WEST HEALTH SERVICES SOLUTIONS GROUP

FINAL REPORT

1 October 2004

CONTENTS

Introduction 3 Remit of the Group 3 Process 3 Information 3 Background 3 Changing Demographics 4 4 Recruitment and Retention 4 Co-operation 5 Co-operation of Nursing Staff and AHPs 6 Co-operation of Non-Clinical Staff 7 Co-operation in Unscheduled (Emergency) Care 7 Consultant Staffing Levels 8 Costings 9 Pilot 9 Conclusion 12 Appendix 1: Full Remit of the Group 13 Appendix 2: Membership of the Group 15 Appendix 3: Information Collected 17 Appendix 4: References 18 Appendix 5: Belford Hospital Admission and Transfer Audit 19 Appendix 6: Summary of Socio-Economic Study 20 Appendix 7: A Rural General Hospital 21 Appendix 8: Managed Clinical Networks 22

For further copies or information please contact: Gavin Brown Chris Meecham Head of Planning, Public Involvement Head of Media, Communications and and Communications Corporate Services Lomond & Argyll Division NHS Highland Hartfield Clinic Assynt House Latta Street Beechwood Park Dumbarton G82 2DS PH33 6BS 01389 604509 01463 704820 [email protected] [email protected]

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Introduction

1. The Solutions Group unanimously believes that the only way forward for the Belford and Lorn and Islands Hospitals is to develop new ways of working more collaboratively, using existing skills and developing new skills that will be of benefit to the whole population of the West Highlands. We believe that, in setting out our conclusions to this report, the Solutions Group has succeeded in fulfilling the most important part of its remit, which was “to sustain and improve the Health Service in the West Highlands” (the full remit of the Solutions Group is set out in full in Appendix 1).

Remit of the Group

2. Following the public reaction to the emerging conclusions of the West Highland Health Services Project, in December 2003, the Boards of NHS Argyll & Clyde and of NHS Highland agreed to set up a Solutions Group to take the work of the West Highland Health Services Project into a new phase. The two Boards consulted on the draft remit for the Solutions Group and revised it extensively in the light of comments received. The two Boards agreed the remit of the Solutions Group at their meetings in February 2004. The membership of the Group appears in Appendix 2.

Process

3. Appendix 2 also lists the meetings of the full Group and the various Working Groups. We should like to thank our colleagues in and the technical help that they obtained in introducing a new way of working for many of us. They created a secure web site that was used for posting information and, to some extent, for carrying on discussion.

Information

4. The previous discussions on service provision at the Belford and Lorn and Islands Hospitals had been restricted by the lack of relevant clinical data. The Solutions Group has gathered significant new data on current case transfers and level of medical expertise required to manage patients in the two hospitals. This information is now available to inform national discussion with patients and professionals on the design of services. This work is listed in Appendix 3.

Background

5. We were made aware that there are a great many pressures for change within the NHS at the present. These pressures are making NHS systems throughout and, indeed, throughout the UK look at ways of reshaping services in order to maintain the service in the face of these pressures. These pressures include the impact of the European Working Time Directive, a trend towards specialisation for consultants, potential recruitment difficulties and the impact of changes to the contractual terms and conditions for consultants, GPs and others.

3 6. These drivers for change can have an increased impact on health services in remote and rural areas because of the particular circumstances of geography and distance. This potential impact has been documented in a series of reports dating back over a number of years. We have listed relevant reports in Appendix 4.

7. We acknowledge that there is a risk in focusing on the pressures and being overwhelmed by their potential adverse impact. There is an equal risk in assuming that these pressures will somehow not affect us. We are aware that there are differences of view about the potential impact of these pressures on remote and rural areas and, in particular, on Argyll and Highland. We have no intention of entering into this debate in this report. We have taken the pragmatic view that those involved in and contributing to the work of the Solutions Group do at least accept that there is a problem for which a solution is required. We confirmed our agreement on the range of pressures at our first meeting on 23 April and we have affirmed our commitment to a joint solution.

8. We have not, however, let these pressures overwhelm us. We have been clear from the start that the most important parts of our remit have been “to ensure a clinically safe and sustainable health service for the communities served by the Belford and by Lorn and Islands Hospitals” and “to sustain and improve the Health Service in the West Highlands”. We believe that the present configuration of services has to change in order to achieve these objectives. Equally crucially, we have taken the opportunity to explore how change can be used as an opportunity to enhance services.

9. In considering the remit to "sustain and improve", some members of our Group based in Lochaber carried out an assessment of the potential effect of the downgrading of the service at the Belford Hospital to a consultant service from 9 to 5, Monday to Friday. The results of this work showed that the effect would be very significant not only for the Belford and its population but also on . A summary of this work appears in Appendices 5 and 6.

Changing Demographics

10. We asked Highland and Argyll & Bute Councils for a report on the census data that should provide information on the likely trend for the foreseeable future until 2017. The key messages were that the 16-24 age group would increase in the Lorn & Islands catchment area and would decline in Skye and Lochalsh but more significantly in Lochaber. All areas show an increase of between 25% and 30% in the older population.

Rural General Hospital

11. At our first meeting we chose to recognise the term, “Rural General Hospital” as descriptive of our aspirations for the Belford and Lorn and Islands Hospitals. We felt that the smaller consultant-led hospitals providing acute services were of necessity different from some of their bigger, more urban counterparts, generally known as District General Hospitals. We recognise that the term “Rural General Hospital” is new. It should imply a model of service capable of delivering 24/7 Acute General Medical and Surgical Services with suitable backup of support services, specialist and investigative facilities supported by junior medical staff who would continue to

4 receive postgraduate medical and surgical training as at present. For more detail on the model of service provided from a Rural General Hospital see Appendix 7.

12. The model of care required to deliver health care in remote and rural area requires strong links with the tertiary care centres and the specialists located there through Managed Clinical Networks. These Networks enable rural consultants to work with the consultants in a major tertiary hospital to deliver specialist services to the patients in a Rural General Hospital. Managed Clinical Networks are explained more fully in Appendix 8.

13. The Rural General Hospital should also encompass a strong commitment to continuing consultant-led outreach services to remote communities including island health care. There is an existing strong ethos of outreach service provided by Lorn & Islands Hospital to communities in Campbeltown, Tarbert, Lochgilphead, Dunoon and the islands of Islay, Mull and others. In parallel, there is a strong tradition of outreach services from the Belford Hospital to Skye and Lochalsh. These services are highly valued and form an important part of the service required of a Rural General Hospital.

Recruitment and Retention

14. We have heard of potential difficulties in recruitment and retention. We believe that the two hospitals should be working together to describe to potential recruits the attractions of two parts of the West Highland area, which we believe is rich in the benefits it offers in terms of lifestyle and leisure pursuits. We noted that a start has already been made by the creation of a West Highland web site, which, we heard, received 200 “hits” a day. Recruitment needs to target trained consultants or those approaching the end of their training. In addition to this, there need to be changes to training to guide medical students to a career path in all aspects of rural health care, including a Rural General Hospital. The Royal Colleges need to encourage and assist in the training of generalists to ensure a future for Rural General Hospitals.

Co-operation

15. Belford and Lorn and Islands Hospitals are two of the six hospitals identified in the 2002 report, Future Practice, as remote and rural. They are also the only two of these that are sufficiently close together to co-operate in a meaningful way. We suggest that this proximity be taken as an opportunity to provide a model whereby the health care for the population of the West Highlands might be enhanced.

16. We heard that this enhancement could take several forms. If the populations served by the two hospitals were viewed in their entirety, this would increase the catchment population significantly. This would make it easier for the two bodies of clinicians in each hospital to be viewed as a complementary team. This would allow the combined workforce to increase the range of medical and surgical specialisations provided. At present the number of consultants at each hospital separately is not sufficient to allow this. The consultants in both hospitals must remain generalists with further development of all-round skills for emergency care, the prime raison d’etre for these hospitals being found in these remote locations.

5 17. In particular this would require consultant workforce planning at the hospitals to be complementary, bearing in mind the existing expertise in each hospital and the needs of the population. By this, we mean that the needs of the West Highlands population, as a whole, would dictate the kind of person recruited to a vacancy at either hospital. The person recruited would be providing a service to the communities served by both hospitals. Consultants could be recruited in future to satisfy needs that are currently unmet locally. We ask the NHS Boards to recognise the potential advantage in this approach.

18. The pooled catchment population would give patient numbers, which are regarded as justifiable for the provision of many specialist services and this could enable the delivery of more services within the West Highlands. This combination of extending current services and offering new services could include for example:

laparoscopic services (keyhole surgery) in Lochaber could be made more available to Argyll residents; chest services, including bronchoscopy, could be made available locally to patients from the Belford catchment area; and comprehensive lung function testing (currently not available between Paisley and Inverness) which could be provided at both sites by a peripatetic technician and equipment.

Other specialty interests should be developed and made available across the West Highlands and should include dialysis, audiology, gastroenterology, diabetes and endocrinology, urology and other surgical specialties.

19. Thus, opportunity for co-operation will focus on scheduled care, and recruitment should be managed to enhance the range of skills both in each individual hospital, and to the West Highland community at large. For example, the recruitment of a general physician with a neurological interest could enhance services in both Fort William and Oban. In time, other specialties could be accessed, with stroke care, diabetes and neurology being medical priorities.

Co-operation of Nursing Staff and AHPs

20. This level of co-operation should extend beyond the service delivered by consultants. We are well aware that, increasingly, health care is provided by multi- disciplinary teams, of which consultant staff are only part. Nursing staff and Allied Health Professionals play important roles in the delivery of health care – and there is scope for enhancing these roles. We recommend that, across the entire range of health care professionals, staff at each hospital are asked to produce practical proposals for co-operative working and enhanced roles for nursing staff and Allied Health Professionals.

21. This should embrace, for example, the following.

Nursing Staff Allied Health Professionals e.g. Physiotherapists, Occupational Therapists, Speech and Language Therapists, Pharmacists

6 Radiographers Biomedical Scientists (Laboratory Staff)

Pressures such as, among others, restriction on working hours and difficulties of recruitment apply also to non-consultant staff within the NHS. This collaborative approach could help to address these issues as well.

Co-operation of Non-Clinical Staff

22. We do not think this co-operation should be confined to clinical staff. In order to achieve the combined workforce planning and complementary recruitment described in paragraphs 16 and 17, the hospitals will need to combine their efforts. We recommend this, in itself, as a constructive step. The Human Resources Departments of the two areas should be working together to attract recruits to the area as described in paragraph 14.

23. Similarly, this complementary workforce requires at the very least an element of joint management. It is essential that the recruitment efforts be combined. We further recommend that the opportunities for co-operation should be explored across the whole range of non-clinical services.

Management Administration Facilities Management (portering, catering etc)

Co-operation in Unscheduled (Emergency) Care

24. The recommendations above for increased co-operation provide opportunities to improve services in the West Highlands. We recognise, however, we cannot build an improved service without being assured of its sustainability. We cannot forget that one of the driving forces behind the work of the Solutions Group was a concern about the sustainability of services. This focussed, among other pressures, on the impact of the European Working Time Directive and the potential adverse effect on recruitment to demanding rotas. This linked to the issue that has consistently attracted the greatest concern among the public and the greatest attention in the media was the provision of “24/7” consultant services in both sites.

25. We were presented with a model for a shared rota covering the “hospital at night “ i.e. from 11.00 p.m. at night to 8.00 a.m. in the morning. This would see the two hospitals working together to provide emergency cross-cover. One night, a physician based at Fort William and a surgeon based at Oban would be on call for both Hospitals. This would alternate each night. An on-call anaesthetist would be available at both sites, 24 hours a day, as at present with the necessary staffing levels to achieve this. This might require additional staffing and training.

26. This model could provide emergency cover for the West Highland Hospitals in both main specialties of surgery and medicine. If there were a medical admission to the site where the surgeon was on call, the on-call consultant physician would provide advice from the other site and vice versa. In particular, the role of anaesthetists to lead the emergency team would become pivotal to the success of the rota. If

7 circumstances judged it necessary, the patient could be transferred to the other site or the on-call consultant could travel.

27. We heard from the Scottish Ambulance Service that their recommendation would be for a solution that ensured their resources, as far as possible, were kept within the existing catchment areas as opposed to the need to transport patients to centres at a distance. If additional transfers were necessary then this would impact and so the aim should be for the consultant to travel to the patient rather than vice versa.

Consultant Staffing Levels

28. The levels of cross-cover described would require an increase on the current staffing level. In considering the shared rota described in paragraphs 25 and 26, we were given an idea of the consultant staffing required to sustain this. The focus on consultant staffing levels was required because of the related focus, mentioned in paragraph 24, on the provision of “24/7” consultant services in both sites.

29. An idea of the impact on current staffing levels is shown in the following two tables. Table 1 shows the current staffing levels but it does not include any indication of the numbers or cost of locums when people are on leave or training. Table 2 shows the staffing levels required to reduce the dependence on locums and to deliver the level of co-operation on scheduled care through the collaborative approach outlined in paragraphs 18 and 19.

30. We have not described the staffing level required to achieve a cross-cover arrangement for the hospital at night. The pilot will enable us to establish this. In particular the role of anaesthetists will become pivotal to the success of the rota and the pilot will ascertain for this group in particular the increased consultant staffing levels.

Table 1: Present Consultant Staffing

General General Anaesthetist Radiologist Paediatrician Physician Surgeon Belford Hospital 2+ 4 3 Lorn & Islands 3+ 2+ 2.6+ 1 1 Hospital

+ Plus locums for leave, training, etc.

Table 2: Proposed Consultant Staffing Level for Rota Compliant Rural General Hospital Model

General General Anaesthetist Radiologist Paediatrician Physician Surgeon Belford Hospital 3 4 Ø 3x Lorn & Islands 4 3 3+(1) 1 1 Hospital

8 + Plus locums for leave, training, etc. x Includes 3 days per week for Skye Hospitals ØIncludes visiting service to Skye Hospitals (1) Likely to continue as existing 2.6 FTE plus locums.

Costings

31.The cost of the current medical staffing arrangements, across both centres is £4,099k; this is £246k more than the established budget of £3,853k. This additional resource is used to cover medical agency and locum costs in excess of budget.

The consultant staffing levels for the proposed rota compliant Rural General Hospital model would require an additional £328k; this is made up as follows:

£’000 Medical Staffing 396 Non pay 27 Secretaries 57 Locum costs (152) Additional resource 328

32. The critical issue here is that the current overspend is not funded within either the Lorn and Islands DGH or the Belford Hospital medical staffing budgets. This has significant implications for both NHS Boards in determining how the current budgetary overspend and the additional costs of the proposed compliant rota will be met.

33. For the purpose of the analysis supporting this proposal, the two centres have been treated as a single entity. However, it is worth noting that the distribution of the additional resource is uneven across the two centres, and that both Boards will need to agree their respective financial contributions.

34. Revised consultant contracts for some of the medical staff working in the two hospitals are still to be finalised. In this analysis, it is assumed that the additional resource required to fund the existing service under the new contractual arrangements is provided for within the respective NHS Boards' financial plans.

35. As Outlined in paragraph 30, the proposed pilot will determine the exact staffing levels and associated costs to achieve a cross-cover arrangement for the hospital at night

Pilot

36. The operation of a shared overnight rota could lead to a change in the pattern of patient travel. We noted that there would be no change to the requirement for patients to transfer to the main centres when their clinical condition required the skill available there. We acknowledged, however, that the development of more specialties locally could reduce the need for patients to travel from the West Highlands for treatment.

9 The implications of this both for patients and for the Scottish Ambulance Service need to be explored.

37. There were issues raised by some of our clinical members about the operation of a shared overnight rota, as well as recognition that it could solve the problems described in paragraph 5 e.g. compliance with the European Working Time Directive. We think it only right that in this report we should register those issues.

38. These issues, which might impact on clinical care, such as the supervision from a distance of the care of a patient or the changing roles of anaesthetists, would need to be discussed with bodies such as the Royal Colleges, the British Medical Association and the Medical Defence Unions.

39. We have reached a position where we feel we can recommend a Rural General Hospital model of care. In order to test whether this can include the shared hospital at night rota and address the issues raised by some of our clinical members, we need to test this rota. Therefore, we asked our clinical members to develop a proposal for a pilot over a period of six months with emphasis on safety. This pilot would enable the two NHS Boards to be satisfied that the rota was safe. In turn, we would not recommend a pilot unless we were satisfied that the pilot itself was safe and a group, including our clinical members, have produced a detailed proposal that satisfies us on this point.

40. The issues described in paragraph 34 and others, which have been identified within the group of clinicians asked to draw up a proposal for the pilot, would need to be monitored and addressed. Moreover there are certain steps that need to be taken in order to enable a pilot of the shared overnight rota to take place. We heard that these included.

Full familiarization of each hospital to be made well in advance of the pilot by all staff concerned, including pharmacy procedures and drug lists protocols etc. No consultant to be asked to cover more than one night a week on the rota (current rotas will be unaffected) No change to the day-time surgery rotas during the pilot A joint protocol in place in advance of the pilot to ensure that all staff (including nurses, junior doctors and A & E staff) are aware of the correct procedures to follow during the pilot. For the period of the pilot, no doctors or patients will in effect be asked to travel. In such cases where this would be necessary, there will be a second on- call doctor at the relevant hospital who will be called out to attend. Provision to be made in the event of full implementation following a successful pilot for a car driver to be made available for any doctor having to travel at night. A named consultant at each site to be responsible for collating the relevant data on a daily basis but that administrative support will be made available to ensure that the data can be processed for the project team to analyse.

41. We agreed that a project team would need to be established. This will have to meet regularly, possibly fortnightly to begin with, to ensure that data is being collated

10 and analysed correctly and consistently and that the team can consider any issues promptly. To this end we have identified the membership of a project team

42. We fully accept that any concerns raised by the openness of a shared overnight rota have to be resolved. The pilot will give an opportunity to work through concerns without compromising patient safety. Our clinical members have worked with their colleagues on a proposal that makes clear the pilot needs to incorporate the following.

Delivery of a satisfactory level of patient care Improved working relationships between the two hospitals Compliance with the European Working Time Directive and with the requirements of the new Consultant Contract and agenda for Change Acceptability by the Royal Colleges and other medical organisations

43. An essential element of the pilot is that its impact will have to be assessed by an independent evaluator. The report of this evaluator will be made available to both NHS Boards and will also be available to the public. The criteria for its success will be measured by the following.

Impact on transport (private as well as ambulance and doctor’s travel) Number of “second” on-call call-outs Impact on admission and transfers where decisions have been based in anticipation of the shared rota for that hospital at night Impact on other groups of staff Cost of implementation and other associated costs Impact on recruitment and retention Public acceptability

We think it worth repeating that, during the period of the pilot, no patient will be transferred who would not be transferred routinely to receive the specialist care in a main centre that his or her clinical condition requires.

Conclusion

44. Early in our deliberations, we unanimously agreed that we could not support a solution that did not sustain 24/7 acute services in medicine and surgery for the population of the West Highlands. The remoteness of the hospitals and the communities they serve, the poor public and private transport links to other centres, the need to avoid any reduction in the current range of clinical services, the provision of acute health care for the large tourist population and the increasing needs of our growing elderly population are all reasons why, at the least, the current level of services remains crucially important to the health economy and viability of the West Highlands.

45. We unanimously recommend a Rural General Hospital service for the West Highlands

46. We are in no doubt that a level of cooperation in day services for clinical and non-clinical staff should start as soon as the details are worked out between the respective staff involved. We have recommended certain areas to be explored in

11 paragraphs 18 and 19 and the consultant staffing levels in Table 2 are based on these. We recommend that steps are taken to have this in place by 1 April 2005.

47. We have also recommended a pilot be carried out over a period of six months to test the feasibility of the shared hospital at night rota that we describe in paragraph 25 and 26. We also recommend to the NHS Boards that they ask the Solutions Group to reconvene at the end of the pilot to hear a report on its operation including the independent evaluation.

48. We have outlined proposals to assist with recruitment and highlighted the role of Royal Colleges in encouraging and assisting the training of generalists to ensure a future for Rural General Hospitals.

49. Endorsement of the concept of a Rural General Hospital service by the respective Boards would represent a huge vote of confidence in the two hospitals and the staff concerned. The West Highland community would welcome such a positive statement of stability for the future that will provide sustainable and enhanced services for the West Highlands.

12 APPENDIX 1: REMIT OF THE WEST HIGHLAND HEALTH SOLUTIONS GROUP

The Boards of NHS Argyll & Clyde and of NHS Highland agreed in December 2003 to set up a Solutions Group to take the work of the West Highland Health Services Project into its next phase. This West Highland Solutions Group will report to the two NHS Boards.

The Boards remain aware that they have to produce proposals to ensure a clinically safe and sustainable health service for the communities served by the Belford and by Lorn and Islands Hospitals, in the light of the pressures that created the need for the West Highland Health Services Project in the first place. The objective of the Project was to sustain and improve the Health Service in the West Highlands. This must remain the objective of the Solutions Group.

The Solutions Group will produce for the NHS Boards a report detailing a vision together with detailed practical solutions for the future delivery of healthcare to the communities served by the Belford and by Lorn and Islands Hospitals.

In drawing up this vision the Solutions Group will:

Engage with patients, public and staff in order to reach a solution based on the clearly evidenced healthcare needs of the communities affected Draw from all the options considered by the West Highland Health Services Project; Take account of feedback from the patient and public involvement activity that has already taken place; Take account of any other sources or material that the Group thinks will assist in its task

In producing its report the Solutions Group will have regard to:

The balance of clinical risks in the solution it proposes The provision of acute surgical and medical services The provision of primary care services; The provision of services taking account of both hospital and primary care out of hours cover The impact on patients and on communities of any changes to the present arrangements for service The impact on any other parts of the NHS of any changes to the present arrangements for service delivery. Compliance with directives governing the work place and standards set by Royal Colleges, unless explicit exemptions have been gained; Sustainability in the medium term, in respect of availability of staff, planned new standards and other factors; Affordability within current resources, although the calculation of current resources will reflect factors such as any uplift for inflation, the cost of service developments and any other additional resources agreed for services in the areas. The Group will be transparent about the cost of the existing service as well as the cost of the proposed solution. The Solutions Group may want to identify an enhanced model for which

13 additional resources will need to be sought but it will need to arrive at a solution that is within the capability of the NHS Boards to implement. Consideration of the wider economic and social impact of the solution that it proposes. Consideration of the impact of the proposed solution on other care and service providers

Method of Working:

Solutions may be the same or different for the communities served by the Belford and by Lorn and Islands Hospitals. The solution for one should not be at the expense of the other, however, and agreement on the precise method of working of the Solutions Group will reflect this. Opportunities for enhancing the service available in each area by extending access to the services available in the other area should be encouraged. The Solutions Group will be chaired by a person or people independent from the two NHS Boards. The Solutions Group will operate in such a way that both the unique and the common aspects of the hospitals will be fully recognised. The Solutions Group will adopt, in both its working style and in its recommendations, the ethical decision making framework of NHS Highland.

12 February 2004

14 APPENDIX 2: MEMBERSHIP OF THE WEST HIGHLAND HEALTH STEERING GROUP

Baroness Michie of Gallanach (Chair) Mr Ken Abernethy, Chief Executive, Argyll & Bute Enterprise Dr Malcolm Alexander, Medical Director, NHS 24 Ms Fiona Ball, Highland Community Health, Lochaber Dr Michael Boyle, GP, Oban Mrs Mary Bruce, Highland Health Council Dr Jim Douglas, Lochaber Local Health Care Cooperative Dr Michael Foxley, GP, Fort William Dr Alison Graham, Medical Director, NHS Highland Operations Division Dr John Goodall, formerly Clinical Director, Belford Hospital Dr Allan Henderson, Consultant Physician and Lead Clinician, Lorn & Islands Hospital Dr Andrew Henderson, Consultant Physician, Lorn & Islands Hospital Mr John Hutchison, Lochaber Area Manager, Highland Council Dr Erik Jespersen, Clinical Director, Argyll & Bute Local Health Care Cooperative Mrs Tricia Jordan, Association of Lochaber Community Councils Mrs Veronica Kennedy, Nurse Manager, Lorn & Islands Hospital Dr Charles Leeson-Payne, Consultant Anaesthetist, Belford Hospital Dr John Lyon, Argyll & Bute LHCC Councillor Olwyn Macdonald, Highland Council Councillor Duncan Macintyre, Argyll & Bute Council Mrs Christine MacFarlane-Slack, Nurse Manager, Belford Hospital Mr Bill McKerrow, Consultant Surgeon, Raigmore Hospital, Area Clinical Forum, NHS Highland Mr Duncan Martin, Argyll & Clyde Health Council Mr Paul Martin, Deputy Chief Executive, NHS Highland Mrs Sandra Melville, Clinical Pharmacy Manager, Lorn & Islands Hospital Mrs Karen Murray, Director of Lomond & Argyll Division, NHS Argyll & Clyde Mrs Katy Murray, Association of Argyll & Bute Community Councils Mr David Sedgewick Consultant Surgeon, Belford Hospital Ms Mandy Sillars, Belford Hospital Mrs Joyce Thompson, Highland Health Council Ms Tina Webster, MLSO, Belford Hospital Ms Charlotte Wright, Chief Executive, Lochaber Enterprise Mr Gavin Brown, Head of Planning, Lomond & Argyll Division, NHS Argyll & Clyde, (Secretary)

The following also attended meetings at some time and contributed to the work of the Group and its Working Groups.

Dr Wagih Antonios, Consultant Anaesthetist, Belford Hospital Dr John Cormack, Associate Medical Director, NHS Highland Mr Douglas Hendry, Argyll & Bute Council Mr Paul Leak, Finance Department, NHS Highland Ms Gill McVicar, Manager, Mid Highland Community Health Partnership Councillor Brian Murphy, Highland Council

15 Dr Chris Robinson, GP, Fort William Mr Alex Taylor, Argyll & Bute Council

We were also greatly assisted in our work by the efforts of the two facilitators at our meetings - Mrs Lesley Benfield, Independent Facilitator, and Ms. Lynn Marsland, Head of Learning and Organisational Development, NHS Highland

Meetings of the Solutions Group

Between April and October, the Group met collectively and in various groups on a total of 12 occasions. The full Group met the following six times.

Friday 23 April Friday 21 May Friday 25 June Friday 20 August Friday 24 September Friday 1 October

In addition a Working Group to agree and collate data met on the following occasions

Friday 18 June Friday 9 July Friday 30 July

In addition, there were meetings primarily of clinicians on Thursday 12 August, Friday 3 September and Wednesday 15 September.

16 APPENDIX 3: INFORMATION COLLECTED

Activity figures for Belford and Lorn and Islands Hospitals

Analysis of overnight admissions to Belford and Lorn and Islands Hospitals in a 6 month period June 2003-April 2004

Belford Hospital Admission and Transfer Audit

Brief evaluation of “block working” arrangements by medical and surgical departments at General Hospital

Demographic Profiles in West Highlands

NHS Highland Cost Cube and Resources in Lochaber Care Programmes

Hospital at Night Activity Figures Theatres Imaging Services Pathology Services

Skills Audit

17 APPENDIX 4: REFERENCES

Acute Services Review (May 1998)

Commentary from the Viking Surgeons Working Group (November 2002)

Future Practice (July 2002)

Health Care Services in Remote and Island Areas Of Scotland (1995)

Keeping NHS Local (February 2003)

Modernisation Agency Report – Hospital at Night

Modernising Medical Careers

Securing Future Practice (June 2004)

White Paper: Partnership for Care (February 2003)

18 APPENDIX 5: BELFORD HOSPITAL ADMISSION AND TRANSFER AUDIT - JANUARY TO APRIL 2004

Summary – Key Points

A 12 week Audit was performed to quantify the need for patient transfer (both for emergencies and for the relocation of elective surgery), should the Belford have Consultant Cover available only from 9am-5pm.

Details of all Medical and Surgical Admissions to the Belford were recorded prospectively for a twelve-week period. This was not seen as a busy time of the year.

This audit can be validated by a team comprising the responsible local clinician and another consultant clinician in the same specialty (with knowledge of local facilities and ideally with practical rural experience) and a facilitator.

In the current Belford Hospital with 24/7 Consultant Cover:

In the 12 week Audit period 647 Patients were identified.

78 (12.1%) of these patients were transferred - one every 26 hours.

If Belford were downgraded to a “Consultant Day Hospital”: . 60% of emergency admissions are during OOH without consultant support.

A further 246 (38.0%) of patients will need transferred.

Total transfers are 324 (50.1%) of total - one every 6hrs 30 mins (a four fold increase)

42 Surgical Operations could not be performed in the Belford

On an Annual Basis:

There would be 1050+ more emergency admissions to Raigmore

And 180 more Elective operations in Raigmore

19 APPENDIX 6: SUMMARY OF SOCIO-ECONOMIC STUDY

The Potential Socio-Economic Effect on the Lochaber Community if Belford Hospital were no longer to have 24/7 consultant-led services

Interim Report

Economic Impact Belford currently contributes approximately £6.7million into the Lochaber local economy on an annual basis; Our ‘first-run’ estimates of the purely hospital related impact of the options are that moving towards a consultant day hospital is likely to reduce this contribution by the order of £1.2 per annum; Movement towards a CDH may induce some additional negative effects through ‘ image detraction’. Adopting a very conservative scenario – if investment in the local economy is affected by just one quarter of 1%, an additional £0.4m (making £1.6m per annum in total) will be extracted from the Lochaber economy.

Impact on Other Community Services Few referrals are currently made to the social work or home care services teams linked with emergency admissions to Belford Hospital and early social service indications are that a CDH would not make a significant difference to this pattern; A CDH is likely to have significant implications for ambulance and air ambulance services;

Impact on Individuals/Families Many in Lochaber are extremely concerned should a CDH ever be proposed, with a loss of 24/7 consultant cover and patient travel implications; A 12-week audit of activity suggests that a CDH hospital would result in over 1050 more emergency admissions and 180 more planned operations being transferred from Belford Hospital to Raigmore Hospital each year; Our current working estimates are that the current situation imposes (net) costs of some £80k per annum that is taken out of the local economy and spent elsewhere. This figures rises to £397m for a CDH and shows this proposal imposes significant financial costs on individuals and families. The above figures only refer to explicit financial costs. There are more subtle implicit costs that must be valued – namely the value of the time that would have been spent locally in some capacity but that is now spent either in transit to/from Raigmore/other hospitals or spent in the vicinity of such facilities. These need to be refined but are also indicated to be equivalent to up to 25% of direct financial costs.

This work will be concluded in October 2004 when the final evaluation will be available.

20 APPENDIX 7: A RURAL GENERAL HOSPITAL

The Rural General Hospital model of service will provide hospital care to its community, both scheduled and unscheduled. Consultant skills, medical, surgical and anaesthetic, will be wide to handle safely the spectrum of unscheduled (emergency) accident and illness arriving at the hospital. Capacity and skills must be adequate for most problems to be dealt entirely within the Rural General Hospital.

Skills must extend to first class resuscitation for those who are requiring transfer, especially with trauma. Rural General Hospital consultants cannot live on trauma and acute illness alone, however, and a range of scheduled services, outpatient and inpatient will be provided, giving local services to local people and maintaining consultant skills, in particular with a variety of more complex procedures (e.g. laparoscopy) possible, and some specialty services delivered locally though Managed Clinical Networks.

Hitherto our hospitals have attracted a rather special breed of consultant generalists, who have found their way to these posts through no planned route, and have usually provided life long service to their communities. Uncertainties of recruitment are now being actively addressed at a national level, with special training posts, attracting interest and offering a path to rural and remote consultant posts. With early recognition of potential enthusiastic young candidates for Rural General Hospital posts, and directed training schemes, it will be possible, in time, to recruit a variety of enhanced skills amongst the generalists in Rural General Hospitals, distributing them in such a way as to provide a variety of skills in a locality, without excessive duplication.

We believe that the work of the Solutions Group has provided an opportunity to state what should be the core services in Rural General Hospitals. Everything else should flow from that position e.g. training, managed clinical networks and patient care pathways.

It is well recognised that, over many years, emergencies have been safely managed in Rural General Hospitals, the most important of which include:

Medical Surgical Heart attacks Abdominal pain assessment Stroke Appendicitis Diabetic coma Bowel obstruction Heart Failure Pancreas inflammation Asthma Gall stones and kidney stones Chest infections Bowel bleeding Self poisoning Head injury assessment Epileptic fits Terminal cancer care Liver failure Deep skin abscess Acute gastric bleeds Acute trauma

We believe that, by defining the Rural General Hospital, there can now be a fresh national approach to combined workforce planning

21 APPENDIX 8: MANAGED CLINICAL NETWORKS

Informal networks of clinicians have by necessity existed between the smaller hospitals and tertiary referral centres before Managed Clinical Networks were emphasised in the Acute Services Review. These networks can determine the safety and sustainability of specialist care in the Rural General Hospital. Furthermore, they allow these services to be delivered to the patient closer to their homes. Managed Clinical Networks are becoming more formalised with executive committees mapping out patient pathways, applying the national standards for care and co-ordinating the collection of audit data. Consultants from Remote and Rural hospitals are now represented on these committees.

The successful working of these networks involves video-conferencing links for the multi-disciplinary team meetings to enable involved clinicians and specialist nurses to discuss the management of each case. Joint operating takes place between surgeons from the Rural General Hospital and tertiary centre in either hospital, depending on the complexity of the procedure or associated medical conditions of the patient. This has been happening regularly for five years between Raigmore and Belford consultants in Urology and Colorectal Surgery. Joint clinics have occurred in medical practice for conditions such as Diabetes. There are similar links between the Oban consultants and specialists based in paisley and the Glasgow hospitals.

Tele-radiology (the transfer of X-rays between hospitals electronically) enables a consultant general surgeon in a Rural General Hospital to manage orthopaedic injuries in conjunction with orthopaedic surgeons in the tertiary centre. Data is being collected centrally to monitor the quality of care and the results of treatment.

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