Improving the Patient Experience of Remote Primary Care
Definition: What is Remote Primary Care?
The Centre for Rural Health defined remote primary care through the development of a Clinical Peripherality Index that takes into account a number of factors including, population density, practice size and time to reach secondary care 2. This Clinical Peripherality map (figure 4 below) demonstrates the scale of remote and rural practice across all areas of Scotland.
Figure 4: Clinical Peripherality Map of Scotland
The map, whilst not defining boundaries to remote Scotland, provides a visual image of the extent to which most NHS boards have remote and rural areas and highlights (in blue) those deemed to be most remote.
Remote Primary Care must sit within the context of an integrated Community Health Partnership ( CHP) model, incorporating the Community Hospital ( CH), where there is one, and/or what is currently known as the Rural General Hospital ( RGH).
Is there anything different about Remote and Rural areas?
The collective term 'Remote and Rural' is used, but this masks large variations between areas, especially in terms of mainland and island. This report proposes an overarching framework that is relevant and fits all remote and rural (and non-urban) areas but is sufficiently flexible to permit application to particular local circumstances.
Rural patients' experience of care differs from that of urban patients in that they often have to travel large distances to receive care 3. Although the pattern of disease is similar in urban and rural areas, differences do exist:
- Higher suicide rates 4;
- Higher incidence of alcohol related disease;
- There are a higher number of accidents in rural areas: on roads, through climbing, farming, diving and fishing;
- Palliative Care workload is proportionally higher than might be seen in urban areas, as patients from remote areas often prefer to or are enabled to die at home, rather than in a distant centre 5;
- Seasonal fluctuation in population
These scenarios can present challenges in response times for traditional emergency services and emphasise the requirement for immediate care skills for remote practitioners.
The demographic picture of Scotland over the next 20-30 years is changing 6. It is projected that there will be increasing numbers of older people and diminishing numbers of working age adults. This is significant not only for the health patterns we can expect to see in Scotland, but for the development of the future health care workforce and the available pool of unpaid carers to support individuals at home. This demographic picture will have significant impact in rural areas where there are smaller numbers of workforce.
Recruitment and retention within remote and rural healthcare is more challenging. 7 Changes in demography have a proportionately greater impact in rural areas where the workforce is smaller. Succession planning is a major challenge as the workforce within rural areas is aging. 8 Maintenance of skills also poses challenges, whilst there is a requirement for a wide breadth of expertise; but skills will decay, where practice exposure is low 9.
Building Blocks of the Extended Community Care Model
The term 'Community resilience' has evolved, and is key to sustaining local healthcare in remote communities. It is defined as a collective and collaborative response within communities to promote independence. Communities are facilitated to look after themselves, utilising all resources available to them, encouraging self care and using volunteers and informal carers within the local community. The Scottish Ambulance Service ( SAS) 1 st Responder Scheme is an example of communities supporting themselves 10. NHS 24 has a key role to play in the promotion of community resilience through working in partnership with NHS Boards, Community Care Teams and patients and carers. This role includes the utilisation of NHS 24's services directly to a patient's own home, the provision of important health information and their role in promoting self care and supporting long term condition management through their telephony and web based structures.
Strong leadership and management will be required to facilitate the building of community resilience.
Extended Community Care Teams ( ECCTs) must promote, encourage and support individuals to self-manage their own care (where appropriate and with support), working together in partnership with voluntary agencies such as self help support groups and informal carers to support the development of self care 11. An example is the use of the fit elderly 'good neighbouring schemes' which check on the frail and vulnerable within the community. Education of the public in self care, should begin at an early age and focus upon health promotion and patient empowerment through information provision.
Evidence has shown that the most frequent reasons for admission of patients to community hospitals are: rehabilitation, as a result of a fall, or chronic obstructive airways disease 12. An analysis undertaken by the NHS Information and Statistics Division ( ISD) shows a rise in multiple admissions for over 65 year olds because of a failure of the out of hours care system to provide preventative and anticipatory care for older people 13. The ECCT would place more emphasis on prevention of disease crises, with systems that anticipate problems, as opposed to reacting to those crises, when they arise 14. This will involve the Community Nurses and the Practice Nurse (crucial to the monitoring of long-term conditions) and the wider team. Technicians from the Scottish Ambulance Service can undertake planned home visits to patients who are at a high risk of emergency admission. These practitioners will carry out risk assessments for issues such as falls, ensuring that patients are managing to feed themselves and take their medication, and liaise with the most appropriate professional where they judge that further action is required. Increased use of e-health solutions to access information and to monitor patients will be required.
Long Term Condition Management
It is suggested, that 'of the eleven leading causes of hospital bed use in the UK, eight are due to conditions which if we strengthen community care could lead to a reduction in admissions' 15. Better management of long-term conditions in the community would have beneficial outcomes for individuals and carers and reduce hospital admissions. This is a significant issue in particular for older people, many of whom, lose functional independence following admission to hospital.
The range of long term condition management activity will be determined by the skills and competencies within the multi-disciplinary team and the resources available for appropriate patient care. This will include routine monitoring of common conditions that do not require specialist input and adjustment of clinical management with the aim of avoiding clinical crisis. For example, paramedics could fulfil this role, reporting any adverse findings to the local General Practitioner ( GP) to discuss the most appropriate clinical management path. Diseases which will require such monitoring are patients with coronary heart disease, diabetes, chronic respiratory problems and mental health illness.
The GP will continue to be the principal 'gatekeeper' to secondary care, although in many areas it may be appropriate for care to be provided by other practitioners. ECCTs must undertake the majority of care locally, where it is safe and appropriate to do so. The use of new technologies should be increased where this will maximise the amount of care that can be provided locally. An example of this would be NHS 24's initiative to develop cognitive behavioural therapy, currently being piloted with the Western Isles and Shetland.
Where there is a requirement for referral to secondary or tertiary care, this should be as part of a robust care pathway. ECCTs must aim to reduce multiple visits to secondary care wherever possible, and to return the patient to care within the community, as soon as is practicable, dependant upon the disease condition and the resources available locally. An example would be local follow up of those patients that would traditionally have been reviewed by the Consultant in an outpatient appointment at the District General Hospital.
Facilities for immediate care of all patients presenting with acute illness or an emergency should be available in the community. Assessment as to whether further management will take place in the community or whether to transfer a patient to another hospital or appropriate facility, which may include a care home, should be made by the senior practitioner involved in the patient's care. Crucial to emergency care is the ability to transport the patient in a timely manner where it has been deemed clinically appropriate to do so. This aspect is covered in the Transport chapter of this report.
Out of Hours
Out of Hours Care must be provided as locally as is possible to remote and rural patients by the Extended Community Care Team ( ECCT), working in partnership with NHS 24. NHS 24's advanced Knowledge Management System ( KMS), which makes the provision of advice to patients in remote and rural areas much more effective, is a welcome development.
The responsibility for the out of hours service lies with NHS Boards who should ensure that sufficient capacity and capability is built within the ECCT to deliver a high quality service. The benefits gained from the new GMS contract in terms of work/life balance for GPs, however, must be maintained. This will require changes in practice in a large number of remote areas, particularly islands where the arrangements for out of hours cover remains with single-handed or small GP practices. A team approach to out of hours involving different members of the team would ensure that the burden of call could be shared. There are examples of this under trial in remote and rural areas e.g.SAS first responder pilots 16, and Unscheduled Care Nurse Practitioners in Highland. Focus Groups undertaken as part of the remote and rural project consistently reported difficulty in managing patients with mental health crisis (particularly out of hours); so it is crucial that mental health services are extended and that practitioners in remote areas have the skills necessary to manage mental health crisis 24/7.
A diagrammatic representation of the model for remote primary care is detailed in Figure 5.
Figure 5: Remote Primary Care Model
Primary care is the centre of healthcare within a community, supporting or providing the majority of care locally, including Health Promotion, Self Care, Anticipatory Care, Chronic Disease Management, Primary Diagnosis, Planned Care and Emergency Care. The community is encouraged to support itself through use of all resources available locally. Where professional care is required, this care should ideally be provided from purpose built premises, and must be supported by good infrastructure and diagnostics, integrated with the Community Hospital ( CH) and/or Rural General Hospital ( RGH) where there is one. Where there is no such facility locally the Practitioner should have access to good local diagnostics and an intermediate care service to prevent unnecessary admission to hospital 17.
Intermediate care is defined as short stay assessment, management of exacerbation of long-term conditions, step-down from secondary care and palliative care. Intermediate care may be provided within a community hospital, or a nursing home or a social care facility and a team who can rapidly respond to patients with intermediate care needs and provide augmented care at home. This occurs in Lochcarron where the GPs use the Howard Doris Centre for intermediate care and in North West Sutherland, where intermediate care is provided in the patient's home.
In order to facilitate benchmarking, remote primary care should have common methods of data collection and data set.
Patients should receive the same standards of care for common procedures irrespective of where they live.
The system of care within remote and rural communities should support self-care, anticipate health needs to avoid crises in chronic diseases and have the capability to respond to emergency situations. CHPs should ensure that:
- Teams are integrated and co-located including health and other relevant organisations;
- ECCTs support individuals to self-manage their own care;
- Priority is given to anticipatory care and the prevention of disease escalation;
- Action plans are developed for implementing long-term condition management;
- There is local access to an emergency care service and that there is collaboration with the SAS to develop robust community emergency response systems.
The system of care should build community resilience to ensure that local people can be cared for as close to home as possible.
Remote primary care should have common methods of data collection and data set.
Explore the use of the wider healthcare team to develop resilience within the community, including the use of NHS 24 skills and technology and a pilot to test the role which Ambulance technicians and paramedics can play in anticipatory care and chronic disease management.
The Remote Community Hospital
The Scottish Government Health Department ( SGHD) has identified Community Hospitals 18 as a key resource for the NHS in supporting the changing needs of local communities. It has also recognised that Community Hospitals currently perform a wide range of different roles and has proposed how, through redesign, might become more aligned. The role of the Community Hospital is particularly important in remote and rural communities, where these exist, but given the separate work to implement the Community Hospitals Strategy, we have confined ourselves to a brief outline of the services that a remote community should expect from its community hospital.
Services provided in remote community hospitals will vary according to local population density and health need, the physical facility available and the skills set of the workforce. It is important that, whatever model exists, that the hospital service is fully integrated across the spectrum of care. However, where the community hospital is the Community Resource Hub for the community, the following are the core services which should be provided:
- Hub for out of hours unscheduled care integrated with practitioner-led minor injury/minor illness units;
- First line resuscitation, triage, transfer or admission as appropriate to the risk assessment of the patient's condition and proximity to secondary care;
- Diagnostic Services;
- Outpatient clinics by visiting specialists;
- Role in pre-operative assessment;
- Intermediate care beds which are accessible by all practitioners ( i.e. some nurse-led);
- Midwifery service;
- Palliative Care;
- Designated Place of Safety for Mental Health Crisis.
Some community hospitals may also provide planned day case surgery. Evidence 19 suggests that if there is investment in local diagnostics this will allow more patients to be managed within their local communities.
It is evident that a sizeable Community, which is distant from either an RGH or a DGH, requires access to comprehensive, high quality intermediate healthcare, provided locally and therefore the level of service required within the Community Hospital (or one of the Community Hospitals) needs to be augmented to that extent. This facility should provide a first line response in an emergency, including assessment, management, admission, where appropriate; or stabilisation, prior to transfer. Current examples include Campbeltown, The Mid Argyll, Dunoon, Broadford and the New Galloway Hospital in Stranraer. The level of emergency department activity 20 is relatively similar to that seen within the RGH, although these hospitals do not provide an emergency surgery service, with those patients being transferred to another centre.
CHPs should review their Community Hospitals to determine which, if any, should be enhanced and develop plans to implement this model.
Remote Community Hospitals, acting as Community Resource hubs, should provide an agreed range of services, including enhanced diagnostics. CHPs should be responsible for reviewing the services provided within their Community Hospital and that these include:
- Acting as a resource hub to the community, integrating and co-locating services provided by health and other related organisations;
- Provision of a first line emergency service and a minor illness/injury service including acting as the Place of Safety for mental health crisis;
- Provision of a range of diagnostic services, as described later;
- Undertaking a role in pre-operative assessment;
- Provision of a range of outpatient visiting services appropriate to the health needs of the local population;
- The provision of an intermediate care service that is accessible by all practitioners;
- The provision of a palliative care service.
What are the Differences between the current model and this emerging model?
The table below provides a summary of current and emergent models for remote primary care.
Current Model of Care
Future Model of Care
- Self care infrequent
- Reactive care
- Variation in care pathways
- Multiple visits to secondary care
- Self care encouraged
- Anticipatory care
- Robust negotiated care pathways
- Shifting the balance of care to locally based care
Four key pillars support this model of care: Workforce, including Education, Networks, Infrastructure and Community Resilience. Professionals within this model must be robustly trained generalists, with educational packages specifically designed for Remote and Rural Practitioners, have good supporting networks from larger centres, and, be supported by technology, transport and retrieval systems.