Rural communities deliver but are they getting their fair share of the spoils? Personally, I don’t think that they are, and I don’t think I’m alone in this. I will digress for a bit – let’s look at some economic facts.
Whisky comprises 70% of Scotlands food and drink exports. It’s not a major employer but indirectly supports many jobs in transport and retail & hospitality sales. The whisky industry on its own contributes £6.2bn to Scottish exports and supports rural communities throughout Scotland.
Scottish exports of fish and seafood reached £1.04 bn in 2022 – a 2% increase compared to 2021. Scottish salmon alone accounted for 40 % of the U.K. seafood exports in 2022.
These are our biggest exports. Where do they come from? Where is our food grown? Where does our clean water come from? All of the aforementioned are products or resources that have their origins in remote / rural areas of Scotland.
Lack of basic needs resulting in rural depopulation
What about the human capital from remote and rural areas? If they don’t have jobs, efficient services, internet links, access to education, healthcare, arts and culture, they leave! In order to stop the exodus of young people and skilled workforces, leading to depopulation and skill shortages we need to do something radical. It’s all very well talking about a well-being economy if the resources are available to everyone, irrespective of whether they are city dwellers or live on an island. We can’t however leave it to a fast-diminishing population in the hinterland to deliver for the rest of us.
What does a wellbeing economy mean? Is it management speak or purple prose? What does it mean to the farmer struggling to maintain high yields to satisfy the needs and wants of our food manufacturing industries…our food security?
What I want to focus on here, is what most ordinary folk understand to be integral to a well-being economy and that is healthcare.
An unmanaged decline in rural healthcare
Gone are the days when a rural GP practice comprised a single GP supported by a nurse trained in midwifery and district nursing. They have been replaced with “multi-disciplinary teams” based in health centres in country towns rather than villages. Recruitment of these “ multi disciplinary teams” has proven to be a considerable challenge for rural & island areas.
As an NHS activist, I’ve spoken to those that have had first-hand experience of rural & remote general practice in particular, and been made aware that people in the front line are currently feeling they are being ignored. These are healthcare professionals that have provided expert solutions to serious challenges we now face, that have been and still feel they are being ignored. Reports, papers on areas of improvement, emails with policy feedback to our MSPs and MPs have been sent and little or no assessment been given. Communication with Scottish Government officials and politicians sadly is practically non-existent and there’s a frustration and weariness that sets in when healthcare professionals realise that they are not being listened to.
All of this become too much for some in general practice and they leave for sunnier climes or retire early.
It’s time to get the whole story out around the demise of rural healthcare and the lack of a coordinated and constructive response to put things right. It’s payback time! It’s time to listen to those that form the backbone of our communities in rural and island communities. They are making a huge contribution to the well-being of Scotlands economy. It’s time to recognise their contribution and provide them with the healthcare they deserve but not to the detriment of those in urban areas. If a well-being economy is to be fairer for everyone, it’s time to start listening to their concerns in general practice especially.
GPs feel frustrated, stressed and undervalued
Having interviewed several GPs over the last few months, it has become evident that they care. Frustration at not being able to provide the care that their patients need, now manifests itself in chronic levels of stress. A vicious cycle has ensued. How can a GP provide the levels of care needed if stressed to the point that they themselves become ill or decide enough is enough and retire or move abroad, where conditions and salaries are more in line with the responsibilities they deal with on a daily basis? Our GPs want to deliver but are being thwarted at every turn. In rural & island areas conditions have deteriorated.
GPs feel undervalued and rightly so. Daily criticism from the right-wing media is adding to their stress. I’m not going into the failures of successive Westminster Governments to address the crisis in GP practice or indeed the wider issues around healthcare in England & Wales. The amateur attempts of an increasingly right-wing government at resolving issues around GP practice are not what the Scottish Government should be looking to adopt, if we are to heal this gaping wound in rural healthcare that has been left untreated for far too long. We must not allow this wound to fester and get to the stage where any measure taken to promote healing is pointless. This article focus on GP practice, but in particular rural & island healthcare provision because, as already mentioned, in order to deliver and support the Scottish government’s goal of a well-being economy we need to look after the people that are providing the means by which a well-being economy is attained. It should be emphasised that in Scotland our healthcare provision and practice is devolved to the Scottish Government. It is our government in Holyrood that has overall responsibility for ensuring that healthcare is delivered in Scotland.
Phil Wilson, Professor of primary care and rural health at Aberdeen University & acting chair of the Rural GP Association of Scotland highlighted in a recent article that it’s been a century since Sir John Dewar established the Highlands & Islands Medical Service.
Sadly the service hasn’t been maintained at the level experienced by earlier generations. The last GP contract negotiated in 2018 between Scottish Government and the British Medical association was only supported by 28% of GPs. Professor Wilson stated he couldn’t find a single rural GP that had supported it. There was no allocation of cash to rural GPs. Instead, the support for hospital treatment and vaccinations was removed, replaced by “ multi-disciplinary teams”.
Recruitment & Retention
Recruitment of rural GPs in Scotland is an ongoing challenge. Vacancies are at an all time high, with “vacancy heatmaps“ showing that every area in Scotland is affected by staff shortages.
The difference between urban and rural GP vacancies is stark. In Glasgow the vacancy rate is 3, in Orkney it’s 12 and Shetland 25 per 100,000 population.
The Scottish Government have introduced a £20,000 incentive bursary to help fill rural vacancies. To qualify, trainee GPs have to commit to a contract lasting between 24 and 36months in an area where vacancies have been hard to fill.
Leaving aside the measures in place to retain staff, it’s obvious that reform of terms & conditions is vital if retention of GPs is to be at the forefront of a rural & remote healthcare service that will improve health to a level which impacts the economy in a positive way.
New initiatives to recruit and retain GPs to rural & island posts are urgently needed. Research has determined that other elements of a good life, such as opportunities to interact socially within a community, housing and educational provision for those doctors with families, are as important as the job itself.
Has there been progress in recruitment?
The Scottish Government continues to commit to the New Deal to support trainee GPs. The BMA says 113 new GPs have been recruited since 2017. The Scottish Government Health Secretary Michael Mathewson says 291 new GPs have been recruited since 2017.
It’s perhaps immaterial who is quoting the correct number as the target set in 2017 was 800, so neither figure is anywhere near being achieved. What is important to note, is that it’s still not enough. Areas in the islands, where single GP practices are the norm and additional skills such as operating a small boat to do home visits are a requirement, additional support is needed, which is not being delivered. When asked, the rural GPs are agreed that the 2018 GP contract doesn’t take account of local practice conditions in rural & island practices.
Despite research outcomes across many western countries finding that GPs who work in rural areas often have higher levels of job satisfaction than those in urban areas, GP retention in rural & island areas is a challenge.
Practice closures are on the increase with contracts being handed back to health boards on a regular basis. Figures published in May of this year show Scotland has lost nearly 90 surgeries in the last decade – with almost one in 10 having closed their lists to new patients. As a result of lists closing, some patient groups have become disenfranchised, due to remaining practices forming clusters in larger towns, sometimes miles from where they are needed.
Scottish government are addressing issues around rural & island General Practice
To improve the quality and availability of primary healthcare across rural and island communities, the Scottish Government established the Remote and Rural General Practice Working Group in 2018. Their report “ Shaping the Future Together “ was submitted in 2020 and the Scottish Government accepted all the recommendations contained in it, including the establishment of a National Centre for Remote and Rural Healthcare for Scotland. Also, in March 2022, the Scottish Government published a Health and Social Care National Strategy committed to developing a Remote and Rural workforce recruitment strategy by the end of 2024.
Total additional funding of £600,000 to support recruitment has been allocated. More recently in June this year, the Scottish Parliament Committee for Health, Social Care and Sport launched an inquiry to investigate concerns of healthcare staff and people working and living in remote & rural areas, particularly around accessibility to healthcare as a means to better understand the specific challenges experienced by people in these areas, where records show the greatest population growth over the last ten years. The committee is already aware that recruitment and retention of health and social care, training for staff and access to services are issues that need addressing.
Let’s hope their primary focus is on improving terms & conditions for rural GPs and an evaluation of why the 2018 GP contract needs revisiting, both long overdue.
As Philippa Whitford has stated: “Independence is key to protecting and strengthening NHS Scotland, for the next 75 years, and investing in the health and well-being of our people – it is only with full powers we can build a fairer, healthier country in the future.”