an iit institute of design conference

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NES NES/12/78 Item 8c (Enclosure) September 2012 NHS Education for Scotland Board Paper Summary 1. Title of Paper NES Supporting Scottish Remote and Rural Healthcare 2. Author(s) of Paper Pam Nicoll & Ronald MacVicar 3. Purpose of Paper To provide an overview for the Board of the current healthcare challenges in remote and rural areas of Scotland and some current NES initiatives that are in place to meet these challenges 4. Key Issues There a number of significant challenges currently impacting on the provision of healthcare in remote and rural areas of Scotland including; recruitment and retention of healthcare staff, fragility of the rural healthcare system and the sustainability of the Rural General Hospital systems. Despite this Government policy determines that equitable access to high quality care is maintained irrespective of geographical considerations and healthcare services contribute in a major way to the social capital of rural communities. There is an important role for NES to work with partner organisations to address these challenges and to championing training, teaching and learning in and for rural practice, and as a result to harness the potential of the rural healthcare system as a rich educational resource. 5. Educational Implications RRHEAL is well placed in its role in leading the evolving Scottish School of Rural Health and Wellbeing to play an important role in leading and coordinating NES’s role in supporting and developing the rural healthcare workforce, in collaboration with partners within NES (notably the North of Scotland Deanery) and out with NES. 6. Financial Implications No financial implications

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7. Which NES Strategic Objective(s) does this align to?

1. We will deliver consistent education-based excellence in education for improved care 3. We will continue to build co-ordinated joint working and engagement with our partners 4. We will provide education in quality improvement for enhanced patient safety and

people’s experience of services 5. We will develop our support for workforce redesign 6. We will provide integrated education to support models of care which are closer to

people in their communities 7. We will support education in partnership that maximises shared knowledge and

understanding 8. We will develop flexible, connected and responsive educational infrastructure which

covers people, technology and educational content 8. Impact on the Quality Ambitions This paper describes a range of approaches to supporting the remote and rural healthcare system in Scotland that supports the maintenance of person-centred, safe and effective healthcare in these communities. 9. Key Risks and Proposals to Mitigate the Risks The rural healthcare system has always been fragile and a range of circumstances have resulted in a shared view within the ‘rural system’ that this fragility is becoming increasingly acute. Any failure by NES to support (and be seen to support) rural healthcare challenges could have significant adverse reputational and practical impact. 10. Equality and Diversity Impact Assessment

NES is required to assess the equality impact of all new or proposed policies, functions and workstreams, and to have due regard to equality considerations when making decisions.

a) Briefly describe your arrangements for assessing the equality impact of any

proposals outlined in this paper.

The Scottish Government has outlined the need for equitable access to high quality healthcare services for all patients in regardless of personal characteristics such as gender, ethnicity, geographic location or socio-economic status. This paper describes some of the challenges in relation to access to healthcare services where inequalities could result from geographical location.

b) What potential or actual impact on people from different equality groups or other

equality considerations have been identified?

c) What actions have been taken or proposed to address the issues you identified?

11. Communications Plan

A Communications Plan has been produced and a copy sent to the Head of Communications for information and retention:

Yes No X

12. Recommendation(s) for Decision

This paper provides an overview for the Board and no specific decisions are requested

NES September 2012 PN/ RMV

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NES Supporting Scottish Remote and Rural Healthcare September 2012

1 Policy Context

1.1 Our 2020 Vision for sustainable Health and Care (1)

“Our vision is that by 2020 everyone is able to live longer healthier lives at home, or in a homely setting. We will have a healthcare system where we have integrated health and social care, a focus on prevention, anticipation and supported self management. When hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm. Whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions. There will be a focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of re‐admission” (1).

1.2 The Need for Change

The Scottish Government has made clear the requirement for significant improvements to be made across the public sector (2). This includes the integration of health and social care services responsible for adult care and new collaborations across higher education institutions. In response to the independent Christie Review of Public Services (3) the government has set out the following four pillars of public service reform. • Greater investment in people who deliver services through enhanced workforce development and effective leadership • A sharp focus on improving performance through greater transparency, innovation and use of digital technology • A decisive shift towards prevention • Greater integration of public services at a local level driven by better partnership, collaboration and effective local delivery

2 Rural Context 2.1 Remote & Rural Fragility

In Scotland some twenty percent of the population live in a remote or rural area spread across ninety four percent of the land mass defined as remote and rural. The Scottish Government has outlined the need for equitable access to high quality healthcare services for all patients in regardless of personal characteristics such as gender, ethnicity, geographic location or socio‐economic status (2). Meeting the requirement for improved quality of service for patients brings with it particular and critical challenges in Scotland’s remote and rural areas. With significant recruitment and retention difficulties, a need to reduce costs, sustain services and improve quality, there is a significant drive to redesign services, develop new roles and new ways of working across the rural hospital and rural community workforce. Implementing improvements is likely to require a significant shift in skill mix across the remote and rural health and social care workforce (e.g. education to support new Rural Support Worker). It will also require structured collaboration across education, health and

Item8c_BoardPaperRemote&Rural130912 Page 1 of 25

social care partnerships to implement innovative new ways of training and educating staff to ensure improvement in quality of service but at a reduced cost. This paper details the need for education and workforce planning alignment in identifying and delivering the required support to develop new ways of working for the remote and rural workforce and to support sustained high quality health and care service delivery. The paper highlights the importance of the NES work already underway and details further work required in support of sustainable health and social care service improvement across remote, rural and Island communities of Scotland.

2.2 Health Impacts from remote and rural demographic, geographical and socio‐economic challenges

Local health services fulfil economic and social roles adding community viability and resilience to rural areas. The remote, rural and Island boards face particular difficulties in sustaining and improving services in line with the Scottish Governments 20:20 vision for health and care. These Boards include NHS Shetland, NHS Orkney, NHS Western Isles, NHS Highland and NHS Dumfries & Galloway, though similar challenges pertain in parts of other Boards, e.g. the Isle of Arran. The effects upon both service delivery and many aspects of the health status of the population from remote, rural and Island demographic and socio‐economic position are inextricably linked to the geographic challenges faced. There are a number of population health impacts facing the remote, rural and Island boards arising from a combination of an ageing population, remote geography both from mainland/ specialist centres and within the islands, and the comparatively low socio‐economic position and dispersed rural deprivation of communities. There is a clear urban/ rural dimension to Scotland's ageing population. While 17% of the Scottish population are 65 and over (2009 mid year estimates), the councils with the largest proportions of over 65s are predominantly rural (eg, Argyll and Bute, Eilean Siar, Dumfries and Galloway, South Ayrshire all at 21%). Age related migration is a key factor here, with net out‐migration from rural (and especially remote rural) areas in the 16‐24 age group (with young people leaving for employment and education reasons). Rural areas also show net migration gains in the older age groups as people move away from urban areas in later life (4). With the expectation of an increasingly ageing population the impacts upon the range of healthcare services required are projected to be significant. The link between socio‐economic deprivation and health outcomes is well known and the targeting of rising health inequalities is a challenge across many of the rural, remote and Island areas. The dispersed nature of these communities makes the challenge yet more difficult as deprivation is not found in the concentrations seen in urban areas. The challenge for rural services is how to tackle the inequalities in a targeted manner given their geographical distribution. The Remote and Rural Healthcare Educational Alliance (RRHEAL) was developed by NHS Education for Scotland (NES) in 2007 and endorsed by the Scottish Government in 2008. RRHEAL provides practical educational assistance to remote and rural NHS Boards and is a linking force between healthcare services and education providers across Scotland. RRHEAL has been structured to be a sustainable resource and to be of value supporting the current and future remote and rural healthcare workforce education needs. RRHEAL is focused on the development and delivery of accessible, affordable and sustainable education solutions that meet the changing needs of the remote and rural healthcare workforce.


RRHEAL was developed to: • Coordinate remote and rural education development for the remote and rural healthcare

workforce across Scotland; reduce duplication, streamline working. • Produce and deliver programmes and educational support that meet the needs of the

remote and rural healthcare workforce. • Promote the development of educational provision that meets the needs of remote and

rural NHS Boards and their workforce. • Make links between existing resources and stakeholders more effective. • Champion remote and rural working as a positive career choice. • Promote Scottish remote and rural working innovations on a national and international

platform.

2.3 Delivering for Remote and Rural Healthcare Action Plan: The Final RRIG Report October 2010 (5)

The Final Report of the Remote and Rural Implementation Group (RRIG) was published in October 2010 (5). The report highlighted the need for Chief Executives of the Territorial and Special Health Boards to be aware of the content of the RRIG report and the implications of the related ongoing actions and recommendations for their Boards. The initial Delivering for Remote and Rural Healthcare report published in May 2008 (6), set out 83 recommendations and forward issues for the delivery of a sustainable model of healthcare for remote and rural Scotland. The Remote and Rural Implementation Group (RRIG) was established to take this work forward with a role to oversee and monitor implementation across the system. RRHEAL successfully delivered the education and workforce objectives outlined by RRIG Action Plan on behalf of NES. RRIG delivered the Final Report to the Cabinet Secretary for Health and Wellbeing in October 2010. The report was accepted in full and the Cabinet Secretary agreed to all the RRIG recommendations. RRIG’s Final Report highlighted a number of areas where action needs to continue and makes a number of further recommendations (Appendix 1). In particular, NHS Chief Executives were asked to note the RRIG recommendations on a revised staffing model for the Rural General Hospital (RGH) in order to ensure continued access to safe and sustainable services in remote and rural areas; the ongoing requirement to develop Obligate Networks; and the workforce issues that are needed around identifying skills and competencies to deliver safe emergency care and agree a common role across RGHs. It should also be noted that a number of the recommendations have implications for all Health Boards, not just those which serve remote and/ or rural communities. Whilst RRIG has completed its work, the Scottish Government has stated (5) the need to maintain the momentum created and to sustain progress by integrating the actions within the implementation of the Quality Strategy and so ensure greater co‐ordination and integration of remote and rural issues within current programmes and initiatives. RRHEAL NES has been requested (5) to continue to implement the educational recommendations from the final RRIG report.

RRHEAL is leading work to implement the RRIG Final Report Action Plan workforce and education recommendations (Appendix 1)


3. Current Service Challenges

3.1 Rural General Hospitals

At the forefront of this programme of work is the need to redesign the rural general hospital workforce to ensure sustainability of RGH services as an integral part of the remote and rural healthcare system in Scotland. This paper details the significant need for education and workforce planning alignment in identifying and delivering the required support to develop and deliver new ways of working for the RGH workforce and to support sustained high quality service delivery. Each of the six rural general hospitals in Scotland operates in different ways and has different support needs. However, what is common to each is the urgent need to redesign the workforce to better ensure ongoing delivery of high quality and sustainable services. Education has a key role to play in supporting service improvement and sustainability by ensuring that robust, affordable and accessible education programmes are available to enable boards to safely and effectively build new or expanded roles within redesigned workforce plans. This process requires NES multi‐directorate coordination and management to ensure maximum impact, best value, and avoidance of duplication while building on existing resources.

The Scottish Government “Delivering for Remote and Rural Healthcare” 2008 (6) describes the Rural General Hospital as an integrated part of the extended community care system which may best be defined as a level two facility. That is the RGH will provide local assessment, diagnosis and treatment. It will be the emergency centre for the community and while much of the activity undertaken could be described as treatment of minor injuries and minor illness, the RGH will undertake first line management of all patients presenting with acute illness. A proportion of these patients may be transferred to a larger centre but the majority will be admitted to the RGH.

Scotland has six Rural General Hospitals: • Gilbert Bain Hospital, Lerwick; • Balfour Hospital, Kirkwall; • Western Isles Hospital, Stornoway;

• Caithness General Hospital, Wick; • Belford Hospital, Fort William; • Lorn and the Isles Hospital, Oban.

The geographical locations are illustrated in the following map from the Emergency Medical Retrieval Service:


The Rural General Hospital is a key resource within the community providing local access to a range of emergency, diagnostic and planned treatment services. The RGH may provide some of the functions of a Community Hospital, but it will also provide a more advanced level of service, similar to some of those services accessed by other communities in their local District General Hospital (DGH), particularly some unscheduled surgical interventions. It is characterised by providing more advanced levels of diagnostic services than a Community Hospital and will provide a range of outpatient, day‐case, inpatient and rehabilitation services. An RGH cannot, however, provide the broader range of services expected in a DGH. For example, an RGH will not have an Intensive Care Unit but will have the ability to provide high dependency care. The RGH exists in a network with larger centres. These may be District General Hospitals or Tertiary Centres. The RGH have arrangements to refer patients appropriately to definitive care, based on robust care pathways that will sometimes by‐pass the more local DGH.

The six hospitals ‐ in Oban, Fort William, Kirkwall, Lerwick, Stornoway and Wick ‐ all now provide core services, including:

• Outpatient, day case inpatient and rehabilitation services

• Nurse‐led care for urgent cases, managing minor injuries and illnesses

• Initial management of broken bones

• Routine and emergency surgery

• Management of acute medical conditions


• Management of patients who have suffered a stroke

• Management of long‐term conditions

• Maternity care, led by midwives

• Management of patients with more complicated problems before they are transferred.

Other local and community hospitals in remote and rural areas will also offer more services, including outpatient clinics, day case treatment, midwifery services and treatment for minor injuries and emergencies.

Delivering for Remote and Rural Healthcare 2008 (6) recommended that NHS Boards should review the service provided within their RGH to ensure that the services provided are consistent with the model described, specifically including:

• A nurse led urgent care service; • The provision of a first‐line emergency care service; • The management of acute medical and surgical emergencies; • A midwife led maternity service should be developed as a minimum, which should

seek to maximise local deliveries; • The management of patients with stroke, step‐down, rehabilitation and follow‐up of

a range of patients conditions; • The management of long term conditions; • The provision of an ambulatory care service for children; • Elective and emergency surgery as prescribed above; • Visiting services appropriate to the health needs of the population; • The provision of the prescribed range of diagnostics and clinical decision support; • The provision of a pharmacy service.

The Scottish Government have expressed a clear policy for all six RGH to be maintained as an integral part of the remote and rural healthcare system, which provides a significant challenge for NHS Scotland. The Scottish RGHs struggle to recruit and retain trained doctors for their consultant vacancies, carrying a high proportion of vacant and locum‐filled posts on an ongoing basis at a time of reducing budgets and the need to improve services contribute to this challenge. Traditional methods of staffing the RGH are increasingly unsustainable and the RGH model of providing acute, secondary and often emergency care to rural areas, is fragile as a result. There is an urgent need to explore, identify and implement new staffing models for medical service delivery that are acceptable to staff and communities, as well as safe and sustainable. This requires a coordinated response from workforce planning and education providers in order that new ways of working and new roles can be introduced with the assurance of long term access to robust education and training programmes that support significant workforce redesign. Without the assurance of reliable education and training the boards face difficulty in building new or adapted roles within their service redesign. There is a significant and urgent need for NES to respond by targeting resources in support of the development of new education and training programmes and adapting existing resources to meet the RGH workforce redesign needs.


3.2 Rural General Practice/Primary Care

Recruitment and retention issues relating to remote and rural general practice and primary care are described in the following section but are not the only challenges facing rural general practice. The challenges of lone‐working and difficulty arranging cover for leave or professional development contribute to the fragility of rural practice. Trainees that increasingly are used to, and trained to work in teams and are used to working in a shift system through their training are ill‐prepared for the realities of remote or isolated practice. Access to education, including peer‐support and peer‐referencing activities is a particular challenge. The increasing availability of electronic and/ or video‐conferenced education can go some way towards meeting the professional development needs of remote practitioners but the availability of good telephone or IT links is inconsistent.

3.3 Rural Workforce Sustainability Issues

As described above, the six Scottish RGHs struggle to recruit and retain trained doctors for their consultant vacancies, chronically carrying a high proportion of vacant and locum‐filled posts. The RGHs largely retain a medical staffing model that is dependent on doctors in training to deliver service, in the main from the North of Scotland’s Foundation or GP Specialty Training Programmes. Under‐recruitment, in particular to GP Specialty Training programmes that include RGH posts has been a feature over the last number of years and the development of a bespoke rural‐track GPST programme based around the RGH systems has yet to impact (7). There are a range of reasons for the recruitment challenges described. Changes in immigration policies impacting on international health workforce fluidity, perceptions of RGH as less desirable career option by doctors in training and trained doctors, national recruitment systems and new working time directives are highlighted by boards as contributing factors. Recruitment and retention challenges are not however felt by the secondary care medical workforce alone. Recent high‐publicity instances of general practice vacancies have highlighted the unsustainability of the 24/7 working model for single‐handed or small isolated practices. NHS Highland alone has recently been carrying a load of 16 GP vacancies in remote or isolated practices and as a result the Board’s Associate Medical Director has initiated a working group to address the issues of rural fragility in primary care by explicitly building on the perceived success of the ‘Dewar Centenary’ initiatives. Ronald MacVicar is contributing to this work from a NES perspective, work that is as yet at an early stage. It is likely that this group will propose the evolution of networks of care with a presumption against single‐handedness and there will be a need for educational and workforce development support as well as an opportunity to develop these networks as key educational hubs for the remote and rural workforce. Although arguably most acute, the recruitment challenges in remote and rural areas are not limited to medicine. In rural areas, recruitment and retention problems, gaps in staffing and their immediate impact on service are often magnified due to smaller overall staff numbers. Difficulties in recruiting and retaining medical staffing in remote and rural areas is an international problem with similar difficulties encountered in many rural areas of developed


nations including Canada, Australia, Sweden and Norway, in addition to widespread difficulties rural health recruitment and retention in developing countries (8). In a recent influential World Health Organisation report on recruitment and retention of health workers to remote and rural areas, the authors described four categories of intervention; education, regulation, financial incentives and personal and professional support (see Table 1) (8).

Table1. WHO Report 2010‐Recruitment & Retention Recommendations: Categories of interventions used to improve attraction, recruitment and retention of health workers in remote and rural areas (8) Category of intervention A. Education A1 Students from rural backgrounds A2 Health professional schools outside of major cities A3 Clinical rotations in rural areas during studies A4 Curricula that reflect rural health issues A5 Continuous professional development for rural health workers B. Regulatory B1 Enhanced scope of practice B2 Different types of health workers B3 Compulsory service B4 Subsidized education for return of service C. Financial incentives C1 Appropriate financial incentives D. Professional and personal support D1 Better living conditions D2 Safe and supportive working environment D3 Outreach support D4 Career development programmes D5 Professional networks D6 Public recognition measures

Locum doctors are, as in urban areas used where there are hard‐to‐fill RGH vacancies. There are concerns around the sustainability of the increased expenditure on locum doctors by NHS Scotland Boards and the Audit Scotland report (2010) (9) has requested Boards to find ways to reduce expenditure on locum doctors. NHS Highland are engaged in a two year “Knowledge Transfer Partnership“ (KTP) project which has been designed to measure the costs and sustainability of current medical workforce across all three NHS Highland Rural General Hospitals. The diagram below illustrates the escalating costs for locum cover (10) in the three RGHs in NHS Highland, which is helping to drive the pace of workforce redesign and examination through option appraisal of different staffing models.


NHS Highland KTP: Total Locum costs

Belford Caithness General Lorn&Islands

The NHS Highland KTP project (10) has identified a short list of future staffing options from a series of stakeholder workshops and consultations. NES/RRHEAL has been involved with this process. The Options Appraisal seeks to assess what outcomes will be achieved through changing staff or service, by assessing the potential benefits and costs of different options against objectives and agreed criteria. A final option appraisal in July/August 2012 will identify the option which best meets the organisation’s objectives for change. Options must address the core medical and surgical services in RGHs. The objectives for change for the purposes of the NHSH project include:

• Reducing locum doctor dependence by employing a different mix of clinical practitioners within RGH medical services.

• Reducing junior doctor dependence by employing a different mix of clinical practitioners within RGH medical services.

• Ensuring that staffing costs associated with medical service delivery are affordable and represent value for money.

• Developing competent, productive teams of clinical practitioners with positive impacts on patient safety and outcomes.

• Developing flexible and appropriately qualified and trained staff working to their maximum potential.

• Having positive impacts on staff recruitment & retention.


4. Remote and Rural Priorities for NES

See Appendix 2 for relevant extracts from the NES Corporate plan 2012 – 13.

4.1 Supporting Service and Workforce Redesign

Each of the Rural General Hospitals in Scotland are now engaged in a process of service and workforce redesign aimed at implementing a sustainable, safe and affordable staffing model that supports long term service provision from each of the six Rural General Hospitals. The Traditional RGH Workforce Model

• Consultants – lead the team(s)

• Trainees and Non‐consultant doctors

provide support (in and out of hours)

• Nursing staff have a secondary

supporting role

Proposed New Staffing/Service Models

• Consultants

• Support staff

• Non‐consultant doctors

• Nurse practitioners

• Physicians assistants

• GPs with suitable skills and enthusiasm

• Trainees (fewer in numbers but with

enhanced educational opportunities)

• “Hospital at night” GP /Nurse led with consultant advice available at distance as required.

Service redesign: Case example NHS Western Isles (NHSWI) are already engaged in a process of service and staffing redesign to try to address the workforce sustainability issues for their Rural General Hospital system. NHSWI are also implementing a new “hospital at night/Out of Hours” staffing model. This involves a rotation of 9 or 10 GPs who provide input within the hospital at night enhanced by Emergency Nurse Practitioners, Clinical Support Nurses and the Community Nurse Night Service. This is a new way of providing care within the RGH in NHSWI and they highlight the need for this new model and new roles to be supported by a range of robust, accessible and affordable education and training programmes.

4.2 Recruitment and Retention

There is an evident challenge in recruiting staff to and retaining them in the remote and rural healthcare environment. National recruitment to training posts and ‘tried and tested’ methods of marketing seem to disadvantage remote and rural training and career options.


There is an opportunity both to understand better what recruitment strategies may be more effective and to implement them where possible.

Case example: Northern Peripheries “Recruit & Retain Project” NHSWI are also leading a large scale piece of work with international rural health partners called the Northern Peripheries Project (NPP) “Recruit & Retain”. This European Union funded £3 million programme aims to identify the factors associated with recruiting successfully and retaining staffing in rural areas using collected data and intelligence from each of the six rural partner countries over the next two years. The outputs will be a range of evidence based products and approaches which are aimed at supporting and improving remote and rural healthcare recruitment. Strategic partners will also use large scale data and cross collaborative work to formulate a final “recruitment & retention of remote and rural public sector workforce strategic plan” in 2014 for uptake across each of the participating countries. NES/ RRHEAL achieved European funding to support this work and are strategic and working partners within this international work programme in collaboration with University of Aberdeen, Centre for Rural Health and NHS WI.

4.3 Rural‐track Medical Training

At the recent second annual NES Medical Education conference, a session on rural‐track training and education showcased the many initiatives that are currently in place both within NES and the University of Aberdeen (UoA) including: • Support for rural school pupils with an interest in medicine (UoA) • Rural‐track option in years 4 & 5 (UoA) • Rural‐track Foundation Programme (NES) • Rural‐track GPST option (NES) • Post‐CCT GP Rural Fellowship (NES) • Rural Surgical Fellowship (NES) • Rural Anaesthetic Fellowship (NES) • Tailored Rural Physician Training (NES)

It was very apparent however that there is little coordination of these initiatives and an outcome from the session was to give consideration on how best to support, develop and broadcast this activity. As a result an existing group led by the North of Scotland Deanery was re‐vamped, to become the ‘Rural‐track Medical Education and Training Development Group’ (RMED), with refreshed aims as follows

• Support the development of initiatives to encourage medical school entrance for school pupils from rural areas • Support the development of rural‐track undergraduate medical education and training


• Support the development of rural‐track foundation training • Support the development of rural‐track specialty training and post/ peri‐CCT rural‐ track fellowships • Investigate and implement ways of supporting rurally‐interested or rurally‐ committed pupils, students and doctors through, and beyond training • Ensure effective communication across the medical school/ deanery interface to facilitate these rural‐track undergraduate medical education and training initiatives, including tracking individuals from undergraduate through postgraduate careers • Facilitate collaboration, innovation and evaluation • Showcase rural medical education and training as a joined up enterprise to NHS Scotland and beyond

There is some evidence that exposure to rural practice during undergraduate or postgraduate training increases the chance of a doctor committing to rural practice but much stronger evidence that recruitment of students from rural areas to medical school will see them return to rural areas to work (8). To address rural recruitment and retention, there is a strong argument to both increase rural exposure during and to preferentially recruit from rural areas. NES continues to support rural‐track training.

4.4 Retaining Dentists in remote and rural areas to improve access to NHS Dental services

Since 2005 the NES Dental Team has played a key role in the implementation of the Dental Action Plan. The focus of this has been on increasing the workforce in order to improve access to Dental Services across NHSS. The Rural Fellowship programme provides support for dentists working in the general dental services in remote and rural areas and facilities access to postgraduate training at the Scottish Dental Schools, through MSc programmes in Primary Dental Care. There are currently 11 trainees enrolled on this programme.

Expansion of dental outreach training centres help meet the student clinical capacity needed by the Dental Schools and help to train dental and therapy students in a realistic primary care environment, at the same time as boosting workforce capacity. Patients benefit from improved access to NHS Dental Services throughout Scotland and free treatment by students. The NES target was to expand dental student outreach across Scotland, in particular to Inverness, Aberdeen, Dumfries and in areas of urban deprivation within Tayside and the West of Scotland. Outreach teaching facilitated by NES is now operational in Aberdeen, Glasgow (2 Centres), Arbroath, Kilmarnock, Kirkcaldy, Cupar, Inverness (Centre for Health Sciences), Campbeltown, Perth, Stornoway, Elgin, Coatbridge, Dumfries, Falkirk (2 centres) and Dundee. The number of patient attendances is being monitored, with Glasgow students responsible for 19,000 patient contacts in 2010/2011, and their Dundee counterparts carrying out 13,979 patient treatments in the same period.

4.5 New Ways of Working: Technology In Practice

The Scottish Government has published the “Telehealth, Telecare Towards 2020” (11) three year national plan to provide continued strategic direction for the use of Telehealth and Telecare within Health, Social Care and Housing in Scotland. The plan sets out the rationale, and specific challenges and opportunities for the use of Telehealth and Telecare in support of the Scottish Government’s 2020 vision for health and social care, and public sector reform


programme. There are particular contributions in support of our national ambitions for Quality in Healthcare, Adult Health & Social Care Integration, Reshaping Care for Older People, Renewing Scotland’s Public Services, eHealth, Mental Health, Digital Scotland and Life Sciences. An ‘Implementation Plan for Telehealth and Telecare to 2015’ (11) underpins the strategy and establishes high level priorities and timescales. There have been a number of specific telehealth and telecare projects and work streams in place across remote and rural Scotland for some years. However there is a significant need to increase the use of technology in every day practice “at scale” across the health & social care sectors to help sustain services and achieve the required improvements to assist remote, rural and Island Boards. Feedback from the remote and rural Health Boards confirms the need is for support in helping the workforce make the culture shift in their expectation to use technology in practice as well as increasing skills and competence in using the technology itself. The Telehealth, Telecare national action plan outlines a clear role for NES to lead on work to support this change and to assist in the development of national education and training programmes in this area. Case example: Technology in Practice RRHEAL are working with partners to develop a remote and rural inclusive multiprofessional, multi agency “Technology in Practice” education and training pathway

. 4.6 The Scottish School of Rural Health & Wellbeing

The Scottish Government has made clear that the “Collaborative Infrastructures in Scotland” are the way in which change and improvements will be driven and achieved. RRHEAL are leading the establishment of the Scottish School of Rural Health and Wellbeing (SSRH&W) on behalf of NES. The SSRH&W will function as a structured collaborative of remote and rural education expertise, building on the established RRHEAL alliance structure and Scotland’s existing capacity in this area in order to increase the quantity and grow the range of education that supports the remote and rural health and social care workforce. The SSRH&W will provide an identifiable single centre for existing and emerging remote and rural education and research expertise in Scotland. It will serve to increase productivity, return on investment and joint working across agencies. It will bring together existing resources across the alliance to design and deliver high quality remote and rural‐specific education, training, research programmes and resources in response to the needs of the frontline remote and rural workforce. The SSRH&W will focus on the design and delivery of education and training using technology to engage with learners at distance across Scotland. Under the leadership of RRHEAL / NES the SSRH&W will provide a coordinated response from remote and rural expert higher education providers to the identified needs of the remote and rural public sector workforce. As the SSRH&W grows in response to needs and demands the structured alliance will be in a prime position to explore opportunities for further collaborations across the voluntary and private sectors, particularly in response to education and training needs associated with Scotland’s growing expertise in the fields of “Digital Healthcare”. The Scottish Government’s improvement programme aims to accelerate sustainable economic growth, improve the quality of public services and tackle Scottish challenges in health outcomes. To achieve the required improvements the Scottish Government has


employed an outcomes approach ensuring the focus of public spending and action builds on the assets of individuals and communities and increasing collaborations across public, private and voluntary sectors. There is a clear requirement to make better use of existing capacities across systems to innovate, design and implement transformational change to achieve improvements across public services. The RRHEAL /NES led development of the SSRH&W is a timely response to the needs of the remote and rural health and social care workforce in support of the Scottish Government’s improvement programme.

4.7 Remote and Rural Education & Training Requirements

Each of the remote, rural and Island Boards have identified the need to develop roles that offer a more flexible, achievable, affordable and sustainable workforce to ensure safe and effective RGH and rural community service provision in the long term. They are involved in a complex process of investigation around the viability of developing new or adapted roles to support a more sustainable RGH and community health and social care workforce now and into the future. The NHSWI redesign experience has highlighted that while some education and training is already available to support some new roles, and so new service models, there is an urgent need to improve access and increase availability, to make the programmes more flexible and to reduce cost in order that they can become part of a sustainable workforce plan and solution. The Boards are highly aware of the need for robust and assured education and training programmes to be available to support new and adapted roles to ensure delivery of safe and improved services. The need for more and improved education and training programmes to support RGH workforce redesign refers not only to medical but also nursing and other healthcare staff. In each of the Board areas discussions are underway to look at new roles to support new ways of delivering service. Rural hospital staff redesign involves a move away from professional demarcation and a patient centred/ service led focus on the development of integrated teams of multi‐skilled, flexible staff taking “a continuum of competence” approach. Education and training has a pivotal role in ensuring that the workforce and public can be assured of different but safe and effective service delivery within hospital and community settings.

NES/RRHEAL is working to develop a cross‐directorate expertise & set of resources targeted at RGH educational support for improvement programme. 4.7.1 Health and Social Care: Rural/ Generic Support Worker

Communities and health service planners in remote, rural and Island areas of Scotland face significant challenges in meeting the changing needs of communities and making best use of available resources and smaller workforce pools to continue to deliver the high quality care required by the changing population needs of remote and rural communities. With a higher than national average population of older adults and further increase predicted the challenges are both in structuring services to provide appropriate care and also in ensuring adequate and skilled workforce is available in the future. The development and integration of health and social care delivery at support worker level is an important consideration for continued health and social service provision and improvement across the remote, rural and Island communities of Scotland. The importance of the role played by support workers in the independent and third sectors must also be recognised.


The Delivering for Remote and Rural Healthcare Implementation Group (RRIG) Action Plan 2008 (6) described the development of a new ‘Generic’ (Health and Social Care) Support Worker role as an essential component for the required stratified workforce. The plan also outlines the objective for RRHEAL to develop an appropriate education programme to support the development of this role.

Remote, rural and island health and social care support workforce change is being driven by;

• demographic changes ;

• existing and forecast difficulties recruiting within smaller population groups

• the demand for a more integrated workforce

• the public demand for person centred, integrated care

• the need for quality improvement and cost reduction

• the need to address inequalities within communities

• the need to deliver care as close to home as possible

• the need to reshape care for people in the community including develop anticipatory and preventative care, reducing delayed discharge and supporting people in their local communities

• the need to improve patient safety

• regulation of the workforce – including requirement to register key groups of social service staff, requirement to adhere to codes of conduct and the development of induction standards and codes of conduct for healthcare support workers and their employers

Increased demands for support from smaller centres of population are creating difficulties in resourcing and recruiting staff, particularly in Island settings. Remote and Rural Health boards are finding increasing difficulty in maintaining the required range of health services within island and many remote and rural settings. Recognition of the changing needs of remote, rural and island populations and of the issues facing the remote and rural health boards and local authorities in continuing to provide appropriate services in these settings led NHS Shetland, on behalf of the North of Scotland Planning Group, to commence a review of needs in this area four years ago in partnership with the Shetland Islands Council. RRHEAL and NES’s ongoing engagement with the remote and rural health boards suggest that the need for a national standardised and accredited education pathway for this role continues to increase. A number of remote and rural health boards have begun to develop Generic Rural Support Worker posts, job descriptions and roles (NHS Orkney, NHS Dumfries and Galloway and NHS Highland). RRHEAL is working alongside SSSC, Scotland’s Colleges, SQA, and the remote and rural health boards to develop nationally accessible, flexible programmes of education that will enable remote and rural local authorities and NHS Boards to develop this role. Remote and Rural Health and Social Care Integration

In supporting the health and social care integration NES working in partnership with the Scottish Social Care Council (SSSC) have provided support to remote and rural health boards and local authorities. Education programmes include developing the role of a Generic/Rural Health & Social Care Support Worker. Requirements in terms of curriculum and education for the role of rural/ generic support worker are being developed and NES has provided funding


2012‐13 which will support the development of the education programme with Highland/ Orkney and an additional Remote and Rural Health Board in this financial year. In May 2012, a workshop session with Learning and Development leads in NHS Highland and Highland Council was facilitated by NES/ SSSC staff. The aim of the workshop was to explore emerging skills, knowledge and values required by the workforce to embed and sustain new ways of working to support the integration agenda. With a focus on service delivery explored how working together within partnerships and teams in an integrated way actually improves the care journey. Last year NES and SSSC offered a programme of ‘action learning’ facilitated by experienced facilitators for health and social care teams in CHP Teams. Teams were invited to identify ‘wicked issues’ related to ‘Reshaping Care for Older People’ in their areas. The facilitators then used action learning methodology in a flexible way to enhance effectiveness in collaboration and to achieve outcomes. A number of remote and rural CHP’s have accessed this programme and include North & Mid Highland, Aberdeenshire and Shetland. The evaluation of the programme has been overwhelmingly positive with success in supporting the development of relationships to a level where real progress on complex issues has been made. The programme is being funded in 2012 – 13 and is currently accepting nominations.

RRHEAL /NES are working with partners to support development of the Rural/ Generic Health & Social Care Support Worker role 4.7.2 Clinical Skills Training and Education in Remote and Rural Scotland

A wide variety of clinical skills training and education is currently being provided to by NES to remote and rural healthcare staff through the NES funded Clinical Skills Mobile Unit (MSU). During 2011 the MSU made seventeen visits to remote and rural host sites including rural general hospitals and GP practices. Over seventy four national and local courses were provided, ranging from the national Paediatric Retrieval Team Training through to locally delivered Basic Life Support Training. During the year over a thousand local health care staff received clinical skills training through this mechanism, with access also being provided to Fire Service and Royal Navy personnel.

Alongside the MSU, NES funds three clinical skills specialist units, BASICS Scotland, Cuschieri Skills Centre Dundee and the Scottish Clinical Simulation Centre (SCSN) Larbert. The training and education provided by these Units include Pre‐hospital Emergency Care courses to over 350 remote and rural healthcare staff; faculty training in the use of the MSU for remote and rural healthcare staff and ENT and Endoscopy specialist training. In addition BASICS is working collaboratively with the Cuschieri Centre, Dundee to develop surgical skills training for remote and rural general practitioners and practice‐based staff.

NES works with partners to support clinical skills maintenance and development of the rural healthcare workforce


4.7.3 NEW RGH Roles

A range of possible new roles are being examined in terms of their ability to better meet RGH service needs. NES/ RRHEAL are working with the boards to identify the competences required for acute care provision within the RGH and to achieve agreed definitions for new role and titles consistent with skills and competences. There is a continuum of need for new roles and new education and work in this area is already underway. The new roles under consideration by the boards include increased use and exploration of the potential for nurse practitioners, hybrid general practitioners, rural practitioners, physician assistants and extended scope paramedics The RRIG “One Year On Event” in September 2009 highlighted the sustainability of services and workforce in remote Community Hospitals as a priority issue for a number of reasons. The most significant of these reasons concerned GPs working in these settings. Such GPs routinely provide a range of extended services including the provision of Acute Medical Care for the community. Regulatory changes for medical staff and the introduction of licensing and revalidation has raised concerns, especially where GPs work entirely with a hospital setting. Further RRIG workshops in 2010 defined specific issues and identified potential solutions for such GPs. Recruitment, education, skills acquisition and maintenance, together with appraisal and revalidation were highlighted as issues to be addressed for this group. A key output of this work has been the development of the National Framework for the Sustainability of Services and the Medical Workforce in Remote Acute Care Community Hospitals (2011) (12). The Remote Community Hospitals Framework sets out seven principles and seven quality and safety measures supported by an obligate network. The Framework is designed to provide reassurance of a robust system which meets revalidation requirements for GPs working primarily in remote community hospital settings responsible officers and employers. The Royal College of General Practitioners have now agreed that equivalent portfolios for GPs working in such settings can be submitted for revalidation purposes. The overall aim of the framework is to provide “a system of clinical governance, including training, education and performance monitoring through which the doctors working in this environment can demonstrate fitness to practice and support revalidation where the standard portfolio of supporting information for revalidation is impractical“.

• GP Rural Acute Care Competencies

RRHEAL and NES North of Scotland Deanery worked with an expert rural group to define the competences required to provide safe and ‘assured’ acute care within a rural hospital setting as described in the Framework for Rural Hospitals (12), and the educational requirements to meet those competencies beyond those achieved through GPST. NES has provided funding and support for implementation of this education programme across four areas in 2012 through the development of four ‘Acute Care GP Rural Fellowships’ by allocating of an element of the GP Rural Fellowship programme funding to this from August 2012, although only one of the posts was recruited to.

NES is working to identify resources to adapt and improve existing education programmes to fully support the implementation of training for the GP with Acute Care Competencies


• Physician Assistant

Some of the remote, rural and Island Boards are considering the potential for the physician assistant role to assist with addressing some key workforce challenges in rural community settings. The physician assistant was established in the 1960s in the US in response to a physician shortage in primary care and rural areas. The physician assistant is a health professional who works under the supervision of a fully trained and experienced doctor. Within the defined physician‐physician assistant relationship, the physician assistant exercises autonomy in decision making but does not seek to practice independently to doctors. They are trained to be aware of their limitations and to consult with physicians accordingly. In the US physician assistants are trained to the medical model of care and licensed to practice medicine under medical supervision. They are assessed as competent to undertake physical examination, diagnose, order and interpret medical tests, prescribe, treat and discharge patients autonomously within a clearly defined scope of practice. In the US, they are also trained to assist in surgery and counsel on preventive healthcare. In 2006 the Department of Health (England) collaborated with the Royal College of Physicians, Royal College of General Practitioners, Skills for Health (the health sector skills Council for the UK) and other partners to produce a competence and curriculum framework for physician assistants. A number of UK universities are currently training physician assistants, and according to the UK Association of Physician Assistants, there are some 114 physician assistants currently employed in the UK in general practice, accident and emergency medicine, trauma and orthopaedics. The University of Aberdeen in association with NHS Grampian are currently training a cohort of 34 Physician assistants with the first cohort due to graduate in July 2013. A Scottish pilot of physician assistants, which ran from November 2006 to October 2008, suggested that in some settings in NHS Scotland there is a mid‐level practitioner workforce gap, that there are currently challenges to fill with the suggestion that a range of practitioners, including the physician assistant, could fill this space. Lack of prescribing rights for physician assistants has been cited as an issue requiring national attention for the NHS in England and in Scotland, where this would be considered particularly useful in rural and remote areas. There is also a need to address professional registration and regulation issues for physician assistants. This together with issues over prescribing rights has proved to be one of the strongest reasons for disinvestment in the physician assistant training programme in Australia. It has been considered preferable to develop advanced rural practice nursing roles instead. At present in Scotland and the UK there is no mandatory regulation body for physician assistants. RRHEAL are working with colleagues in remote and rural boards and those leading the Aberdeen University physician assistant programme to investigate adaptation of the P.A curriculum in order that rural acute care competences can be included to produce a remote and rural specific or inclusive PA education programme.

RRHEAL is working with partners to adapt and improve existing education programmes in relation to the Rural Physician Assistant potential role.


• Rural Practitioner (new role) Island Nurse

Work with the remote, rural and Island boards in relation to this proposed new role indicates that the necessary competencies of a rural practitioner include assessment, diagnostic and autonomous decision making skills required to deal with emergency admissions. RRHEAL has initiated work to establish an agreed definition for Rural Practitioner skills and competences across the remote, rural and Island boards. There is a strong indication from some of the boards they would wish to consider this to be a new or adapted nursing role. Some island boards have expressed a need for a combined acute/ community “rural practitioner nursing role” with skills to work either in the rural acute care setting and/ or Island nurse (non GP) community setting. This type of role may be comparable with the “Arctic Nurse” role and skill set established in Greenland to meet remote service needs. A new or adapted programme of education to meet the competences ascribed to this role is required. RRHEAL and NES NMAHP are leading work to define a common core set of acute and community competencies and educational needs in relation to the “Rural Practitioner –Nursing Role”.

RRHEAL /NES is working to adapt and improve existing education programmes to fully support the required remote and rural role of Rural Nurse Practitioner

• Advanced Practice Nurse Practitioners

These are registered nurses with increased autonomy and capacity to make decisions within a defined scope of practice. Advanced nursing roles were introduced in the UK to address inequalities in healthcare provision, geographical distribution and rising costs of healthcare. The International Council of Nursing defines the Advanced Practitioner Nurse as a registered nurse who has acquired the expert knowledge base, complex decision making skills and clinical competencies for expanded practice. They have the competency to assess, diagnose and treat normal or acute problems and are able to provide follow up care and treatment for chronic conditions. They are competent to perform physical examination, assess a patient’s health situation and history, order diagnostics or laboratory tests, prescribe medications (with prescribing rights), refer patients for further care or treat and discharge patients from hospital. The Scottish Government has developed guidance and an online toolkit to assist in benchmarking these roles in terms of clinical competencies and educational pathways. NHS Education for Scotland has developed a tool to support NHS Scotland Boards in service needs analysis and development of advanced nursing practice roles.

RRHEAL/ NES is working to support territorial Boards in the implementation of remote and rural Advanced Practitioner Nurse roles

5. Quality Improvement Science and the Quality Improvement Hub

The Quality Improvement (QI) Hub was formally launched in June 2011 and was established to provide support for all Boards including those with a remote and rural responsibility. The QI Hub aims to bring improvement science into the everyday work and language of NHS Scotland staff and to support demonstrable improvement in patient care through quality improvement activity. The QI Hub was formed following extensive stakeholder consultation with a focus on engaging and involving NHS Scotland Boards in shaping its development.


Boards with a remote and rural responsibility were included in these preparatory activities. The QI Hub partners have worked with NHS Boards to create and design NHS Scotland’s first national partnership approach to quality improvement. The partnership has allowed the collaborating organisations to align their quality improvement agendas and to create a cohesive and coordinated approach to quality improvement.

The intention is to support NHS Scotland in excelling in quality improvement for the benefit of patients and to place Scotland as a world leader in healthcare quality. This vision will be delivered through partnership working with the NHS Scotland Boards, and by combining resources from partner organisations. The QI Hub will serve to support the implementation of the Quality Strategy through the provision of support, education, training and technical expertise in improvement science.

6. Summary

Each of the remote, rural and Island areas has different support needs. However what is common to each is the urgent need to redesign the workforce to better ensure delivery of high quality and sustainable services. Remote and Rural inclusive education has a key role to play in supporting service improvement and sustainability by ensuring that robust, affordable and accessible education programmes are available to enable boards to safely and effectively build new or expanded roles within redesigned workforce plans. This process requires coordination and careful management to ensure best value, avoid duplication and build on existing resources.

Pam Nicoll & Ronald MacVicar September 2012


Key References:

1. The Scottish Government, Our 2020 Vision for sustainable Health and Care 2011

2. The Scottish Government, The Healthcare Quality Strategy for NHS Scotland, May 2010

3. The Scottish Government, Report on the Future Delivery of Public Services by the

Commission chaired by Dr Campbell Christie. Published on 29 June 2011.

4. http://www.scotland.gov.uk/Publications/2010/11/24111237/4

5. The Scottish Government ,The Final Report of The Remote and Rural Implementation Group

October 2010

6. The Scottish Government, Delivering for Remote and Rural Healthcare, The Final Report of

the Remote and Rural Work stream. Edinburgh: Scottish Government, 2008

7. http://careers.bmj.com/careers/advice/view‐article.html?id=20006803

8. The World Health Organisation, Increasing Access to Health Workers In Remote and Rural

Areas Through Improved Retention, Global policy Recommendations, WHO 2010

9. Audit Scotland, Using Locum Doctors in Hospitals, Edinburgh: Audit Scotland, 2010

10. Knowledge Transfer Associate Highland KTP Summary on Sustainable Staffing Issues for NHS

Highland Rural General Hospitals, August 2011, unpublished summary paper.

11. The Scottish Government “Telehealth ,Telecare Towards 2020”

12. Remote Acute Care Community Hospitals Working Group 23 December 2010. The National

Framework for the Sustainability of Services and the Medical Workforce in Remote Acute

Care Community Hospitals (2011). (unpublished).


http://www.scotland.gov.uk/Publications/2010/11/24111237/4

http://careers.bmj.com/careers/advice/view-article.html?id=20006803

Appendix 1. Summary: Final Report of the Remote and Rural Implementation Group October 2010 Forward Actions & Recommendations Education & Workforce Recommendations for the Future: RGH Next Steps As noted above the priority areas for action have been identified as: sustaining core services and developing networks to ensure access to four key specialist services not routinely available in RGHs, including Child Health, Mental Health, Radiology and Laboratories. These priority areas are not an exhaustive list, however, further priorities will be for NHS Boards to determine. Education Agreed Actions RRHEAL will continue to : Work with the R&R NHS Boards, using their learning and development plans to prioritise education and training needs. Develop “Distributed Education System and Platform for Remote and Rural Workforce”. Work with Educational providers to ensure that programmes are appropriate to need, accessible and viable for the long term. Respond to priority needs across a number of boards to identify more appropriate training to support new and emerging roles for nurses in remote and rural practice. This work will provide the remote, rural and Island nurse education input to the National Review of Nursing in the Community. Agreed Actions Boards with RGHs will compare current RGH model with the role and function defined within Delivering for Remote and Rural Healthcare to determine whether the service model is consistent with the recommended model and address inconsistencies. A review of the Needs Assessment by NoSPHN has been commissioned and will be shared with Remote and Rural Boards with RGHs to support local redesign.

Appendix 2


NES CORPORATE PLAN 2012 – 2013 Remote and Rural Healthcare Our educational support for remote and rural healthcare builds on our core work programmes to create a productive network between stakeholders in order to :‐

• link remote and rural health services to education providers • advise on methods of delivering education to remote and rural staff • map existing and new education and identify gaps in educational needs • work with technology experts to support learner access to education • design evaluation tools to assess remote and rural education

Rural General Hospital Workforce We will identify and deliver education for the rural general hospital (RGH) workforce across Scotland to assist in developing a sustainable workforce structure. By the end of March 2013 we will:‐ (1) complete a detailed map of the priority education needs of the RGH workforce (2) deliver new RGH education programmes. Rural Acute Care We will provide a structured education programme for GPs delivering care in remote and rural acute care settings. By the end of March 2013 we will:‐ (1) agree the funding and design of the programme (2) complete design of the evaluation framework (3) recruit GPs and commence the programme. Rural Health and Social Care Workforce We will develop and deliver education programmes that are accessible, sustainable and affordable for remote and rural support workers, nurses and mental health teams. By the end of March 2013 we will deliver 2 new education programmes supporting health and social care integration within remote, rural and island communities. Rural Health and Social Care Technology We will develop and deliver education programmes that support increased use of technology to improve access to care for those living in remote, rural and island communities. By the end of March 2013 we will deliver a new ‘Use of Technology to Deliver Rural Care’ education programme. Scottish School of Rural Health and Wellbeing We will establish a ‘Scottish School of Rural Health and Wellbeing’ to provide training, education and research for the remote, rural and island health and social care workforce. By the end of March 2013 we will:‐

(1) establish the school (2) deliver new education programmes


Pharmacy Remote and Rural Support We will review, further develop and integrate our pharmacy distance, e‐learning and online resources and the people who support remote and rural learners to ensure a consistent approach to educational delivery. By the end of March 2013 we will:‐ (1) develop videoconferencing facilities and support by local tutors to remote sites (2) develop e‐learning resources on our website (3) develop a programme of webinars/webcasts and virtual room training. GP Remote and Rural Training We will help to ensure a quality rural GP workforce. During 2012‐13 we will provide 10 GPs for the remote and rural workforce.


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