Rural Round-up: Being Rural - exploring sustainable solutions for remote and rural healthcare

Dr Miles Mack, RCGP Scotland Chair-elect writes:

RCGP Scotland Policy Paper written by the Rural Strategy Group Scotlandⁱ

Scotland is by no means unusual in having difficulties in recruiting to remote and rural posts. At present there are many isolated mainland and island practices that are unable to recruit and in many places the Health Boards have been forced to employ short term locums or even take over the running of practices to ensure patients are provided with the care they needⁱⁱ.

What is perhaps unusual about Scotland is that we have a long history of acknowledging and successfully overcoming such problems. In 1912 the UK government set up the “Dewar Committeeⁱⁱⁱ” that travelled the length and breadth of the Scottish Highlands & Islands to enquire about the state of medical services. What they found was truly shocking. In Ross-shire 40% of deaths went without a medical certificate as patients did not even have access to a doctor for their final illness. Many communities had no medical or nursing provision and the proposed National Insurance Scheme was unworkable in the crofting* communities. The result was the setting up in 1913 of the Highlands & Islands Medical Service^iv (HIMS), the first state funded health service in the world. It was startlingly successful and was, in fact, the only model of care quoted in the1944 National Health Service white paper^v.

In 2012 the North of Scotland Faculty of the Royal College of General Practitioners took advantage of the centenary of the report and the HIMS to research and share its history^vi. We were struck by the similarities to problems facing rural communities now, except things have moved on. In the Dewar Report they advocated better use of technology. Then it was the telephone and internal combustion engine, now it is broadband and mobile phone access. This has led us to develop a mind-map^vii defining the problem and this has been core to reports by NHS Education for Scotland^viii and NHS Highland^ix. The RCGP Scotland “Being Rural” report goes further than these two documents and has defined core problems and solutions across seven areas: -

• Connectivity (mobile phone/broadband)
• Transport
• Fragility of support services
• Workload (including the 24 hour commitment)
• Professional development
• Education and training
• Professional and social isolation, including
• Adverse effects on family life

RCGP Scotland is now committed to working with others to begin to tackle these problems. We have already had meetings with Scottish Government on issue of connectivity and are beginning to discuss changes in the selection and training of medical personnel in line with the WHO Global Policy Recommendations^x. As a result of concerted effort across different agencies across Scotland there is clear evidence of a different mood in remote and rural health. In addition, many of the issues in this paper will be important to non-rural areas too. The model of closely integrated health & social care with effective decision support for expert generalists holds a great deal of promise in tackling increasing multi-morbidity in an ageing population.

Dr Miles Mack
Chair-elect, RCGP Scotland 

* Crofting is a system of rural agriculture peculiar to the Highlands of Scotland. It was developed to overcome difficulties in land ownership in the late 19th century and continues as a system of smallholder type agriculture with particular legal rights to this day. It arose from the ashes of the "clearances" when so many highlanders headed for other parts of the empire...

References
i. http://www.rcgp.org.uk/policy/rcgp-policy-areas/rural-general-practice.aspx  
ii. http://www.heraldscotland.com/news/health/health-board-fails-to-recruit-gps-for-rural-care-overhaul.22153621  
iii. Dewar report
iv. http://www.ournhsscotland.com/history/birth-nhs-scotland/highlands-and-islands-medical-service
v. Proposal for a National Health Service War Cabinet, 5th February 1944
vi. http://www.ruralgp.com/wp/dewar2012/dewar-events/dewar-conference-2013/  
vii. http://milesmack.wordpress.com/2012/07/28/dewar-2012-the-fragility-of-remote-rural-healthcare
viii. NHS Education for Scotland : Supporting Remote and Rural Healthcare; NES Board Paper, August 2013, Ronald MacVicar & Pam Nicoll
ix. An Approach to Building Sustainability of Health and Care Services in Remote and Rural Areas
x. World Health Organisation published the Global Policy recommendations – ‘Increasing access to health workers in remote & rural areas through improved retention’