“What are the factors that make remote and rural General Practice a rewarding and satisfying career choice and what more could be done to increase that reward and satisfaction to ensure a sustainable future for remote and rural healthcare”.
Dewar Committee 1912
Medical provision in the Highlands has always been challenging due to the geography and isolation of many of the communities.
In 1912 the “Report on the medical Services of the Highlands and Islands” or Dewar Report gave a stark description of the inadequacies of medical services of the time, the justification for exceptional treatment and a proposal for the future. As a result the Highlands and Islands Medical Service (HIMS) was established as the first state funded and centrally planned health service some 30 years before the NHS. By 1936 the Cathcart Report noted:
“This service has revolutionised medical provision in the Highlands. It is now reasonably adequate in the sense that for all districts the services of a doctor are available on reasonable terms.”
The success of the service led to other areas lobbying to be included and indeed one of its administrators sat on the Beveridge Committee, influencing the development of the NHS across the UK.
Despite this proud past the organisation of General Practice in these remote areas is again under strain: –
- As the NHS developed the General Medical Services (GMS) contract failed to meet the needs of these GPs leading to the creation of “inducement scheme” which itself had serious flaws
- The GMS contract as renegotiated in 2004 had no specific recognition for the needs of these practices, many of whom are reliant on the “minimum practice guarantee” to maintain their viability but this was only ever meant as a stop-gap answer
- Many areas are again struggling to recruit suitably experienced doctors resulting in piecemeal solutions to each locality
- Despite carefully constructed training schemes it is increasingly difficult to attract newly qualified doctors to train and work in the Highlands and Islands
Having said that, many of the doctors working in these areas also report the work to be satisfying and challenging, in equal measure. The experience of these doctors, their communities and NHS organisations is urgently needed to plan healthcare delivery to these areas.
Dr Lachlan Grant
The methodology for Dewar has many similarities to modern day qualitative research. His committee collected existing evidence, surveyed the remote and rural doctors and other stakeholders and drew up proposals for change from the answers received from those subsequently interviewed. Many of the themes from that time such as contractual arrangements, domestic logistics, technology and professional isolation appear to remain relevant to the present time.
A qualitative research project is proposed to provide: –
- A review of available existing data
- An opportunity for stakeholders to contribute to the debate and design the future models for healthcare
- An opportunity to build on the progress made in celebrating the centenary of the Dewar Report as a means of raising the profile of remote and rural general practice.
- An opportunity to explore alternative contractual terms for General Practice.
It has been noted that solutions from inner-city practice rarely translates to a rural setting but that solutions to rural problems do translate the other way; the NHS evolving from the Dewar Report’s HIMS being a case in point.
Various opportunities exist to progress this idea: –
- The ongoing activity of the Dewar Group, including a meeting in the near future with the Cabinet Secretary and health service leaders
- The newly formed “Rural Fragility Group” being led by Dr Ken Proctor and NHS Highland (cf my blog with Mind Map)
- The appointment of Prof. Phil Wilson as Professor of Rural Health in Inverness
- Consideration by Scottish Government of changes to the GMS contract to better represent the needs of Scottish General Practice
- The Northern Periphery Programme has already established international links across Scotland, Ireland and Scandinavian counties to consider these issues.
This will be a large undertaking but it would be a worthy project to continue the fine work of Sir John Dewar 100 years ago.
Dr Miles Mack