“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
Introduction
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
26.7.2012
milesmack 
Comments on: "Dewar 2012- an outline for an qualitative research project in Remote and Rural General Practice" (5)
Does the Rural Fragility Group include representatives of remote and rural communities? There are a number of local development officers employed by anchor organisations in remote and rural communities who could be usefully involved in this sort of thing. Who is involved in the group?
Alison,
Many thanks for your comment.
The Rural Fragility Group is being led by Dr Ken Proctor, Associate Medical Director at NHS Highland. I have only been at one meeting and I am unsue of the entire make-up. I agree that the voice of communities is crucial in planning for the longer term and would be central to my proposed research that I hope would have wider remit than just NHS Highland and include the Island Health Boards.
It will also be crucial for all these community groups to be networked and connected to shar ideas and experience.
Thanks,
Miles
SKYE, LOCHABER, DINGWALL AND APPIN GPS TO TAKE PART IN A “DEWAR” RADICAL REVIEW OF THE NHS IN THE HIGHLANDS AND ISLANDS
Dave Thompson MSP will chair an important meeting in Fort William on Friday the 7th September aiming to outline a new model for the NHS in the Highlands and Islands. Recognising the unique geography and population density, and the challenges these create for the provision of the health service.
The meeting takes its inspiration from the Dewar Report, published 100 years ago, which laid the foundation for the NHS today. Mr Thompson is bringing together three important groups for the discussion. The Dewar Committee is represented by Dr James Douglas (Fort William), Dr Miles Mack (Dingwall), Dr Steve McCabe (Portree) and Dr Iain McNicol (Appin). NHS Scotland will be represented by Jill Vickerman, Policy Director and Elizabeth Porterfield, Head of the Planning team, both from the Scottish Government Health and Social Care Quality Unit. NHS Highland will be represented by the Chairman Garry Coutts, Gill McVicar, Director of Operations for the North and West Highlands and Ken Proctor Assistant Medical Director.
This meeting with senior officials will provide the opportunity for all sides to come together and look at how better to improve the current model of the NHS in the Highlands in providing the necessary level of service for rural communities. There will be a wide ranging agenda that will look at every aspect impacting on the delivery of the NHS in the Highlands and Islands.
Commenting on this, Dave Thompson said:
“The NHS faces many challenges in the Highlands and Islands where the distances between population centres are huge. Given the unique population density in our region it is imperative that the service be adaptable enough to fully serve the needs of the people in rural communities.
Several practitioners have suggested that the current model of the General Medical Services contract is perhaps more appropriate for urban communities, and therefore it is important that we question whether the system can be adapted to better serve all communities in Scotland.
This meeting will bring together General Practitioners working in the highlands with senior officials from both the Scottish Government and NHS Highland, and is a real opportunity to look at radical changes that could make a real difference to the operation of our NHS in the Scottish Highlands.”
ENDS
Notes
Sir John A. Dewar commissioned a report into overcoming the difficulties of implementing the National Insurance Act in crofting areas. The report was published in 1912 and the recommendations created the basis for the Highlands and Islands Medical Service (HIMS). HIMS was well received by the Cathcart Report of 1936, and then became the template for the National Health Service in Scotland.
The mind map is a useful springboard to capture thoughts and promote debate. I would propose some additions that may have been considered behind some of the labels:
Deprivation – is there a need for a metric for remote/rural deprivation which is different from more urban-centric measures?
Practice boundaries – is there an opportunity to review and rationalise practice boundaries and other service provision separation
Premises – does the existing NHS estate place constraints on service provision and/or represent expectations of continuity of current care locus
I would welcome the opportunity to provide the viewpoint from Highland remote & rural general practice management to the work stream.
Hi Andrew, thanks for the comments, watch this space!
Miles