Emergency Response and Transport
In remote and rural areas, the Scottish Ambulance Service ( SAS) are presented with huge challenges in fulfilling accident and emergency response, which is one of their main functions, the second of which is patient transport. This is mainly due to the wide geographical areas to be covered within limited available resource. An audit undertaken as part of this project demonstrates some of the difficulties presented by the dispersed populations across remote and rural areas (see Annex 7). Another example is that of the Island Boards who have particular issues with the outer islands of Orkney and Shetland not having emergency land ambulance responses and so rely on local GPs or Nurses responding and utilising local transport to transfer patients to the local RGH.
The SAS have risen to these challenges by modernising their workforce and implementing modern technologies to improve responsiveness. These include new air ambulances; use of digital mapping technology, including automated vehicle location systems; and the extension of the role of SAS personnel to support local delivery of care. The SAS are keen to develop a multi-disciplinary team approach with other local healthcare providers.
However, it is clear that for remote and rural communities the SAS needs to adopt a more creative community emergency approach to fulfil its responsibilities. For example schemes such as the SAS 1 st Responder Scheme 51 and GPs, Community Nurses and Community Paramedics. It is proposed that the SAS and NHS 24 take a lead role, in collaboration with their territorial NHS Board colleagues, to develop appropriate collaborative emergency response models in remote and rural communities.
Throughout the process of engagement and wide consultation in the production of this report, the lack of an integrated response to transport has been raised consistently as being problematic, resulting in delays for patients accessing appropriate healthcare. Currently, health related transport is provided by a range of different providers/agencies, including voluntary drivers, the Patient Transport Service of SAS, and the more specialised neonatal transport and paediatric retrieval services. In addition, this project has proposed the establishment of a pilot to demonstrate the benefits of an Emergency Medical Retrieval Service ( ERMS).
There appears, however, to be little or no planning or co-ordination between and within agencies. The result is a fragmented approach sometimes resulting in duplication which is an inefficient use of scarce resource.
The transport infrastructure is crucial in the support of healthcare in remote and rural communities and is not the responsibility of any one organisation to resolve. A nationally co-ordinated response, which brings together all of the existing or proposed services under the umbrella of one organisation, but one which is more embedded in the NHS Territorial Boards than SAS currently is, will be required to develop responses which will overcome all of the difficulties presented by the geography and dispersed populations.
There is a pressing need for a co-ordinated and collaborative response to the development of an integrated transport infrastructure necessary to support healthcare across Scotland and in particular in remote and rural communities. This will involve the development of creative solutions across agencies including land, air and maritime responses. Therefore it is proposed that in order to improve health transport a national approach is adopted. In the interim SAS should become more closely aligned with local healthcare delivery through closer integration with local systems. In other countries 52, the ambulance service is often managed by the hospital service.
An integrated transport strategy that is responsive to remote and rural patients' needs must be developed.
The SAS should be responsible for ensuring that robust and responsive local community emergency response models are developed.
The Scottish Government should consider the development of an integrated transport strategy, including health.
Consider how closer integrated working arrangements between the SAS and NHS Boards can be achieved.
The Emergency Medical Retrieval Service
The National Framework for Service Change ( NFSC) 53 suggests that "…poor access will adversely affect outcomes,,," for rural patients but this was challenged on the basis of a pilot carried out in NHS Argyll and Clyde 54, which demonstrated that through upskilling rural practitioners, providing them with rapid access to emergency medical advice and the ability to rapidly transfer a consultant with critical care skills to the patient, whatever their location, outcomes can be greatly improved. Consequently, the Remote and Rural Steering Group were tasked with reviewing the role of the Emergency Medical Retrieval Service ( EMRS) and, if necessary, enhance the service in remote and rural Scotland.
The Emergency medical retrieval service pilot has the following aims:
- Creation of an integrated and well governed system of rural emergency care;
- Augmentation of rural healthcare practitioner training in emergency care and transfer;
- Provision of on-line expert advice on patient management and transfer;
- Rapid on site provision of emergency and critical care interventions; and
- Safe transfer directly to definitive care.
A subsequent EMRS sub-group report recommended that:
- NHS Scotland should establish an Emergency Medical Retrieval Service to support the care of seriously ill and injured people in Remote and Rural Scotland;
- This service would retrieve patients with life threatening injury or illness where advanced medical intervention is appropriate to optimise safe transfer;
- The service would be additional to that currently provided by SAS and would only be deployed if the consultant staff determine that medical intervention is required;
- The service should be established in a phased manner, building on the successful pilot within Argyll. Phase one should be implemented to cover the west coast of Scotland, covering three rural general Hospitals, thirteen community hospitals and a number of remote general practitioners. The first phase is likely to last 18 months;
- During this first phase, independent evaluation of the requirements for the whole of rural Scotland would be undertaken, including the clinical requirements for the Northern Highlands and Northern Isles, the implications for the air ambulance service, a health economic assessment and the impact on the areas where the service has been implemented;
- Following completion of the review, assuming a positive evaluation the service should be rolled out across all remote and rural Scotland.
During the consultation phase of the Remote and Rural Steering Group, specific questions were asked about transport generally and the EMRS proposals specifically.
Overall, there was broad support for the evaluation of the ERMS. However, many participants felt that in light of weather restrictions, it may be more beneficial to invest in road infrastructure or other means of transport such as boats. A large number of respondents suggested the need for an integrated transport strategy for remote and rural areas, because even the fundamental building blocks were missing in some areas. Pleas were made for creative solutions across agencies.
Benefits were perceived as the potential to reduce the waiting time for transfer of patients and ensure that they reach definitive care as quickly as possible, enhance support to local clinicians and protect them from leaving to undertake transfer duties. Additionally participants reported another benefit as that of the patient being collected by clinically experienced staff.
A number of risks were also identified however, including the dependency of ERMS on helicopters and the implications of adverse weather conditions, particularly for the islands. Participants also highlighted that the number and placement of centres for this service needed to be carefully considered. To illustrate, the examples of time delays currently being experienced in awaiting the arrival of the neonatal retrieval team (up to 6 hours). There was also a significant degree of concern regarding the opportunity cost of investment on such a service to local services.
One of the potential gains of a national EMRS service is the potential to change the model of care offered locally, however, participants during the consultation were not convinced that this would be the case.
The EMRS subgroup determined that whilst the pilot in Argyll and Clyde 55 has been successful and improved patient outcome, a further pilot would be required to determine:
- The scope and design of an EMRS to support emergency care in Remote and Rural Scotland
- The effectiveness of an EMRS across Scotland.
The pilot would cover the west coast of Scotland, including three rural general Hospitals, thirteen community hospitals and a number of remote general practitioners.
A two-phased approach to service scoping and development was proposed to the then Scottish Executive in May 2006. The Cabinet Secretary for Health and Well-being agreed in June 2007 that Scottish Government Health Finance would underwrite the 18-month pilot of an emergency medical retrieval service ( EMRS) serving all remote and rural health care facilities in the West of Scotland. The Cabinet Secretary recognised the importance of the EMRS to the future sustainability of healthcare in remote and rural areas of Scotland. Allowing for the recruitment process the ERMS pilot should officially commence on the 1 st of April 2008.
The establishment of the EMRS service has always included an element of evaluation. The evaluation should be undertaken by a body or organisation, which is independent of those providing the service. This was considered necessary to reassure the Scottish Government, NHS Boards, referring and receiving clinicians on the efficacy of the service. During preparation of the initial Proposal, a brief health economic overview was undertaken, however, it was recommended that if the pilot were approved, a full health economic appraisal should be included within the evaluation.
Aims of the Evaluation
- Assess the requirements for the whole of rural Scotland, including the clinical requirements for the Northern Highlands and Northern Isles;
- Undertake a health economic assessment; and
- Assess the impact on the areas where the service has been implemented.
The Emergency Medical Retrieval Service ( EMRS) Pilot should be established as soon as possible.
The EMRS 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.