Highland NHS Board1 June, 2010

Item 5.3

EMERGENCY RESPONSE AND TRANSPORT STRATEGIC OPTIONS FRAMEWORKAND MEMORANDUM OF UNDERSTANDING WITH SCOTTISH AMBULANCE SERVICE

Update Report by Pete Ripley, Director of Service Delivery, SAS, and Gill McVicar,General Manager, Mid Highland CHP on behalf Pauline Howie, Chief Executive, SASand Roger Gibbins, Chief Executive, NHS Highland

The Board is asked to:

Note the updated position on mapping, modelling and gap analysis against theStrategic Options Framework.

Agree the proposed timetable for the work leading up to a final implementation plan inOctober, 2010.

1 Background and Summary

NHS Highland Board received a paper in February 2010 which provided the background tothis work and outlined the key actions necessary to develop an implementation plan inrespect of the Strategic Options Framework (SOF) and Memorandum of Understanding(MOU), which have been developed through the Remote and Rural Implementation Group toensure that there are robust and responsive systems in place within remote and ruralcommunities to respond in emergency and urgent situations. The Scottish AmbulanceService (SAS) has the lead role and will work with the territorial Boards and their constituentCommunity Health Partnerships. The SOF and MOU clearly represent a significant shift inthe way that the NHS should plan to respond to emergency and urgent care requirementsand the framework provides a tool for SAS, as the organisation regarded as having thestrategic responsibility for securing pre hospital emergency and urgent response, to lead thework with Partner organisations to design and commission the required response systems. Itis recognised that changes will take time and considerable work with communities will berequired.

This topic, and the need for community engagement and comfort, has been highlighted againrecently with the publication of the Health and Sport Committee’s report on Out of Hourshealthcare provision to remote and rural communities, which acknowledges the challenges ofproviding emergency response in remote and rural areas and highlights the need for a fullyjoined up and innovative service that is developed in consultation with local communities.

The SOF is included in the recently published Scottish Government Quality Strategy and willbe the subject of a Health Department Chief Executive Letter. The letter will again outlinethe steps required to assure the Scottish Government of progress towards sustainingappropriate emergency and urgent response. The response should include access to aCommunity First Responder scheme, within 30 minutes drive and appropriately trained tonationally recognised First Person on the Scene (FPOS) level.

The steps in summary:-

SAS assumes lead role to implement the framework in collaboration with Board andCHPs

Mapping of current emergency and urgent service provision to identify gaps SAS in collaboration with Partners, engage local communities to develop options Detailed implementation plans including timescales for delivery by October 2010

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Existing performance management arrangements to be used to monitor progress onachieving standards

New modes to be evaluated after 6 months Good Practice event to be held in autumn 2010

This paper will describe the progress made, summarise the SAS Strategic Framework,demonstrate the mapping and modelling work done to date and will highlight some ongoingand potential initiatives for the future.

2 Progress so Far

NHS Highland and SAS have a long history of joint working and SAS has accepted the leadrole supported by NHS Highland.

Previous work on mapping, modelling and simulation has provided an excellent foundationon which to build sustainable, effective and efficient services for the future. However, someof the activity data requires to be updated and although the gap analysis is underway, furtherwork on this is required. This paper contains examples of the work done to date and includesArgyll and Bute although the format is slightly different. This will be standardised as part ofthe ongoing work.

There has been some community engagement work in connection with Primary Care Out ofHours services and also First Responder schemes as well as the SAS Strategy consultation.Indeed, the recent report on Out of Hours services commended the work of the West Rossgroup. However, further community engagement as well as specific initiatives in respect ofcommunity capacity building and resilience is seen as being essential and will be an integralpart of the implementation plan.

It is acknowledged that the Framework will take time to implement but this paper will describethe work in train to ensure that a plan with implementation timescales will be available byOctober 2010.

3 Current situation

The current NHS Highland Out of Hours (OOH) Service has demonstrated high qualitystandards and significant over-achievement in response targets but is extremely costly andunder utilised.

The Scottish Ambulance Service has similar challenges with low utilisation especially inremote and rural areas but has the additional challenge of meeting response times standardsdue to the distances covered by SAS crews in remote and rural areas. It is not possible tohave ambulances in every rural community and therefore national standards are particularlydifficult to meet. This leads to communities feeling vulnerable and therefore more reliant onPrimary Care services even though they are not, in the main, configured to deliver anemergency response. NHS Highland does support some Immediate Care GPs who haveadditional training through BASICs and are available to provide emergency care and dualresponse on behalf of SAS.

Solutions for the future will inevitably be joint as it will not be possible to vastly increase thenumbers of ambulances available across the NHS Highland area, and innovative approacheswill be required. The use of technology will require to be maximised and working with otheragencies such as the voluntary sector, other emergency services and local communities willalso be explored.

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4 Scottish Ambulance Service Strategic Framework – Working Together forBetter Patient Care

Working Together for Better Patient Care 2010 – 2015 was published in January 2010following an extensive consultation process with patients, members of the public and staff.The strategic framework sets out a vision to deliver the best patient care for people inScotland, when they need us, where they need us, with three main goals:

To improve patient access and referral to the most appropriate care To deliver the best service for patients To engage with all our partners and communities to deliver improved healthcare

Our aim is to make best use of all Scottish Ambulance Service, NHS and other resourcesavailable to respond to patients and make sure there is clarity and consistency in the deliveryof a service which is focussed on clinical need.

At the frontline of NHS Scotland, the Scottish Ambulance Service currently provides anemergency, unscheduled and planned service to more than 5.1 million people acrossmainland Scotland and its island communities. The service employs 4,300 highly skilled staffand responds to nearly 600,000 accident and emergency calls a year, around 450,000 ofwhich are 999 emergency calls. Almost 1.6 million patients are taken to and from hospital bythe Patient Transport Service each year and SAS have around 30 Area Service Offices,planning and co-ordinating these requests. The Air Ambulance Service deals with more than3,000 incidents per year and SAS transport over 96,000 patients between hospitals inScotland, by road and air annually.

The work of the Remote and Rural Implementation Group (RRIG), along with output fromvarious workshops, seminars and primary and secondary research methods, has establishedthat there are risks surrounding the provision of sustainable and effective scheduled andparticularly unscheduled care in remote and rural Scotland. The Strategic Framework is setclearly within the context of community engagement and the development of sustainablesolutions.

Accepting this situation, the Scottish Ambulance Service, in conjunction with its partners,aims to develop effective solutions to these long-term issues. Some examples already exist,for example, First Responder schemes and Retained schemes. The notion of genericworkers needs to be considered, as does local integrated working. The programme will alsoneed to reflect on and recommend ambulance solutions looking at both patient to care andcare to patient and ensure that the challenges of communicating and engaging withcommunities are addressed.

The Scottish Ambulance Service has now moved into the implementation phase of theStrategic Framework and as part of this process has established a programme boardresponsible for engaging with and developing sustainable Remote and Rural andCommunities.

The key objectives for this programme are:

To develop a current picture of communities across Scotland, which are vulnerable interms of resilience, through data mapping and a review of existing service provision;

To develop a long list of options for consultation with stakeholders; To work with local communities and stakeholder groups to identify and implement

options; To formulate jointly high level action plans with NHS Boards and partners to develop

community resilience and take forward RRIG service models as appropriate;

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To identify costs for appropriate options and develop the necessary business casesto support their implementation;

To ensure that meaningful relationships and alliances are developed between serviceproviders and their local communities;

To construct and implement a robust communications and engagement plan that willensure appropriate information sharing and stakeholder buy in;

To develop a framework for measuring quality outcomes for patients, partners andcommunities;

To design and implement an appropriate level of corporate badging for any sharedresources that properly reflect Service / community integration;

To adhere to the SAS’s “Management of Change” policy for any HR changes requiredby the project;

To monitor closely the progress of the programme through regular meetings andupdates

5 Mapping, Modelling and Gap Analysis

Within NHS Highland and the North Division of SAS, a considerable amount of joint work hasbeen done previously and the first part of this section provides a resumé of the mapping,modelling and simulation exercise that was done in 2008 based on data from 2006/7.

The table below illustrates OOH performance in each of the NHS24 time stratifications (1, 2and 4 hour recommendations) and confirms that a minimum of 83% of patients requiring ahome visit within 1 hour are provided with this response. The average responseperformance is 94.1%. In respect of PCEC appointments within 1 hour, the lowestperformance is 76.1% in one rural area, with the average being 94.1%.

This clearly demonstrates that the patients with the most urgent requirements are receiving aquick response. In addition it can be seen from the table that the OOH service is meeting andexceeding proposed targets in all areas of response time provision.

Table 1

Home Visit Centre VisitPriority Priority

Not Specified < Not Specified <GPUtilisation <1 hour <2 hours <4 hours <1 hour <1 hour <2 hours <4 hours <1 hour

Inverness 47% 83.1% 96.2% 99.2% 100% 83.5% 94.4% 99.5% 96.3%

Caithness - Wick 12% 90.5% 99.0% 100% 100% 95.1% 98.6% 100% 100%

- Thurso 12% 90.5% 99.0% 100% 100% 95.8% 100% 100% 100%

East & Cent.Sutherland 19% 91.1% 99.2% 100% 100% 96.3% 97.2% 100% 98.7%

Easter Ross Dingwall 37% 96.0% 100% 100% 100% 94.8% 99.5% 100% 96.4%

Easter Ross Invergordon 83.8% 94.7% 100% 100% 94.1% 97.7% 100%

Badenoch & Stathspey 4% 100% 100% 100% 100% 100% 100% 100% 100%

Greater Fort William 8% 95.7% 99.1% 100% 100% 98.6% 100% 100% 100%

Skye - Broadford 14% 100% 97.5% 100% 100% 94.3% 99.4% 100% 100%

Skye – Portree 23% 93.9% 100% 100% 96.4% 93.1% 99.5% 100% 97.3%

Argyll – Dunoon 9% 99.5% 100% 100% 99.0% 100% 100%

Argyll – Oban 16% 88.1% 97.5% 100% 92.1% 97.8% 97.9% 100%

Wester Ross Lochcarron 2% 96.8% 100% 100% 100% 100% 100% 100% 100%

Wester Ross – Gairloch 5% 100% 100% 100% 100% 92.3% 100% 100% 100%

Wester Ross – Ullapool 5% 98.0% 100% 100% 100% 76.2% 100% 98.7% 100%

Wester Ross - Glenelg 1% 100% 100% 100% 100% 100% 100% 100% 100%

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8%

18%

20%

54%

ASAP Within 1 Hour

Within 1 Hour

Within 2 Hours

Within 4 Hours

< 1 hour < 2 hours 2 - 4 hours > 4 hours

Maximum

Wait

Average

Wait

Inverness 2,401 248 76 4 6.25 0.49

Caithness 591 70 10 - 3.37 0.51

East & Central Sutherland 367 27 4 - 2.70 0.56

Easter Ross- Dingwall 1,261 57 1 - 2.10 0.51

Easter Ross- Invergordon 303 49 17 1 4.25 0.57

Badenoch & Strathspey 118 1 - - 1.50 0.58

Greater Fort William 354 18 3 - 2.05 0.52

Skye - Broadford 153 3 1 - 1.00 0.34

Skye - Portree 133 6 2 2.13 0.61

Argyll - Dunoon 359 5 - 1.50 0.57

Argyll - Oban 153 3 1 3.50 0.42

Wester Ross-Loch Carron 90 2 - - 1.05 0.52

Wester Ross-Gairloch 143 5 - - 1.33 0.54

Wester Ross-Ullapool 122 3 1 - 2.65 0.57

Wester Ross-Glenelg 15 - - - 1.00 0.52

6,563 497 116 5

< 1 hour < 2 hours 2 - 4 hours > 4 hours

Maximum

Wait

Average

Wait

Inverness 4,840 1,291 320 2 10.60 1.42

Caithness 1,069 57 21 - 3.25 0.65

East & Central Sutherland 735 40 11 - 3.95 1.00

Easter Ross- Dingwall 2,636 129 17 1 4.40 0.42

Easter Ross- Invergordon 989 58 16 1 4.05 0.40

Badenoch & Strathspey 190 - - - 1.00 0.39

Greater Fort William 286 2 - - 2.51 0.42

Skye - Broadford 1,351 87 8 - 2.20 0.29

Skye - Portree 998 103 21 3.03 0.52

Argyll - Dunoon 550 3 - - 1.50 0.58

Argyll - Oban 1,222 86 28 24 6.00 0.83

Wester Ross-Loch Carron 31 1 - - 1.05 0.52

Wester Ross-Gairloch 90 5 - - 1.42 0.54

Wester Ross-Ullapool 118 16 3 - 3.92 0.57

Wester Ross-Glenelg 7 - - - 0.67 0.57

15,112 1,878 445 28

Home Visit

Waiting Time

Centre Visit

Priority

The chart below demonstrates the waiting times underlying the response performance.

These have been shown in detail with numbers of patients in waiting time bands included inorder to illustrate the outliers which may skew overall average waiting times.

The chart below confirms the percentage of patients falling into each of the timestratifications, with the majority, 54% recommending that care is delivered within a maximumof 4 hours from the NHS24 call.

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In respect of utilisation it is clear that the current OOH service does not have a high level ofutilisation of resources. This is particularly evident in rural areas where there is extremely lowutilisation of less than 5%. Although the rural areas with lower demand and low utilisationlevels demonstrate high response performance, lower utilisation does not necessarily lead tosignificant increases in response performance, or in significantly reduced waiting, i.e. theGPs who are less busy do not necessarily provide a much higher quality of service incomparison with busier areas; indeed waiting times and response performance are directlycomparable with those in areas where GPs have much higher utilisation rates. (However theinfluence of geography on this cannot be discounted).

The Board should note that the GMS out of hours arrangements in Campbeltown, Bute, Islayand Lochgilphead are delivered by formal contracts with GP practices providing an integratedhospital unscheduled care, A&E and GMS service. This service configuration reflects thisunique arrangement and the primacy of maintaining on-site medical input to the hospital andA&E with the GMS home visit response being prioritised lower. This service model has beendeveloped to balance the utilisation demand with maintaining local access to this serviceprofile.

The extremely low levels of utilisation seen in a number of areas would indicate that there issignificant spare capacity in the current system. However there is a need to consider thegeographical constraints associated with these mainly remote and rural areas, which maymean that a safe, high quality service in those areas carries an inherently high level of sparecapacity as a result of the geographical context. Modelling for the future has considered thepotential for relocating some of this capacity and the impact of this on the performance of theservice in respect of waiting times and performance.

The same considerations apply to SAS provision where similar levels of utilisation can beseen in the rural areas identified as having ‘spare capacity’. For ambulance resources,utilisation is the number of active hours divided by the number of planned hours with astandard figure of 36% set for average utilisation as a UK ambulance service benchmark,e.g. if an ambulance is rostered for a 10 hour shift it would typically expect to spend just over3.5 hours assigned to calls. It should be noted that this utilisation rate is applicable topredominantly urban resources so a lower rate of utilisation is to be expected in more ruralareas.

Ambulance response performance for all areas is shown in Table 2 overleaf. SAS keyperformance criteria currently stands at 75% for Cat A (life-threatening) calls within 8 minutesand 95% for Cat B/C calls within 14/18/21 minutes, depending on population, for each HealthBoard area (21 minutes for the NHS Highland area).

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Table 2

NHS Highland 2009/10

Area Cat A % Cat B %1 hr urgent

%

South Argyll 65.7% 84.5% 78.2%

Dunoon 86.2% 94.1% 85.3%

North Argyll 53.3% 80.9% 96.3%

Oban 70.8% 94.0% 100.0%

Easter Ross 54.4% 88.0% 92.5%

Inverness 86.5% 97.3% 93.2%

Nairn, Beauly, Strathcarron & FortAugustus

45.3% 84.0% 94.1%

Wester Ross 48.1% 69.0% 93.8%

East Sutherland 39.7% 71.8% 89.7%

NW Sutherland 33.9% 66.7% 83.9%

Caithness 66.3% 85.8% 88.9%

Skye & Lochalsh 43.8% 75.2% 90.8%

Lochaber 64.9% 89.9% 93.3%

Fort William 77.1% 96.1% 93.1%

Badenoch & Strathspey 51.9% 90.7% 95.9%

NHS Highland 66.0% 87.4% 89.9%

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6 Geographical Coverage

The following maps illustrate the geographical extent of response coverage from each of theOOH/SAS bases in Highland and show the location of other services available for patientresponse. These include First Responders, BASICS GPs etc:

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10

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The population map provided overleaf illustrates the spread of population across Highlandand the relative densities. Read in conjunction with service provision maps above and theusage rates table it can be seen that services are, in the main, appropriately provided in theareas where required by population density and usage rates. Areas of coverage from currentbases for minimum OOH response requirements (1 hour) include all major settlements and asignificant majority of locality populations.

A key aim of the modelling work undertaken to inform the options for change has been toensure that OOH services are developed in the context of the wider provision of unscheduledcare and that account is taken of where there is additional need on the basis ofgeographical/demographic challenges.

However the same mapping comparison for SAS coverage shows that although ambulancebases are generally located in area of main settlements, there are areas where localitypopulations lie outside of the response coverage, particularly for the 8 minute responseprovision.

This is of particular significance when changes are proposed as described overleaf.

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7 Proposed way forward

As previously discussed, the maps require to be standardised and updated and the activitydata requires to be remodelled to ensure that it is as up to date as possible. This will bedone in advance of the next report to the Board.

7.1 Gap Analysis

The SOF sets out the emergency and urgent response standards to be achieved. Anassessment of current performance against these standards is currently being developed.This will help inform the areas for attention and the types of solution.

7.2 Identification of Priority Areas

Through the mapping and gap analysis work, together with local intelligence and previouschallenges, the following areas have been identified as areas that require to be addressedmost urgently:-

West Ross Ardnamurchan Inverness Islay Campbeltown Oban – particularly inner islands Dunoon/Cowal Lochgilphead North West Sutherland Glenelg Skye Badenoch and Strathspey

7.3 Service Delivery Options

The RRIG SOF described 7 models of delivery which are non-mutually exclusive. Initialreview of the priority locations above suggests that the following delivery options are worthyof further consideration:

(a) Community Paramedics and Unscheduled Care Practitioners

The Community Paramedic role is operating in a number of Health Board areas and isstaffed by State Registered Paramedics with additional training and education in minor injury/minor illness assessment and treatment skills, including the capacity to administer a range ofdrugs not available to a State Registered Paramedic. This service model supports thedelivery of emergency ambulance services and has shown a high level of efficacy andpatient benefit when integrated with Health Board unscheduled care services.

From 17th May 2007 until 3rd March 2008 a trial using community paramedics based aroundInverness attended a total of 364 incidents, of these:

245 Emergency Incidents were specifically targeted for this purpose 54 as 1st response or back-up to A/E crew 38 GP Urgent calls 12 NHS24 Urgent requests 15 Requests from Primary Care Centres and the HUB

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Of these 264 patients 57% did not travel to an A&E department and were either treated athome or treated and referred along a more appropriate care pathway, 25% were conveyedby the community paramedic and 8% required conveying by an A&E ambulance.

As part of the trial the community paramedics would standby at the A&E Department and theMedical Receiving Ward at Raigmore as well as Primary Care Emergency Centres (PCEC)in Invergordon and Nairn. As part of the role they have visited patients for the PCECs andthe HUB when there has been no GP available.

There is now an opportunity to establish the community paramedic role on a full time basis,although the model will vary. For example, in the Inverness area it would be possible to useexisting resources to provide a dedicated community paramedic resource. In the short term(next three months) this can be done by releasing a small number of already qualified stafffrom rosters, however in the longer term this would mean redesigning existing servicesthrough consultation to release the staff on a permanent basis.

In more rural areas there are insufficient numbers of ambulance paramedics to extractdedicated community paramedic teams; however existing paramedics could be trained up tocommunity paramedic level and then use those additional skills to provide appropriate care.This option would take between 3 and 6 months to implement in specific areas. Wherepossible ambulance resources should be based at PCECs to provide additional capacity forthe centre and also to help the paramedics and technicians maintain their clinical skills. Inaddition the community paramedics could be linked to the main treatment centres viatelemetry so that advice on patient treatment can be given to save unnecessary journeys tothe A&E.

The unscheduled care practitioners are registered paramedics with additional core trainingand education. This includes:

Paediatric presentations Chronic disease management Care of the elderly Wound assessment & management Common neurological syndromes and abnormalities Psychiatric examination

The range of additional modules accompanying this role is agreed in partnership with thelocal Health Board and reflects the demands placed on the local unscheduled care service,including Ambulance Services.

In addition the unscheduled care practitioner has clear operational links with, and in supportof, Health Board unscheduled care services. Consequently more formal and robustprofessional to professional links exist which support access to a greater range of directreferral pathways e.g.

Primary Care Radiology Medical Assessment Unit

Finally, the practitioners Continuing Professional Development is, to some extent, derivedfrom the close professional relationship and operational links as there is an obviousrequirement that the group must have appropriate skills and competencies to fulfill their crosssystem role.

The use of unscheduled care practitioners should also be considered in certain areas toprovide both an emergency response and a primary care resource working in partnership

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with GP practices and other healthcare professionals to provide integrated health provisionwhere required.

The use of unscheduled care practitioners is a longer term solution that would requireinvestment for training and for dedicated posts; however the benefits of using theseautonomous practitioners linked by telemetry to the main treatment centres would beimmense. Practitioners could be introduced within 6 to 15 months, which would bedependant on either recruiting trained practitioners or having to train existing paramedics upto this level.

(b) Emergency Medical Dispatch Centre (EMDC), NHS 24 and Highland Hub CoLocation

At the present time the Inverness control centre is being refurbished to accommodate theambulance control, NHS 24 and the Out of Hours services. Once the work is complete andthe services reoccupy the building, the emphasis will be on collaboration to redesign moreseamless care.

All parties working closely together would create a single point of access, so that when apatient requires medical care they are quickly routed to the most appropriate service, with theservices working together to ensure streamlined services. The integrated approach alsosupports shared systems and clinical best practice in telephone triage and resourcedeployment. Key to making an integrated service work effectively will be having a widerange of care pathways available and agreed protocols for inter-service working.

For the Argyll and Bute catchment area, SAS EMDC is co-located with NHS 24 in Cardonaldservicing the west of Scotland. GMS service support is delivered by the Inverness controlcentre.

(c) Common Triage Tool

The common triage tool programme is designed to ensure that patients receive a consistentassessment and outcome based on their individual clinical presentation. Recognising thatpatients will call 999 when they have primary care issues or may contact NHS 24 when theirproblem is potentially life threatening requires a form of assessment that can route thepatient to the most appropriate NHS response irrespective of which route they select toaccess health care. From a remote and rural perspective this will afford patients access to aresponse that focusses on matching the appropriate skill set, the appropriate speed ofresponse and the most suitable location of care with the clinical need of the patient, takinginto account the challenges of geography, weather and other compounding factors.

(d) Other opportunities

The use of retained ambulance staff - the first retained ambulance model is now livein Lerwick. Six volunteers have been trained to intermediate first person on scene,and equipped with a vehicle and appropriate driving skills so they can provide aconveying response. They will next be trained to ambulance technician level,supported by the local full time ambulance personnel.

Increased numbers of First Responders including Fire and Rescue – there are nowover 80 First Responder Schemes in Scotland, ranging from community schemes toschemes provided by sister agencies.

7.4 Possible Options for West Ross, Ardnamurchan and Inverness

Wester Ross – in the short term up-skill the paramedics at Gairloch and Lochcarronto community paramedic level to complement the existing unscheduled carepractitioners as an integrated part of the multi professional healthcare team in that

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area. Use technology to support the service and consider the introduction of a PreHospital Emergency Care GP Service.

Ardnamurchan – in the short term up-skill the paramedics at Strontian to communityparamedic level and in the longer term introduce unscheduled care practitioners asan integrated part of the healthcare team in that area.

Inverness – in the short term release paramedics from existing resources to providea dedicated community paramedic response in that area and in the longer termredesign existing resources to provide a full time community paramedic team.

8 Next Steps

The work on gap analysis, risk assessment and prioritisation will continue and NHS HighlandBoard will receive a report on progress, together with a draft delivery programme completewith recommended timeframe, in August. A full implementation plan will be presented to theBoard in October, 2010.

However both services are keen to develop solutions quickly and so we are proposing toconcurrently develop options for the Wester Ross and Ardnamurchan areas which can bepiloted over the next few months.

The South West Division of the SAS and the Argyll and Bute CHP are also progressing aseries of service implications falling out of the ongoing scoping process, building on reviewsand issues regarding inter-hospital transfer activity, air ambulance utilisation and tasking,compensatory rest implications and role of paramedic practitioner etc.

NHS Highland Board is asked to note progress to date and to agree the programme andtimescale for the next steps.

9 Contribution to Board Objectives

”Better Health, Better Care, Better Value”.

The work on unscheduled and urgent care will fit well in the ‘Changing for the Better’framework by linking closely to planned and health improvement agendas, redesign workand improving the value for money by utilising multi professional, multi agency models.

10 Governance Implications

Staff Governance – there are inevitable changes required to the way staff in bothorganisations operate and there are significant training implications. This will entailinvolvement and negotiation with individuals and staff side partners.

Patient and Public Involvement – communities at present are concerned about any changeand effective involvement and releasing community capacity will be essential to the successof building sustainable solutions

Clinical Governance – as stated in the NHS Highland Unscheduled Care Framework,services that are considered for change require to provide safe cover. Risk assessments willtherefore be undertaken on all aspects of the plan.

Financial Impact – as stated above, the financial impact of providing these services isimmense and has knock-on consequences in the form of opportunity cost for other remoteand rural services.

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11 Impact Assessment

The final plan and any resulting areas of activity will be impact assessed.

Pete RipleyDirector of Service DeliveryScottish Ambulance Service

Gill McVicarGeneral ManagerMid Highland CHP

21 May 2010