Archive | Research

Capturing the essence of rural practice

Dr Kevin Woodbridge, who was the GP for North Ronaldsay in Orkney, was one of the GPs to feature in the original book "Single Handed"

Dr James Douglas, a GP in Fort William, introduces an exciting new project to capture the essence of rural and remote practice in a series of recorded interviews, to complement the “Single Handed” photo-documentary published ten years ago…

The book “Singlehanded General Practitioners in Remote and Rural Areas” was published in 2000 by Rosie Donovan and John Bain.  Rosie Donovan is a black and white photographer and John Bain was Professor of General Practice at the University of Dundee.

Like all good ideas it had a classical simplicity.  John Bain had spotted a medical species which was about to become extinct and had seen some of Rosie’s previous work capturing working people in Canada.  Rosie travelled Scotland to photograph the “GP characters” and capture their thoughts on singlehanded practice.  The stories told themselves and the book became a classic to inform policy and widen understanding of remote practice in Scotland.

The photos even gained a permanent hallowed place in the Royal College of General Practitioners in Queen Street, Edinburgh.  Ten years after Single Handed and the disappearance of single-handed practice, there is a need to capture the thoughts of the current generation of remote and rural GPs in order to guide policy and educational planning in the same manner as the original Single Handed.

While black and white photographs can give an enhanced artistic perspective in portraits there seems to be a need to use new media for a new generation. Thus the recycled idea in a new form!  We hope that this first podcast will be of interest to doctors and students considering a career in remote and rural general practice in the UK.

I would be delighted to get any feedback or contributions to this project!

Dr James Douglas, GP, Tweeddale Medical Practice , Fort William

Dr Iain McNicol was the GP for Port Appin in Scotland, and a founder member of BASICS Scotland.  Dr Douglas interviewed him during a meeting of the Rural Fellowship project held at Skeabost in Skye, in January this year.




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Dot.rural aims to bring together researchers from a wide range of disciplines, in order to explore the digital challenges and opportunities for rural communities across the UK.  Based at Aberdeen University, they have focused on five channels: Accessibility & Mobilities, Healthcare, Enterprise & Culture, and Natural Resource Conservation.

They have recorded presentations and documents from their seminars and made them available as videos – worth a look.

One particular presentation from their Healthcare channel has a very direct relevance for future remote and rural medicine.  Alasdair Mort, Healthcare Research Fellow, has been working on ways of using technology to improve the prehospital emergency response, and seems to have a very pragmatic view of the challenges experienced in this field.

His presentation is available on the Dot.Rural website here (turn the volume up and fastforward a minute)… plus there is a YouTube video below with further information.


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Time to Care: RCGP reports on Rural Deprivation

RCGP Scotland has just released its report Time to Care – which aims to be a pragmatic contribution to the efforts in improving healthcare to Scotland’s most deprived areas, including rural areas.

The following explanation, taken from the Foreword, outlines why the report is not to be seen as “yet another” document outlining the already-knowns in health & deprivation…

“At the outset, the working group made three decisions. First, given the plethora of reports on inequalities in health, collating research evidence, there was no need to produce another report of this type. Second, the report would not comprise a “toolkit” for general practitioners, implying that others know the answers and general practitioners simply need to implement the solutions.

Third, the working group would engage with general practitioners working in the most deprived areas, capture their experience and views, and communicate these findings to others.  This would focus on the 100 practices serving the most deprived communities in Scotland (which we named the ‘Top 100’ practices) but would also include general practitioners working in remote and rural areas out-with the Top 100 as there are many people living in pockets of severe deprivation which are not large enough to register within analyses of deprivation based on datazones. We also commissioned a short review of the literature on the challenges faced by these communities (Chapter 4).”

The report is available from the RCGP Scotland website.

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Tranexamic Acid in Major Haemorrhage

The CRASH-2 trial was published in the Lancet in June 2010, and presents strong evidence for the use of tranexamic to reduce haemorrhage in the context of major trauma.  The fact that tranexamic is cheap, seems to be safe, and is easy to obtain & administer makes it an attractive drug for general use. The study used a 1g IV bolus over 10 minutes (within 8 hours of injury), followed by 1g IV infusion over eight hours.

It would seem that tranexamic acid may have the particular potential to benefit patients who have suffered major trauma in rural areas, where the logistics of transfer/retrieval can result in prolonged time to definitive surgical care.  Permissive hypotension is standard practice, with a similar rationale to avoid destabilising clot formation that has already occurred.  The question now is whether it can be used routinely in rural community hospitals, or even by emergency responders such as  BASICS GPs, or is there a need to wait until more specific guidance?  In a bid to gauge its current use, a discussion has been start on the RuralGPNetwork, and any relevant updates will be posted here.  In the meantime comments are welcomed below too.

  • The original article (PDF;  The Lancet).  CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with signifi cant  haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; published online June 15. DOI:10.1016/S0140-6736(10)60835-5.
  • The associated editorial (PDF; The Lancet) by J Levy.

Dr Levy has also issued a YouTube video on this paper:


… and The Lancet has recorded its press conference when the paper was published: you can listen to it here.


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Portable Head CT Scanning

Access to CT scanning has risen in importance, particularly with the tight timescales for stroke thrombolysis.  However, scanners still have a relatively high cost, in many cases too much for smaller community hospitals to justify (or have space for). This means that stroke patients can only achieve thrombolysis if rapid identification, assessment and transport to mainland facilities are available.

Yet rural populations often have a larger proportion of patients who are at risk of cerebroembolic events, to the extent that such presentations can be considered common.  The challenges of accessing CT facilities were raised in a recent article in the Scottish Medical Journal (Todd & Anderson, 2009)

So it’s interesting that the Summer edition of the Canadian Journal of Rural Medicine includes an article about the use of portable CT head scanners.  These are lower in cost, require less space and – as the article highlights – potentially more feasible for the community hospital setting.

So what does it look like?  There are various videos on YouTube but most are quite dated.  The best I could find was this video about similar scanners which are used for paediatric imaging in the USA.

If/when we emerge from the current cutbacks, perhaps this is on the horizon for our rural hospitals, stored next to the portable Xray machine?!

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Being a new mother in rural England

Another report from the Commission for Rural Communities has been published, this time focussing on the challenges of providing and accessing maternity services in rural areas [link no longer available].

Recent health policy has focussed on patient choice.  However, as the report states: “Delivering these choices in rural areas, presents particular challenges. With less availability and variety of provision in rural localities, choice can often only be exercised by women who are able to draw on their own resources, particularly in relation to capacity to access information and transport. It is therefore unclear whether ‘choice’ in maternity services actually helps to address inequalities but may instead serve to aggravate them.”

RuralGP was alerted to this item via the Institute of Rural Health Newsflash, a regular compilation of rural health items which is sent to IRH Associates.
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Being a young carer in rural England

“In the UK there are 175,000 children under the age of 18 who are informal (unpaid) family carers. There are also 230,000 young adult carers aged 18-24, Rural young carers face particular barriers in accessing and receiving services and support, compounded by distance, lack of adequate public transport, isolation, stigma and lack of privacy”.

This report from the Commission for Rural Communities highlights the challenges and barriers for young carers, that are particular to living in a rural area.

RuralGP was alerted to this item via the Institute of Rural Health Newsflash, a regular compilation of rural health items which is sent to IRH Associates.
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PhD in Rural Health

The Welsh Government has recently been developing a Rural Health Plan and is in the process of starting the process of implementation. In parallel to this the University of Wales has established a Scholar programme – one of these Scholars will have a responsibility for Rural Health and will be based with the Institute of Rural Health and the University of Swansea.

The Scholar will have a research role and will be involved with the evaluation of a number of the rural health projects established by the plan. Instead of the Rural Scholar being answerable to a commercial company (as stated in the advert), he/she will be answerable to to the Rural Health Plan Implementation Board and the University.

The Scholar will receive a bursary and expenses. He/she will be expected to write up their PhD at the end of the three years.

For details, see the advert.  Note that whilst the closing date for expressions of interest was in June, it may still be possible to apply – contact the office for more information.

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Study: Rural Placements for UK Medical Students

It’s increasingly recognised that rural practice can offer undergraduate medical students excellent learning opportunities, with higher-than-average satisfaction compared with their urban counterparts.  There can be many reasons for this, not least that students are often forced into immersing themselves in the local community, as a rural placement will normally involve staying within the locality, instead of being able to return home from an urban practice which is normally easier to commute to.

Furthermore, there is good evidence that giving students a good experience of rural practice during the early stages of their careers, stimulates a considerable number of them to seriously consider taking up rural posts once more qualified.  That’s certainly the case in my experience, when a fulfilling 5 week placement at the Group Practice in Stornoway made me think more about rural general practice as a career option.

However, how rural practice is offered to undergraduates, is implemented in many different ways across the UK.  Of course, that is no bad thing, but we are starting to better understand the relationship between early student experiences and later career choice.

This piece of research from the IRH considers the rural practice opportunities for students at Keele University, and reports on some of the key findings from conversations with students who have benefitted from such placements.

>> Rural and Remote Health Journal – View Article.

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Feature Link: Centre for Rural Health

There’s always been a link to the Centre for Rural Health from this blog, but they’ve recently made some great improvements to their site.

The Centre is based in Aberdeen University, where there seems to be a lot of rural research going on – for health as well as other topics too.  Aberdeen is now home to one of 3 UK Rural Digital Economy Hubs. In April, the University was awarded £12.4 million to investigate how digital strategies can help enhance rural communities, including the potential benefits for healthcare.

You can see a full list of the Centre’s current research projects on their website.

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