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CHAPTER FIFTEEN: REMOTE AND RURAL CARE FOR CHILDREN AND YOUNG PEOPLE

The section details 5 key milestones for measuring progress and 7 actions relating to remote and rural care for children.

15.1 MILESTONES

The consultation document asked whether consultees agreed with each of the milestones and, again, a large majority (around 90%) of those replying at each question voiced agreement with the milestones.

Dedicated training package

In order to avoid the need for staff to travel to access training, one Professional Body suggested that outreach and local delivery be considered and an NHS Management & Strategy Group expressed concerns about the delivery of training, suggesting a link with the NES virtual school of healthcare project. This comment also applied to the milestone on accredited training.

It was suggested, by a Professional Body, that the training package should include "practical experience in a remote and rural area whether for GPs, specialists or nursing staff" and a Voluntary/ Charity Body asked that the specific needs of children and young people with PMLD be included.

Table 15.1
32: A dedicated training package is available to support the provision of child healthcare in remote and rural settings by 2006

Base: All those responding in each category

Clarification was requested, from a Professional Body, on who the training package is aimed at and whether completion of this would be a prerequisite of taking up a post in a remote and rural setting. Again this comment also applied to the milestone on accredited training.

In addition to supporting the provision of child healthcare, one consultee commented that there could be a dedicated training package to support staff in remote and rural areas.

Two consultees felt that the timescales should be extended, perhaps by a year.

Explicit support arrangements

In addition to a named consultant, consultees also felt there should be:

• appropriate arrangements for deputising (2 mentions);
• a named nurse (3 mentions);
• a named AHP, with an associated comment on the need to move away from a solely medical focus (1 mention).

There were 2 suggestions for a senior clinician from each DGH to be responsible for oversight of local arrangements and liaison with specialist services and a Local Authority pointed out that island services may access more than 1 hospital.

Table 15.2
33: All remote and rural areas have explicit support arrangements with a specialist children's hospital, including a named consultant by 2007

Base: All those responding in each category

Arrangements for discharge

The importance of liaising with other agencies was highlighted by two consultees and another commented that "Recent NES (Knowledge Services) investment in ICT for education and development communications has application for clinical use and may offer support for the implementation of this milestone." Remote or rural settings can place additional burdens on young carers; a Voluntary/ Charity Body stressed the importance of considering the needs of young carers in these situation.

Table 15.3
34: Arrangements for discharge of all children to remote and rural settings is structured to reflect care options available locally by 2007

Base: All those responding in each category

Access to effective clinical and educational support via telemedicine

One response stressed the need to ensure good quality telemedicine facilities and another highlighted the need to extend this support to all staff groups. Two consultees expressed concern over the timescale with one commenting that although NES is currently working with the Scottish Centre for Tele-health "are still unsure how realistic this target is and therefore are unable to agree or disagree with this key milestone".

A Professional Body and an NHS Board both suggested that consideration be given to rotational programmes to main centres and also to what attracts staff to work in remote and rural areas. These 2 comments were made in relation to both this and the following milestone. One Professional Body expressed reservations "given the experience of NHS 24".

Table 15.4
35: All remote and rural areas to be able to access effective clinical and educational support via telemedicine links by 2007

Base: All those responding in each category

Accredited training

Two consultees commented on the lack of detail and one on the need for separate training in relation to young people. One Voluntary/ Charity Group commented "Any dedicated training programme must be given the time due to it and staff supported to access the training programme taking account of their own home commitments. The training cannot be 'yet another thing to do' for staff already heavily committed, but space created to enable meaningful and effective participation".

Table 15.5
36: Staff providing care to children and young people have completed the accredited training being developed through NES by 2008

Base: All those responding in each category

General comments on the key milestones

Seven consultees commented on the need for tailoring to needs and an NHS Clinical Group commented, " We feel that a one size fits all model should be resisted as each rural community has significantly different needs.". An NHS Management & Strategy Group also pointed out that "The reference to the RARARI work is useful but the project concentrated on the Western isles proposals and spent limited time elsewhere and therefore recommendation of this model for elsewhere should be treated with caution".

The timescales were seen as being challenging, with 2 consultees commenting on this and a further consultee mentioning the need for adequate resources.

An NHS Management & Strategy Group felt there should be another milestone "'Clear arrangements should exist in R&R areas for the immediate management of acute mental or physical illness, supported as part of a formal network, to ensure appropriate clinical decision support. These arrangements should be supported by robust retrieval and transport systems". They described this as fundamental.

A lack of understanding of the challenges presented by remote and rural settings on the part of those who do not work there was highlighted by 2 consultees. Two consultees commented on the different needs of communities which are rural but are not remote.

15.2 ACTIONS

Managed Clinical Networks

There were a small number of comments, from 1 consultee each, on this action:

• ensure flexibility so that appropriate care can be accessed;
• should also be the responsibility of NHS Boards;
• all agencies should have access to relevant MCN;
• there should be practice based education, secondments and exchanges to and from specialist areas;
• important to establish the number and type of MCNs.

An NHS Management & Strategy Group felt the wording should be changed to "Formal network arrangements should be developed between remote and rural areas and appropriate specialists services to deliver appropriate local care and support decision making in the care of children".

Designated Paediatric unit for each remote and rural area

One Voluntary/ Charity Group expressed "a preference for a team visitation to rural areas to meet a range of medical needs at one time rather than a single named consultant" and a Royal College commented on the need to have a full multi-disciplinary team, including AHP provision, in place.

One consultee commented on the joint challenge faced by children in remote and rural areas who have complex needs.

One consultee felt this should be done jointly with NHS Boards and another commented that this action may take place across RPGs.

Discharge planning co-ordinator

The need to be clear about the remit of the role and funding provision was highlighted by 3 consultees. An NHS Service Provider felt this should be linked to other discharge planning while a Royal College commented that "The discharge planning co-ordinator must be aware of needs of remote and rural areas including needs in respect of AHP services". One consultee felt that RPGs should be involved in planning this action instead of NHS Boards, and another stressed that the co-ordinator must be aware of the particular needs of remote and rural areas, including needs relating to AHP services.

Accredited training

One NHS Management & Strategy Group asked "Is there a need for other professions to develop a similar model?". Other staff pinpointed for receiving accredited training included:

• all clinicians who work in paediatrics (1 mention);
• all GPs (1 mention);
• all paediatricians (1 mention);
• all physicians and clinicians with an interest in adolescent health (3 mentions).

One Professional Body commented "We are hesitant about the practicalities of this Action. We believe that remote and rural issues in relation to service provision for children and young adults in remote and rural areas are mainly about geographical isolation, transport and having practical locally developed networks. This requires multi-disciplinary input incorporating the views of general practice. Provided there is adequate funding to support multi-disciplinary input to the local delivery of child health services we are broadly supportive of the aims of this Action".

Expanded outreach support

One NHS Management & Strategy Group suggested that "this needs to be supported by ongoing links and a structure of specialist support for local practitioners developing skills through such training opportunities", while another commented that the wording could be changed to emphasise the focus on developing a shared approach for the benefit of the child. A Royal College felt the action should include mention of access to CCN teams and networks.

Dedicated training packages in paediatric care

Specific comments on this action included:

• linking this to the work of the remote and rural education strategy group and training pathways(1 mention);
• the need for a regular annual update (1 mention);
• these should be delivered locally in partnership with external partners (2 mention);
• the need for national protocols and guidelines (3 mentions);
• include awareness of issues facing parents, carers and siblings (1 mention);
• include training for parents (e.g. injections) (1 mention).

One consultee reported that local paediatric nurses were not aware of the package and asked whether qualified paediatric staff will be required to complete the training.

Telemedicine links

One consultee felt this should be assigned to NHS Boards as well as RPGs. A Professional Body commented on the usefulness of telemedicine in many settings, not just rural, and another felt it should be developed in urban sites as well. A Royal College felt all members of the multi-disciplinary team should be able to access and use telemedicine.

One consultee reported on their positive experience of telemedicine in remote and island settings but another pointed out the need for investment in kit and training.

One Royal College suggested the wording be changed from 'paediatric' to 'children's'.

Other comments on actions relating to remote and rural care

Other areas which consultees felt could be included in this section were:

• support for staff working in remote and rural areas, e.g. housing, transport etc (1 mention);
• the need for funding in place locally to support service development (1 mention);
• the need to provide local support to children with complex needs in remote and rural areas (1 mention);
• the provision of a "better definition of the areas of Scotland that are viewed by the Executive as remote, rural, remote and rural". Professional Body;
• the importance of confidentiality in small communities.

Examples of good practice were provided by 2 consultees.

At the seminar workshop sessions the issue of provision in the Western Isles and North of Scotland featured in questions that were posed to the panel. These included queries on the appropriateness of Raigmore serving as a specialist centre to RGHs; whether RGHs would have an on-site clinician and where Community Hospitals fit in the proposals for child health care in remote and rural areas.

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