Caithness Press Responses Sept 15 2015 – 19 February 2016

Caithness press responses Sept 15 2015 – 19 February 2016

Responses in red

Sept 1 John O’ Groat Journal - Been hearing that the lab manager at Caithness General has resigned and leaves in a couple of weeks and another senior member of staff is also going, leaving only one senior member in post. Is that right? We have received two resignations. However, we have been working with colleagues across Highland for some time on sustaining Laboratory services in Rural General Hospitals and are confident that we will be able to maintain safe services. Two candidates have just been appointed to the vacancies and locum staff will be used to support the service while the new appointees are in training, while managerial and professional support will continue to be provided within the framework of the Area Laboratory Service.

What impact will that have on services such as A & E? Been told it could put that department under strain. Also that the hospital may not be able to provide patients who need lifesaving emergency treatments - clot busters for heart attack and stroke victims. Comment? As above, the measures taken are designed to protect diagnostic and transfusion work both in hours and out of hours. There should be no effect on the type of lifesaving emergency treatments mentioned.

See that NHS Highland has advertised for consultant general physician and emergency practitioner. Any response so far? There have been some enquiries but so far there have been no firm applications.

Are you also trying to recruit for consultant surgical posts or is the emphasis more on day- care procedures. We are working with Raigmore with the aim of maintaining and indeed expanding local surgical services. Over the years in all hospitals there has been a marked increase in the number of procedures done as day case, indeed, that has been a stated objective, Caithness General is no exception. We have been successful in appointing a new surgeon who will be part of a rotational service aimed at strengthening the role of CGH.

Finally, a GP has told me there is a crisis in GP service in Caithness with many practices not up to complement and have vacancies. That could have a knock-on effect on A&E, out- patients and emergency admissions. Reaction? We do have vacancies in General Practice. This is a national issue and NHS Highland has been exploring methods of strengthening primary care services for some time. In other areas we are developing a more team based approach and will support local Practices in whatever way they need. We have a meeting set up this week with Practices and this will be followed up over the next few weeks and months. Clearly if general practice is under pressure there is potential for a knock on effect elsewhere in the system, however, we closely monitor all aspects of care to ensure that patients see the most appropriate person at the right time. We will continue to work with all parts of the patient journey to sustain services. We have certainly seen an increase in people attending Emergency Departments instead of primary care services such as general practice, community nursing and pharmacists and would direct people to the publication ‘Know who to turn to’ to help them in this regard - http://www.knowwhototurnto.org/.

16 Sept Press & Journal – We have seen something on the Public Contracts Scotland website about NHS Highland seeking to procure a contract relating to the supply of heat and

1 hot water to Caithness General Hospital and the Old Medical Centre in Wick. Can we have a comment? Response: This contract would represent a great deal, financially, environmentally and socially. The existing, ageing boiler plant at Caithness General Hospital burns expensive heavy fuel oil, which produced the most pollution of all fossil fuels. NHS Highland is committed to meeting emissions reduction targets, and our Strategic Carbon Management Plan has enabled us to take a leading role nationally. This new arrangement heat supply arrangement with Ignis Wick Ltd would allow us to continue our progress towards achieving our 80 per cent renewable heat target by 2017. Joining the Wick District heating scheme would have the added advantage of being less capital intensive, freeing capital for other projects. Biomass is essentially emissions free and reducing emissions will also yield a significant public health benefit. The scheme produces affordable heating in an area of recognised deprivation, and NHS Highland signing up to it would help to secure a long-term future for the scheme, ensuring local residents continue to benefit from affordable energy. The journalist was also sent a link to the Standard Business Case for the Caithness General Hospital biomass project, approved by the board in 2012.

1 Oct STV, BBC – can they speak to someone about the investigation into the death of a newborn in Caithness? Response – Dr Rod Harvey, Medical Director, did both interviews

P&J, STV, Scotsman, BBC – regarding the release on the baby in Caithness – when did this happen, was it a boy or a girl, what are the circumstances surrounding the death? Response: This happened a few weeks ago. The full results of the post mortem are not yet available but preliminary results would strongly point to a severe infection. We will not be releasing further detail on the baby.

John O’Groat Journal At present, will it only be elective Caesarean section births which will be carried out at CG? No there will be elective caesareans plus births consistent with midwife led unit How long will the probe last? It is not possible to put a time-scale on it but it will progress as quickly as possible When did the death occur? A few weeks ago Was the baby a boy or a girl? We will not be releasing that information

6 Oct P&J - Hoping you could help on a quote for a story I’m writing on GP shortages in the north and north-east. The piece is nosed on people having to go to private as they either don’t have a family doctor, or feel they have to wait too long for an appointment. It would be great to have a quote from Highland GP (or most relevant person) on the following: Why has there been a surge in a lack of doctors? What effect is this having on those who pay taxes and NI? What is currently being done to help the situation? Response: The particular situation you have outlined isn’t one we recognise. However, we are of course fully aware of the difficult GP recruitment situation nationally and we are actively engaged in measures to ensure the continued provision of a high-quality and sustainable models of primary care delivery. We believe that NHS Highland is a sensitive barometer of what will happen around the rest of the country in the next few years, although the scale and pace of the disintegration of previously robust general practices across Scotland has taken even the primary care experts somewhat by surprise. It is a complex scene and multi-factorial in its genesis. Senior colleagues in NHS Highland are working with Scottish Government colleagues from the Primary Care Division on a regular basis regarding these issues.

NHS Highland has faced almost continuous GP recruitment challenges over the past 15 years. During this period, NHS Highland’s primary care team has built strong working relationships with all GP practices and is aware of the challenges they face. There are 100 GP practices scattered across the NHS Highland area, covering urban and rural communities. Of these, 18 are currently (as at July 2015) run by the health board. The other 82 are run by GPs under a General Medical Services (GMS) contract. Recruitment of staff, particularly but not exclusively GPs, has been a longstanding challenge across the rural and remote parts of Highland in particular. More recently, it has become a problem affecting more urban places as well. Practices in all settings are starting to find a whole range of innovative ways of replacing doctors who leave. Sometimes they do manage to source a replacement doctor, but often they seek other healthcare professionals to assist and to take on some aspects of work previously undertaken by the doctor. For example, nurses of all grades and skills, prescribing pharmacists and pharmacy technicians, healthcare assistants, Allied Healthcare Professionals and ambulance technicians and paramedics are all in the mix. Furthermore, a new breed of healthcare professionals known as physician associates is another idea gaining interest. These individuals ‘fit’ between senior nurses and doctors and can work on their own, but with support from a doctor which may be remotely. Each practice makes its own decisions on how to replace doctor vacancies. It is worth noting that very few GPs now work what would traditionally be thought of as ‘full-time’. Increasing numbers have portfolio careers working a set number of sessions as frontline GPs. The precise level of doctor activity in a practice cannot therefore in any way be equated against the number of doctors who work in the practice. Figures on vacancies on recruitment are all therefore fairly indicative based on local current knowledge of what is happening, but cannot be taken as an accurate guide to a complicated and changing landscape of general practice provision. Over the past 15 years we have taken every opportunity to coalesce and amalgamate practices together, particularly in the more rural settings. NHS Highland is currently involved is a major initiative to find different and innovative ways of sustaining health and care services in remote and rural communities. The three-year project was launched in 2013 with funding totalling £1.5 million from the Scottish Government as part of its 'Being Here' programme, and NHS Highland's brief was to devise and test innovative ways of recruiting and retaining healthcare professionals – and particularly GPs. Since its launch, NHS Highland has set up a specific website, http://nhshighland- rural.scot.nhs.uk/, detailing GP vacancies and featuring video testimonials by GPs from overseas who have settled in remote and rural practices. A locum GP page has been added to the website. NHS Highland is also working with other organisations to enhance the image of North Highland and Argyll and Bute as a place to live and work, and is looking at issues such as accommodation, transport and IT connectivity. It recognises that training and career development is important for healthcare professionals, and through Being Here NHS Highland is implementing a programme of accredited training, workshops and awareness-raising. NHS Highland is also working to develop some common principles about rural NHSScotland requirements in the future. NHS Highland is regularly represented at various training and career events and last week attended the annual conference of the Royal College of General Practitioners, giving doctors an insight into practising in remote and rural parts of Highland and Argyll and Bute. Last year NHS Highland mounted a bus and billboard GP recruitment advertising campaign in Leeds, and recently advertised for GPs and other healthcare professionals in the Netherlands. NHS Highland also makes use of the rural fellowship scheme managed by NHS Education for Scotland. This gives newly-qualified doctors the opportunity to practise in a remote and rural setting for a year, giving them a taste of life and work in such communities.

North of Scotland Newspapers – Doing a follow-up to this story about more Caithness mums-to-be having to go to Raigmore following the tragic death of a baby at the Wick hospital. Will this decision put added pressure on Raigmore, especially at a time of budget difficulties? Believe there was an overspend of £3.4 million between April and August although that figure could rise to £5 million by the end of the year. Can the hospital cope with the extra demands which will be placed on it? How long is the situation likely to last at Caithness General before it is resolved? Mary Scanlon has been expressing concern about the position at Raigmore. Any response to her concerns? Response: Our absolute priority remains the health and wellbeing of patients. As with so many situations, NHS Highland must constant adapt to meet changing circumstances and we are doing so with this situation. However, we anticipate that the numbers of mothers involved on a week-by-week basis will be relatively small and are confident that the additional demand on Raigmore will not be problematic. Of course, we will be monitoring the situation on an ongoing basis. We are hoping to resolve the situation as soon as possible but cannot put a timeframe on our expectations. As for the predicted overspend, NHS Highland’s board will today (Tuesday 6th October) be invited to confirm that it is content with the actions being taken to ensure that the break-even target is delivered at the end of the financial year.

8 Oct North of Scotland Newspapers – Have received a detailed e-mail from a hospital insider relating to the tragic death of this baby at Caithness General Hospital. In it the person claims NHS plans to downgrade the maternity services at Caithness General Hospital “under the guise of patient safety, in view of recent death of a newborn baby.” Part of a hidden political agenda. An announcement expected shortly. Comment. Any downgrade would be so drastic few women would be able to give birth in Caithness in future. Comment. The insider also maintains that staff at CGH should not be held responsible for what happened but the special baby care unit at Raigmore Hospital. Comment. The person also takes issue with the claim the death was “potentially avoidable” and says the outcome would have been the same if the mother had been at Raigmore Hospital. Comment. The insider further claims that no “strenuous efforts” are being made to recruit permanent consultants as part of a strategy to let CG “die a slow death.” Comment. The person describes as “shameful and sinister” any plan to downgrade CG maternity unit and says it has a better safety record than Raigmore. Comment. All people who run CG are out with Caithness except the locality manager. Even the midwifery lead is based in Golspie. Comment. Response: If a whistleblower went to a newspaper with allegations against NHS Highland which the paper found to be true, then it would clearly be in the public interest to publish them and we would have to face the consequences. I'm not sure how the public interest is served by an article based on untrue, unsubstantiated and spurious claims or comments, even if we refute them - which we do. As we have already said in our original statement on this tragic case the safety of mothers and babies is our priority and arrangements to minimise risk to them interim arrangements are in place pending the outcome of significant adverse event review.

20 Oct P&J - The OPAH inspection report for Caithness General has been published, does NHSH have a comment Response: NHS Highland has welcomed the Healthcare Improvement Scotland report published today following an unannounced inspection to Caithness General Hospital as part of its programme of inspections on the standard of care for older people in acute hospitals.

The inspections focus on the three national quality ambitions for NHSScotland, which ensure that the care provided to patients is person-centred, safe and effective. The inspections will ensure that older people are being treated with compassion, dignity and respect while they are in an acute hospital.

The inspections, which took place in August this year, found 11 areas of strength and 14 areas for improvement. The recent inspection noted areas where NHS Highland was performing well in relation to the care provided to older people in acute hospitals.

Pam Garbe, Associate Lead Nurse for Caithness General Hospital is pleased that wards were found to be calm, quiet and uncluttered and that interactions between staff and patients were seen to be positive and caring with a large majority of the patients interviewed and surveyed reporting positively about their experience.

She said: “Staff were seen to address patients by their preferred name and our patients were seen to have familiar personal items with them in hospital which can be of comfort. Our nurse call buzzers, which all patients had easy access to, were also seen to be answered promptly.

“The recent inspection found there was clear leadership and team working within the wards, that staff had a positive attitude and demonstrated team working and I’m extremely pleased that the majority of patients felt that our staff treated them and their belongings with consideration and respect.”

Comments from patients included ‘staff are all very helpful and approachable’; ‘I feel respected by staff’; ‘I’m very comfortable and well looked after’; and ‘all staff are very caring and attentive even though I can be difficult at times’.

Other areas of strength identified include the 4AT assessment tool to identify delirium was being consistently used and improvement work was being undertaken to improve outcomes for patients with delirium was embedded within nursing and medical documentation.

The Queen Elizabeth ward was noted for reviewing all risk assessments within 24 hours of admission to the ward ensuring that where patients have been transferred from other areas, assessments are up to date and accurate to inform care planning and effective risk management.

Also noted was the multidisciplinary daily safety huddle which communicates information on bed availability, safety and the staffing situation. This is embedded within the culture of the hospital and the reported benefits to patients are reduced waiting times and for some a reduced length of stay in hospital.

The inspectors also commended the hospital on its adherence to protected mealtimes which ensures non-essential interruptions and they also noted that this was well managed with an appointed mealtime coordinator.

Tracy Ligema, Deputy Director of Operations for North and West, said: “There were a number of positives highlighted during the inspection but we do recognise that there are areas which we can improve on. An action plan has been developed and work has already started on the points raised.”

These pieces of work include new documentation and guidance being introduced as part of an NHS Highland wide review of documentation which will ensure that a consistent approach is taken. A key part of this is Patient Centred Assessment and Care Planning which is being rolled out across all inpatient areas within NHS Highland.

Ms Ligema advised that admission assessment checklists are to be trialled to ensure that all required assessments are completed and these will be audited on a regular basis to ensure this improves.

She said: “Our guidance on do no attempt cardiopulmonary resuscitation (DNACPR) has been reissued and we will also be holding briefing sessions for all nursing and medical staff, this will be audited and reported to our Quality Improvement Group.

“We very much welcome these inspections as not only do they highlight areas where we are working well but they also show areas that can be improved on giving us the opportunity to immediately look at what we can do to enhance the service we provide.”

22 Oct NOSN – We’re looking to run a story highlighting the number of people who do not turn up for their GP appointments in Caithness. Would you be able to provide figures for the NHS Highland-run practices? Response: Data from Caithness practices re DNA’s

June July

Riverbank, Thurso 107 119 (19.83 hrs) The practice started sending letters out to patients in July and some improvement in August.

Riverview, Wick 177 165

Lybster 49 (June/ July)

Pearson, Wick 47 30 (nurse on holiday for 2 weeks)

Dunbeath 16 (June/ July)

Castletown/ Canisbay 90 68

Thurso & Halkirk 157 158

This is for all appointments (GP and Practice Nurse). Appointments times vary e.g. GPs are usually 10 or 15 min appointments, Nurse 20 minutes (sometimes longer). Some practices send out warning letters after a certain number of DNA’s and some will remove patients from their list if they are a persistent DNAer.

NOSN – Looking for an update on the current situation at Caithness General Hospital regarding maternity services. Earlier this month, measures were put in place to send more pregnant women to Raigmore rather than stay at CGH as a result of the death of a baby earlier this month. Has the situation changed? Can you confirm how many women have been sent to Raigmore since the measures were introduced? Response: The situation remains the same. Three women have been sent to Raigmore since the measures were introduced.

4 Nov STV - Has there been a conclusion to the investigation into Caithness Maternity following the death of the baby? How many more women have come to Raigmore to give birth since the interim measures were put in place? Response: The investigation is still to conclude, a Significant Adverse Event Review (SAER) is taking place later this month. Interim measures for the unit remain in place. Since they were put in place five women have come to Raigmore.

18 Nov BBC - Someone has phoned in saying that patients at Caithness and Belford requiring care at a larger hospital are being/will be transferred to hospitals in Glasgow. My understanding of the call is that it is patients who should have been going to Raigmore from Caithness and Belford, but instead are now being sent to Glasgow because of the norovirus. Response: Not true, we are still open for transfers as clinically appropriate

24 Nov Caithness Courier – A Highlands Conservative candidate for the Scottish Parliament has called on NHS Highland to sort out the problems with 24/7 surgical cover at Caithness General. Malcolm Mackay, the candidate for Skye, Lochaber and Badenoch said he would be surprised if the hospital keeps its A&E unit for the next five years without emergency cover. He is also calling for the Scottish Ambulance Service’s North division to take over out-of-hours cover and scrap NHS 24 which for “so many in the Highlands is a confusing waste of time. Being so rural, we need a one stop shop for urgent care here.” Mr Mackay claims the main challenge to NHS Highland is training and retention of staff. “I think scrapping enrolled nurses was a terrible mistake and failing to hold on to GPs is a tragedy. My plan for the NHS involves bringing back enrolled nurse training using New Zealand’s 18 month diploma in our local colleges, and to directly fund a GP returner’s scheme for those returning from abroad,” he said. Can I get a comment from NHS Highland about his claims? Response: Mr Mackay has not been in touch with us directly but we would be very happy to meet with him to discuss some of his ideas. The low volume of emergency work in Caithness General does not require 24-hour presence of a consultant surgeon in Wick, and it has already been demonstrated that the sickest patients can and should be transferred to Raigmore for on-going care. The current arrangements have been in place now for almost a year, are safe and working very well. On the other points raised about the NHS as far as enrolled nurses go, that is not a Highland issue specifically, and we have not had them for many years. What we can say is that NHS Highland has introduced a new role of health and care support workers who carry out a similar role with an educational framework to support them. These are more flexible roles to allow care to be provided in a wider range of care settings. We are also exploring the development of a care academy which would support new and existing roles. The issue of holding onto GPs and recruiting to new GPs is not a simple issue and again not specific to Highland. NHS Highland has been working hard to test new ways of recruiting doctors to the area, making roles more attractive and providing additional support but going into the future a much more multi-professional approach will be required. We have prepared a detailed briefing on the subject and would be happy to share that with Mr MacKay.

25 Nov North of Scotland News - Just a couple of points following on from our earlier correspondence. In your e-mail to me today you stated: “The low volume of emergency work in Caithness General does not require 24-hour presence of a consultant surgeon in Wick, and it has already been demonstrated that the sickest patients can and should be transferred to Raigmore for on-going care. The current arrangements have been in place now for almost a year, are safe and working very well.” Does this mean NHS Highland is ruling out the need for 24/7 surgical cover at CG? Thought that was still an option? If that is the case when was a decision reached. Who took it and when was it implemented? Again if that is the case will the rota system, involving Raigmore, continue to operate in the longer term? What would the implications be for patients? Would more people have to travel south out of hours? The Caithness-wide redesign exercise has been running for three years – five if you include the earlier one – and there is still no outcome. Is there a deadline for delivery on this or a timescale when the various options can be put out to consultation. I understand a similar exercise in the north Sutherland area only took a matter of months to come up with three options. Why is the Caithness one taking so long? Response: The situation is that we have still got a surgeon on call in Caithness General but they do not operate out of hours. This was based on strong clinical advice and was also supported through the options appraisal exercise carried out earlier in the year. There is a strong focus on strengthening emergency cover. This need was raised by the public and also clinicians. The priority is to ensure that we have people with the skills and competencies to assess, stabilise, treat and transfer if necessary. To support this we have

7 recruited to a Rural Practitioner post who will start in February. This is a practitioner with enhanced emergency skills. The Raigmore rotational surgical service was also discussed through the Options Appraisal process and NHS Highland has now been successful in recruiting a surgeon to enable this rotation to progress. They will take up post in January and the aim is to ensure that all surgical operations that can possibly be carried out in Caithness General are done so. In addition, because some more specialist surgeons will participate in the rota, some other planned procedures will also be able to be undertaken that could not take place before and so the range of local service provided will increase. In terms of the wider Caithness Redesign this is complex and ever evolving. One aspect is to embed new approaches to develop community services including working with communities themselves and voluntary sector, as well as NHS Highland directly delivered services. Many of the findings and improvements have already been implemented because they did not require significant investment or change. A lot of work has taken place within Caithness General to improve patient flow (reducing admissions and length of stay and this has progressed very well. Improvements include the development of an acute assessment unit, ambulatory care unit, and better bed spacing for health care environmental reasons. The next phase of work within the hospital will require capital investment and a bid has been submitted to progress this element of the redesign. Re-designing services across an entire district which includes several hospitals, community and primary care services and recruitments challenges is complex and time consuming. It’s also not a one-off exercise and it is constantly evolving. There will never be an end-point to redesigning services although there will of coursed be some conclusions to particular phases. Follow up - Just a couple of points for you to clarify, please. You mention there is a “surgeon on call in Caithness General but they do not operate out of hours.” Maybe I am missing something here but if they do not operate out of hours what is the point in having them on call? Is the surgeon on call based at Raigmore but covers CG? Response: The surgeon on-call is based in Caithness but they may seek advice from Raigmore or elsewhere. The consultant surgeon on call is able to make a clinical assessment of the patient and provide advice and management. This is the key to deciding on the management plan. Most scenarios do not require immediate surgery but instead requires attention to careful assessment, resuscitation and transfer to an appropriate unit that has adequate critical care support.

26 Nov Caithness Courier – What is the position with the Dunbar in Thurso and the Town and County in Wick with regard to the ongoing Caithness redesign exercise? Response: Not much more to report than in previous updates but, to clarify, the initial focus has been on the use of clinical space within Caithness General and Wick Town and County and how best to provide medical, clinical and social care across both facilities. This work is ongoing and includes a key consideration as to how best to address the situation that the majority of patients in Wick Town and County do not require to be in a hospital facility. Under the current phase of the review there have been no recommendations about Dunbar but it similarly, in terms of inpatient beds they are currently occupied with patients who would be better served in care home facilities.

27 Nov Caithness GPs (issued to Caithness Courier) – There have been challenges in recruiting to GPs in Caithness for a number of years. Locally the early warning came in December 2012 when NHS Highland had to take on the management of Riverbank in Thurso. This was a direct consequence of the Independent Practice not being able to recruit to GPs. It is unusual for a health board to run a GP practice as big as Riverbank (which has a patient list of 6000), but it reflected the challenging circumstances. Since then our recruitment difficulties have been increasingly reflected across the country. The underpinning reasons are complex and multi-factorial and NHS Highland has been looking into these for some time. Our conclusion, and indeed that of others, is that the future shape

8 of health and social care including primary care (eg GP practices) is that services across the country will have to change. Overtime it will see a move to more multi-professional working and closer collaboration across GP practices and overall services supported by fewer doctors. Specifically in Caithness other practices have started to experiencing challenges with and it’s in response to these circumstances that NHS Highland has been meeting with all the local practices to support joint working, sharing and learning. Dr Paul Davidson, clinical director for north and west said: “A first meeting was held on 3rd September when some of the common themes across Caithness were considered. These included looking at challenges in recruiting to GP and sourcing locums; benefits of using other practitioners to support GPs; wider awareness for the public as how and when to access services; and other possible new ways of working. It was as a positive session with a number of ideas explored and actions agreed. The meeting earlier this week was a follow up to continue to support joint working and update on actions. It was encouraging to hear some of the progress being made including appointments of nurse practitioners and practice nurses. Additional pharmacy resource will also shortly be in place working across practices. We heard positive feedback from some practices which have triage systems in place which is working well. There was also a feeling that some people are attending their GP practice or hospital because they are not aware of alternatives. While there is a national initiative to support this ‘Know Where to Turn to’ NHS Highland has agreed to produce a version for Caithness and distribute to all homes early in the New Year. It was also felt it would be helpful to raise the profile of different professionals such as advanced nurse practitioners, practice nurses, pharmacists and the benefits of triage systems and it’s hoped to promote a series of profiles. It was a really useful session and there continues to be a willingness to work together including how best to train nurse practitioner and to how best to provide locum cover across all practices instead of each practice having to find their own. There was recognition that all of the services need to be considered together, for instance there are knock on consequences for the hospital if patients cant access GP services. The group were also pleased to hear that a rural practitioner has been appointed to work in Caithness General and arrangements are in for surgeons to rotate from Raigmore to Caithness General.

30 Nov NOSN - Can you tell me when the last out-of-hours op was performed at Caithness General Hospital? Response: The last general surgical out of hours case was on Saturday 28th November and the last obstetric out of hours case was on 29th November. NOSN (follow-up) – I am confused. So two out-of-hours ops were carried out at the weekend in Caithness General Hospital. But on Thursday in response to questions from NoSN, you said “a surgeon is on-call at CG but does not carry out emergency ops in the evenings or weekends.” Maybe I am missing something here but that seems to be contradictory. Could you clarify please? Response: The situation is that we are working towards a situation where there will be no out-of-hours surgery at Caithness General. However, we are not quite at that stage yet and we are still carrying out the occasional out-of-hours emergency surgical procedure at the hospital. Some of these operations may well have started during the in-hours period and carried over into the out-of-hours period. The last general surgery carried out out-of-hours (on Saturday) was a relatively minor procedure. Until we get to the stage when general out- of-hours surgery is no longer carried out at Caithness General, some minor surgical procedures will be undertaken there if it has been determined that they can be carried out safely.

1 Dec Caithness Courier – Just off the phone to David Flear. Wanted a comment from him about what is happening at Caithness General. He fears what is happening there is “death by a thousand cuts” and is concerned about the long-term future of the hospital. He says it could become little more than a cottage hospital and has challenged NHS Highland to say what its vision for the future of CG is and also what is the future of the Dunbar and Town and

County. Cut away this, trim that, make changes and the public have to accept it Downgrading by the back door, he said. Response: There is absolutely no question of Caithness General Hospital being subjected to ‘death by a thousand cuts’. Clearly, we have had well-documented challenges in relation to the recruitment and retention of staff at Caithness, but these are issues we are addressing with a view to ensuring that the services we provide there are safe, sustainable and best meet the needs of the population. We see Caithness General as an important asset, not only to the Caithness community but to NHS Highland as a whole. Far from cutting services there, we are working towards the situation where more planned surgery, rather than less, will take place in Caithness General. Furthermore, we are continuing to work on an ongoing Caithness redesign exercise which is looking at making best use of clinical space in Caithness General. And significant work on that process has already started, with progress having been made on the hospital’s acute admission unit and with provision for ambulatory care. The Caithness redesign work will provide strategic direction for all services and his may include some further key changes to the hospital. Caithness General Hospital is a very important facility, and we are determined to ensure that it continues to develop in the years to come.

3 Dec Caithness Courier – Has there been a change in the situation regarding maternity services at Caithness General Hospital? Response: There has been no change to the situation.

8 Dec NOSN – I want to clarify the situation with pregnant women in Caithness who are deemed at risk giving birth having to relocate to Inverness. Do they have to pay for their own accommodation to stay in hotels or other accommodation if NHS Highland is asking them to move to Inverness in the final few weeks of pregnancy? Response: These patients are accommodated in Kyle Court on the Raigmore Campus. The cost of the stay is charged to the maternity unit, not the patient. In the unlikely event that Kyle Court is fully occupied, patients have to get their own accommodation and they are reimbursed at a rate of £35 per night. NOSN – (follow-up) Can you please tell me how many times in the last six months has Kyle Court has been over occupied? Response: No maternity patients from Caithness have been unable to secure patient accommodation in the last six months.

10 Dec NOSN – A woman from Freswick has started an online petition to highlight “the decreasing services and facilities” at Caithness General. She is particularly concerned about maternity but also the increasing number of patients who have to travel to Raigmore for appointments and treatment. Her petition received almost 1000 signatures in just three days.

She had “a traumatic experience” herself last December when she was taken into CG to have her third child. As she was under 37 weeks pregnant and there was a shortage of specialist cots available in Scotland she was initially told she would be transferred to Newcastle. That however, was later changed and she was taken to Dr Gray’s in Elgin where she gave birth to her daughter. She thinks CG should have the same facilities as Dr Gray’s and points out that she has had to go to Raigmore dozens of times so her daughter can see a paediatrician. The youngster had an infection and collapsed lungs when she was born.

She argues that if CG had the required facilities it would reduce the stress of mothers and cut back on the workload for staff at Raigmore. She has no issue with the nurses and doctors and described them as “a big support.”

If you could respond to the points she has raised and give me a quote from NHS Highland please. Response: NHS Highland is not aware of the petition and nobody has been in touch with us directly to discuss service provision in Caithness. We would of course be happy to discuss with anyone who has concerns

In common with many parts of Highland and indeed Scotland it is the case that services are changing. It would be more concerning if they were not. These changes are driven by many things not least healthcare standards, advances in medical assessments and procedures as well as staff capability and availability.

In Caithness General we are providing as much care as we can as safely as we can. This excludes the provision of on-site paediatrics service which we simply could not sustain due to low volume for skills maintenance. This is not a new arrangement.

P&J – Can we have the statement you sent to the Caithness Courier please? Response: The above statement was issued to the P&J. Follow-up - Could I just check what the current position is on maternity provision up there at the moment. Obviously there was the review launched after that death of a newborn back in September/October but there hasn’t been anything since. Is the situation just the same as it was, with the threshold lowered for women being brought down to Raigmore? Or this there something else has happened with the situation since? Response – There has been no change to the situation in relation to maternity services at Caithness General.

23 Dec STV – Can you tell me what the situation is with your maternity review? Has it been completed? Response: No, it hasn’t been, and with a number of external agencies involved we cannot give a definitive completion date.

Northern Times – Can you explain the scoring system in the options appraisal for the north course redesign? Response: System explained.

24 Dec North of Scotland Newspapers – Who made the decision to axe out-of-hours surgery at Caithness General Hospital and when was it made? Could I also check how the recruitment drive for consultants, emergency doctors and auxiliaries is going? Has the overspend in the budget affected these efforts? Response: There is currently still a surgeon on call out of hours at Caithness General Hospital but clinical advice is that surgery should be carried out in rare emergency situations only. In cases where major surgery is required, patients are transferred; that is not a new situation. We have successfully recruited a rotational surgeon and one emergency practitioner. Unfortunately, despite several attempts, we have not recruited to vacant physician or anaesthetic posts. The vacancies are being filled, at considerable cost, by locums. It would be much less costly to have substantive staff so, no, the budgetary position is not affecting our efforts adversely.

13 Jan 2016 North of Scotland News - Out-of-hours surgery at CG has been effectively stopped and, as I understand it, only happens on a rare occasion. Does that constitute a significant change to procedures at the hospital and if so, has the Scottish Government being notified? If a significant change takes place would there not be a period of public consultation? When was the decision made to stop out-of-hours surgery at Caithness General and when was it made?

Response: There remains a surgeon on-call at Caithness General but as previously reported, out of hours operating is limited according to available expertise but is focused on the principle of life and limb threatening conditions. Most of those conditions fall in to the category of patients that would routinely be transferred to Raigmore, or elsewhere, as appropriate. This is in keeping with other centres, based on clinical advice and consistent with standards of care provided across the UK. It has been implemented on grounds of clinical safety and the decision was taken at the end of 2014.

Gill McVicar director of operations for north and west added: “These changes have been explained at meetings with Councillors, Community Council meetings, District Partnership, and through wider engagement work culminating in options appraisal event which identified a preferred model which included enhanced emergency cover.

“We are working on implementing a surgical rotational model with Raigmore, which will develop the range of surgical operations and treatment that we will be able to offer in Caithness General Hospital. To support the new arrangements we have appointed a rotational surgical, a rotational physician post as well as an Emergency Practitioner. We have also appointed Clinical Development Fellows, who are doctors who have completed their training but have not yet specialised. In addition we are working with the Scottish Government on developing a Rural Acute Fellowship training programme.”

These are all interim arrangements, taken for operational and clinical safety reasons but no final decisions on the wider service configuration has been taken. Work is ongoing to determine what will be the most safe and sustainable model for the longer term. Some of that work has taken place with an options appraisal event in June last year but further work is required.

The Scottish Government is fully aware of staffing and service pressures at Caithness General. Should any recommendations from the Board constitute major service change that would require formal public consultation and ultimately would go to the Cabinet Secretary for a final decision.

18 Jan NOSN What role does the on-call surgeon have at Caithness General if very few ops are being performed there out of hours? Response: The on-call surgeon (or appropriate senior clinician) retains responsibility for the overall management of the surgical patients in the hospital. They may be required to assess new patients and provide post-operative surgical care and treatment. If required they may also have to stabilise patients, as part of an urgent care team, and take any decisions on the need to transfer a patient. As clinically necessary they are available on call to provide advice to other members of the clinical team. So, have out-of-hours ops at Wick effectively been stopped? The capability to carry out operations during the out-of-hours period exists but we would expect this only to happen on a small number of occasions. It is really important to set this in context; to do otherwise would is very misleading. Modern standards of post-operative care require that for major surgery an intensive care capability is essential. Caithness General does not have that capability and so for several years major surgery has been undertaken in Raigmore Hospital to ensure the best outcomes for patients. Furthermore, nationally, clinical advice has been clear that out-of-hours surgery should be avoided, again to ensure the best possible outcome for patients. Our decision at the end of 2014 clarified a trend in care provision that was already changing surgical care in Caithness General and indeed in surgical units across the country. The focus of activity for Caithness is the rapid, effective assessment, initial management and safe transfer of such patients to the specialist centre in Raigmore. Operational decisions on ground of clinical safety are taken by senior clinicians jointly with senior managers Any timescale for the implementation of the long-term model?

There is considerable work under way to both protect current care provision and move towards a new model for Caithness General. Currently, the traditional model of consultant cover remains in place, albeit via the use of locum or rotational surgical staff. The future model of care will be primarily an elective surgical service with out-of-hours cover provided by appropriate senior clinical staff able to provide the safe assessment, management and transfer role, with specialist support from Raigmore. This has been trialled and evaluated successfully. We continue to advertise and recruit rural practitioners to fulfil this role but this will take time. All avenues are being explored but we are not in a position to provide a time- table. It would be fair to say though that this could take a number of years to bring in any future model and as previously stated would be subject to wider consultation. Meanwhile patients should be reassured that it’s pretty much business as usual.

21 Jan John O’Groat Journal - Would it be possible for you to provide information on the number of women from Caithness who were recommended to give birth at Raigmore Hospital in Inverness rather than Caithness General Hospital in Wick during 2015? Also, can NHS Highland confirm the reasons why pregnant women in Caithness would be asked to give birth at Raigmore Hospital in Inverness rather than Caithness General Hospital and specifically reasons why during 2015? Response: In 2015, there were approximately 250 births to Caithness women; of these two thirds were born in the Maternity Unit in Caithness General with the remainder born in the Maternity Unit in Raigmore. The majority of the pregnant women giving birth at Raigmore fell into the high risk category. However, in October last year temporary arrangements were put in place. This followed the tragic death of an infant delivered at the Maternity Unit in Caithness General. Since the new arrangements were introduced women who previously would have been delivered locally, such as first-time mothers, elective caesarean sections and those requiring induction of labour, have been transferred to Raigmore Hospital. This has resulted in an additional 34 women who had to be transferred to Raigmore Hospital to give birth with three transferred by the Scottish Ambulance Service. Caithness General is classed as a consultant-led maternity unit with no neonatal intensive care unit facility. Care is delivered by midwives supported by three consultant obstetricians. While there are monitoring facilities for new born babies and anaesthetic support there are no paediatric facilities on site.

26 Jan Caithness Courier – Looking for a response from NHS Highland regarding a claim by a source who says health bosses are using the death of a baby at Caithness General last year as a “shameful disguise” in a bid to downgrade the maternity unit in Wick to a midwife- led rather than a consultant-led unit. The source also claims the interim period for transfers of pregnant women from Caithness to Raigmore has been extended until March, and says only emergency Caesarean operations are performed locally. Several women who have gone to Raigmore to give birth have been “totally dissatisfied” with the care they received there, and had post-delivery complications which had to be dealt with at Caithness General, according to the source. The source also claims that no effort is being made to recruit consultants at the unit, which is staffed by expensive agency locums. Could NHS Highland comment and such claims and respond to them? Response: Dr Rod Harvey, medical director for NHS Highland, said: "We take great exception to any suggestion that we are in any way using the tragedy of the death of a baby to 'downgrade' the maternity unit. "The situation is this: it is the absolute duty of the health board to ensure the safety of our clinical services. It is for that safety reason alone that a temporary restriction has been placed on deliveries undertaken at the Caithness maternity unit. "The initial review into the baby's death concluded that there were avoidable factors. The ability to care adequately for this baby was compromised by the facilities available for

13 neonatal paediatric care and surveillance at Caithness General Hospital. There, is therefore, a potential systemic problem that could affect the babies of other women delivering at the unit. Our focus is on the safety of women and babies and interim arrangements will necessarily remain in place until our investigations are complete. "The Significant Adverse Event Review is in the final stages of being signed off by all concerned and I hope we will be in a position to report on the outcome and any next steps in the very near future. "It is vitally important that anyone who is unhappy with their care, whether in Caithness General or Raigmore, gets in touch with us so that any issues can be fully investigated and, if necessary, acted upon. "With regard to medical staffing, it is absolutely not true that no attempts are being made to recruit. Considerable efforts have been invested in our attempts to recruit consultants, and recruitment efforts are ongoing. "Two out of the three obstetrician consultant posts at Caithness General posts are filled substantively. However, we do continue to experience difficulty in recruiting consultant staff to Caithness, but this is well reported in public and for reasons unconnected with this specific issue. "A change in focus allowing consultants to rotate between Raigmore and Caithness General has proved to be more successful and we have now recruited a surgeon and a physician who will, together with colleagues, support services in Wick reducing our reliance on locums. "We have also successfully recruited to a new post of rural practitioner - a doctor with enhanced skills in emergency care and resuscitation - and further posts are being advertised. On top of this we are supporting clinical fellowships to have more doctors’ work in Caithness General."

28 Jan Caithness Courier/John O’Groat Journal – “I have obtained a copy of the Significant Adverse Event Review into the death of a baby at Caithness General last year and am writing a piece for the Groat on Friday. Wondered if NHS Highland has any comment to make on the eight recommendations and, particularly, on seven and eight." Response: As clearly stated yesterday the Significant Adverse Event Review (SAER) is still in the final stages of being signed off by all participants and remains confidential. It has also still to be shared with the family and this breach in the agreed process will be deeply distressing for them at what is already an extremely difficult time. The formal process of ratification, acceptance or otherwise of the recommendations is not yet complete. There are very good reasons why this process exists as it allows external scrutiny and consideration of the recommendations prior to their acceptance and implementation. The further steps required may result in recommendations being accepted, rejected, added or amended. What we can confirm is that NHS Highland's medical director, Dr. Rod Harvey, has already taken steps to set up a wider review of the safety of neonatal care at the Caithness General Hospital. This was on the basis that it would be very unwise to base firm conclusions on the circumstances of a single case, and the expectation that this would be a recommendation of the current review. Dr. Harvey also commented: “Members of the review group, as with all SAERs, are subject to a confidentiality agreement and are asked not to share the contents of their discussions or any draft versions of their report outside the group until the report has been agreed and ratified. The reason for this is to ensure that members can have the confidence to contribute to the discussions fully and openly in a non-judgemental fashion in support of our overall aim of maximising the opportunity for learning from the event to improve the safety and quality of future care. It is, therefore, extremely disappointing that in this case someone has chosen to breach this mutual agreement. This has not only fundamentally compromised the process in this case, but could also have serious implications for the effectiveness of any future investigations through undermining the confidence of our staff in the process.” Otherwise, we will not be commenting further until the process of finalising and considering the report internally has been completed.

29 Jan Press & Journal – This inquiry relates to today’s story in the John O’Groat Journal. Firstly, I know it’s unlikely but is there any way of you sending us a copy of the report referred to? Secondly, can you verify that what’s in the story about this report is all factually correct? Response: You asked two questions, and the answer to the first is no and the second is no, we cannot. However, we would like to offer you the following statement. Dr Rod Harvey, NHS Highland’s medical director, commented: “Members of the review group, as with all Significant Adverse Event Reviews (SAERs), are subject to a confidentiality agreement and are asked not to share the contents of their discussions or any draft versions of their report outside the group until the report has been agreed and ratified. It is, therefore, extremely disappointing that in this case someone has chosen to breach this mutual agreement. This has not only fundamentally compromised the process in this case but is also deeply distressing for the family. We will not be commenting further until the process of finalising and considering the report internally has been completed. The public should be reassured that it is our absolute intention to make a statement in public when we are in a position to do so.” Follow-up – Is there is a scheduled date for when the final report is due out, and can it be sent to us? Response: No, there is no scheduled date. It has always been our intention to issue a media release and to put the final report on our website.

2 Feb John O’Groat Journal - I am contacting you regarding the massive social media response in Caithness to NHS Highland Chief Executive Elaine Mead cancelling her meeting to discuss the future of maternity services at Caithness General Hospital due to bad weather on Monday night. Her decision has created a stir in the county with many councillors finding it ‘ironic’ that NHS Highland are asking pregnant women to travel over 100 miles to Raigmore Hospital to give birth due to the temporary position at Caithness General Hospital at present. Councillor Gail Ross’ Facebook page is only one of a number of people who have criticised Mrs Mead’s decision not to travel due to bad weather. Wick Community Council, Sinclair Bay Community Council along with Wick councillor Bill Fernie and Landward Caithness councillor Willie Mackay have also publicly criticised the decision due to pregnant women deemed at risk having to travel to Inverness to give birth at present. Can I get a comment from NHS Highland about the reaction from the public and if the reason why Mrs Mead chose to cancel her meeting was due to bad weather like councillors and community councillors informed us? Also would it be possible to get an update on the maternity services situation at Caithness General Hospital? Response: We are very surprised and extremely disappointed to see such remarks. The response we got from Wick Community Council when we called to say we would not be travelling due to the adverse weather caused by Storm Henry was: "That's fine and understandable". As we made clear last week we would not be commenting further on maternity services until we get the final report into the Significant Adverse Event Review.

P&J – Can we have a statement from NHS Highland following the backlash on social media regarding NHS Highland chief executive Elaine Mead cancelling her meeting in Caithness? Response: We are very surprised and extremely disappointed to see such remarks. The response we got from Wick Community Council when we called to say we would not be travelling due to the adverse weather caused by Storm Henry was: "That's fine and understandable". We apologise for any inconvenience or upset but stand by our decision not to travel on this occasion. We are in the process of rearranging the meeting.