The view across Scotland – the work
of the National Managed Clinical
Network
Dr Lance Sloan
Consultant in Rehabilitation Medicine
NHS Fife
Chair Remote and Rural subgroup of ABI NMCN
Recommendations
• Better training for rural doctors
• Better use of transport and technology
• Guaranteed minimal levels of service despite
geography
Highlands and Islands Medical
Service Committee Report to the
Lords Commissioners of His
Majesty’s Treasury
Sir John Dewar, 1912
Royal College of Physicians of
Edinburgh report 1851
• Only 62 of 170 parishes had a resident doctor
• 41 parishes would be regarded as ‘destitute of
medical aid’
• What about brain injury services in 2011??
Differences between rural and urban
health in Scotland
• Higher suicide rates (Paykel et al, 2000)
• Higher incidence of alcohol related disease
• There are a higher number of accidents in rural areas:
on roads, through climbing, farming, diving and fishing
• Palliative Care workload is proportionally higher than
might be seen in urban areas, as patients from remote
areas often prefer to or are enabled to die at home,
rather than in a distant centre (Baird et al, 2003)
• Seasonal fluctuation in population
Delivering for remote and rural healthcare, 2007
Development of Acquired Brain Injury (ABI)
National Managed Clinical Network (NMCN)
• 2000, Scottish Needs assessment report (SNAP)
• 2003 review of progress – one of
recommendations referred to MCNs
• 24th Jan 2005 – group of clinicians from across
Scotland met to agree a proposal for NMCN for
ABI to submit to the National Services Division
• Proposal agreed in 2006 with NHS Lothian
hosting MCN
National MCN for ABI
• Steering group first met on 1st Feb 2007
• Chair Dr Brian Pentland
• Wide membership including physicians, health
professionals, patient representation, Social
Work, voluntary agencies, research workers
Objectives of ABI MCN in 2007
• Map out current services for people with ABI
• Promote adoption of recognised standards of care
• Identify the educational needs of health care
groups involved in the care of people with ABI
• Identify information requirements of patients and
carers
• Website development www.sabin.scot.nhs.uk
ABI NMCN
steering group
Mapping group
Standards group
Managed care
network
Patient and carer
group
Education and
training group
Children and
young people
group
Remote and
rural
Information and
data
management
Equity of access
Defining
Rural or Remote?
Living In Scotland: An Urban-Rural
Analysis Of The Scottish Household
Survey
2003. Rural Development Department,
Social Research Branch
with assistance from the
Scottish Agricultural College
Definitions
Rural
Settlement < 3,000 pop < 30 min. from urban centre >10,000
pop
Remote
> 30 minute from
urban centre >10,000 pop
Very Remote
> 60 minute from
urban centre of >10,000 pop
Clinical peripherality
• Clinical peripherality index devised by Centre
for Rural Health
• Takes account of factors such as population
density, practice size and time to reach
secondary care
Aim of Remote and Rural subgroup of
ABI MCN
• To bring together interested individuals to
explore and scope the remote and rural issues
around ABI and produce an Action Plan
Rural / Remote
Rehabilitation
Traumatic Brain Injury
•Increased incidence?
•Increased severity?
Residents of
rural areas have a higher incidence of and
mortality from TBI than residents of urban
areas, but they have poorer access to specialist
brain injury rehabilitation resources
•
•
•
•
•
Woodward A, Dorsch MM, Simpson D. Head injuries in country and city. Med J Aust
1984; 141: 13-17.
Glabella B, Hoffman R, Marine W, et al. Urban and rural traumatic brain injuries in
Colorado. Ann Epidemiol 1997; 7: 207-212.
Johnstone B, Nossaman L, Schopp L, et al. Distribution of services and supports for
people with traumatic brain injury in rural and urban Missouri. J Rural Health 2002; 18:
109-117.
Sample P, Darragh A. Perceptives of care access: the experience of rural and urban
women following brain injury. Brain Inj 1998; 12: 855-874.
Schootman M, Fuortes L. Functional status following traumatic brain injuries:
Population-based rural-urban differences. Brain Inj1999 Dec;13(12):995-1004.
Rural / Remote
Rural NSW residents
have similar rehabilitation outcomes
to urban residents after severe TBI
Harradine PG, et al. Severe traumatic brain
injury in New South Wales: Comparable
outcomes for rural and urban residents.
Medical Journal of Australia 2004 Aug
2;181(3):130-4.
Remote and rural subgroup
•
•
•
•
•
•
•
•
Review available documents
Equity of access
Pathways
AHP workforce and aspects
Telemedicine
Health Informatics
Clinical standards
Case scenarios
• The National Framework for Service Change in
NHS Scotland - Rural Access Action Team,
2004
• Delivering for Remote and Rural Healthcare,
2007
Farmer J, Kilpatrick S. Are rural health professionals also social
entrepreneurs?. Social Science & Medicine 2009 Dec;69(11):1651-8.
Farmer J, West C, Whyte B, Maclean M. Primary health-care teams
as adaptive organizations: Exploring and explaining work variation
using case studies in rural and urban scotland. Health Services
Management Research 2005 Aug;18(3):151-64.
Farmer J. Connected care in a fragmented world: Lessons from rural
health care. British Journal of General Practice 2007 Mar; 57 (536)
:225-30.
Case scenario 1
• The individual who has no significant physical
impairment and is sufficiently orientated to be
allowed home but has persisting cognitive
impairments
Case scenario 2
• A patient who is medically stable but has
mixed physical and cognitive impairment
without major behavioural issues. He requires
physical assistance with transfers and all
mobility activities and because of mixed
cognitive and language difficulties needs
supervision in activities of daily living
Case scenario 3
• An acutely behaviourally disturbed person
who, because of cognitive/language
impairment, is unco-operative with ward staff,
attempts to leave hospital and can be
aggressive to staff
Case scenario 4
• Persisting challenging behaviour in a person
who is aggressive to staff but lacks cognitive
capacity to comply with the staff or go to the
community
Case scenario 5
• An individual in a vegetative state/minimally
conscious state. Medically stable but requires
nursing care for all needs and has been in this
state for some weeks
Humpty Dumpty sat on a
wall,
Humpty Dumpty had a
great fall,
All the king’s horses,
And all the king’s men,
Couldn’t put Humpty
together again
Conclusions
• Opportunity
• Scottish islands and mountains will always
pose difficulty for delivery of healthcare
• But history indicates it can be can be a source
of innovation in technology, professional team
working and education
Is rural and remote ABI service
provision a problem or part of a
wider solution?
(adapted from Dr James Douglas, 2005)
Thank you
www.sabin.scot.nhs.uk