Policy responses and statements

Name of organisation:

Scottish Parliament - Health and Sport Committee

Name of policy document:

Inquiry into out-of-hours Health Care Provision in Rural Areas - Call for evidence

Deadline for response:

6 November 2009

Background: The Health and Sport Committee is undertaking a short inquiry into out-of-hours health care provision in rural areas of Scotland. The inquiry will examine the changes to out-of-hours provision in rural areas and the resultant effect on:

• The quality of out-of-ours care in rural areas, with a specific focus on clinical safety and effectiveness
• The accessibility and availability of out-of-hours care in rural areas
• The sustainability and cost of out-of-hours care in rural areas

Questions:

To inform the inquiry, the Committee sought views on the following questions:

• What do you think is the most sustainable and cost-effective way to provide adequate out-of-hours services in rural areas?
• What are your views on the quality of out-of-hours care provided in rural areas, in particular clinical safety and effectiveness?
• What are your views on the accessibility and availability of out-of-hours care in rural areas?
• How well do you think does NHS 24 and the Scottish Ambulance Service link in with existing out-of-hours services?

The Committee will consider all submissions received and identify issues emerging from the evidence which it wishes to investigate further through oral evidence sessions.

COMMENTS ON
SCOTTISH PARLIAMENT HEALTH AND SPORT COMMITTEE
INQUIRY INTO OUT-OF-HOURS HEALTH CARE PROVISION IN RURAL AREAS: CALL FOR EVIDENCE

The Royal College of Physicians of Edinburgh is pleased to respond to the Health and Sport Committee of the Scottish Parliament on its call for evidence on the Inquiry into out-of-hours Health Care Provision in Rural Areas.  The College is a very “broad church” and this response reflects the views of our Fellows in the hospital and primary care sectors, particularly those living and working in rural and remote parts of Scotland.

What do you think is the most sustainable and cost effective way to provide adequate out-of-hours services in rural areas?

The College has some concerns about the use of “adequate” in this context.  Patients across Scotland and their medical advisers should have the same opportunity to access effective care; albeit that the shape and level of services may differ from those in more urban conurbations.

The College recognises that the traditional pattern of GP care had to change with extremely challenging recruitment to rural practices, influenced in large part by the pressure of work out-of-hours.  However, our Fellows advise that the development of GP co-operatives providing local cover from a central location had been extremely effective, and patients (after initial worries) were largely satisfied with the service.  Local GPs bring the benefit of a strong understanding of local needs and geography and are familiar with traditional patient flows and the working arrangements and staffing in other essential teams, including local ambulance crews.  However, it is important to recognise that out-of-hours care in very rural locations across Scotland, including the smaller islands, continues to be dependent on resident GPs. Recruitment problems in the future remain for these communities.

The College advises that local care requires flexibility and a standard model will be neither appropriate nor sustainable across Scotland.  For example, the impact of extended nurse practitioners and physicians’ assistants will be different in smaller hubs (eg Belford Hospital, Fort William) than in more urban areas.

In very remote areas, emergency support via voluntary first responder groups (mountain rescue, fire service etc) supported with training from the ambulance service can offer communities reassurance in the event of sudden collapse, and this has worked well.  This fits well with the self-sufficient culture in these rural locations, but has added to the suspicion of cost cutting in rural communities with the rationalisation of ambulance cover etc and is in danger of becoming politicised.

The demographic mix in rural areas is such that complex frail elderly patients make up a significant component of primary care workload, and this will increase as the population ages. Future planning must take account of this dynamic.

What are your views on the quality of out-of-hours care provided in rural areas, in particular clinical safety and effectiveness?

Patients may not receive the same standard of care as those closer to major hospital teams, but isolation should not result in harm.  However, the general view is that clinical care is not compromised significantly by the model of care in place, although the tendency to risk aversion is causing patient inconvenience and inefficiency.

Stability in the medical workforce is critical in rural areas; importing less experienced locum cover with little local knowledge or understanding of the rural environment is expensive and less effective.  Physicians in Fort William are, with the help of this College, developing a training programme to create a flexible “hybrid” specialist doctor in medicine to address the needs of rural communities, create a valuable post that will attract high quality applicants and make best use of valuable medical time.

The policy of triage through NHS 24 has much merit in terms of reducing trivial and inappropriate calls to general practice but the algorithms are risk averse, particularly in cases of frail elderly or paediatric patients.  This risk aversion, combined with relatively inexperienced (locum) practitioners results in unnecessary journeys by the emergency GP and/or the patient and inappropriate use of limited out-of-hours resources, including ambulances.  In a rural setting with no public transport, particularly out of hours, it can be difficult to return patients home, resulting in unnecessary admissions and disruption to patients and their families.  An example given by a GP Fellow was of a young female tourist seeking advice for minor swine ‘flu symptoms from NHS 24 and the use of the phrases ‘breathing difficulty’ and ‘chest pain’ triggered the despatch of an emergency ambulance. Further investigation by an experienced clinician may have prevented this wasted (long) journey and significant unnecessary anxiety for the patient.  Many GPs set aside urgent (next day slots) for their own patients to avoid unnecessary out-of-hours consultations or admissions with no compromise to clinical safety.

The withdrawal of out-of-hours community nursing has added to the workload on GPs in terms of support for fail elderly (eg catheter care) and for palliative care.  However, high risk patients could be flagged up in advance by GPs to alert out-of-hours teams to their risk status. Early alerts could also apply to terminally ill patients, the quality of whose care in rural areas can be determined by the individual commitment of dedicated palliative care nursing staff and local GPs who will often leave a personal contact number for emergency support.

The care of sick babies is a core component for out-of-hours teams, given the distance to a specialist paediatric unit and the need for clear assessment. Inexperienced doctors are highly risk averse for this group of patients, and there is some evidence of admission rates varying with geographical location. In general, Fellows in primary and secondary care greatly value the support of their colleagues in the ambulance service, and “see and treat” services have been introduced in some parts of Scotland.  However, the College is unaware of any audit or governance of this development and would recommend that this is reviewed carefully before wider roll-out is agreed.

Fellows are concerned about the governance of training in rural areas for consistency and to ensure training posts are filled by high quality candidates.  This will have an indirect effect on patient care.

What are your views on the accessibility and availability of out-of-hours care in rural areas?

There are no explicit standards against which to measure the accessibility of rural care and compare with other areas of Scotland.  Patients in rural areas accept their geographic location may require a different approach, but are suspicious that changes in the delivery of care are politically driven through cost constraints; for example, the loss of locally based ambulances and crews.  Also, the location of Primary Care Centres are often a significant distance from remote communities, and the lack of public transport deters presentation or requires an ambulance.  Delays in transfer time can also be a problem between facilities given the journey times in rural areas and the multiple calls on the time of ambulance crews.

Air ambulances, thought to be of most benefit to the islands, may have more impact on some mainland isolated communities where the travelling times to hospital are much longer than the larger islands.

Telemedicine can support some elements of patient care but is limited in rural out–of-hours applications when clinicians may not be well known to each other and there has been no opportunity to build confidence across the teams.  This could apply to inexperienced GPs and to enhanced nursing practitioners.  It seems unlikely that critical decisions for a complex frail elderly patient or a very sick baby would be helped by the addition of current telemedicine applications.

Work intensity is different in rural locations, although rotas have seemed onerous and periods of duty long.  The European Working Time Regulations (EWTR) cause a particular problem for rural locations, with less intensive work loads which can be less rewarding and difficult for training and which add to recruitment and retention problems.  It seems likely that the EWTR will have a disproportionate effect on the staffing of services in rural locations and this should be monitored carefully.

How well do you think the NHS 24 and the Scottish Ambulance Service link in with existing out-of-hours services?

Working relations at the clinical level are positive (often teams are personally known to each other), but there are concerns that this co-operation is not always evident in joint planning at an organisational level between the local out-of-hours services, NHS 24 and the Scottish Ambulance Service.

Good local nurse-led triage systems were dismantled in remote areas in favour of NHS 24 and the lack of local knowledge and training has contributed to the risk averse culture that drives hospital attendance.  In addition, the NHS 24 triage system breaks down at times of high patient volume (eg Christmas and during epidemics), and the support systems through emergency GPs, ambulance services and A&E department are burdened with inappropriate referrals. 

The strategies of both organisations are ambitious as they seek to expand their services eg the ambulance service delivering support in chronic disease management.  The College recommends that NHS 24 and the SAS focus on core services for rural areas before taking on new areas of work, particularly in addressing the risk aversion within their referral algorithms.

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

[9 November 2009]