Infrastructure to Support Remote and Rural Practice
Time and again throughout this process the need for formal, obligatory networks has been repeated as remote and rural health systems cannot exist in isolation but need to network with others to sustain local care, support practice and treat patients. There are few networks between primary and secondary or tertiary care, however, evidence shows that formal networks do improve the service to patients in remote areas and reduce the need for multiple visits to secondary or tertiary care 47.
Obligate networks should be developed as partnerships and should incorporate responsibility for the development of robust care pathways (both for planned and emergency care), and to provide support to remote and rural localities 24/7.
It has been suggested that two types of network arrangements are needed:
- Laterally between remote practices or RGHs to develop agreed standards, protocols, training and development, support and share good practice; and
- Vertically working with specialist experience in another location to ensure quality and sustainability of appropriately devolved local services. This is likely to be condition/specialist based e.g. cancer, neurology organised as part of a managed clinical network.
The benefit of establishing networks is mainly to support the local delivery of care, but includes:
- Access to expert opinion to inform local clinical decision making;
- Peer group support, training and education;
- Rotation for skills update and maintenance;
- Development of shared protocols and pathways;
- Transfer debriefs;
- Increased practitioner confidence;
- Improved discharge planning.
The development of these obligate networks are likely to have a bigger impact on the day to day working of those in the larger centres than in the remote and rural communities, however, these are crucial to sustainability of local services and appropriate clinical decision making. Regional Planning Groups, through Directors of Planning and Board Medical Directors should facilitate discussions between those in R&R areas and those in larger centres to establish such networks.
Vertical obligatory networks between RGHs and larger centres should be established.
Lateral networks between RGHs should also be established.
Directors of Planning and Board Medical Directors should agree the nature and form of lateral and vertical networks.
Robust Care Pathways should be developed for the most common patient conditions.
Quality Assurance and Governance
Remote and rural healthcare needs to be supported by robust systems of governance and should be judged on the basis of the standards developed for NHS Scotland. Remote and rural healthcare providers need to have systems in place to assure the public of the level of competency to deliver identified activity. They are required to meet the appropriate standards and should have processes in place to demonstrate this. Where an RGH considers that a procedure beyond the core service can be provided locally, there should be a robust system for assessing whether the service can be supported locally. That system needs to take account of the skills and competences of the whole multi-disciplinary team.
Remote and rural areas must be subject to the same good practice standards as other geographical areas and should not be judged on the basis of lower standards. It is recognised, however, that there are difficulties for some remote and rural areas achieving national standards. Non-achievement, however, can often be due to reasons of structure and/or processes rather than a low standard of outcome. It is proposed, therefore, that future standards developed by NHS Quality Improvement Scotland ( QIS) for NHS Scotland services should be considered in the context of the different structures and processes necessary to provide services in remote and rural areas. To effect this, NHSQIS have agreed to establish a system through which Remote & Rural Clinical advice from an Advisory Panel is sought during the development of standards and, where appropriate, other publications.
Remote and Rural healthcare should be judged using the same standards adopted throughout Scotland.
NHS Quality Improvement Scotland ( QIS) should appoint a Remote and Rural Clinical Advisor to ensure an understanding of remote and rural issues sought in the development of its standards. This Clinical Advisor should establish a Remote and Rural Reference Group to support him/her in this work.
- Disparate bases
- Access to intermediate care variable
- Variances in IT
- Minimal diagnostics
- Purpose-built premises
- Local access to Intermediate care services
- Broadband access and Tele-health
- Good diagnostics
Currently, practitioners in the community are based in different locations. Teams should be integrated with services based in the GP Practice to enhance communication and make best use of local resource 48. The ECCT where possible should be based within a purpose built building and NHS Boards should take this into account when prioritising capital plans.
The majority of practitioners other than GPs still reported utilising dial-up modem Internet access. Any new premises must have broadband capacity with access for all the multidisciplinary team, with shared links to health and social care computer systems. Computerised systems must be integrated with electronic referral to secondary care.
Where there is a community hospital within the locality, it is suggested that this be aligned to the GP Practice and act as a local resource centre.
Diagnostic capability has been highlight as one of the key aspects of healthcare that remote and rural communities expect to have local access to. There are different levels of access across primary care, within a Community hospital and within the RGH. Locally provided diagnostics can reduce unnecessary trips for patients 49. There follows a menu of diagnostic tests that are being proposed as minimum requirements in remote and rural areas. In the development of these proposals, there has been collaboration with other national workstreams such as the Diagnostics Collaborative and the Community Diagnostics Project. These workstreams have given initial support for the remote and rural diagnostic proposals, however these workstreams are due to report at a later date, therefore some amendments may be required.
As described in the primary care model, patients are to be encouraged and supported to manage their own care. This will include the utilisation of e-health solutions to monitor long term conditions which could be accessed in the patient's own home.
There is only limited diagnostics capability available within primary care, and a study was therefore undertaken in the Western Isles to establish evidence to underpin the proposals to invest in local diagnostic capability (see Annex 6). The outcomes of the study supports the case for investment in the increased provision of diagnostics, the enhancement of intermediate care facilities and coupled with the use of new technology, the balance of care would be shifted more from secondary and tertiary to primary care. The range of diagnostic capability recommended below has been based on the outcomes of the study, the views of clinicians in remote and rural areas and validated through the national Community Diagnostics and Diagnostic Collaborative Programmes.
The diagnostics capability required will differ with a practitioner in a GP Practice to those with responsibilities for a Community Hospital. In very isolated or small practices, it may be possible to share this capability. The specific range of diagnostics tests which should be available in remote Primary Care locations are:
- Blood Gas Testing including haemoglobin, white blood cell count, urea, creatinine, creatinine kinase and amylase, Troponin T, and INR;
- Electronic access to laboratory results;
- Electronic access to digitised imaging reports;
- Ultrasound scanner;
- E-health link for clinical decision support and tele-clinics;
- Cervical Screening.
ECCTs should also have access to high quality and robust videoconferencing facilities to facilitate networking, learning and minimise travel times for professionals. There are examples where this system works well currently as in Orkney and the Western Isles. Telemedicine links should also be available to facilitate clinical decision-making support and for tele-clinics, thus increasing local management of patients 50. The use of tele-health solutions must also be explored to increase local access to services.
A wider range of diagnostics tests should be available within a Community Hospital, including:
- Point of Care Testing: blood gas analysis (including haemoglobin and white blood cell capability), and electrolyte measurement, blood coagulation and cardiac enzyme measurement;
- Cardiac Exercise Testing;
- 24 hour blood pressure monitoring;
- Simple imaging ( i.e. plain film X-Rays);
- Digitised imaging utilising the PACS system;
- Ultrasound scanner;
- E-health link for clinical decision support and tele-clinics;
- Endoscopy (although this may be a mobile resource).
It may be more cost effective to consider mobile diagnostic facilities for:
- Aneurysm screening;
- Breast Screening Service;
- Osteoporosis Screening;
It is recognised that whilst the above lists are core diagnostics that should be available, there may be some community hospitals who may wish to augment locally available diagnostics. For example the New Galloway Hospital in Stranraer has a CT Scanner and it has been shown that since its introduction, this diagnostic tool has reduced the need for transfer of patients by 25%.
Diagnostics in Rural General Hospitals
A wider range of diagnostic facilities will be available within the RGH including:
- Imaging: digitised image capture, ultrasound and CT scanning;
- Laboratory medicine: a range of core tests as detailed in the BMS section in the disciplines of biochemistry, haematology blood transfusion and microbiology (where agreed);
- Endoscopy: upper and lower GI and Cystoscopy;
- Surgical intervention/investigation: e.g. biopsy of lesion;
- Cardiac testing: exercise stress testing and echocardiography.
In addition, the fabric of a number of the RGHs is also poor and NHS Boards should ensure that this is also addressed within capital planning.
Management of risk in remote communities is more challenging than in more urban areas. A key aspect of managing risk is to ensure that these communities have the tools to support nationally approved screening programmes.
Such screening would include antenatal screening, screening of the newborn, breast screening, cervical screening and large bowel cancer bowel screening. There is also a range of rural relevant programmes where the outcome advantage is predicated on where the person lives and access to specialised care e.g. aortic aneurysm. There may be advantage on building on this model in remote and rural areas to minimise risks.
The concept of utilising e-Health in the remote and rural situation is not an addition or an add- on, it is more of a developing philosophy which should permeate thinking around every aspect of the remote and rural agenda. The principles to underpin a technological approach are:
- That specialist advice can be provided from a distance by videoconference, telephone or e-mail.
- Travelling to a central point can be obviated by the use of videoconferencing to an RGH. Community Hospital, GP Practice or indeed in certain circumstances direct to a patient's home.
- Digital data can be transferred from remote sites to other points, enhancing diagnosis. So, for example, blood tests, ECGs, images of all sorts and sounds can be sent to a central point from a peripheral location. RGHs could therefore supply a network of Community Hospitals and/or a Tertiary Centre could likewise supply scarce intellectual resource to the RGH, Community Hospital and isolated practitioners.
There are existing examples of relatively small scale projects supplying such services. The Scottish Centre for Telehealth is in the process of supporting evaluation and development of these and is currently looking at around 12 practical proposals.
In addition, with the wider e-Health agenda, there is a focus on the creation of the electronic patient record which will be a significant development in improving communication across the continuum of care.
The principles outlined above apply to clinical care, education and enhanced self-care. They are dependent not only on a formalised service network being put in place, but on the development of a robust infrastructure, capable of using broadband technology for videoconferencing. At the moment the gold standard depends on fixed telephone lines, which are expensive and inflexible. In addition, various NHS Boards have different policies around the implementation of their Information Technology projects, leading to problems with communication across firewalls and regions.
A piece of work is going on at this moment to develop a network that is technologically robust for Scotland, but it is unlikely that this will be in place until around two years from now. The Scottish Centre for Telehealth has stated that it will support interim solutions until the longer-term network is in place.
It is important that connectivity between remote and rural communities and larger centres and within remote and rural communities are identified and addressed as part of the NHS Scotland response to e-health. The infrastructure, the level and quality of connectivity should be the same throughout Scotland. This may mean that the level of investment is significantly disproportionate. This will of necessity include investing in high-specification links between those most remote centres and the larger centre that provides clinical decision support and should include image and data transfer and video-conferencing. It is also important that larger health economies invest in appropriate e-health solutions. Anecdotally, the most difficult place for R&R health professionals to communicate with, using technology, is that which is most centrally located.
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.
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.
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 centre.
A remote and rural diagnostics network should be established to ensure local access, consistent standards of care, support of services and professionals in remote and rural areas and make best use of scarce resource.
The roll out of digitised imaging ( PACS) should prioritise remote and rural areas.
The eHealth Strategy Board should review their investment plans to ensure that the level and quality of connectivity should be the same across Scotland.
Remote and Rural Communities in Scotland should not expect anything less than a first class IT infrastructure to support local delivery of care. The IT infrastructure must therefore be robust across the whole of Scotland to allow for rapid and safe communication and reduce the need for patient and staff travel.
The concept of utilising e-heath in the remote and rural setting must permeate every aspect of service planning and delivery in remote and rural healthcare to maximise local access and reduce the need for patient travel.
NHS Boards should review their existing premises and ensure any new premises have access to a range of modern communication tools including broadband access, video-conferencing and tele-medicine as a minimum.