Reflections from WONCA Rural Dubrovnik 2015

wonca_logo_final_01Today I am attending RCGP Scottish Council in Edinburgh.  As part of this, I was asked to report on my experience in attending the WONCA World Rural Health Conference in Dubrovnik – on 14-18 April 2015.  I thought it might be helpful to share this report here.

WONCA Rural Conference, Dubrovnik – 14-18 April 2015

Report to RCGP Scottish Council

In April 2015 I attended the WONCA World Rural Health conference, held in Dubrovnik.  Five months on, it is helpful to reflect back on the experience of attending WONCA Rural, and what I have acted upon since my return from Croatia.

Firstly, I would like to thank RCGP Scotland for financial support to attend the conference.  Such support is effective and appreciated to help release GPs like myself from practice commitments.  It is clear that Scotland has much to share about developing and innovating rural general practice, as well as being able to learn from approaches taken by our international conferères too.

I am also grateful for support from Drs Miles Mack, John Gillies and the RCGP Scotland team in preparing material for the conference.

WONCA Rural 2015 brought together rural practitioners from across the world. Historically there has been a higher proportion from the UK, Eastern Europe, Canada, USA, Australia and New Zealand.  However it is clear that there is growing membership from African and Asian countries, and indeed there are intentions to hold the next WONCA Rural Conference in Africa.

There were many lessons, benefits and conversations during the 4 day conference.  As usual, informal discussion amongst confrères opened up more learning than the conference presentations: and there was plenty of inspiration and quality research/innovation being presented in these sessions. Whilst in Dubrovnik, I posted a number of podcast interviews to this website.

WONCA World President, Michael Kidd, addresses the conference…

There were a number of core themes that I took away from WONCA Rural…

International similarities

Rural practitioners are united by similar challenges and attractions of rural practice. There are often frustrated levels of bureaucracy as a result of providing a wide spectrum of care across traditional domains of healthcare.  From connectivity and immediate care provision, to blurred funding streams between primary care and community hospital work, and a constant difficulty in navigating the politic that goes with negotiations; it was reassuring to listen to more experienced GPs from other countries who have the same issues that we have in Scotland.  Younger rural GPs all express a frustration with the need to ‘learn politic’ and persuasion skills in order to achieve even basic improvements in clinical care. This is made particularly challenging as management training is lacking from most GP training programmes.

Recruitment and retention challenges exist internationally, and there are common approaches to this.  The role of mentorship models is increasing, along with recognition that ‘single handed practice’ is declining in popularity and sustainability – and are being replaced by federated, group or other networked practice models.  There was interest in the GP Rural Fellowship programme in Scotland, which has helped to introduce recently-qualified GPs into rural posts.  However the challenge of filling posts remains ever-present and similar across the world.

We found that one presentation in particular – on the ‘pipeline approach to (rural) GP recruitment‘ – resonated with taking the recruitment challenge in Scotland forward.

It is widely accepted that harnessing the interest and enthusiasm of medical students in rural practice, can be a powerful means by which the attractions (and realistic perspective) of rural practice can be highlighted.   Action is needed to ensure that funding is increased to facilitate greater involvement of undergraduate training opportunities in rural practice; similarly support to trainees in rural practice needs to be protected and expanded.  The John Flynn programme – run by the Australian College of Remote & Rural Medicine (ACRRM) is a great example of what can be achieved by supported training opportunities in rural practice.  Pragmatic support of undergraduates and trainees is vital: appropriately funded accommodation, travel and consideration of the impact on spouses/partners and family.

That said, we are not alone in having to navigate the constraints of geographically-defined training schemes, although there is work especially in Canada and the USA to provide rural-track training programmes, similar to the ones now in place in Scotland.

Social Media

There are numerous networks to join, and participation in these international approaches is important to develop further within Scotland.  Social media is an easy way of reducing professional isolation, and there were several workshops looking at how to encourage others to join the conversations, and improve fluency in its use.  Throughout the conference, the twitter hashtag #woncarural2015 was used and a search for this now will reveal the active conversations taking place at the time.

I use Twitter regularly to keep an eye on recent trends/new guidelines etc.  It was great to meet some of the faces behind these twitter profiles!


@davidrhogg @IVLINE @ruralgreengp @ruralflyingdoc and Leslie Rourke


Rural practice needs to improve its collective identity.  It was apparent that those countries with a thriving network of rural GPs had a stronger buzz about rural GP opportunities – as well as highlighting generic benefits of general practice.  The ACRRM is perhaps a model that we need to reconsider in Scotland – by building up and consolidating what we already have.  The current setup of relatively un-linked institutions, from RCGP, Rural GP Association of Scotland, School for Rural Health & Wellbeing, NES, RRHEAL, Centre for Rural Health and the RCGP Rural Forum serves to dilute the collective identity, duplicate certain efforts, and I think something needs to be done to pull these organisations tighter together with a more collaborative strategy.

In November 2014 the Rural GP Association of Scotland (RGPAS) became the new name for the Remote Practitioners’s Association of Scotland (RPAS) and we have been building specifically on work to support practising rural GPs, as well as undergraduates in rural practice.  We’ve also improved social media and online presence.

There remains a wider need to realise the potential synergies that could be realised by organisations working better together.

Use of existing mechanisms 

One particularly interesting conversation with an experienced GP in Australia, led to learning about the set up of a ‘Managed Educational Network’ – and how such established routes of networking can be harnessed to achieve wider goals.  He advised on the importance of identifying existing organisations and their objectives, in galvanising resource to make projects happen.

On my return, I met with RRHEAL and NES, and highlighted the obligations from RRHEAL’s mission objective to facilitate managed networks in rural practice.  This has resulted in a PDSA to assess whether a Scotland-wide MCN (clinical network) or MEN (educational network) could help to link up Scotland’s rural GPs by VC on a semi-regular basis.

Innovation in rural health care

There were some great examples of where rural practice is leading new approaches in training, clinical skills development and other aspects of clinical care.  Some of these are similar again to current work in Scotland.  The increasing role of simulation training particularly for high intensity low frequency clinical scenarios was evident from several speakers.

Lessons from conference workshops have already been put into action on Arran where we have been developing the use of simulation training.

The increasing role of ultrasound in clinical practice was also raised frequently.  Given that this is a safe, potentially transmissible and higher acuity diagnostic near-patient test, we are likely to see its use in rural practice develop considerably.

The role of the rural GP in providing leadership and advocacy in more generic challenges of rural living was apparent.  Whether representing rural healthcare on a political level, engaging in media work or leading projects such as improvements in connectivity – all these aspects of professional life were common.

Presentation of ‘RCGP Scotland Being Rural’ 

I presented the RCGP Scotland paper to an audience of approximately 50-60 on the Saturday morning of the conference.  This was well received, and the twitter conversation continued well past the conference conclusion too.   The wider perspective provided by Miles Mack’s mind map of challenges to rural practice, was appreciated and recognised by colleagues across the globe.  In particular, the constraints resulting from infrastructure difficulties in rural areas was a common theme.

Here’s a summary video of the main points of the Being Rural paper.


Attendance at WONCA Rural allowed an important Scottish input to the debates and conversations about international rural health.  It was an opportunity to obtain a wider perspective on how others are dealing with common challenges including recruitment, retention, burnout, effective training of the ‘next generation’ and representation of the generalist approach amongst an increasingly specialist medical world.  I hope that Dr John MacLeod, Lochmaddy GP and one of the founding members of WONCA Rural, would have been proud of the ongoing Scottish participation from those of us who made it to Dubrovnik.  Personally, it helped to open many doors for future collaborative working, particularly with confrères in Australia, New Zealand and Canada.

Next actions

There have already been outcomes from participating at Rural WONCA.  The priority now is to share the momentum that exists amongst WONCA partners to inform, enthuse and stimulate better representation, and an effective collective identity, amongst rural GPs in Scotland.  RCGP Scotland has a pivotal role in supporting both existing and prospective members and I hope that it will be possible to translate this effectively into useful actions via the RCGP Scotland Rural Strategy Group.

David Hogg, September 2015

Now want a different perspective?  See these other reports from Dubrovnik 2015.


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