Annex D – Remote and Rural General Practice and the New Contract: a Crisis of Identity
By Dr Kirsty Brightwell, GP, Western Isles
The 2018 GP Contract in Scotland was inevitable – the old one had come to an end in 2016. The content was perhaps predictable: reduction of risk for GPs as employers, property owners and clinicians with money promised to even out earnings and provide a team around the practices to share the load and free up the GP to meet the requirements of General Practice now and in the future.
Much promise was made in terms of support to a professional workforce under threat. A team to support the work, a focus on quality, a minimum income guarantee and a desire to work collaboratively to create solutions together to the presentations forged by complex, system-based problems of distress, poverty and austerity.
What wasn’t expected by those meeting in closed rooms, shut off from the world over the 4 years of negotiations was the remote and rural backlash. These concerns, initially expressed through the language of finance, contained a sense of loss which is little to do with money and everything to do with identity. The new contract set out a vision of a very different future for General Practice. The idea that others would provide services traditionally met by the practices, challenges what it is to be a remote and rural GP.
General Practitioners have had years in glorious isolation especially in remote and rural Scotland. We have been the architects, the foot soldiers and the warriors. For small health boards with little resource it has made economic sense to contract GPs to provide services. As working employers, we have some control over our workforce (we often make up the largest part of it) and enough flexibility in terms of skills to accommodate niche services such as sexual health, minor surgery and out of hours. Indeed, when the Vaccination Transformation Programme was announced there was generally very little concern in the remote boards as it was anticipated that the practices could be relied upon to pick up the slack.
Some practices have become reliant on this additional funding to maintain the staffing required to keep small practices in remote locations open 8 am – 6 pm Monday to Friday. A symbiotic relationship developed with GPs as innovators, crafting local solutions for their populations and Health Boards assured of the quality of service through reporting structures and the lack of complaints. When it worked, the local population was well-served, less dependent on secondary care and did not have to travel for services.
We have never defined it but being a remote and rural GP felt like the pinnacle of General Practice. As our secondary care colleagues became more specialised gravitating towards, larger tertiary care facilities with aspirations of professorship, the GP in search of betterment could become an expert generalist in a remote setting.
A rural GP is the original Expert Medical Generalist. We are at the top of our game in terms of clinical knowledge and skills. We don’t have the luxury of sending our patients to an A&E 10 minutes down the road and our patients want to stay at home or in their communities for as long as possible. We are specialists in individuals and communities. We know our patients, staff and therefore the local community sometimes over several generations. With these relationships comes trust and a desire to do the right thing. We are personally invested in the future of our communities. We are driven by the need to do the right thing for our patients.
In recent years the difficulties facing practices in Scotland in terms of a reduced workforce and increasing demands have started to percolate through to remote and rural areas. Where this has de-stabilised practices, it has been disastrous. Health Boards are left with the near impossible task of providing 24/7 primary medical services to people no matter where they live without consistent, senior clinicians leading the team. The result is escalating costs and dissatisfaction.
The new contract comes at this time of huge challenge. We should be careful not to conflate the challenges with the contract. The dwindling supply of GPs, increasing rates of consultation and ever more complex combinations of problems are not the fault of the new contract. The end of QOF with the fundamental shift in how we deliver services to those with long term conditions brings much opportunity. Remote and rural GPs are well placed to show others how it is done. It may feel like our identity is threatened but I suggest the opposite is true. Our identity, what it means to be a rural GP is what the rest of Scotland needs to develop. The new contract has much to recommend it, but remote and rural GPs have been doing it for years. In this crisis of GP identity remote and rural has much to be proud of. We offer to the rest of the country a template for the future of General Practice.
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