Future Practice: A Review of the Scottish Medical Workforce
2.2 Doctors in remote and rural areas
This is a particularly important issue for Scotland.
Delivery of acute and elective care is influenced by distance and access to expertise.
There is a need to define remote and rural practice and to recognise that, as a consequence, there are specific requirements and strategies for delivering health care.
Traditional models for the medical staffing of small general hospitals will be difficult to sustain in the face of increasing specialisation and constraints on working hours.
Networks, including managed clinical networks, provide one way for sustaining services.
Many of the strategies for delivering remote and rural health care are also relevant to delivering care in the remainder of Scotland.
42. This section deals with the remote and rural dimension of medical workforce planning. It complements work being led by the Remote and Rural Areas Resource Initiative (RARARI) and builds on the recent report of the RARARI Solutions Group 13.
43. Remote and rural areas share most of the workforce and service delivery issues that apply elsewhere in Scotland. However, some difficulties are intensified because:
Together these two factors make services vulnerable.
44. There is no standard definition of remote and rural clinical practice. We feel that there should be. Providing one will make it easier to identify, promote and develop strategies for the remote and rural environment and to commit to particular investment and actions.
45. We do not offer a definition here but one way of approaching this is to look at geography. Broadly the islands, north and west highlands and the south-west experience the effects of scarce resources and the impact of distance most intensively, though other areas can also have long drive-times to services. The two maps and accompanying charts illustrate the 'drive-time' to reach a hospital accepting acute admissions 14 and to a major accident and emergency unit 15. The charts confirm the proportions of the population across a spectrum of drive-time (from less than 30 minutes to greater than 120 minutes). They provide a useful guide:
Chart E: Scottish Population Drivetimes to Acute Admission Hospitals (%)
Chart F: Scottish Population Drivetimes to Hospitals with A&E Units (%)
Drivetimes for Hospitals Accepting Acute Admissions ( see footnote 14)
Drivetimes for Hospitals with Accident & Emergency Units ( see footnote 15)
Doctors delivering services
46. In remote and rural areas uncertainty and lack of knowledge about the services that are available and how they will operate to meet particular needs can compound patients' anxieties about their health and health care. There are a few centres offering limited secondary care and thus there is a necessary reliance on larger urban centres to provide more specialised services. There is no consultant-based Accident and Emergency service, as we have defined in the accompanying charts, in any of these areas.
47. We believe that it is feasible to sustain and improve quality services in remote and rural areas, but only if expectations about those services are realistic. There is a balance to be struck between providing equity of access to services and the standards of care that the services can deliver. This was recognised in the Acute Services Review.
48. The public and professional staff need clarity about what are core local services delivered by resident health professionals, and what services should involve travel to or from larger centres by staff or patients. This means distinguishing clearly between situations where travel time is linked to risk and where it is simply inconvenient.
49. Appropriate arrangements will vary by locality. It must also follow that the way standards of care are defined should allow for variation in the methods used to achieve the standards.
50. These issues must be addressed clearly and honestly at community level and with full public involvement. We feel that the experience of doing so will provide valuable insight for the whole of Scotland into determining optimum strategies for delivering modern, sustainable services.
51. Flexible models of service provision. Network supported approaches to service delivery are essential to make the most effective use of scarce and dispersed resources, both for the delivery of care and for the maintenance of clinical skills. Networks must be used imaginatively and include:
'hub' and 'spoke' practices in primary care linked to increased support to small remote practices;
developing the role of community hospitals to deliver more acute care closer to home;
teams with multi-professional membership working across the primary/secondary care interface;
managed clinical networks; their development should be accelerated and extended, and they should be managed positively;
further and more effective linkage of central to distant secondary care facilities to support services and staff development in the distant centre;
'hot' (emergency) and 'cold' (elective) pairings of secondary care facilities;
'lift and run' arrangements linked to emergency centres (see paragraph 55);
creative partnerships with infrastructure services such as the ambulance service, NHS24, local authorities and police; and
maximising the benefits of new technology for service delivery and professional development through Telehealth16.
Such networks can co-exist with local service arrangements, should be recognised in the community planning process and in Local Health Plans and be provided and managed in a coherent way. They should involve partnerships across the spectrum of the healthcare community. Local Health Care Co-operatives (LHCCs) have an important role to play.
52. Flexibility includes developing (training) specialists within primary care and generalists within secondary care, and planning for effective and sustainable use of intermediate care (see paragraph 27). It includes multi-professional teamwork and a realistic assessment of how different types of services can be 'packaged' or grouped more effectively and delivered across geographical and organisational boundaries. There are markedly different models from which to learn, for example, experience across the different island groups. Study may show that different practices reflect local circumstances and the individuals involved, but may also reveal scope for greater consistency.
53. General practice. The national GMS (General Medical Services) contract for GP services no longer adequately supports solutions for each remote community. The PMS (Personal Medical Services) contract option, which is now available, offers options for that flexibility through the provision of services that reflect local needs. The RARARI Solutions Report (see paragraph 42) is supportive of this development. Out of Hours Co-Operatives have been successful in supporting changes in working practices amongst GPs.
54. Small remote and rural hospitals. Known and expected pressures on the medical workforce, especially the Working Time Directive, mean that the current arrangements for delivering acute services in small remote and rural hospitals cannot be sustained in isolation where the workload is inadequate to sustain clinical skills or education and training in sufficient volume to allow deployment of training doctors. The hospitals we have in mind are:
together with even smaller hospitals supported by outreach services, such as those in Stranraer and Arbroath.
55. There are three basic options for handling access to acute services provided in such hospitals at nights and weekends:
increase the number of specialist staff;
increase service outreach of specialist staff from larger centres linked, where practicable, to rotational training programmes for junior doctors incorporating both central and remote and rural hospitals; or
change the hospital to a community hospital with more specialist general practitioner and nurse practitioner input and improved patient transfer arrangements for urgent situations ( 'lift and run').
56. We believe these options and combinations of them need to be appraised taking into account issues of:
sustaining service quality;
the affordability and availability of skills;
public awareness and public expectations; and
increasing difficulties in recruiting and retaining staff.
Doctors as health professionals
57. Remote and rural service provision depends on the recruitment and retention of staff in the face of some influential negative factors. Targeted incentives are needed to overcome practical drawbacks of rural life for the individual and his or her family. The positive aspects of rural practice need to be sold more effectively to:
trainees who may not be aware of them. Training for doctors in remote and rural areas needs to be supported by developing appropriate rotational training opportunities to and within that environment; and to
practitioners working in these areas who will benefit from participating in personal development programmes to maintain the breadth of clinical competence required. They need to be sure that a rural post will not be an isolated or dead-end experience without scope for professional development. If necessary there should be strategies to enable return to 'main-line' clinical practice.
58. These factors apply to all health professionals (not only doctors) in remote and rural areas. The section on recruitment and retention beginning at paragraph 82 applies to all Scotland but its messages have particular importance and sensitivity for remote and rural areas.
A cross-cutting infrastructure to support planning
59. There are proposals for a regional dimension to service planning and workforce development and our recommendations at (see section 4) reinforce that trend. However, the remote and rural fringe of Scotland cuts across potential regional planning units. We think it is important that the infrastructure for supporting remote and rural service solutions, including the use of technology, training provision and interchange of staff, should be organised in a coherent cross-cutting way across the proposed regions and not split to function separately within each of the new regions.
Recommendations (doctors in remote and rural areas)
remote and rural practice;
core services for each remote and rural community; and
standards by outcome, allowing variation in methods to achieve them.
14 Conduct an option appraisal for maintaining acute services in small hospitals.
This is urgent
15 Politicians, managers and professionals to engage with and involve the public in the process of determining effective, sustainable services. This is urgent
16 Maximise effective use of staff through flexible arrangements for service provision supported by networks:
17 Establish remote and rural strategies for staff development but linked to proposed regional planning provisions.