The agreement of the new Scottish GP contract has triggered real concerns about just how seriously the challenges facing Scotland’s rural communities are being considered by our professional and political leaders – and how rural NHS services are being considered in the context of the overall NHS Scotland team. In RGPAS (the Rural GP Association of Scotland) we believe that there has been little attempt to rural-proof the contract, and any plans to do so have been sidelined until ‘Phase 2’ which, of course, might never happen.
Rural GPs tend to be a robust lot. We have to be, particularly with the professional isolation and sometimes downright scary clinical presentations to manage, with distance and geography providing an ever-dynamic challenge. Much of our professional resilience and stamina is generated by the support and trust that is handed over to us by the patients we work for, and the teams we work with, in ways that spark professional satisfaction greater than any other career imaginable to us. And it is that privilege, responsibility to advocate and sense of duty, that has driven our concerns about the future of Scottish general practice as defined by the new contract.
Articulating our concerns has, at times, been difficult: we lack the political vocabulary, media experience and strategic confidence to communicate these concerns as effectively as we might if we didn’t have a significant day and night job to do. Challenge has also presented in terms of time; returning home after a busy day in the surgery and a night oncall, to find 20 messages from journalists seeking an informed and on-record representative view is, I suspect, a world away from the luxury of a media team and press officers. But surely we shouldn’t have to employ a media team to represent rural communities in a GP contract?
We have, however, had extraordinary encouragement, including from some who have been able to offer expertise in the areas of media and strategic engagement. Throughout, we have been determined to maintain a respectful tone with our colleagues, confreres and appointed representatives. Despite the shortcomings of the contract, I really believe that those involved all aim to act as professionally and ambitiously as any of us. However we suspect they just don’t understand rural practice enough to see the opportunities that many of us saw for a new contract to sustain healthcare to rural communities in Scotland. Throughout, it has been stimulating to work with bright, impassioned and committed colleagues. And whilst journalists might collectively get a bad name, we have been fortunate to engage with ones who have respected our need to continue the day job, and put up with our own limitations of returning calls and emails between otherwise busy days.
It is clear that the new contract has failed to take into account the challenges and opportunities of providing healthcare in rural Scotland. The honest admission from one of the SGPC Senior Negotiators during a roadshow that rural practice has been “parked” until a Phase 2 of the contract that might not even happen, was a bombshell moment for many of us listening in Inverness. It appears that rural practice has been put on the ‘too difficult’ pile for the time being. And there is ongoing confusion around the much-promised Short Life Working Group for rural practice. Our First Minister advises that it has been set up. Government tells us that it hasn’t, and won’t be for another few months. RGPAS members are ideally placed to offer much-needed perspective, ideas and innovative ways forward, but we understand that because we raised concerns about the proposals, our invite to the group may not be forthcoming.
In November last year, I worked with our vice-chair Alida MacGregor and the rest of our committee to rapidly write a response document that provided positive solutions for the key issues that were identified in the proposed contract. Informal feedback was complimentary about the realistic and constructive tone struck. We realise that coming up with a Scotland-wide contract is difficult. There are huge challenges across the primary care landscape of Scotland. The efforts to identify some effective and realistic ways forward were recognised in our response. Unfortunately, however, we have yet to receive any formal recognition or reply to the suggestions made in this document – from our negotiators or Scottish Government. The document includes an executive summary, which summarises our key areas of concern.
We wanted early on to avoid creating too much division between urban and rural effects of the proposed contract. General practice across Scotland is in need of increased resource. The system has been in a state of crisis for some time, and there is no prospect of improvement unless big changes and more funding is provided. Collapsing practices are becoming too common an occurrence across Scotland, and – particularly as a small country – we would like to see #RealisticMedicine recognised in a #RealisticContract: to work together as GPs to boost the sustainability of primary care across the country. Workload is the rising tide that needs to be addressed, along with tackling the premises issue also seems to be a major stress-point for our urban colleagues.
And yet, as we learned more about the process, intentions and impact of the new contract, it became evident that the challenges of rural practice have been sidelined and placed on hold for a number of years yet. Even more surprisingly, we learned that inner-city deprivation and health inequalities have been apparently forgotten in the new contract too. It is widely accepted that measuring rural deprivation is difficult, and scores such as SIMD (Scottish Index of Multiple Deprivation) still do this poorly. SIMD is far more robust for detecting and measuring urban deprivation. However even despite the excellent work of the Deep End Project to focus on ways of alleviating urban health inequalities, it seems that an opportunity has been missed to address urban health poverty and deprivation.
The funding allocation has not produced the consistent increase in funding to Deep End practices that would allow unmet need and the inverse care law to be addressed. In reality this means that funding streams for patients in the most deprived third of Scotland are not at parity with the rest of the population. This situation will continue to impact on A&E departments, hospital use and premature mortality and morbidity, as documented in many Deep End reports. That is an unfortunate consequence of the inaccuracy of the weighting formula.
Dr Anne Mullin, Chair of the Deep End GP Project (December 2018)
Returning to rural, our negotiating colleagues will highlight the steps forward with golden hellos and relocation packages. We note them but are not very convinced – they haven’t worked so far. They will also highlight that ‘no practice will lose out’, and that our practice funding is protected for the foreseeable future. However being placed on ‘income support’, whilst discovering that the official workload estimation formula greatly underestimates the true workload in rural GP practices, is not the strategy that we see fit for a country where 20% of the population lives rurally, and many more visit for their holidays. The many additional services that are currently provided for our rural patients have gone completely unrecognised.
Prof Phil Wilson, Professor of Rural Health & Primary Care at the Centre for Rural Health in Inverness, and RGPAS Committee member has commented:
The new workload allocation formula is based on an outdated and unrepresentative sample of practices (the PTI dataset was abandoned as worthless by SGHD in 2013), and relies simply on consultation numbers (or Read codes) per patient as the driver for allocation of funds to practices.
Funding allocations are now simply calculated on the basis of patient numbers, age and SIMD scores, and the cost of supply of medical services (higher in rural areas) is now excluded from the formula for reasons that have not been made clear.
Arguably it is patients in rural and remote areas that are most reliant on their practices to deliver health care. They have no option to register with a nearby practice or attend an A&E department if their practice collapses. Over 90% of practices in the northern Health Boards will be in the income support category. It is rural practices that have the biggest problems recruiting GPs and there are already large swathes of Caithness, Sutherland and the Isles where patients cannot access a doctor without travelling huge distances.
Yes, we are protected from the considerable cuts that would otherwise occur (up to 85% for some practices!), but there is an absence of any additional resource which is so greatly needed in some areas. In addition, it seems that it was left to us to work out the impact for ourselves – using carefully mapped ISD data and some helpfully released contract impact data, to visualise the impact. If the impact of the new contract was sufficiently scrutinised from the outset, why not address the rural/urban issue from the outset, instead of relying on others to process the figures? As a result of this, some of us found the contract proposals to be a ‘scratch and sniff’ document, and unfortunately many times we found ourselves scratching through rhetoric and aspiration, to find a smell that was not particularly rosy. Expert academics have lambasted the interpretation of econometric analysis provided by Deloitte: they were particularly surprised as Scottish Government have a reputation for normally doing workload allocation formulae rather well.
Fundamentally, the approval and implementation of a resource allocation formula that so drastically works against rural areas is surprising from a Government that should be reflecting the demographics of a country that is proud of its rural landscape. We explained this in our letter in December to Shona Robison, our Cabinet Secretary for Health. The question that our leaders in education, social work and other public services have been asking: ‘is this the precedent for future funding to rural areas?’. For easy reference, here’s that map again:
Turning to the recruitment elements of the contract: we need to recognise that a strong driver for recruitment is retention. Students and trainees who see fulfilled, fairly-treated and adequately resourced GP teams are more likely to go into general practice. Golden handshakes, relocation allowances and bonded undergraduate education can all be implemented with some effect. However, we need to embrace the pipeline model of recruitment & retention. We need to recognise that leaks further downstream (particularly if for negative reasons) can be hugely detrimental to recruitment. We need an integrated, positive, pragmatic and holistic approach to why folk come to and go from work in rural communities.
The internationally regarded Prof Roger Strasser, Professor of Rural Health & Dean/CEO of the Northern Ontario School of Medicine in Canada, is considered an expert in rural health recruitment, retention and delivery. He has been moved to comment:
This situation seems paradoxical. On the one hand, the Scottish government is investing in education, training and service initiatives to improve health in rural and remote areas, and on the other hand the government is undermining these initiatives by undervaluing and demoralising the rural practitioners who are the cornerstone of care.
It appears to be a classic example of decisions being made to address issues/concerns in the cities/dense population areas that have unintended negative consequences for people in rural and remote communities.
Unfortunately rural practitioners and their communities are left questioning whether these consequences are truly ‘unintended’.
The ball is now in the Scottish Government’s court. Rural GPs in Scotland are as ready as we ever have been to continue innovative, realistic and community-focussed healthcare design, and we hope to see our involvement invited in the near future. We need to see the work of rural GP teams recognised more accurately, supportively and fairly if we are to find a positive way forward from the difficult months that have resulted from a contract that has been inadequately rural-proofed.
Rural practice in Scotland has always been fertile ground to serve up great solutions for the challenges of modern healthcare. This new contract has delivered a body-blow to rural GPs and their teams. Give us respect, recognition and realistic resource and we will deliver.
Find out more about RGPAS concerns regarding the new contract at our #RememberRural information page: http://ruralgp.scot/rememberrural/