HUB AND SATELLITE LINKS
The interim report recommended that NHS 24 and Health Boards with remote and rural areas assess appropriate models along the lines of the "hub and satellite" model currently being developed at Raigmore Hospital in Inverness designed to benefit the Highland and Islands Health Boards. But the question of whether and to what extent NHS 24 operations should be decentralised is wider than meeting remote and rural service needs. It is related also to the issues of staff recruitment, changes to protocols, handling of calls, relationship to service providers and Health Board responsibility. Our interim report uttered a strong caveat that the model being developed in Inverness should be regarded as a pilot, to be reviewed on the basis of aims and objectives, and then evaluated and assessed on actual delivery. We were concerned lest, for expediency, NHS 24 might be under pressure to repeat the mistakes that had been made in rolling out all 3 centres (North, West and East) without pausing to benefit from lessons learned.
A number of arguments are put forward by Health Boards for the introduction of "hub and satellite" models. Some are more convincing than others. One of the loudest is that if you can link up with the locality of the caller (no matter how large that "locality" might be) then there will be some sort of guarantee that all the local knowledge for all local issues (from where exactly clinicians are located at any particular time, through to the nearest chemist shop and when it closes on a Saturday) will be wholly understood and correctly conveyed. In these days of high technology, satellite navigation and tracking, etc, we have to think that this argument is more emotive than real. There is another argument that, in the case of any patient likely to require local services (whether nursing, medical or social) then the sooner that call is transferred to the vicinity of those services, the better. But that does not necessarily entail anything particularly sophisticated: it requires compatible, integrated communication linkages. There is an argument that a "mini centre" (as the hub and satellite model is often described) would allow co-location of all the essential out-of-hours care partners. We think co-location is a very sound objective - and we think that there are very significant benefits to be had from co-location, particularly in or adjacent to a hospital which provides a critical mass of medical, nursing, A&E, paramedic and other support services - and there might be some advantage being co-located in a local out of hours centre. Again, the vital component is the ability to communicate quickly and effectively with the appropriate service and that takes us back to high quality, shared and effective communication linkages. The important point here is that, however it might be described - "mini centre", "hub and satellite", "dispersed model" - not one of those will actually do anything. They are simply enablers. So we must all (NHS 24, Health Boards, A&E services, Primary Care and Scottish Ambulance Service) keep reminding ourselves that these linkages, however modern, however sophisticated, are not an end in themselves: they are 'merely' an important means to that end.
A number of Health Boards are offering to host a "hub and satellite" model on the basis that they can then successfully recruit nurses locally who, after going through NHS 24-led training, would be available to take over cases on behalf of NHS 24 when necessary - whether to triage and advise or carry out face to face consultation. We have encouraged NHS 24 to explore that avenue for the future but, as suggested in our interim report, we think it would be wrong to start to think of one "hub and satellite" in every Health Board area. We remain firmly of the view that that would be tackling the problem from the wrong end. If the current pilot about to run in NHS Highland proves the case for an extension of "hub and satellite" linkages - and we hope it does - then we think it is for NHS 24, in consultation with SEHD and Health Boards, to determine the likely ideal number of those linkages required geographically to cover Scotland on a 'cost/benefits' basis; otherwise there is a risk of "mini centres" - and then perhaps "micro centres" - steadily spreading as the definition of "local services" reaches down as far as individual Community Health Partnerships. That could put at risk the fundamental policy of 'national standards' and 'one single point of contact' for the whole of primary care out-of-hours.
That said, when considering the number of "hub and satellite" linkages required and where they might be positioned, it will be important to differentiate between urban and remote-and-rural areas of Scotland. We accept that in the latter the communications linkages might well have to be sensitive to the peculiar problems of remote and rural services. And here it is not local knowledge per se that we are talking about; it is that the geography, the inaccessibility, and in particular the distance of any subsequent journeys - not just clinician to the place of the call, but then the journey to the appropriate NHS location - mean that time is ever of the essence and delays can increase risk. (Conversely, we discuss later how advances in technology might well compensate for some of these disadvantages.)
Any 'hub and satellite' design in remote and rural areas should seek to ensure that the provision of additional new technology (from telemedicine to 3G camera facility to satellite navigation, to tracking every on-duty NHS vehicle at any time) should also be installable - if not immediately, then in the future. Some new technology opportunities are already being piloted alongside the hub and satellite model in Inverness.
If NHS 24, Health Boards and SEHD do decide to go ahead with whatever number of "hub and satellite" connections, we think there has to be simultaneous discussion on a number of important related issues:
- the need to implement NHS 24 process re-design and revised process roles as part of any devolved operation and not simply replicate the current model on a smaller scale;
- preserve the benefits of a standard high quality triage/assessment process;
- bear in mind that fluctuation in demand across the country is often more manageable within a single system;
- retain capacity and demand modelling;
- continue to monitor claims made that this model is, in fact, improving nurse recruitment and retention;
- continue to emphasise that all out-of-hours patient care is simply a part of the larger primary care responsibility of the Health Board and that that accountability remains whether or not it has its own "hub and satellite";
- the importance of keeping an eye on the bigger NHSScotland general and ICT planning pictures - eg, the impact that the introduction of a personal electronic patient record might make.
Although the Health Boards which are to have any future "hub and satellite" will be impatient to get the go-ahead, there has to be a sensible timetable. Our interim report, while supporting the principle of some dispersed 'hub and satellite' models, made the caveat that those should go ahead on the basis of evaluation, assessment, lessons learned. We think that dispersed 'hub and satellite' models have a part to play in the future but that part is still a bit unclear in terms of specifics and those need to be factually assessed.