NHS Highland Argyll & Bute Health and Social Care Partnership Oban Lorn & Isles Locality Planning for the Future Group 13 January 2017 Lecture Theatre Lorn & Islands Hospital, Oban Present - Members of the Group as per Terms of Reference Elaine Wilkinson (EW), Chair by VC Annie Macleod (AML), Locality Manager by VC Dr Peter Thorpe (PT), Clinical Lead Dr Richard Wilson (RW), Clinical Lead Dr Ella Tolloczko (ET), Consultant Surgeon Bill Staley (BS), Information and Projects Manager Caroline Henderson (CH), Local Area Manager Cllr Elaine Robertson (ER), Argyll & Bute Council Linda Currie (LC), AHP Lead Stephen Whiston (SW), Head of Planning & Performance Mr John Abraham (JA), Consultant Surgeon Lorraine Paterson (LP), Head of Adult Services (West) Dr Erik Jespersen (EJ), GP Donald Bruce (DBr), Public Representative John Colston (JC), Public Representative Stella Cockburn (SC) by VC Jackie McGeoch (JMG) by VC Dr David Binnie (DBi) by VC Liz Higgins (LH), Lead Nurse by VC In Attendance Andy Brady (AB), Scottish Ambulance Service Hilary Brown (HB), Deputy Lead Nurse Caroline Champion (CC), Public Involvement Manager Katrina Flannigan (KF), Respiratory Nurse Specialist Dr Jason Davies (JD), Consultant Anaesthetist Dr David Robinson (DR), Consultant Anaesthetist Sandra Melville (SM), Pharmacist Dr Angus Cameron (AC), Medical Director Dumfries and Galloway and Scottish Government by VC David Ritchie (DR), Press Officer by VC Apologies Member of the Group as per Terms of Reference Dr Fiona Johnson (FJ), Consultant Physician Dr Rod Harvey (RH), Medical Director Apologies from non Members of the Group as per Terms of Reference Dr Nicky Campbell (NC), Medical; Associate Colin Whiteford (CW), Scottish Ambulance Service Dr Isabella Bodzioch (IB), Consultant Physician 1
1 Welcome and Apologies Action EW welcomed everyone to the meeting apologising for non-attendance in person due to the ferries not running. Introductions were made around the table in L&IH and by VC from the other sites. Apologies were read out, as listed above. 2 Notes of Last Meeting DBr asked for the notes of the last meeting to be amended. Page 7 under Communication & Engagement to state DBR felt that we should be cautious about what information is released to people as he felt that too much or incorrect information could be frightening and misleading to people. With this one amendment the notes of the meeting held on 11 November 2016 were agreed as a true reflection of the meeting. 3 Matters Arising 3.1 Revised Terms of Reference Those present were advised that the Terms of Reference had been updated since the previous meeting and all were asked if it is now an accurate record of what we want from the Review. SW felt that the membership list needs updated further and asked that the governance arrangements for this meeting were reporting to the Strategic Management Team before going to the Integrated Joint Board. It was also noted that on Page 4 the Belford Hospital should not be referred to as a Community Hospital and pharmacy should be added as support service. The meeting agreed that the TORs would be made available to the public on the website. AML 4 Government Overview of Clinical Strategy of Rural General Hospitals AC was welcomed to the meeting. He outlined that he is the Medical Director Dumfries and Galloway and is also advisor to Scottish Government and has had a role in contributing to and overseeing implementation of the National Clinical Strategy. AC updated the group on developments arising from the National Clinical Strategy which was published 1 year ago. He highlighted the following: the pathway for patients starts and ends with primary care; a proactive approach was required to avoid hospital admissions and that the Scottish Government certainly isn t recommending closing hospitals it is regretful that more has not been done to move the Clinical Strategy forward in the last 12 months but a meeting is arranged next week involving the Chairs of all Health Boards in Scotland and the Scottish Government; 2
the Scottish Government are to appoint a Chief Executive to look at regional planning for each area, ours being the West of Scotland and he outlined the activities which will be addressed. The timescale is short with the work to be completed by September 2017; a clear picture is required for the next 10-15 years to see what is needed to do our work in the future, and mentioned estates/buildings in particular; a draft National Workforce Plan is being released in April 2017 and that better IT is required eg broadband, especially in rural areas; island and rural proofing is mentioned in the document as the Scottish Government is keen that patients in rural areas are not disadvantaged. In the follow-up discussion the following points were made: hopefully we would see more traction with this report as nothing had happened following previous reports/projects such as the Kerr Report and West Highland Review; it is important that we have national solutions as the problems we currently face can t be fixed locally, particularly with regard to training for rural areas. AC said that he would be happy to feed this back to the Scottish Government that a solution is urgently needed. training for consultants is vital and that all services need to be safe and sustainable the dogmatic adherence to national conditions of employment for doctors did not allow anyone to offer incentives to encourage people to work in rural areas and we need the Scottish Government s help with this. AC said that he agreed that the Scottish Government need to recognise the need to be flexible with working terms and conditions. It was noted that we do have representation at the West of Scotland Regional Planning Group. The meeting was advised that the West of Scotland are in advance of other areas which was one reason why the pace of progress has been so slow and a more dynamic approach is required. It was noted that as RGHs are small which means that the on call commitment is currently too onerous which makes jobs undesirable. AC said that he was certainly aware of this problem in RGHs which is also a problem in his own local area. There is no solution to this at the moment but it will be addressed by the Scottish Government. It was suggested that even more rural hospitals than L&IH may ask staff to work elsewhere to gain more knowledge to help them use specialist skills when required. The meeting was reassured to hear about island and rural proofing although AC had had no clear commitment re clinical leadership within the regional planning work as yet. Work would commence with clinicians and then involve the public as they needed to ensure that clinicians were behind this. Members of the Group had been involved in the work of the West Highland Review some time ago and heard that the term RGH had been developed then. It was noted that general surgeons and general physicians are needed as is acute medicine and AC was asked why was this not mentioned in the Strategy? He was also asked if the Scottish AC 3
5 Draft Project Plan Government are planning to move this to primary care and he was also asked what services does an RGH expect to deliver? AC said that there is an increasing demand for acute medicine and demands on primary care are also increasing, and will continue to do so. He said that we have to appreciate that a patient with complex needs may have to travel to another hospital for an operation, however some local services will continue. Information was requested about timings of progress from a national perspective and AC said that progress should be visible from Spring 2017 but that no information would be released until September 2017. It was noted that as we work through the work of the review it would be good to test any emerging models against the national guidance. This document had been issued with the Agenda. Following some discussion It was agreed that BS/AML/SW would meet to progress the development of this document which should include who is leading on pieces of work, training, communications and the Government s timelines for regional planning. AML/BS/ SW 6 Current Services PT talked through a presentation on a number of possible medical models for the future sustainability of the hospital. He said that he had based this on the medical model as that was what he understands best and that other services can be built around this. An alternative way is to look at the service model, and build the medical model around it. PT said that the presentation today was based on his own ideas, and that of his colleagues. He said that the essential requirements, as he saw it, were that we must provide a 24/7 A&E service and that it was crucial that we get this message across to the public. He said that he was hopeful that a meaningful network could be set up with Glasgow but this had not happened yet. He said that to run a service we need surgeons, physicians and anaesthetists and that general consultants are no longer being trained. He also said that larger hospitals have a less onerous on-call commitment which make them more attractive for consultants to work there. PT said that rural practitioners don t exist in large numbers, however there is one model in Skye but this appears to be very expensive to run. PT described that 50% of elective activity across Argyll and Bute is performed by GGC at a cost of 50M. The LIH budget is 14M to offer the other 50% of activity. This suggests at least that Glasgow cannot be seen as a cheap option and the cost of moving any services into Glasgow must be taken into account when determining potential savings. PT had looked at an Enhanced Consultant Model to see how this could be done. He said that our current workload would justify the recruitment of a fourth consultant physician. PT said that if we had more flexibility with contracts then we could attract more consultants to the area which is already being done in other countries eg Canada and Australia. 4
PT said that we need to define the scope of care in order that we can develop as a RGH. He said that the urology service was a good example of this. He told those present that a urology service used to be offered by a general consultant surgeon but when he retired the service couldn t be offered to patients as it is now considered as a speciality in it s own right. He said that if we had a meaningful relationship with Glasgow then we could perhaps have employed a urologist to work across the West of Scotland. The service is now provided by GG&C and costs over 200,000 for a small number of patients who require the service. PT discussed the possibility of a GP-led model but he said there was no appetite amongst local GPs for this model and that GPs also have problems with recruitment both in Oban and in Lochgilphead, who currently operate this model of care. He said that it is not a cheap option. It was pointed out that if we had a community hospital we would lose our training status for medical staff and, as this is not part of the Terms of Reference for this Group, it was felt that this should be removed at the outset. However, it was agreed by the Future Planning Group that this should remain as one of the long list models for consideration at this stage. With regard to the Rural Practitioner-Led Model PT said that it is very difficult to recruit to these posts as a lot of training costs and time is built into the post. He said that we would not be able to offer the same degree of service as we do now with this model. Nurse-led Model PT felt that this was not an acceptable model but was the only one which would be cheaper than the model we currently have. JMG said that from a GG&C planning perspective, there has been discussions about how they could offer their service better and that they need to look at how to establish better relationships. She said that rotation of staff within posts is very difficult and that they had looked at doing this with urology but there was no interest in this type of post. She said that they do have clinicians who rotate to the Vale of Leven and Inverclyde but this is easier for staff than travelling to Oban. In answer to a question JMG confirmed that the Vale of Leven only carry out elective procedures and have a minor injuries and minor ailments service, they do not have an A&E service. It was noted that The change to the GP contract changed in 2004 had supported the GP service as they were going through a recruitment crisis at that time. We do need the GPST (training) posts to help the hospital and general practice. It was also noted that local GPs did cover A&E in the old West Highland Hospital for free. L&IH have dispensation from NES to allow junior doctors to operate overnight on their own with consultant support from home. GPs who come to L&IH to train often stay in the area because they like it here. The inter-dependency everyone has on each other between primary and secondary care. Concerns were raised if we were moving surgery away from RGHs because it is needed to grow. We should be using this as a development opportunity to look at 5
the SLA, the transportation of patients and development of the consultant model A suggestion was received that the group short list the models which they wish to look at and get these worked up financially and assessed against the principles agreed by the group. Growth and development was the way forward and that Oban is the growth area within Argyll & Bute and we should be concentrating on expanding our services. One suggestion that we should be looking at how we can bring back the urology service to L&IH and that perhaps we could have both an RGH and a community model within the hospital? Following some further discussion:- Some present felt that the GP model would not work but they understood the problems with recruitment. They were supportive of a growth model and also understood that we may have to look at doing less than we do now and look at how best we can deliver this in L&IH. It was important to give reassurance to the public that we would continue with 24/7 A&E cover and that the hospital would remain open. It was agreed that much more work is needed before we get to a stage to carry out an option appraisal and the process was outlined which must be followed using the relevant guidelines. Agreed that we need to identify what services we want to offer and that the service must be safe and sustainable. It was felt that some of the options outlined can be ruled out as they don t align with the agreed principles for the future planning group. It was proposed to shortlist the models and testi against what actual services we want to deliver and the agreed principles for the review. Recognition that staffing is an international problem. AC was sorry that the list of options did not include an ANP model and felt that some more imaginative models should be included. He was advised that we do have an ANP/ENP system within L&IH but that medical cover is currently provided 24/7 and to not have this would give further problems. AC was asked if he was suggesting that we do away with medical on call overnight and the meeting was advised that this may need to be considered along with some other radical solutions.. Following some further discussion it was agreed that SW/AML/PT/SC would meet to look at all the ideas put forward and assess them against safety, sustainability and cost criteria for the next meeting of this group. It was suggested that a nurse representative also participate in this process AML/SW/ SC/PT/LH PT said that he didn t circulate his presentation in advance of the meeting because he felt it needed explanation and discussion on the day, and was concerned it would be perceived negatively. He re-iterated this is part of a long list of options that need to be explored further or excluded. SW said that the public will need to see the options being considered when they are further developed. AML asked AC if he could send her any models used elsewhere and she confirmed that she was happy to work with the small group suggested. AC to send models 6
7 NHS Greater Glasgow & Clyde Planning Update JMG agreed to speak to the Medical Director, Chris Jones, about the Future Planning Group JMG said that we can t deliver everything in the local area and we need to be linked into the wider regional planning work. EW asked her to provide information which will allow us to understand the service model being developed in GG&C and the relevant pathways. She said that we need more information to help inform what we want to provide in L&H. EW asked JMG for a presentation about the GGC/Inverclyde plans at the next meeting AM to coordinate date JMcG 8 Data Collection to Date It was agreed to consider the information collected by BS at the next meeting of the group. BS 9 Draft Communication Plan AML had circulated a draft plan she had prepared and mentioned the CEL4 standards which are being adopted by the Integrated Joint Board. CC advised that CEL4 had been issued by the Scottish Government in 2010 and confirmed that these are the national standards we need to work to. CC outlined the 4 stages which we will work through and she advised that the Scottish Government will decide if the proposed changes constitute a major service change. She agreed to circulate the flow chart to the group. EW suggested that three bullet points of key messages, (an elevator pitch) be decided upon for distribution immediately after this meeting. AML said that a Communication & Engagement Group would be set up to support the Planning for the Future Group who would take on the responsibility for this in future. CC AM/CC EW asked that DR and CC take on the task of circulating the key messages from this group. Following some further discussion it was agreed that the bullet points would be:- 1 Lorn & Islands Hospital is not closing 2 24/7 provision of acute care continues 3 State the reason that the future planning group is happening that the group planning the sustainability of the hospital service for the future. It was noted that:- People want to be treated locally. That there are local concerns about L&IH continuing as a consultant-led service due to recruitment issues, which was not our fault. It was suggested that we should be putting pressure on our MSPs to find a national solution. By the end of the future planning groups work everyone will know 7
what will be provided, and who will be providing it, which should give everyone reassurance for the future for staff and the public. ER mentioned the public meeting which has been arranged by Oban Community Council for this evening and she said that we need to be able to say what s happening in the short term. It was agreed that We need to say why we are looking at future planning of the hospital which is due to issues with recruitment and the use of locums. It was noted that when planning for the future, we will always need locums but the use should be managed very closely. We should use plain English when communicating about the work of the group. That this process has not been imposed on the hospital, that the review is being done by ourselves to look at our future. It was suggested that we do not use the word close at all and simply say that the hospital remains open The Communication Team pull together the key messages and circulate to members for comment, in particular to the public reps on the Group. It was agreed that DR would do this afternoon. DR The meeting was advised that Christina West will attend the public meeting this evening as will Dr Peter Thorpe and Dr Richard Wilson. SW, LP and CH will also attend. ER said that she was delighted that health representatives will be attending the meeting and some discussion took place around the mis-representation of the review which has been in the press this week. AML advised that she has held an Open Session for staff earlier in the week with another planned for later today. AML said that she was unable to attend the meeting this evening herself and was very grateful to those who were attending. AML asked that SW provide RW and CH with information regarding the urology service for the public meeting which SW agreed to do. SW 11 Draft Risk Register AML said that this will continue to be developed and asked if anyone had any additions to the Register to contact her directly. ALL 12 Publication of Health and Social Care Delivery Plan The link to this had been provided on the Agenda for information. 13 AOCB 13.1 Press Release DR said that it was important to put out a message after each meeting and suggested that this be prepared for issuing next week. EW said that she would like the press release issued today. DR 8
13.2 Statistics BS said that he had noticed some interesting stats had come out of the work he had undertaken to prepare the presentation which would be shown at the next meeting. BS 13.3 Scottish Ambulance Service AB asked that patient transport be included in the Risk Register and it was agreed that it was important to consider the impact on the SAS on any models being considered. 13.4 Review AML Following some discussion it was agreed that the term Review was misleading and this group would be known as the Planning for the Future Group from now on. 13.5 Pharmacy SM offered to become a member of the group to represent Pharmacy and said that Pharmacy is not mentioned in the Terms of Reference. She reminded the group that Pharmacy is not an AHP. EW said that she would consider this request and said that she needs to ensure that the membership of the group is balanced but there was an opportunity for clinicians to contribute through the Clinical Reference Group. EW 13.6 Planning in Glasgow JMG said that a big planning process is currently happening in Glasgow. EW requested that JMG bring a paper or presentation to the next meeting of the Group which was agreed. JMG 13.7 Financial Plan Some discussion took place around the need for the Integrated Joint Board to sign off our financial plan. It was suggested that we should be able to look at some financial information for the next meeting. SC 14 Date of Next Meeting The next meeting will be held on 20 February 2017 at 12.30 pm in Bay 2 of the Nelson Ward, Lorn & Islands Hospital, Oban. 9