A plea from the frontline of rural healthcare

susan bowieDr Susan Bowie shares her 30 years of experience as a GP in Shetland, and says rural healthcare in Scotland is facing a perfect storm.


I’m desperately worried about the National Health Service in Scotland.

I’ve been a GP now for 30 years. I trained in Ruchazie in Glasgow, but most of my working life has been spent providing care through our practice in Hillswick, Northmavine, in the far North of Shetland.

As well as being a GP I’m also a patient, a mother of three (two of whom are medical students), a wife, and I have seven years experience of being a hands-on carer to my mother who had dementia.

Our practice may be small, but it’s like a microcosm of the health service. Primary care is mostly what I do, though I work in the hospital too as a GP with special interest in paediatrics. We still provide our own out-of-hours services, like many very rural GP practices, and we don’t use NHS 24. We answer the phones ourselves.

Originally, and some of you may not know this, the Highlands and Islands Medical Service, designed by Sir John Dewar 100 years ago, was the first ‘state run’ health service, and was the forerunner of, and blueprint for, our NHS.

The health service has indeed come a long way since then, but the Dewar Report of 1912 and its conclusions makes interesting reading today! The document’s recommendations still ring true, with its references to access to medical services, social issues, morbidity, deprivation and the recruitment and retention of a medical workforce.

Another thing you may not know is that most of the work of the health service in Scotland takes place in GPs’ surgeries. Primary care do 90% of the work, for less than 9% of the budget. The Put patients first: back general practice report from the RCGP shows how the work of the GP has grown in the last ten years, including a vast increase in total patient consultations.

We must remember that the UK NHS is worth preserving. It still largely remains, despite the bashing it gets from the the Daily Mail and the Tories, one of the best and the cheapest health care systems in the world.

Source:  The Commonwealth Fund
Source: The Commonwealth Fund
Source: The King's Fund
Source: The King’s Fund

I have lived through quite a lot of health service changes, and my plea to the politicians would be tinker around the edges if you must, but no more huge reorganisations with unintended consequences please. It’s my health service, as much as yours. I was born because of it, I have survived because of it, and I take terrible exception to anyone who tries to mess it up.

And always, but always, keep patients at the heart of it..

If you were designing a health service now, I’d hope that’s what it would be about. In the words of the RCGP campaign, “Putting patients First”. So if we design the health service around the patient, what would we need, what couldn’t we do without?

We need first to ensure great emergency care. It’s vital to be able to respond quickly if a patient has a disaster, either at home, on the road or at the health centre.

Patients need easy and prompt access by phone to get help, book appointments or organise prescriptions. There shouldn’t be great waits for appointments at the health centre.

In 1912 Dewar said that GPs needed premises, telephones, and that transport was a problem. It still is today. If we were designing the service now, patients would be seen near their homes, their chronic diseases looked after by their GPs and primary care teams, and those with minor ailments and accidents wouldn’t have to go to casualty.

In fact GPs manage most of the chronic diseases really well in their surgeries today, often with close liaison with hospital services. That has been one of the success stories over my 30 years, brought in by Labour. Meanwhile the number of patients with chronic conditions has risen over the last 10 years quite dramatically.

However, the reality for many at the moment is that they don’t have easy access to GP services ‘out of hours’ near their homes. I was horrified to see that in Lanarkshire the patients in Rutherglen were potentially going to have to go to Hamilton to access out-of-hours services. Completely hopeless for the sick, frail and elderly, and so it’s no wonder that patients with minor ailments end up in casualty.

A&E departments which are clogged mean long waits for the seriously ill. And there is a knock-on detrimental effect on our consultant colleagues in the hospitals.

If we were designing a health service now, we wouldn’t want patients in hospital for a moment longer than they need to be. That means being able to manage the increasing numbers of frail poorly patients and the dying in their own homes. Which is where, if asked, people would generally choose to die.

Primary care teams, and GPs in particular, are good at that, but to manage patients at home we need really good, compassionate at-home care for our elderly. Not just 15 minutes twice a day, with patients padded up.

And that means good hands-on nursing care too. Margaret McCartney in her book Living with Dying makes an excellent case for diverting funds from expensive dementia treatments that barely work to better care at home for people living with dementia, and I’d agree with that wholeheartedly.

With better care at home too, it may mean that a lot of frail elderly wouldn’t end up in hospital in the first place, or they’d get home sooner. This would have a knock-on effect of easing the pressure on hospitals and hence A&Es.

Providing extra, better at-home care has been shown to be a way of ensuring that beds are not blocked.

In reality, with money from the SNP Government tight, home care services are able to provide LESS care rather than more, while at the same time overall bed numbers in hospitals are being reduced, in favour of nursing ‘in the community’.

A case in point is the opening of the new Southern General Hospital, with the loss of hundreds of beds as other hospitals close. And in the future we can expect even more elderly needing care, when the baby boomers come to that age.

I like the idea of health and social care integration, being able to ask for more home care when I see vulnerable patients at home that need it. But will I get it any more than I do at the moment, if health service and social care money is being squeezed ? Or will it be rob Peter to pay Paul? Not surprisingly we as GPs have hardly been consulted on this, and we are already anxious about what this change may bring.

I like the idea too of being able to ask for insulation for the cold and old, but will I get that if we continue to have an SNP Government that is freezing the funding?

To put patients first and to ensure their prompt, high quality treatment, we need to ensure there are enough GPs. The last Labour government did well with the NHS . It was a time of good funding, investment in primary care, and GPs were released from the burden of having to organise their own on call. This was done with the laudable aim to ensure that there were no over tired GPs on call, posing a risk to patients. At the time too there was the looming crisis of GP recruitment.

Great as that seemed, some of us were worried about the consequences for our own patients, especially out in those very rural areas – in our case 40 miles from the nearest casualty, and a 2 hour transfer time by emergency ambulance.

Worse, it was all or nothing. We were given the choice of either dumping the out-of-hours services or not, we couldn’t just have a bit of time off. So, like other mainly rural practices across the Highlands and Islands, we in our practice decided to carry on providing the service.

The loss of income for being relieved of out-of-hours services was set at £6000 per year, and so most practices leapt at the chance. Translated that means that those of us that do carry on doing the work for our own patients are paid just £30 per night, compared to more than ten times as much were we to give up and work for the board instead. And that level of commitment to being on call more than 50% of the time can be gruelling.

And for the last few years of this SNP administration, funding has gone down, money has got tighter, and we have lost services for patients. We are struggling in primary care.

Perhaps the biggest problem of all is the perfect storm resulting from the ‘modernising medical careers’ programme, meaning that not enough GPs who want to be in Scotland are being trained to replace those retiring. This means that we are in serious crisis in Scotland, especially in the rural areas. We are totally overstretched, some practices being 50% down in GP numbers, at a time when workload has gone up, and most GPs are working 11 -12 hr days.

Recruitment is desperate. It has never been worse in my 30 years as a GP, and morale amongst GPs is at rock bottom. Even the well-paid health board out-of-hours arrangements are finding difficulty recruiting.

Health boards more and more often are having to take over practices that have lost their GPs. These “2c” practices interestingly are twice as expensive to run as GP-run ones are. If a GP runs their own practice they pay staff costs, and have to cover their own sick leave and maternity leave. The cost of locums to the boards is astronomical, at a disgraceful £10k a fortnight. That makes recruitment even worse.

When trained GPs know they can earn big money as locums, why would they want to come and work for me, in a low earning practice, where we still provide our own on-call services for patients?

It’s not just about recruitment. It’s also about retention, and making General Practice seem an attractive and valuable option to our medical students so that they don’t feel Australia beckoning. Perhaps the biggest scandal of all is that while the numbers going through GP training have dropped hugely, 352 of this year’s new medical graduates have no job to go to at all, and may be lost to the UK altogether if they decide to cut their losses and move abroad.

It costs a staggering £200,000 to train a doctor, so that’s not just £88 million thrown away, but it’s the disgraceful loss of talent and resource we should be holding on to as tightly as we can. We must ensure that every medical graduate is offered a job in this country at least for the first two years until we can get them to the start of GP training.

Our practice is very, very vulnerable. We rely on dispensing to keep us viable. Already many rural practices have closed or been put under threat of hostile takeovers by private pharmacies, a problem only partially put right by the legislation brought in hurriedly in June. This has led to a catastrophe in Millport where the two incumbent doctors lost dispensing, and therefore most of their income; they left, and the health board has since had to replace them with locums, a doctor and six advanced nurse practitioners at fantastic cost.

As the RCGP says, Scottish rural healthcare is in crisis.

Meanwhile many of us feel undervalued. GPs are rarely consulted. Health and social care integration was a case in point. We have even had a crisis in simply obtaining oxygen for our patients in emergencies, with GPs no longer able to prescribe it!

And naturally health boards, starved of cash by this government, desperate to save money, are looking closely at whether areas like the Highlands and Islands can ‘afford’ to keep smaller practices at all. But close the wee practices that are providing great comprehensive services, and the wee schools as is also happening, and you kill communities stone dead.

Although there are great campaigns such as Doctors For The NHS looking to encourage a pride in ‘service over profit’, how many GPs will want to carry on providing this valuable rural service to patients in the face of cuts, indifference and impossible demands?

How do we restore that sense of service and pride in serving their communities in GPs who come after me? Because surely we must try?

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