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

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Appendix 2 Implementation Plan

Commitment

Why

Who

Timescale

This new model of safe and sustainable health services for remote and rural areas with formal working links between rural areas and those in larger centres should be introduced.

Sustain and improve local access to appropriate services.

The North of Scotland Planning Group should take a lead role, bringing together Regional Planning Groups ( RPGs) and their constituent NHS Boards, to implement this framework, supported by a National Project Manager.

December 2009

Improving the Patient Experience of Remote Primary Care

Patients should receive the same standards of care for common conditions irrespective of where they live.

Patients may currently be receiving sub-optimal care or have to travel needlessly.

The North of Scotland Planning Group should take a lead role, bringing together Regional Planning Groups ( RPGs) and their constituent Boards to facilitate the network of RGHs in conjunction with larger centres to develop care pathways for common conditions. RGHs should share the role of developing draft pathways in collaboration with CHPs and seek approval.

April 2008

The system of care within remote and rural communities should support self-care, anticipate health needs and have the capability to respond to emergency situations.

Patients should expect health and social care professionals to anticipate health needs to avoid crises in chronic diseases and be able to respond to emergency situations.

CHPs should review the service they provide to ensure that it is consistent with the model described. Specific actions should ensure that:

  • Teams are integrated and co-located including heath and other agencies;
  • The ECCT supports individuals to self-manage their own care utilising self help groups and informal carers;
  • Priority is given to the provision of anticipatory care and that systems are in place for the prevention of disease escalation;
  • Action plans to implement long term condition management;
  • There is local access to emergency care provision within the community and work with the SAS to develop robust emergency community response systems.

December 2008

The systems of care should build community resilience.

To ensure that all available scarce resource is utilised towards local patient care.

CHPs and SAS should explore the use of the wider healthcare team to develop resilience within the community, including a pilot to test the role which Ambulance Technicians and Paramedics can play, particularly in anticipatory care and long term condition management.

Out of Hours services should be reviewed.

December 2008

Remote primary care will have common methods of data collection and data set.

To ensure that information is available to guide planning.

ISD should work with CHPs to develop a common data set and make arrangements to routinely collect and report.

August 2009

Remote Community Hospitals, acting as a community resource hub, should provide an agreed range of services, including enhanced diagnostics to ensure the right treatment by the right person in the right place at the right time.

Patients will have access to services locally and will know what services they can expect to receive.

CHPs must ensure that their Community Hospital is an integrated resource within the spectrum of care.

CHPs should review their Community Hospitals to determine which, if any, should be enhanced, and develop plans to implement this.

CHPs should review the service provided within their Community Hospital(s) to ensure that these services are consistent with the model described. Investment should be appropriate to meet clinical demands of safety. This includes:

  • Utilising the Community Hospital as a resource hub to the community, integrating and co-locating services provided by health and other organisations;
  • First line emergency services are provided along with a minor injury/illness service; this will include acting as a Place of Safety for Mental Heath crisis;
  • A range of diagnostic services are provided as described below;
  • Undertaking a role in pre-operative assessment;
  • Providing a range of outpatient visiting services, appropriate to the health needs of the population;
  • Provision of an intermediate care service provided, accessible by all practitioners;
  • Provision of a community midwifery service; and
  • Palliative care services are provided.

December 2009

Sustainable Secondary Care

The RGH is a Level 2 + facility undertaking the management of acute medical and surgical emergencies and is the emergency centre for the community, including a Place of Safety for mental health emergencies. It is characterised by more advanced levels of diagnostic services than a Community Hospital and will provide a range of outpatient, day case, inpatient and rehabilitation services.

To improve local access for patients to local secondary healthcare.

NHS Boards should review the service provided within their RGH to ensure that these services are consistent with the model described. NHS Boards should ensure that:

  • The role of their RGH(s) is consistent with the definition contained in this Report;
  • A core range of services is provided in the RGH(s), consistent with those described in this Report.

For unscheduled care: nurse-led urgent care service, first-line emergency treatment, an acute medical and surgical service, midwifery-led maternity service, including neonatal resuscitation and appropriate transfer arrangements.

In terms of planned care, the RGH should manage patients with stroke, step-down, rehabilitation and follow up of a range of patient conditions; management of patients with long term conditions; ambulatory care for children; routine elective surgery and visiting services, appropriate to the health needs of the population.

The surgical procedures provided within the RGH is consistent with those prescribed within the RGH Surgery Report and that governance process are in place for where there is a defined health need to provide surgery outwith the prescribed list.

The range of diagnostic capability includes endoscopy, surgical intervention ( e.g. biopsy), cardiac investigation, digitised image capture, ultrasound and CT scan, and laboratory services providing biochemistry, haematology and cross match blood.

RGHs should also have appropriate clinical decision support via e-health links to other centres, along with a pharmacy service.

  • NHS Boards should review their surgical services against the described model, and ensure that any procedures to be undertaken which are not included in the core model are subject to explicit NHS Board approval following formalised governance processes.

December 2009

The amount and range of secondary care undertaken locally should be maximised.

NHS Boards should undertake an analysis of appropriate activity linked to population intervention rates.

ISD should work with NHS Boards to develop a common dataset for RGHs, which is routinely collected and published.

NOSPHN should support Boards to progress this.

December 2008

Larger centres have an obligation to support services within remote and rural communities. Formal obligatory networks should be developed to support this.

To improve the patients experience of secondary care through supporting local care delivery and decision-making.

NHS Greater Glasgow and Clyde, Grampian, Highland and Lothian should enter into formal agreements with remote and rural providers to develop obligatory networks. This may require larger centres to review working patterns.

The North of Scotland Planning Group should take a lead role, bringing together Regional Planning Groups ( RPGs) and their constituent NHS Boards, to facilitate the development and introduction of these Networks.

NHS Boards should ensure a clear governance framework for these Networks.

August 2008

December 2008

December 2008

Formal networks should be established for radiology and laboratory services.

To improve local access to services and specialist opinion.

The North of Scotland Planning Group should take a lead role, bringing together Regional Planning Groups ( RPGs) and their constituent NHS Boards, to develop formal networks for both radiology and laboratory services.

August 2008

Maximise the range of diagnostic and secondary care interventions available locally.

R&R communities should expect that a core range of diagnostics and interventions are available within local communities.

NHS Boards, supported by the NOSPHN should investigate the variations in population intervention rates and seek to maximise the amount of secondary care undertaken locally.

August 2008

Establish a network of Rural General Hospitals.

To develop common protocols and standards for appropriate local intervention.

The North of Scotland Planning Group should take a lead role, bringing together Regional Planning Groups ( RPGs) and their constituent NHS Boards, to establish a network of RGHs.

April 2008

Mental Health Service

The focus of mental health services in remote and rural communities must be upon early detection and prevention of disease escalation.

To reduce the number of times where patients with mental health problems experience a crisis situation.

NHS Boards should ensure that their mental health services focus upon early detection and prevention of disease through proactive case finding and targeting hard to reach groups and those in need.

December 2008

The extended community care team must have the ability to manage mental health crisis 24/7.

Patients should expect to receive a response which meets their needs in a timely and professional manner.

NHS Boards should ensure that their PEP is current, includes specific contingencies for the management of mental health crisis in remote and rural areas 24/7 and that their staff have received the necessary training in the management of mental health crisis.

December 2008

Formal support networks should be developed with larger psychiatric centres.

To ensure robust systems are established to support the care of patients living in remote and rural areas with mental health problems.

The North of Scotland Planning Group should take a lead role, bringing together Regional Planning Groups ( RPGs) and their constituent NHS Boards Rural NHS Boards should work with regional partners to establish a formal regional psychiatric service networks.

December 2009

There must be responsive retrieval systems for patients experiencing mental health crisis.

Patients should expect to be transferred to definitive care where that is required in a timely fashion.

The Scottish Ambulance Service ( SAS) should review their transport arrangements for responding to mental health crisis, and also ensure that the 30 minute response target for picking up specialist psychiatric support teams is met.

April 2009

A pre-hospital psychiatric emergency care course must be developed and be accessible to practitioners working in remote and rural areas.

To ensure that practitioners are competent to manage mental health crisis.

RRHEAL must urgently ensure the provision of a pre-hospital psychiatric emergency care course utilising a ' BASICs-type approach'.

December 2008

Child Health Services

The model of care for children and young people promotes ambulatory care and intermediate care with the majority of care being provided in the community as part of a formalised network with larger paediatric centres.

To increase local care provision for children and young people.

The North of Scotland Planning Group should take a lead role, bringing together Regional Planning Groups ( RPGs) and their constituent NHS Boards, including the four main paediatric centres to establish a Paediatric Network(s) and to negotiate the shape of local service delivery, with robust care pathways for the management of the most common conditions.

Network establishment will also include the identification of consultants responsible for remote and rural support, the use of e-health links and the agreement of discharge planning arrangements where a child has been treated in secondary or tertiary care.

August 2008

Paediatric teams within remote and rural communities should have the necessary training to undertake their role.

Patients expect to be cared for by competent practitioners.

The Paediatric network should support CHPs and RGHs to identify practitioners who will be included in paediatric teams.

A training needs analysis of those practitioners should be undertaken, the outcome of which should inform education and training packages for local delivery brokered through the Remote and Rural Healthcare Education Alliance ( RRHEAL), supplemented by outreach training through the formal paediatric Network.

December 2009

There must be responsive retrieval systems in place for transfer of the acutely ill or injured child or young person.

Children and young people who require transfer to definitive care should expect a responsive service.

The Scottish Ambulance Service ( SAS) should review their transport arrangements to ensure responsive systems are in place for transfer of the acutely ill child.

December 2008

The review of Specialist Services for Children and Young People should consider expanding the role of the Paediatric Intensive Care Retrieval Teams to incorporate those patients from remote and rural areas requiring transfer to high dependency care.

April 2008

NES, through RRHEAL, should ensure that appropriate and accessible paediatric educational solutions are in place for remote and rural practitioners.

December 2009

The Rural Training Pathways Steering Group should ensure that future curriculum for medical remote and rural practitioners incorporate specific elements of paediatric training.

April 2008

Regional Planning Groups should commission their Child Health Planning Groups with considering the principles of the Remote and Rural Child Health Report and their applicability to urban areas.

December 2008

Workforce

Health and Social Care should be organised as integrated teams, known as Extended Community Care Teams ( ECCTs).

To ensure maximisation of scarce resource within small communities.

To reduce professional isolation and enhance the services available to local communities.

CHPs should work with Local Authorities, SAS, and Voluntary Sectors to ensure integrated working across agencies.

NHS Boards should consider opportunities to link single handed practices.

December 2009

The ECCT should be co-located with other services, both within normal working hours and out of hours. Specific services to be considered are health, local authority, ambulance service and voluntary sector.

To ensure maximisation of scare resource within small communities and to enhance communications within teams.

NHS Boards should co-ordinate discussions with other services as part of a property strategy to review the location and premises of their teams.

December 2008

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

To ensure that there is staff competence that is appropriate to the role and capacity of the facility.

CHPs should review the skill mix within their Community Resource Hubs to ensure that there is the appropriate competence that is appropriate to the role and capacity of the facility.

December 2009

The RGH will have a medical workforce which will be predominantly consultant led in the areas of anaesthetics, surgery and medicine, supported by GPwiSI or Rural Practitioners.

To improve access for patients to local secondary healthcare which is inappropriate to be provided at the primary tier.

NHS Boards should review the workforce within their RGH(s) to ensure that it is devolved appropriately and is consistent with the model described.

The Remote and Rural Steering group should commission the North of Scotland Public Health Network to undertaken an audit to evaluate the effect of a consultant-led medical service, as compared to GPwiSI-led medical service as part of an obligate network, on local service delivery.

August 2008

April 2008

Establish a pilot to test the hybrid acute medicine/general practitioner role.

To improve the range of medical skill available to Remote and Rural communities.

NES should, in collaboration with the Academy of Medical Royal Colleges, establish a pilot to test the proposed curricula for the hybrid role and, if successful, should make the necessary arrangements to seek PMETB approval as an accredited training route.

April 2009

To evaluate and validate the role of the GPwiSI in remote and rural communities.

The Academy of Royal Colleges should commission research into the acceptability and attractiveness of the GPwiSI in remote and rural communities.

April 2008

Proleptic appointment to remote and rural areas should be encouraged and should be extended beyond Consultant medical staff roles.

To ensure continuity of service delivery whilst additional site-specific training is being undertaken.

The Scottish Government should review the proleptic appointment scheme to consider funding of proleptic appointments in multi-professional areas as well as for consultants in remote and rural areas.

NHS Boards should consider proleptic appointments in multi-professional areas as well as consultants in remote and rural areas.

April 2008

April 2008

Locally based services will be enhanced by visiting specialists as part of obligatory networks.

To improve access to patients to local secondary healthcare.

The North of Scotland Planning Group should take a lead role, bringing together Regional Planning Groups ( RPGs) and their constituent NHS Boards to review their organisational arrangements and working patterns of larger centres to support the needs of the RGH/Community Hospital.

April 2009

Nurses in RGHs should be multi-skilled generalist practitioners.

To ensure that there is capability to manage the spectrum of patient care needs.

NHS Boards should audit the skills of nursing workforce within the RGH and work with RHEAL to ensure that there are accessible training programmes developed to fill any gaps identified.

NES should ensure that undergraduate training for nurses takes account of the generalist skills set required to work in R&R areas.

April 2009

The Nurse with a Special Interest (Nw SI) in Acute or Enabling Care will be developed.

To support nurses with generalist skills.

The North of Scotland Planning Group should take a lead role, bringing together Regional Planning Groups ( RPGs) and their constituent NHS Boards to review their nursing workforce within the RGH to develop a skill mix which includes NwiSI according to local population need.

April 2009

AHPs should be multi-skilled generalised practitioners within own profession.

To meet the appropriate therapeutic needs of patients across the spectrum of care.

The North of Scotland Planning Group should take a lead role, bringing together Regional Planning Groups ( RPGs) and their constituent NHS Boards to review their AHP workforce and establish programmes to ensure consistency with models described.

April 2009

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

The North of Scotland Planning Group should take a lead role, bringing together Regional Planning Groups ( RPGs) and their constituent NHS Boards to review their AHP workforce and develop AHPwiSI according to local population need.

NES, through RHEAL, should commission education programmes to support the emerging roles as required by workforce planning.

August 2009

December 2009

The radiography team within the RGH will be flexible and consist largely of advanced generalist practitioners who combine plain film, CT and ultrasound imaging. There is an opportunity to develop assistant practitioners where adequate supervision by radiographers can be provided.

The North of Scotland Planning Group should take a lead role, bringing together Regional Planning Groups ( RPGs) and their constituent NHS Boards to review their radiographer workforce to ensure consistency with models described and define their skill mix according to local need.

NES, through RHEAL, should commission education programmes to support the emerging roles.

August 2008

April 2009

A team of multi-skilled generalist Biomedical Scientists who are part of a formalised laboratory network will be required to support service delivery in remote and rural areas.

To ensure that patients have access to a wide range of diagnostic tests locally available within remote and rural areas.

The North of Scotland Planning Group should take a lead role, bringing together Regional Planning Groups ( RPGs) and their constituent NHS Boards to audit the skills of Biomedical Scientists within the RGH and work with RHEAL to ensure that there are accessible training programmes developed to fill any gaps identified.

April 2009

There is appropriate access to pharmaceutical support within R&R communities.

To ensure pharmaceutical care is well managed.

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.

August 2009

A generic support worker role will be developed.

To support the work of nurses, AHPs and social care professionals.

NHS Shetland will lead the work of the development of the Generic Support Worker, in collaboration with other Rural Boards and RHEAL, including the development of an education programme.

NES, through RHEAL should commission an appropriate education programme and support the development of an accessible programme.

Scottish Government should commission an independent evaluation of the benefits of such a role.

April 2008

December 2008

December 2009

Education

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

To ensure continued sustainability and development of R&R healthcare.

NES should ensure that training programmes include appropriate exposure to R&R healthcare, during training.

December 2008

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

To ensure professional updating and peer group support for remote and rural practitioners.

The North of Scotland Planning Group should take a lead role, bringing together Regional Planning Groups ( RPGs), their constituent NHS Boards and RHEAL to establish a Practice Education Network.

August 2008

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

To ensure that practitioners have the wide range of competences required to care for patients living in remote and rural communities.

RRHEAL should work with NHS Boards, utilising their Learning and Development Plans to identify training needs and work with Educational Providers to ensure the development of appropriate and accessible training programmes.

RRHEAL must ensure that the educational response meets the speed of change in remote and rural service.

December 2009

Educational Programmes for remote and rural practitioners should, wherever possible, be accredited.

To ensure that career progressive opportunities are available to individuals who work in remote and rural practice.

RRHEAL should ensure work with Educational Providers to ensure that learning is accredited wherever possible.

April 2009

Robust systems should be developed that establish a critical mass of remote and rural learners that secures viable investment for learners.

To ensure that remote and rural practitioners have the wide range of competences required to care for patients living in remote and rural communities. .

RRHEAL should ensure that the needs of the remote and rural learners are used collectively to create a critical mass in order to make it a viable option for educational providers to deliver appropriate and accessible educational training programmes

August 2008

Remote and rural areas will continue to provide an important training opportunity for doctors in training, especially, although not exclusively for doctors wanting to specialise in R&R practice.

To ensure that the supply of remote and rural physicians, surgeons anaesthetists and GPs.

NHS Scotland should recognise the importance of remote and rural areas as a training resource for doctors in training and NES should establish appropriate training opportunities through new Specialty Training posts, if necessary.

April 2008

Fit for Purpose Training Programmes for Doctors aiming to enter R&R practice will be introduced.

Training should cover a curricula that will ensure that the doctors has the appropriate skills and competencies for the role expected.

To encourage recruitment.

The Specialty Training Boards should ensure that R&R specific programmes, based on the proposed curricula developed by the Rural Training Pathways Group, are developed.

August 2008

Remote and Rural systems will not be destabilised through changes to training.

To ensure sustainability of remote and rural services.

The Scottish Government should ensure that implementation of MMC takes account of the need to continue to deliver service in remote and rural systems.

April 2008

Infrastructure

Support Networks

Vertical Obligatory Networks between RGHs and larger centres should be established.

To improve the patients experience of secondary care by meeting quality and care standards and by providing consistency, continuity and integration.

The North of Scotland Planning Group should take a lead role, bringing together Regional Planning Groups ( RPGs) and their constituent NHS Boards, to facilitate Networks to determine the exact range of local and visiting services that should be provided on the basis of population need within the framework of core services.

Where additional services are provided, NHS Boards should develop a clear governance framework.

August 2008

December 2009

A lateral network between RGHs should be established.

Robust Care Pathways should be developed for the most common patient conditions.

To improve the patients experience of secondary care by meeting quality and care standards and by providing consistency, continuity and integration.

The North of Scotland Planning Group (No SPG) should take a lead role, bringing together RGHs to facilitate the establishment of networks to develop agreed standards, protocols, training and development and share good practice. This should include the development of robust Care Pathways for the most common patient conditions.

August 2009

December 2009

Quality Assurance and Governance

Remote and rural Scotland should be judged using the same standards as throughout Scotland.

To ensure that QIS standards are outcome based and take cognisance of different process used to achieve those standards in remote and rural settings.

NHS Quality Improvement Scotland ( QIS) should appoint a Clinical Advisor to ensure an understanding of remote and rural issues are sought in the development of its standards.

The Clinical Advisor should establish a remote and rural reference group to support him/her in this work.

April 2008

Physical Infrastructure

Primary Care premises should be purpose built.

To ensure that the multi-agency teams in remote and rural communities are co-located and have premises that fit for integrated purpose to enable them to deliver the maximum of care locally.

NHS Boards should review their primary care premises and prioritise their capital plans to include purpose built premises, working in collaboration with Local Authorities and other agencies to facilitate the co-location of teams.

December 2008

RGHs should be fit for purpose

Services should be provided in modern and appropriate premises.

NHS Boards should ensure that the fabric of RGHs is fit for purpose and ensure that, where necessary, this is addressed in their capital plans.

December 2008

Diagnostics

A remote and rural diagnostics network should be established.

To ensure consistent standards of care, support of services and professionals in remote and rural areas and make best use of scare resource.

The North of Scotland Planning Group should take a lead role bringing together the Regional planning Groups and their constituent NHS Boards, to facilitate the establishment of a remote and rural diagnostics network.

August 2008

There should be an agreed menu of diagnostics available locally, and local access to a wider range of tests provided and reported by larger centres.

Patients should not have to travel needlessly for those diagnostic tests that can either be provided and accessed locally or provided locally and reported within the larger centres.

NHS Boards should review the diagnostics provided within their areas to ensure that the service provided is consistent with the menu of diagnostic services described for each care setting, including self care within patient's own home.

December 2008

The roll out of digitised imaging ( PACs) should consider the needs of remote and rural areas and prioritise accordingly.

Patients should not have to travel needlessly for those diagnostic tests that can either be provided and accessed locally or provided locally and reported within the larger centres.

The National PACs project should consider remote and rural areas as a priority for the roll out of digitised imaging and ensure that transmission performance is as good as for urban settings.

April 2008

E-Health

IT infrastructure must be robust across the whole of Scotland.

To allow for rapid and safe communication and reduce the need for patient and staff travel.

The e-Health Strategy Board should review their investment plans to ensure that the level and quality of connectivity should be same across Scotland.

April 2008

Premises in remote and rural communities should have access to a range of modern communication tools including broadband, videoconferencing and telemedicine as a minimum.

Provision of this service to rural areas will reduce the need for patients to travel.

NHS Boards should review their existing premises and ensure that any new premises have access to a range of modern communication tools including broadband access, videoconferencing and telemedicine as a minimum.

December 2008

The concept of utilising e-health in the remote and rural setting must permeate every aspect of service planning and delivery in remote and rural healthcare.

To maximise patient access to local healthcare delivery and reduce the need for patients to travel.

NHS Boards must pro-actively consider the use of e-health solutions in every aspect of service and work with the SCTEH to change cultural views of the use of new technology. This will include as a very minimum the use of technology for:

  • Information sharing;
  • Linking to larger centres;
  • Diagnostics;
  • Telemedicine; and
  • Monitoring of long-term conditions in the patient's own home.

NHS Boards should collaborate with the SCTEH to ensure that staff undertakes adequate training in the use of new technology.

December 2008

December 2009

Emergency Response and Transport

The Fundamental Building Blocks

Robust and responsive local community emergency response systems should be developed.

Patients should expect to receive a responsive emergency service.

NHS Scotland should consider closer integrated working arrangements between SAS and NHS Boards.

The SAS should be responsible for ensuring that robust and responsive local community emergency response models are developed.

December 2008

December 2008

An integrated transport strategy must be developed that is responsive to remote and rural patient's needs.

Patients who require transport/transfer should expect to receive a responsive service.

The Scottish Government should consider the development of an integrated transport strategy, including health.

December 2008

An Emergency Retrieval Service for Remote and Rural Scotland

The Emergency Medical Retrieval Service ( EMRS) pilot should be established.

To support the care of the seriously ill and injured in people remote and rural communities.

NHS Scotland should establish the ERMS in a phased manner, building on the successful pilot within Argyll. Phase One should be implemented to cover the west of Scotland, covering three RGHs, thirteen community hospitals and a number of remote general practitioners. The first phase is likely to last 18 months.

December 2009

The ERMS pilot should be supported by an independent evaluation including a prospective study which identifies the needs of the northern Highlands and the northern islands of Scotland.

To support the care of the seriously ill and injured in people remote and rural communities

NHS Scotland should commission an independent evaluation of the first phase of the ERMS pilot. The evaluation should identify the requirements for the whole of rural Scotland for the Northern Highlands and Northern Isles, include a health economic assessment and risk assessment, the implications for the air ambulance service, a health and the impact on the areas where the service has been implemented.

April 2008

Equality & Diversity Impact Assessment

Opportunities for promoting equality will be maximised.

To eliminate or minimising any negative consequences.

NHS Boards will, when progressing local implementation of the models presented in the report, conduct and report on Equality and Diversity Impact Assessments according to locally agreed guidelines.

December 2009

Support for Change

Adequate capacity must be built in order to ensure implementation of remote and rural policy commitments.

To ensure that service change is effected as a result of the remote and rural policy commitments.

The Scottish Government should consider the providing funding for the appointment of a National Programme Manager with appropriate administrative assistance to support the implementation of remote and rural commitments.

January 2008

The cost of providing remote and rural services should be acknowledged and adequately funded by the Scottish Government.

To ensure that service change is effected as a result of the remote and rural policy commitments.

The Scottish Government should consider the impact of the NRAC review on NHS Boards ability to maintain and develop remote and rural services.

December 2009