PID-Rural Steering Group Group

PROPOSAL TO ESTABLISH AN EMERGENCY MEDICAL RETRIEVAL SERVICE FOR REMOTE AND RURAL SCOTLAND

Report by Roger Gibbins, Chief Executive, NHS Highland/Chair, Remote and Rural Steering Group and Annie K Ingram, Project Director, Remote and Rural Steering Group

The Board is asked to approve:

The establishment of a phased pilot to determine the need and define the scope and function of such a service;
The proposed cost sharing arrangement between the Scottish Executive Health Department, the Scottish Ambulance Service and the participating territorial NHS Boards;
The costs for phase one of the project for NHS Highland; and
Note the potential costs for NHS Highland for phase two of the project.

1.0Purpose of the Report

This Report is being presented to the Board of NHS Highland on behalf of the Scottish Executive’s Remote & Rural Steering Group.

The Report seeks the approval of NHS Highland Board to a proposal to fund a pilot programme to determine the scope and design of such a service to support rural emergency care.

2.0Recommendations

Members are invited to approve:

The establishment of a phased pilot to determine the need and define the scope and function of such a service;
The proposed cost sharing arrangement between the Scottish Executive Health Department, the Scottish Ambulance Service and the participating territorial NHS Boards;
The costs for phase one of the project for NHS Highland; and
Note the potential costs for NHS Highland for phase two of the project.

3.0Background

Delivering for Health[1] highlights the importance of ensuring that the design of health services supports the needs of those living in remote and rural communities, providing appropriate access to services as close to home as appropriate. It also identified the need for robust arrangements to be in place to ensure that when patients need to be transferred to larger centres for specialist services, particularly following an emergency or trauma, those are appropriate. The specific actions arising from Delivering For Health included:

“Review of HEMS and, if necessary, enhance in remote and rural areas” (p60).

The Remote and Rural Steering Group established four sub-groups and one linked project, including a Project Board to ‘Review the need for an Emergency Medical Retrieval Service for Remote and Rural Scotland’, led by Dr Stephen Hearns, A&E Consultant at the Royal Alexandra Hospital in Paisley.

4.0Summary of Recommendations from the Emergency Medical Retrieval Service Project Board

The Emergency Medical Retrieval Service (EMRS) Project Board submitted a proposal to the Scottish Executive Health department in May 2006, seeking the establishment of a pump-primed eighteen-month pilot project to establish the needs for an Emergency Medical Retrieval Service.

This report recommended that:

NHS Scotland should establish an Emergency Medical Retrieval Service to support the care of seriously ill and injured people in Remote and Rural Scotland.
This service would retrieve patients with life threatening injury or illness where advanced medical intervention is appropriate to optimise safe transfer.
The service would be additional to that currently provided by SAS and would only be deployed if the consultant staff determine that medical intervention is required.
The service should be established in a phased manner, building on the successful pilot within Argyll. Phase one should be implemented to cover the west coast of Scotland, covering three rural general Hospitals, thirteen community hospitals and a number of remote general practitioners. The first phase is likely to last 18 months.
During this first phase, independent evaluation of the requirements for the whole of rural Scotland would be undertaken, including the clinical requirements for the Northern Highlands and Northern Isles, the implications for the air ambulance service, a health economic assessment and the impact on the areas where the service has been implemented.
Following completion of the review, assuming a positive evaluation the service should be rolled out across all remote and rural Scotland.

A copy of the full Report from the project Board is attached at Appendix 1.

5.0Funding

The Steering Group considered how this service might be funded and concluded that there were options for both the initial pilot phase and the longer term funding.

During the pilot phase, two options were identified:

Pump priming by SEHD for the period of the eighteen month pilot;
Funding as part of the initial implementation of the Inter-Hospital transfer Service being proposed by the Scottish Ambulance Service (SAS).

The Steering Group favoured option 1 on the basis that given the lead-time for financial planning, NHS Boards were unlikely to have made any provision for this service in the 2007/8 and the difficulties experienced by SAS in establishing the Inter-Hospital transfer Service would negate option 2, in the near future.

SEHD have intimated, however that it is unlikely that option 1, as proposed, will be accepted and have proposed an alternative solution, with the costs of the pilot in phase one being shared equally between SEHD, SAS and the participating territorial NHS Boards and extended to cover those other Boards in Phase two.

A breakdown of the projected costs for this project over the period of the pilot are summarised in Table 1 below.

Table 1: Pilot Phase 1 costs

Initial equipment costs
£ / Pilot independent
Evaluation
£ / 12 month operational costs[2]
£ / Total year 1 costs
£ / SEHD share
Year 1
£ / SAS share
Year 1
£ / Territorial board share
Year 1
£
120,000* / 66,000 / 936,043 / 1,122,043 / 312,014 / 312,014 / 312,014

*Total equipment required: £230 000. £110,000 of equipment has already been purchased for existing Argyll and Bute service.

The costs in table 1 are for the initial 12-month period of the pilot and include initial set up costs (equipment and costs of an independent evaluation of the pilot). It is intended that the initial pilot will run for 12-months, during which data for the pilot evaluation will be collected. The pilot will be evaluated over a further six-month period, during which time the service will continue within the west coast Boards. The costs for the remaining 6 months of the pilot (based on annual operational cost of £936,043) will be £156,007 each for the SEHD, SAS and the collective territorial boards using the service.

Costs of by health board are shown in table 2.

Table 2: Pilot Project Costs Per Health Board For Year 1 (based on population share)

NHS Board / % Share by NHS Board / Year 1
Costs
£ / Year 2
6-Month Cost
£
Ayrshire & Arran / 4.1 / 12,793 / 6,396
Dumfries & Galloway / 18.8 / 58,659 / 29,329
Greater Glasgow & Clyde / 0 / 0 / 0
Highland / 59.7 / 186,272 / 93,136
Tayside / 0.6 / 1,872 / 936
Western Isles / 16.8 / 52,418 / 26,209
100 / 312,014 / 156,007

The costs by participating territorial NHS Board are calculated by means of the population catchment predictions contained in the Project Board’s report[3].

Independent Evaluation

Whilst the pilot within Argyll has shown that the service has improved outcomes within that geographical area, the Project Board have recognised that the added value across a wider geographical area requires to be demonstrated and have therefore proposed an independent evaluation be carried out to assess this. SEHD have intimated that in addition to sharing a third of the cost of the pilot, they will also fund this evaluation.

Capital Costs of Pilot

SEHD have also confirmed that the additional capital requirements will be funded from central sources.

Exit Strategy

The Project Board have recognised that there is the possibility that the pilot will not demonstrate the predicted outcomes for the Remote and rural populations and have proposed that any appointments should be fixed term for the length of the pilot.

In the event that the pilot is not accepted and a full service is not implemented the service would be discontinued at the end of the 18-month pilot. The service in Argyll, which began as a pilot but has continued for 18 months beyond the initial project, has demonstrated benefits will be less easy to discontinue. The Project Board would seek early discussions with NHS Highland and NHS Greater Glasgow and Clyde on whether the service could continue and, if so, how this might be funded.

Longer term costs of an established Service

Whilst the evaluation will provide evidence for the appropriate future configuration of any service, the project Board has considered what the likely options for an extended service covering all remote and rural areas of Scotland might be. The Options appraisal considers that either a single centre or a two-centre model are more likely to provide the greatest coverage and best value for money.

All of the options are discussed in the full Report from the project Board however the indicative costs of these two options are shown in Table 3.

Table 3: Costs Of Long Term National Service

Initial Equipment costs
£ / Annual operational costs
£ / Cost per patient
£
Phase two – one centre option (B: Glasgow) / Nil
(All equipment purchased in pilot phase) / 1,025,4832 / 3,715
Phase two – two centre option (D/ E: GlasgowAberdeen or Inverness) / 230,976
(Equipment required for a second centre) / 1,649,6472 / 5,977

How any eventual service may be resourced has yet to be determined, however the Project Board have considered the impact of such a service on the territorial Boards. For illustrative purposes, the costs per board based on population are shown in Table 4.

Table 4: Costs of National Rural EMRS by NHS Board

National service / % pop’n[4] / One Centre / Two centre
Ayrshire & Arran / 2.7 / 27,688 / 44540
Dumfries & Galloway / 12.1 / 124,083 / 199607
Greater Glasgow & Clyde / 0 / 0 / 0
Highland / 57.1 / 585,551 / 941948
Orkney / 7.9 / 81,013 / 130322
Shetland / 9 / 92,293 / 148468
Tayside / 0.4 / 4,102 / 6599
Western Isles / 10.8 / 110,752 / 178162
100 / 1,025,483 / 1,649,647

NHS Greater Glasgow & Clyde medical staff will provide the service, in collaboration with colleagues from the Ambulance service, during the pilot phase. As such, NHS Greater Glasgow & Clyde are not expected to share the costs of the service but will require reimbursement for the provision of the service.

6.0Health Economics Review

The Steering Group recognised that there should be a robust Health Economic Review undertaken as part of the options appraisal process and during the pilot phase. An initial overview was undertaken by the Project Board and is included within the Report at Appendix 1.

The pilot phase of the project should however be supported by a robust assessment and review. This is included within the costs but the independent reviewers still need to be identified.

7.0Conclusions

Delivering for Health required that the need for an Emergency Medical Retrieval Service to support remote and rural communities be undertaken. This review has shown that there is likely to be a need but that further review is required. The Project Board concluded that the most appropriate way to take this forward was by means of a pilot to establish the need and define the scope and function of such a service.

SEHD has identified that the funding of the pilot should be shared equally between the participating territorial NHS Boards, the Scottish Ambulance Service and the Executive. The costs of this are detailed above.

The final outcome of the project will be determined following an evaluation of the service.

8.0Contribution to Corporate Objectives

The proposal is designed to meet the Board’s objectives of improving the quality of and access to services in the remote and rural areas. It meets a key pledge in Delivering for Health. Potentially the service supports the sustainability of rural general hospitals and allows for the consideration of different models of health provision in remote areas.

9.0Governance Implications

The proposal has significant clinical governance implications. It is designed to provide access to emergency retrieval services in remote areas that is readily available by conventional transport and retrieval in urban areas. The clinical effectiveness of the service will be a key aspect of this evaluation. In respect of staff governance, NHS Highland will not be employing the staff who provide the service but the service will be a support to our practitioners working remotely.

The financial implications for Highland are as follows:

For the period of the Pilot there will be a cost of £186k in 2007/08 and £93k in 2008/09. These sums are non-recurrent and are provided for in the 2007/08 and 2008/09 budget. If the post- Pilot evaluation recommendsprogression to full implementation,and the full cost was to fall to Boards, then there will be a recurrent FYE impact of £586k or £942k depending on whether a one or two centre model is implemented. The larger sum is included in the list of provisional commitmentsin 2009/10. Note thatit is not included in the Approved Plan at this stage and the Board should consult the Approved Planto assess the affordability of the project in the event of theFull Business Case forPost Pilot implementation being considered."

10.0Impact Assessment

This will form part of the evaluation.

Dr Roger Gibbins
Chief Executive, NHS Highland /
Chair,Remote and Rural Steering Group / Dr. Annie K Ingram
Project Director
Remote and Rural Steering Group

23 March 2007

[1] (2005) “Delivering for Health”, November 2005, Scottish Executive

[2](2006) “ Scotland’s Emergency Medical Retrieval Service” EMRS project Board Report, 27th April 2006, p33

[3] (2006) Ibid, p21

[4] (2006) ibid, p21