RCGP Scotland Rural Strategy – a personal view

RCGP Scotland has today published its Rural Strategy report, written by GPs Miles Mack, Hal Maxwell, John Gillies and David Hogg.  Here, one of the authors, David, provides his personal thoughts on the paper…

See the press coverage featured in The Herald here: Article, Editorial, Case Example

rural-1-2Being a rural GP can be great.  In 2005 I delighted in experiencing my first student surgery whilst on a GP placement with Dr Bob Dickie in Stornoway.  Little did I realise the impact that this would have on my future career.  Dr Gordon Baird deserves the credit (or blame!) for kindling my subsequent interests in rural practice, with plenty other icons of rural practice involved in influencing my career choice – which ultimately took me to a GP Rural Fellowship on Arran in 2010.  I have remained here since.

Since my student days, I have been lucky to get involved with various national groups; latterly these have included BASICS Scotland and RCGP Scotland.  Throughout, I have been intrigued by the challenge faced by our profession’s leaders of how to put the ‘day job’ in the context of decisions that need to be made on a macro or national level.  However, I have witnessed a consistent level of personal conviction in those ‘at the top’ which is largely due to one reason: the majority of GPs who take part in these decision-making activities  continue to consult with patients at least once or twice a week – and normally more.  It’s probably an essential tenet of maintaining credibility.   And so you’d expect decisions to be taken with pragmatism and ‘grass-roots’ insight.

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So why is rural practice in its present situation?  Report upon report has highlighted, detailed and warned of the challenges facing rural practice – the biggies such as recruitment & retention, as well as the downright perplexing such as threats to dispensing practices and policies without any thought to rural-proofing.  Since Dewar 1912 (and before) we have known that geography, communication, housing and professional resilience are the areas that continue to be problematic in delivering sustainable rural healthcare.

And yet, guess what?  These same issues feature in our report too.

Same old?

We’re well aware that there will be some (?many) including those already disengaged , who will look at this report and say ‘So what?’.  So many times, instead of taking ideas forward to the stage of implementation, each new project or committee seems to go back to redefining the problem, repeatedly stalling at the point of getting on with proposed solutions.  The pen may be mightier than the sword, however sometimes one just needs to implement some elbow grease to tackle the issue. I wonder if the scientific approach taken to some of these projects, has resulted in becoming naturally bogged down with definition and evidence, when in fact we really need implementation and enablement.  My biggest fear for our paper is that it becomes yet another futile addition to the library of attempts to provide ‘the solution’ to rural general practice.

Inspiration

rural-9Thankfully, we can find some inspiration in examples of where progress has been made.  The rural fellowship programme, the rural-track training pathway, the mobile clinical skills unit, Sandpiper-Trust enabling BASICS Scotland education and response, the recent change of the law regarding dispensing practice, and the Emergency Medical Retrieval Service, to name a few.  An unrelenting enthusiasm continues from undergraduate students to experience the rural life – at least for a bit – and they usually find their eyes opened wider to the concepts of core clinical skills and doctor-patient relationship.  We’re looking forward to this year’s intake being as enthusiastic as last year’s, and I’m sure we won’t be disappointed.  All these improvements should be celebrated, recognised and harnessed to drive forward our ambitions for good quality rural health care.

Crisis response

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However, rural practice is in crisis.  More than any marketing campaign, pilot project, golden handshake, first responder group, co-production initiative, helicopter service or fancy photography will alleviate.  For all that GP contracts have been media-bashed of late for being ‘private contractors’ – despite being tightly controlled and nationally negotiated – in fact there is a wide community of rural GPs who will continue to innovate, entrepreneur, lead and work together, and this needs to be enabled by avoiding putting any further bureaucratic hurdles and misinformed judgement in the way.  That creativity and local initiative is – I believe – best fostered in most cases by the current model of GPs as independent providers.  There is certainly no doubt that the last thing we need is contractual reorganisation to distract from tackling core issues.  I look to England and the increasingly piece-meal NHS sell-off to truly private contractors, and find reassurance that our Scottish Government has avoided such privatisation of our NHS.

We need to get into gear,and get sleeves rolled up.  That includes macro decision makers – on boards, committees etc. within healthcare but far wider too.  As demonstrated by Dr Miles Mack’s mind map of issues affecting rural practice, the answers are certainly not limited to decision mechanisms within our own profession.

Here’s my less official wish list:

  • recognise that the digital equivalent of the inverse care law is happening in front of us now.  The forgotten 5% (over 200,000 people) who continue to miss out on broadband and 3G cannot be forgotten any more.  When our phone line gets soggy in the rain (no joke) I can’t access our NHS24 system from home.  Access to unscheduled and emergency care is hindered in remote communities by poor mobile phone signal.
  • ensure that every national policy is truly rural proofed.  Decisions such as the STAC agreement for oncall staff including radiographers, look set to seriously threaten the viability of community hospitals and rural emergency care in the next 4-5 years.  30% of Scotland is rural, so this is not a consideration for the minority.
  • recognise that GP work IS becoming more challenging.  Sore throats are now sore throats on methotrexate.  Cellulitis is more often in the context of insulin-dependent diabetes.  Holidaymakers present between chemotherapy cycles, or are even taking it whilst they are away.  Alcohol withdrawal is accompanied by increasing polypharmacy and comorbidity.  And of course we are seeing a continual shift of work from secondary care to primary care, without the same flow of resource.
  • make it more feasible for students and rural healthcare teams to share the superb opportunities that exist in rural practice for quality learning: better substantive financial support for undergraduates (evidence based as an effective strategy for future recruitment), a GP training scheme that allows effective training for those who want to prepare early for a career in rural practice (building on the rural track programme in the North of Scotland), and development of fellowship-style supported introductions to rural practice for qualified GPs.
  • accept that GPs are usually more costly per hour/day worked, but we will (usually) see anything.  There are economies of scale that will never be realised in rural practice, and there will always be less pricier alternatives, but that does not translate into value for money.  Whilst we need to be open minded, it is probably impossible to replace a GP, trained in generalism with considerable experience over at least 10 years until qualification, with anything else – unless the focus is to change to an approach of reduced experience and generalism, and a different kind of care.
  • consider pension benefits to those who work outside the 8am-8pm window.  We need to get to grips with the real-life unhelpful barriers being placed in front of GPs.  Our latest pension reforms mean that at a level of income which many GPs are at due to full-time partner work, it simply makes no financial sense to carry out additional out-of-hours work in some areas.  In addition, those of us who do our share of unscheduled care are wondering just how feasible it is to continue in this way until the ever-increasing age of retirement.  Hundred hour weeks and disturbed sleep patterns seem (surprise surprise) to become less tolerable with time.
  • enable the ‘can do’ attitude of those rural GPs who want to innovate: good ideas need support.  GPs have a wide scope of responsibility, with local patient care the priority.  The time lost to frustrating issues such as IT/connectivity failures, lack of contextual understanding, and an absence of will from those who can make budgets and innovation happen, is not acceptable when we need to get going with the changes identified.

What can we do?

The point is this.  We know what the problems are, and have a good idea of the solutions too.  Countless reports have been written already, however our latest contribution is motivated purely by the opportunity for effective implementation.

For that implementation to happen, we need everyone with a responsibility to rural infrastructure (medical, social and otherwise) to act on that responsibility.  To resist the urge for further work on definition or scoping.  And to come up with the goods that will actually address the problems, not just describe them.  Connectivity is particularly important to address.

Rural practice still has the potential to offer a fantastic career, but its sustainability depends on implementing the tangible solutions that have been described too often.  We need a serious injection of high level attention to this, and a drive to get on with the changes we know need to happen.

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