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Orkney RARARI Project Report 2001-2003 A new model of consultant-supported intermediate care in remote areas

The Orkney Experience of Re-Design NHS Orkney is lucky to be one of the first areas to undertake the re-design of a major service area. This report gives an overview of our experience; it looks at the necessity for change, the change process, and the interdependency of projects and work practices within Orkney.

The Orkney RARARI Project has enabled us to explore our vision of healthcare for the people of Orkney. It has given us the opportunity to pilot the elements essential to our vision of a sustainable health care service.

Judi Wellden, Chief Executive NHS Orkney.

Orkney Demographics Orkney is an archipelago of many islands of which 17 are inhabited. 85% of the resident population of 19,245 live on the Orkney Mainland.

Only three islands are connected by causeways, therefore air and ferry links between the islands and to mainland Scotland are of vital importance. On 18 days during 2001 the islands were completely stormbound, cut off from the Scottish mainland. The weather impacts on the transport of patients to Aberdeen and on in-coming services such as visiting consultants and vital supplies.

Traditionally the island economy is based on farming and fishing, but during the last 20 years employment has extended into the manufacturing, tourism and food-processing industries. Tourism brings a significant population increase during the summer months, which our health service planners have to take into account.

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Our Hospital

The Balfour Hospital, Kirkwall provides all the local inpatient care for NHS Orkney. It has a total of 94 beds and provides surgical, medical, rehabilitation, care of the elderly, maternity and palliative care services. There are regular visiting consultant outpatient clinics from Grampian University Hospitals NHS Trust, Grampian Primary Care Trust, and Raigmore Hospital NHS Trust. Patients requiring in-patient facilities beyond the local facilities and expertise are transferred to Grampian University Hospitals Trust and Highland Acute Hospitals Trust in accordance Service Level Agreements. Locally there are two surgical consultants supported by a part-time staff grade surgeon, with two consultant anaesthetists and one GP anaesthetist. Medical cover is provided by a team of General Practitioners supported by consultants from Raigmore Hospital NHS Trust (Inverness) acting in an educational and development role. Maternity, Palliative Care and Elderly Care services are also GP led.

Background to National RARARI

The “Acute Services Review” 1998 and the report “Services for Remote and Rural Communities” (Skilbeck Report) 1999, highlighted the many challenges affecting the delivery of Primary and Secondary Care across remote and rural Scotland. The report recommended several key areas for action to “develop healthcare services and support for professional staff in remote and rural parts of Scotland.” In November 1998 the then Secretary of State Donald Dewar MP, following recommendations by the Chief Executive of Scotland Mr. Geoff Scaiffe and Sir David Carter the Chief Medical Officer, announced the Remote and Rural Areas Resource Initiative (RARARI).

A steering committee under the Directorship of Dr. Jim Douglas GP was appointed to represent the various remote and rural areas of Scotland and the mix of health professions. The National RARARI Project and their project funding cycle commenced in March 2000.

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Orkney’s need for Change Orkney in-patient medical services at this time were provided, initially by all six Orkney Mainland and linked south Isles GPs and latterly by all the GPs from the four major mainland practices. There was no locally based consultant physician, lead physician nor Senior House Officer programme within medicine. In-patients from the smaller islands were allocated on a rota basis to a mainland practice and tended to stay under the care of that practice in respect of their need for hospital medical care, for life. Case management and recording methodologies were very much the prerogative of individual GPs. GPs could contact colleagues at the Aberdeen Hospitals for advice, or access their own informal or Practice networks for support. This method of working was proving unsustainable as the Health Service in general moved to a more managed approach requiring auditable practice against nationally set standards and guidelines eg SIGN Guidelines.

Issues of recruitment and retention of GPs with the skills necessary for remote practice, including GPs with hospital medicine as a sub-specialism, were arising. In an attempt to tackle these issues, NHS Orkney had already started exploring the possibility of designing an SHO programme which would provide potential future remote and rural GPs with the enhanced hospital practitioner experience that is desirable for those wishing to specialise in remote and rural health care. The question of how to structure and support the GP-led local in-patient medical service remained.

“Orkney has always felt that supporting the GPs to deliver Acute Medical Services was the most sustainable way forward for the islands. The investment in time, effort and resources by everyone in the system is proving well worth it. The benefits to the whole organisation are being clearly demonstrated,” Dr Malcolm Alexander, Strategic Director RARARI and former Medical Director NHS Orkney. NHS Orkney Vision and National Agenda Orkney has a tradition of having a primary care centred health service particularly in the fields of obstetrics and hospital medicine. In the Orkney Health Board “Business Case” Feb. 1998 the objective to support GPs in the sub-specialism of medicine was born. “The development of a consultant led service would progress an outcome based service delivered to agreed protocols using a consistent approach. The service would be developed on the basis of outcomes of local audit, with resultant changes in practice where necessary. ”

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The arrival of RARARI two years later created the opportunity necessary to facilitate a three-year pilot project of this concept. NHS Orkney in conjunction with Highland Acute Hospital Trust and the recently created Highlands and Islands Health Research Institute submitted successful linked bids to RARARI and the Orkney “Acute Medicine Project” was launched.

“I sit on the project board as a patient representative. It has been fascinating to be part of this development, which puts the patient at the centre and recognises the importance to the community of locally delivered healthcare.”

Annabel Eltome, Chief Officer, Orkney Local Health

Council.

The Orkney Acute Medicine Project The Orkney Acute Medicine Project’s aim is to pilot a model of working where a Consultant based in a District General Hospital provides both the clinical and educational support required by generalist clinicians providing secondary medical care in remote communities. In this instance Raigmore Hospital Inverness provides the consultant with a base where he has a consultant peer group, can maintain his own clinical skills and where the throughput of patients is sufficiently great to help maintain his skill base.

“Being the consultant lead has been a challenge. I’ve been a regular commuter on the Inverness/Orkney flights and I have got to know the British Airways crews well! It’s been immensely satisfying leading this innovative project and watching the new team structure take place.” Rod Harvey Consultant Physician

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The Orkney clinical aspects of the Consultant role includes the development of care-pathways and protocols designed to support the non-consultant in the consultant environment, networking where essential or desirable with mainland Scotland facilities. It is our intention that clinical intervention taking place locally matches national audit requirements and, where feasible, information required for audit purposes is gathered as a by-product of Care Pathways. The educational component of the Consultant role is a mixture of regular teaching ward rounds and more formal education sessions led by the post holder or his Raigmore colleagues. The “classroom” sessions are open to all general practitioners with representation invited from all professions involved in the clinical team, take place twice a month and cover topics relevant to Orkney’s admission profile. Our desire is to open these sessions to all staff but at present space proves a limiting factor.

“The introduction of the SHO training programme has provided a huge impetus for education in Orkney. The majority of this educational activity has taken place within the medical and surgical teams. The challenge now is to learn from this experience and widen the education opportunities to meet the need of all healthcare professionals within Orkney.” Dr Charles Siderfin, GP and post-graduate tutor. The Highlands and Islands Health Research Institute (HIHRI) were enlisted to provide an independent evaluation of the project and it’s potential application to other remote and rural areas. (Ref. 10) Service Delivery and Clinical Governance In order to meet the changes necessary to design a sustainable secondary medical care model extensive parallel change was necessary, these included: 1. The introduction of a Clinical Management structure to support medical services

1.1. Medical Sub-specialist GP teams. GPs working in the sub-specialism of acute hospital medicine have formed themselves into two geographically based teams, namely East and West Mainland. The smaller outer islands GP Practices have been linked to the Medical teams in a way that mirrors the local Community Nursing organisational structure. The West Team is formed from the entire GP complement (5) from both the Stromness and Dounby Practices, with their duty rotas

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accommodating 24-hour cover for their medical in-patients. The East Team is formed from a sub-set of members (5) of the two Kirkwall based practices and has organised itself to ensure a “hospital doctor of the week” and out of hours cover from within their number.

“Orkney is breeding a new kind of doctor. The skill mix of acute hospital medicine and general practice is very attractive and a way forward for Orkney’s future.”

Dr Dan Wilkins - Lead GP for Acute Medicine

1.2. Acute Medicine Planning Group “It’s great to be involved in such an important development. By talking across the disciplines and working together as a team we are making a big difference to patient care.” Rosemary Wood, Nursing Team Lead.

This group oversees the implementation and monitoring of the changes in practice, with each clinical lead acting as a reference point for their colleagues in the wider team. Frequent meetings of this small action group achieve change by members setting realistic goals within short timeframes. Following an initial period of weekly meetings, meetings of this group now take place on a fortnightly basis. Consultant Physician Dr. Rod Harvey chairs the sessions either in person or by telephone link and membership consists of the Lead GP, Lead Nurse, AHP representative, Assistant Director Medical Services, Commissioning Manager, Documentation Group Lead and the local RARARI Project Manager.

1.3. Interdisciplinary Acute Medicine Team. Monthly interdisciplinary meetings now take place. These meetings give all involved in the local delivery of acute medicine the opportunity to explore clinical, educational, and operational issues in a shared forum. The team acts as the local advisory group on acute medical care reporting to the Medical Director.

“As surgeons we find that the team approach taken by the GPs makes discussion on clinical management issues easier.” Mr Ameir Al-Mukhtar, consultant surgeon.

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2. The introduction of Senior House Office (SHO) posts in Remote and Rural Healthcare

Initially four, SHO posts were created; this has now been expanded to five. These posts are unique in aiming to help equip doctors with the skills required for isolated general practice and are hospital based. The SHOs spend three months in surgery, including accident and emergency experience and three months in acute medicine, including rehabilitation and palliative care, in a multi-disciplinary environment. Out of hours work involves covering both acute specialities. Work is currently in progress towards achieving formal external approval for the posts from the Roya l College of General Practitioners.

These posts were “considered to be good experience for the middle year of a VTS type training” (Deanery Quality Assurance visit Oct 2002.) 3. RARARI Informatics for Medicine (RIM) Project The move to design a more integrated approach to the delivery of acute medical care at Balfour Hospital brought with it a need to review case recording methods. The existing record keeping system was proving inadequate not only in respect of compliance with national guidelines on auditability eg “The Immediate Discharge Document” SIGN 65, but also in meeting local desires for an interdisciplinary record system and the wish to access support from consultants based outwith Orkney. New inter-disciplinary records, initially paper based, have been developed, and are designed to include the clerking document, continuation notes, nursing and AHP notes, and ICPs for specified conditions such as acute coronary syndrome. It is however acknowledged that logistically such comprehensive and integrated notes can only be effectively managed and maintained by electronic means. To this end development of RIM commenced. The basic requirement is a real time secure near patient record, which emulates and will replace the paper record.

The design brief is that RIM must support the concept of a problem orientated medical record and be suitable for unselected emergency admissions, as well as supporting defined integrated care pathways. It must provide for standardised clerking and routine follow up notes, track test requests and investigation results, as well as supporting good protocols for prescribing. The system must be able to produce full discharge documentation, including discharge letters and prescriptions suitable for electronic transfer. It must allow remote consultants to provide clinical support to resident hospital doctors. It must meet the requirements of a large hospital as well as a small one. A tall order and a challenge, with the

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software design and development being tackled by Philip Westwell the project’s Development Officer and additional funding support coming from the Scottish Executive’s Information Management and Technology Strategy Group.

“We are very fortunate to be able to use recent significant advances

in information technology to design the electronic patient

record. The current standard of electronic communications allows

me to work from Orkney or Edinburgh as I require, and one of our aims is to develop means of off

island Consultant support using similar technology.”

Philip Westwell, Project Development Officer 4. The Local Strategic Approach. The integration of individual service developments both within NHS Orkney and with our partner providers is essential to the future of our Community. To this end NHS Orkney’s Projects Board includes membership from both the Local Health Council and Orkney Islands Council Social Work Department, thus allowing a co-ordinated and inter- agency approach to be taken to the local management of related projects in line with the Joint Futures Agenda. Projects addressed by this Projects Board include ECCI, RARARI, North of Scotland Tele-Education Project, the forthcoming Managed Clinical Networks, plus a reporting reference point for Orkney Islands Council led projects such as the “One-Stop Shop”(which is developing Orkney-wide inter-agency physical and virtual information and access points for housing and community care related services following a Community Care Plan Consultation exercise in 2000). “This Project Board encompasses health and social service-led initiatives. We are working across the boundaries, grasping the challenges and opportunities that electronic communications offer us, as joint agencies working in remote communities .” Gillian Morrison, Head of Strategic Services NHS Orkney and Orkney Islands Council

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The Months Ahead In the months to come we hope to consolidate and capitalise on the work to date. Clinically, by developing further Care Pathways and Protocols, by offering Acute Medicine GPs the experience of working in a District General Hospital setting, by moving RIM off the drawing board and into clinical use, and by making the most of telemedicine opportunities given. Organisationally by continuing to explore options for the delivery of a sustainable healthcare service. Educationally by integrating our clinical education programmes and capitalising on opportunities afforded us by the North of Scotland Tele-education programme.

“ It has been great to help make an idea become a reality. Local hospital services play a key part in our community and this looks like a way of matching local needs to the national agenda”

Mary Doyle – RARARI Project Manager

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References 1. Acute Services Review 1998. 2. Orkney Health Board Business Case Feb 1998. 3. Services for Remote and Rural Communities (The Skilbeck Report) 1999 4. Orkney Health Board Health Improvement Programme 1999-2004 5. Orkney’s One–Stop–Shop Modernising Government Fund 2nd Round Bid 2000 6. Remote and Rural Areas Resource Initiative Mid-term Report. 2002 7. 2001 Census. (Orkney) 8. Future Practice (Temple Report) July 2002 9. NES North Scotland Region Deanery Orkney Visit Report October 2002 10. Evaluation of Medical Services in Orkney - A new model for consultant supported

intermediate care in remote areas? (HIHRI) May 2003 11. RIM Project Documents 2001/2003

?? Project Clinical Aims and Objectives ?? Problem Definition ?? Project Initiation Document ?? Project Phases ?? Development Process Overview ?? Proof of Concept Example ?? Technical Design ?? Use Case Analysis

?? www.hie.co.uk/orkney/aboutorkney.html ?? www.rararibids.org.uk/rarari/index.asp?TopicID=137 ?? www.rarari.org.uk ?? www.show.scot.nhs.uk/shorm/sho%20home.htm Glossary of abbreviations AHP Allied Health Profession(s) (Physiotherapy, Occupational Therapy etc) ECCI Electronic Clinical Communication Infrastructure EPR Electronic Patient Record GP General Practitioner ICPs Integrated Care Pathways IT Information Technology RARARI Remote and Rural Areas Resource Initiative RIM RARARI Informatics for Medicine SHO Senior House Officer VTS Vocational Training Scheme