Rural Service Provision Issues

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Rural Service Provision Issues

• 1. Aligning the Community Nursing Workforce to
  meet the health needs of the people of Highland
• 2. Remote Service Futures Project Developing a
  Toolkit for Patient Involvement in Remote
  Communities

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NHS Highland

• 1 District General Hospital
• 3 Rural General Hospitals
• 2 Mental Health Hospitals
• 20 Community Hospitals
• A wide range of community services throughout

• Area 12,507 square miles
• Population 299,000
• Budget 522m
• Staff 11,500

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Challenges

• Providing safe sustainable health services
• Reducing inequalities in healthcare
• Demographic changes- population and workforce

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Ageing Population
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Population in lt15 and 65 age groups, Scotland
1950-2042 (GAD projection)
Source http//www.esrcsocietytoday.ac.uk/ESRCInfo
Centre/Images/demography_seminar_tcm6-7919.pdf
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The Health Inequalities Gradient
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Key Policy Drivers

• Reducing health inequalities
• Getting it Right for Every Child
• Managing long term conditions
• Living and Dying Well

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We have nothing to fear but fear itself-
nameless, unreasoning, unjustified terror which
paralyzes needed efforts to convert retreat into
advance
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Model of Community Health Nursing
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Challenges

• Change
• Choice
• Chance
• Chinese whispers

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Ask not what the policy can do for the
model but what the model can do for the policy
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1
Thurso
Tain
Badenoch and Strathspey
Helensburgh and Lomond
Mid Argyll
Kintyre
RONC Pilot Sites
RONC Pilot Sites
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15 Standards for Practice

• Building the Picture
• Getting us where we need to be
• Making the concept real

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• Each Community Health Nursing Team has an
  established Team Leader
• Each Community Health Nursing Team has completed
  training plan based on individual Learning
  Development Plans
• There is a single point of access to Community
  Health Nursing Team

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• Each Community Health Nursing Team has Workload
  Management Systems in place which ensures
  effective communication and information sharing
  across the whole team
• Each Community Health Nursing Team has introduced
  agreed assessment and care planning tools for all
  new referrals to the team

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• Referral Criteria are agreed for Community Health
  Nursing services and are available to other
  professionals, agencies and public
• Each Community Health Nursing Team has procedure
  for identifying Named Nurse
• Each Community Health Nursing Team has skills
  profile based on public health needs and
  community profiling tool

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• Each CHN team has identified key objectives and
  devloped annual plan to meet public health
  priorities within their community
• Each Community Health Nursing Team has a system
  for prioritisation of care, using the intensive,
  additional and core classifications, in place
  for all patients, families and groups

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• Care Aims has been implemented within each
  Community health Nursing Team
• Case Management for those with complex needs has
  been introduced within each CHN team
• Values Based Care (derived from 10 Essential
  Shared Capabilities) delivered by each Community
  Health Nursing Team

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• Clinical Supervision Model implemented by each
  Community Health Nursing Team
• Each CHN Team is actively promoting models of
  self care, utilising range of identified skills

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Can we Change?YES, WE CAN
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Rural Service Provision Issues Remote Service
Futures Project Developing a Toolkit for
Patient Involvement in Remote Communities

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The Centre for Rural Health

• A joint research centre between UHI Millennium
  Institute and the University of Aberdeen,
  established in 2001 to focus on rural health
  issues
• 3 main research streams
• Access and Delivery of Services
• Health of Rural People
• Technology and Rural Health

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Context Health Care in Scotland

• The UKs National Health Service (NHS) is the
  worlds largest publicly funded health care
  system
• Local Councils provide social work and social
  care
• Scottish Ambulance Service provide emergency
  response in conjunction with NHS services
• Scottish Government have created distinct health
  care targets

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NHS Scotland
NHS Highland Population 306,700 Area 32,518 km²
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Context Remote and Rural Scotland

• Much of Scotland very remote
• Ageing population
• Fragile services
• Traditional service models changing
• Community involvement not always successful
• Mistrust and standoff situations can arise
• Major concerns within communities about
  emergency response
• Policy indicating changing attitude towards
  remote and rural health care delivery

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Recent Policy Developments

• Policy Documents
• Patient Focus and Public Involvement
• Better Health Better Care
• Delivering Fair Shares for Health in Scotland
• Delivering for Remote and Rural Healthcare
• Main Points
• Involving patients in their own care
• Shift from acute response towards primary care
• Prevention rather than cure
• E-solutions including Tele-care monitoring and
  video conferencing
• Less centralised decision making, including
  involving citizens in the planning process

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What is the problem?

• Structures not always in place to allow managers
  to effectively co-plan services with communities
• Traditional approach to involvement can be
  reactionary or perfunctory (tick box involvement)
• Information re engaging with communities does not
  take into account unique remote and rural
  circumstances
• Mistrust and confrontation between communities
  and NHS can occur

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Remote Service Futures Project

• Two year project looking at finding best practice
  for engaging remote communities in service design
• Four communities in the project, two mainland and
  two islands
• Initial community profiling carried out to
  establish which services are provided within the
  community, how often and at what cost
• Data used to adapt the basic process of
  engagement for each area

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Baseline Engagement Strategy

Stage 1 Inform and Obtain Permission and
Community Profiling
Stage 2 Identify challenges to service provision
Stage 3 Future Visioning and Fresh Ideas
Stage 4 Planning and prioritizing a budgetary
trade-off exercise


ACTION Information disseminated prior to
visit. Introduce project to community and
determine interest
ACTION Information disseminated prior to
visit. Establish challenges and assets within
each community with regards to service provision
ACTION Information disseminated prior to
visit Further discussion of desirable future
vision and introduction of new ideas how are
other remote communities dealing with the same
challenges?
ACTION Information disseminated prior to
visit Allow community to undertake theoretical
planning in several different contexts, according
to preference and ability
METHODS Posters, email, mail, internet Individual
informal interviews not recorded Community
forum with dialogue between researchers and
community
METHODS Posters, email, mail, internet
Individual informal and semi-structured
interviews, Interactive community
display Community workshop with dialogue between
researchers and community
METHODS Posters, email, mail, internet Individual
semi-structured and unstructured
interviews Community conference with
presentations and dialogue b/w stakeholders and
community Activity in local primary school
METHODS Posters, email, mail, internet Individual
and small group variation of the planning
game Multi stakeholder planning game and short
planning for the future session Planning session
in primary school
Throughout process there will be involvement
via project website (discussion forums and web
polls), email, telephone and mail surveys. All
stakeholders will be kept informed of project
progress and given the chance to inform the next
stage
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Guiding Principles

• Inclusion of underrepresented voices and use of
  multiple methods
• Transparency and openness
• Early intervention and dialogue creation before
  crisis arises
• Cross pollination of innovative solutions from
  other communities making the process meaningful

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Innovation in rural communities

• First Responder Schemes
• Time Banking
• Telecare and Telehealth solutions

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The Planning Game sample card

• FEATURES
• Visit people in their homes or in care homes,
  providing care for patients and supporting family
  members
• Work with patients, teaching them to care for
  themselves, give care to relatives
• Keep hospital admissions to a minimum and
  support patients at home
• Especially useful when high incidence in
  community of elderly patients, recently
  discharged patients, physically disabled
  patients, or the terminally ill
• Can work on their own or with other groups such
  as social services, voluntary agencies and other
  NHS agencies
• BENEFITS
• Keeping people in their homes
• Adaptable service
• Can advise relatives on how to care for patients
• DISADVANTAGES
• In very remote areas, much of their day may be
  taken up with travelling, not seeing patients
• District nurse position may have higher costs
  than, for example, community nurse
• In small remote communities, much of the District
  Nurses work could be filled by social carer or
  home visitor role (i.e. helping an elderly
  patient out of bed, making sure they are fed)

District Nurse Average cost per visit 53 Average
yearly salary 20,000 - 30,000 (depending on
experience) NHS
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Early conclusions?

• CHALLENGES
• Bounded vs. Unbounded communities
• Contracted vs. salaried GP practice
• Sensitive vs. more trusting communities
• Lack of uniformity in data collection across
  regions is any information comparable?
• Which information can help planning?
• Willingness to share financial information
• Lack of detailed data collection at a local level
  across all organisations
• Communities suspicious of the process but respond
  well to practical aspects
• SUCCESSES
• Multiple methods have allowed broad participation
• Practical aspects (or added value aspects) of
  the project well received
• Communication lines established between
  stakeholders
• First Responder Scheme established in one
  community to assist emergency response

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Next steps

• Complete engagement strategy and data analysis
• Which methods were successful and which were not?
• Follow up with communities and service providers
  six months following the process has dialogue
  been continued? Have any positive changes
  occurred?
• Create, based on profiles, a final toolkit for
  engaging remote and rural communities

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• Pat Tyrrell, Lead Nurse, Argyll and Bute CHP
  p.tyrrell_at_nhs.net
• Christina West, Clinical Services Manager/
  Associate Lead Nurse, Argyll and Bute CHP
  christina.west_at_nhs.net