Remote and Rural Healthcare Education Alliance

RRHEAL is part of NHS Education for Scotland (NES).  It works across all the remote, rural and island areas of Scotland helping to co-ordinate remote and rural healthcare education development and support education and training for the remote, rural and island workforce.  Its aims are to increase access to affordable, sustainable education, training and development opportunities. 

Background

Rural General Hospitals (RGH) across the Highlands and Islands utilise varying workforce models for the delivery of care. Acute services may be provided using a variety of medical models, including anaesthetic cover in conjunction with surgeons and physicians, or GPs with a specialist interest or qualification. Nurses with advanced practice skills and experience provide the continuum of care in varying capacities.

Lower population density and variable patient presentation creates peaks and troughs in critical care throughput, leading to challenges for knowledge and skill maintenance. There is also variability in how care is delivered in different rural centres.  There are several reasons for this including historical, geographical and resource differences.

High dependency and critical care needs in a RGH

RGHs need to fulfil the functions of a District General Hospital; people get ill in remote and rural locations just as they do elsewhere and there is also a need to support surgical procedures resulting in a need for level two care.  There is a need for critical care for a range of situations; with an increasingly elderly population comes increasingly complex healthcare needs.  Likewise, obstetric needs can generate specific surgical and other care needs, and resuscitation can be required for both mothers and babies.

The challenges

A variety of issues including transport and weather can make care delivery challenging.   The remote and rural environment can sometimes be an adverse environment; there is a lot of occupational and travel related activity, for example the oil and fishing industries, which can result in trauma and near-drowning, producing a group of people who require critical care.

Challenges for RGHs

Same health and care needs as other parts or Scotland, but:

• Situations encountered infrequently
• Variation in critical care requirements
• Unique occupational and travel hazards
• Weather and transport impact on transfer opportunity
• Limited access to specialist services and interventions

It is often the best for the patient if appropriate high dependency and critical care can be provided locally. However, nursing staff may not always have the knowledge and range of skills required to deliver the level of care required, particularly when medical staff have a wide range of roles and are ‘on-call’ for many departments and locations. and may be dealing with other emergencies. In addition, staff experience certain illnesses and critical care infrequently and thus it is difficult to maintain competencies and confidence in dealing with critical care patients.

There are acknowledged difficulties in recruiting and retaining healthcare staff in remote settings.  This is not unique to ‘remote’ with a general trend developing across Scotland.  However, in remote areas a broad and generic skill set is required, and staff can feel exposed without immediate access to support, particularly in poor weather and when travel and the ability to transfer patients is limited.

Post graduate/ Post registration education

Post graduate/ post registration education does exist but is not always accessible in the manner required for this sector of the workforce. Many centres engage with Scotland’s Emergency Medical Retrieval Service (EMRS), the ScotSTAR Paediatric Retrieval Service, the Clinical Skills Managed Educational Network (CSMEN) and Mobile Skills Unit to support ongoing continuing professional development (CPD).

A course of study that demands significant time away from an individual’s home base/ ‘off island’ is challenging, not only due to cost and subsistence, but also release from service. Personal and family commitments also have an impact.

Workforce challenges

• Recruitment and retention
• Staff vulnerability/isolation
• Variability in knowledge and skills of nursing and other staff
• Knowledge and skill acquisition and maintenance due to population and unpredictable patient flow in critical care
• Access to education
• Finance, in terms of subsistence and service release
• Inability to travel for education due to family and other commitments