Party ‘blame culture’ helps no-one as we seek to improve rural health

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Delivering the NHS faces different challenges in Scottish rural areas

The NHS is under close scrutiny and has been turned into a partisan issue, hardly in the interests of the best-run service. Attacking the government’s record is morale-sapping, and pretending there isn’t a problem is counter-productive.

So far, attention has focused on the population centres but what is the story in rural Scotland? Here an experienced GP – writing in a personal capacity – outlines specific issues: recruitment, retention, lifestyle and pay.

By Dr Stephen McCabe

I have worked on the front line in the NHS in Scotland for nearly 30 years. We still have probably the best primary care in the world in Scotland. But our secondary care is now falling short and our care home system likewise. The situation in rural areas is particularly bad.

Recently, I received a plea to come and do some shifts at Caithness General Hospital which seems to be on the verge of meltdown because out of a total of 12 consultant posts they currently only have 4 filled. It seems possible that junior doctors will be pulled out of there if there is no improvement and the hospital will then be in real difficulties.

NHS Highland hospitals currently have consultant vacancies in double figures and a similar story can be found in other parts of Scotland such as Fife and Dumfries & Galloway. NHS Highland also currently has double figure chronically unfilled GP posts.

nhs highlandIt’s impossible to underplay the current recruitment and retention issues in rural Scotland. I wrote a paper for the then Scottish Executive in 1999 suggesting practical measures that they could implement to improve remote rural recruitment and retention. But little has changed.

One of the big problems for me is that all too often managers and politicians look at each individual job in isolation and ask ‘What is it about this job that nobody wants to do it?’ Of course such questions are important and if you are offering a job that requires someone to work in relative personal and professional isolation, expecting them to take on more responsibility as a consequence but then paying them less for it, then it should not come as a big shock that there is no rush to fill such a vacancy.

This is certainly the case with remote rural GPs like myself – we are more isolated, we deal with all sorts of critical situations which our urban and sub-urban GP colleagues never see yet we earn 20% less than our urban colleagues.

It is not that my work is any less demanding in other ways – we still have drug misusers and alcoholics; we still have chronic mental health problems; we have way above the national average of very elderly patients with all the multiple co-morbidity that that implies; and we still have deprivation and social dysfunction.

When I first came to Skye 18 years ago I saw levels of deprivation that I had never previously witnessed even in my time working in one of Scotland’s more notorious ‘inner city’ housing schemes (Wester Hailes). There were people in north Skye still living in houses with earth floors, leaking roofs, broken windows and no inside toilet (they used outside ash pits instead). So, even the notion of some cosy rural idyll is somewhat off the mark although I accept we do have substantially less in the way of crime and violence.

But my point is we must not look at these hard-to-fill jobs in isolation. There is just so much more to it than that and if we are ever going to tackle the problems of recruitment and retention here we need an umbrella approach that addresses most if not all of the following issues:
– lack of employment opportunities for partners – the majority of people not employed in public sector jobs in remote communities are employed in tourist-related industries which by nature are seasonal, unreliable, hard and poorly paid
– public transport both within these localities and to places distant to these localities is usually poor (or absent), slow and expensive.
– the higher cost of living in remote areas – estimated to be as much as 40% higher than average in some parts of rural Scotland according to the Joseph Rowntree Foundation.
– lack of good-quality, affordable housing
– relative under-performance of some rural high schools
– weak or absent mobile phone signal and no prospect at all of 3G or 4G
– weak or absent broadband connections with many who have a connection only getting speeds of 0.5MB and no prospect at all of superfast.

NHS Highlands plans a new hospital at Broadford, Skye
NHS Highlands plans a new hospital at Broadford, Skye

And so on…

What the politicians need to decide is do they truly value our remoter communities enough to put in the kind of investment that is really needed to support and sustain them? To grow the population of a remote Hebridean island will require substantially more than that island’s per capita share of national income: is that something that politicians and society as a whole are prepared to do? If not, then the long-term future of many of our more remote communities is bleak and the increasing urbanisation of our society is inevitable.

There are issues in many areas. Here is what I found out when I did some digging in December 2013:

Orkney – problems with smaller islands and with finding locum cover for annual leave/study leave. Unable to recruit to post providing 17 weeks cover a year. GPs willing to do obstetrics down from 4 or 5 to just 1. Trying to recruit a Consultant Obstetrician.

Eilean Siar – Recruitment and retention is their single biggest issue. Western Isles are part of the EU Northern Periphery Project which also includes Scandinavia. They are a leading part of the project – looking at the issue of “unconnectedness” as part of recruitment and retention. They are also looking at how to design packages that will attract and retain people. The main issues at present are with secondary care – Consultants, pharmacists and specialist nurses.

West Lochaber – here there had been a failure, despite two rounds of advertising, of NHS Highland to recruit six GPs to fill the vacancies in West Lochaber such that area now had one permanent GP when it used to have 7. Why did NHS Highland feel that it was appropriate to offer a 61 hours per week remote rural GP (with all the added responsibility that such a role entails) only £75,000? That is £5,000 less than the top end of the scale for a 37 hours per week Band 8 nurse. Why were doctors were being offered £7,000 less than a top end of the scale head teacher? Remember these GPs would be at the top of their pay scale. And you wonder why no-one wants to do it?

Here in Skye we have seen our incomes fall by over 20% in the last five years. Even with the money we earn from looking after the community Hospital, we still earn nearly 20% less than Scottish average or 40% less than English average. If I had taken one of the West Lochaber posts I would have actually INCREASED my earnings by nearly £5,000.

Tomorrow: In part two, Stephen will address solutions to these questions

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