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10 CHAPTER TEN NEW WAYS TO DELIVER RURAL HEALTH CARE

01 One fifth of the Scottish population lives in a rural area (Scottish Executive, 2004). Of these, a significant number live in very remote areas that require healthcare arrangements suited to times of enforced self reliance due principally to weather and transport difficulties.

02 The dominant model of healthcare thinking in Scotland is distinctly urban based. It is from this model that assumptions have been made and systems applied to remote and rural care, including assumptions on clinical safety, training and education and workforce planning. The bulk of rural health delivery occurs in primary care, but access to secondary and tertiary care facilities are also critically important for rural people, and can be the source of considerable individual and community concern.

03 We need to address the following key issues to plan adequately for the health of people in remote and rural Scotland:

• recruiting and retaining a workforce that has the skills and competence to deliver a general healthcare service by working collaboratively in multidisciplinary teams.
• improving education and training structures and processes that are currently not readily accessible, often have low levels of relevance to remote and rural practice, and can result in lengthy amounts of time away from base for participants
• establishing transport infrastructures and systems to allow access to services for people in remote and rural Scotland
• recognising deprivation that is often not transparent and addressing unmet needs
• improving information systems and research programmes that are not sufficient to support service development and ensure safety.

Remoteness, rurality and clinical peripherality

04 In addressing these issues it is important to establish a definition of rurality and remoteness that is relevant to healthcare provision and to the development and maintenance of the rural health workforce. The bulk of rural health delivery occurs in primary care, but access to secondary and tertiary care facilities are also critically important for rural people, and can be the source of considerable individual and community concern.

05 Defining rurality and remoteness is a complex issue, and the definition chosen may vary (Farmer et al 2001). Previous work has focused on drive time to major population centres, settlement size, or some measure of population density to define rural and remote communities. The Scottish Executive has recently adopted a six-fold classification of settlements, adapted from the earlier Scottish Household Survey classification, for much of its work on rural policy (Scottish Executive, 2004). It is generally recognised that composite measures may be more valuable than a single index to reflect the characteristics of a community.

06 Consequently in considering a framework that would be of relevance to healthcare in remote and rural areas, an index of "Clinical Peripherality" has been developed. The index reflects the characteristics of rural and remote general practices and the communities they serve, including their access to secondary care facilities and to centres of decision making and professional education and support.

07 A study in West Highland demonstrated that this index correlates well with the range of demands on rural healthcare providers (Swan et al., 2004). The study examined multiple demographic and geographic characteristics of all 59 general practice communities in three rural local health care cooperatives ( LHCCs) and concluded that four main factors directly contributed to the peripherality of a practice:

• practice list size
• population density at the practice ward area level
• travel time from the practice to the nearest acute receiving hospital (that is, a hospital
  providing consultant-led services)
• travel time to the regional health board headquarters (which was recognised as a centre of decision making and professional support).

Travel times took account of single-track roads and ferry services, where appropriate.

08 The four factors were combined using factor analysis to generate a clinical peripherality index. This was found to correlate strongly with the spectrum of roles undertaken by health practitioners.

09 A summary plot of clinical peripherality scores for non-urban practices in each NHS Board area is shown in Figure 10.1. NHS Boards serving the more remote and rural areas of Scotland show greater median values and a wider scatter of clinical peripherality values for their practices.

A detailed analysis can be found in the Rural Action Team Report. http://www.show.scot.nhs.uk/sehd/nationalframework

Figure 10.1
Clinical peripherality scores by NHS Board area (Swan et al., 2004)

The box plot shows median values and interquartile range of scores for each NHS board area. Higher values represent greater clinical peripherality.

10 Although the median data by NHS Board area provide some insights into the scale of peripherality issues faced by boards, they conceal individual areas of more extreme peripherality within Boards such as several island communities and the western portion of Dumfries and Galloway. A more comprehensive picture of clinical peripherality is therefore provided by mapping scores from individual practices, as shown in Figure 10.2.

Figure 10.2
Clinical peripherality scores for individual non-urban practices

11 What is the significance of clinical peripherality for health service planning? Underlying the clinical peripherality of practice communities is a concept of insularity. Islands, remote from their nearest receiving hospital and NHS Board, are inevitably peripheral. But mainland communities located at the end of poor road communications are also effectively insular. This has great relevance when configuring rural transport services and emergency retrieval systems. Figure 10.2 shows that such practices exist even within the geographical centre of the country.

12 Change in the location of acute receiving hospital facilities or decision-making centres such as NHS Board headquarters can profoundly affect the level of peripherality of individual practice communities. The range of services provided by rural general hospitals and their location consequently becomes a key determinant of peripherality.

13 Health practitioners ( GPs, nurses and others) in more remote areas have to offer a broader range of services than their urban counterparts (Boerma et al., 1998). This has specific implications for education and training, and is mirrored in the training requirements for rural hospital practitioners.

Action required

14 Taking all of this into account, we have identified six areas where action is required to ensure that the future healthcare needs of remote and rural Scotland are fully recognised and met:

• maximising services provided locally
• delivering integrated health care across traditional boundaries
• providing out-of-hours (OoH) care
• defining the role of rural general hospitals
• developing a skilled and competent workforce
• creating an integrated transport system.

15 In our view, the key to the first of these challenges - retaining and expanding local services - lies with achieving the integration required by the second challenge - delivering integrated health care across traditional boundaries. In addition to maximising care delivered locally, we need to ensure that patients aren't disadvantaged by their distance from specialist centres. A recent Royal College of General Practitioners ( RCGP) statement on rural general practice (Mungall et al., 2004) warns:

'rural patients have greater access difficulties for health care. It is a safe assumption that poor access will adversely affect outcomes.'

16 The challenge is to design a service that overcomes some of these difficulties in accessing services. The action required will include new approaches to training for rural practitioners, developing the role of community and rural general hospitals, creating rapid emergency retrieval services, improving transport infrastructure, increasing the use of tele-health services and mobile diagnostics, and continuing to develop Managed Clinical Networks by ensuring they include the rural dimension to service provision.

Primary care

17 At the forefront of our framework for rural health care is the enhancement and extension of primary care. We need to maximise services that can safely be made available in rural towns and villages. That will mean an extended role for GPs and other members of the rural healthcare team.

18 There should be further development and piloting of the Family Health Nurse role. This model embeds the role of the skilled generalist in primary care and encompasses a broad range of duties. Family Health Nurses deal with many issues as the first point of contact and refer on to specialists where a greater degree of expertise is required. The impact of this role has been reported through the findings from the initial phase of the World Health Organization ( WHO) Europe pilot (Scottish Executive, 2003).

19 In addition to the need for the broad-based generalist role, there is scope to develop specialist nursing and allied health professional ( AHP) roles in remote and rural areas. These roles will support and complement services delivered through a generalist model, providing supervision to isolated practitioners.

20 Rural GPs value their generalist skills. GPs in small remote practices have developed extended skills to allow them to manage the early stages of severe sudden illness and trauma. The uptake of Advanced Training Life Support ( ATLS) and British Association for Immediate Care ( BASICS) courses is high among rural GPs and community nurses, who recognise the delivery of immediate care as an important part of their role in the community. We need to ensure access to this type of continuing professional development for new and existing rural practitioners.

21 There is scope to develop GPs with a special interest ( GPwSI) in specialties such as dermatology, ENT, ophthalmology and musculoskeletal medicine in rural localities serving larger populations, as has been the case in England. These practitioners could work closely with and support the visiting consultant service provided within these localities.

22 The future of visiting clinics may be threatened with the inclusion of travel time within contracted hours under the new Consultant contract. NHS Boards need to maintain links between specialists and rural communities. Maximising the efficiency of these clinics with GPwSIs will allow consultants to concentrate on the most complex cases and provide support and education to local clinicians. The GPwSI will act as a resource within the locality. He or she will accept referrals and provide advice and support to colleagues.

23 Practices across the area should be encouraged to work collaboratively to provide the widest range of services to the whole community. The Centre for Change and Innovation is currently supporting a number of pilot projects among NHS Boards under the Community Outpatients initiative.

24 Developing enhanced roles for GPs in emergency medicine, minor surgery, palliative care and care of older people will be more appropriate for some localities (see Box 10.1). As well as their continuing generalist role, the GPwSI would be responsible for leading service development and ensuring that all clinicians in the locality are providing safe, effective and high-quality services in their specified area. They would work closely with nurses and AHPs who are also developing enhanced roles in many of these areas and who can often undertake the lead role.

25 But it's important to endorse the generalist skills rural GPs will continue to require. The OoH component of their work may require expertise in the management of a wide range of conditions including traumatic, cardiac, obstetric and psychiatric emergencies. The development of GPwSIs should be complementary to the support given to rural doctors to develop their extended generalist skills.

26 Clinical nurse/ AHP specialists and nurse/ AHP consultants in remote and rural areas can deliver enormous benefits to patient care, both in terms of a direct clinical role and in supporting the local delivery of services. We believe nurses and AHPs have three core functions across the range of services:

• first-contact care: assessment, treatment, care, referral and discharge
• management of long-term conditions and providing continuing care and rehabilitation
• public health and health promotion to improve health and reduce inequalities.

27 These roles can be expanded to include diagnosis, treatment, and direct referral to medical consultant services (including direct referral for surgery, where appropriate). Practitioners will also be involved in the pre-elective episode of care, providing continuity throughout the patient journey by co-ordinating pre-admission and aftercare.

28 Integral to role expansion will be robust arrangements for competence assessment, supervision, education and continuing professional development.

29 Building the knowledge and expertise of community practitioners around the public health agenda is an essential in remote and rural areas. Increasing local capacity is necessary to address key health issues such as poverty, alcohol misuse, smoking, and sexual and mental health.

30 Role extension is an essential prerequisite of the extension of primary care. Our vision of extended primary care in rural Scotland shares many of the features of 'intermediate care' as described by Temple in his 2002 report to Ministers, Future Practice (Temple, 2002). He wrote of intermediate care:

'We define this as lying at the interface of Primary and Secondary Care, it will have a key role in delivering the service of the future. It is important to explain and secure the support of the public for this new approach to service delivery. Its hallmarks are:

• New relationships between Primary and Secondary Care Practitioners that ensure that the skills of both are applied to each patients care in the most effective way;
• Specific roles for General Practitioner/Community Hospitals providing care more locally and relieving pressure on the secondary sector;
• Closer working with Social Care to develop the hospital at home, supporting timely discharge, and prevention of re-admission schemes;
• An extended role for General Practitioners and an increase in the capacity of Primary Care and;
• Improved access from Primary Care to investigations e.g. imaging perhaps through Ambulatory Care Centres'

31 Consideration should be given at NHS Scotland level to developing a Scottish Network for Extended Primary Care, through which best practice can be exchanged.

Community hospitals

32 The general practice will be a key resource in providing extended primary care in rural communities. So too will the community hospital.

33 Patients receiving care in community hospital beds will be those who cannot be cared for at home, but who do not require the expertise and specialist diagnostic and treatment facilities of a more distant hospital.

34 In a community hospital setting, extended primary care services will care for patients needing clinical assessment, re-assessment or who have a condition or problem that requires clinical and supporting interventions.

35 The service will provide care and treatment for local patients admitted from their own homes/communities or who are transferred from other parts of the healthcare system prior to complete hospital discharge. They may also, on occasion, admit patients from other localities.

36 It is a vital role that will become more important as tertiary health care becomes increasingly focused in specialist centres located in cities or large towns.

37 It is essential to maintain the accessibility of community hospitals to patients throughout Scotland. With extended primary care provision as their fundamental function, particular services provided in different areas may vary. Differences in service provision will occur due to local need, accessibility of other services and a desire to develop specialist or enhanced roles within the extended primary care team arising from an overall strategic assessment of actual local needs and service provision at Community Health Partnership level.

38 A recent stakeholder questionnaire ( SEHD, in press) shows that community hospitals provide a variety of services, including palliative care. There is, however, a mistaken view that community hospitals provide only care for older people, but this need not and should not be the case in future. They could and should add pre-admission and routine testing, outpatient and specialist clinics, day surgery, convalescence and rehabilitation to their repertoire of services.

39 Integration of community hospitals within the healthcare system will be enhanced by the continuing development of clinical and care networks facilitated by appropriate communications technologies such as tele-medicine and video links.

40 Joint Future, the introduction of Community Health Partnerships and the prevailing policy climate highlight the desirability and importance of shared goals, understanding and team working across all the stakeholders involved in primary and community health care. Patients benefit when teams integrate, share skills, share information and avoid duplication of work.

41 Responses to the community hospital stakeholder questionnaire, referred to above, showed that a clear strength of current community hospitals is their encouragement of multidisciplinary working. Respondents made it clear that a shared vision for development of community hospitals involved their use as resource centres for the local extended primary care team and, indeed, the local community.

42 We suggest that community hospitals could form a 'hub' or 'base' to house 'traditional' community and primary care, social work and voluntary sector staff, AHPs and visiting consultants/outreach service providers. Co-locating these staff would foster interdisciplinary work and help to develop the culture of collective understanding and shared information inherent in the ethos of Joint Future.

43 Co-location would also foster team-working, allowing the development of appropriate skills within multi-skilled teams rather than within individuals or professional groups. This is an important feature in ensuring breadth and coverage of skills across the team and for long-term sustainability of services. Quality standards developed for community hospitals should apply across the team and consideration could be given to developing standards for team-working.

44 Resource centres could progress in relation to local needs and may consider developing diagnostic services and near-patient testing. Clinical pharmacy may also have a role, but its development in situ should be considered with reference to existing local pharmacies and dispensing general practices whose sustainability may otherwise be fragile.

45 In their role as local resource centres, community hospitals could provide an ideal base for OoH providers. Again, a multidisciplinary perspective could help to ensure the appropriate skill mix of OoH teams. There is also an urgent need for the service to develop expertise in the OoH hub in co-ordination of service provision in remote and rural areas and review its governance and management arrangements. A feasibility study on the development of a single national system of triage and service co-ordination that links local knowledge to triage and dispatch activities should be undertaken.

46 The ultimate realisation of the community hospital as an extended primary care community resource would be seen in the formation of partnerships with the local community in using the resource centre for a range of health-enhancing activities, including sports, exercise, educational and social activities.

Implications

47 These proposals have implications:

• appropriate contractual arrangements need to be in place
• the budget for extended primary care services needs to acknowledge their place in the system
• investment in equipment, staff and training will be required
• consideration needs to be given at strategic level to the number and location of extended primary care facilities; current services may not be in the right place, and there may be a case for extended primary care facilities in urban areas.

48 Development may imply investment in buildings, staff, skills, equipment and other resources. Development of community hospitals as an out-of-hours base would require equipment and medicines availability.

49 Appropriate contractual arrangements need to be in place for resource centres to ensure in-hours and out-of-hours providers work seamlessly and effectively, and appropriate supporting measures (information, communication and resources) should be introduced to assure this.

50 Extended primary care resource centres could produce economies of scale in support staffing, but co-locating the extended primary care team might pose other administrative and management implications. The team would require administrative and technical support. As a key part of an extended primary care system operating on a multidisciplinary basis, it would be important to ensure appropriate management arrangements were in place to set out clearly local responsibility for the operational and strategic management of the centre. The possession of local working knowledge will be crucial when making such appointments. Budgets could reside in local teams through the CHP, further engendering an imperative for joint working.

Access to urgent and unscheduled care

51 Access to urgent or unscheduled care was a major issue during our consultation meetings in rural Scotland. Many of the presentations of illness that occur out of hours can be adequately dealt within the local community.

52 The main area of concern for remote and rural communities is the retention of appropriate systems to cope with the 5% of OoH activity that is genuinely emergency. Traditionally, there has been a reliance on the local GP to bridge both the time and care gap. These GPs provide emergency and trauma care services in addition to primary care, and often augment the local ambulance response.

53 A resilient rural community would have the following in place.

• Immediate telephone access, perhaps through a satellite link, to an emergency triage and dispatch organisation. The organisation would assess the level of emergency need and either dispatch appropriate response or arrange for further assessment.
• First responders - people drawn from the local community who were trained and supervised by the local health systems.
• Professional emergency response graded to need. This would include nursing, paramedic and medical personnel. Healthcare outcome improvements have been linked to the delivery of medical expertise at the site (Brampton, 2001).
• Access to diagnostic facilities where definitive diagnosis cannot be made at the incident site. Patients would be transferred to the nearest diagnostic centre capable of defining the condition and stabilising the patient. This may be a community hospital or rural general hospital or, in extreme cases, a specialist trauma centre.
• All of these expertise needs would be available within agreed response times that were achievable and sustainable for the individual community.

54 The difficulties of travel across remote and rural Scotland must be taken into account in any consideration of an emergency scheme. While road transport will remain the mainstay for most remote and rural communities, support will be required from high-quality air transport systems involving a mix of helicopters and fixed-wing aircraft.

55 The Helicopter Emergency Services ( HEMS) system offers a more appropriate means of providing medical assistance in remote areas, with a significantly wider action range (Lackner and Stolpe, 1998). Helicopters have a role in providing emergency cover over large and remote geographical areas and in situations inaccessible to land ambulances. But planning and investment in infrastructure will be necessary to ensure an effective and sustainable response.

56 A robust analysis of the benefits of helicopter transport is given in a study for Northern Ireland services in 2003 (Booz Allen Hamilton, 2003). In essence this report says;

'Effective HEMS (in any response role) requires an integrated (as opposed to fragmented) pre-hospital emergency care system and the development of a significant amount of (usually new) 'institutional' mechanisms including a system of clinical coordination, and implementation of an effective operational and clinical audit regime.'

57 While it's tempting to think that rapid transportation of patients can solve many of the emergency problems in remote and rural areas, this is not borne out by the literature. International evidence shows a clear need for the integrated system of care proposed in this chapter.

58 Airway management at the scene has been identified as the crucial factor in survival pre-hospital (Nicholl, 1996). The emphasis in air transport is focusing more and more on primary transport of patients who have already been stabilised by ground rescue squads .

59 As distance and time increases with rurality and remoteness, so there is a greater need for an integrated pre-hospital emergency care system.

60 We recommend that:

• The interdependence of local NHS Boards, NHS 24 and the Scottish Ambulance Service in providing effective unscheduled care services in remote and rural areas needs to be recognised. An integrated unscheduled care service should be planned at regional level building on the approach outlined elsewhere in this chapter, and delivered locally.
• The Scottish Ambulance Service should be asked to lead a review of current first-responder schemes, involving local NHS Boards and local communities, with a view to establishing a national system of first response in remote and rural areas with appropriate accreditation, support and governance.
• The role of HEMS should be reviewed and, if necessary, enhanced in remote and rural Scotland.

Rural general hospitals

61 While our work has been aimed at extending local provision of rural health care, we also recognise the importance of the Rural General Hospital ( RGH). We defined the Rural General Hospital as:

'A hospital sited in an area distant from urban conurbations which because of compromised patient travel times provides a locally based consultant led service to meet the healthcare needs of a population.'

62 The role envisaged for the RGH builds on that described by the West Highland Solutions Group in their report of October 2004. It described a model of acute health care based on the collaboration and joint working of staff in Belford Hospital in Fort William and Lorne and Islands Hospital in Oban.

63 We see the Rural General Hospital as providing care in the following areas:

• emergency medical care: triage, diagnosis, resuscitation and stabilisation on a 'treat where possible, transfer when necessary' basis
• locally-based routine elective care: diagnosis, treatment or transfer and follow up
• care for long-term conditions: care of older people, stroke and diabetes care and renal dialysis.

64 Collaboration is key to ensuring that this model is effective. All Rural General Hospitals must have defined links to one another and with larger hospitals. The larger hospitals, in collaboration with Rural General Hospitals, have responsibility for ensuring that the bulk of the remote community's healthcare needs in emergency and planned care are met.

65 The RGH model of service will provide scheduled and unscheduled care to its community. A range of medical and surgical skills will be required if most problems are to be dealt with on site, but it will be just as important to be clear about limits in competence of the RGH as it will to have a suite of core procedures that can safely be delivered.

66 Skills must extend to first-class resuscitation for those requiring transfer, especially with trauma. But the Rural General Hospital cannot be sustained on trauma and acute illness alone, and a range of planned services should be provided, maintaining local services and consultant skill levels.

67 Each RGH should examine what level of elective service it can safely support using the basket of day case surgery discussed in Chapter 8 as a starting point and considering how it might appropriately be extended through Managed Clinical Networks. Over time, we would expect to see a more definitive range of services emerge. The North of Scotland Regional Planning Group should act as a facilitator for developing the menu of services, given that some may only be sustainable with networked or visiting support from a larger hospital.

68 We recommend that:

• NHS Scotland should recognise the key place of Rural General Hospitals at Lerwick, Kirkwall, Stornoway, Wick, Fort William and Oban in the delivery of scheduled and unscheduled care.
• The North of Scotland Regional Planning Group, in collaboration with the West group, should be charged with establishing a strategic network to oversee the development of the Rural general Hospita as outlined above, including the development of formal links with specialist centres and the development of hospital at night models.

Transport

69 At present, many rural communities have a range of transport services available to them, some provided by statutory agencies, others by charities or volunteers. A step-change is needed to provide systems that will foster an integrated transport solution in Scotland and allow healthcare providers to support rural patients to gain access to services.

70 Active co-ordination of transport for patients is vital. This must be planned as a key component of networked services to ensure that people who are distant from provider centres have transport that is:

• easily accessible
• patient focused, by having the flexibility to meet the changing needs of the patient
• sustainable
• capable of becoming part of an integrated transport network.

71 We recommend that:

• Community Health Partnerships should have responsibility for the planning and co-ordination of transport systems to meet the healthcare needs of the community.
• The Scottish Ambulance Service should work with Community Health Partnerships, NHS Boards and Regional Planning Groups to ensure that appropriate transport solutions are developed to support local sustainability.
• Regional Planning Groups should link with the new regional strategic transport partnerships to ensure integration of health needs in statutory transport plans.

Workforce issues

72 Staffing of remote and rural healthcare services must be planned and rational. This will require recruitment of individuals with the skills needed to provide the core service at local, regional and national levels. Opportunities for development of cross-boundary (primary and secondary) care is essential to the success of this model.

73 The remote and rural healthcare workforce requires a wide base of skills and competences to meet health requirements and sustain services. Education programmes should be tailored to meet these needs.

74 The education opportunities in rural general practice or in RGHs must not be overlooked. Trainees will make worthwhile contributions to the service as part of their learning experience. Education will also underpin the innovative role development opportunities available to nurses and AHPs, which must be pursued actively.

75 Sustainable remote and rural services will depend on career pathways which support practitioners in remote and rural environments. NHS Scotland should ensure that a culture of positive value is developed for remote and rural practice. Career management should be underpinned by:

• development of career pathways for the remote and rural environment
• access to mentors
• joint appointments/attachments with larger centres for 'hard to fill' posts
• succession planning, in collaboration with partners
• professional networks with larger centres and among remote and rural practitioners
• links with the higher and further education sector, including access to research and study facilities and time.

76 We recommend that:

• Rural General Surgeons and Physicians should be recognised by NHS Scotland and the Royal Colleges as specialisms in their own right, and appropriate training and career pathways should be developed.
• All healthcare practitioners in remote and rural areas should have access to ongoing education, mentorship, research and attachments to larger units. The remote and rural environment is, however, a good learning environment and should be recognised as such.
• NHS Scotland should develop local access programmes to attract people in remote and rural communities into healthcare careers, and most education should be accessible as locally as possible.

Summary of recommendations

• Recognition of the interdependence of local NHS Boards, NHS 24 and the Scottish Ambulance Service in providing unscheduled care to remote and rural areas.

Lead responsibility at Regional Level

• There is a review of current first-responder schemes. Lead responsibility Scottish Ambulance Service
• Develop expertise in OoH hubs in co-ordination of service provision in remote and rural areas.

Lead responsibility at Regional Level

• Review governance and management of OoH hubs, undertaking a feasibility study on the development of a single national system of triage and service co-ordination.

Lead responsibility at National Level

• Undertake a review of HEMS and if necessary enhance in remote and rural areas.

Lead responsibility at National Level

• There is recognition of the key place of Rural General Hospitals in the delivery of unscheduled and scheduled care.

Lead responsibility at National Level

• The development of rural general hospitals, formalising links with specialist centres.

Lead responsibility at Regional Level

• There is planning and co-ordination of transport systems to meet the needs of the community.

Lead responsibility at Local Level ( CHP and NHS Board) and Regional Level

• Links should be formed with the new regional transport partnerships to ensure integration of health needs in statutory transport plans.

Lead responsibility at Regional Level

• Rural General Surgeons and Physicians should be recognised by NHS Scotland and the Royal Colleges as specialists with the development of appropriate training and career pathways.

Lead responsibility at National Level

• There is development of local access programmes to attract people in remote and rural communities into healthcare careers, with most education being delivered locally.

Lead responsibility at National Level

• Develop networks of rural hospitals to ensure continued access to key elements of acute care and establish a Virtual School for Rural Health Care to ensure workforce development.

Lead responsibility at National Level

References

Boerma WGW, Groenewegen P P, Van der Zee J. (1998) General practice in urban and rural Europe: The range of curative services. Social Science and Medicine 47(4) pp 445-453.

Booz Allen Hamilton (2003) Feasibility Study on a Helicopter Emergency service ( HEMS) for the Island of Ireland.

Brampton WJ. (2001) Using Helicopters for Secondary Transfer - Does the Patient Benefit?, Anaesthesiol Reanimat 26, Heft 4

Farmer J, Iversen L. Baird G. (2001) Rural deprivation: Reflecting reality. British J. General Practice 51(467) pp 486-491.

F uture Practice(2002) A Review of the Scottish Medical Workforce - Professor John Temple. July

Lackner CK, Stolpe E. (1998) New Order of Things: An international overview of Air medical transport, Air Medical Journal

Mungall, I, in collaboration with members of the RCGP Rural Standing Committee Rural General Practice (2004).

Nicholl J,P, Brazier,J,E Snooks,H,A.(1996) The Costs and activity of the London Helicopter Emergency Medical Service. Journal of Health Services Research Policy 1(4)

Scottish Executive (2003) Family Health Nursing in Scotland A report on the WHO Europe Pilot

Scottish Executive. (2004) Annual Rural Report

Scottish Executive.(2005) The Review on A Strategy for The Future of Community Hospitals
(in press)

Temple J. Securing Future Practice (2004) Shaping the New Medical Workforce for Scotland

Swan G, Godden DJ, Walker KM, Selvaraj S. (2004) Clinical Peripherality: characterising remote and rural primary care. University of Aberdeen. Report to Scottish Executive Remote and Rural Areas Resource Initiative.

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