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

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Sustainable Secondary Care

Patients should expect to be able to access core secondary care services as close to home as possible and only travel for those more specialised services that cannot be provided locally. As part of the development of the model for the Rural General Hospital ( RGH) the North of Scotland Public Health Network undertook a Needs Assessment. This comprised a rapid appraisal of the current use of hospital services by the catchment populations of rural general hospitals to determine the relevance of the emerging model of an RGH21. An additional analysis of the same data was used to produce surgical procedure profiles of each hospital. This work was conducted alongside an ongoing needs assessment in NHS Orkney. A review of the literature was conducted to seek information and evidence to inform work. The full RGH Needs Assessment Report is available as Annex 1 to this report. The main findings of the needs assessment were as follows.

RGH Needs Assessment

The literature review sought to answer the following questions:

  • What is the evidence-base for cost-effective delivery of healthcare services in rural general hospital?
  • How can quality and safety be assured in RGHs?
  • What are the sustainability issues and how can they be addressed for RGHs?

Material was systematically retrieved from a wide range of both electronic databases and from the grey literature including specialist web sites. Analysis was by a qualitative, narrative method that consisted of a 3-stage process of identification, collation, thematic coding and critical analysis. The level of evidence was graded using the system adopted by SIGN22.

Main findings

Analysis identified six main themes that cut across service delivery areas in a remote and rural hospital: models of care delivery, quality of care, recruitment and retention, diagnostics, telehealth and sustainability. The main service areas that were commonly reported on were cancer care, chronic disease and care of the elderly, rural paediatrics, surgery, maternity services and mental health.

Implications

Review of the literature indicates that there could be diversity between RGHs - this arguably demonstrates they are meeting local needs appropriately. The concept of having a core of services with a variable range of additional services seems logical on that basis. Although the majority of findings were derived from level 3 evidence 23, the following five themes emerged:

  • While there is great potential for surgical work, the decision that RGHs will not provide intensive care, limits appropriately, what can be done in them. (Level N/A)
  • Intrapartum care should be provided only for low risk women with no identified risk markers at the time of birth and who have normal weight babies. (Level 2-)
  • RGHs should have a defined level of diagnostic capability. (Level 3)
  • Better outcomes for many of the cancers are associated with specialised care and if cancer care is to be delivered locally, it should involve shared care with outreach clinics and deliver the same outcomes. (Level 2+)
  • Recruitment should take account of both nature and nurture factors i.e. rural backgrounds not necessarily Scottish-based and involvement in training programmes designed to promote rural healthcare. Although multiple barriers to retention exist, access to flexible continuous medical education including maintenance of advanced procedural skills is an important requirement. (Levels 2++ to 3)

RGH Rapid Appraisal

Rationale

Early work to develop the model for the RGH was described within the context of non-standardised hospital-based activity. This did not allow for consideration of the degree to which local populations health needs are currently being met. However, hospital activity can be analysed to give standardised rates, which allows for structure as well as size differences in populations. On this basis, total hospital utilisation by catchment populations around RGHs can be compared with the national average without such bias (rural populations tend to be more elderly). In addition, the degree to which the overall hospital utilisation rates of local populations are being met by the uptake of the local RGH services can be assessed.

The main findings of the assessment are based on 3 years of hospital data SMR01 (2002/03-2005/06 inclusive) and are as follows:

  • Based on all interventions, in all hospitals in Scotland (emergency medical, elective medical, emergency surgical and elective surgical), there was a wide variation in the intervention rates 24 of the catchment populations of each RGH which this study does not explain and requires further investigation.
  • The proportion of the total intervention rate 25 of the catchment population that was taken up at the local RGH, also varied widely between the catchment populations. This reflects the wide spectrum in the type of activity undertaken within the individual RGHs.
  • There were no systematic differences in the types of total intervention rates. For example, some catchment populations experienced high emergency and high elective intervention rates. Conversely, for some populations, both elective and emergency interventions were relatively low when considered against the Scottish average. In yet others, only the elective intervention rates were high.
  • For total intervention rates and with only one exception, the surgical day case activity was significantly higher than the national average. Again with one exception, medical day case activity was significantly lower.
  • The total intervention rates of all of the catchment populations included significantly higher elective surgical rates for cancer patients than expected on a national basis. For 4 out of 6 catchment populations, this activity was predominantly taken up locally.

The implications of these findings apply locally to the populations around individual RGHs and potentially, generically to those around all RGHs.

Local Implications

The reason for some of the variations found is thought to arise due to differences in patient pathways, suggesting that there may be an opportunity to align patient pathways. For example, low medical day case rates but high elective medical in-patient rates for the island populations, where travel times are such that an overnight admission is more feasible than a procedure on a day case basis.

Another example is the relatively high elective surgical in-patient rates for patients with cancer, where local practices differ from the specialised centres in terms of not providing a one-stop service. Other variants possibly need more investigation such as the almost universally high surgical day case rates. These variations should be looked at to confirm or otherwise, the local understanding of the patient pathways and to understand the appropriateness of these variations. In addition, only medical activity pertaining to the acute specialities was analysed, ie it did not include admissions to GP care only. However the total elective medical rates for the catchment populations served by RGHs are, with the exclusion of one hospital, 1.3 to 3 times higher than expected on the basis of the national average. This range included a RGH which exclusively admitted medical patients to GP care only.

Generic Implications

The variations between individual RGHs in respect of the population intervention rates and ratios of local to out of areas uptake reinforces the need to standardise the service provision by adoption of a core model for the RGH. It is also important to understand why these variations exist, as this should provide evidence to support the services provided beyond the core requirements. If, for instance, some of the variations are as a result of lack of qualified, supported, competent clinicians, this suggests that an improved training pathway and recruitment of appropriately skilled staff is required to support the patient pathways. Effectiveness and clinical cost-effectiveness issues should also be taken into account and any changes to current patient pathways subject to clinical governance arrangements such as audit activity. These changes will not just impact on the RGH, but also on the District General Hospitals ( DGH) and Regional Centres, particularly in terms of professional support, communication and effective network working. These variations have raised a number of questions and further work is recommended to investigate the variations in population intervention rates.

RGH Surgical Procedure profiles

Rationale

The rapid appraisal, which measured the relative total intervention rates of catchment populations and the proportion of total service uptake by these populations to the local RGH, revealed large variations both between RGHs and against the national average. Surgical day case activity tended to be higher and medical day case activity lower than the national average. Elective surgical rates in patients with cancer were higher than the national average for all populations around all RGHs. On the basis of these variations, it was requested that a comparison of profiles of surgical procedures should be carried out for each RGH.

The main findings are based on SMR01 data covering episodes over 3 years ( FYE 2003 to 2006) for each of the six RGHs analysed using the OPCS4 procedure code 26, recorded in the primary diagnosis position, only for identifying the procedure. Four different profiles were compiled:

1. All episodes (day cases and inpatients), all diagnosis;

2. Day case episodes, all diagnosis;

3. All episodes, (day cases and inpatients), cancer diagnosis only (in primary coding position);

4. Day case episodes, cancer diagnosis only (in primary coding position).

The findings can be summarised as follows:

  • Overall, 50% of total procedures were carried out as day cases for patients with any diagnosis;
  • 58% of patients with a cancer diagnosis were treated as a surgical day case;
  • For all diagnosis, Endoscopic upper GI examination was the most common procedure, with Chemotherapy either second or third depending on inpatient or day case admission;
  • For cancer diagnosis, the top four procedures were similar for day case or inpatient admission and these were Chemotherapy, other infusions, excision of skin lesions and blood transfusions;
  • Variations between hospitals were noted as:

i. Relatively higher rates of gall bladder removal in two hospitals.

ii. One hospital had a very high rate of mastectomies compared with the other RGHs, although the actual number was low.

iii. Diagnostic endoscopic examination of the bladder was relatively high in one RGH and very low in another.

iv. There was a relatively high rate of blood transfusions, mainly as day cases, in one RGH.

v. Only three RGHs provided a locally delivered Cataract service.

vi. Diagnostic fibreoptic examination of lower respiratory tract is carried out in only one centre.

vii. There were a number (56) of procedures coded as 'unspecified other operations on unspecified organs' in one centre but none in other hospitals. This may be a coding issue.

Local and generic Implications

Some of the variations are possibly explained by variations in clinical coding e.g. unspecified operations. However, others are not and raise a question as to the degree to which hospitals are meeting the needs of local residents and should be investigated further. There is also the question of clinical safety associated with low volumes of some, particularly more complex, procedures e.g. total mastectomies. This should be an area for further investigation.

Commitments

NHS Boards should seek to maximise the provision of appropriate secondary care undertaken locally.

Through further analysis of the population-based activity, NHS Boards should identify the reasons for variations between RGHs, in terms of surgical profiles, patient pathways, practitioner or patient preferences and differences in patient management. NHS Boards should also use collaborative analysis of the key features of the local work to understand and develop a rationale to inform the detail of the service modelling.

The North of Scotland Public Health Network should support NHS Boards to further investigate the variations in population intervention rates, ensuring that further work is framed within wider contexts such as the impact on receiving hospitals, community hospitals, other small urban general hospitals and primary care.

Through a network of RGHs, common protocols and standards should be developed for appropriate local intervention.

The Rural General Hospital

This chapter outlines the framework for improving access to secondary care, detailing the model of the RGH, as an integrated part of the Extended Community Care system. Six Rural General Hospitals are identified in the NFSC and the full Rural Access Action Team report 27 and these are:

  • 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.

Definition: What is a Rural General Hospital?

A definition has been developed which seeks to describe the service that should be provided within an RGH:

"The RGH undertakes management of acute medical and surgical emergencies and is the emergency centre for the community, including the 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."

Some of the facilities, currently defined as Community Hospitals, provide a similar range of services to those identified above in this definition, for example the New Galloway Community Hospital. Redefinition of these hospitals is beyond the remit of this project but NHS Boards will find this framework helpful in orienting such hospitals on the continuum of care.

The National Framework for Service Change ( NFSC) have defined services in levels of care 28, from level 1 - community provided services, such as General Practitioners and NHS 24, to level 4 - nationally delivered, highly specialised services. Level 2 facilities will include assessment, diagnosis and treatment for routine conditions. Level 3 facilities are identified as the core admitting services, with locally available 24/7 receiving in general surgery, general medicine, and orthopaedics; with anaesthetic and radiology support. In addition, one or more of following specialities may support these on a receiving basis: paediatrics, obstetrics and gynaecology.

Although the RGH does not easily fit into any of the above categories, it is best regarded as a level 2+ facility. The model described 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. Whilst a proportion of these patients may be transferred to a larger centre, the majority will be admitted to the RGH.

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. 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 will exist in a network with larger centres. These may be District General Hospitals or Tertiary Centres. The RGH should have arrangements to refer patients appropriately to definitive care, based on robust care pathways that will sometimes by-pass the more local DGH. Formal arrangements will exist between the larger centre and the RGH to support local delivery of care, known as obligate networks. This should include formally agreed specialist clinical links, with an obligation to support local delivery of care and local decision making within the RGH. This will be available in a number of core specialities on a 24/7 basis. The current practice of visiting specialists should be reviewed and extended where appropriate.

The RGHs should also network with each other and with the larger centres to develop agreed, evidence-based protocols. This will ensure that the clinical standards are similar across Scotland. RGHs will also be part of local networks linking with the locally based extended community care team, with the principle that the RGH is retained to manage the more complicated conditions that cannot be cared for at home, or within a community hospital setting.

All RGHs must be supported by robust retrieval and transport systems to ensure that safe and effective patient transfer to other centres is available when needed.

Core Services within the Rural General Hospital

The definition above suggests that the RGH will initiate immediate emergency triage, resuscitation, and stabilisation; it will provide treatment, when appropriate, and transfer when necessary. There will be a range of appropriate diagnostic facilities, access to specialist opinion, including a range of visiting specialists and will provide certain services on the basis of networks with others. A number of underlying principles have been agreed as necessary to underpin all RGHs, as follows:

  • A CORE range of services should be provided that are not different in different places;
  • Standard protocols for procedures and transfers should be agreed;
  • Formal links with other centres, developed through obligate multi-disciplinary networks should be established;
  • Access to a standard range of diagnostics - some local, some distant;
  • Practitioners who are competent to deliver the level of care required - not necessarily consultant led in every discipline;
  • Appropriate training programmes;
  • Skills update and mentoring should be supported by larger centres;
  • Transfer from local services should be directly to definitive care, where it is possible to determine this.

As a minimum an RGH should support the following services:

Unscheduled

Planned

  • Nurse led Urgent Care service managing minor injury and minor illness;
  • Ability to resuscitate patients;
  • Ability to manage acute surgical and medical admissions;
  • Initial fracture management and manipulation of joints;
  • Midwifery led maternity service;
  • Neonatal resuscitation;
  • Capability to diagnose and initially manage acutely ill or injured child;
  • Capability to manage patients requiring a higher dependency of care before transfer;
  • Clear and appropriate retrieval and transfer arrangements.
  • Management of patients with stroke;
  • Rehabilitation and step-down;
  • Post-op step down, rehabilitation and follow-up;
  • Management of patients with long term conditions, including haemodialysis, and cancer care as part of a network;
  • Provide ambulatory care for children within the locality;
  • Routine elective surgery;
  • Visiting services.

Diagnostic

Support

  • Diagnostic capability, including:

    Imaging: Digitised image capture, Ultrasound and CT scanning;
  • Laboratories:

    Limited range of Biochemistry, Haematology and cross match blood.
  • Endoscopy: Upper and lower GI, Cystoscopy;
  • Surgical intervention: e.g. biopsy of lesion
  • Cardiac Investigation including:

    Stress testing and Echocardiography.
  • Clinical decision support via e-health links to other centres;
  • Pharmacy support.

Details of current RGH activity by speciality are available in the Technical Annex of this report.

An Emergency service is required within the RGH. Nurses can manage the majority of the activity with appropriate skills in the management of minor injuries and minor illness, but they need to be supported by appropriate clinical decision support.

An Anaesthetic service within the RGH will be pivotal. There are two defined roles of anaesthetic practice within an RGH, as follows:

  • Emergency care, including resuscitation and stabilisation and administration of anaesthesia for emergency surgery. This includes emergency airway management, however these skills are not unique to anaesthesia.
  • Administration of anaesthesia for elective surgery, which will require a level of activity to maintain skills and retain professional interest.

This service will be required 24/7.

Medical activity is by far the largest proportion of RGH in-patient work, accounting for 60% of total in-patient admissions and there remains a clear role for acute medicine and secondary care support for the management of long-term conditions within the RGH, including a wide range of outpatient clinics. It is difficult to prescribe what should and should not be admitted to the RGH. Those patients transferred will depend on the competency of the team and clinical decision making of the doctor. An increase in the visiting medical services should be considered e.g. locally available non-interventional cardiology.

The future role and shape of surgery in the RGH is to provide elective outpatient, in-patient and day case services and a 24-hour emergency service, acting as part of a regional network of surgical services, within the following agreed boundaries.

24-hour surgical services should provide local assessment, triage, resuscitation stabilisation of emergency surgical and trauma patients followed by admission and surgical intervention, if appropriate, and transfer, when necessary, in collaboration with the relevant receiving hospital. In addition, due to the specific risk factors, island surgical services should provide an emergency Caesarean Section Service.

The key role of the surgical service in the RGH is the provision of planned surgery, primarily on a day case basis for the local community. Procedures which would be included within the core surgical workload of the RGH, both on an emergency and elective basis, are described in detail in Annexes 3a and 3b but are summarised in the table below:

Emergency Surgical Workload

Planned Surgery

  • Appendicectomy;
  • Caesarean Section;
  • Endoscopy (including injection of varices);
  • Evacuation of retained products of conception;
  • Lacerations;
  • Initial fracture management and joint dislocations;
  • Repair of perforated ulcer;
  • Control of haemorrhage (including splenectomy);
  • Resection and anastomosis of bowel;
  • Ruptured ectopic pregnancy surgery;
  • Chest drain;
  • Drainage of pericardium injury (for cardiac tamponade) plus suturing of penetrating injury.
  • Biopsy of lesions;
  • Cholecystectomy and/or exploration of common bile duct;
  • Circumcision;
  • Endoscopy;
  • Nail bed procedures;
  • Peri-anal procedures;
  • Resection and anastomosis of bowel;
  • Simple undescended testes repair;
  • Scrotal surgery including vasectomy;
  • Varicose veins surgery.

Where breast surgery is to be carried out within an RGH, it should be concentrated into the workload of one surgeon, and that surgeon should become part of a formal network with either a DGH or a tertiary centre.

Services that should be provided on a visiting basis include ophthalmology, Ear Nose and Throat, Urology, Gynaecology and Orthopaedics. Some surgeons within the RGH already have the necessary training and supporting team competencies to provide some of the visiting services listed (for example, orthopaedics and urology).

Surgical services that should not be core provision within the RGH, and therefore should not be provided unless explicitly agreed by the NHS Board, through appropriate clinical governance arrangements, include:

  • Surgery on children under the age of 5 years (with the exception of suture of cuts, drainage of abscesses and foreign body removal where specialist expertise in that field exists and where there where there is competency and practised paediatric anaesthesia);
  • Neurosurgery (such as emergency burr holes);
  • Operations on the neck and chest (other than emergency tracheostomy);
  • Stomach (excepting perforated and bleeding ulcer surgery) and rectum operations;
  • Liver;
  • Vascular surgery;
  • Ovarian (with the exception of ovarian cysts or torsion or haemorrhage);
  • Vaginal or penile operative procedures (with the exception of circumcision).

Where there is a proposal to provide such local surgery which is not included within the core service these need to be explicitly agreed though formal governance processes which would include the demonstration of local health need, team competences, outcomes expected (demonstrated to be at least as good as other centres) and approval by both the local NHS Board and the Regional Surgical Service Network. Links have been established with the national Volumes and Outcomes workstream in the preparation of the model of surgery that should be provided within the RGH.

The RGH surgeon should provide outreach day case surgery in Community Hospitals where such facilities exist.

Maternity

There are different models of maternity care within each of the RGHs but the number of births in each centre is low, ranging from less than 1 birth per week in Fort William to 4 per week in Caithness. Emergency caesarean sections are regularly performed in 4 RGHs, in two hospitals (Caithness and Western Isles) these are carried out by locally based consultant obstetricians, in others by a General Surgeon, however the frequency of this is also low.

Whilst the birth rate across Scotland has continued to rise from its lowest point in 2002, the birth rate across remote and rural Scotland is decreasing. As a minimum, therefore, a midwife led service is proposed as the most appropriate model in remote and rural areas. In light of this recommendation, the role and competencies of midwives working in remote and rural areas has been reviewed and is reported in Annex 2. NHS Boards should seek to maximise local deliveries.

Commitments

The RGH should be defined as a Level 2+ facility.

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.

Where additional services are provided, a clear governance framework should be developed.

Forward Issue

Obligatory Networks should developed and should determine the exact range of local and visiting services that should be provided on the basis of population need within the framework of the core services.

Other Core Services

Five key groups have been identified to support the core service within the Rural General Hospital. These were Child Health, Mental Health, Endoscopy, Imaging, and Laboratories. The emerging models for Mental Health and Child Health are summarised below, whilst the others are discussed in the chapter on Infrastructure.

Mental Health

The Mental Health Delivery Plan 29 set the policy context for the model of mental health services in Scotland between now and 2010. This report therefore will confine itself to the issues which have been raised as specifically challenging for remote and rural areas to deliver. A full report of the remote and rural sub-group can be seen at Annex 4 of this document.

During the process of producing this report a number of issues have arisen in the management of patients in remote and rural areas experiencing mental health crisis. These issues have been raised by generalist practitioners and hospital based clinicians and include the availability of a Place of Safety locally and access to specialist advice. Having identified these issues work is now being done with the Scottish Government and through the Remote and Rural Group to ensure that the standards set in relation to meeting the needs of those in crisis are met through existing resources or the development of new ways of working.

The focus of mental health services within remote and rural communities must be on the early detection of disease, with pro-active case finding targeted at difficult to reach people and those in need, the aim of which is to prevent disease escalation. One such example is Guided Self Help Workers in NHS Highland who identify people with depression at an early stage and focus upon the prevention of escalation of disease. There is also an opportunity for remote and rural areas to develop creative solutions in prevention of mental health crisis by utilising Choose Life Co-ordinators, and pulling on the work being done by the Mental Health Foundation, SAMH and the Mental Health Collaborative improvement programme on reducing hospital re-admissions and the development of an assessment/appraisal tool for Boards and partners to use to assess progress against delivering these standards.

Despite the focus upon early detection and prevention of disease escalation, there will inevitably be situations where individuals will experience a mental health crisis and these will require management, sometimes by generalist practitioners and sometimes by generally trained physicians. There are well documented challenges for remote and rural areas in meeting the National Standards for Crisis Services 30 however, it is important that the needs of those in remote and rural areas are addressed, even if this means that the national standards need to be reviewed to ensure that they are achievable across Scotland.

CHPs must, therefore have contingencies in place which support practitioners in remote and rural areas to manage a mental health crisis and ensure that individuals receive a response which meets their needs in a timely and professional manner. This may include containment and stabilisation within a place of safety, which may be in a Community Hospital or an RGH where these exist, until onward transfer to a specialist centre. Mental Health services should be organised as part of a formal network, with a specialist centre and there should be appropriate retrieval arrangements to allow access to inpatient care. Locally available services should include a crisis service and assertive outreach to sustain, as far as possible, patients in their home environment. Contingencies which should be in place to support the management of mental health crisis in remote and rural areas would usually include:

  • Specific arrangements for the management of mental health crisis in remote and rural areas to be included in NHS Boards' Psychiatric Emergency Plans ( PEPs);
  • The requirement to review the need for the extension of current mental health service provision to cover out of hours;
  • The development of formal obligatory networks with specialist psychiatric centres, including communication across the system involving case management and critical incident reviews;
  • Responsive retrieval systems for patients experiencing mental health crisis;
  • The need to establish robust e-health links between remote and rural healthcare settings and psychiatric centres.

In order to ensure that practitioners in remote and rural areas have the necessary skills to appropriately manage an individual experiencing mental health crisis, there is an urgent need for the development of a pre-hospital psychiatric care course, delivered utilising a ' BASICS' type approach.

Child Health

Over recent years, various groups and initiatives have explored the most appropriate and sustainable healthcare provision for children and young people in remote and rural areas in Scotland. These include the Kerr Report, the Remote and Rural Areas Resource Initiative ( RARARI) Paediatric Project, and recently, Delivering a Healthy Future: An Action Framework for Children and Young People's Services 31' 32' 33' 34.

The common themes emerging from these reports include:

  • Difficulties faced by local clinical staff in providing high quality care for children with significant acute or chronic illness given the small number involved and the lack of immediate specialist support.
  • A perceived lack of understanding on the part of the clinicians working in dedicated paediatric units of the particular circumstances faced by staff in remote and rural settings.
  • Variable quality of discharge planning after episodes of specialist care.

These reports are consistent in their recommendations in the types of models recommended for providing health services locally which are safe and appropriate for children. Paediatric models described within the reports above are based around the principles of a Managed Clinical Network and this report concurs that remote and rural child health services should be firmly embedded in a formal network with a larger paediatric centre, providing ambulatory and intermediate care, locally, with the majority being provided in the community.

In terms of the workforce required to deliver a local ambulatory and intermediate care service for children and young people, CHPs, including the RGH staff, should identify their paediatric teams and ensure that these staff have the necessary training and educational support necessary (and appropriate access to this) to develop and maintain the competences required to resuscitate, stabilise and initially manage an acutely ill or injured child and transfer when appropriate. All staff will also require access to the appropriate equipment locally and should have guaranteed access to clinical decision support from larger centres. A robust system of retrieval of children with high dependency or intensive care is essential.

A full report on the model for Remote and Rural Child Health can be seen in Annex 5.

Commitments

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

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

Formal support networks should be developed with psychiatric centres.

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

The Remote and Rural Healthcare Educational Alliance ( RRHEAL) should urgently address the training needs of remote and rural practitioners through the development of a Pre-hospital Psychiatric Emergency Care Course which should be delivered utilising a ' BASICS' type approach.

An ambulatory care service should be provided for children. This service should be part of a formalised network with a paediatric centre.

Paediatric teams within RGHs should be identified and CHPs should ensure that these teams have the skills required to manage the care of an acutely ill or injured child 24/7.

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