A Synopsis of the Remote and Rural Steering Group Report by xiaohuicaicai


									A Synopsis of the Remote
and Rural Steering Group

                  Andrew Sim
                 February 2008
The Remote and Rural Steering Group‟s report was submitted to the Cabinet Secretary for Health
and Wellbeing on 30th November 2007. It has been referred to in a specific section (Appendix) of
the Better Health Better Care Action plan (December 2007) and an implementation plan is
expected early in 2008. The early signals are that the recommendations will meet with approval.


In less than ten years remote and rural healthcare has progressed from being a rather romantic and
eccentric part of the Scottish health service, which had received scant attention since the Dewar
report on the Highland Islands Medical Service in 1912, to a recognised and important national

The present process of serious and concerted consideration of healthcare in Scottish remote and
rural areas started with Professor Sir David Carter‟s Acute Services Review (1998); in this the
problems of healthcare in remote communities were explored and a recommendation made that
both a task force to consider the needs of remote communities and a resource centre should be set
up. Partly as a consequence of this the Scottish Executive Health Department invested £8 million
in the Remote and Rural Area Resource Initiative (RARARI), a three year project (2000 – 2003)
which gave workers in remote and rural areas the opportunity to explore aspects of healthcare
delivery. In the first of two reports on the Scottish Medical Workforce, Future Practice (July
2002), Professor Sir John Temple highlighted recruitment and retention difficulties and
recommended the establishment of remote and rural strategies for staff development, linked with
regional planning provisions. His second report Securing Future Practice (June 2004) painted a
much bleaker picture of the future for remote and rural care and indicates the service will become
unsustainable unless significant redesign occurs. The Board of Science of the BMA (chaired by
Professor Sir David Carter) published Healthcare in a Rural Setting (January 2005) setting out a
series of recommendations for future consideration. This publication remains an important
statement on rural healthcare delivery and its problems.

With this background Professor David Kerr embarked on developing a National Framework for
Service Change in the NHS in Scotland; the sub group on Remote and Rural Access fed
information into this consultation. The report from this consultation, Building a Health Service
for the Future (May 2005) (“the Kerr Report”), contained a clear recommendation to ensure that
remote and rural healthcare was firmly on Scotland‟s agenda for healthcare development. Later in
2005 the Scottish Executive responded with Delivering for Health in which they clearly state:
“We will respond by developing a framework of care specifically for remote and rural
communities”. This led onto the formation of the Remote and Rural Steering Group chaired by
Dr Roger Gibbins and managed by Dr Annie Ingram, it held its first meeting in December 2005.

The Remote and Rural Steering Group
This parent group had four subgroups covering:

       The Primary Care Framework
       Rural General Hospitals
       Rural Education Strategy
       Emergency Medical Retrieval

A fifth group dealing with medical Remote and Rural Training Pathways was set up as a
collaboration between the Remote and Rural Steering group, the Academy of Royal Colleges and
NHS Education Scotland. This had four subgroups to cover general practice, general medicine,
anaesthesia and general surgery and a fifth group to deal with current problems and issues which
covered all four medical specialties.

The report covers the work of all of the groups, most of which is complete but a few aspects are
ongoing. It describes the model of care in primary care with separate consideration of the remote
community hospital. A needs assessment for secondary care is reported and the core functions of
the rural general hospital are defined. Consideration is given to the staffing models, workforce
education and rural training pathways for medical practitioners. Attention is paid to the
infrastructure needed and specific detail of the support networks, quality assurance and
governance, physical infrastructure, diagnostics and e-health. A specific section is devoted to
emergency responses and transport with a look at the fundamental building blocks and the
development of an emergency medical retrieval service for remote and rural Scotland. An
implementation plan is suggested.

The Primary Care Framework
An extended community care system based on community resilience forms the heart of the
future remote and rural primary care. Partnerships between NHS 24, volunteers, informal carers,
community care teams to promote self care and long term condition management are required.

Anticipatory care must be effective in prevention of predictable health care crises requiring
emergency and secondary services. This will be achieved by use of community and practice
nurses and technicians from the Scottish Ambulance Service (SAS) with an increased use of e-
health solutions to access information and monitor patients. Much of this will have direct
relevance to the management of patients with long term chronic disease.

The new workforce model will be known as the Extended Primary Care Team (EPCT) it will
encompass a partnership approach between agencies and multidisciplinary teams. It will
incorporate the GP and all other health and social care professionals. The core EPCT should be
co-located to enhance communication and team working. The wider team including ambulance
paramedics and technicians may also be based within the GP Practice and utilised to support the
EPCT in undertaking anticipatory care within the community when they are not required for
emergency response. The EPCT should work in partnership with other agencies. Where the wider
professionals from Social Care, Housing, Education, NHS 24 and the Voluntary Sector are added
to the EPCT team, this will be defined as the „Extended Community Care Team‟ (ECCT). The
ECCT where possible should be based within a purpose built building and NHS Boards should
take this into account when prioritising capital plans.

Unlike the current Primary Care Team which is viewed as being fragmented, derived from
different organisations, duplicating work and providing reactive care; the Extended Community
Care Team will be integrated, involved in partnership working, provide seamless and
anticipatory care.

The specific range of diagnostics tests which should be available in remote Primary Care
locations are:

       Blood Gas Testing including haemoglobin, white blood cell count, urea, creatinine,
        creatinine kinase and amylase, Troponin T, and INR
       Electronic access to laboratory results
       Electronic access to digitised imaging reports
       Ultrasound scanner
       E-health link for clinical decision support and tele-clinics
       Cervical Screening

Emergency care and out of hours solutions for remote and rural areas should include use of
NHS 24‟s advanced Knowledge Management System with inclusion of different members of the
ECCT to share the burden of on call duties. SAS first responder and Unscheduled Care Nurse
Practitioner pilots should be evaluated.

Community Hospitals have been identified by the Scottish Government Health Department
(Developing Community Hospitals – A Strategy for Scotland 2006) as a key resource,
particularly in remote and rural areas. They should be a hub for out of hours unscheduled care
integrated with a minor injury/minor illness unit. They should provide: first line resuscitation,
triage, transfer and admission if appropriate; diagnostic services; a visiting specialist outpatient
service; preoperative assessment. They should have: intermediate care beds; a midwifery service;
facilities for palliative care and a designated place of safety for patients with mental health crises.
Nurses within community hospitals will lead the minor-injury/minor illness units. They will also
have a role in acute emergency care, medical admissions and in rehabilitation within the
community hospital.

The Community hospital will have a wider range of diagnostics tests including:

       Point of Care Testing: blood gas analysis (including haemoglobin and white blood cell
        capability), and electrolyte measurement, blood coagulation and cardiac enzyme
       Cardiac Exercise Testing
       24 hour blood pressure monitoring
       Simple imaging (i.e. plain film X-Rays)
       Digitised imaging utilising the PACS system
       Ultrasound scanning
       E-health link for clinical decision support and tele-clinics
       Endoscopy (although this may be a mobile resource)

The community hospital should be aligned to the GP Practice and act as a local resource centre.
The size of the Community Hospital and the facilities it contains will be determined by distance
from the nearest Rural General Hospital or District General Hospital.

There should be cross over of staff between hospital and community services, mainly led by
General Practitioners with a Special Interest (GPwiSI), supported by the wider multi-
disciplinary team. There is a view that the term GPwiSI does not adequately reflect the
competence required and it has been suggested that the description: Specialist in Primary care
medicine better describes the role.

The Remote and Rural training Pathways Group proposed the following training
recommendations for GPs working in a remote and rural environment:

       Competency assessments need to be developed for the Rural Fellowship in a similar
        manner to GPST to match the new remote training competences.
       The GP rural fellowship requires a certificate of satisfactory completion. The group
        proposes a tripartite panel including RCGP Scotland, NES and the employing CHP
        establish a framework for certification.
       All GP rural training pathways and accreditation mechanisms must maintain flexibility to
        allow established urban GPs to move to remote and rural practice at a later point in their
        careers. Three-month orientation and allocation of a GP peer mentor are recommended,
        with CHPs funding training gaps during this time to courses such as BASICS.
       A curriculum and competency framework which follows on the educational methodology
        of GPST needs to be developed for GPs working in Community Hospitals which could be
        completed during a Rural Fellowship after GPST.

Community Nursing

Nurses are the largest professional group within any healthcare system. Nurses in remote and
rural settings can be characterised as having a wide range of key skills, although these may be
only practiced to a limited degree.

Community Nurses will be integral to the hospital team ensuring facilitation
or early discharge and return to self-care.

Work is currently in progress to implement the recommendations of the Review of Nursing in the
Community, with NHS Highland as one of the development sites. The outcome of this work will
influence the future model for nursing within the remote and rural community.

Allied Health Professionals

Allied Health Professionals (AHPs) will work across the spectrum of care. Their role is described
in further detail in the RGH section.

Community Pharmacists

Whilst many remote and rural areas don‟t currently have access to Community Pharmacists, the
Pharmaceutical Care Services Plans being developed by NHS Boards, combined with contractual
changes for Community pharmacists may provide an opportunity to strengthen support to remote
and rural areas, particularly in support of people with a long term conditions. In many remote
communities dispensing practices provide access to medicines in the absence of community

Rural General Hospitals (RGH) – Sustainable Secondary Care
Delivering for Health states that patients can expect that:

If they stay in remote and rural areas, the NHS will provide them with a core set of services in
Rural General Hospitals.

and that:

The North of Scotland Planning Group is taking the lead in agreeing a list of
safe core services for RGHs that will comprehensively reflect health care needs in
rural communities.

To inform the work of the Rural General Hospital group a needs assessment was carried out.

RGH Needs Assessment

The analysis recognized six matters that cut across service delivery in the RGH: models of care
delivery, quality of care, recruitment and retention, diagnostics, telehealth and sustainability.

From a literature review five themes emerged:

       The lack of intensive care units in the RGH limits surgery that can be performed
       Intra-partum care should only be provided for low risk pregnancies with no identified risk
       RGHs should have defined diagnostic capability
       Cancer care should be shared with specialised units
       Recruitment should take into account pre-existing rural backgrounds and remote and rural
        healthcare training; retention barriers should be addressed by flexible continuous medical
        education which includes maintenance of advanced procedural skills.

The rapid appraisal (assessment) highlighted, but did not explain, the following:

       There was a large variation in the intervention rates for the catchment populations of each
       The wide spectrum of activity undertaken within each RGH was illustrated by the
        variation in the total intervention rate.
       Some catchment populations experienced high emergency and high elective intervention
        rates, others had elective and emergency intervention rates lower than the Scottish
        average and others had high elective intervention rates.
       Surgical day case activity was higher than the national average (with one exception);
        medical day case activity was lower than the national average (with one exception).
       Elective surgical intervention rates for patients with cancer were higher than expected.

The Rural General Hospital

The functional definition of the RGH is:

“The RGH undertakes management of acute medical and surgical emergencies and is
the emergency centre for the community, including the place of safety for mental
health emergencies. It is characterised by more advanced levels of diagnostic
services than a Community Hospital and will provide a range of outpatient, day-case,
inpatient and rehabilitation services.”

The RGH will have a medical workforce which is predominantly consultant led in the areas of
anaesthetics, medicine and surgery, supported by GPwiSI and doctors in training.

The RGH is regarded as a level 2+ facility which provides assessment, diagnosis and treatment
for routine conditions and admitting services with locally available 24/7 on call in general surgery
(with some orthopaedics) and general medicine with anaesthetic and radiological support. It may
have acute paediatric and obstetric and gynaecological support. It does not have an intensive care
unit but will have the ability to provide high dependency care.

NHS Boards should ensure that the fabric of RGHs is fit for purpose and ensure that, where
necessary, this is addressed in their capital plans.

The RGH must be part of a network with a larger centre(s) this will include development of
obligate networks, which comprise formally agreed specialist clinical links assisting local
delivery and decision making; the core specialties will be supported 24/7 and visiting specialist
services will be reviewed and extended where necessary.

To ensure similar clinical standards across Scotland individual RGHs will network with each
other to develop agreed evidence based protocols.

A core range of services will be provided in all RGHs, supported by standard protocols, formal
links with other centres and a standard range of diagnostics. The care will be delivered by
appropriately trained competent practitioners sustained by mentoring and skills updating from
larger centres.

As a minimum the RGH will provide:

Unscheduled care: A nurse led urgent care service dealing with minor injury and minor illness;
the ability to resuscitate patients; the capability to manage acute surgical (including initial
management of fractures and dislocations), acute medical admissions and the acutely ill or injured
child; a midwifery run maternity service; neonatal resuscitation; high dependency care before
transfer and clear and appropriate retrieval and transfer arrangements.

Planned care: the ability to manage patients with long term conditions including stroke, renal
failure (haemodialysis) and cancer; rehabilitation with post-operative stand down; ambulatory
care for children; routine elective surgery and visiting specialist services.

Diagnostic: imaging will include digitized image capture, ultrasound and CT scanning;
biochemistry (limited), haematology and blood cross matching; upper and lower gastrointestinal
endoscopy and cystoscopy; surgical biopsies; stress testing and echocardiography.

Support: tele-medicine and e-health links to other centres; pharmacy.

Core medical services will be provided by anaesthetic, general medical and general surgical
specialists. These will provide an elective service and 24/7 emergency cover.

    Anaesthesia will provide a service for resuscitation and stabilization and anaesthesia for
       emergency and elective operations; it will be predominantly consultant led and delivered,
       there is a role for GPs with appropriate training to support the service.
    It is envisaged that a team of three will be required.
    Specialist anaesthetists for RGHs should have additional training including:
       consolidation of general skills by training in one or two RGHs; experience with a „shock‟
       or retrieval team to provide adult and paediatric transport medicine experience; neonatal
       resuscitation skills, chronic pain management and palliative care.

General Medicine1
    There is a clear role for general medicine in: acute medicine, in patient management of
       long term conditions and a wide range of outpatient clinics.
    Five out of six RGHs have a consultant led and delivered acute medical service, the sixth
       RGH has a medicine service led by trained GPs with a special interest. Views differ on
       how general acute medicine should be delivered in the future.
    Three „team‟ members will be required to provide a 24/7 service.
    A proposal for training for specialists for RGH general medicine describes three routes:
            o CCT in General Internal Medicine (acute medicine) with a special interest in
                remote and rural medicine (level 3 competence in General Internal Medicine)
            o CCT in a medical specialty with level 2 competence in General Internal Medicine
            o CCT in General Practice combined with level 2 competence in General Internal
       It is proposed that NHS Education for Scotland and the Academy of Royal Colleges
       should establish pilot studies of the „hybrid acute medicine/general practitioner‟ role.

General Surgery
    A list of core surgical procedures has been produced. Surgical services that are not
       within the core list for RGHs include: surgery on children under 5 (with some specific
       exceptions); neurosurgery; neck; thoracic (except emergency tracheostomy), liver,
       vascular, ovarian and vaginal or penile (except circumcision) operations; most stomach
       and major rectal surgery. Breast surgery should be the responsibility of one surgeon
       working in a formal network with a designated breast unit.
    Surgical procedures not within the core list can be performed as long as they are
       explicitly agreed through formal governance processes which include demonstration of
       local health need, team competences, outcomes and approval by the local NHS Board and
       Regional Surgical Service Network (Obligate network).
    A minimum of three specialist general surgeons, trained in remote and rural surgery, will
       be required.

 A statement of what will comprise the core general medical service should be available after the General
Medical Workshop being held on 20th February 2008.

       RGH surgeons should undergo general surgical training with participation in a particular
        remote and rural curriculum this will require:

             o   A broad generic training
             o   Experience in emergency medicine, orthopaedic surgery, urology, obstetrics and
                 gynaecology, neurosurgery, otorhinolaryngology, ophthalmology and plastic
             o   In some specialties an understanding of the principles rather than acquiring
                 specific skills will be what is required.

A midwife led maternity service should be developed as a minimum. The roles and competencies
of midwives working in rural areas has been reviewed. NHS Boards should seek to maximize
local deliveries.

Networked Medical Staff
The RGH will be supported at a distance by other specialists (radiologists, psychiatrists and
laboratory medicine specialists) through obligate networks.

Visiting Services
Other services can be provided to the RGH by visiting specialists from larger centres. An
individual will be identified to be responsible for provision of a particular service to the RGH.

Other Services
Five key groups have been identified to support the core service within the RGH. These are: child
health, mental health, endoscopy, imaging and laboratories. Specific reference is made below to
child and mental health.

Mental Health
The focus of mental health services within remote and rural communities must be on the early
detection of disease to prevent disease escalation.

Mental health crises will sometimes require management by generalist practitioners and
sometimes by generally trained physicians. Meeting the National Standards for Crisis Services
will pose challenges in remote and rural areas and will need to be addressed. Containment and
stabilization in a place of safety sited in a community or rural general hospital may be required
before transfer to a specialist centre. A crisis service and assertive outreach to sustain patients in
their own home should be locally available. Contingencies to manage mental health crisis will

       Specific arrangements for the management of mental health crisis in remote and rural
        areas to be included in NHS Boards‟ Psychiatric Emergency Plans (PEPs)
       The requirement to review the need for the extension of current mental health service
        provision to cover out of hours
       The development of formal obligatory networks with specialist psychiatric centres,
        including communication across the system involving case management and critical
        incident reviews
       Responsive retrieval systems for patients experiencing mental health crisis

       The need to establish robust e-health links between remote and rural healthcare settings
        and psychiatric centres.

Child Health
A number of reports have explored appropriate and sustainable healthcare provision for children
and young people in remote and rural areas of Scotland. Common themes emerge:

       Difficulties faced by local clinical staff in providing high quality care for children with
        significant acute or chronic illness given the small number involved and the lack of
        immediate specialist support.
       A perceived lack of understanding on the part of the clinicians working in dedicated
        paediatric units of the particular circumstances faced by staff in remote and rural settings.
       Variable quality of discharge planning after episodes of specialist care

Paediatric models described within the reports are based around the principles of a Managed
Clinical Network and this report concurs that remote and rural child health services should be
firmly embedded in a formal network with a larger paediatric centre, providing ambulatory and
intermediate care locally, with the majority being provided in the community. CHPs (including
RGH staff) should develop a paediatric team and ensure that the staff have the necessary training
and educational support. All staff will require access to appropriate equipment and have
guaranteed access to clinical decision support from larger centres. A robust retrieval system is

Nursing Workforce
Although nurses in RGHs will be multi-skilled, generalist practitioners specific roles appropriate
to the RGH need to be developed these could include:

               Multi skilled generalist nurse who will be a nurse up to the level when higher
                level of practice roles are being developed
               Multi skilled generalist nurse with a special interest who will develop additional
                knowledge and skills in a specific area, in a clinical team, based on patient need.
               Acute Care nurse who will be involved in emergency level 1, high dependency
                and intensive care.
               Intermediate Care nurse whose role would include: care coordination,
                rehabilitation, anticipatory care, discharge management and self care.
               Specialist nurse who will take on a senior role and develop in a needs based
                manner with a special remote and rural interest but not condition specific.
               Nurse led services with either consultant supported nurse led services or
                independent nurse led services working at a high/very high level of decision
                making and authority.

Support workers are an essential component of the emerging nursing model. Generic support
workers will: support rehabilitation programmes ensuring they can continue at home; support
self care; deliver health promotion sessions to support self and anticipatory care; support for
chronic conditions; provide a home based nursing/care service for short periods to prevent
unnecessary hospital admissions; provide a scheme of early supported discharge from hospital;
use a broad range of knowledge to sign post other services for people; support young families;
undertake basic observations and screening (over 75, falls risk assessment, home environment
screening). The generic support worker will be developed to support the work not only of nurses
but Allied Health Professionals and Social Care Professionals.

Allied Health Professionals (AHP)
AHP services are diverse and the size and scope of the workforce varies considerably between the
various professional groups. It is clear that remote and healthcare requires locally based services
often centred within the RGH: physiotherapy, occupational therapy, diagnostic radiography,
dietetics, podiatry, speech and language therapy. A visiting service will be required for
professional groups such as othoptics and orthotics and patients will have to travel to access
others including: prosthetics, art therapy and therapeutic radiography.

While the majority of AHPs will retain a broad generalist remit in remote and rural areas
specialization in some areas will be required. The development of specialist AHPs or AHPs with
special interests (AHPwiSI) could provide the bridge between the specialist and generalist AHPs
in rural parts of Scotland.

The AHP workforce model for remote and rural healthcare will be composed of a range of
practitioners, at different levels, within each professional group.

       Consultant AHP - Clinical leader within a specialism, driving strategy through
        innovation, service and practice development, research and education. Will manage a
        caseload related to the specialism. Likely to work across professional and organisational
        boundaries. Examples include Consultant Radiographer in Emergency Care, Consultant
        Dietician in Diabetes, and Consultant OT in Stroke.
       AHP Professional lead/Manager - Overall responsibility for planning and delivery of an
        AHP service within the organisation. Examples include AHP Manager, Professional
        Head of Service, and Service Manager.
       Specialist AHP Practitioner - Experienced practitioner with post registration training and
        experience in a defined speciality. Caseload is focused almost entirely in the speciality.
        Some will work at advanced level. Examples include Specialist CAMHS OT, Specialist
        Musculoskeletal Podiatrist
       AHPwiSI - Experienced practitioner, specialist in general practice with education and
        competence in a specific specialist area providing a local/enhanced service to particular
        conditions or patient groups. Some will work at advanced level. Examples include
        Physiotherapist with special interest in injection therapy, Speech and Language Therapist
        in hearing impairment, Dietician with a special interest in obesity.
       AHP advanced generalist Practitioner - Practitioner with extensive experience and
        education in general practice who leads and develops an element of a service, act as a
        team leader and as an expert resource in their field. Such practitioners may have extended
        their role to support flexible and locally delivered services.
       AHP specialist generalist Practitioner - Experienced practitioner with developed skills in
        general practice working as part of an extended primary care team. Extended roles may
        form part of their role to support locally delivered services.
       AHP Practitioner - A practitioner consolidating and developing their skills with support
        of more experienced staff. Will usually carry a mixed caseload.
       AHP Assistant Practitioner - An experienced support worker who has undertaken
        accredited training to develop their skills, delivering patient care, delegated by a
        registered practitioner within a supervision framework.
       AHP Support Worker Support workers deliver patient care as delegated by a registered
        practitioner. May be generic (supporting a range of professions) or profession specific.

Diagnostic Radiographers

Radiographers will need to work as part of a multi-disciplinary partnership network across NHS
boundaries to sustain and support clinical pathways in the RGH.

The emerging model will require a workforce resembling:

       Radiography Consultant/Lead Clinician/Manager - Service Managers or Leads will carry
        overall responsibility for the planning and delivery of the radiography service and deliver
        an element of the clinical service. The Radiography Consultant will bring expert clinical
        skills and leadership and their role will focus on innovation, practice development,
        research and education.
       Advanced generalist radiographers covering a range of imaging modalities with reporting
        capabilities and utilizing other skills. A radiographer with extensive experience and post
        graduate education with competence in a wide range of imaging techniques and with
        reporting abilities. Could hold team leadership role. Will define the scope of practice of
        others and develop radiography services to meet patient needs.
       Generalist Practitioner Radiographer A radiographer with general imaging skills, working
        as an autonomous practitioner. May supervise assistant practitioners.
       Assistant Practitioner An assistant practitioner performs non-complex, protocol-limited
        clinical tasks under the direction and supervision of a registered radiographer.
       Radiographer support worker/generic support worker Radiography support workers
        undertake clinical or administrative duties as delegated by a radiographer. Generic
        support workers may cover more than one professional group.

Within remote and rural healthcare attention needs to be paid to the opportunities for developing
imaging services in particular: CT reporting, barium studies, plain film reporting, radiographer
prescribing and other opportunities.

Biomedical Scientists

A multi-skilled generalist Biomedical scientist (BMS) who can deal with core testing (blood
transfusion, haematology and biochemistry) should be developed.

A limited microbiology service dealing with: routine urine cultures, swabs, sputum, fluid and
blood cultures, occult blood testing, MRSA screening and sensitivity may be required.

The Wider Team

The role in remote and rural healthcare of smaller professions such as clinical psychology will
need consideration in the future.

The role of the Physician Assistant has not been explored in remote and rural healthcare. The
role may have the potential to be of benefit to remote and rural areas if innovative approaches to
supervision can be developed and limitations to prescribing are relaxed.

Rural Education Strategy
Practitioners working in remote and rural areas require to be generalists with a wide
breadth of knowledge across the spectrum of care. They must have a range of „specialist‟
skills in immediate care so that they are able to provide care until a support or retrieval service
can arrive. Remote and Rural Specific education must be increased. The accessibility of remote
practitioners to robust supported learning programmes, and rotation of remote and rural
practitioners to bigger centres for skills update, must be facilitated. Education programmes which
are specific and responsive to the needs of remote and rural practitioners should be introduced.
The possibility of developing a specialist degree for practitioners working in remote areas should
be explored.

The Remote and Rural environment should be recognised as a rich source for training

The North of Scotland Deanery of NHS Education for Scotland led the project to develop a Rural
Educational Strategy for NHS Scotland. Four objectives were identified for this Group:

    1. Develop a proposal for a Virtual School of Rural Health Care.
    2. Establish a Rural Educational Strategy group with involvement of the Scottish Medical
       Royal Colleges, Rural NHS Boards and other partners.
    3. Align the Rural Educational Strategy to the future shape of rural services, especially the
       Rural General Hospital (RGH)/ rural Community Health (and Social Care) Partnership
       (CHP) axis.
    4. Develop a mechanism for development of appropriate education and training for the
       remote and rural NHS workforce.

After an extensive consultative process the Remote and Rural Healthcare Education Alliance
(RRHEAL), supported by a remote and rural Managed Education Network was developed. The
RRHEAL will provide a linking role between the service and educational providers and be a
sustainable structure supporting rural education for the NHS Scotland for the future. It is managed
under governance arrangements as part of NHS Education for Scotland (NES) as a Programme
Board with supporting infrastructure.

There is a commitment for RRHEAL to: introduce Educational Programmes which are specific
and responsive to the needs of remote and rural practitioners; ensure that Educational
Programmes, wherever possible, are accredited; develop robust systems that establish a critical
mass of remote and rural learners that secures viable investment for learners.

Remote and Rural Training Pathways Group
The Remote and Rural Training Pathways Project was developed as a tripartite
collaboration between the Academy of Medical Royal Colleges and Faculties in Scotland, NHS
Education for Scotland (NES) and the Remote and Rural Steering Group. It had the following

       To gain an understanding of the service requirements within remote and rural healthcare
       To define the skills and competencies of medicine in the context of the multi-disciplinary
        team required in remote and rural practice

       To scope the educational requirements required to attain competence
       To develop appropriate frameworks for the establishment of educational standards for
        remote and rural healthcare, which are transferable between disciplines, but specifically
        address the needs of Anaesthetists, Physicians, Surgeons and General Practitioners
        working in a remote and rural environment
       To ensure that the framework has the flexibility to adapt to the changes in medical
        practice and training accreditation
       To develop appropriate curricula and training programmes, with supporting accreditation
        mechanisms, to deliver training
       Identify infrastructure to deliver CME/CPD programmes in remote and rural medicine
       Ensure that there are appropriate links between the development of educationally sound
        practitioners and the different aspects of remote and rural healthcare needs
       To identify solutions which address immediate recruitment and retention issues, including
        development of bespoke educational programmes

The work was divided into work streams dealing with anaesthesia, general medicine, general
surgery, and general practice. Much of the outcome of these groups has been described in
previous relevant sections.

A fifth work stream looked at more generic immediate service needs, such as recruitment and
retention, and the uses of technology and mentoring.

Recommendations made by this group include:

       Comprehensive information packs should be available to all prospective candidates for
        remote and rural posts. These should include information on social and environmental
        aspects as well as information about the post and service. DVDs such as „Live and Work
        in Lochaber‟ should be considered for those areas that do not yet have access to this type
        of marketing.
       Opportunities should be provided prior to appointment to explore the negative as well as
        the positive aspects of a professional living in a rural and remote community, and advice
        and support on dealing with these offered.
       Formal Networks with DGH and Tertiary Centres should be developed and supported to
        allow for professional development, opportunities for job swaps, skills maintenance,
        professional leadership and learning. The concept of a mentoring institution should be
        further explored.
       The use of technology for clinical, professional development, training, networking and
        meetings should be actively encouraged and the necessary infrastructure should be a
        priority for NHS Scotland.

Proleptic Appointments
All five groups made recommendations about proleptic appointments. As far as possible
appointments should be made in advance of need to allow sufficient time for targeted training.
Boards have a responsibility to ensure that sufficient skills are acquired to allow the candidate to
function appropriately. The Fifth Workstream was awarded monies for the proleptic appointment
of practitioners outwith the present SpR scheme, and is liaising with the Boards to identify
appropriate posts.

Additional Work
More work is being undertaken on : acute resuscitative care including advanced airways
management; treatment of the acutely ill child and formal mentoring and networking.
Telemedicine needs to be reviewed in a wider context, with remote units linking to larger centres
across Scotland. Evidence suggests that there is a place for a local champion for this work.

Doctors in Training
Remote and Rural healthcare provides an important training environment and we need to ensure
that the following trained doctors are produced each year:

       Physician:       Acute medicine/ Rural track to CCT                     Two ST3
       Surgeon          General Surgery/ Rural track to CCT:              One or two ST3
       Anaesthesia: Anaesthesia/ Rural Option                                  One ST7
       General Practice /acute medicine
        Post-GP CCT/ Acute medicine slot                                          One ST 3
       General Practice: existing NoS Deanery Rural GPST output,
        linked to the existing Rural Fellowships

Other important outcomes from this group include:

       The Academy of Royal Colleges should commission research into the attractiveness of
        the GPwiSI role within remote and rural areas.
       The importance of remote and rural areas as a resource for doctors in training should be
        recognised and appropriate opportunities should be identified to ensure the supply of
        remote and rural physicians, surgeons, anaesthetists and GPs.
       The proposed training curricula, developed by the Remote & Rural Training Pathways
        Group, should be adopted.
       Remote and rural systems should not be destabilised, as a result of the full
        implementation of MMC.
       NHS Education for Scotland should, in collaboration with the Academy of Royal
        Colleges establish a pilot to test the hybrid acute medicine/general practitioner role.

Infrastructure to Support Remote and Rural Practice

Support Networks

The need for formal networks has been emphasized, remote and rural health systems cannot exist
in isolation but need to network with others to sustain local care, support practice and treat
patients. Obligate networks should be developed as partnerships and should incorporate
responsibility for the development of robust care pathways and to provide support to remote and
rural localities 24/7.

Two types of network arrangements are needed:

Laterally between remote practices or RGHs to develop agreed standards, protocols, training and
development, support and share good practice.

Vertically working with specialist experience in another location to ensure quality and

sustainability of appropriately devolved local services. This is likely to be condition/specialist
based e.g. cancer, neurology organised as part of a managed clinical network.

The benefit of establishing networks include:

       Access to expert opinion to inform local clinical decision making;
       Peer group support, training and education;
       Rotation for skills update and maintenance;
       Development of shared protocols and pathways;
       Transfer debriefs;
       Increased practitioner confidence;
       Improved discharge planning.

Quality Assurance and Governance

Remote and rural healthcare needs to be supported by robust systems of governance and should
be judged on the basis of the standards developed for NHS Scotland. NHS Quality Improvement
Scotland (QIS) should appoint a Remote and Rural Clinical Advisor to ensure an understanding
of remote and rural issues in the development of its standards. This Clinical Advisor should
establish a Remote and Rural Reference Group to support him/her in this work.


The concept of using e-Health in the remote and rural situation is a philosophy which should
permeate thinking around every aspect of the remote and rural agenda. The principles to underpin
this approach are:

       Specialist advice can be provided at a distance by videoconference, telephone or email.
       Travel can be reduced by the use of videoconferencing.
       Digital data can be transferred to and from remote sites.
       A Tertiary Centre could be an intellectual resource to RGHs, Community Hospitals and
        isolated practitioners.
       There are existing examples of relatively small scale projects supplying such services.
       The wider e-Health agenda has a focus on the creation of the electronic patient record a
        significant development in improving communication about patient care.

Any new premises must have broadband capacity with access for all the multidisciplinary team,
with shared links to health and social care computer systems. Computerised systems must be
integrated with electronic referral to secondary care.

The eHealth Strategy Board should review their investment plans to ensure that the level and
quality of connectivity should be the same across Scotland. Remote and Rural Communities in
Scotland should not expect anything less than a first class IT infrastructure to support local
delivery of care. The IT infrastructure must therefore be robust across the whole of Scotland to
allow for rapid and safe communication and reduce the need for patient and staff travel. The
concept of utilising e-heath in the remote and rural setting must permeate every aspect of service
planning and delivery.

Emergency Response and Transport
An integrated transport strategy that is responsive to remote and rural patients‟ needs must be
developed. The Scottish Ambulance Service should be responsible for ensuring that robust and
responsive local community emergency response models are developed.
The Scottish Government should consider the development of an integrated transport strategy
which includes health. Closer integrated working arrangements between the SAS and NHS
Boards should be explored.

Emergency Medical Retrieval Service (EMRS)

The Remote and Rural Steering Group were tasked with reviewing the role of the Emergency
Medical Retrieval Service to, if necessary, enhance the service in
remote and rural Scotland. A decision was made to recommend that an EMRS Pilot should be
established as soon as possible; this pilot should be supported by an independent evaluation
including a prospective study which identifies the needs of the northern Highlands and the
northern islands of Scotland.

The EMRS pilot has the following aims:

       Creation of an integrated and well governed system of rural emergency care;
       Augmentation of rural healthcare practitioner training in emergency care and transfer;
       Provision of on-line expert advice on patient management and transfer;
       Rapid on site provision of emergency and critical care interventions; and
       Safe transfer directly to definitive care.

An EMRS sub-group report recommended that:

       NHS Scotland should establish an EMRS to support the care of seriously ill and injured
        people in Remote and Rural Scotland
       This service would retrieve patients with life threatening injury or illness where advanced
        medical intervention is appropriate to optimise safe transfer
       The service would be additional to that currently provided by SAS and would only be
        deployed if the consultant staff determine that medical intervention is required
       The service should be established in a phased manner, building on the successful pilot
        within Argyll. Phase one should be implemented to cover the west coast of Scotland,
        covering three rural general Hospitals, thirteen community hospitals and a number of
        remote general practitioners. The first phase is likely to last 18 months
       During this first phase, independent evaluation of the requirements for the whole of rural
        Scotland would be undertaken, including the clinical requirements for the Northern
        Highlands and Northern Isles, the implications for the air ambulance service, a health
        economic assessment and the impact on the areas where the service has been
       Following completion of the review, assuming a positive evaluation the service should be
        rolled out across all remote and rural Scotland

The EMRS subgroup determined that whilst the pilot in Argyll and Clyde had been successful
and had improved patient outcome, a further pilot would be required to determine:

       The scope and design of an EMRS to support emergency care in Remote and Rural
       The effectiveness of an EMRS across Scotland.

The pilot would cover the west coast of Scotland, with its three rural general Hospitals, thirteen
community hospitals and its remote general practitioners. The Cabinet Secretary for Health and
Well-being agreed in June 2007 that Scottish Government Health Finance would underwrite the
18-month pilot of an emergency medical retrieval service serving all remote and rural health care
facilities in the West of Scotland. The Cabinet Secretary recognised the importance of the EMRS
to the future sustainability of healthcare in remote and rural areas of Scotland. Allowing for the
recruitment process the ERMS pilot should officially commence on the 1st of April 2008.

Equality and Diversity Impact Assessment
Within the Equalities legislative framework it is expected that each NHS Board will, when
progressing local implementation of the models presented in the report, conduct and report on
Equality and Diversity Impact Assessments according to locally agreed guidelines.

Support for change
The Scottish Government should consider providing funding for the appointment of a National
Programme Manager with appropriate administrative assistance in order to ensure capacity is
built to support the implementation of the remote and rural framework.
The Scottish Government should consider the impact of the NRAC review on NHS Boards‟
ability to maintain and develop remote and rural services.


              Extract from Better Health Better Care Action Plan

Remote and Rural Health Care

Building a Health Service: Fit for the Future recognised that a one size fits all approach can not
meet the challenges of providing health care in remote and rural areas and established a national
steering group to develop a framework for the provision of services in those areas. A further
group was established to develop specific training for doctors working in remote and rural areas.
Both groups have now reported and we will issue guidance on how we expect their
recommendations to be implemented early in 2008.

The proposed framework presents a model for sustainable remote and rural services
which maximises the contribution of each member of the health and social care team,
and encourages further integration of services. Primary care teams are recognised as the
bedrock of the health care system. Recommendations are made to extend, as far
as is possible, the range of diagnostic tests and specialist support available to those teams to
prevent unnecessary onward referral and travel for patients. The potential to upskill
members of those teams to provide more local services - for example through the
development of GPs with special interests – is also recognised.

The Framework describes a suite of safe and sustainable core services for Scotland‟s Rural
General Hospitals, supported by a modern staffing model which secures quality of care for
patients. Rural General Hospitals will develop formal networks between one another, and with
larger hospitals in urban centres, which will include agreed specialist clinical links. The current
practice of visiting specialists will be reviewed and extended where appropriate. This will allow
local decision making to be informed by access to specialist opinion, peer group support, training
and education, the development of shared protocols and pathways across and between different
facilities and opportunities for staff rotation that can help maintain and develop necessary skills.

It is clear that we can do much more to exploit the opportunities offered by eHealth and
particularly telehealth in remote and rural areas. Travelling to a central point can be avoided
through the use of videoconferencing, telephone or email, whilst digital data such as blood tests,
ECGs, and images can be transferred from remote sites to other points to enhance diagnosis. This
requires protocols and agreed service standards and the Scottish Centre for Telehealth will be a
critical source of information and advice for NHS Boards as they start to deploy these
technologies more effectively.

The Medical Training Pathways group has applied an understanding of the service requirements
within remote and rural areas to develop educational standards for doctors within a multi-
disciplinary team, specifically considering Anaesthetists, Physicians, Surgeons and General
Practitioners. The report makes recommendations on a competency framework for each of these
key medical specialities, adapting the general training curricula for each specialty when required.


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