Final day and lessons learned
I left Skye with a heavy heart, but the final part of my journey was still to come.
For my last day in Scotland I was lucky enough to have been invited to Inverness for the Rethinking Remote Conference 2018, a meeting place for the good and the great of the global rural medicine community. A space to learn, share and develop new and interesting ways of meeting the common challenges faced.
There were people from all over, including rural practice veterans from Australia, Canada, Sweden, Norway discussing ways to address challenges. Organisations such as RR Making It Work provided great insights in how they were addressing workforce challenges.
Some great concepts that I took home were Realistic Medicine (well established in Scotland), and the fact that 'Remoteness' isn't merely about distance - other factors such as Weather and Access can play a part too.
I also learned of the work being done in Orkney that achieved full recruitment status, and the work that the Scottish Rural Medicine Collaborative are doing (more on these below).
I also got the chance to speak to another GP who had done the fellowship and stayed, as well as Fiona Duff who was part of the Scottish GP Contract negotiations, to get her take on the Contract and its impact on rural practice.
Why is Recruitment/Retention so hard?
From the outside its easy to see the obvious barriers. Purely from an anthropological point of view, people generally gravitate to cities in search of opportunity. Digging deeper, there can be a perception that urban practice might somehow be ‘more cutting edge’ than rural practice. I didn’t have this perception going in, but I did leave with a deeper respect of my rurally/remotely based colleagues. I would argue that experienced rural GPs will be some of the more clinically robust in the profession.
Pipeline Looking upstream, at school and medical school - there isn’t the desire to practice rurally. In addition to the well documented ‘brain-drain’, remember that most teaching is done in big shiny tertiary centres. In the UK General Practice accounts for 90% of the NHS Consultations. Yet most learning at med school is done in tertiary care. It’s no surprise that a) GP isn’t seen as ‘sexy’, and b) students who then go on to work in Secondary/Tertiary care may have at best a skewed understanding of General Practice as a whole, and at worst a complete blind spot as to what primary care actually involves and how presentation of illness is completely different in the community versus that which is ‘filtered’ to secondary or tertiary care. And rural primary care? Even more grave, perhaps.
Human factors - It’s a big life move. Leaving networks, family, friends. If you have a partner, then considering impacts on them in terms of the above as well as employment are also things to consider. The accommodation issue was particularly pertinent in Skye - it was so hard to find rental accommodation as landlords found short term holiday lets much more profitable. Maslow will remind us that this is an important barrier to overcome. Then there’s schooling, settling kids. And the weather!
Clinical pressures - Some people will not feel comfortable with the level of risk. Facilities are limited, proper secondary care is far away and a lot is managed in the community by the GP. This widened scope brings the need for a wider skill set and a pragmatic, can-do mindset. It requires working within a different kind of pressure than what metropolitan GPs might be used to. General Practice is often described as a ‘risk sink’. Perhaps rural GP is more of a ‘risk tub’. My conversations with the GPs I met come to mind; each had their anecdotes of going beyond their comfort zones. Having to manage critically unwell patients because repatriations/evacuations were delayed (sometimes for days!) due to adverse weather conditions.
Health tech - there is perhaps a perception that if you want to be at the cutting edge of ‘digital health’ then the cities are ‘where it’s at’.
Retention - some will leave as it was ‘not for them’. Some because it was always going to be a short stint, an adventure. All that stay, it seems, do so because they absolutely love it.
Why is it great?
The big draw for me was the ability to do more of what we were 'trained to do’ as Jess had put it. That role that the government wants to push of the ‘Expert Generalist’. Complex decision making, human interaction, improving quality and outcomes for your community, a community that you are part of and integral to. There was certainly less of the repetitive administrative pressures that frustrate many of us. The community also includes the myriad of amazing healthcare professionals working in the community. District/practice nurses, nurse practitioners, clinical pharmacists, physios, paramedics, healthcare assistants. For it to work, and be fulfilling, it needs a structure built on mutual understanding, trust and support.
Technology has allowed better communication and shared-decision making with specialists in secondary care - who seem to have an appreciation for what is done in the community.
Systems and technology infrastructure need to be supportive of patient access, doctor workflow and all in between. It was clear to see that there were technological solutions being used to help bridge the remoteness gap - ECG links, HD video links to the paediatric team, rapid blood testing - not at the cutting edge of new technology, but more crucially - in use, and making genuine impact.
If like me, you missed your days in acute/emergency medicine, you’d certainly get an opportunity to flex this muscle. You are the health service out there. As Al put it, it truly is 'full on generalism'. If the weather is bad, that helicopter evac may not arrive for hours/days. How would you handle that? Not just clinically, but on a personal stress management point of view?
What is being done?
There seems to be a slow, creaking, but emerging recognition of how important and valuable the rural GP role is by decision makers.
Whilst it may be that the volume of patients seen are less, Richard pointed out that rural GPs actually do much more for their patient communities. Some of this is funded, and some of it isn’t. Clearly, recognising these ‘intangibles’ or ‘un-measureables’ will go a long way.
Hopefully the Scottish GP contract will continue to evolve, recognise and reward the Rural Practitioner role with a true understanding of how it is so unique. There remain challenges within these negotiations even at the time of writing this, and rural GPs remain committed to solving rural problems as (perhaps) only they can. In Scotland, organisations such as the SMRC exist to promote rural practice in school, medical school and post-graduate training. Gill Clarke. She was kind enough to offer me a place to stay before the conference, and we talked a bit about the work that the SMRC was doing.
She explained that the Scottish Rural Medicine Collaborative was set up and funded to promote rural general practice as a viable and desirable career choice, to support this notion all the way along the pipeline. The concept of the Rural Pipeline has good evidence in Australia, Canada and the UK that if school students are supported to go to med school or other healthcare roles, they are more likely to return and work in a rural setting.
School students living rurally are inspired, encouraged and supported to take healthcare roles into higher education. In addition Postgraduate students in medical training interested in working rurally are offered 1 year 'Longitudinal Integrated Clerkships' designed to offer exposure to working rurally, and there are currently schemes at Dundee and St Andrew's University.
Moving along the pipeline, there are plans to expand VTS (the GP vocational training scheme) to encompass rural GP exposure, but crucially there are moves for other specialties like surgery to have rural placements. This gives them the increasingly needed generalist surgical skills (in what is hopefully a welcome U-turn from the growing super-specialism seen in cities and tertiary care), and also an appreciation of the pragmatism and difference on the ground that is present rurally.
Finally, for those who are already GPs, and interested in practicing rurally, the rural GP fellowship exists to support and up-skill those interested in making the jump.
In Orkney - GP Charles Siderfin used the power of community to help retain GPs - It would be great to hear a discussion from other rural practice organisations in the UK who are trying to address these problems.
WONCA have regular rural practice conferences to share global experiences. Australia and Canada also have well developed environments to promote rural practice, as do the Scandinavian countries (as I discovered at the Rethinking Remote Conference).
There is more to working in rural practice than just ‘working somewhere beautiful’. The sweet spot exists somewhere at the intersection of work/life balance, professional fulfilment and ‘belonging’.
Those that try attract people to work rurally realise this, and the drive to plug the workforce gap will need to not address the problem in isolation, but more within the context of many of the points raised above, and more.
If you are interested in working rurally:
In Scotland, there is the rural GP Fellowship. A 1 year programme that is aimed at providing the experience and support required to making the jump to rural practice.
Here is are some links with more info
Locum in a rural practice/OOH for a short time (the JFDI mentality a la @keithgrimes) Local UCC/ED work Pre-hospital care courses/ALS/ATLS/BASICS. PROMPT Course. England, Wales and Northern Ireland have rural areas, you may want to explore working in these regions
Alternatively, perhaps reading this has reinforced the notion that Rural Practice is not for you. That’s great. But hopefully you, like me will go back to your day with an appreciation of the awesomeness of the rural Generalist. Not an old-fashioned, mythical, barefoot creature. But an dynamic, forward thinking, innovating force for change in their community. If you should see them in the local rural pub on your travels do as the sheep farmer, and tip your hat to them.
There are many to thank - Richard Moss, the Scottish Rural Medicine Collaborative, (in particular Gill Clarke, Martine Scott), Al Innes, Keith Grimes (for the intro to Al!), Rethinking Remote (Bill McKerrow), Fiona Duff, Sarah Elliot, Jess Cooper, Ema Kufel (GP View) and of course Brunelle Pentier-Upadhyay (wife and complete legend).