Director of surgery says 24/7 surgery not required in Caithness

6th March 2015

About 60 people attended a meeting in the Pentland hotel, Thurso on Wednesday 4th March 2015.

The following is the report put out by NHS Highland about the meeting. It covers items brought up by health staff and does cover the questions etc brought up by people at the meeting.

From NHS Highland
One of the items for discussion was an update on the redesign of hospital services, and particularly those at Caithness General.

Some members of the public attended the meeting specifically for this item, reflecting concerns around heavy reliance on locum cover and the likely loss of 24/7 surgical operations in the future.

Ron Coggins, general surgeon and clinical director for surgical services in Raigmore Hospital, provided an overview of some of the changes in surgery and why he believed the status quo was not an option.

He said: "My view is that the way forward is to look at the shape of the service across Highland and indeed Scotland and identify where care and treatment can be most safely delivered.

"While 24-hours surgical emergency care in Caithness has never stopped, we do need to look at what services and skills are actually needed 24/7. In my opinion, some things need to change fairly urgently if we are to provide a safer and more sustainable service for people in Caithness.

"The reason the status quo is not possible is that it requires people with generalist skills, and they are no longer being trained. It also requires a population that can provide enough pathology, whether it's emergency or elective, to allow a surgeon to maintain his or her skills over a lifetime, and that is not achievable in the current model. I am not speaking on behalf of physicians but I believe the situation is the same for them."

Mr Coggins added: "If asked: ‘Do we need 24/7 on-call surgery in Caithness?' then my answer is no. Strengthening the emergency services 24/7 would support a safer model. Carrying out surgery out of hours is very rare and anything serious already comes to Raigmore or to one of the other bigger centres. The most common procedure seen during the out-of-hours period in Caithness is a dislocated shoulder and the surgeon is not trained in this whereas emergency practitioners are."

A clinical staffing sub-group, made up of senior clinicians from Caithness, Raigmore and the board medical director, including public members and elected members, has been looking at possible future models for Caithness General.

Various possible options were described to the meeting. The current preferred option would be to move away from heavy reliance on locums and the one-in-three rota by securing in-hours surgical and medical consultant-led services based in Caithness, and 24/7 strengthening of the Emergency Department with generalist emergency doctors, advanced nurse practitioners and a fairly new role of physicians assistants. In this model, there would not be the facility for 24/7 surgery.

Gill McVicar, director of operations for NHS Highland's north and west operational unit, asked the meeting if this model should be explored further and this was supported. Members of the public, staff and patients will be further involved in shaping the option and there would also be wider consultation.

Caithness General Hospital is now 30 years old and in that time there has been little change in infrastructure despite significant changes in requirements. The present configuration is now in need of redesign and upgrade. Significant work has taken place over the past 12 months which could see a number of key improvements, including increasing bed spacing, increasing the number of single rooms, creating a surgical unit on one floor and increasing the Emergency Department, co-locating out of hours and transforming out-patients. An acute assessment unit has already been recently established and it was confirmed that there has been no change to overall bed numbers. Further work will be required as part of the Caithness Master Plan to determine future bed numbers across the county to meet future needs. This will need to take into consideration various factors including further move to day surgery and developments in community services.

The Caithness adult services review and redesign adult service group was launched two years ago as part of NHS Highland's proposals to shape service to meet future needs. Similar work is happening across Highland.

Gill McVicar told the meeting: “With an ageing population, recruitment and retention challenges and changes in medicine, technology, health and social care cannot stand still and Caithness is no exception. Unless we change to new ways of providing care across Scotland, every two years we would need to build the equivalent of a new Raigmore Hospital and every two weeks a new care home - and that simply is not going to happen."

Progress has already been made on a number of fronts to improve local community services.

Andrea Madden, care at home manager for Caithness and Sutherland, provided an update on work to reduce falls, including ‘Right Call for a Fall’, a collaboration of Red Cross, the Scottish Ambulance Service and NHS Highland. This is already reducing the number of people being admitted to hospital.

New ways of working in the Dunbeath Centre was described as being more successful - “bringing people together, great hospitality and very welcoming". It is a model which has potential to be rolled out.

Challenges in further developing home-based services were described, and it was explained that key to further success was collaboration across all service providers. The appointment of a health and social care co-ordinator and a joint approach to care planning through a formal weekly structure are all helping to make better use of resources.

Further work has also been done to prioritise a number of business cases which have been developed by working groups.

• Dementia Day Care Proposal
• Befriending Proposal
• Dementia Link Worker
• Nurse-led Palliative Care Assessment & Rehabilitation

The redesign work in Caithness General will require significant capital investment and a business case will be required to be submitted to Scottish Government, as part of wider Caithness Master Plan setting out service requirements for the future.

Mrs McVicar said: “It is important to see the work in Caithness General as part of the wider work and indeed the approach we have taken is the one Scottish Government would expect. They want to see a focus on services and not buildings and I feel we can show significant progress with that.”