Policy responses and statements
- Name of organisation:
- Academy of Medical Royal Colleges
- Name of policy document:
- Centralisation and Specialisation of Hospital Services - bigger is not necessarily better for rural and remote communities
- Deadline for response:
- 1 April 2006
Background: In October, the Academy received the attached paper, which had been written by a working group which the Academy had established representing the medical Royal Colleges and the Rural Health Forum, as well as representatives of the various Departments of Health. The Academy was keen to take this work forward, so that the issues raised can be addressed without delay. The paper makes some specific recommendations, and the Academy wrote to each of the Colleges to request that they formally considers these recommendations, and comment on or respond to them.
There are trends towards centralising hospital care within the NHS, for many excellent reasons. Yet this has a disproportionate impact upon those patients who live at greater distances from their hospitals; this impact has not been well reported or researched though studies have demonstrated that utilisation of services is inversely related to the distance of patients from hospitals; so called “distance decay”.
This paper examines the trend and describes the reasons for it and the impact on those people who live in remote and rural communities. It argues that health service planning should be patient-centred, in line with the White paper, Creating a Patient Led NHS, and similar policy in each of the jurisdictions in the UK. It points out that, although providing services to rural communities is more expensive than for urban populations, a balance should to be struck between cost-effectiveness and providing accessible and equitable services for all of our patients. It makes certain recommendations. The Kerr Report of 2005 makes very similar points, and will be debated by the Scottish Parliament in late 2005. Many of the recommendations from Kerr’s Rural Access Action Team are equally applicable throughout the UK, and should be considered by all bodies considering health policy in areas with remote and rural patients.
The report argues for a debate to help to define where the balance point should be, and to make certain recommendations. This debate is especially important, as the professions respond in England to the Department of Health’s document ‘Keeping the NHS Local - a new direction of travel’ and elsewhere in the UK to similar policies in each of the other jurisdictions.
COMMENTS ON
ACADEMY OF MEDICAL ROYAL COLLEGES
CENTRALISATION AND SPECIALISATION OF HOSPITAL SERVICES - BIGGER IS NOT NECESSARILY BETTER FOR RURAL AND REMOTE COMMUNITIES
The Royal College of Physicians of Edinburgh is pleased to respond to the Academy of Medical Royal Colleges on its consultation on Centralisation and Specialisation of Hospital Services - bigger is not necessarily better for rural and remote communities. Our comments are as follows:
Recommendation 1: College Support
Largely welcomed and agreed. The Scottish Academy has already established a group working with the Scottish Executive Health Department and local planning teams to progress this important work. The College recommends that any UK Academy group should liaise with the Scottish Academy on these issues.
The College is not convinced of the need for a separate specialty of remote and rural medicine. Acute medicine, complemented by (post CCT) additional modules according to the particular needs of the specific role, would provide appropriate training. The College believes that adopting such a modular approach to additional training would also benefit consultants working in remote DGHs or the proposed Rural General Hospitals (Kerr Report), who may have been discouraged from developing specialist interests as a result of increasing centralisation. However, contractual arrangements may require review to facilitate this development.
Services may require a different approach in more rural areas, and this offers opportunities to develop a team approach to the delivery of care. However, consultants will continue to play an important role in standard setting and in the supervision of care delivered through other team members.
Recommendation 2: Minimum Standards of Access to Care
Agreed. The Kerr report includes useful information on the definition of rurality and the surprising finding (to some) about the extent of rurality in Scotland. This is not just an issue for the Highlands and Islands. Implementation may be a greater challenge across the UK than planners understand.
Recommendation 3: Communication Standards
Agreed. The College feels it is worth stating that telephone and e-mail can also play a valuable role; it is not just about sophisticated video conferencing and telemedicine. However, the required investment is huge eg in the Highland region, with one of the most widely dispersed populations in Scotland, there is no PACS system to link hospitals to facilitate out-of-hours reporting, and video conferencing has just started.
Recommendation 4: Transport
Kerr is limited in his conclusions, which rest largely in improving the road infrastructure. This is long term and a little unrealistic for many parts of remote Scotland.
The standard set of placing emergency ambulance 30 minutes from people may also be unrealistic, even in England, and certainly in Scotland. The definition of “ambulance” should recognise that local first responders may be not be in traditional ambulances, and may utilise other rescue services including fire and mountain rescue teams.
Reliance on air transport may not solve all difficult problems, even if affordable. The Scottish topography and climate often frustrate both helicopter and fixed wing aircraft pilots.
Recommendation 5: Rural Proofing
Agreed.
Recommendation 6: Implementation of Enhanced Use of Information Technology
It is not just rural hospitals that require video conferencing; this should be standard for communication at DGH and tertiary centres, and may be required in some community hospitals. The Kerr report recommends that community hospitals become the home base for enhanced primary care, and in very isolated areas these will be the first and only response teams.
Recommendation 7: Equitable Funding
“Equitable” may not be the most appropriate term. The issue is about weighting the funding formula to reflect the access challenges of local areas to achieve acceptable minimum response and treatment standards (as per recommendation 2). Rural services may never benefit from equitable services, but minimum standards must be achieved. Local expectations must be managed to ensure patients are confident in the level and quality of care available to them.
Recommendation 8: Kerr Report
The College cautions that Kerr’s recommendations will be modified as the detailed work progresses. For example, the out-of-hours shared rota as proposed for medical cover in rural hospitals in the pilot study at Belford and Oban hospitals was abandoned very quickly due to concerns over patient safety. This proposed a model of sharing out-of-hours senior medical support between 2 hospitals located 1½ to 2 hours apart (driving time). Patient safety problems arose very quickly, and the pilot was abandoned rapidly. Senior accessible medical cover is essential for in-patient care, although this could sometimes be provided by a local GP with additional training in acute medicine, liaising with a consultant at the more distant site.
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[31 March 2006] |
