NHS Highland Chief Executive s Office Assynt House Beechwood Park Inverness, IV2 3BW Telephone: 01463 717123 Fax: 01463 235189 Textphone users can contact us via Typetalk: Tel 0800 959598 www.show.scot.nhs.uk/nhshighland/ PE1591/C By email Ned Sharratt Assistant Clerk Public Petitions Committee petitions@scottish.parliament.uk Date: Your Ref: Our Ref: 19 January 2016 EM/MT/MM Dear Convener CONSIDERATION OF PETITION PE1591 (Major redesign of healthcare services in Skye, Lochalsh and South West Ross) Thank you for your letter of 15 th December concerning the above and setting out some specific areas the committee would like NHS Highland to respond to. Having studied the transcript colleagues have also identified some factual inaccuracies which I have taken the opportunity to address (Appendix 1). I am aware that members have received some briefing materials but I also wanted to bring to your attention the full consultation report This was the final document that the board of NHS Highland considered before coming to a view on a proposed way forward. I understand members have not previously seen this report. While it is lengthy it does provide a comprehensive overview of the process including a review of all the feed-back received together with our responses. Clinical rationale underpinning the redesign of services and how the option was arrived at: There are nine GP practices within the scope of the redesign area. Significant effort has been made to achieve a clinical consensus across the medical profession (as well as other health and social care professionals) about the redesign of services. This has been supported through a series of clinical workshops, ongoing meetings and discussions over a number of years. Indeed, the process began with a workshop for clinicians where a consensus on the need for change was obtained. An independent facilitator, Dr Aileen Walker, was appointed to further develop the clinical model with the clinicians. Headquarters: Assynt House, Beechwood Park, INVERNESS IV2 3BW Chair: Garry Coutts Chief Executive: Elaine Mead
Some of the main issues causing clinical concern in the current arrangements include splitting of resources across the two hospital sites (Broadford and Portree) which are relatively close together (40 minutes apart).this has issues of sustainability in terms of being able to staff and maintain a skilled workforce. More generally in the view of the clinicians and Scottish Ambulance Service there would be significant benefit in removing the confusion that the two centres can create. A better clinical flow will result from a single central inpatient model, closest to tertiary referral centres (Belford Hospital in Fort William and Raigmore Hospital in Inverness) that can be staffed and safely run 24/7. The petitioners themselves acknowledge that for quite some time there has been a desire among some clinicians in Skye to have a central hospital because they believe that will make it easier to provide care. They have also stated that they are not campaigning for the status quo. You may not be aware that the two hospitals have different roles which offer very different levels of care and therefore are staffed and equipped differently. Portree Hospital mainly functions as an older adults inpatient rehabilitation unit with GP led medical services and a minor injury/ailment service; Dr Mackinnon Memorial in Broadford caters for more acute patients with medical cover provided by Rural Practitioners who are GPs with advanced clinical skills in emergency and urgent care, stabilisation and transfer. The Accident and Emergency service is based in Broadford and patients from across the area who require an acute level of emergency and inpatient care already go to Broadford and these arrangements will continue. There are also some other imperatives to change the current model. The condition of both hospitals is not fully compliant with Healthcare Environment Inspection Standards and there are also challenges to meet current fire and safety regulations. The total capital cost of addressing back-log maintenance is around 5.5million. Even with additional investment the buildings cannot be made to be fit to deliver modern health and social care. This is a fact not disputed by the petitioners and agreed by the public as part of our consultation. There are already some real challenges to maintaining safe services. In September 2014, NHS Highland had to suspend endoscopy services in Broadford on grounds of environmental safety. It will not be possible to reinstate this service until new arrangements are in place which means patients currently have to travel to Fort William or Raigmore. In terms of the re-design process itself clinicians have been actively engaged and are supportive. Indeed you will have seen that Dr Steve McCabe, a senior partner in the Portree Practice, provided a supporting statement about the consultation in the summary document - which was sent to every home early on in the consultation:
We have to see this as the chance to have a state of the art facility in our locality as a positive development for the whole the community. It would help to future-proof healthcare in the locality for years to come. This is only a recommendation and the public consultation is an opportunity for everyone to contribute their views. I hope they will. We may only get one chance to get the model right and we must all work very hard on achieving that goal. The Portree Practice has also provided NHS Highland with a notification of interest of their Practice being located as part of the spoke facility in Portree, a further recognition of their support for the way forward. They have also expressed an interest in being involved in providing day hospital services in the North of Skye. They have, however, also expressed some concerns about some changes to the out of hours service and that is subject to ongoing discussion. However, the GP s are keen to stress that this issue is not part of the major service change consultation and should be viewed entirely separately. They are supportive of a single site inpatient Hub facility, and whilst they would have preferred to have that built in Portree, they are content to acknowledge due process was followed, the consensus arrived at and the outcome of the consultation. The proposed new service model and location was determined through a two stage process: Stage 1 Case for change and identifying future models of service The committee will be aware that the latest engagement regarding the current need to redesign services has been ongoing since December 2012 when a Steering Group was established. This work culminated in a public consultation which ran from 19 th May to 29 th August 2014. The group had wide membership including senior clinicians and members of the local communities drawn from across Skye, Lochalsh and South West Ross. As the full report sets out NHS Highland involved clinicians, public and partners in a three stage process on: i) model of service; ii) location of services and iii) site of hospital Hub. The Steering Group initially looked at agreeing key criteria that any new service would need to deliver to be an improvement on the current arrangements. From this a range of service model options were considered and these were whittled down to a short-list of three: Option 1 Do minimum Option 2 Community resource centre and hospital Hub with Spoke Option 3 Community resource centre and hospital Hub
Through a well established options appraisal process, led by an independent facilitator, the options were scored with Option two scoring highest (800 points out of 1000); followed by option three (788), with option one scoring only 400 points. NHS Highland took advice from Scottish Government officials and Scottish Health Council around whether it would be appropriate to move to public consultation on the model of service alone, (leaving aside the issues of location for the time being), or whether further work should be done on recommending a location for the proposed Hub and Spoke prior to public consultation. Given that both option two and option three would both require a decision on location, NHS Highland was directed to carry out further work to seek to recommend a preferred location for the Hub and Spoke. Stage 2 Rationale for indentifying potential location for Hub and Spoke Only Portree and Broadford were considered to be possible strategic locations for the Hub and Spoke. A land search determined that possible sites were available in each locality making both options feasible, as follows: Option 2a Hub new build in Broadford with Spoke in Portree Option 2b Hub new build in Portree with Spoke in Broadford A further Options appraisal exercise was carried out to assess both locations. In this case Option 2a scored 766 (out of 1000) and option 2b 702 (out of 1000). Both options scored highly indicating both options could perform well in terms of satisfying the criteria for the Hub facility. The most influential factors favouring Broadford were better patient flow (including closer to Raigmore Hospital and other tertiary referral centres) and geographic centre of the redesign the area. Of all the criteria considered patient flow was ranked as the highest and this was something that clinicians were also agreed on. Sensitivity analyses were carried out and through various scenario testing Option 2a consistently scored higher and on this basis was the recommendation of the Steering Group. All of this information has been documented and is in the public domain. Consultation and questionnaire As requested a link to the consultation survey is provided: https://www.surveymonkey.com/r/cywjvvy
Members should be aware that a hard copy plus Freepost envelope was issued to every home and business in the area. This is not a requirement of the consultation process and indeed NHS Highland is not aware of any other board taking such steps to seek feed-back in such a comprehensive and unbiased way. We did not use sampling and did not rely on people having to request the information or access it at meetings. As already mentioned a summary consultation document was also sent to every home and this made it very clear that while a preferred option was being recommended the final decision had yet to be taken. This message was reiterated throughout the consultation at meetings and events (there were some 50 events) and in local media releases. In terms of three specific points raised by the petitioners they make an assertion that: [1] the survey is unscientific, self-selecting sample of opinion that was not subject to any independent audit. [2] Alan Macrae then goes on to state For example, there were 2,500 responses to the consultation... but almost 20 per cent of the responses had no address on them. It is statistically bonkers to take these into account... [3] And from Catriona MacDonald [3]... the questionnaire was biased. In going through the questionnaire, you got to a point at which you were given a choice about the preferred site for the hospital; there were several sites in the Broadford area. The design of the questionnaire was such that, if the majority of answers were from people from Broadford area they were it would appear that the overwhelming majority of people supported the Broadford area as the preferred site. Taking each of these points in turn, I would respond as follows. [1] Through the public consultations process NHS Highland set out a programme of work to seek views on proposals and the plan was approved by the Scottish Health Council. To say the process was self-selecting when a survey form was sent to everyone seems a rather unusual interpretation. You will see from the map that responses were received from throughout the area. Furthermore both the design of the form was overseen by the Scottish Health Council and analysis carried out by departments external to the operational unit, namely the Clinical Effectiveness Team and Public Health Intelligence Team. The analyses carried out for the survey is statistically valid. Mr MacRae s point would only have been relevant had sampling been undertaken. Notably, however, even if we did weight the responses to reflect the differences in population it only made a small difference to the percentages. [2] To address Mr MacRae s point, NHS Highland received 2,273 responses and 16.6% of submissions did not provide enough information to code them onto a geographical location. However, as you will see from the Report on the survey the analysis was carried out including and excluding these submissions and it did not alter the results.
[3] As I explained, consistent with the process, NHS Highland was testing out the steering groups recommendations on the case for change, proposed new model including the location and a potential site with the wider public. Anyone who was not supportive of the model, or of Broadford as the Hub had an opportunity to make their views known. Consideration of the site would only come into play if a) there was support for the model and b) Broadford as the preferred location for the hub. It is not the case that a determination on the location was based on the feed-back on the responses to the site. This was assessed from a separate question which determined that, of those who responded, 2:1 were in favour of Broadford. Provision of Transport It is not the case that NHS Highland has stated that they are unwilling to provide transport. However at this stage the detail regarding what exactly is required has still to be determined. In my view this has been taken out of context. From the various feed-back it is obvious that the transport issues are wider than access to healthcare facilities with a number of social issues also being raised. Therefore the redesign process is being used a catalyst to take a partnership approach to try to find more wide-ranging solutions. Clearly people have to be able to access any health facilities that exist or are being developed and providing transport by bus may be one of the solutions. For your information as part of the consultation responders were asked about car ownership or access to a car and overall 84% indicated they did have a car or had access to one. The new arrangements are still a number of years away and so it s not surprising that the assessment and plans are not yet complete. A Transport and Access Groups has been established and their terms of reference are HERE In conclusion in response to Angus MacDonald s comment: I would have thought that a transport assessment would have been paramount, I would totally agree and it has always been our intention to do so. We have repeatedly made this point and indeed it was a condition of the Cabinet Secretary s approval. Views on the Petition NHS Highland has been through a lengthy and an extensive process to seek to find a consensus and worked closely with clinicians, staff and public. I can confirm to the committee that there is broad and strong clinical support both for the need to change as well as the proposed new clinical model. This includes the GPs in the Portree Practice who have actively engaged throughout the process and continue to do so. There is overwhelming support from the public (86%) for the proposed future model.
Inevitably there was going to be a tension around any decision to be made around location. NHS Highland did not have a pre-determined view on location but through the Options Appraisal process a recommendation was made in favour of Broadford and when put to the public this was supported by 57% whereas only 29% supported Portree (Option 2b). Positive feedback on the consultation process and the preferred model has also Been received from partner agencies including the Highland Council, Scottish Ambulance Service, Scottish Fire and Rescue, Highlands and Islands Enterprise and the Highland Hospice. It is inevitable that the people of North Skye will be disappointed that the new facility will not be in Portree but the same would be true for communities in the South had the facility been located in Portree. In terms of financial implications the cost to build and staff a new facility would be similar whether in Portree or Broadford. I would like to close by reassuring the committee that NHS Highland will continue to work with all the communities and clinicians. As already outlined we are still some years away from making the changes and work will be ongoing to develop all the detail and implement all of the component parts of the re-design. Yours sincerely Elaine Mead Chief Executive
Map 1: Distribution of survey respondents by place of residence across the Skye, Lochalsh and South West Ross public consultation area
Appendix 1 Points of clarification Column 3 Portree will be left with nothing but a day clinic - The main change to the Portree facility is the closing and transfer of 12 inpatient beds. Almost all other services will remain including outpatients and Minor Injury Unit. In addition some services will be expanded in the North. Column 3 A report on travel times was prepared and was available as part of the deliberations and consultation. Column 3 - Deprivation NHS Highland is considering issues relating to deprivation as part of the wider process. However, such matters are not addressed by have a small number of hospital inpatient beds in but by much wider public health and socio economic considerations. Column 5 The public consultation documents refer throughout to Portree Hospital being the spoke to the new hub in Broadford. Nowhere do they admit the proposed spoke is not a hospital at all but merely a clinic. There are no beds, so it is not a hospital. - see comments above. For the committee s information there is in fact no single definition of a hospital. However the key point here is the consultation was carried out explicitly on the basis that in the proposed new model there would be no inpatient beds in the spoke which will be in Portree. In the summary document send to all homes in the area on page 1 it states: The proposal, if implemented, would mean there would be no inpatient beds provided in Portree Hospital Column 8 Alan MacRae It is a statement of fact that it is up to the Ministers to call for an Independent Scrutiny Panel and so in answer Mr MacDonald s query, NHS Highland did explain the process. Column 8 The reference to Kate Earnshaw and independent review relates to the likelihood of the proposed changes being major service changes and therefore subject to Independent review by the Scottish Health Council which did take place. Column 8 - The reference to information not being received is factually inaccurate and out of context. It only refers to one aspect of data collection and in any case, although provided at short notice, was available.
Column 12 Malcolm Henry s comment that The public are ignorant As set out in our response a wide range of information is considered including public feed-back. CEL 4 (2010) provides clear guidance on informing, engaging and consulting people in developing health and community care services including requirements for a public consultation. This document also clarifies the role of the Scottish Health Council during service change which is to quality assure the engagement process and produce a report on their findings for the Board to submit to the minister. These are public services and it is right and proper that the public have a say.