Moray coast branch surgeries closure: independent report

Introduction and background

Hopeman and Burghead, along with Roseisle, Cummingston and Duffus, are small villages on the Moray coast, home to (according to latest figures provided by MIJB) 5448 people, of whom 3051 are registered with the Moray Coast Medical Practice. 2076 are registered with the Maryhill practice in Elgin. 321 are registered elsewhere (figures for HSCM). The part-time branch surgeries (2 clinical rooms each) have served these villages for around 30 years.

Moray Coast Medical Practice has a main practice base in Lossiemouth in a purpose-built health centre. This is between 10-15 minutes by car from the branch surgeries though, up to three hours return journey on a public bus route (via Elgin). (This is not an exhaustive list of the numerous travel options, but represents a minimum and maximum).

In common with a number of branch surgeries across Scotland, the Hopeman and Burghead branches closed at the start of the Covid-19 pandemic, due to factors including service prioritisation, infection control measures and staffing pressures. These branch surgeries never re-opened.

Moray Coast Medical Practice did not have a written contractual requirement to provide services from Hopeman and Burghead. It is understood that there is an inconsistent picture nationally around how branch arrangements were incorporated into contracts at the point of award/commissioning.

From early 2021, the practice indicated to the IJB that they did not wish to return to the practice building. Discussions were held within Health and Social Care Moray and NHS Grampian’s Asset Management Group relating to the redevelopment of vacant dental space within the Lossiemouth Health Centre, linked to the disposal of the practice buildings in Hopeman and Burghead. Papers were presented which sought approval in principle to carry out the Lossiemouth refurbishment work to create 5 additional clinic rooms and a waiting room area. NHS Grampian’s Asset Management Group approved this in principle dependent on funding being identified, and a public consultation being undertaken along with the completion of relevant Equality Impact Assessments.

This was then discussed at a MIJB Development Session where it was agreed that a formal paper should be presented to the MIJB outlining the plan for the Engagement and Consultation Activity, along with a timeline.

This duly occurred, and this process is detailed below.

During this period, a group, Save Our Surgery (SOS), was formed, with aim of providing a counter voice to HSCM’s plan for the permanent closure of the branch surgeries. They have engaged both within and outwith organisational structures throughout this period. A paragraph from an email from a spokesperson serves to summarise their position more succinctly than I could: “...our main concern...[is]...access to (or the burden to access) basic primary health care to the whole of our population, and not limited to the most vulnerable house bound patients. The thinking behind this...is that easy access to primary health care will allow faster identification of health issues, strengthen proactive approach and prevent escalation which will require more complicated care including at secondary level.” (email SOS member to HSCM officer, 20/11/23).

A Community Engagement Steering Group was constituted, with at least half community membership, to progress the engagement related to the branch surgery closures. This has since become a locality planning group, The group utilises locality health and social care data to set health and social care priorities for the locality. Members of this group are also members of SOS, and remain opposed to the acceptance of HSCM of the branch closure without the development of acceptable alternate provision.

MIJB noted the closure of the branch surgeries at the meeting of 26^th January 2023 (amended minute approved at the IJB on 30^th March).

In September 2023 the practice formally informed the IJB that they had terminated the lease of one building (Burghead) and were not going to return to the other building (Hopeman). This was formally reported to the IJB on 28 September 2023.

Regulatory framework

Guidance relating to branch closures is minimal, and is covered in two short paragraphs in the Guidance Note on premises (PCA2004(M)22):

NHS Boards and GPs in Scotland are free to review branch surgery provision and either extend or rationalise provision of branch surgeries, but only after due consultation conducted in accordance with the relevant provisions of National Health Service Reform (Scotland) Act 2004.

Given the diverse circumstances which apply across Scotland it is for NHS Boards and the GP subcommittee of the Area Medical Committee to agree the criteria which should be employed in any such local review of branch surgery provision

The implication of this is that Boards have the power to make decisions relating to branch surgery provision, and that consultation is required, however the extent and purpose of this is not made clear, and engagement and consultation standards and best practice have changed significantly since the 2004 Act. Healthcare Improvement Scotland are accepted as the best advisors as to the best practice at any given time.

It is also worth noting the 2004 context for these regulations, and the link to the new GMS contract and broader changes and investment in Practices and practice premises (the 2004 contract also drove an uplift in practice incomes). Speaking simplistically, the regulations hold the implicit assumption that out-of-date branch surgeries would be rationalised as part of a wider estates strategy of investment in up-to-date health centre facilities, the trajectory being one of growth. The regulations were not designed at a time where sustainability concerns might be a primary driver for general practice.

Timeline of engagement and decision making

On 24^th September 2021, a letter was sent to all members, 16 years of age or older, of the Moray Coast Medical Practice patient population. The letter informed patients of the proposal to carry out the engagement activity and directing them towards further information as required. In total 8500 letters were delivered.

Following a MIJB development session, a paper was presented to the MIJB on 30 September 2021 recommending engagement and consultation on the branch surgeries. Moray Integration Joint Board Meeting Details 30 Sep 2021 In effect, this began the formal process towards a decision on the branch surgeries.

An engagement plan was developed with input from Health Care Improvement Scotland and the NHS Grampian Engagement Team.

Engagement occurred between October 2021 and April 2022. This was reported to the MIJB on 26^th May 2022. Moray Integration Joint Board Meeting Details 26 May 2022 This report noted the practice intention not to return to providing from the branch surgeries. Equality Impact Assessments were also completed, which detailed mitigations should the branch surgeries permanently close. This was a detailed report which showed consideration of a number of operational and strategic areas. It acknowledged that “respondents overwhelmingly stated they wished the branch surgery buildings to remain open,” however this was not the focus of this report.

It was agreed this IJB meeting to approve a formal consultation with patients of Moray Coast Medical Practice on the future model of health and social care provision, including permanent closure of the branch surgeries.

A consultation plan was developed with input from Health Care Improvement Scotland and the NHS Grampian Engagement Team.

An Engagement and Consultation Steering Group was convened to oversee the process (but not the outcomes). This group had terms of reference and contained a combination of community members and health and social care practitioners.

A report on the outcome of the consultation activity was presented to the MIJB on 26 January 2023. Moray Integration Joint Board Meeting Details 26 January 2023

This report made clear that the majority (75%) of those who responded to the questionnaire opposed the proposal and was transparent about the feedback relating to predicted negative impacts. It recognised a view from some respondents that the consultation was a “meaningless exercise”. The concerns were acknowledged. Updated EQIAs were also provided.

The recommendations from this report were revised and approved at the IJB of 30^th March. In particular, this changed an “approval” of the closure of the branch surgeries to a “noting” of the practice decision not to return to the sites. I understand that this revised set of recommendations was developed following community and stakeholder feedback. This was a key decision point, and I note that this revised and formally approved decision meant that no formal decision was taken by the IJB to “close” the practice sites, but accepted the status quo whereby the practice did not operate from those sites. This is nuanced, and (as per the discussion below) may have given cause to some ambiguity or differing understandings of the decision-making to which the engagement and consultation processes tended. I also note, however, that role of the IJB as an independent public body is, in consultation with stakeholders, to frame and agree decisions and document them appropriately and I am wholly satisfied that it has done so.

Progress reports were submitted to the MIJB on 29 June 2023 (Moray Integration Joint Board Meeting Details 29 June 2023) and 28 September 2023. Moray Integration Joint Board Meeting Details 28 September 2023. It was agreed that further updates would be incorporated into the Forres and Lossiemouth Locality Plan updates to the IJB on a six-monthly basis.

In September 2023 the practice formally informed the IJB that they had terminated the lease of one building (Burghead) and were not going to return to the other building (Hopeman). This was formally reported to the IJB on 28 September 2023.

Learning from Save our Surgery

I met a number of community members, informally part of the “Save our Surgeries” grouping on the morning of 15^th January 2024, in the Hopeman hall.

I was privileged to talk to a group extremely passionate about the provision of health and social care close to people’s homes; about ensuring the provision of care to the most vulnerable in communities; engaged in complex issues relating to remote and rural sustainability and the strategic direction of integrated health and social care; knowledgeable about the link between population outcomes and individual experience; respectful (if frustrated) about the constraints within which officials delivering public services operate.

The group demonstrated clearly to that they understood the reasons behind the closure, the developments in modern general practice, the importance of digital access and multi-disciplinary working in the current context. However, they also expressed reasonable challenge around a number of issues, including:

Frustration that the practice had made what appeared to be a business decision, which had not been challenged by the HSCM, rather the HSCP had “gone along” with the decision. This had led to a clear perception that the closure was a “done deal”.

Clear challenge around a number of the reasons and rationale offered through public meetings, formal papers and communications relating to: the sustainability of recruitment to the area (“we were told people don’t want to work here”) and undue fears around lone working; the state of the buildings and their suitability for present and future service provision; a perception that commitments made by the landlords of the Burghead building to meet the full costs of refurbishment had been ignored by HSCM.

The group expressed frustration that innovative ideas relating to the provision of a nurse-led service, such as a one-stop-shop or hub in the Burghead building, or a nursing outreach/mobile clinic had not been progressed by HSCM. The group recognised that GP services did not just mean General Practitioners, but that the wider team was just as important.

Differing views from HSCM around what the utilisation data, where available, showed in terms of need for the local branch surgeries – and, indeed, disagreement around whether the data provided were salient or the correct measures for outcomes/effectiveness.

Frustration around the available transport options, particularly on the use of volunteer services for transport, or the unfeasibility of the scheduled bus service (via Elgin to Lossiemouth).

The group expressed a strong challenge around the purpose of the consultation, and whether the reports to the IJB fully reflect the strength of opposition to the closure. In this sense, the group felt that the decision was a “done deal” from the start, and this feels to be an understandable view. The group expressed a desire that HSCM had been more explicit from the start that re-opening of the branch surgeries was not an option, and that a failure to do so had resulted in a loss of trust. I have since seen emails which referred to a “tissue of lies” in relation to the consultation by HSCM. Based on the evidence I have I cannot conclude this is a true statement, however it is reflective of a perception that is strongly felt around the extent to which the community and HSCM shared a starting point for their discussions. I will come back to this point below.

These are all real and valid challenges to a situation where opinion differs significantly around the outcome, and in a context where difficult decisions must be made by health and social care providers, but the impact of those decisions is felt most acutely by communities. It would be outwith my remit to provide a view on each of the points of difference. Dialogue and ongoing collaboration are the only feasible resolutions to this.

These challenges around the loss of local services are real and understandable. However, by far the most inspiring chapter of our discussion focussed on the potential for innovation and service improvement, rather than an acceptance of decline. The group queried whether options for community buyout or ownership of the building were feasible; whether the community could contract with their own practice; whether they could support and test the development of digital services within the coastal villages. As one community member put it memorably: “we are not going to be the only rural community this happens to, so why can’t we be the example of where things get better and not worse?”. I understand that the Glasgow School of Art had been commissioned to support work around innovation, but the community remain frustrated around progress in this area. A further concern relates to the current financial context and the impact of this on any potential developments. The group recognise opportunities for more financially effective solutions locally and remain keen to see these progress.

I came away from our discussion feeling this was the route which offered most in terms of how HSCM and the community support rural services in the future and would encourage all parties to progress this thread. Indeed, I came away with a strong feeling that the Moray Coast Communities, working alongside HSCM, have the potential to provide a model for the rest of the country tackling this real issue of rural service sustainability.

Learning from HSCM

I met with stakeholders from Health and Social Care Moray in Forres Health Centre in the afternoon of 15th January 2024.

I heard from a committed group of professionals tackling a set of challenging issues with thoughtfulness and an awareness of the impact on patients and their families. In particular, our discussion engaged with issues relating to premises and poor quality of the general practice estate; multi-disciplinary teamworking and its role in modern general practice. I felt that the team approached engagement with the community with integrity and a genuine desire to reach better solutions through dialogue. I did not sense an unwillingness to listen or a lack of openness to the possibility of different emergent views.

HSCM referred to the contribution of members of the community, including those I met in the morning, and to their thoughtful and committed engagement on issues which matter to HSCM and to the community. I came away with a clear sense that my admiration for the individuals I met in the morning was shared by HSCM employees.

HSCM reflected that discussion with the community continued through the Locality Planning Group, and that a broad range of information such as outcomes data was interrogated. They reflected that these discussions were often challenging, but that this reflected the commitment and insight of community members and that this was a positive thing.

By far the biggest proportion of our discussion, however, focussed on general practice sustainability.

I heard that Health and Social Care Moray saw the sustainability of independent general practice as a primary concern, and took at face value the position of the Moray Coast Practice that a return to delivery from Hopeman and Burghead would jeopardise their ability to continue to function as a partnership.

I have no reason to doubt this position, and there is significant evidence in the public domain relating to the increased number of contract terminations within General Practice, and the reduced quality, efficiency and person-centeredness linked to the failure of the independent practitioner model. HSCM’s commitment to this model seems entirely reasonable. Indeed, participants reflected that Lossiemouth practice had been escalated to Level 3 (full suspension of services) on the General Practice Escalation Framework on occasion. I note this was not explicit in the accompanying documentation. At our meeting the practice manager was eloquent on the challenges faced by the practice, particularly the worsened position on coming out of the Covid-19 pandemic. I heard also great commitment to general practice in trying times, to doing the best for the practice patients, despite difficult decisions, and utmost respect for the community members engaged in those difficult discussions.

However, it is also reasonable to question whether appropriate governance distinctions were made between the practice decision, as a contractor, not to re-open the branch surgeries and the IJB acceptance, as a commissioner, of this decision. There does not appear, at least within documented and governed meetings, to have been any meaningful challenge or decision points between these two parties. On one hand the commitment to seeing this problem as a shared and collaborative one is commendable and I understand the position has emerged through extensive discussion. On the other, it is easy to see how this could give rise to community members feeling the parties were, as one person put it, “in cahoots”. This particular situation is more complex in that the practice did not have a written contractual obligation to provide the branch surgeries, however the Board (as commissioner) could well have taken the view that an implied contractual obligation was in place given 30 years of historic provision and sought to ensure some checks and balances met the practice request for closure. This may well have resulted in the same joint consultation.

It is inevitable that different stakeholders hold different perspectives, especially as regards public service providers and the public they serve. However, in discussion with HSCM representatives it struck me clearly that their thinking and approach existed in a somewhat different place to community members. Implicit in their thinking was the great challenge facing general practice and the sustainability challenge across Health and Social Care more generally (this is covered in the Audit Scotland analysis of IJBs 2021/22: “IJBs have reached the point where significant transformation will be needed to ensure the long-term capacity, financial sustainability and quality of services individuals receive”). Participants acknowledged that it would have been impossible for the practice to re-open the branch surgeries, and also accepted the challenge that this was not explicit in their message to either the IJB or to communities. They also accepted the challenge that the loss of a local surgery was indeed a loss for that community, however this was mitigated with broader changes to the wider health and social care system. My feeling is that this lack of explicitness around the sustainability challenge may reasonably have driven the feeling of community stakeholders that the outcome was a “done deal”, despite HSCM’s genuine desire to work with communities to seek the best outcome. In a sense, both views are correct.

Having considered both the clear process, rigorous documentation (detailed above) and the rationale as described by HSCM representatives, and noting the best-practice approach of consultation with Healthcare Improvement Scotland, I find that a rigorous engagement and decision making process has been adhered to. Indeed, HSCM Moray have gone beyond the minimal requirements of the regulations. This is supported by clear and transparent decision making through MIJB.