Sustainability and Seven Day Services Taskforce Interim Report

Remote and rural

In recognition of the particular challenges facing the delivery of sustainable services in remote and rural areas, we have established a Remote and Rural Group sub-group to consider this issue. The Group immediately recognised that a range of initiatives have been implemented over the past decade and that much good work continues to be undertaken. In order to avoid repetition, in the first instance a review of all the existing work was undertaken and compiled as a register.

The range of existing initiatives/projects include:

• Being Here - Scottish Government/NHS Highland programme of work to test new approaches to delivering healthcare in remote and rural areas of Scotland.
• The Supporting Remote and Rural Healthcare report that describes current NHS Education for Scotland (NES) initiatives to support the educational needs of the remote and rural healthcare workforce^[20].
• Being Rural Policy and Action Plan from the Royal College of General Practitioners^[21].
• The Strategy for Attracting and Retaining Trainees in Scotland (START) programme being jointly led by NES and the Dean of the West of Scotland focussing on attracting and retaining trainees, in which remote and rural issues feature strongly.
• Bespoke rural-track GP specialty training programme in the North region / NES GP rural fellowships.
• Health and social care transport pilots.

The last comprehensive review of remote and rural services Delivering for Remote and Rural Healthcare was published in 2008^[22]. This report made a number of recommendations. These have been reviewed in order to identify those that have been successfully implemented and those areas where challenges remain. The implemented recommendations from that report that have been highly successful include the development of the Specialist Transport and Retrieval (SCOTSTAR) retrieval service and the creation of community hospitals utilising extended skill practitioners. The development of educational facilities to meet the specific needs of the remote and rural workforce has also been a notable success.

Emergency Medical Retrieval Service

A robust, rapid and effective retrieval service is an important component of any strategic plan for the delivery of sustainable remote and rural services. For the Islands and areas of rural Scotland this needs to be by air. The Scottish Government has already invested in the Scottish Ambulance Service's Air Ambulance Service, which undertakes around 3,500 missions each year. In April 2014, ScotSTAR was launched as a national service for the safe and effective transport and retrieval of Neonates, Children and Adults in Scotland. ScotSTAR has brought together three existing services (Scottish Neonatal Transport Service, Emergency Medical Retrieval Service, and Transport of Critically Ill and Injured Children) under one umbrella. This provides a vital road and air service for critically ill patients across Scotland, taking skilled clinicians directly to the patient thereby ensuring the best possible pre-hospital care.

A central base for this service is currently being constructed at Glasgow Airport and will open in summer 2015. From spring 2015 all retrievals will be centrally coordinated by a Specialist Services Desk. Draft quality standards and indicators have been developed and the outcomes for patients will be audited.

Rural General Hospitals

The Group identified that a key remaining area of challenge was the recruitment and retention of staff to work in Scotland's six Rural General Hospitals (RGHs)^[23]. The NHS is not unique in this, living and working in a rural area doesn't appeal to everyone and remote and rural recruitment challenges exist at all levels and in many industries in rural areas.

For medical staff, the Taskforce have agreed to explore the establishment of formal links between individual RGHs and urban Hospitals. This will build on the current obligate networks that have successfully provided visiting specialists to RGHs for the provision of elective care. This could provide a number of benefits - patients in rural areas would have access to clinicians with skills maintained in hospitals with a high volume of cases, there could be greater opportunities for collaborative working between visiting and local staff, it could support the out of hours and emergency rota in the RGH, reduce reliance on locums and increase the number of patients treated close to home.

Several models as to how this would work in practice are being discussed. The simplest of these models has been progressed for the RGH in Fort William whereby a link for continuing professional education / development has been developed between NHS Lothian and the surgeons in Fort William. As a result two experienced surgeons have recently been recruited to positions that in the recent past attracted no suitable applicants. Surgical services in Fort William are now sustainable with three full time surgeons in position. We intend to coordinate further work with key stakeholders to consider innovative solutions to sustain the RGHs and this and other models are being explored with other NHS Boards with a view to developing further pilots. While this initial work has focussed on medical staff, this provides a model that could be used for other staff such as nurses and AHPs.

The Group have also been reviewing examples of excellent and innovative practice from rural services that may be suitable for wider implementation. A particularly interesting example is the provision of the GP out of hours Accident and Emergency /acute admissions service in Stornoway. In this model^[24] GPs staff the Emergency Department overnight, supported by extended role nurses both in the hospital and in the community. This includes managing acutely ill children and neonates as well as adults. In addition to providing stainable service it is of note that in the pilot period from May 2012 to May 2013, overnight hospital admissions fell by 17% when this model was introduced. There were also marked reductions in the requests for laboratory tests (10%) and radiological examinations. A key component of the success of this model is in utilising the skills of the GPs in making judgements based on clinical examination combined with investment in developing the skills of paramedics, community nurse practitioners, emergency nurse practitioners and clinical support nurses.