EFFICIENCY & EFFECTIVENESS IN RURAL HEALTHCARE - PowerPoint Presentation

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EFFICIENCY & EFFECTIVENESS IN RURAL HEALTHCARE

Lessons For Wales From Other Countries

Tom Brooks

Retired Management Consultant

CONTEXT

DELIVERING QUALITY HEALTHCARE TO RURAL POPULATIONS IS NOT EASY

WALES CAN PERFORM VERY MUCH BETTER

KEY POINTS – FOLLOW UP REFERENCES IN PAPER

THE WELSH GOVERNMENT AND RURAL HEATHCARE ACCESS

The “Welsh Assembly Health, Social Care and Sport Committee” Promise: Rural Health and sparse health facilities is a growing issue and a priority for scrutiny during the year.

The Wales “Rural Health Plan” says in bold type “

Accessing services is the foundation of effective rural

health and a basic human right”.

The Royal College of General Practitioners (RCGP) statement on rural general practice states: “….. rural patients have greater access difficulties for health care. It is a safe assumption that poor access will adversely affect outcomes”.

The Parliamentary Review of Health & Social Care in Wales New models of care should address specific rurality issues, not least, access to care.

Lord

Elystan

Morgan

IN RURAL HEALTHCARE, WALES HAS A DEFICIT IN

STATUTORY RIGHTS AND PROTECTION FOR THE RURAL DWELLERSIDENTIFYING THE HEALTH NEEDS OF EACH INDIVIDUAL RURAL AREA AND HENCE THE APPROPRIATE RESPONSE

A DELIVERY MECHANISM TO ADDRESS “DISTANCE DECAY” IN BOTH THE SERVICES AVAILABLE IN RURAL HEALTH ESTABLISHMENTS AND IN PERIPATETIC RURAL HEALTH DELIVERY

IN DUAL ROLE STAFFING IN RURAL WALES, BOTH OF THE NECESSARY EDUCATION AND TRAINING AND THEIR SUBSEQUENT DEPLOYMENT

IN NATIVE LANGUAGE (CYMRAEG) HEALTHCARE DELIVERY

‘OTHER COUNTRIES PROVIDE MORE STATUTORY SUPPORT TO PATIENTS THAN WALES’

In Canada, the Canada Health Act 1984 provides basic guarantees that residents of rural areas, and particularly first nation Canadians should have equitable access to healthcare 

“In the United States,

federal levers have been used to promote access in rural or remote areas and provide context for state and local policy decisions. The US Rural Health Clinics Service Act of

1977,

and the Federal Office of Rural Health Policy provide a mechanism for rural health campaigners to receive significant support ” – Elsevier review .

Australia healthcare statute derives from the Health Insurance Act 1973. Healthcare in Australia is the subject of split responsibility between the Federal Government and the individual States.

Just recently, the Federal Government has announced creation of a National Rural Health Commissioner.

‘OTHER COUNTRIES PROVIDE MORE STATUTORY SUPPORT TO PATIENTS THAN WALES’

OECD &

WALES “Wales has chosen to abolish the purchaser-provider split and does not accept that competition is the best driver for quality improvement. Given that Wales cannot use patient choice or the purchaser-provider split, efforts

must be made to ensure that other quality levers are working effectively.”

Mid Wales Healthcare Collaborative

Has not

controlled enough levers to make the hoped for impact. “Insufficient resources, limited Ministerial support and no permanent statutory powers”.

Despite the support for rural healthcare from the New Zealand 2005 & 2012 Charity Acts, Michelle

Thompson, chief executive of

the Rural Health Alliance of New

Zealand

said in Sept 2017: “The

parties haven’t really understood the specific challenges rural people face accessing health and social services due to factors such as low population density and/or

isolation”.

PATIENTS IN RURAL WALES ARE DEVOID OF EFFECTIVE RIGHTS

‘WHERE IS RURAL WALES’

POPULATION DENSITY MAP

NEW WELSH CONSTITUENCY BOUNDARIES

Countess of Chester

Shrewsbury

Hereford

THE TWO PICTURES TELLS A STRAIGHT FORWARD STORY

THE WELSH NHS HEALTHCARE DELIVERY STRATEGY IS URBAN BASED

INSTEAD OF HEALTHCARE PENETRATING THE RURAL HEARTLANDS, RURAL DWELLERS HAVE TO MIGRATE TO OBTAIN ACUTE CARE

BETSI CADWALADR GP CLUSTERS

PLANNING TOO GENERAL, IMPRECISE & UNRESPONSIVE

England and Other Countries Have Good Examples of Granular Needs Assessment & Targeted Response

‘IMPROVING RURAL HEALTH CARE IN WALES’

GP CLUSTER ANALYSIS DISGUISE HUGE VARIATIONS BETWEEN WELL-BEING AREAS 

“I

t is clear that there is no uniform solution

to the challenge of providing first class services to all. This is a “whole system” issue -

REQUIRING A SENSITIVE AND LOCAL NEEDS ANALYSIS” – Wales Delivering Rural Health Care Services.

GP PRACTICE PROFILES

ARE MORE USEFUL, BUT –* MORE THAN ONE PRACTICE COVERS MANY WELL-BEING AREAS* NO PUBLISHED PLAN OF THE HEALTHCARE DELIVERY RESPONSE AND WHY IT IS APPROPRIATE IN IMPROVING OUTCOMES

BUT RURAL AREAS IN WALES DO NOT BENEFIT FROM LOCAL NEEDS ANALYSIS AND RESPONSIVE PLANS

‘DISTANCE DECAY’ AND

RURAL HEATHCARE OUTCOMESStudies have demonstrated that utilisation of services is inversely related to the distance of patients from hospitals; so called

distance decay” –Mungall 2007

“Unfortunately, urban-based policy makers and health service planners often seem to think that the country is just like the city but with a different population distribution, and that it is possible simply to transplant modified urban health services to rural

areas” – Strasser .

77% of the 106 included studies identified evidence of a

DISTANCE DECAY association, whereby patients living further away from healthcare facilities they needed to attend had worse health outcomes than those who lived closer. 6% studies identified a reverse situation –

BMJ

Systemic Review 2016 Nov 24

A study in Norfolk showed that the number of visits to hospital (outpatients and inpatients) falls with increasing distance from the patient’s home to hospital

.

Haynes &

B

entham

LATEST BOUNDARY COMMISSION MAP SHOWS THE TRUE RURAL AREAS.

WITH TWO EXCEPTIONS ACUTE SERVICES ARE

OUTSIDE RURAL WALES.

THE AIM OF THE 2013 NORTH WALES REORGANISATION WAS SERVICES CLOSER TO THE HOME – TO REDUCE DISTANCE DECAY.

‘ADDRESSING DISTANCE DECAY – CARE CLOSER TO HOME’

SERVICES SHOULD BE MIGRATING INTO RURAL AREAS.

THE AIM OF THE 2013 NORTH WALES REORGANISATION WAS SERVICES CLOSER TO THE HOME.

THE REALITY WAS SERVICES OUTSOURCED TO THE COASTAL FRINGE

IN LINE WITH THE RURAL HEALTH PLAN EASIER ACCESS FOR RURAL DWELLERS

ACCESS TO HEALTHCARE FOR RURAL DWELLERS IS MUCH MORE DIFFICULT

INCIDENTS AND COMPLAINTS IN THE MEDIA HAVE SOARED

‘THE REALITY - DISTANCE DECAY INCREASED’

LEARNING FROM SCOTLANDProf Marcus Longley visited Broadford [LEVEL 2 ½ HOSPITAL]

for the MID WALES HEALTHCARE STUDY Report for Welsh Government

“MAXIMISING SERVICES FROM RURAL HOSPITALS”

The Isle of Skye has a model of ‘rural practitioners’ where the Broadford

Hospital

is staffed by GPs with additional skills/training. Nearby is the Broadford GP surgery – a four GP practice with branch surgery.

SERVICES AT DR MACKINNON MEMORIAL HOSPITAL INCLUDED

24 hour on call medical cover24 hour nursing cover24 hour A&E service

24

hour radiography cover

25 Beds used for Medical Surgical and occasional Paediatric

care

Scotland’s Vision

2020

records, “Major Community

H

ospitals

have three main functions.

They

support the rehabilitation and recovery of patients after a stay in an acute

hospital;

They

provide the specialist end of community services,

co-locating

services that patients have traditionally had to travel to bigger sites

for;

T

hey

provide

a wide range of

diagnostic and outpatient

services”.

The Chief Executive of NHS England in a Daily Telegraph interview on May 30th 2014 said, “A number of other countries have found it possible to run viable local hospitals serving smaller communities than sometimes we think are sustainable in the NHS”.

“Most of western Europe has hospitals which are able to serve their local communities, without everything having to be centralised”.

SIMON STEVENS NHS ENGLAND

THE COMMUNITY HOSPITAL IN ENGLAND

SWAFFHAM COMMUNITY HOSPITAL NORFOLK AFTER REVAMP

Despite Sustainability and Transformation Partnerships closing some community hospitals investment continues in many.

MALTON COMMUNITY HOSPITAL, NORTH YORKS

“THE SMALL COMMUNITY HOSPITAL ”

LEARNING FROM NEW ZEALAND

Buller Health in Westport uses a multidisciplinary approach to patient care

working with lateral thinking and role collaboration as the key to delivering excellent services in rural communities.

Buller Health brings together the primary practice, inpatient care, community services, allied health, care of the elderly, outpatient services, maternity

services

and residential care to name a few. The Buller Health Plan

provides the core services locally, to support needs such as chronic disease management. •X-ray department •Occupational therapy unit•Physiotherapy department

•District

Nurses •

Public Health Nurse

•Social Worker and Field

Workers •

Dietician

•Health promoters - sexual health, cervical screening, diabetes educator, cardiac and respiratory nurse

specialists•26

bed residential care home facility

The

unit includes

:

•8 bed acute medical ward •A & E department

•

Palliative care unit (Kowhai)

•

4 bed birthing unit (

Kawatiri

)

•

Outpatients department serviced by visiting

specialists

LEARNING FROM AMERICA

“Small Hub Hospitals & Mobile Outreach to Sparsely Populated Hamlets”

As

early as 1977 in the USA, the Rural Health Clinic Services Act

was enacted to address

serving Medicare patients in rural areas and to increase the utilization of non-physician practitioners such as nurse practitioners (NP) and physician assistants (PA) in rural areas. Rural

Health Clinics (RHC) must directly furnish routine diagnostic and laboratory services having on-site a number of laboratory tests. It must immunisation and vaccinations. It must provide telehealth links to specialists at remote sites.

Kayenta Reception AreaKayenta Arizona, New Hospital Base

RHCs have 24 hr beds typically for

6 to 10 patients

.

The unit may include an “extended stay” element leased out to a nursing care provider.

A

RHC can provide any type of specialty healthcare service, such a stroke service, provided that it primarily in the business of providing primary and community health care.

LEARNING FROM AMERICA

“Rural America - Outreach from Hub Base”

Healthcare is pushed outward further from the small

Hub hospitals like Kayenta into rural USA via mobile clinics, many part funded by the US Department of Veteran

Affairs.

The units provide typical primary care services and are equipped with reliable wireless connectivity, including satellite, which compensates for the poor Wi-Fi and mobile signal services often present in rural areas and makes the unit an effective telemedicine base.

The equipment installed for rural clinic ‘tours’ variously enables them to provide a range of diagnostic services, such as connection to Picture Archiving and Communications Systems, Radiology Information Systems,

even Computed-Tomography-scanners and of course video conferencing for clinical and administrative purposes.The clinics also provide a base for counselling for mental health ailments as well as providing assistance for claiming benefits and other social need assistance, etc.

Telemedicine consultation

Mobile outreach vehicle in rural Arizona

Mobile outreach vehicle in Canada

Cardiology

monitoring such as ECG trace

telediagnosis

,

teledermatology

, retinal imaging,

Such mobile clinics exist in several countries, in some cases on boats.

“Multi-skilled Staffing Roles”

RURAL MODELS IN STAFFING

When she was the Minister responsible, Edwina Hart stated – “New workforce

models are required to deliver improved services across the NHS. These new models will need to be based on multi-skilled roles. I

believe there is real merit in the notion of a new Rural Practitioner

roleAustralian Recruitment Companies are seeking nurse radiographers who can work in remoter locations especially if they have experience of medical imaging CT Scaning

. For those who have dual skills but want a holiday, the Company can arrange for back-packing holidays with locum work in nursing and medical imaging.

Nuffield Trust point out that “dual training would create a larger pool of staff with a wider range of skills”, but that “the desired roles do not yet exist in the UK”.

“MULTI SKILLED STAFFING ROLES”

LEARNING FOR OTHER COUNTRIES

Isle of Arran Healthcare

Delivering a ‘multi-factorial’ healthcare workforce requires speciality training

. Aberdeen

University provides training for medical, nursing and therapies staff, a ‘Remote and Rural’ option for undergraduates giving them experience of the

Rural localities

For example in the USA, the Progressive Healthcare Group services rural Benson Arizona with outreach including to Cochise native Americans through rural general practitioners, rural nurse practitioners, rural paramedics, medical imaging nurse, and combined trained

OT/PTs,

all being flexible on role content

.

Ayr

& Arran Health

Board which takes

pride that their GPs offer a wide range of skills, including minor surgery, acupuncture, well woman clinic, travel clinic, fracture clinic, medical examinations (including Mountain Rescue).

The highest densities of Welsh speakers are found in the rural northwest of Wales. Experience in the USA and New South Wales dictates that - the Medical School for Welsh Speakers must be based there.

The “Delivering Local Health Care” Plan

declares: “To be

effective, the Welsh language requirement in local care,

must

be addressed”. Improving The Welsh Language Service

Preferential education with financial incentives are standard in both the USA and Australia. Indians Into Medicine ProgrammeAboriginal Medical Workforce Initiative,

etc “ADDRESSING THE NEED FOR NATIVE LANGUAGES”

BUILDING EFFECTIVE HEALTHCARE IN RURAL WALES

A STATUTORY ORGANISATION FOR RURAL HEALTHCARE

STATISTICAL HEALTHCARE NEEDS ANALYSIS FOR EACH WELLBEING AREA

REPORT ON DUAL ROLE STAFFING

BANGOR MEDICAL SCHOOL TO ADDRESS WELSH LANGUAGE CARE DELIVERY

A Challenge For The Welsh

Assembly Health, Social Care and Sport

Committee : To Consider

A STATUTORY RIGHT FOR RURAL DWELLERS TO GOOD HEALTHCARE

IMPROVE AND INCREASE RURAL HOSPITALS TO MINIMISE “DISTANCE DELAY”

MOBILE HEALTHCARE RESOURCE UNITS FOR REMOTE AREAS