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Healthcare in a rural setting

January 2005
Board of Science

The local provision of specialised acute and emergency services
In some rural/remote areas there is a reliance on larger urban facilities to provide more specialised acute and emergency services. [go to reference 14] However, travel time to this care equates to risk in emergency and acute conditions, [go to reference 14] and patients from rural/remote areas will encounter longer travel times than patients from urban areas. Patients from rural areas therefore need local access to specialist care, particularly emergency care, for example surgical services and obstetrics and gynaecology. [go to reference 100] This local access to emergency care and acute services must be balanced with maintaining viable services of appropriate quality. [go to reference 100] The quality of service provided locally can be compromised by small populations, making it difficult to provide services economically while complying with working time restrictions, and for clinicians to maintain and update clinical competence.[go to reference 14] In the context of the surgeon as a risk factor, determinants of outcome included technical skill, volume of work and complexity of case mix. [go to reference 101] An assessment must be made on what core local services must be provided because travel is linked to risk, and what can be provided by central facilities. [go to reference 14] Sustainable, longterm solutions to providing these core services must then be found. Different models of providing appropriate emergency and acute services will be needed for different rural areas.

The current arrangements for delivering acute services in some small and remote hospitals in Scotland cannot be sustained. For example, the West Highland project looks at service provision in two small consultant-led acute hospitals in the West Highlands. [go to reference 70] The project has found that current service provision is very fragile due to difficulties in recruiting and retaining healthcare professionals; a premature resignation, retirement or long-term sickness would cause severe staffing difficulties. The consequences of the trend towards medical specialisation, long working hours and a lack of support structures for key staff are also found to be problematic. Different service delivery models are suggested, based on appropriate services being provided locally wherever possible. A suggested sustainable long-term solution is a move towards a holistic, more integrated primary care and secondary care service, with healthcare professionals working in a more integrated way. GPs with specialist interests such as surgery, and consultants with community
interests such as care of the elderly, could be appointed. [go to reference 70]

The problem of the long-term care of patients with an acute illness, who need to be seen by a specialist centre at a distance from rural/remote areas, needs to be considered. Patients require the benefit of an assessment by an expert in their particular disease, with continuous supervision from local healthcare providers. This could be achieved in the form of a managed clinical network where good communication is developed between centres, a common treatment plan is developed and the specialist centre-based consultant makes regular visits to rural areas. [go to reference 102]

Case study – NHS Orkney: a model of consultant supported intermediate care (UK)
Orkney is an archipelago of many islands, 17 of which are inhabited, only three of which are connected by causeways. [go to reference 103] Healthcare provision was previously based around primary care and the development of a consultant-led service was considered beneficial. A new model of service provision was therefore piloted across NHS Orkney from 2001 to 2003, in conjunction with Highland Acute Hopsital Trust and RARARI. The GPs providing generalist secondary medical care were supported by a consultant based in a district general hospital in Inverness on the mainland. The consultant provided clinical and educational support to the GPs, for example through ward rounds and ‘classsroom’ sessions and regularly commuted to the Orkney islands. The consultant had a base where clinical skills could be maintained through patient and peer contact. Interprofessional working was also encouraged through monthly interdisciplinary meetings. In addition, an SHO programme was developed to help provide doctors with hospital-based skills, to equip them to work in isolated, rural/remote general practices. [go to reference 103] NHS Orkney has undergone a consultation process on future service provision and working groups are being established to oversee service redesign once final decisions have been made. [go to reference 104]

In rural/remote areas, emphasis should be on screening and the early detection of disease, to prevent the need for emergency care.[go to reference 100] An ongoing Highlands and Islands aortic aneurysm screening programme is currently analysing data from the first three years and has presented preliminary findings. [go to reference 105] The study was set up against a background of increasing centralisation of vascular surgical services, resulting in difficulties in providing emergency care for ruptured abdominal aortic aneurysm in remote and rural areas. The possibility of identifying aneurysms by screening in remote and rural areas, thereby reducing the need for emergency intervention, was identified. The study set out to determine whether screening could be successfully carried out in these areas by inviting men aged between 65 and 74 years to attend screening at their GP practice.

The study has resulted in an extremely high level of uptake of screening, even amongst those living in the most remote areas. This suggests that screening can be effectively delivered with high compliance in the most remote and rural areas of the UK. Initial indications are that the number of emergency procedures for ruptured abdominal aortic aneurysm in the screened group has fallen since the programme began, although data is still being analysed.

Recommendation 12
There is a need to assess and review options for sustaining and improving local access to secondary healthcare due to the pressures on acute and emergency service delivery in rural/remote areas. Sustainable, long-term solutions to providing core services must be found. Different models of providing appropriate emergency and acute services will be needed for different rural areas.
• Emphasis should be on screening and early detection of disease in rural areas, to reduce the need for emergency care.
• A suggested sustainable long-term solution is a move towards a holistic, more integrated primary care and secondary care service, with healthcare professionals working in a more integrated way. [go to reference 70]