Citizen Participation and Public Petitions Committee
Scottish Government submission of 17 September 2021
PE1890/A – Find solutions to recruitment and training challenges for rural healthcare in Scotland
The Scottish Government fully recognises that Health Boards operating in remote and rural areas face distinct training, recruitment and retention issues. We, and our partner organisations, such as NHS Education Scotland (NES), are dedicated to ensuring that our health care professionals have the right skills, and are in the right place at the right time, to meet the needs of our patients and services. This is why the Scottish Government and our partners have a number of initiatives underway to address the particular challenges faced in remote and rural settings.
Centre of Excellence in Remote, Rural and Island Healthcare and Digital Innovation
Following the 2021 Scottish Parliament elections, the recommendation to create a Centre of Excellence for Rural and Remote Healthcare became a Scottish Government Programme for Government 2021 commitment in order to ensure that our islands and rural areas are not left behind as we work to improve health services.
Background to the Centre of Excellence
On 25 May 2018, Sir Lewis Ritchie published an independent external report of Out of Hours services in Skye, Lochalsch and South Wester Ross (“SLSWR”). One of reports recommendations was for a centre of excellence style ‘approach’ to learning, education and training that would allow NHS Highland to engage more closely with education and training partners.
On 16 January 2020, Sir Lewis Ritchie published his “Shaping the Future Together: Remote and Rural Working Group Report”. The Cabinet Secretary accepted all the recommendations in the Report including establishing a Centre. The recommendations were also accepted by the Remote and Rural General Practice Working Group.
The Scottish Government remain committed to the recommendations in the Report, which aims to enhance primary care across remote, rural and island communities by ensuring stability for rural GP incomes alongside other measures that support innovative approaches to the use of IT and physical infrastructure, as well as recruitment and retention practices. The Remote and Rural GP Working Group reconvened on 5 May 2021, for the first meeting since January 2020. At that meeting the group reaffirmed their support for the Report’s recommendations.
In response to the Ritchie Review, NHS Education Scotland’s (NES) Remote and Rural Healthcare Educational Alliance (RRHEAL) had been collaborating with NHS Highland, multi-agency and community partners since 2018 to co-produce the proposal for the Centre of Excellence (CoE) in Remote and Rural Healthcare. They design, deliver and support education and training specifically to meet the needs of remote, rural and island healthcare staff. This is aimed at both supporting our existing remote, rural and island staff and also helping making working in these areas a positive career choice. They are currently developing a specific Rural Advanced Practitioner Pathway in collaboration with university and multi-agency partners. https://learn.nes.nhs.scot/786/rrheal.
The Scottish Government restates its unequivocal commitment to maintain the Income and Expenses Guarantee introduced by the 2018 GP General Medical Services contract. We have increased GP relocation packages from £2,000 to £5,000 and widened eligibility to all remote and rural practices.
To support the recruitment of GPs to remote and rural practices, Sottish Government have allocated £200,000 to support Rural Relocation expenses, and £400,000 to fund Golden Hellos. These initiatives will help address workforce challenges across remote, rural and island general practice. Since 2016 we have supported the Scottish Rural Medical Collaborative to develop recruitment and sustainability measures. In 2020-21 this investment was £342,218.
The Scottish Government have allocated funding to NHS Shetland to support the ‘Rediscover the Joy’ project. This project has seen 30 doctors recruited from other areas to work up to 18 weeks a year in remote and rural practices that previously found it difficult to attract a GP.
Integrated Health and Social Care Workforce Plan (IWFP)
The Scottish Government’s Integrated National Health and Social Care Workforce Plan, published in December 2019, recognises the distinct training and recruitment issues across health and social care in remote, rural and Island areas. The Plan profiles various measures to increase the supply of nurses and doctors in rural areas.
Regarding nursing, this includes extended ‘return to practice’ programmes, improved recruitment and retention, particularly in rural areas, and support to attract and retain nurses. We also fund the Open University to deliver a pre-registration programme for almost 80 nursing students including for mental health, particularly in remote and rural areas.
This includes funding the Scottish Rural Medicine Collaborative (SRMC) to develop ways to improve the recruitment and retention of doctors and multi-disciplinary healthcare staff working in remote, rural and island areas.
Allied Health Professions Education Review
The Scottish Government is undertaking a review of Allied Health Professions (AHPs) education. Our aim is to consider whether our existing AHP education provision is compatible with the current and future health and social care needs of Scotland. The review, which is expected to be published in Winter 2022, will include potential solutions to key issues facing Scotland’s remote and rural services. These concerns have been a feature of the initial discussions with professions, higher education institutions and employers.
Shortened Midwifery Programme
A shortened midwifery programme was established and agreed with NES, universities and NHS partners as a time limited two year scheme in response to a workforce need in northern Scotland’s Health Boards. This provision was in addition to the normal commissioned undergraduate midwifery numbers. Following two cohorts of students on this programme, a decision was made to not approve a third cohort of the pilot for 2021. The decision was made at a stakeholder meeting in January 2020, and involved all key stakeholders including the Scottish Government, NES, the University of the Highlands and Islands (UHI) and partner health boards. The continuation of the programme depended on a higher number of students being seconded from Boards than were available at the time.
Further consideration was also given to the likelihood of students remaining in rural posts following their completion of the programme. The learning and experience from the shortened programme informed the NES comprehensive workforce and education review, commissioned by Scottish Government, the report of which is available here. (https://www.nes.scot.nhs.uk/media/kmnod1av/the-midwifery-workforce-and-education-review-for-scotland.pdf)
This review resulted in a number of recommendations, one of which requires the offering of shortened midwifery programmes to meet specific regional workforce needs as well as additional funding for midwifery practice education facilitators to support sustainable implementation. In addition, midwifery has an established workload tool that is regularly refreshed to ensure it continues to reflect evolving practice models reflecting current maternity policy.
Medical Students and Trainee Doctors
Several targeted initiatives have been implemented in recent years to support the training and recruitment of doctors in difficult to recruit areas, including remote and rural settings. These initiatives include:
- Increasing undergraduate education: the Scottish Government is currently implementing the specific recommendation from the Gillies Report to increase clinical placements for undergraduates in a variety of primary care settings including remote and rural, with the aim of making a career in General Practice more attractive to aspiring medical professionals.
- ScotGEM: ScotGEM is Scotland’s first graduate entry programme for medicine and is run jointly by the Universities of Dundee and St Andrews in collaboration with the UHI and partner Health Boards. ScotGEM was commissioned by the Scottish Government to meet the contemporary and future needs of the NHS in Scotland. The course content has a focus on remote and rural medicine and healthcare improvement, and is designed to develop interest in a generalist career within NHS Scotland. Students are offered a “return of service” bursary, which is worth £4,000 per student per year in exchange for four equivalent years of service. The first cohort of graduate students commenced in the 2018-19 academic year and are due to graduate in the Summer of 2022.
- Targeted Enhanced Recruitment (TERS) Bursary for GPs in Training: the Scottish Government offers one-off, taxable bursaries of £20,000 for trainee GPs who agree to fill posts in certain hard to fill and in remote and rural locations. The bursary payment is made to trainees as a lump sum upon taking up the post and in return they agree to complete the three year training placement in the specified location. This incentive is helping distribute trainees more evenly across Scotland i.e. away from central areas and towards harder to fill locations.
- Development of credentialing of medical skills: credentialing will allow fully qualified doctors to be recognised as a specialist in new or additional areas of expertise without having to undertake lengthy training for a full Certificate of Completion of Training (CCT). A credential in remote and rural medicine (unscheduled and emergency care) has been developed by NES and is currently undergoing regulatory approval.
- Introduction of the one-year GP Rural Fellowships: these Fellowships have been in place since 2000 and offer the opportunity to develop the generalist skills required to work in some of the more remote and rural areas in Scotland. There are two distinct GP fellowship options, one focussed on curriculum for rural practice. The other is focused on the acute care competencies needed to support hospital based care which includes supporting midwives and managing psychiatric emergencies.
- Improving recruitment to Psychiatry trainee posts: a Psychiatry Priority Programme has been running in the North of Scotland which offers priority programmes to trainee doctor applicants in advance of standard foundation programme recruitment. This means every trainee in the programme will: rotate through a psychiatry placement in the second year of Foundation Training; be offered a psychiatry mentor; and, automatically have access to the Scottish Royal College of Psychiatrists conferences.
- Medical Foundation Training: we are increasing the number of Medical Foundation training posts by 51 in 2021 and by a further 54 in 2022, therefore increasing the number of established Foundation training places by 105 overall. These extra places are to accommodate the first of the additional medical undergraduate places that have been added since 2016. The new places will create a greater range of placements for trainee doctors, particularly in general practice and psychiatry and in remote and rural parts of Scotland.
Enhancing Recruitment and Retention of Rural Doctors in Scotland: the Scottish Government is currently providing funding of around £300,000 for a mixed methods study through the Chief Scientists Office, and the University of Aberdeen, on Enhancing Recruitment and Retention of Rural Doctors in Scotland. This piece of research will gather sector specific information on factors that influence career decision making regarding remote and rural working.
Mental Health Workforce
The Scottish Government has committed to develop a long-term Mental Health Workforce Plan in the first half of this Parliament, in which we will consider the distinct challenges of recruitment in remote and rural areas.
Existing Mental Health workforce commitment include, but are not limited to, the following:
Providing funding for around 320 additional staff in Child and Adolescent Mental Health Services (CAMHS) over the next 5 years, to support those who require mental health interventions, but do not require the clinical response of CAMHS. This will provide downstream support and reduce pressure on CAMHS.
Recruiting 800 additional Mental Health Workers to A&Es, GP practices, police station custody suites, and prisons, ensuring that local provision and support is at the heart of our plans.
Creating a network of 1,000 additional dedicated staff in Primary Care Mental Health and Wellbeing Services by 2026 to ensure every GP practice in the country has access to a dedicated mental wellbeing link worker who can help grow community mental health resilience and help direct social prescribing.
Although there are many positives about rural life, we also recognise that there can be challenges relating to rural isolation. These may be increasingly felt by those in remote communities as a result of the pandemic. In partnership with the National Rural Mental Health Forum, we will develop an approach to ensure that these communities have equal and timely access to mental health support and services, including consideration of whether dedicated pathways are needed.
Our Mental Health Transition and Recovery Plan lays out a comprehensive set of actions to respond to the mental health need arising from the pandemic. In February 2021, we announced an additional £120 million for a Mental Health Recovery and Renewal Fund, which is the single largest investment in mental health in the history of devolution, and which will ensure the delivery of the Mental Health Transition and Recovery Plan.
We have agreed early priorities for Recovery and Renewal investment and NHS Board allocations of £34.1 million have already been agreed to deliver:
Improved community Child and Adolescent Mental Health Services;
Expansion of community CAMHS from age 18 up to the age of 25 years old for targeted groups and those who wish it; and
Clearance of any waiting list backlogs for CAMHS and Psychological Therapies (recognising that this may take up to two years).
NHS Highland has received £2.2 million from this fund for 2021/22. In addition, NHS Highland has been provided with £54,625 to enable recruitment of a full-time Director of Psychology to improve clinical leadership, management and accountability. We will allocate the remainder of the investment over the next few months – with a focus on wider support for mental health and wellbeing, including Primary Care and Community Services.
As part of our Recovery and Renewal Activity, we will work with NES to further increase the training intakes identified in the IWFP. More information on these developments will be made available as the details are agreed and finalised.
NHS Scotland Flexible work location policy
It is recognised that agile working, as an approach, is becoming more common place. The current Homeworking Policy that sets the standard for NHS Scotland Health Boards is being refreshed and modernised to reflect the changed working environment. This work has involved consideration of: Fair Work commitments, equality and diversity impacts, and environmental considerations.
The updated Flexible Work Location Policy will help to support employees and managers in considering and agreeing options for flexible work locations. This includes working from home. Notwithstanding potential challenges associated with connectivity due to a lack of national infrastructure, the option to work from home will:
- Offer more choice for individuals where they live and work. It will increase employment opportunities for those living in rural areas
- Aid recruitment by increasing the pool of candidates from a wider geographical area.