1. Small practices and isolation offshore.

For remote offshore islands, isn’t this cutting the foot to fit the shoe ? How could it apply?

However in the previous para it says "For Scotland, the formula includes an additional component relating to economies of scale ……….. for a limited number of practices". But now the Scottish Allocation Formula does not after all seem to include this – have I missed it?

Colonsay is geographically too isolated for individual staff members and equipment to be "aggregated or amalgamated" with a mainland practice… a doctor visiting once a week is effectively inaccessible the rest of the time … a defibrillator available on the mainland is no use to us here…

Again, the costs of travel and medivac would be in no way reduced by amalgamation with a mainland practice. Does the allocation formula include such costs? It seems that under "remoteness and rurality" it would allow for distance from the mainland if the island were in a practice based on a mainland surgery, but not if the practice is based on the island itself. Have I understood correctly? If so, isn’t this a nonsense?

Isn’t there a powerful case for diseconomies of scale to be fully included in the formula for small remote island practices? Shouldn’t it have already been strongly made?

Is it too late to make it? A BMA document earlier last year promised a Review of the formula, to be implemented sometime after September 2006, with "diseconomies of scale" as one of the items to be considered. I found another reference to this Review as starting in October 2004. How can submissions to it best be made? What is the latest projection for a date for it to take effect?

2. The "sum of £13,000"

This sum was mentioned by Dr Lyon at the Colonsay meeting of 22/10 as the amount available for the Colonsay practice when the current practitioner retires. I assume from the context that it includes at least an approximation to the "Global Sum Payment" which is estimated to account on average for 50-55% of a practice income (but probably more in the case of a small practice?). Does it also include other payments eg for quality, enhanced services, seniority, etc ? Is it just an informed guestimate, or was it worked out in detail? From the context I assume it excludes the MPIG.

This seems to be a very grey area. The sources are confusing, but they do not unequivocally support witholding an equivalent scheme from a replacement contract when our GP leaves or retires.

In the Explanatory Notes to the PMS(Scotland) Bill (paras 85-88 ) we are told that "to avoid destabilising existing practices, the contract originally proposed a three year transitional protection scheme", but as a result of "significant concerns amongst many GPs", "transitional protection has been replaced by the MPIG… The purpose of the MPIG is to ensure that the financial viability of practices is not endangered by the new funding mechanisms." ………… "The principle of the MPIG is permanent but the policy intention is that the vast majority of practices will quickly discover that the new contract will leave them in a better financial position than the current (one)…. at which point they will cease to be losers and will no longer require the MPIG" (my italics).

The original Contract itself also (para 5.27) says that "transitional protection will be provided until March 2007 when it is anticipated that adjustments arising from the review of the formula ………..might be implemented" Once again it is made clear that the new scheme is not set in stone and it might be worth waiting for the review before assuming the demise of all "endangered" practices.

And in September 2003 Malcolm Chisholm was assuring the Scottish Parliament’s Health Committee that

"The bottom line on inducement practices is that the MPIG will apply to them, and no inducement practice will be worse off. Indeed, they will benefit from the ending of the existing arrangement ….. That is the basic guarantee to inducement practitioners. Some of the detailed mechanisms are still being discussed and negotiated, but there is no doubt about the principles and the guarantee".

On the other hand, the SEHD’s Draft GMS Statement of Financial Entitlements (para 3.10) says (my italics): "The MPIG calculation is a one-off calculation, which will remain unchanged. It is only to be made in respect of GMS contracts that take effect, or are treated astaking effect, on 1st April 2004. Except as provided for in paragraphs 3.11 to 3.14 [re practice mergers or splits], a contractor with a GMS contract which takes effect, or is treated as taking effect, after1st April 2004 will not be entitled to an MPIG". Seemingly, no other mechanism is offered to supplement practice incomes not viable under the allocation formula.

This closely follows a smiliar document emanating from the English DOH, and appears to be in direct contradiction to the earlier Scottish sources quoted above. Will it be confirmed in the final document?

Annex D2 of the Scottish draft says that inducement practices "will be subject to the same general UK-wide review of the allocation formula and MPIG arrangements as all GMS practices", though it adds ominously that this will be "in line with the general principle of moving practices towards mainstream arrangements".

But what is the legislative authority, let alone the wisdom, for applying this "principle" indiscriminately?

The new GMS contract says (para 4.14) " An increasing number of GPs have expressed a preference for salaried contracts. The global sum will give practices new flexibility to appoint salaried staff, and PCO direct provision will offer a new PCO salaried option ". … And again (para 4.23): "The new flexibility for PCO and practice-based salaried options may also be particularly useful in rural and remote areas"

In Scotland the Policy Memorandum to the PMS(Scotland) Bill says (my italics):

improve life for GP practices in island communities and, as a consequence of this, the health care

Could this be another option for Colonsay in the future?

Angela Skrimshire. 04 February 2004

I agree that there are two related but distinct aspects to the NP question, namely

filling the current vacancy for a nurse on the island, and eventual replacement of a GP by a NP.

I believe that a NP, if she had the skill and personality to match her training, would be a great asset to Colonsay as a colleague for the resident doctor. It has to be a welcome opportunity for a GP to work with a nurse of that calibre and to help her further her training, even if in the long term this were to become a succession of such nurses because of a lack of scope for retaining them here. And this especially if the alternative was likely to be a nurse of lesser calibre, even if qualified.

However, without the prospect of eventually replacing the GP, is there any chance of recruiting at this level? And I know also that, other things being equal, some people believe they would feel more comfortable with a traditionally trained District Nurse, if one could be found.

This is where the option becomes problematic for most of us. I’m sure some of our anxieties would be allayed by getting to know and have confidence in a good NP. But at the moment there are many questions.

The nurse practitioner role is relatively new and untried in this country. There is evidence that a NP can play a very good role at the point of first contact with patients, giving quality of care that "seems to be equivalent to that of doctors" – but the research has mostly "been based on nurse practitioners providing care for patients requesting same day appointments predominantly for acute minor illness and working in a team supported by doctors." . As one research team say, "Our results do not therefore relate to nurse practitioners who are working independently".

She is trained, "often at graduate level, to work autonomously, making independent diagnoses and treatment decisions". But "the RCN (Royal College of Nursing) does not believe that the nurse practitioner is a doctor substitute, or a means of providing medical services at reduced cost.The nurse practitioner offers a complementary source of care to that offered by medical practitioners".

I know, as was said at the meeting, that the RCN is "a union", ie a professional association, as is the BMA. But unfortunately there is no official description of the nurse practitioner by the Nursing and Midwifery Council (NMC), which seems not to have yet recognised her status or set standards for her education and practice, though it recognises "specialist" practitioners including the "specialist community public health nurse". Hence there is still ambiguity over the content of her training and definition of her role.

There is a "lack of good evidence" about the costs of care by NPs relative to care by GPs. There are restrictions on her legal authority to prescribe (though Mairi has explained how she is trained to prescribe at an extended level of "nurse prescribing" and how she works with the mainland GPs in her team to overcome the problems of remaining restrictions). Doctors have anxieties about the role of NP which are lessened but not fully allayed by the experience of working with and gaining confidence in one.

The local rural health network RARARI describes the "perception that not having a doctor in a first responder role at all times [is] an intolerable situation" , and many people here at the moment feel exactly that. Yet as the quotation continues, "in most urban areas immediate response is not by a doctor".

Isn’t the problem for us again the one of relative isolation? The RARARI report says "Truly life-threatening emergencies that need a doctor’s skill within an hour are now less common" - but such events do still happen, don’t they? The report goes on: "Urgent medical and surgical management can be safely delegated to nurses and paramedics…. … ‘Time to definitive care’ professional pathways ..…need not involve personal contact with a doctor…… until time has elapsed or distance [been] travelled"

But how much time and distance? Remember we are not talking averages here, but those "extreme" cases that, though rare, do happen now and then. Has the LHCC consulted the local Fire, Coastguard and Air Ambulance Services specifically about the situation on Colonsay? How long can it sometimes take to get a Colonsay patient flown to the mainland? What kind of care can sometimes be needed while a patient is transported to the airstrip and waits there for the plane or ‘copter? And what about the days when Colonsay is inaccessible by both sea and air due to storm or fog? Is this a question of cutting costs for the NHS at the expense of the Lifeboat service?

Many people have specific anxieties related to their own or their relatives’ condition. We do not ourselves have the knowledge to judge whether or not a NP would have the relevant skills.

For instance, people have queried whether a NP would be as able as a doctor to monitor daily and adjust doses of powerful drugs that can have serious side effects, eg to control epilepsy in a young child, or neuropathic pain in a stroke victim.

Isn’t it this level of detailed information that seems to be missing from the public discussion so far? Don’t we need the chance for individual residents to discuss these anxieties with both our GP and a NP, if possible together, before making any informed judgement on whether we would accept a NP as replacement?

A NP working independently on the island would need support and relief just as does a GP. She would be part of the team of a mainland practice, with access to the rest of the team by phone, video link and e-mail etc, but who would support and relieve her on the island? Would she be on 24-hour call as the GP is? The GP until very recently has had a qualified nurse in his team here. Would the NP have any other qualified colleague resident on the island above the level of nursing assistant? (If so, at what level, and wouldn’t the same problems of recruitment apply as at present?) And what arrangements would be made for her relief? Are there enough nurses qualified at an equivalent level locally to relieve her? What happens if she is suddenly taken ill? All these considerations also apply to a GP - but have they been thought about in detail for a NP?

There are a very few islands with no resident doctor at all that are equally or more remote (eg Fair Isle, the Out Skerries, Foula). The others of any size seem to be within about 30 minutes’ sea crossing (often far less) from the mainland or another island with a GP practice. Even Lismore is only 10 minutes from the mainland for foot passengers, and the 50 minute vehicle ferry does not cross open sea.

The "super nurse" on Fair Isle said in 1999 that he worked "as a nurse, midwife and health visitor on a non-doctor island. I carry 24hour/7 days a week responsibility for the entire island including the provision of emergency services." From the 2001 Census data, Fair Isle’s population appears much younger than Colonsay’s and is probably otherwise rather different – and maybe there isn’t a similar huge influx of ordinary family visitors, etc – but wouldn’t it be valuable to consult the nurse now in post there?

Ultimately, with an independent NP as with a GP, the quality of the person is almost or quite as important as the level of training – is it fair to think that a nurse at or aspiring to a high level of her profession might be more likely to be of very high calibre than some future GP, given the desperate recruitment problems that are predicted for single handed rural GPs in the coming years? There is of course no guarantee of this, only a balance of probabilities…

We probably should be careful neither to accept nor to reject this option without a lot more detailed information, professional guidance, and reflection. It does appear to work in some other, often very different, circumstances – but we need to have much more specific, detailed information in order to judge for ourselves.

Angela

4 February 2004

Dear Angela

Thank you for your letter received by e-mail on 5^th February, which Dr Lyon has subsequently forwarded to me for a response. I will do my best to respond to you on the points raised in your letter concerning the proposal for a nurse practitioner for the Isle of Colonsay and regarding changes in the new GMS contract for GPs.

1. Filling the Current Nursing Vacancy

May I firstly point out that at the public meeting on Colonsay I presented three options for future nursing services on Colonsay. None of the options included replacement of the current post. The three options include: a District Nurse with wider Community Outreach Role; a visiting District Nurse service with island based auxiliary nursing cover and the nurse practitioner model.

I will be presenting a paper to the LHCC Board regarding the Colonsay Nursing Options at the end of February. The last time the draft options paper was discussed the Board were not prepared to consider putting a district nurse permanently on Colonsay. The main reasons for this being the lack of suitable work and the de-skilling of the practitioner.

2. Eventual Replacement of a GP by a Nurse Practitioner

4. Salaried GPs

I hope this letter is useful to you in attempting to answer some of your questions, while also acknowledging that some of them cannot be easily answered at this point in time.

I will ensure that the community are informed of the LHCC Board’s decision on the future of nursing services on Colonsay in early March and I can also assure you that after receiving a decision a new model will be implemented as quickly as possible to ensure continuity of care.

Yours sincerely

Dear Moira, thank you for your very prompt and thoughtful reply to my e-mailed attachments ...

I'm afraid it doesn't really meet all of the worries here, though -

For instance, other islands:

it's hard to "take comfort" from Lismore's experience - the island is different from Colonsay, and  not a very convincing comparison - relatively sheltered in Loch Linnhe and so close to the mainland at Port Appin.  I know there are occasional days when a northerly gale for instance stops all ferries from getting out of Oban, but it has to be very different from the kind of crossing (by sea or air) which is needed sometimes here.

I haven't been able to identify many other islands, in as distant and exposed a position offshore as Colonsay, which have experienced being permanently without a doctor.  In fact so far I've only found three, in Shetland - the Out Skerries, Foula and Fair Isle.  Fair Isle's population has a very different age structure , and is probably different in other ways, and is unlikely to have the hordes of ordinary family visitors of all ages that come and stay on Colonsay every year...  am I right?

Gigha , Papa Westray, Bressay and Fetlar are all within 20-30 minutes by ferry of the mainland or a large island with a doctor. Most other "no doctor" islands seem either to have a fixed link or to be within 15 minutes or less of the mainland or a larger island with a GP practice.

Protocols: I'm not qualified to judge this, but I can't help feeling that though someone like Mairi would obviously be well able to apply them with intelligence and flexibility, yet they somehow don't sound like much of a substitute for years of experience and training as a GP (provided of course that one is comparing like with like - and not with some future incompetent or very newly qualified GP) -

As for "the details" of the changes if they happen - well "the devil's in the details", isn't he?  I do feel really that there hasn't yet been enough hard discussion of hard data and detailed info about the situation here and the specific worries that people have, for anyone yet to be confident about any changes that will happen ... 

However, thank you for explaining about the way you have considered cover for  a nurse practitioner, and about the "Flying Healthcare Proposal", and I was probably being silly about a defibrillator - but the principle of amalgamation in a broader sense does seem to mean something different when you can't just jump in a car and drive to wherever you or some drugs or equipment are needed urgently.

But anyway, it's good to have your reply and I'm grateful.  I've passed on to other people who were at the meeting  my own pages of questions and comments for discussion, and will offer them to  Colonsay's website.  I hope it's OK to pass on your reply as well? 

Many thanks again,

Yours sincerely,

Angela Skrimshire

Dear Angela

I do understand that not all the worries put forward by islanders may have been addressed. You raise the question about un-doctored islands. I am aware of a couple of examples that you did not mention, the isle of Ronaldsey has a resident doctor and no nurse with visiting service provided once a month or as required, Papa Westray has a nurse and no doctor, Each of these island situations tends to be different. In some instances there is health visiting, midwifery and district nursing provided by one or more  than one person, in some cases a nurse practitioner model is being developed, in some a new qualification, the Family Health  Nurse, is being piloted.

I think that the important point is to make sure that each situation is looked at separately to make sure that the population, transport links, links to other services are all taken into account.

Regards
Moira

Dear Moira, thanks again for your reply -

I do appreciate that as you say each island situation is different and that it's important to look at each situation separately.. I think that's exactly why it's difficult to have confidence in extrapolating from one island's experience to another at this very early stage in the development of the various "models" being considered.

I did actually mention Papa Westray - I know it doesn't have a doctor - but it is only 30 minutes by ferry from Westray, to which I believe it also has a much used and very quick airservice (only a few minutes). So as long as Westray itself (with only a little over 500 people) can retain its GP, Papa Westray doesn't sound to be geographically so relevant to ourselves.

and found his last paragraph particularly relevant: He says: "I sat on a local enquiry in the 1980s about the future of medical practice on this island and the conclusion was, that in financial terms, it was still the best option to have a doctor on the island. If you have a nurse practitioner or paramedical service they would require purpose-built premises and some form of medical backup, and the investment would not be dissimilar to having a self-employed doctor with an inducement allowance. As long as doctors continue to come to islands like this, then there are strong arguments to maintain the current arrangements."

Do you know anything about that enquiry? Is he correct? Have things changed so much since the 1980s?

Anyway - thank you again for taking the time to reply. As I said in my last e-mail, I am circulating our correspondence to other people here who are very concerned with the whole issue. It is very helpful to be able to communicate like this.

Best wishes,

Angela