxon Broadford&StrathCC Peter Richell Crossroads Robbie Bain Ward 6 Manager, Highland Council RogerTanner ConsultantforStrategem Ros O’Connor Practice Manager, Portree Sarah McLeod Lead Midwife SteveMcCabe GP,Portree Tom Davison NHS Highland Communications Team Tracey MacRitchie Staff-side Rep Tracy Ligema NHS Area Manager (West) Wil Nel Rural Practitioner, MacKinnon Memorial Hospital Willie MacKinnon Ward 11 Manager, Highland Council

69 APPENDIX 10

Proposed Modernisation of Community and Hospital Services in Skye, Lochalsh and South West Ross

Preferred Option for Location of Hub and Spoke Hospitals

Options Appraisal Workshop — 11th March 2014

Sarah Marshall (Chair)

A North Skye Action Group Critique

18th November 2014

(The chair is not the author of the report. The author is not a member of the committee but happy for committee to take ownership – this was confirmed with the author) 70 1.0 Summary

1.1. On 11th March 2014, some 18 months into the New Hospital Project, a “workshop” was held to identify the “preferred option” for the location of the Hub and Spoke within the chosen new model of hospital service for Skye, Lochalsh and South West Ross. Much has been said elsewhere about the area to be served, but it is fair to claim that few of the stakeholders (the general population) would disagree with the chosen model being centred on The Isle of Skye. The working brief for their task was to appraise the “non-financial” issues affecting the quality of healthcare which the chosen new model would deliver.

1.2. Established Locations Centre(s) Main population centre Portree Principal GP registrations Portree Current hospitals Broadford and Portree Main Commercial Hub Portree Main Tourism Centre Portree High School Portree Transport Hub Portree Highland Council Offices Portree Site for “new” Supermarket Portree Major Elderly Care Units Portree

1.3. Preferred new Hospital “hub” Broadford

1.4. What strange alchemy could turn the gold of our long awaited new hospital service into base metal? The answer lies in the deliberations of a deeply flawed Options Appraisal Workshop.

1.5. We will consider the participants in the exercise, the methods used, the choice of Benefits Criteria which were identified, ranking and weighting of their relative importance and the “consensus” scores awarded by the group to each criterion.

1.6. Recent reference to the list of members participating in the 11th March Workshop confirms that there was a significant numerical imbalance, of the order 2 to 1 in favour of Broadford. It is perhaps unsurprising that the outcome was as follows:

1.7. The “overall weighted benefits scores”, where the maximum possible is 1,000, were then applied for both the Broadford and Portree options to deliver the following verdict: Broadford 764 Portree 717

1.8. Thus the decision was made that The Steering Group would proceed with the Public Consultation on the “preferred option” of a Broadford Hub, based on a rather modest advantage of 47 points out of a possible maximum of 1,000.

1.9. The author of this paper, with wide application experience of the technique, presented an alternative outcome to the August 14th Public Meeting in Portree. This single person’s exercise adopted the same 7 Benefit Criteria and applied the “consensus scores” from the April Workshop, despite reservations about the relevance of the chosen criteria to quality of healthcare. Different ranking and weightings were applied to reflect more accurately the declared objectives of the appraisal exercise.

1.10. Alternative “overall weighted benefits scores” were as follows: Broadford 656 Portree 733 Advantage to Portree, 77 points out of maximum score of 1,000. 71 1.11. Whilst acknowledging this may well be a biased outcome, we would argue that it does produce the result that the preferred option should be Portree. Over 60% of the GP Registered population depend on North Skye practices, and the invariable principle that the main hospital should be established as near as possible to the main population centre reinforces the argument.

1.12. We submit that the Location Options Appraisal must be the subject, at the very least, of an Independent Review, carried out by a qualified practitioner.

1.13. Without such a review this deeply flawed exercise and its perverse, not to say irrational outcome, will result in our much needed and most welcome new hospital being located away from the majority of those stakeholders who will depend upon its services for the next 100 or more years.

2.0 Options Appraisal Workshop 2.1. Participants

2.1.1. The NHS Highland Website presented the report of the Options Appraisal Workshop held on 11th March 2014. This report (more or less verbatim) was included also as Part 4 of the Full Public Consultation Document, entitled ‘Proposed modernisation of community and hospital services in Skye, Lochalsh and South West Ross’.

2.1.2. Part 3.3.1 Financial Appraisal addressed financial feasibility issues of the alternative “models” for the modernisation and concluded that the so-called “Hub” and “Spoke” model was the most appropriate. Few would disagree with the Steering Group’s conclusion thus far.

2.1.3. The workshop participants were tasked to “appraise the non-financial benefits of the potential locations for the Hub and Spoke”.

2.1.4. We were not informed about the participants in the workshop, but it would now appear there was a heavy bias towards Broadford and South Skye. Subsequent advice suggests that of the two Portree GP’s on The Steering Group, only one took part in the day-long exercise. Recent sight of the list of participants from The Steering Group confirms that the imbalance of membership was indeed significant, with at least a 2 to 1 ratio in favour of Broadford.

2.1.5. A fundamental principle of the options appraisal/benefits analysis procedure is that both parties to the argument are equally represented and informed about the process. In light of the predictable subsequent fallout, a Control Group of Stakeholder Representatives, assembled pro-rata to the GP Registrations, should have been invited to complete a parallel procedure using the same criteria. The outcome would no doubt have been different, though it would certainly be a fair, more acceptable and sellable “preferred option”. It may not represent the doctors’ choice, but surely the needs of the patients come first. 2.2. Benefit Criteria

2.2.1. The first task of the workshop was to agree the Benefit Criteria on which the two “hub options” would be judged for their non-financial benefits. A total of seven Criteria were identified by the group as relevant. We will approach these in the order chosen, which would not represent our view of relevance.

72 2.3. Patient Flow (Rank 1)

2.3.1. This was defined by the group to be the movement of patients between home and GP premises, then onwards to Hospital Hub and/or Raigmore Hospital. A clear and unchallengeable issue, which depends totally on Geographic location relative to the hub and Raigmore. The objective must be to reduce Patient Flow for the maximum number of patients and movements between home and the alternative treatment centres.

2.3.2. We would not argue with the importance of this criterion to healthcare quality but the Workshop ranking of ONE is questionable. 2.4. Suitability for development as Spoke (Rank 2)

2.4.1. The Workshop clearly overlooked the instruction to appraise the non-financial benefits of the proposed locations. This particular criterion certainly has nothing to offer towards the quality of healthcare and belongs elsewhere in Feasibility Study or Financial Appraisal. Despite this a ranking of TWO was awarded. 2.5. Demographic Centre (Rank 3)

2.5.1. This was defined by the group as: where people live, taking into account age, illness profiles etc. It would have been most instructive to witness the debate, which concluded that this particular criterion should deserve to languish in equal rank of THREE with the following Geographic Centre. Surely in any objective assessment it would be ranked at least in equal FIRST place.

2.5.2. It is logical and conventional practice that any regional hospital should be situated near to the major population centre. How can Rank THREE be justified? 2.6. Geographic Centre (Rank 3)

2.6.1. This was defined by the group as: “travel times/distances for patients, family, visitors, staff and potential economic impact on local rural communities”. In all but name Patient Flow above addresses the same factors and the inclusion here amounts to a double count for a high value criterion.

2.6.2. Whilst we may not exclude it, only a much lower ranking would be awarded to avoid any distortion of the outcome. 2.7. Recruitment and Retention of Staff (Rank 4)

2.7.1. The proposed new hospital undoubtedly will generate a demand for many more staff, including doctors, nurses, radiographers etc., than the present number of excellent, committed and dedicated individuals living on Skye. Attracting people to move to this beautiful yet remote location from their more conveniently placed mainland homes will be as big a challenge as getting the appropriate buildings and medical facilities.

2.7.2. These new recruits will be judging a possible move, based on the facilities which are available to their families. Of particular interest will be proximity of schools, shops, library, cinema, theatre, swimming pool… to name but a few. That this was awarded a rank of only FOUR appears quite remarkable. Rumour has it that existing Broadford based GP’s are most concerned that they might be required to sell up and move house were the new hub to be in Portree. So far as we understand their Primary Care Facilities would not be transferred from Broadford. In the alternative outcome we do not hear from Portree GP’s that this would be an issue for them to move house to Broadford.

73 2.7.3. Regardless of the wishes of doctors, surely the situation of more than 60% of stakeholders needing to travel to a Broadford hub, should take precedence in any appraisal of quality of healthcare provision. The interests of patients must always come first. 2.8. Travel time for visiting consultants/services (Rank 5)

2.8.1. Whilst this issue is of some relevance to the quality of healthcare, we are not aware of any concerns from the consultants themselves. They already attend clinics in both Broadford and Portree and those questioned have expressed no preference and are not aware of others who would object to visiting the new hub, wherever it may be placed. A ranking of FIVE is only inappropriate in context of some placed higher during the workshop. 2.9. Ease of Acquisition (Rank 6)

2.9.1. This was defined by the group as: “ease of acquisition for land, current ownership, and acquisition timescales”. It is difficult to appreciate how this could be considered within the context of quality of healthcare provision. Indeed, when offered three acres in Portree, the Steering Group declined, as this “was not an over-riding factor” in identifying the preferred option. Whilst the ranking of SIX, places this lowest of the chosen Criteria, the weighting it received was most significant. (More of this in Part 3 below)

2.9.2. We also understand that to date there has been no involvement of any Planning Authorities, until this week’s informal approach in Portree by Councillor John Gordon, on behalf of this Action Group which he chaired.

3.0 Rank and Weighting of Criteria

3.1.1. The workshop identified the criteria, numbering them 1 to 7 to suggest relative significance. As stated in the summary, we decided to retain the same criteria, even maintaining the same ordering to simplify the comparisons. We have however introduced alphabetic identities, to demonstrate that our appraisal has differing views of their impact (if any), on the quality of healthcare provision.

3.1.2. In the Consultation Document the Rank and Weight of the seven Criteria were presented in tabular form. This is represented here, with two additional columns, which show our revised rank and weight. These are based on our judgements made in Part 2 above and afford the reader a simple direct comparison.

74 Benefit Criteria Original/Revised

Rank Weight Rank Weight

A Patient Flow 1 17 2 22

Suitability for Spoke B Development 2 16 5 12

C Demographic Centre 3 15 1 27

D Geographic Centre 3 15 6 5

Recruitment and retention of E Staff 4 14 3 20

F Travel time for Consultants 5 12 4 14

G Ease of Acquisition of Land 6 11 7 0

Total weight 100 100

3.1.3. It will be noted that Suitability for Spoke Development, Geographic Centre and Ease of Acquisition of Land are now ranked the three lowest criteria and are thus awarded reduced weightings. Their lower ranking reflects our view that they have little if any impact on the quality of healthcare provision. Perhaps an argument could be made that our revised weightings for two of these criteria are still too generous. Combining the weightings of our second and sixth ranked criteria which we have described as double counting matches the weight of our highest ranked, so we may be rather relaxed on the issue! Only the lowest ranked receives zero weight, as the Steering Group acknowledged it was “not an over-riding factor” in their deliberations.

4.0 Workshop Consensus Scores and Weighted Scores

4.1.1. Once the criteria were agreed, ranked and weighted, the assembled individuals scored, out of 10, each criterion for both Broadford and Portree Hubs. This task was, or should have been, undertaken without any group collaboration, to avoid the risk of undue influence. Consensus, Optimistic and Pessimistic scores appeared in the results table to indicate the degree of variance of opinion. It will be observed that there was only occasional difference across the group. This suggests either a remarkable harmony within the workshop or more probably an inappropriate level of collaboration in this most individual of tasks.

4.1.2. Rather than produce our own new individual scores, we concluded that it was appropriate to accept the wisdom of the larger group and apply their “consensus” scores to our revised weightings.

4.1.3. The reader will note also that our two lowest ranked criteria, received the only scores with more than a single point difference between Broadford and Portree. Differences of 2 and 3 points respectively were both in favour of Broadford.

75 Benefit Criteria Consensus Scores

Broadford Hub Portree Hub

A Patient Flow 8 7

Suitability for Spoke B Development 7 8

C Demographic Centre 7 8

D Geographic Centre 9 7

Recruitment and retention of E Staff 5 6

F Travel time for Consultants 8 7

G Ease of Acquisition of Land 10 7

4.1.4. The final act of the appraisal was to produce Overall Weighted Benefits Scores, for the Broadford and Portree Hubs. Using the workshop consensus scores and our revised weightings (Score x Weight) we have calculated Revised Weighted Benefits Scores.

4.1.5. These are presented alongside the workshop scores in Part 5. Comparison of Weighted Scores.

5.0 Comparison of Weighted Scores

5.1.1. Combining the 100 points shared by the seven Criteria with the scores out of 10, for each Criterion, yields an Overall Weighted Benefits Score, with a maximum value of 1,000. The following table provides a comparison of the results of the original workshop results with those of our own exercise.

76 Benefit Criteria Overall Weighted Scores

Broadford Hub Portree Hub

Original Revised Original Revised

A Patient Flow 136 126 119 168

Suitability for Spoke B Development 112 84 128 96

C Demographic Centre 105 189 120 216

D Geographic Centre 135 45 105 35

Recruitment and retention of E Staff 70 100 84 120

F Travel time for Consultants 96 112 84 98

G Ease of Acquisition of Land 110 0 77 0

Total weighted Benefits Scores 764 656 717 733

5.1.2. Thus we find an advantage of 47 points to Broadford in the original appraisal and a greater advantage of 77 points to Portree in the revised version. Each of these measures should be considered against a maximum score of 1,000 points.

5.1.3. By such slender threads hangs the choice of location for the “hub” hospital in the “preferred model” and thereby also location of the “spoke”.

6.0 Commentary on Appraisal Outcome

6.1.1. The sole objective of any Benefits Analysis/Options Appraisal exercise is to achieve an outcome which is measurable, unchallenged and acceptable to both (sometimes all) interested parties. Certain ground rules must be established and followed in order that this may be the result.

6.1.2. The outcome of the Options Appraisal Workshop held on 11th March bears all the hallmarks of a pre-determined result.

6.1.3. It would be instructive perhaps to consider how the workshop performed against those ground rules.

6.2.1. Define the terms of engagement This was stated clearly as follows: Appraise the “non-financial” benefits of the potential locations for the “hub” and “spoke”, which may be interpreted to consider the quality of healthcare provision.

6.2.2. Avoid any pre-determined outcome There remains a strong impression that this ground rule was ignored.

6.2.3. Ensure all parties are equally represented Recently we have been able to confirm the number and identity of participants from The Steering Group, and there was an imbalance in representation of at least 2 to 1 77 in favour of Broadford. To borrow a medical term, a Control Group should have been established to conduct a parallel exercise. This would be drawn pro-rata from all GP Patient Registers, thereby ensuring equal and fair representation.

6.2.4. Agree Benefit Criteria which address the terms of reference Only four out of the seven agreed criteria can be considered relevant to quality of healthcare provision. Two others, suitability as spoke and acquisition of land, belong properly in a Feasibility Study or Financial Appraisal. The third, geographic centre, covers the same issues as patient flow, effectively double counting the impact. This is also skewed with the questionable inclusion of South West Ross in the study

6.2.5. Rank and Weight Criteria fairly to meet terms of reference The rank and weight awarded to some agreed workshop criteria fail this important ground rule. Criteria ranked 2nd, 6th and equal 3rd, which we considered irrelevant to the quality of healthcare provision, were weighted to account for more than the advantage of Broadford in the eventual Overall Weighted Benefits Scores. Our revised appraisal ranked these three 5th, 6th and 7th. It is instructive to note that our 7th ranked criterion was “not an over-riding factor” according to The Steering Group. Despite this, with the weighting awarded it represented 33 of Broadford’s 47 point advantage.

6.2.6. Each Participant must “score” all Criteria independently This final stage of the process must be completed by each participant, with absolutely no reference to other colleagues. All of the debate and argument has been completed and these scores must represent the independent opinion of each member. The Public Consultation document reports consensus scores, along with optimistic and pessimistic results (highest and lowest). All three scores show a quite remarkable consistency, which may suggest either great harmony or undue levels of collaboration within the group! The two criteria showing the greatest divergence of scores between Broadford and Portree, of 3 and 2 points score (out of 10) respectively, in favour of Broadford, were ranked 7th and 6th in our revised Options Appraisal.

7.0 Conclusion

7.1. The above critique provides overwhelming support for our conviction that this 11th March Options Appraisal Workshop was deeply flawed at every stage, with one exception: the terms of engagement were very clear. As a consequence the outcome in favour of Broadford as the “preferred option” for location of the hub, is both perverse and irrational. Invariably a regional hospital should be built as near as possible to the main centre of population. Any other outcome is illogical and offends against natural justice. The hub must be located in Portree with the spoke in Broadford

Note – Designation of those in North Skye Action Group will be forwarded to NHS Highland in due course along with other information.

78 APPENDIX 11 – Summary of points raised at meetings, events and correspondence

After the consultation closed comments were categorised to allow some themes to be considered. Feedback relating to service model, aspects of current and future services are summarised. These are not listed in order of priority.

Points specifically relating to the consultation process, including geography and demographics, were considered as part of the report to Highland Health and Social Care Committee (6th November) and not repeated here.

Themes

1. Service model: ‘Hub’ and ‘Spoke’ 2. Service model: Other 3. Patient flow 4. Future service and service specification 5. Existing services 6. Emergency provision and response (including SAS) 7. GP/Primary care 8. Care at home/carehomes 9. Beds 10. Respite/palliative care 11. Staff 12. Buildings 13. Travel times 14. Travel and access 15. Other

79 Category Points raised NHS Highland response 1.1 Service Nobody is questioning the The consultation shows that there is little support for the status quo but strong support for Model: ‘Hub’ model but concern over the model: ‘Hub’ and ‘Spoke’. The contentious element has been location. There is no and ‘Spoke’ “dividing the island” – need full ideal solution. Having a full range of services in both areas with 24/7 A&E would not be range of services in both areas consistent with the model. Nor would it be sustainable in terms of ability to staff or with 24/7 A&E. affordability. Resources currently tied up in buildings require to be released in order to build capacity in the community. 1.2 History of deteriorating services This was a feeling expressed in particular about beds. The way services are delivered (referring to the north). mean across Highland there is less reliance on beds. It is clear, however, that this has had an impact on how some people have viewed the consultation. 1.3 Is there any possibility of getting If this means two new facilities with the same or extended range of services in both two new hospitals? locations then this option was not short-listed. This model is not considered to be sustainable and why wider reconfiguration is being considered. 1.4 Build a new hospital in Portree If it was decided that the ‘Hub’ was to be in Portree it would be necessary to build a new and keep MacKinnon as is. hospital on a new site. Dr MacKinnon Memorial will need to be replaced whether it is a ‘Spoke’ or ‘Hub’. However, the preferred option (prior to consultation), is to have the ‘Hub’ in Broadford. 1.5 Portree Hospital has a priceless Under the preferred option there will be no change to the location of the hospital. If was to asset – a view be the ‘Hub’ however it would need to be built in a new location 1.6 Will there be a new build in Yes. The location of the current hospital is “land-locked” and would not allow the Portree if it is to be the ‘Hub’. modernisation and expansion that would be required. However, the preferred option (prior to consultation), is to have the ‘Hub’ in Broadford. 1.7 Prefer an entirely new single The preferred option (prior to consultation), is to have the ‘Hub’ in Broadford. site in Portree 1.8 There should be a new build for Under the preferred option, it is believed there would be no requirements for this as Portree the ‘Spoke’ – it would be more Hospital could be adapted. There has been significant investment in the fabric of Portree cost effective? Hospital in recent years. If Broadford was be the ‘Spoke’, however, then the existing facility would not be suitable. The options around this would have to be considered. 1.9 People would prefer the status This is a personal opinion and not borne out by the consultation where only 1% opted for quo – modern standards less status quo. When asked providing services from modern hospitals 91% were supportive. important than quality of care. NHS Highland has a duty to ensure that all facilities and care meet required standards. There are good clinical reasons why this should be so and it’s what a majority of people would expect. Under current arrangements all new builds would be required to have 100% single rooms with en-suite facilities. 1.10 If the ‘Spoke’ was in Broadford If Broadford was to be the ‘Spoke’ then the facility would not be suitable. The options would it be in the existing around this would have to be considered. This work has not yet taken place. However, the building? preferred option (prior to consultation), is to have the ‘Hub’ in Broadford. 80 1.11 If the ‘Spoke’ is in Portree would Yes. Portree Hospital could be adapted to meet the requirements of the ‘Spoke’. it be in existing building? 1.12 If the ‘Hub’ was built in Portree Further work would have to take place to determine this, however, an initial trawl of the area where would it be located? has identified that there are possible sites, in terms of quality factors. In addition a local landowner offered free land of three acres. However, this is not the preferred option at this stage. 1.13 Why not Sligachan? While it would be the most central point for Skye and Lochalsh there is no supporting infrastructure or services 1.14 Not so concerned with the The clinical specification has still to be agreed in detail. There will be improved facilities but location of ‘Hub’ so long as at this stage it seems unlikely that it would include a CT scanner. The important thing is to improved facilities and a CT agree the pathways and level of care appropriate to provide and staff and then agree what scanner (or room for it). diagnostics are required to underpin the model. 1.15 The model will maintain more The re-design is about delivering modern sustainable services as local as possible for the local services and reduce the population of Skye, Lochalsh & South West Ross need to travel to Inverness.

2.1 Service There is not enough detail in the Further detailed work will be required, if and when the preferred option is approved Model: Other clinical model. (wherever the ‘Hub’ and ‘Spoke’ are located). The requirement to provide further detail comes later on as part of the Business Case process. An outline of the ‘Hub’ and ‘Spoke’ is provided together with a summary of other services (Appendix 10). 2.2 Appears to be “Hospital or To achieve this, however, requires a number of things to happen, including: nothing” needs to be more in Whole-health and social care system redesign to allow more people to stay well and between. independent at home Greater community resilience involving families, communities, third and voluntary sector working together to impact on things like care-at-home, social isolation, transport Change the way resources are used 2.3 Will there be enhanced Yes. The benefit of the preferred model is that it would allow additional investment in community facilities? community services such as: community nursing and care services, long term care options, intermediate care, respite care, care at home. In addition NHS Highland has committed to invest in more consultant care of the elderly input for Skye. 2.4 Will people with mental health Currently the psychiatrist holds clinics in Portree and Kyle and that will continue along with problems have to travel to currently sited CPN teams in North and South Skye. Broadford?

81 2.5 People want to see a doctor. This was a personal opinion and is not a widely held view. NHS Highland is utilising the Having a Nurse Practitioner is a skills of Nurse Practitioners in a range of areas already from providing first line support at step backward: “I personally night in Raigmore to the provision of Out of Hours consultations in PCECs and peoples’ would rather see someone who homes across Highland. This position is reflected in the widespread use of such is totally trained” practitioners in other areas UK.

What people want is to be treated in a timely manner with people with the appropriate skills and training.

Advanced Nurse Practitioners/Paramedics are fully trained to see and treat patients within defined competencies. They would be backed up by doctors/consultants and others as appropriate. Given the challenges to recruit and retain doctors these models have been actively pursued by NHS Highland and there are now many examples of established practice. Services require to be built on appropriate skills and competencies rather than job titles or disciplines.

Notes Sakr et al (2003) study found that a minor injury unit led by nurse practitioners produced a safe service where the total package of care was equal to, or in some cases better than, the A&E care. The primary outcome measures used were, number of errors in clinical assessment, treatment and disposal.

Horrock's et al (2002) systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors concluded that the increasing availability of nurse practitioners in primary care is likely to lead to high levels of patient satisfaction and high quality care.

2.6 Will you be able to guarantee No. We simply can’t guarantee this across all specialities. Our commitment is to try to consultants travelling from significantly reduce anyone having to travel unless they really need to do. Belford and Raigmore to Skye? During the consultation people have fed-back at their frustration of travelling for “five minute appointments.” A lot more can be done by consultants/specialists supporting GPs to manage patients locally with appropriate support and advice and by better use of telephone, email and tele-medicine consultations with specialist nurses. Subject to being able to recruit and retain staff we will invest greater consultant input to care of the elderly which will bring a wide range of benefits

82 2.7 Surely it makes more sense for It doesn’t make sense for anyone to travel unless they really need to. consultants to travel than for Last year 2013/14 NHS Highland spent £1m for consultants to travel. The more time people to travel to consultants? consultants spend travelling then the fewer patients they are able to ‘see’. 2.8 Will the preferred model free up The current arrangements are neither efficient nor cost effective and by re-designing resources and if so will this be services there are opportunities to free up resources. The proposal is to use these retained locally? resources to invest in community services, care-at-home and a contribution to community transport provision.

3.1 Patient Flow If the new facility is not in There are clear challenges to providing services across such a large area. The options Broadford it would not make appraisal process sought to take this into account with patient flow a key criterion. sense to go to Portree? (comment from South west Ross Community) 3.2 Don’t mind where the ‘Hub’ is This is an important point. While there is a lot of debate about the location of the hospital as long as infrastructure in services the most important thing is meeting people’s needs: in hours and out of hours; place to respond to planned care and emergency. This means having confidence in wider extended teams; use emergencies. of technology and other arrangements such as transport. 3.3 Conflicting and confusing Patient flow is term used by professionals to describe how patients move through the health definitions of flow. and social care system. It might mean be between acute hospital and community hospital or between community hospital and home and so on. The main example is the pathway for emergency referrals and admissions and the current flow between hospitals: Portree, Broadford and Raigmore. This was given the strongest weighting in the options appraisal. In the view of senior local clinicians who took part in the options appraisal or fed into the process that the current arrangements can be confusing with patients sometimes being initially taken to the wrong hospital. In terms of the location if the ‘Hub’ was in Portree it would have the effect of taking significant numbers of patients in potentially the opposite direction from necessary transfer to higher levels of secondary care which they may later need to access (in a short-time frame). This was a term understood by participants. 3.4 If you live in the North you have Where ever the main facility is located people will have to travel. If you live in the north no choice where to go to; If you travelling time to Braodford would be less than the travel time to Inverness for these live in South Skye, Lochalsh or communities. More generally people should not be treated in an acute setting unless they South West Ross there is an need to be. Broadford as a central location provides most benefits in this regard. option to go to Raigmore. (Appendix 13).

83 4.1 Future Prefer wards not single rooms. This was a personal opinion. All beds in the new hospital will be in single rooms- this is services and Scottish Government policy. There are good clinical reasons, particularly regarding control service of infection, for having all single rooms. In addition single rooms also help with bed specification 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.”

 NHS Highland has a duty to ensure that all facilities and care meet required standards. There are good clinical reasons why this should be so and it’s what a majority of people would expect. Under current arrangements all new builds would be required to have 100% en-suite facilities 4.2 Clarification about what will be Further detailed work will come as part of the Business Case process but an outline is in ‘Hub’ and ‘Spoke’ wherever provided (Appendix 12). they are located. 4.3 Need to agree what diagnostics Further detailed work will come as part of the Business Case process but an outline is will be provided and not raise provided in Appendix 12. This will be agreed in partnership with specialists in Raigmore expectations (e.g. CT) and will look to future-proof the requirements 4.4 What will be in the ‘Spoke’- will The consultation revealed a lack of clarity about what the current services are and people’s there be 24/7 A&E; will there be view on whether they are currently adequate. An outline is provided in Appendix 12. There extra Ambulances? is not currently 24/7 A&E in the ‘Spoke’ and this is not being proposed. The current service from Portree Community Hospital offers minor illness and ailment and Primary Care Emergency Centre. No changes to the level and access of service are being proposed. Further detailed work will come as part of the Business Case process 4.5 Will there be x-ray facilities in No – this is not being proposed ‘Spoke’? 4.6 Will there be any additional Yes. But the detail will come later when the full clinical specification will be required to be services? developed as part of the Full Business Case. Access to specialist input, chemotherapy and infusions have been raised 4.7 Are the day case surgical No. These are included as part of the proposals. services at risk?

84 4.8 Will there be greater use of new The new facility will be fully equipped to take advantage of new and emerging technologies technology and tele-medicine including increased use of tele-medicine with consultants/specialist nurses. consultations? 4.9 Will the x-ray service be Yes it will be in the ‘Hub’. New more modern X-ray equipment will be provided bringing an enhanced? overall improvement. 4.10 Will children’s services be co- Children's services staff might be, but the children's services themselves would continue to located in the ‘Hub’ and be delivered closer to home (schools, health centres, homes). ‘Spoke’?

4.11 Just putting existing facilities in The re-design of services is much wider that the building. What goes into the new ‘Hub’ a new building would be a facility will be based on what is required to deliver the agreed levels of care. Any services missed opportunity. developed need to be sustainable. This means in terms of staffing, costs and clinical governance 4.12 Would make a big difference to There are no plans to develop a pain clinic on Skye. This is a very specialist service and have a pain clinic on Skye. difficult to sustain a Highland-wide service. 4.13 Need more car-park facilities Detailed work will be carried out to determine the correct level of car-park facilities. This will be taken into consideration when selecting the site. 4.14 Need to have a helipad close to This will included as part of the proposal the hospital.

5.1 Existing Lack of clarity about what exists The consultation has revealed a lack of clarity about what the current services are and Services now particular relating to Out-of- people’s view on whether they are currently adequate hours, A&E; The re-design will also help to address a long-standing issue around terminology A&E, Difference in opinion as to when Casualty, Minor Injury Unit. Portree Hospital can be accessed out of hours. 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. 5.2 Portree should have a doctor Portree Community Hospital doesn’t currently have a doctor on site 24/7 but there is access 24/7 for A&E. to a doctor via on-call. Going into the future the cover may be via Nurse Practitioner. It is not currently proposed to move to 24/7 cover 85 5.3 Clarify about “there is no This is referring to hospital storage not community equipment store for aids and adaptations” 5.4 Need to provide relatives room This could be provided but will need to be considered alongside other priorities. Local and provision for people people will have an opportunity to influence these discussions/priorities. Other services like travelling and who can’t get café/ dining facilities will be discussed. In these deliberations we will seek to balance home after being taken to patient/visitor requests with costs and impact on local providers. hospital e.g. by Ambulance. 5.5 Language it’s not A&E it This has been raised during the consultation and was consistently clarified. Further actions provides a minor injuries and will be taken to improve communications around this. PCEC service. 5.6 Unhappy with current provision Dental services in the Skye & Lochalsh area are provided by a combination of Public Dental of dental services in North. Service (PDS) teams employed by NHS Highland and General Dental Practitioners whom What are the future proposals? are independent contractors. The PDS teams are the sole providers of dental services on Skye and have clinics in Portree and Dunvegan. There are 2 GDP practices in Kyle and one in Gairloch each of which are currently offering NHS dental registration to new patients. One of the GDP practices has branch surgeries In Lochcarron and Ullapool and in these locations patients have to wait for registration.

Prior to 2014 neither of the Kyle GDP practices were accepting new patients for NHS registration. With the change in their policy it has meant that there is no longer a waiting list in Kyle and patients have direct access to NHS dental services and the waiting list for dental registration in the Skye and Lochalsh area has dropped by 31% . Going forward the focus for the PDS team in Kyle is the provision of services for patients with additional needs e.g. housebound, anxious etc either through referral or continuing care arrangements.

On Skye there continues to be a waiting list for NHS dental registration with 419 people on the waiting list for Portree and 101 people on the waiting list for Dunvegan. A proportion of these patients are currently registered with a GDP in Kyle but have asked to be placed on the waiting list which could provide them with a service that is more accessible to them.

In the future the challenge on Skye will be to free up PDS resource to pro actively address oral health inequalities for the most vulnerable patient groups including those whom require domiciliary care and to develop meaningful partnerships with other health and social care providers to improve outcomes for patients. This may require the exploration of the potential to re-balance primary care dental services on Skye with GDP provision of services in a similar way to Kyle and which would be consistent with the Scottish Goverments direction. 86 5.7 Facilities for caring with people This was a specific issues raised by a family and a meeting is in the process of being with physical and learning arranged. disabilities

6.1 Emergency Golden hour crucial for patient It is not possible to have centres equipped to deliver the necessary treatment within the provision care. If ‘Hub’ in Broadford 'golden hour' all over Scotland and so SAS Paramedics and others, are trained to deliver the and would not be able to realise this treatment under the guidance of Specialists. SAS has technology on board ambulances response for some communities. The that link Electro Cardio Graph and other recordings directly to Specialists. In addition, NHS (Including example of Kilmuir was given Scotland has invested in increased capacity for Emergency Medical Retrieval Services, helicopters that bring Specialists to patients and the SAS is increasing its air wing capacity, SAS) and therefore the ability to take patients to definitive places of care more quickly.

These issued are relevant wherever the ‘Hub’ is located. Notably, however, the only difference being proposed is the removal of in-patient beds. Development of new specialist paramedics, First Responder Teams and role of SAS as partners with NHSH to deliver emergency treatment and response are all part of emergency response. Emergency patients would continue to be taken directly to Broadford as they should be now. SAS have been taking serious emergencies to MMH for the last 10years. Stopping en route at Portree is not the recommended pathway as it can delay definitive treatment. 6.2 Will there be an increased risk No. Appropriate clinical risk management will be in place. The model will be safer because of harm if move from two to one it will reduce confusion and allow more sustainable staffing levels. centre? 6.3 Where would patients be Emergency patients would continue to be taken directly to Broadford as they should be now. stabilised (referring to North of SAS have been taking serious emergencies to MMH for the last 10 years. Stopping en Skye). route at Portree is not the recommended pathway as it can delay definitive treatment. 6.4 Main concern around Although this is an SAS responsibility, NHSH is working closely with SAS . Going forward emergency care and evacuation we need a team approach including community resilience - First Responder/ Emergency (Raasay). Responder. There is a good team approach already in place between NHS, community, SAS, lifeboat and ferry with contingency plans for air retrieval if unsuitable to manage retrieval by sea. 6.6 What is the pathway for people If they required hospital they would be taken to the nearest appropriate setting. The in Lochcarron who call 999- emergency pathway is described. would they go to Broadford or Raigmore.

87 6.7 Concern re SAS location- are No the location of the five bases across Skye Lochalsh and South West Ross will remain ambulances all located in one the same place. 6.8 The Portree ambulance is called Portree and Broadford are equally busy, Portree does a lot of transfers. Kyle is also busier out more often than any others than Dunvegan. It is understood that SAS will remain in current locations apart from the in the district so it seems clear being co-located at the ‘Hub’. Further work will take place to place to promote what services that there is a greater need for A will be available and emergency care pathways, including having a map showing & E cover in the North of the ambulance bases, staffing arrangements (on-call), helipad, lifeboat landing facility Island. 6.9 The Scottish Ambulance NHS Highland is working closely with SAS at both local and National level. They are Services have expressed supportive of the model and preferred option. SAS have not expressed these concerns to concern that because of NHSH. In fact this is not a new pressure. The serious emergencies have been going to increased travel times they will MMH for the last 10 years. Stopping en route at Portree is not the recommend pathway as it be unable to respond to would delay definitive treatment. emergencies in the North of Skye (where most of the calls come from) as they will be en route to Broadford.

6.10 Need to provide suitable lifeboat NHSH is happy to support any improvement to the landing facility at Sconser and Broadford. landing facility at Sconser/ We have written Highland Council on behalf of the community . Broadford (if Hub is to be located at Broadford

7.1 GP Re-instate Uig Branch surgery There are currently no plans to re-open the surgery. 7.2 Supportive of proposal but want There are no proposals to change the local arrangements. As with all remote and rural to keep local surgery (Glenelg) primary care provision (Scottish Government supported ‘Being Here’ project) we are currently reviewing the way in which small isolated practices are provided to ensure that these are sustainable into the future. This includes reviewing how out of hours care is provided and how GP input during core hours are provided. 7.3 Getting rid of all doctors in the Doctors will continue to be available when required. north of Skye is a “disgrace”

8.1 Care at Care at home is in crisis what This has been an on-going problem for many years now and we feel this is something that home , Care are you going to do about it? / needs to change regardless of anything else. Through the District structure there will be an Home and Support for more care-at-home expansion in capacity to allow more care-at-home to be delivered. This will be both through but how will this be achieved review of existing ways of working such as reviewing packages, re-design of shift patterns 88 Nursing and better scheduling (already underway). Through Self Directed Support, opportunities will Homes be explored to develop social enterprise in communities to deliver care at home. We already have a successful example within t Highland. More generally there needs to be much more local community resilience including all agencies working together. The re- design provides a significant opportunity to support making these changes. 8.2 Are you developing Nursing We are working closely with our local nursing and care homes and will continue to do so to Home Capacity? maximise on opportunities as they arise. 8.3 Need to ensure new service has This is part of the proposals and further detail will be provided as part of the Business case more step-up/step-down beds. process. This will be linked with the development of community based services and consideration of what is required to support people to maximise the potential to remain in their communities 8.4 How can we develop services This underpins the whole model of care and is supported by integration. This will require a and support to keep people at multi-faceted approach including: home or if admitted, home as  Whole-health and social care system redesign to allow more people to stay well and soon as possible. independent at home  Greater community resilience involving families, communities, third and voluntary sector working together to impact on things like care-at-home, social isolation, transport  Change the way we use resources and change our expectations 8.5 Do existing care homes have All of the work to look after more people at home will mean people should be going into capacity to expand? home later we will also be considering the availability and type of long term care required to meet needs in the future. 8.6 Care Homes are situated in the In terms of age profile these are set out as part of the Local Health Profiles which have been North of the Island as is a large carried out for the area (Appendix 14). Budhmor (Portree), Home Farm (Portree) and the amount of Sheltered Housing. Haven (Uig) are in North Skye, An Acarsaid in Broadford and Howard Doris in Lochcarron. The vast majority of the elderly Sheltered accommodation is available across the area. The most important factor is to get in the area live in the North of the community services, care-at-home and community resilience in place. Often people end Skye. The elderly are more up in hospital as there are no alternatives. The re-design offers the opportunity to invest likely to require the services of and re-design the range of services and support services rather than a focus on buildings the ‘Hub’. and beds.

9.1 Beds Are there enough beds included The final number of beds has not yet been decided on though we have done some initial in the proposal work to inform the public consultation. Our Health Intelligence Unit will be carrying out  Concern about the number of further modelling work to assist in any final decision (Appendix 14). Local medical beds closed over the years experience; service planners will work out the right number which will take into account and whether more beds flexibility and future requirements. The current stated estimated provision is between 28-32 would be lost beds. 89  Concern for provision of inpatient care for older Currently it is not always possible to use all the beds because they are in bays of four or six. people This may not always suit the mix of males and females. It can also mean whole bays have to be  Need more beds due to shut when there are infection outbreaks. The new hospital will have all single room; bringing a ageing population wider range of benefits including higher occupancy. The number will be based on the optimum requirement; not the exceptions. The trends show reduction in the number of beds required (see Section 1.2 of the Report) 9.2 Concern for frail elderly if loss of A new Transport and Access Group has been established and will look at how patients, staff beds in Portree (i.e. visitors not and visitors are able to access the ‘Hub’. able to travel). 9.3 No beds in the ‘Spoke’ is a We appreciate it is a concern but by having one in-patient facility we can maximise our concern wherever it is? recourses and expertise to provide safer care. Re-design offers the opportunity to invest and re-design community services rather than a focus on buildings and beds. The model will be safer because it will reduce confusion and allow more sustainable staffing levels. It will also allow people to remain in their community as long as possible.

10.1 Respite, Not enough capacity now how The re-design offers the opportunity to invest in and re-design community services which Palliative will it increase? will support more people to die at home where this is their choice. Respite care is available and end of in the district but the feedback is that it is not meeting the aspirations of individuals and life care families and so alternatives are currently being explored. 10.2 Highlight the importance of end The re-design offers the opportunity to invest and re-design community services which will of life care. support more people to die at home where this is their choice 10.3 Palliative care beds in North Palliative care is delivered every day by primary and community teams and only rarely do Skye are a must. patients have to be admitted to hospital for pain and or symptom control. The re-design offers the opportunity to invest and re-design community services which will support more people to die at home where this is their choice. 10.4 Have there been any discussion Yes the Hospice has been part of the consultation and they are supportive of the model and with the Highland Hospice. working collaboratively. Could there be palliative care Yes beds in the ‘Spoke’?

11.1 Staff Will local doctors be providing Medical cover will be provided by the current hospital workforce. Options will be considered the medical services at the new for the involvement of local GPs should this be something they wish to consider. hospital? 11.2 Will local people be employed in Existing staff whose jobs will be affected by the proposals will be given the opportunity of the new hospital? moving to the new facilities, any posts remaining unfilled will be filled in the usual way, local 90 people will of course be given the opportunity to apply and adverts will be placed locally. 11.3 Will there be any redundancies? At the time of writing the report the NHS in Scotland has a policy of no compulsorily redundancies. If changes are required staff will be given the opportunity to either work in the new facilities or be redeployed to other areas. 11.4 Are you going to have enough Yes. The new arrangements will easier to staff and it is generally accepted that modern staff to support the model, facilities are an aid to recruitment. The exact number of staff required will depend on the wherever ‘Hub’ and ‘Spoke’ clinical model and layout of the building. While putting two in-patients units into one will located. mean less nursing staff single room layouts will require a higher establishment than open wards. 11.5 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. There is inevitably a longish lead in time allowing for issues to be considered and new arrangements to be in place. This will be supported by travel analysis based on where staff currently live.

12.1 Buildings What would happen to Dr  Should this be a requirement the existing building will be disposed of in accordance with MacKinnon if a new hospital NHS Scotland/Scottish Government regulations for property surplus to requirements. built in Broadford? 12.2 What is the process for  Should this be a requirement, NHS Highland will be asked to declare it surplus to disposing of hospital buildings? 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. 12.3 Would Dr MacKinnon’s be viable  No. All of the issues that make it not suitable to be modernised equally apply for care as a care home? homes

13.1 Travel Times The reality of travel times means Detailed work was carried out on travel times looking at different catchments and are and there is great inconsistency in available on the website. Given the issue was raised; however, travel times were re-looked pathways the proposals. at this time to exclude the communities of South West Ross. This did not substantially change things (Appendix 13). There is not an ideal solution and wherever the ‘Hub’ is located some communities would have longer travelling times. Travel times crucial for life or Immediate and emergency care is already provided from Dr MacKinnon Memorial Hospital. death. The only difference being proposed is the removal of in-patient beds in Portree Community Hospital. Appropriate clinical risk management will be in place. The model will be safer because it will reduce confusion and allow more sustainable staffing levels Development of new specialist paramedics, First Responder Teams and role of SAS as partners with HHSH to deliver emergency treatment and response are all part of emergency response.

91 13.2 The clinical reasons for not In terms of patient pathways in reality is it is more complex. In general it makes more sense transferring from Lochalsh or for acutely unwell patients to be moving in the direction of definitive care (South). However, South Skye to Portree (i.e. that we also move patient’s dependant on need and where that need can be met. patients may then have to be transferred to Raigmore) are A central location holds benefits here. In the view of the clinicians and SAS, greatest equally true for those living in pathway benefit is in removing the confusion that two centres create. A better flow results South West Ross or Glenelg from a single centre model that can be staffed and safely run 24/7 with consequently the going first to Broadford. greatest impact on harm reduction. The other important point is that patients should not being cared for in an acute setting unless they have an acute need. Raigmore should not be used as a “community” facility for Lochalsh and South West Ross. 13.3 It would be a significant increase Yes there would be an additional travel time of from Portree to Broadford. It would also be in travel time for people in North the case there would be additional travel time for people in the South if ‘Hub’ was in Portree. to access Broadford. Under the current arrangements people in North already have to travel to Broadford for more acute and specialist services. The travel time analysis shows there is not an ideal solution (Appendix 13).

14.1 Travel and It’s important that visitors are This will be considered by the Transport and Access Group. The re-design will support Access able to visit relatives. more people to not need hospital care and those that do will not need to stay in for so long 14.2 Query about NHSH Travel A claim can commence from the patient’s home. Patients, who have to travel more than 30 scheme – where can you miles (or more than 5 miles by water) to hospital, can claim repayment of travel expenses commence your claim? without test of means less the first £10 (for each appointment). Patients in receipt of certain benefits will not have to pay the first £10 of any expenses claimed. The information is available on the NHS Highland website but further work will be done to promote this. 14.3 How is transport going to work? This will be progressed through a local Access and Transport Group 14.4 City Link and Cal Mac don’t City Link and Cal Mac have been invited to take part in Transport Group work together – transport needs to be integrated. 14.5 What happens when road Although not common it does happen and is something that NHS Highland in partnership closes and people can’t access with all Emergency Services plan for. We have Business Continuity Plans for all sorts of Broadford. scenarios. A more general point is that the better local resilience is the less disruptive any closure or adverse events have. 14.6 Transport infrastructure must be Transport infrastructure is of paramount importance and needs to be developed. While NHS in place to support relocation of Highland is not a transport provider, we believe the redesign is a catalyst to facilitate joint hospital services. working across various partners. At the first meeting of the group it was agreed that the scope should be wider than health.

92 15.1 Other Have a fully trained adviser of This would make a lot of sense and will be considered as part of the business case process. case-worker on site would free up medical and nursing time 15.2 Consideration of high numbers All true, although large events happen elsewhere. The main point, however, is they are of people coming to Portree via unlikely to require rehabilitation type care as currently provided by Portree Community cruise ships, tourists major Hospital. If they needed acute medical attention it would already be in Dr MacKinnon sporting events and proximity to Memorial Hospital. Other medical care would be via GP – and this arrangement would not the ferry terminal at Uig be changing. In terms of sporting events – the services provided from the Minor Injury/PCEC would be available and emergency incidents would be provided with treatment in Broadford. Again these types of events would not be appropriate for inpatient care in a community hospital such as Portree 15.3 Increasing number of yachts True for the whole of Skye and Kyle. If medical assistance was required it would be more from all over the world come into likely to need primary care, not hospital care. Minor injuries could still be treated in the Portree to refuel, shop etc. ‘Spoke’ in Portree as they are now and emergency treatment would be provided with treatment in Broadford as now. The changes being proposed do not alter the current pathways 15.4 Proximity to the High School There are also colleges in Sleat and Broadford and secondary school in Plockton. Children and West Highland College: and young people are more likely to need primary care, not in-patient care such as provided 1000 children and young people by Portree Community Hospital. The changes being proposed do not alter the current each week day attend the pathways. various schools and college. Furthermore, children are statistically more likely to require medical care. 15.5 Public Consultation (Page 8) This is because patients are registered with a practice near to their place of residence; takes no account of the fact that Portree Practice will not in general, allow South Skye patients to register. .By and large you many from South Skye in fact need to have an address in the practice area to be registered. Where this is not the case use medical services in Portree people can be seen under the temporary residents rules - if it's a genuine emergency any as it is their place of work or practice can see someone as a TR. If it's people would be advised to see their own GP. education. Very few South end patients use the Portree Practice. All of this, of course, is the same in the opposite direction. People in the north being in the north. 15.6 It would be easier to attract Not aware of any evidence to support this and is rather disrespectful to staff currently good staff to live in Portree working in other parts of the district. While there are more facilities in Portree, South where there are more facilities Skye/Kyle also a range of facilities. The reasons behind recruitment are many and varied, including proximity to mainland services, main transport routes and availability of or proximity to place of work for spouses. This was one of the criteria used when considering the location of the ‘Hub’ and indeed Portree did score higher than Broadford on that 93 particular aspect. 15.7 Trend toward greater economic These proposals will all be considered when planning the new services. development in the South, Gaelic College, proposed new village in Sleat and Broadford would support Mountain Rescue teams in the area

94 APPENDIX 12 – Outline of services proposed for from Hub and Spoke (*)

‘Hub’ ‘Spoke’

• Outpatients as current but will include telemedicine capability. • Outpatients as current and will include telemedicine capability. • 28-32 Inpatient beds with 24/7 Nursing cover • Minor Injury/Illness Centre 0800-2300 • Emergency/resuscitation room • PCEC 1800-2300 weekdays, 0800-2300 weekends • Rural Practitioner cover 24/7 (unscheduled care practitioner) • Care of the Elderly Physician input • Community midwifery base • Community Casualty Unit with 24/7 on-site medical and • Care of the elderly physician input nursing cover • Base for local integrated team, nursing, therapy, social work • Primary Care Emergency Centre 1800-0800 weekdays, • Appropriate specimen testing to support PCEC 24hr weekends • Potential for day case and ambulatory activity led by community • Radiology services (24/7 cover) with Ultrasound elective and primary care team capability • Health Centre co-located • Point of Care state of the art modern automated lab facility based Laboratory services • Ambulatory diagnostic and treatment Centre (day case) No inpatient beds, no radiology • Endoscopy, elective day case surgery, fracture clinic, infusion service • Rehabilitation/Enablement beds • Midwife led maternity unit including 2 room delivery suite • Chemotherapy suite (Macmillan supported) • Other: Designated Place of Safety Facility, Health Centre located nearby (location of facility still to be decided) SAS co-located in Hub. Helipad on site. District Equipment store, ITL/Social Work/Care at home base and Educational Centre with bookable meeting rooms

(*) - The detailed work to develop the clinical specification forms part of the business case. NHS Highland is not yet at this stage of the process. The information provided for Hub and Spoke is a best guess at this stage subject to cost, clinical agreement and changes or advances in practice and ongoing service planning across NHS Highland.

95 APPENDIX 13 – Skye and Lochalsh population within estimated drive times to selected sites

The following maps and tables update work initially undertaken in November 2013 to assess the population living within drive times of current hospital locations on Skye in Skye, Lochalsh and South West Ross. This report focuses exclusively on the population of Skye and Lochalsh and excludes any potential catchment population living in the South West Ross area.

 Table 1: Community Health Index Practice list population of Skye and Lochalsh (excluding South West Ross) within 30 and 60 minute drive time of existing Community Hospital locations in Portree and Broadford and a central location on Skye

30 minutes 60 minutes Portree Hospital 5,492 11,261 MacKinnon (Broadford) Hospital 4,381 11,448

Central point 5,897 12,581 Data source: Community Health Index Population 2014 (April)

 Table 2: Percentage of the Community Health Index Practice list population of Skye and Lochalsh (excluding South West Ross) within 30 and 60 minute drive time of existing Community Hospital locations in Portree and Broadford and a central location on Skye

30 minutes 60 minutes Portree Hospital 41.9 86.0 MacKinnon (Broadford) Hospital 33.4 87.4

Central point 45.0 96.1 Data source: Community Health Index Population 2014 (April)

 Table 3: Number and percentage of the Community Health Index population of Skye and Lochalsh (excluding South West Ross) who live beyond 60 minutes drive time of existing Community Hospital locations in Portree and Broadford and a central location on Skye.

Portee MacKinnon (Broadford) Central Point Number 1,837 1,650 517 Percentage 14.0 12.6 3.9 Data source: Community Health Index Population 2014 (April) 96 APPENDIX 13 (cont’d) Map 1: Portree Hospital

97 APPENDIX 13 (Cont’d) Map 2: MacKinnon (Broadford) Hospital

98 APPENDIX 13 (Cont’d) Map 3: Central Location

99 APPENDIX 14 – Further work identified to understand future bed numbers and District Profiles

The Health Intelligence team of the Directorate of Public Health and the NHS Highland Service Planning team have been commissioned 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 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 January

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 Epidemiology and Health Science Team, Directorate of Public Health 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

100 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 on the internet:

Adults: Adult_Profiles (internet)

CAYP: CAYP_Profiles (internet)

101 Making decisions

The Board of NHS Highland will consider the recommendation at their meeting to be held in Inverness on 2nd December 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 about this report

Gill McVicar Maimie Thompson Director of Operations Head of public relations and Engagement

Tel: 01349 869221 Tel 01463 704722 [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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