Delivering for Remote and Rural Healthcare: The Final Report of the Remote and Rural Workstream

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The Remote and Rural Workforce

Team working, integration and shared competencies are key to the future staffing of services within remote and rural healthcare. Many of the solutions to the development of sustainable and affordable health services will need to involve a range of doctors, nurses, midwives AHPs, and healthcare scientists and their support staff, working creatively to deliver new models of skill mix and interventions that are safe, effective and patient centred.

The current workforce is ageing and organised in a fragmented and reactive way. If care is to be sustained, then the future workforce must be organised differently and NHS Boards must ensure that adequate workforce planning mechanisms are in place to ensure the sustainability of services. The age profile of the remote and rural workforce is available in the Technical Annex of this report.

Primary Care

Current

Future

Primary Care Teams

  • Fragmented
  • Different organisations
  • Duplication
  • Reactive care

Extended Community Care Team

  • Integrated
  • Partnership working
  • Seamless care
  • Anticipatory care

Currently teams within the community are typically fragmented and disparate in terms of the care provided and the location of teams. The team in some areas may be limited to a single-handed GP practice. This can lead to duplication of effort and disjointed care. Professional skill levels and mix vary between geographical locations despite similar workloads. It is proposed that all professional resource within the community must be integrated, both in terms of teamwork and of location and that single-handed practices should be actively discouraged and, where possible linked to others. This has patient safety benefits as it addresses the challenges experienced by isolated practitioners. This new model will be known as The 'Extended Primary Care Team' ( EPCT) and will encompass a partnership approach between agencies and multi-disciplinary teams.

The EPCT should incorporate the General Practitioner ( GP) (although this may be a visiting service), and include all other health and social care professionals such as the Community Health Nurse, Midwife, Care Manager, Social Workers, Support Workers and education. Each practice should receive visiting services from Community Psychiatric Nurses, Allied Health Professionals ( AHPs) and Specialists such as the Macmillan Nurse or Clinical Psychology. The core EPCT should be co-located where possible to enhance communication and team working. The wider team such as 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). All available resource within the locality should be utilised to build 'Community Resilience'. An example of this would be the extension of the 1 st responder schemes to incorporate the Coastguard, Fire Brigade and Forestry Commission.

In rural areas the EPCT will benefit when co-located with other services including those provided out of hours, such as NHS 24 hubs. This is likely to be either the GP Practice or may be the Community Hospital within the locality. The generic term of Community Resource Hub will be utilised to encompass GP Practices or Community Hospitals where staff and services are integrated. Where there are lone workers, NHS 24 should be utilised as important information, advice and peer support resource. 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. A wider range of local services must be provided and visiting specialist services increased.

Commitments

Health and social care within remote and rural areas should be organised as integrated teams, known as Extended Community Care Teams ( ECCT). Current organisational barriers should not stand in the way of efficient service alignment.

The ECCT should be co-located when possible with other services, both within normal working hours and out of hours.

NHS Boards should consider opportunities to link single handed practices to reduce professional isolation and enhance the range of services available to the Community.

Community Nursing

Nurses are the largest professional group within any healthcare system. Nurses have a key role in supporting people within their home environment acting as the lead professional in the delivery of care. Nurses in remote and rural settings can be characterised as having a wide range of key skills, although these may be practiced only to a limited degree.

The role of nurses in remote and rural practice has been reviewed in the context of the current Review of Nursing in the Community in Scotland 35. This report defines the role of nursing in the community as concerned with:

  • "Improving health and well-being;
  • Maximising individuals' and communities' self-care potential;
  • Reducing inequalities;
  • Delivering safe and effective services within a multi-disciplinary, multi-agency context as close to the patient's home as possible, particularly for those with long-term health conditions;
  • Supporting social and health care services in protecting the public from harm;
  • Contributing to reducing length of patient hospital stays by providing acute, short-term support to individuals on discharge from hospital." 36

The new Framework for Nursing and AHPs in Scotland 37 underpins the core values around caring, enabling and proposes a rights and evidence based approach to practice, which places the emphasis on preventative health care and earlier intervention.

It is envisaged that the nursing workforce model should be based on the skills set required to support the patient through the continuum of care. All roles will require a level of competency in specific generalist skills. The graph below (Figure 6 describes the stages of the patient journey as they move from independence (self care) through dependence (acute care) gradually regaining independence (enabling care) and reaching full independence again, where possible (self care).

Figure 6: Community Nursing Along the Continuum of Care

Figure 6: Community Nursing Along the Continuum of Care

Where the patient cannot regain total independence, perhaps through a long-term condition or because they are at the end of life, the dependency level will rise and the community nurse's role becomes crucial in the support of that patient and their family. Throughout the journey, where the balance of patient need shifts from nursing to social care, the lead role will change to the profession with the most appropriate skills ensuring that care provided is needs led. A wide range of skills will therefore be required with practitioners working in a flexible way as part of an, integrated and multi-disciplinary team.

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.

The Remote Community Resource Hub Staffing Model

The remote community resource hub will have a generalist team covering a wide range of competencies, based on the needs of the local populations. Teams should comprise of medical, nursing, AHP, social and voluntary care backgrounds, incorporating informal carers from the community as appropriate. Only the roles of the main professions have been outlined here to avoid duplication of the implementation of the Community Hospital Strategy.

Medical Staff

Medical staff will be responsible for leading the inpatient service and for supporting the nurse-led minor injury/illness service both within and out of hours. A combined medical staffing model with a skill mix of GPs, GPs with a special interest ( GPwiSI) and/or Rural Practitioners dependant upon the agreed role of the hospital. For example, where hospitals deliver an enhanced service such as those in Stranraer, Mid-Argyll, Skye and Benbecula they will be staffed by GPs with a Specialist Interest ( GPwiSI), or Rural Practitioners and in others, such as Hawick or Islay, will have GPs.

Nursing Staff

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

Allied Health Professionals

Allied Health Professionals ( AHPs) will work across the spectrum of care. Their role is described in further detail under the heading of RGH Staffing model below.

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 pharmacies.

The RGH Staffing Model

The future RGH staffing model is also characterised by a team based competency approach and is described in Figures 2 and 3 above 38. These are discussed below by discipline, as there are differing implications for different professions, particularly in relation to education and training.

Competence in the management of acute medical, surgical (including initial fracture management and manipulation of joints), delivery of anaesthesia and mental health emergencies are core skills/competencies required within the RGH. Other competencies include management of low risk births, neonatal resuscitation, endoscopy, rehabilitation and management of chronic conditions. These competencies must be available and sustained within the multi-disciplinary team.

Medical Staff Models

Anaesthetic Service

As noted above, within the RGH the anaesthesia service will be predominantly Consultant-led and delivered, 24/7. There is a role for GPs with appropriate training to support this model 39. It will be for individual NHS Boards to determine their workforce numbers and skill mix dependant upon need, however it is envisaged that a team of three will be required to deliver this service.

Acute Medicine Service

Acute and Internal Medicine is the largest proportion of activity within the RGH and there is therefore a clear need to sustain and develop such services. The Needs Assessment undertaken by the NoSPHN showed that the different medical staffing models which currently exist within RGH medical services have evolved historically and there is a need for further analysis to understand whether different models result in different levels of service delivery, for example different transfer rates to other hospitals 40. It is therefore proposed that an audit be commissioned to evaluate the effect on service delivery of a Consultant led medical service as compared to a GPwiSI led medical service as part of an obligate network.

Across the remote and rural community, there are diverse views on the most appropriate medical staffing model for the delivery of acute medicine within the RGH. In 5 out of the 6 RGHs there is a consultant-led and consultant delivered acute medical service; in one RGH this is led by locally trained GPs with a special interest, in a networked arrangements with a larger centre. There are diverse views on the future model. Some areas prefer a consultant-led and consultant delivered service, delivered by either specialist in remote and rural healthcare or dual trained consultants ( e.g. in general medicine and diabetes), whilst others support a mixed economy, with GPwiSIs leading local delivery, as part of an obligate network with specialists in a larger centre 41. This might include. The Remote and Rural Training Pathways acute medicine sub group in collaboration with the General Practice sub group, has proposed that the model might include GPs who have undertaken training to Level 2 competency in acute medicine, and NHS Education in Scotland have identified funding to pilot this new potential model.

Clear pathways of care and robust clinical decision support will be required where the agreed model includes an element of General Practice and work has been undertaken as part of the remote and rural project in NHS Orkney, in collaboration with NHS Grampian, to develop protocols for the most common medical conditions. These can be seen in full in the Technical Annex of this Report.

The workforce model for the delivery of medical services in the RGH is not prescriptive and NHS Boards should have the local flexibility to determine the skill mix that best matches the health needs of their local population. Three team members will be required in any medical team to provide a 24/7 service.

General Surgical Service

A 24/7 surgical service, which delivers planned and emergency, in-patient, outpatient and day case services will require access to a team of three specialist general surgeons trained in remote and rural surgery as a minimum. The surgical team must be able to demonstrate the range of competencies required to support the agreed workload, however this must extend beyond the surgeon, to the whole team.

The surgical service must be arranged as part of a network with a larger centre. This might include the RGH surgeon visiting a larger centre to maintain skills and pursue a particular interest.

Networked Medical Staff

A number of other specialists will be required to support the RGH at a distance through formalised obligate networks. These include radiologists, psychiatrists and specialists in laboratory medicine. There do however need to be clear arrangements for accessing specialist opinions. This will require a change in current working patterns and arrangements within those larger centres.

Visiting Services

Other services can be provided either by visiting specialists or by networks with larger centres. Where the medical input to a service is accessed at a larger centre distant from the RGH, that larger centre will need to alter their systems to ensure that an identified individual has responsibility for the provision of support to the RGH. This changing model will require an Emergency Retrieval System, at times staffed by doctors, in addition, to ambulance personnel.

Nursing Workforce

Nurses in an RGH are currently delivering patient care within a model of multi-skilled generalist nursing practice. This role is necessary due to small numbers of patients, low volumes depending on patient need and infrequent exposure to certain situations. Nurses within an RGH have therefore developed a wide and diverse range of skills. There is a need for future nursing models to focus their skills in order to ensure regular use and guarantee competence and confidence in an emergency and/or unpredictable situation, identifying where nursing roles are most appropriate, where supported nurse led services can be further developed and/or become independently nurse led and agreeing where care needs would be better met by other professions or disciplines.

Acute and Intermediate Care

Within the general inpatient area, from a nursing perspective, certain patients can have similar core needs and consequently require similar broad nursing knowledge, competence and skill needs. Competences required for the delivery of this type of nursing care should be 'clustered' around specific patients' needs to ensure more frequent use and therefore maintenance of acute knowledge and skills. For example, nurses with acute care competences could care for patients requiring acute and/or emergency or high dependency care. This clustering approach could be developed for other types of patient needs, for example, nurses with intermediate care skills would care for patients requiring rehabilitative care and enable them towards self and independent care.

The competencies described are skills that would be required of a registered nurse 24/7 and at this point are of a relatively generalist nature and not yet at an advanced practitioner level.

Specialist Care

There are groups of patients within the RGH the care of whom will require specific knowledge, skills and expertise, for example, patients with long-term conditions, paediatrics, diabetes or renal disease. For this reason, a sufficient number of nurses will require to develop specialist skills, in these particular areas, to ensure the level of expertise is consistently available to meet patient needs. This role is described as a practitioner with a special interest in a particular field of practice, and would require to meet defined levels of competence, with clear lines of accountability and supported by formal education standards.

Throughout the remote and rural process of engagement, nurses reinforced the need for a formal supporting structure. This opens up debate around whether there may be an opportunity for the development of a regional role of a Nurse Consultant in Remote and Rural Healthcare and this needs further exploration. The development of such a role would not, however preclude individual NHS Boards flexibility to develop local Nurse Consultant roles where there is a defined need, for example, in the case of a Nurse-led Service.

RGH Nursing Model

Development of the new nursing model, as described, would contribute to the enhancement of retention of current staff and make recruitment more attractive. Figure 7 below identifies the future roles.

Figure 7: RGH Nursing Model

Figure 7: RGH Nursing Model

Development of the roles described within the model and the knowledge and skills required to deliver these, will need to be considered in the context of patient need, the subsequent demands on the whole clinical team and which role is most appropriate to meet those needs. In order to progress the model, the competences required of these roles have been mapped against the proposed Career Framework for Health 42 and Figure 8 (below) describes this in greater detail. The model should not necessarily be seen as a hierarchical, as they may be diagonal or lateral. The role of the ward sister/charge nurse is deliberately excluded, as there is a separate national piece of work ongoing which will report on this role and will required to be considered in light of the needs of remote and rural nursing.

Further work will need to take cognisance of the Agenda for Change bands and the Knowledge and Skills Framework.

Figure 8: RGH Nursing Roles

Potential Roles for Development

Descriptor

Higher level roles for development within Healthcare team

Nurse Led Services

Scope to expand/extend nurse led services and develop roles as requires within needs of clinical teams

Consultant supported nurse led services current senior roles

Future independent nurse led services with nurses working at high/very high level of decision making and authority

Specialist Nurse

Project in progress with SEHD. When completed consider how this work influences and/or informs remote and rural practice

Senior role

Link with current review of specialist roles at SEHD

Intermediate Care Nurse

Starting level of competent generalist nurse working to a level of responsibility and autonomy, developing additional knowledge and skills in a specific area based on patient need and within clinical team needs

Would require lead role at advanced practice level but team would include a range of levels of competent generalist nurses in this field of practice

Acute Care Nurse

Starting level of competent generalist nurse working to a level of responsibility and autonomy, developing additional knowledge and skills in a specific area based on patient need and within clinical team needs

Would require lead role at advanced practice level but team would include a range of levels of competent generalist nurses in this field of practice

Multi skilled Generalist Nurse with Special Interest

Starting level of competent generalist nurse working to a level of responsibility and autonomy, developing additional knowledge and skills in a specific area based on patient need and within clinical team needs

May be at advanced practice level but needs discussion as for example, paediatric knowledge may be a t level of paediatric generalist nurse

Multi skilled Generalist Nurse

Range from newly registered nurses consolidating experience, to those developing roles to higher level of practice

Role currently in place informally

Support workers

Mix of basic support to a higher level delivering care under supervision but without direct supervision

Appropriate roles to be identified within this model

Essential to the successful development of this model are:

  • Established formal networks;
  • Planned programme of clinical and educational competences relevant to the area of practice;
  • Post registration development for the Remote and Rural Generalist Nurse;
  • Development of career structures for support workers and registered practitioners.

Further work would be required based on local need to determine skill mix.

Support Workers

The role of the support worker is an essential component of the emerging nursing model. It is envisaged that Generic Support Workers would work across the health and social care spectrum, with formal training and appropriate supervision.

The core function of the generic worker includes:

  • Support of individuals with rehabilitation programmes ensuring that they can continue their rehab programme once at home;
  • Supporting individuals with self care;
  • Delivery of health promotion sessions to individuals and/or groups to support self care/anticipatory care;
  • Supporting individuals to manage their chronic condition;
  • Provision of a home based nursing/care service to support people at home for a short period of time to prevent unnecessary hospital admission in the cases of acute exacerbation of chronic conditions;
  • Provide a scheme of early supported discharge from hospital;
  • Be a worker with a broad range of knowledge and skills who could then sign post other services for people;
  • Support of young families - domestic and parenting skills;
  • Ability to address all the activities of daily living including undertaking basic observations/tests as required e.g. temperature, pulse, blood pressure, respirations, urine testing;
  • Screening processes e.g. over 75 screening, falls risk assessment, home environment screening.

This role is being developed and evaluated currently by NHS Shetland for communities that have no health or social care provision at present.

Allied Health Professions ( AHPs)

AHPs have an important contribution to make to the delivery of sustainable clinical teams in remote and rural settings. Their expertise allows them to work as first point of contact practitioners as well as 'lead' practitioners in a variety of settings. This has already been demonstrated in a number of key areas such as diagnostics, triage and treatment of musculoskeletal patients, rehabilitation and long-term condition management, amongst others.

Due to small numbers, AHPs work across the spectrum of healthcare in remote and rural areas. AHP services are diverse and the size and scope of the workforce varies considerably between the professional groups. During the scoping exercise, it has become clear that the following AHPs will have services based in remote and rural healthcare locations and some directly within the RGH. These will include:

  • Physiotherapy
  • Occupational Therapy
  • Diagnostic Radiography 43
  • Dietetics
  • Podiatry
  • Speech and Language Therapy

The other professional groups are too small to provide a sustainable service located within the RGH, or the surrounding area, but would provide a visiting service, e.g. Orthoptics and Orthotics.

Some of the professions, because of the small number of funded posts, limitations on the scope of the service, or the dependence on equipment to deliver their service, are likely to remain located in larger conurbations, DGH or Teaching Hospitals and patients will have to travel to access the service. These are:

  • Prosthetics;
  • Art Therapy;
  • Therapeutic Radiography.

Whilst the majority of AHPs will retain a broad generalist remit in remote and rural areas, there is the potential for specialisation within individual professions, or by individuals who have developed an interest. There will be different levels of specialism based on healthcare needs. These roles could be described as Specialist AHPs or AHPs with a Specialist Interest ( AHPwiSI).

A specialist AHP could be defined as an experienced practitioner with post registration training and experience in a defined speciality whose workload is focused almost entirely in that speciality. For example, there are well-established roles for Specialist AHPs in Stroke, Respiratory, Diabetes and Paediatrics etc.

The opportunities to develop AHPwiSI are usually, but not exclusively, based in locations with larger communities or groupings of communities serving a population of greater than 50,000 or more in some cases. There is potential, however, to share such AHP posts between NHS Boards, although, there will always be a limit to the number of Consultant and Advanced roles for AHPs.

The AHPwiSI model provides an alternative or additional approach bridging the gap between specialists and generalists for more rural parts of Scotland. Further work is required to consider the need for generalists, specialists, advanced or consultant practitioners and AHPwiSI within the workforce model for remote and rural healthcare. The workforce solutions are likely to involve a range of grades and solutions and further work using the Career Framework for Health to determine the components of the AHP workforce is required. In parallel with other disciplines, a career structure for AHPs within remote and rural health care must be maintained from support worker through to clinical leader or Consultant Practitioner.

The Model of AHP Workforce in Remote and Rural Healthcare

The AHP workforce model for remote and rural health care will be composed of a range of practitioners, at different levels, within each professional group. The majority of the workforce will work in a generalist capacity providing a flexible locally accessible service; however a component of the workforce will hold specialist skills and work either as an AHPwiSI, Specialist AHP or Consultant AHP. Work is ongoing in NHS Scotland on defining advanced practice for AHPs but the following definitions provide some clarity on the emerging skill and role mix in the AHP workforce with relevance to remote and rural health care.

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 CAMHSOT, 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.

Clearly the AHP workforce requirements need to be developed locally within CHPs based on a clear assessment of the health care needs and priorities in each locality.

Diagnostic Radiographers

Due to their key role in the support of remote and rural service, one specific group of AHPs, diagnostic radiography, has been examined in more detail and a tiered approach considered. It is recognised that 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 workforce model used in these locations needs to take into account the following factors:

  • Skill mix
  • Flexibility
  • Education, training and CPD
  • Governance

Extended role

Opportunities exist to ensure rapid reporting of film and scan results through role extension at advanced practitioner level. There are examples of this already working satisfactorily in some RGHs e.g. plain film reporting. Where extended roles are supported, benefits can be realised by embedding the Radiographers within the wider medical/surgical team to provide opportunity for case conference etc.

Inter-board working

Given the likely interdependency of the RGHs with other DGHs and Teaching Hospitals, opportunities exist to support innovation and inter-board working. For example, if there is insufficient volume for a particular type of investigation in one Island Board to ensure maintenance of skills in the technique inter-island services should be explored. It may be possible for an advanced radiographer with training and experience in barium studies to support 2 island services in a model of planned diagnostic provision where clinics can be booked in advance. The introduction of PACS also provides opportunities to consider emergency service provision through inter-board collaboration.

Future model of Workforce for Radiography

The emerging model for each hospital site is likely to be in line with the following:

Role

Level of Practice

1 x 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 ( WTE to be confirmed) covering a range of imaging modalities (with reporting capabilities and utilising 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 ( WTE to be confirmed)

A radiographer with general imaging skills, working as an autonomous practitioner. May supervise assistant practitioners.

Assistant Practitioner ( WTE to be confirmed)

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 (based on workload assessment/requirements)

Radiography support workers undertake clinical or administrative duties as delegated by a radiographer. Generic support workers may cover more than one professional group.

The radiography consultant role could be shared between NHS Boards, particularly the strategic leadership functions.

It is anticipated the advanced generalist radiographer would hold the necessary qualifications and skills (through undergraduate or post graduate training) to provide plain film, CT and possibly ultrasound services. Many would also be trained to undertake some reporting, particularly of plain film skeletal images, however further extension of skills to other areas of reporting should also be included to support a flexible and sustainable radiography workforce. This advanced role could provide a team lead function in areas where a managerial post is unsustainable.

Some of the larger RGHs may be able to sustain a number of advanced generalists in addition to individual sonographers as part of the radiography team. However consideration would need to be given to workforce flexibility and affordability and where demand would not require a full time Sonographer, the integration of this role with the advanced generalist radiographer could be considered. Some of these roles already exist in RGHs in NHS Highland.

Within remote and rural healthcare there are opportunities for further development in imaging services:

1. CT reporting as part of a network - there is evidence of radiographers successfully extending their role to CT head reporting (for example) in other parts of the UK.

2. Barium studies could be undertaken locally, however there is increasing evidence to suggest that the demand for this test will reduce as new technology is developed. NHS Boards should determine whether this should be provided within the RGH.

3. Plain film reporting There are examples of Radiographers in Scotland and other parts of the UK, with the required training and competences, undertaking reporting of chest or axial skeleton images resulting in a reduction in waiting time for reports assisting in the rapid diagnostic process.

5. Prescribing Radiographers are one of 3 AHP professionals who are currently able to work within supplementary prescribing legislation. Progress towards independent prescribing may also be considered in future. There are opportunities to utilise this increased flexibility within the workforce to reduce complex patient pathways and minimise hand over between professional groups, thus streamlining the patient journey.

6. Other opportunities Where demand is sufficient, there may be opportunities to increase the range of diagnostic imaging in the RGH to include videofluoroscopy, hysterosalpingogram and injection under fluoroscopy, thus reducing referrals to specialist centres. Further work in this area to consider demand for these diagnostic procedures in each area needs to be completed.

Clinical Governance

Radiographers have identified the importance of clinical governance and in particular clinical risk management within the scoping exercise for the RGH workforce. They have also recognised the limitations of the service as well as opportunities for role extension. There has been repeated mention of the importance of regular audit of practice, second opinion, case review, mentoring, training standards and the importance of integrating the radiography workforce into the clinical team in the RGH. A formal radiology network, in which the RGH radiographers participate and seek clinical decision support from radiologists within larger centres, will therefore be essential. Radiographers have also acknowledged that the physical presence of Radiologists on site as part of a visiting service is highly valued and an important part of maintaining effective governance and supports the team approach.

It is acknowledged that concerns remain within the clinical community on how far role extension can be taken due to medico-legal and accountability issues. However, the recently published joint guidance from the College of Radiographers and the Royal College of Radiologists provides clarity on these issues. It is essential that developmental work be undertaken to alleviate these concerns if the RGH model is to be accepted and sustained.

Biomedical Scientists

There is a requirement for all Biomedical Scientists ( BMS) to be able to undertake core tests in the disciplines Blood Transfusion, Haematology and Biochemistry so that they can participate in the laboratory service provision within and out of hours. A multi-skilled generalist model for Biomedical Scientists ( BMS) should therefore be developed, with all BMS working within the RGH competent to deal with a core range of tests including:

Blood Transfusion

Haematology

  • Grouping and Screening
  • Cross Match
  • Issuing of Fresh Frozen Plasma and other blood products
  • Full Blood Counts
  • INR
  • Making and interpreting films
  • IM testing

Biochemistry

  • Urea and Electrolytes
  • Glucose
  • Liver Function Tests
  • Amylase, lipids, microalbumin
  • Troponin Levels
  • Blood Gases
  • Thyroid Function
  • BNP
  • Salicytate or alcohol levels
  • Bone Profiles
  • Pregnancy testing

There is also a requirement for BMS to undertake quality management and audit, including the quality assurance of near patient testing equipment for utilisation in the primary and secondary care settings.

During the consultation, there were some Boards who intimated that there would also need to be a limited microbiology service provided locally. This was not identified as core but where it is provided, then the following limited workload has been identified.

  • Routine Urines
  • Swabs
  • Sputum, Fluid and Blood Cultures
  • For Occult Blood
  • MRSA screening
  • Sensitivity Testing

Work is currently underway nationally to create a National Strategy for Healthcare Science in Scotland. The strategy will examine such areas as workforce development, education and innovation. It is recommended that this strategy include accessible educational programmes to facilitate the development of the generalist biomedical scientist working in the Rural General Hospital.

The Wider Team

It is recognised that there are other, smaller professions such as Clinical Psychologists who provide valuable services within the remote and rural setting. Unfortunately, within the constraints of this project, it has not been possible to cover all professions in detail.

The role of the Physicians Assistant has been piloted within Scotland, however, to date there have been no pilots within remote and rural areas. During the development of this framework the potential for this role in remote and rural areas has been debated and it has been suggested that at this stage, the role might be of limited benefit, given restrictions on their ability to prescribe and the need for supervision. This 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. There are views however, that nurses offer a wider range of competence, without these identified limitations.

Commitments

Community Resource Hubs should have a skill mix appropriate to the health needs of the community.

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

Nurses in RGHs should be multi-skilled, generalist practitioners.

The Nurse with a Special Interest ( NwiSI) in Acute and in Enabling Care will be developed.

AHPs should be multi-skilled generalised practitioners, to meet the therapeutic needs of patients across the spectrum of care.

AHPs should develop special interest roles ( AHPwiSI) where there is a defined healthcare need.

The radiography team within the RGH will be flexible and consist largely of generalist practitioners.

A team of multi-skilled generalist Biomedical Scientists who are part of a formalised network will be developed.

A generic support worker will be developed to support the work of Nurses, AHP and Social Care professionals.

There should be robust systems established to allow for proleptic appointment of professionals to remote and rural areas.

Forward Issues

Working patterns within larger centres need to be reviewed to support the needs of the RGH.

Research into the acceptability and attractiveness of the GPwiSI within remote and rural communities is required.

An audit should be commissioned to undertake an evaluation of the effect on service delivery of a Consultant-led medical service as compared to a GPwiSI led medical service as part of an obligate network.

A pilot should be established to test the hybrid acute medicine/general practitioner role.

NHS Boards are encouraged to develop innovative solutions to providing access to community pharmacy services in remote and rural areas in the Pharmaceutical Care Service Plans.

Education

Generic Issues

Current Education

Emerging model of Education

  • Varied skills
  • Difficult to access
  • Not rural specific
  • Minimal rotation to bigger centres
  • Generalists
  • Remote and Rural Specific
  • Blended and Distance learning
  • RRHEAL
  • Supported rotations to bigger centres for CPD

Currently the trend for professional training is geared towards the development of a specialist practitioner. Practitioners working in remote and rural areas require to be generalists with a wide breadth of knowledge across the spectrum of care. They must also 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, undertaking such courses as provided by the British Association of Immediate Care Skills.

Practitioners currently experience difficulties in identifying suitable and gaining access to specific, remote and rural education. The problems include the availability of specific courses, coupled with the need to travel and have their post backfilled in order to undertake this study. There must be an appreciation of the high costs incurred by remote areas in attending such courses and educational providers should be encouraged to provide programmes that are accessible from remote locations. This is not a uniquely Scottish issue and in other countries 44, for example, a Continuing Professional Development subsidy fund, to assist practitioners in remote and rural healthcare to participate in conferences and skills development opportunities relevant to remote and rural healthcare have been introduced.

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, should be implemented. The possibility of developing a specialist degree for practitioners working in remote areas should be explored. For example, there is the potential within the review of pre-registration nurse training by the Nursing and Midwifery Council to incorporate a generalist non-branch option which would be of enormous benefit to remote and rural areas.

Skills decay is an acknowledged problem in remote areas where exposure rates to practice are low 45. There must be more locally delivered training such as utilising the method of 'Clinical Fire Drills' to run through scenarios which practitioners are likely to face. The potential use of the e-library and the Rural Portal should be explored for professional updates, keeping up with the latest good practice standards and e-learning.

The GP appraisal and revalidation system and the nursing and midwifery fitness to practice process are good methods of ensuring that practitioners are constantly evaluating their professional development.

Commitment

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

A Practice Education Network for remote and rural healthcare should be established.

Education programmes which are specific and responsive to the needs of remote and rural practitioners should be introduced.

Remote and Rural Healthcare Education and Learning Network

The North of Scotland Deanery of NHS Education for Scotland led the project to develop a Rural Educational Strategy for NHS Scotland. The Project identified four objectives 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.

Access, rural specific content and support for remote and rural learners were the key issues to be addressed. Remote learners need opportunity to access learning in a range of ways using modern media, whenever feasible. Learning needs to be relevant to the range of competences required and the context in which they must practice. The importance of team and peer support must also be recognised and tools to consciously support remote learners should be developed.

The concept of a Remote and Rural Healthcare Education Alliance ( RRHEAL) supported by a remote and rural Managed Education Network emerged through an extensive consultative process. The RRHEAL would 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 would be managed under governance arrangements as part of NHS Education for Scotland ( NES) as a Programme Board with supporting infrastructure. The NES role will be to provide a governance structure and infrastructure that will manage and enable a coherent managed education network for remote and rural areas throughout Scotland, that encompasses territorial NHS Boards, their rural CHPs, and Educational Providers, both institutional and non-institutional.

In developing detailed plans for the RRHEAL, a commitment remains to the establishment of a network that makes links between existing resources, systems and institutions more effective.

Establishing and Sustaining Educational Infrastructure

In order to identify education gaps the NES Rural work stream commissioned a project to map relevant rural education, define and then design an information resource for rural-based and rural-interested learners. This work is complete and a searchable database was embedded in the NES Rural E Library in early 2007 46.

Delivering Educational Support for National Clinical Priorities

It is inevitable that further workforce development needs will be identified as the national Rural Projects work streams develop their plans, and the NES Rural office will provide a focus for educational provision and enquiry from the rural NHS and contracted workforce.

NES provides many opportunities through existing strategies to develop rural-relevant and rural-accessible and well-supported training and education. In seeking access to financial resource to promote rural relevant design of training intervention RRHEAL stakeholders are contributing to discussion around mental health, children and building workforce capacity.

Appropriate workforce development products/programmes will be identified or developed to support emerging and extended roles. The outcome will be improved recruitment and retention, locally delivered services that are fit for purpose, rural career development opportunity and quality assured education.

GPs with Special Interests

In support of shifting the balance of care, NES is resourcing the development of rural GPs with Special Interest in Ultrasound Imaging using outreach educational methodology delivered from a Higher Education Institute ( HEI). Accreditation from the HEI is available for successful GP participants. Evaluation is ongoing with reports due at the end of the 2-year programme (January 2008). The intended outcomes are reduced patient travel, improved access to diagnostics (reducing demand on hospital-based imaging systems) and improved operational use of existing facilities, including extension and use out of hours.

Commitments

RRHEAL should introduce Educational Programmes which are specific and responsive to the needs of remote and rural practitioners.

RRHEAL should ensure that Educational Programmes, wherever possible, are accredited.

RRHEAL should develop robust systems that establish a critical mass of remote and rural learners that secures viable investment for learners.

Remote and Rural Training Pathways for Doctors

The National Framework for Service Change highlighted the need to develop specific pathways for the training of remote and rural doctors, and asked the Royal Colleges to develop such models. The Remote and Rural Training Pathways Project was developed as a tripartite collaboration between the Academy of Medical Royal Colleges and Faculties in Scotland (The Academy), NHS Education for Scotland ( NES) and the Remote and Rural Steering Group on behalf of NHS service requirements.

The objectives of this group were:

  • To gain an understanding of the service requirements within remote and rural healthcare, including definition of a baseline of the health needs of the population
  • To define the skills and competencies of medicine in the context of the multi-disciplinary team, required in remote and rural practice, linking as necessary with evidence base within the UK and beyond
  • From the service requirements, 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 of the Training Pathways Group has been based around the four key medical specialties of Medicine, Surgery, Anaesthesia and General Practice. A Fifth Workstream looked at more generic immediate service needs, such as recruitment and retention, and the uses of technology and mentoring.

The main focus of the medical subgroups has been to design a competency framework to train doctors for practice in the Rural General Hospitals adapting the general training curricula for each specialty when required. It was also noted that these initiatives on training might provide valuable contributions to the recruitment of other doctors who may wish to move to rural hospital practice, while at the same time being sufficiently broad-based to allow practitioners who so wish to practice elsewhere.

The work of the five subgroups is summarised below. The full reports from each group, including curricula where appropriate, are available separately on the Remote and Rural Portal of the NES e-library.

Programme and Curricula Development

The work of all four medical subgroups has centred on the generic curriculum for that specialty, and the recommendations from the groups are as follows;

Anaesthesia

This group recommended specific training to be achieved within an advanced module during years five to seven of run-through training, potentially requiring one year of training time. This could readily be incorporated educationally as the current curriculum has the facility to allow for up to a year of "off-rotation" training. The availability of this training on a post- CCT basis or for an existing consultant wishing to relocate to a RGH, would depend on a new funded slot either through NES/Scottish Government initiatives such as the new consultant scheme or by proleptic appointment by rural Boards.

Key areas meriting additional training and experience include:

  • Consolidation of general skills appropriate to the spectrum of practice would be gained by 3 - 6 months' training in one or two Rural General Hospitals;
  • Adult and paediatric transport medicine achieved by 3 months' rotation to West of Scotland Shock Team or equivalent;
  • Neonatal resuscitation by rotation to an appropriate teaching hospital service for 6 weeks
  • Aspects of chronic pain management and palliate care to be achieved in a major centre over 6 weeks.

General Practice

This group has developed a set of rural competences that follow the RCGP curriculum, addressing clinical, governance, education and patient safety issues for practitioners working in isolation. The group recommends that these competences be followed in the GP Rural Fellowship Programme. It also suggests that single-handed work in remote and rural General Practice should be considered a GPwiSI in its own right. The group has outlined the different staff models and levels, and GP specialty training categories, how they are met and governed.

Other recommendations include:

  • 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.

Medicine

This group suggests a mixed economy of routes into remote and rural medical practice, the main training pathway being via a CCT in General Internal Medicine (acute medicine) with a special interest in Remote and Rural Medicine. It is likely that the consultant led model will continue. However, GPs appropriately trained may provide important input in some areas.

The routes:

  • CCT in General Internal Medicine (acute medicine) with a special interest in remote and rural medicine (level 3 competence in General Internal Medicine)
  • CCT in a medical specialty with level 2 competence in General Internal Medicine
  • For GPs who will contribute to Acute Medicine, a CCT in General Practice combined with level 2 competence in General Internal Medicine. Preliminary work on this model has been funded by NES and begins in January 2008.

Surgery

This group proposes that the construction of a curriculum for remote and rural practice is a relative easy process, given that the intercollegiate Surgical Curriculum Project and the Orthopaedic Competence Assessment Project have developed curricula from which it is a straightforward process to abstract the knowledge base and necessary competences required of a surgeon working in relative isolation.

Other considerations:

  • Surgeons in remote and rural practice require a broad generic training.
  • This would include experience in some aspects of Emergency Medicine (formerly A&E), Orthopaedic Surgery, Urology, Obstetrics and Gynaecology, Neurosurgery, otorhinolaryngology, ophthalmology and plastic surgery. Most of these elements could be achieved during attachment to busy A&E Departments with secondments to specialist departments built into the curriculum.
  • In some specialties, Neurosurgery for example, the trainee would be required to acquire understanding of the principles of the specialty rather than a list of specific skills since there would be very few occasions in which these skills would be required.

The Fifth Workstream

This group explored and advised on cross cutting immediate service delivery issues. In particular, there is a need to develop sustainable approaches to recruitment and retention and to suggest ways of making posts attractive to prospective candidates. This group also researched the uses of technology and mentoring schemes.

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.

Additional Work

Acute resuscitative care including advanced airways management

The Fifth Workstream is currently looking at issues around the setting of recognisable and consistent standards for acute resuscitative care including advanced airways management. It was agreed that these aspects of practice were not uniquely related to anaesthesia and that the competencies required more closely resemble those defined for airway management in the College of Emergency Medicine curriculum. Round the clock provision of acute care, resuscitation and airways management was agreed as being a key issue in both RGH and community hospital settings. The current work involves identifying the skills and competences needed, how to make this option accreditable for non-anaesthetists, and how to maintain skills in low-volume practice. This work is ongoing and a report is expected in December 2007.

Treatment of the Acutely Ill Child

Work is currently underway to develop a competency framework for the treatment of acutely ill children in remote and rural areas. It was agreed that this work was needed in view of the fact that many remote and rural physicians and practitioners feel ill equipped to treat children. It is difficult to attract consultant paediatricians to single handed posts in remote and rural locations, and a two-tier model is currently being researched; GPwiSI in Paediatrics and Child Health and GP Physicians with high level competence in Paediatrics and Child Health. This work is linking with the Emergency Care Framework for the Acutely Ill and Injured Child National Group.

Proleptic Appointments

All five groups have made recommendations in the area of proleptic appointments, suggesting that as far as possible appointments should be made in advance of need to allow sufficient time for targeted training. It is felt that 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 appointing of practitioners outwith the SpR scheme, and is currently liaising with the Boards to identify appropriate posts.

It is also strongly felt that training leave should be in place to allow individuals to maintain and upgrade skills.

Technology

The generic Fifth Workstream explored the various uses of telemedicine, which range from diagnostics to psychological treatments and patient visiting by videolink. Whilst the technology is in use, it is apparent that it is not currently used to best effect and technical support is lacking in some areas. It is suggested that this could be maximised to support both current and emerging models and reduce isolation for rural practitioners. Telemedicine needs to be reviewed in a wider context, with remote units linking to larger centres across Scotland, rather than attempting to support solely within individual Board areas. Evidence suggests that there is a place for a champion for this work, and that in pilot projects this had led to a move towards the option of telemedicine sooner.

Formal Mentoring and Networking

It is clear that there are some existing strong and invaluable links between consultants, but these are often forged through personal relationship and previous working arrangements rather than formal networks. All groups believe that networks could be strengthened and explicit and could also provide professional leadership within a clinical governance framework. The concept of a 'mentoring institution' was explored, whereby a rural general hospital ( RGH) would, in its entirety, be formally supported by a larger unit. Managed Clinical Networks work well in some areas and for some conditions, but it was thought that these could be further developed.

Doctors in Training

Remote and Rural healthcare does and should continue to provide an important training environment and we need to ensure that the following trained doctors are produced each year:

Physician

ST3 Acute medicine/ Rural track to CCT

2 x ST3 available each year

Medicine Training Board

Surgeon

ST3 General Surgery/ Rural track to CCT

1 - 2 x ST3 available each year

Surgical Training Board

Anaesthesia

ST7 Anaesthesia/ Rural Option

1 x ST 7 slot each year

Anaesthesia and Emergency Medicine Training Board

General Practice /acute medicine (new hybrid programme

(D)

Post- GPCCT/ Acute medicine slot

1 x ST 3 acute medicine slot each year

General Practice Training Board

General Practice

(B/C/D)

Existing NoS Deanery Rural GPST output, linked to the existing Rural Fellowships

General Practice Training Board

Impact of GP 18 month training

Changes to GP training programmes moving to GP 18 month training will commence in August 2008 and there is a concern that the effect of this on rural hospitals will be disproportionate, given the small numbers of doctors in training in these systems, the majority of whom will be in GPST programmes. Early work suggests that across the six RGHs there will be six posts that are affected. This will have a significant impact on service delivery and legal rota systems for junior doctors in these areas. The Scottish Government has agreed to discuss the options for dealing with this change with the affected Boards to ensure services in these hospitals can be maintained during the implementation of this change.

This report strongly recommends that that a commitment is made to fund replacement posts, supported by the necessary educational approval, to ensure that we can continue both to deliver a sustainable service and to attract junior doctors to these posts. The current proposed solution of backfill with specialty FTSTAs may not be a tenable option in these localities where specialty approvals are not necessarily in place or achievable.

A full report from the Training Pathways Project will be made available on the Scottish Government Health Department's website.

Commitments

NHS Boards should consider proleptic appointments, either on an individual NHS Board or regional basis, to Consultant posts in order to allow for time for appointees to undertake site specific training prior to taking up the substantive post.

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 training resource for doctors in training should be recognised and appropriate training opportunities should be established, through new Speciality Training posts if necessary, 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.

Forward Issues

The Scottish Government should review the proleptic appointment scheme to support sustainability of R&R services.

The Remote and Rural Training Pathways Group should seek to establish approval for the new curricula through the relevant medical training accreditation bodies.

The Training Pathways Group will progress the work in the areas of acute resuscitative care and airways management, and treatment of the acutely ill child.

NES, in collaboration with Remote and Rural NHS Boards, through the Deanery structure must continue to ensure adequate training opportunities for doctors in Remote and rural practice.

NES, through the deanery structure must ensure that a commitment is made to fund replacement posts for backfill of the 18 month GP training, and that these posts are supported by the necessary educational approval, to ensure that we can continue both to deliver a sustainable service and to attract junior doctors to these posts.

NHS Boards should undertake a review of the current medical workforce to provide NES with clear forward projections for training numbers.