Chamber and committees

NHS Grampian submission of 3 October 2021

PE1845/U - Agency to advocate for the healthcare needs of rural Scotland

Thank you for your letter, dated 10 September 2021, seeking the views of NHS Grampian on the above petition and explicitly to understand the steps we take locally to minimise the challenges associated with rural access to services.

My initial reflection relates to our overall approach, expressed through the work in both Moray and Aberdeenshire, to maintain services as locally as possible through general practice, community pharmacy, optometry, dental, out of hours provision and community hospitals.  Our network of community hospitals deliver many services which, in other areas, you might have to travel to a major centre to receive. We support this work with our local clinical and managerial leadership.

We actively participate in remote and rural issues as a matter of course and are represented on the Scottish Rural Medicine’s Collaborative. We have a named GP member of SRMC, and our Career Start programme lead has supported the SRMC at national GP recruitment events. Since inception in 2016, SMRC has worked to:

• Understand and address retention issues for working age GPs;
• Promote Scottish General Practice as a positive career choice;
• Encourage alumni to stay in / return to Scotland;
• Develop sustainable models of remote and rural primary care;
• Support the education infrastructure in primary care;
• Providing high quality support and information for prospective GPs in Scotland;
• Make the most of expertise of remote and rural GPs at the end of their careers;
• Support implementation of NHS Scotland Partnership Information Network (PIN) policies.

All Primary Care clinicians in Grampian are aware of the challenges of trying to provide sustainable market town and village primary care. This is reflected in their active involvement in, and commitment to clinical education, starting early by supporting school leavers in their locality to gain entry to University, moving through to undergraduate, early junior doctor training and ultimately GP specialty training. In addition, the PCIP programmes for the more rural HSCPs in Grampian specifically address the challenges of recruiting, training and maintaining Multi-Disciplinary teams in Primary Care. This maps across to pharmacy, optometry, dental and out of hours provision and includes the training and development of additional Primary Care specialists; Advanced Nurse Practitioners, Paramedics, Pharmacists and more recently Physicians Assistants.

NHS Grampian has supported the GP rural fellow programme for many years. We recognise that there are specific and additional skills needed in order to operate effectively and safely in remote locations. Providing additional training through the Rural Fellowship aims to hold onto those Doctors motivated to live and work in this way. The detail of the programme is described:

The ‘standard’ rural fellowship has been in operation since around 2000 and is based within rural and remote general practice. It provides extra training and support for GPs who wish further experience in rural practice and is based on the curriculum for rural practice developed by the Remote and Rural Training Pathways Group (GP sub-group Final Report Sept 2007). 

Service redesign, workforce issues and revalidation issues have conflated over the last number of years in a need for a complementary approach to provide extra training and support for GPs who wish to work in a more intermediate care setting, including no-bypass hospitals and small district general hospitals. The GP Acute Care Rural Fellowship option was developed based on the agreement of a list of GP Acute Care Competencies following from the agreement of the Framework for the Sustainability of Services and the Medical Workforce in Remote Acute Care Community Hospitals.

The agreed aims of these two fellowship options are:

1. To promote rural general practice as a distinct career choice.
2. To help GPs to acquire the knowledge and skills required for rural general practice
3. To help those GPs who wish to develop skills to provide acute care in remote hospitals develop these competencies
4. To provide the opportunity for GPs to experience rural community living.

Despite all of the above, Primary Care Leadership in NHS Grampian recognise that the existing challenges of maintaining and developing General Practice and Primary Care in ‘non city’ settings is a challenge, one made more pressing by the recent Pandemic and it’s consequences for staff attrition. A number of our rural villages /towns have had significant challenges in providing ongoing GP services as existing staff retire and we have temporarily taken control of some practices that were experiencing difficulties operating under the standard GMS contract. In others we have assisted by supporting a reduced level of their usual enhanced services activity if appropriate. 

At a grass roots level, Cluster Leads and Community Hospital Medical Directors are fully aware of the rural challenges and have been involved actively in recruitment & retention of both GPs and other clinical professions, supporting clinical education and development, and exploring portfolio working to provide diversity and opportunities for younger doctors.   This has included temporary changes to contractual status, Enhanced Services and Service Level agreements. Providing additional local services, such as minor surgery, diagnostic imaging and near patient testing carries a benefit for patients, whilst at the same time adding value to the clinical role. 

There are obviously challenges joining up services such as CTACs, VTP, Blood Hubs and Pharmacotherapy within a diverse non-urban environment, and in sustaining them in the face of staffing demands and opportunities. There is a fixed and limited pool of professionals such as Physiotherapists, Dieticians, Psychologists, Occupation Therapists and Community nurses, most of whom are unlikely to be found living in a town with a population of 5-10,000 people, let alone a village of 1500. Creating teams in a rural context needs to take into account travel times and distance, team members operating in multiple locations and teams, and the communication, delegation and decision making difficulties this brings. On the positive side, the explosion of non face to face solutions brought by the Pandemic has already provided opportunities to support both clinical and managerial solutions to some of these challenges. 

Considering the various existing streams of work and planning moving forward both within Primary Care and the wider organisation, and adding in the potential impact of designing and delivering a National Care Service, it will be important to keep a focus on the challenges faced in delivering equitable and effective health and social care in more sparsely populated areas.   The proposal to have a network of Remote and Rural GP Champions is one way of keeping a focus on these populations in the forefront of planning groups in Health Boards, although existing structures, particularly in Moray and Aberdeenshire, are already aware of the problems (and indeed the potential solutions). Where such posts are positioned in terms of seniority and influence would be key to their success and, critically, Accountability and Governance would need to be considered should such posts be adopted in future. This concept mirrors, in many ways, the development of MCNs in the past, which, where effective, have added huge value to the work of Health Boards and ultimately patient care, but which have often suffered from being external to the ‘usual way of doing things’.

We have a long established network of community hospitals.   The work, especially in Aberdeenshire, has for some twenty years aimed to establish many services within their network of community hospitals (ultrasound, x-ray, endoscopy, blood transfusion, minor surgery) with the aim of delivering many services, traditionally delivered in acute hospitals, locally.   This work was led in partnership with acute hospital colleagues.   Its success was dependent on local GPs having an interest in developing the skills and identifying the time to deliver the services (their time obviously being remunerated).   The pandemic disrupted much of this work.   Changes in the staffing within the community hospitals is still in place and the resumption of these services is not yet clear.

For the Moray population there is also access to the district general hospital in Elgin which is called Dr Gary’s hospital (DGH). This has much wider services including medicine and surgery, as would be expected in a general hospital.

I hope that these comments are helpful to the work of your Committee and if I can provide any other information or further detail on anything here then please let me know.