Viewpoint / Viewpoint: Rural GP practices face perfect storm
Northmavine GP Susan Bowie joined local MSP Tavish Scott last month to discuss the difficulties in recruiting GPs to rural practices with health minister Shona Robison. Here Bowie, a doctor for 30 years, says she is desperately worried for the future of the NHS in Scotland and warns that the crisis in rural healthcare can only get worse.
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.
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.
Most of the work of the health service in Scotland takes place in GPs’ surgeries. Primary care does 90 per cent of the work, for less than nine per cent of the budget.
We must remember that the NHS is worth preserving. It still largely remains one of the best and the cheapest health care systems in the world.
It’s my health service, as much as it is 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, 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.
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.
Clogged A&E departments mean long waits for the seriously ill and detrimental knock-on effects 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.
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 four times 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.
In reality, with money from the Scottish 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.
I like the idea of health and social care integration. But will I get 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?
To put patients first and to ensure their prompt, high quality treatment, we need to ensure there are enough GPs.
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 per cent down in GP numbers, at a time when workload has gone up, and most GPs are working up to twelve hours a day.
Recruitment is desperate. It has never been worse in my 30 years as a GP, and morale amongst GPs is at rock bottom.
Health boards more and more often have to take over practices that have lost their GPs. These so-called ‘2c’ practices interestingly are twice as expensive to run as GP-run surgeries.
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 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 last year.
Meanwhile many of us feel undervalued. GPs are rarely consulted. Naturally health boards, 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.
Dr Susan Bowie, Hillswick
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