Archive | Rural Deprivation

RGPAS survey indicates extent of #gpcontract concern

A members’ survey carried out by the Rural GP Association of Scotland (RGPAS) has revealed a considerable level of concern across rural GPs in Scotland about the new GP contract proposals.  Of 115 members, 74 have responded (65% response rate).

One reason for conducting this survey, is the refusal to publish the geographical breakdown of the results of the national poll.  We understand that this may be due to a technicality of the voting process and therefore hope that this is useful information for SGPC and Scottish Government to view the perspectives of rural GPs in Scotland about the new contract.

Click to download the report (2.6MB, PDF)

In November last year, RGPAS published a constructive appraisal of the proposed new GP contract.  Since then we have attempted to engage with SGPC and Scottish Government to understand how appropriate steps can be taken to ensure that the very acute needs of Scottish rural general practice will be adequately addressed.  RGPAS wrote a letter to the Cabinet Secretary for Health, Shona Robison, and a phone call took place on Wednesday 13th December to discuss our concerns in more detail.  A formal response to this letter was promised, but as yet we have not received this.  Specific concerns highlighted at this time included whether the GP contract proposals were compatible with the Scottish Government’s ‘Realistic Medicine’ strategy, and the effects of the proposed Workload Allocation Formula (WAF) in delivering much-needed additional resource only to urban-based practices.  Notably, these specific concerns about the WAF are echoed by our ‘Deep End’ colleagues – GPs who work in some of the most deprived communities in Scotland.

In the last few days, further concerns have been raised by Prof Phil Wilson about the methodology behind the proposed new Workload Allocation Formula as well as the process of polling GPs across Scotland – from which the SGPC will decide whether to go ahead with the proposed ‘Phase One’ of the proposals.  [STOP PRESS: A further letter from Prof Wilson was sent on 8th January with additional concerns about the allocation formula].

RGPAS remains ready to work with SGPC and the Scottish Government to address the issues being raised by our members, whether the new contract goes ahead or not.  The survey results below indicate the strength of feeling, but moreso the passion that rural GPs – like many GPs across Scotland – have for advocating for their communities, and delivering quality primary care in some particularly challenging circumstances.

RGPAS believes these concerns need to be addressed with the utmost urgency, and not wait until or whether Phase Two of the proposed contract is enabled – if Phase Two happens, we understand that it won’t be for another 2-5 years.  We do understand the plans to form a ‘Short Life Working Group’ for rural practice.  However, the time for action is now, not least to address the constructive concerns raised already in this process about the proposals of Phase One.

This is critical for the future of Scottish rural primary care, and the RGPAS committee and membership is ready now to see more effective representation of the health needs of Scotland’s rural communities than what has been proposed.






Some of the comments at the end of the survey are particularly illuminating…

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RGPAS response to the Scottish GP contract proposals

The Rural GP Association of Scotland (RGPAS) today publishes its response to the Scottish GP contract proposals.  Following much discussion on our members’ email discussion group, RGPAS videoconferences and wider engagement on social media and contract roadshows, we have collated the opportunities and challenges that we believe to exist in the proposals.

We recognise that a new vision for the future of Scottish primary care is vital.  We are keen to collaborate and inform the development of these plans in order that Scotland’s rural communities (at least 18% of the Scottish population) are represented appropriately.

You can read the GP contract proposal at the BMA Scotland website.

You can find out more about RGPAS at

Click to download the report (2.6MB, PDF)

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What happens when Deep End goes Rural?!

Many readers will be familiar with the Deep End project, originating in Glasgow but which has spread far and wide in describing the work of GPs working in areas of urban deprivation.  The original project brought together 100 general practices serving the most socio-economically deprived populations in Scotland.  The project team has carried out a fantastic amount of work to highlight the impact of inequalities on prevalence of medical conditions and access to healthcare.

So what happens when a Deep End GP (or a GP and GP trainee, to be precise!) travel out for some time in a remote island practice?  Dr Maria Duffy and Dr Elizabeth Dryden did exactly that, when they travelled to Benbecula to spend a week with rural GP Dr Kate Dawson… and produced this short video of their experience…


You can follow the Deep End project on Twitter – see below.

We look forward to the sequel!

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New Report: Health & Wellbeing in Rural England

Thanks to David Syme for highlighting this report which was published on 11th March 2017.

It offers a comprehensive view of the challenges and positive aspects of accessing and providing rural healthcare in England.

The report mentions eight key ‘health risks’ of rural areas:

  • Changing population patterns
  • Infrastructure
  • Digital access and exclusion
  • Air quality
  • Access to health and related services
  • Community support, isolation and social exclusion
  • Housing and fuel poverty
  • Employment and under-employment

There will of course be similarities between the issues raised in this report, and communities elsewhere in the UK and beyond.

You can download the report from this link.

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Rural connectivity in Scotland – a step forward?

phoneOn Wednesday 10th September, I attended a meeting in Edinburgh about connectivity in rural Scotland.  Following the report ‘Being Rural’, launched a few weeks ago by the RCGP Scotland Rural Strategy Group, the meeting was organised to discuss our concerns with the relevant departments of the Scottish Government.

Is this important?

Connectivity has become a crucial issue for the sustainability of rural areas – and not just for healthcare.  The digital divide is now more evident than ever, and the gap continues to drive inequalities of access to healthcare.  With integration of health and social services due to commence in April 2015, there will be an inevitable requirement for greater sharing of data and collaboration.  It will be vital that adequate connectivity is in place – in terms of reliable landline, mobile and broadband networks.  It is clear that connectivity needs to be placed high up the agenda if integration – as well as the wider sustainability of public services in rural areas – is to succeed.

Of course, focus should not rest exclusively with health services.  Access to broadband is a strong determinant of social functioning, as well as professional collaboration.  For rural areas to remain attractive to tourists, new business and to maintain a vibrancy of community, this will depend on improving equity of access to decent network capacity.

What’s RCGP Scotland doing about this?

So through the RCGP Scotland Rural Strategy Group, last week’s meeting followed from one held a few months earlier, and this time it was clear that we were speaking to the decision-makers at the core of Scotland’s broadband and mobile network strategy.  Representatives from Community Broadband Scotland, the Digital Directorate of the Scottish Government and the Digital team of the Scottish Futures Trust met with us to get a better insight into the problems we are facing… and it was useful for us to get an insight into the scale of the challenges that they face too.  ‘Backhaul’ – or the data capacity required to connect exchanges, as well as subsea and cross-country fibre cabling – is a major issue.  There seemed to be a commitment to get this right the first time, not least as this will determine how future-proofed the longer term strategy will be.  Aside from the copper cabling connecting your surgery to the exchange, every mobile phone mast and exchange needs to plug into larger data ‘pipes’ to keep the information flowing.  This can be complex, costly and time consuming – and yet is an essential component to achieving better connectivity.

What is clear is that there are a number of high-level organisations working on the issues.  It is therefore important that we ensure that health care (specifically general practice) connectivity needs are well represented.  There is over £300 million of public money, being used to attract around £3 billion of investment into Scotland’s digital infrastructure over the next 5 years.  This is all designed to tie into the Scottish Government’s ‘World Class 2020 vision‘ to be a world class digital nation.

On the one hand, I do take the view that development of local connectivity infrastructure is outwith the remit of a rural GP/practice team, especially with so much other clinical/non-clinical work going on.  However, it is clear that engagement with communities to consider their options, and represent their difficulties effectively, is necessary for this investment to be spent appropriately.  At the very least, we need to help RCGP members to navigate the complex state of multiple organisations being involved with superfast broadband rollout, to ensure that any engagement is as relevant and fruitful as possible.

All very good, what does this mean for me?

For rural GPs and healthcare teams across Scotland, we’ve been keen to give decision-makers a pragmatic view of the challenges faced at present.  These include:

  • branch surgeries being unable to operate properly as remote access to computer records (such as EMIS/Vision notes, Docman’d ECGs/discharge letters and other medical information) being reliant on broadband speeds above 2Mb/s
  • difficulties in setting up group/federated/branch practices – particularly at a time when increasing numbers of surgeries are considering this option for recruitment/retention reasons
  • isolation faced by rural GPs by not being able to connect to webinars, online video and other CPD material
  • difficulties faced by BASICS GPs and First Responders in being available on-call (or more frequently, being tethered to the home phoneline – which makes for a poor level of work/life balance)
  • dangers faced of lone working without mobile phone coverage, sometimes taken for granted in less rural areas

Site visits have already been undertaken by some of the organisation mentioned, in some areas, and there are local examples of excellent progress – for instance the Isle of Coll, and Applecross.  An invitation to Arran has been taken up by the Scottish Futures Trust, and this will be arranged in the near future.

What can I do?

Over the next few months, we hope to report frequently on engagement between RCGP Scotland and the organisations mentioned above.  Much of this work has been building on the ton of work done already by Dr Drew Inglis from the Emergency Medical Retrieval Service – you can read more about this work at – and you may already be receiving Drew’s regular email updates.

In short, keep your ear to the ground, and ensure that your wider advocates – not least your MSP – are aware of connectivity issues in your area.  The next few years look set to stage some fervent action to get Scotland’s connectivity up to decent standard including in rural areas.  We need to ensure that the needs of rural healthcare teams are placed high up the agenda.

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New Zealand: Rural connectivity is an issue there too

nzrgpn14-logoThe New Zealand Rural General Practice Network held their annual conference last weekend.

They’ve helpfully recorded a series of video interviews with their speakers and leaders, and these are available here.

Earlier this week, we published this article about the problems faced by rural communities in accessing adequate mobile phone coverage, and fast broadband internet.

This interview with Craig Young of Chorus, a telecoms company in New Zealand, explains some of the strategies that they have adopted to improve rollout of digital connectivity to rural areas of the country.

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Rural connectivity is no trivial matter

Julian_Tudor_Hart_2007-01-19The availability of good medical care tends to vary inversely with the need for the population served.  This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.  The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.

Dr Julian Tudor Hart, 1971

Tudor Hart’s analysis remains a pertinent reflection on the difference between demand and need, and the tendency to inequality when healthcare provision is left to supply/demand (market) forces.  Yet health & wellbeing inequalities have been allowed to worsen due to market forces dictating access to digital connectivity.  Access to a mobile phone network and the internet is increasingly being viewed as a ‘basic need’, and yet there is a wide variation in this access across Scotland.  We are now at a point where unless the issue is taken more seriously, this digital divide between the ‘most and least connected’ threatens to create a very real inequality within Scotland.

phoneTen years ago, it may have been assumed that those living in rural and remote areas should not be surprised to miss out on the opportunity to use their mobile phone for calls and texts, never mind email and internet video.  However, now the poverty of connectivity in rural Scotland is no longer an acceptable fact of rural life.

The threat that poor coverage now poses to rural areas, is such that this deserves to be a high priority issue at corporate and government levels.  The ‘digital divide‘ – the difference between those who have access to fast broadband, 3G/4G cellular coverage and ‘always on’ technology; and those who don’t, has become a driver of numerous subsequent inequalities – access to information, business development, freedom of speech, the right to be heard and interaction with services essential to everyday living.  It is now commonplace for certain services – from both commercial and public organisations – to offer only online ways of interacting,  with the assumption that this is universally available across Scotland.

Even on stripping the necessities for communication right down to functions commonly viewed as ‘vital’ – such as summoning and co-ordinating emergency care – there is a paucity of acceptable network coverage.  For example on the Isle of Arran, we see the following examples of the difficulties presented by poor mobile phone coverage:

  • Difficulty in contacting on-call staff including medical and midwifery staff.  Our system is as safe as we can get it – we carry radiopagers which have improved coverage, but this offers no means to respond to the one-way message that this can send, nor any confirmation that the message has been received.
  • Difficulty for our ambulance First Responder teams – both in missing calls and subsequently volunteers naturally losing interest as they are either tied to their home phone, or have to relinquish their commitment to volunteer on a regular basis
  • The great benefits offered by SMS callout of our Mountain Rescue Team (allowing rapid assessment of who is immediately available) are overshadowed by poor coverage throughout the island – and in particular for the volunteers who live in Lamlash which is a particular blackspot.  This is dependent on 2G only, in an area that includes hospital, ambulance, lifeboat, coastguard, medical, local authority and other centres, including Arran High School.
  • The Emergency Medical Retrieval Service from Glasgow have invested heavily in making the most of iPads and iPhones to achieve and maintain gold standards in critical and transfer care of patients.   However, as our community hospital in Lamlash has no mobile phone coverage, it is impossible to access these unless sticking to offline content.  In addition, this also makes it very difficult for the EMRS team to stay in touch with their base, and maintain phone availability to other rural centres who may also have critically ill patients to discuss with them.  This example is detailed more fully in the NoBars section of this website, and is replicated across rural hospital sites across Scotland.


targetA number of emergency teams on Arran can make use of a basic 2G signal to find the position of a phone during emergency situations.  For example, ambulance service resource tracking (including availability of BASICS GPs) is reliant on GPS-units which continue to send a GPS position over the 2G network. When a medical emergency arises, ambulance control can quickly pinpoint who is available, and where they are.  Without 2G, this function is lost, and this is the case throughout much of Arran and other rural areas in Scotland.

Another example is in the case of finding a missing person, for example lost walkers on the hills of Arran.  In certain circumstances, Police Scotland can trace the signal from a mobile call, and work out its location.  This information allows emergency teams, for example the mountain rescue team, to rapidly reach the missing person or casualty, saving vital time in preventing ongoing injury or hypothermia.

Without any mobile coverage, these functions are simply impossible.

Smartphones are smart

Smartphones are now so commonplace that they bring an almost-universal access to their other key functions.  Email, maps and key documents whilst on the move can all be facilitated by 3G access, and the vast majority of phone customers are already on 3G contracts.  In being prevented the use of 3G functions whilst away from home wifi, this simply causes an even greater void between what is now currently possible, and what is available to folk living in rural areas.

Access to social media is also increasingly important to form and maintain professional networks, as well as keep up to date with medical news and advances.  In my own experience, much of this is possible through Twitter – our colleagues in Australia have been particularly active on this front – and yet, during a typical 8am-7pm day at work it is not possible to engage with social media due to having no connection.

The situation is further exacerbated by the barring of social media sites by many employers (in my case, our NHS IT team) for fear of activating virus activity from online contacts.  With professional and social isolation being a considerable risk and concern in rural practice, this lack of appropriate phone connectivity does nothing to improve social contacts with colleagues elsewhere in the country and further afield.

What about wired broadband?

In addition, we have seen a similar divide develop with access to hard-wired internet connections.  With urban areas now seeing access to rapid fibre-optic connections, many rural areas still lumber on with fixed copper-wire, offering no more than 6Mb/s – and often the connection is as low as 2 Mb/s.  So on both accounts (mobile and fixed networking), we are seeing the digital divide widen at an exponential rate.

Hotels now rely on online bookings and customer review sites.  GP practices rely on networked access to results, records and reporting systems.  Commercial and charitable organisations rely on cloud-based document storage.  Schools rely on adequate IT access to ensure that students are IT-savvy for the wider world.

Scotland, as a forward-looking country, needs to realise the widening disparities being created by differences in digital connectivity.

The double-whammy of 4G

flagFor many of us working and living in rural Scotland, we will look to Germany with some degree of envy.  When 4G technology came along – promising broadband-speed mobile connectivity – mobile network providers were keen to bid for licences, in order to  rollout of this service to urban areas where the money was easiest to make (no problem with that in the context of business).

Germany, at this point, realised the prospect of widening inequalities in access to digital connectivity.  The German Government therefore began their 4G licensing process by prioritising rural areas for 4G licences first.  Only after providing 4G to these areas , could mobile providers then move on to obtaining licences for more urban areas.  This, I understand, has been successful in closing the digital divide, but without significant penalty to those in cities, as high-speed fibre-broadband was generally already available.

In addition, 4G could rapidly become a surrogate for hard-wired broadband access.  The increased costs in laying fibre-optic cable across rural geography is a prohibitive and costly factor for bringing faster broadband to rural communities.  There is some realisation even within the industry, that implementation of decent 4G roll-out to rural areas would improve internet connectivity – as well as the advantages in  mobile phone coverage.

Why the concern now?

If this has long been the case, why the concern now?  Until relatively recently, mobile applications were new, and most folk living in rural areas have come to expect (justifiably) that digital rollout tends to happen in more urban areas first.  That is where the larger consumer-base is likely to be found, and so it makes sense on many levels, including for profit.

However, the last five years have seen a rapid expansion of the opportunities to network at professional, personal and social levels by having access to 3G coverage or more.  Along with this we have seen it become increasingly important to have an internet connection in order to engage with systems – road tax, online shopping, news and media, and especially professional networks.  The loss of local post office services has exacerbated this dependence on online public services.  Videoconferencing is commonplace, and virtual collaboration is essential for progressing with initiatives and projects.  Poor connectivity simply stifles this productivity.

In 1971, Dr Julian Tudor Hart’s work on describing the ‘Inverse Care Law‘ raised awareness of the fact that in order to benefit those who need it most, healthcare should not blindly follow market forces, and that demand does not equal need.  Whilst the telecommunications industry is rightly a highly competitive and demand-led consumer business, it must be realised that telecommunications per se are an essential component to successful, healthy and productive communities.  Scotland needs more effective action to tackle this inequality if it is to benefit from the vibrancy, innovation and productivity available from more rural areas of the country.  It is vital to close this digital divide.

You can find out more about the NoBars project by visiting

CNET story on the importance of rural connectivity

BBC report on the rural digital divide

Photo Credits
Tudor Hart by Wikimedia Commons, Phone by ‘Cubosh‘, Target by ‘happy via‘, Flag by ‘Wiki Commons
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‘From Cart to Air Ambulance’


Papers from a conference celebrating 100 years of healthcare in Skye & Lochalsh

Skye & Lochalsh Archive Centre have come up with this fantastic collection of papers which document the history of healthcare in their local area.  Against the backdrop of the 1912 Dewar Report, they have collected an insightful range of anecdotes, figures, stories and analysis of the healthcare situation over the last one hundred years.

Chapters include:

  • Dewar and the Highland Hospitals
  • Highland Medicine before and after Dewar
  • The Gesto Collection: Dr Lachlan Grant and some Predecessors at Edinbane

Even better, is that this resource is available for free download, and the Dewar Group would highly recommend a look.

Congratulations to the Archive Centre for coming up with such an interesting piece of work.

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RPAS Conference 2013 – a great meeting

This year's conference included BASICS Scotland workshops.

This year’s conference included BASICS Scotland workshops.

The RPAS 2013 Conference was held successfully at the start of November.

Access to all the presentations is now available at this page.

Much thought-provoking discussion was stimulated, particularly in areas of recruitment & retention and aligning rural health care with developments in secondary care – such as in sepsis and acute coronary syndrome.

A twitter feed also resulted from the conference.  You can view this here.  We even had some real-time input from Australia, which was inspiring.

Watch out for details of RPAS 2014 – likely to be similar time next year.

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