Archive | Reports

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 www.ruralgp.scot

Click to download the report (2.6MB, PDF)

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Setting the right path for Canadian rural practice

Thanks to Dr Douglas Deans for highlighting this recently-published report from a collaborative taskforce in Canada, which has been set up to identify positive actions that are likely to result in a more robust, sustainable and supported rural health service in Canada.  The collaboration comprises the Society of Rural Physicians of Canada (SRPC) and the College of Family Physicians of Canada (CFPC).

The report is refreshingly succinct, relevant and pragmatic, and likely to be of interest to anyone who is trying to work out how to articulate the balance between effective action and strategic direction to influence national policies, in the context of conflicting and difficult policy decision-making.  Many rural GPs and educators will be familiar with the challenge of identifying realistic interventions which can translate into more sustainable recruitment and retention to rural communities, so this road map from Canada is likely to be a welcome read.

Recruiting and retaining family physicians in rural areas through financial incentives alone is not enough.  We need a coordinated and thoughtful alignment of education, practice policies, community involvement, and government support.  Family medicine residents who are educated in rural training sites, who immerse themselves in the communities and who see themselves supported by peers, specialists, health care providers, and evolving distance technologies, are more likely to choose rural and stay rural.

Dr Trina Larsen Soles – SRPC Co-Chair of Taskforce

News Release   Download the Report

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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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Report from Islay: GURRMS Medical Student Conference

Student led conference in Islay provides novel long-term solution to rural GP recruitment

By Keenan Smith, Gregor Stark and Alistair Carr

Six months ago, we were sitting in the Glasgow University Union listening to Alistair explain his plan. He’d just returned from a five week GP placement on Islay where his eyes had been opened to the challenges and excitement that lay in rural general practice.  Despite the recruitment crisis facing general practice everywhere, and rural general practice in particular, he was convinced that if other students could experience what he had, it would inspire them too.

That evening, the five of us formed the Glasgow University Remote and Rural Medicine Society (GURRMS).  Our founding goal was to host a conference with a real and lasting impact.  With a message that no delegate could ignore: rural GP provides an exciting and dynamic career that should not be written off as a sleepy backwater of a career.

We wanted to create something that would change not just how 60 medical students thought, but that would become a staple of the undergraduate social and educational calendar – changing perceptions for years to come.

If we were going to make that much of a difference, we were going to have to think big.  We knew this had to show off everything that rural practice had to offer and that this meant going to Islay.

The Gaelic College in Bowmore was the conference venue

To say we didn’t have doubts would be a lie, we had thousands, but the largest was the central premise of the entire project: if we offered this to students, would they even want to come? A close second to this was: how would we find the funding for a conference involving the immense logistical challenges of providing transport, accommodation, and catering in an island with a permanent population of 3,500.

Despite our reservations our 60 delegate tickets sold out within four and a half hours – clearly demonstrating the demand among medical students for more exposure to rural practice. Following this, we were successful in securing sponsorship from organisations that were able to appreciate the vision and scope of what we were trying to achieve.

Dr Angus MacTaggart explaining the joys of being a rural GP

When Friday 10th of March came around, every seat in the Gaelic College was filled with eager students. Most were from Scotland but some had come from as far away as Plymouth, Oxford and Hull.

A spectacular view across Loch Indaal was the backdrop to the inaugural National Undergraduate Remote and Rural Medicine Conference. The morning session started with a talk by Dr Angus McTaggart defining what rural medicine is and the rewards it can offer. This was followed by the EMRS team talking about their role and how they interact with rural GPs.

EMRS doctors Michael Carachi and Kevin Thomson

Following a short break Dr Kate Pickering talked about the importance of medical leadership, after which a workshop took place. This gave the opportunity for two of Islay’s retired GPs, Drs Chris Abell and Sandy Taylor, to engage the students in a discussion about the benefits and challenges of working in a rural environment. Simultaneously to this another workshop took place, led by the Rural GP Fellows Drs Jess Cooper and Durga Sivasathiaseelan, leading a discussion about how to act in a rural emergency and also providing information about the Rural GP Fellowship programme.

During lunch the students chatted with patients who had volunteered to come in to speak about their experiences of rural healthcare and also to give a flavour of island life. Following lunch, Mr Stuart Fergusson kicked off with a talk about rural surgery in Scotland, after which Professor John Kinsella, Chair of SIGN Guidelines, gave a talk about the limitations of guidelines in a rural setting where he made the interesting comparison of rural medicine to the ICU environment.

Obligatory visit to sample local produce!

After another break, with more excellent catering by the Gaelic College team, the EMRS guys provided a brief overview of the realities of pre-hospital care which was then followed by five student presentations. These provided a showcase of the projects that students have undertaken whilst on rural placements or undertaken during intercalated degrees. The educational content of the day finished with a panel discussion about what Realistic Medicine is and how that applies in the rural context.

The Saturday was used to explore rural life and further experience the community we were being invited to be a part of. Some of the students explored the beautiful scenery by going for a hill walk and some participated in a joint RNLI and coastguard training exercise which involved three of the students being winched out of the sea. For the students that had caught wind of Islay’s whisky reputation, a tour of the Bruichladdich distillery was arranged where they were treated to some proper Islay hospitality.

Students participating in the Saturday hill walk

The informal feedback we have got thus far has been overwhelmingly positive: certainly more than one rural elective is being sought after last weekend. A recurring theme has been how impressed students were by the strength of the island’s community and the generosity of the locals.  Formal feedback is in the process of being collected and will be made available in due course.

The 2017-18 GURRMS committee has now been elected and have exciting plans for the future. Watch this space!

GURRMS 2017-18 committee – what does the future hold?

Cool shades featured throughout the conference!

GURRMS would like to thank all our speakers: Dr Angus MacTaggart; Dr Michael Carachi and Dr Kevin Thomson; Mr Stuart Ferguson; Dr Kate Pickering; Dr Jess Cooper and Dr Durga Sivasathiaseelan; Dr Chris Abell and Dr Sandy Taylor; Professor John Kinsella; Cameron Kay; Beth Dorrans; Josie Bellhouse; James McHugh; Eloise Miller and Hannah Greenlees.

Also our sponsors: the Royal College of Physicians and Surgeons of Glasgow; the Rural General Practitioner Association of Scotland; the Faculty of Pre-Hospital Care of the Royal College of Surgeons of Edinburgh; the University of Glasgow; NHS Highland and Bruichladdich distillery.  And finally a huge thanks to all of the medical team of Islay for your support and for believing in us.

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New: Historical Perspectives on Rural Medicine

A key new text reflecting the development of rural practice over the last century, has just been published by the Wellcome Witnesses to Contemporary Medicine series.

Introduced by Professor Geoffrey Hudson, this volume comprises edited transcripts of two Witness Seminars held in 2010 and 2015 on the history and development of rural medicine. Participants in London and others world-wide contributing via video link, addressed the development of the curriculum for teaching rural and remote medicine; the importance of community involvement; and the growth of national and international networks and organizations. Discussion also included: the impact of specialization; professional identity and status; the relationship to other health professions; technological developments; and the challenges of isolation.

The collection of evidence for the series included input from UK rural GPs Jim Douglas, Gordon Baird, John Wynn-Jones, Iain McNicol, Jim Cox and David Hogg.  International stalwarts included Bruce Chater, Roger Strasser, Jim Rourke, Sarah Strasser, Ian Couper, Richard Hays, Oleg Kravtchenko, Tanja Pekez-Pavlisko and Jo Scott-Jones.

Subjects ranges from pre-NHS rural practice to modern day technology, and the use of that for activities such as Practice Based Small Group Learning, and initiatives such as the Northern Ontario School of Medicine, and Scottish GP Rural Fellowships.  Themes include 24-hour working, the psychosocial stresses of rural medicine, and the interface between generalist practice and secondary care.

Making this tome available as a free online PDF means it can be easily accessed and searched, including for future research activity.  You can also purchase it online at amazon.co.uk (RuralGP.com does not receive any commission from this).

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BASICS Scotland reports on over 15,000 hours of tele-education

BASICS Responders provide prehospital care across Scotland, especially in rural and remote areas.

BASICS Scotland – the charity that promotes the provision of high quality pre-hospital emergency care by health professionals across Scotland – recently produced a report that brings together experience of providing over fifteen thousand hours of online educational material.  And the conclusion: it’s cost effective, it increases access (particularly to remote and rural practitioners) to high quality education, and it works.

Tele-education has been available from BASICS Scotland since 2011, and since then the team have built on their experience to improve the learner’s experience, and reflect on what makes this form of learning most accessible.

Some participants manage to join these sessions in real-time, but the sessions are also recorded so they can be viewed at a later date via the BASICS Scotland website.  The sessions are usually packaged to run over ten weeks, covering adult and paediatric emergency prehospital care respectively.  A dedicated IT Facilitator assists participants with any initial difficulties in using the Adobe Connect software – which has proven to be an effective platform on which to deliver the content.  Participants who are watching in real-time are able to ask questions or type comments, and all of this is recorded for later viewing too.

As well as tele-education, BASICS Scotland also uses this technology for its Clinical Governance meetings (open to all member responders) and for Board meetings.  Scottish rural broadband speeds continue to pose some problems, but having knowledgeable IT assistance allows some of the technicalities to be tweaked, to maximise the use of available bandwidth.

The report (PDF) can be downloaded from the button below.  Further details on the tele-education programme can be found here, along with all the other training opportunities that BASICS Scotland provides.  A BASICS Scotland tour of the Adobe Connect platform can be found here.

Download the report here (PDF 733KB)
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New research: rural recruitment & retention

rural-4In January this year, I was contacted by Pauline von Zabeltitz, a final year student at the University of Aberdeen, who was studying for an MA (Hons) in Economics and International Relations.

For her dissertation, she was keen to explore the various projects and initiatives being used to improve recruitment and retention to rural GP practice in Scotland.

Pauline has very kindly agreed to having her dissertation published on RuralGP.com in order to share the analysis that she has undertaken over the last six months.  Her report provides yet more substance behind some of the core issues that we know affects rural recruitment & retention, whilst providing another perspective and some new ideas to add to the present work on this area.

Coming from a family with a strong medical background, healthcare related issues have always been of great interest to me and throughout my degree, I got the chance to explore this topic further through a Health Economics course. Discussing Health Economic issues and policies led me eventually to my final Dissertation topic, writing about the recruitment and retention issues in rural Scotland regarding healthcare providers such as GPs.

Specific issues highlighted include rural connectivity, access to undergraduate placements and the GP Rural Fellowship scheme.  She manages to cover a wide spectrum of other considerations, and some evaluation of present approaches to this problem.

You can download her report by clicking on the button below.

An analysis of current initiatives targeting the recruitment and retention of GPs to remote and rural Scotland [1.4 MB]

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Scotland OOH Care Report now out

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Rural OOH presents specific challenges

The widely anticipated report into safeguarding the future of Scottish out-of-hours care is now available.

Led by Prof Sir Lewis Ritchie, the report – commissioned by the Scottish Government – offers a comprehensive assessment of the challenges and opportunities into providing sustainable, quality out-of-hours care across Scotland.  The challenge of recruiting GPs (amongst other health professionals too), the rising demand from comorbidity and our ageing population, as well as rising expectations generally… make for a tricky landscape for which to design a strategy like this.

However, the opportunities in more co-ordinated working, building on the strengths of integrated teams and more effective (and efficient) approaches to unscheduled care – appear to be a cornerstone of the report, which was published yesterday.

In addition, it makes clear that the service needs to seize more benefits offered by technology – for example in remote assessment and co-ordination of service providers.  Technology cannot offer all the solutions, but we need to be better connected.  It is apt that another story ran yesterday about the scale of the lack of connectivity in rural parts of the UK – and that’s just on the roads.  The need for high-level pressure on connectivity providers is clear, if the recommendations of the OOH report are to be realised.

Another welcome observation is that OOH can be a stimulating area of practice, and a useful learning environment – for students, GP trainees and other practitioners wanting to increase their experience of unscheduled care.  There is also a hint towards the fact that current OOH centres often struggle to offer appropriate rest/catering facilities for their staff.

There is regular consideration throughout the report of the ways in which services have to consider local geography and other service provision.  It appears to be a great example of a rural-proofed document, that takes Scotland’s rural populations well into account in its recommendations.  There is a lot to digest, and of course the challenge will be in implementation.  However, as a major stepping stone towards a more sustainable OOH service, it appears to hit the mark.

The report is available in full here: http://www.gov.scot/Publications/2015/11/8463/downloads

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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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Dewar 2013 – Outcomes Report

Miles giving his radio interview at the Dewar 2013 Conference.

Miles giving his radio interview at the Dewar 2013 Conference.

A report of the Dewar 2013 conference is now available – highlighting a very broad approach to some very acute problems being faced in rural Scotland.

Written by Dr Jim Douglas of Fort William, the report covers the many areas explored during plenaries and breakouts that took place during the conference, which was held in Fort William in April this year.

You can download the report here.

 

 

 

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