Since the Health Foundation began running improvement programmes a decade ago, we’ve supported dozens of projects and fellowships in every region of England, and over a hundred in Northern Ireland, Scotland and Wales too. As our newsletter this month highlights, this work has taken us to some of the remotest corners of the UK, where the challenges of improving health and care services can be at their most stark.
Providers serving small or isolated communities often face a seemingly daunting range of barriers. Services can be harder to access, often requiring significant travel. Population dispersal can make it more difficult to reach particular groups, and bring with it higher levels of social isolation. Smaller patient volumes can render some kinds of specialist services unviable, while remote locations can make it harder to recruit people. As the recent Morecambe Bay Investigation and subsequent National Maternity Review both highlighted, on occasions these factors can combine to produce more complex and deep-seated quality problems.
But creative responses to overcome these barriers can also breed inspiring innovation, like the projects we are profiling this month.
The Scottish Ambulance Service is training fire fighters and volunteers to provide a first line of emergency response in situations like cardiac arrests, where speed can make the difference between life and death – adapting a model used in other countries to Scottish needs. Better use of community assets is also a theme of our GenerationQ Fellow Cathie Cowan’s account of transforming health services in Orkney, where volunteers on its many islands help drive ambulances and even set up landing lights.
Telehealth and video-conferencing are also a major theme – on the increase everywhere, but in remote locations a necessity rather than a convenience. NHS Orkney has developed outpatient clinics where specialists join by video-conferencing to support clinical decision-making. The orthopaedic team at the Royal Cornwall Hospitals Trust, meanwhile, is rewriting the rules by setting up a virtual clinic for follow-up care after hip or knee surgery, not only improving clinical productivity but saving some patients a three-hour round trip.
Because of their distinctive geographies, Scotland and Wales have historically had a greater policy focus on health care for remote communities – including Scotland’s recent Remote and Rural framework and Wales’ Rural Health Plan. In England, by contrast, these issues surface less frequently and usually within more general area-based initiatives. Most of the devolution deals containing a health component, for example, have been geared towards city-regions – though Cornwall stands as a notable exception. A few of the New Care Models ‘Vanguard sites’ have explicitly highlighted the challenge of improving services for their rural populations – including Multi-Speciality Community Providers in Fylde and Calderdale and the Primary and Acute Care Systems in Northumberland and Harrogate. Elsewhere the Cumbria Success Regime is grappling with how it can improve services for isolated towns and villages. And it will be fascinating to see how these issues figure in some of the Sustainability and Transformation Plans when they are finally published later in the year.
One lesser known but highly relevant initiative is the Acute Medical Model Programme, announced in last year’s NHSE planning guidance, which is enabling a number of small District General Hospitals in England to tackle clinical and operational sustainability issues in their acute medicine pathways. Central to this will be efforts to improve recruitment and retention and to explore alternatives to traditional acute medical rotas, either through collaboration with neighbouring sites or new, multi-disciplinary workforce models.
These thorny recruitment issues are picked up by Professor James Buchan in his piece on the things you need to consider when building a health care workforce in remote areas. He argues that we need to provide better support to health professionals in these locations to ensure they don’t become isolated, including putting funding behind the development of professional networks.
This is something the Health Foundation has seen in action in our work with NHS Improvement to develop Q, a UK-wide network of people skilled in improvement. Social network analysis of its founding cohort shows that in the first six months members built ten new connections with others in the community, with the density of connections between members in different regions and nations of the UK increasing three-fold – as one member put it, ‘making the UK a wee bit smaller’. Look out for more on recruitment to Q on our website.
Of course, networks matter not only to tackle professional isolation but also to spread ideas. And what the improvement projects we are highlighting this month show is that, in being forced to confront the challenges of geography and demography, people working in health care in remote areas are driving improvements in service delivery from which the rest of the country can take inspiration and learn.
Tim Horton is Associate Director (Insight & Analysis) in the Health Foundation’s Improvement team. @timjhorton