Health, Social Care and Sport Committee

Meeting date: Tuesday, December 19, 2023

Official Report 667KB pdf

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Healthcare in Remote and Rural Areas

The second item on our agenda is our fifth oral evidence session as part of the committee’s inquiry into healthcare in remote and rural areas. Today, we will hear from representatives of healthcare professional associations. I welcome to the meeting Dr Iain Kennedy, chair of the British Medical Association Scottish council; Julie Mosgrove, chair of Optometry Scotland, who joins us remotely; Mhairi Templeton, who is from the Society of British Dental Nurses; and Laura Wilson, the Royal Pharmaceutical Society’s director for Scotland.

We will move straight to questions. Sandesh Gulhane will ask the first questions.

I declare my interest as a practising national health service general practitioner and as a BMA member, given that Dr Kennedy is here and my first question is for him.

I am rather concerned about the potential for a two-tier health service, given the issues that we have with recruitment and more generally, specifically when it comes to physician associates. I saw a job advert for a physician associate at Raigmore hospital that said that they would actively undertake clinical supervision of ward nursing staff, junior doctors and student PAs to facilitate the development of clinical skills and practice. NHS Highland followed up by saying that that was an error and that the role in question was a General Medical Council-recognised role. Given that PAs will be regulated by the GMC, might an increasing number of PAs across rural areas be supervising doctors?

I was concerned after seeing that PA advert when it came out at the weekend, because a PA who has perhaps had two years of training after a science degree would be supervising doctors who might have had 10 years of training, so I was not too surprised when I saw the Twitter storm yesterday involving many of my members across Scotland. A senior executive in NHS Highland has told me that that was an error, and NHS Highland has said on Twitter that it was an error.

The BMA Scottish council is concerned about the position with physician associates and anaesthesia associates, and we have made representations to the Cabinet Secretary for NHS Recovery, Health and Social Care about that. We would prefer it if they were called assistants, not associates, because they are not of the profession. They are not doctors, and we know that patients are confused when they see them because they think that they are seeing a doctor.

We have also asked the cabinet secretary whether he would consider using a regulator other than the General Medical Council, which was, of course, set up to ensure that patients were seeing doctors. Therefore, I share your concerns about PAs.

On your general point about there being a two-tier service, I have said many times that I think that we have a three-tier service. There are people in Scotland who can afford to pay for private healthcare; there are more fit, less frail patients who access services such as the national treatment centres; and there are older, generally frailer patients who are languishing on NHS waiting lists. Over a number of years, BMA Scotland has been speaking up about widening inequalities. We are sleepwalking into at least a two-tier service; I would argue that we have a three-tier service.

Specifically on the need to address the situation in rural areas—there is a distinct difference between our urban belt and our rural belt—has the GP contract, which has centralised the provision of things such as vaccinations, been a success in our rural Highland areas? Was the Government warned in advance of the contract being introduced that it could cause a specific problem for our rural and island populations?

I am here representing BMA Scotland—I am the chair of BMA Scotland—but I think that it is well known that I led the “no” vote on the GP contract in Scotland when I was the medical director of the Highland local medical committee, so my views on the 2018 GP contract are very well known. The Government was advised at that time and I advised it on behalf of my colleagues, who made very strong representations.

The 2018 contract has been only partially implemented across Scotland and, sadly, it has not been a success anywhere. From listening to my rural members across the country, I know that they remain deeply unhappy about the outcome of that contract because of how it distributed resources and because, arguably, it made inequalities worse—not only in rural areas but in deprived areas.

There is one potential solution, which the chair of the BMA’s Scottish GP committee, Dr Andrew Buist, is pushing the Government to implement, and that is phase 2, which would help to address the excess costs of delivering health in rural areas, including staff costs. The aim of phase 2 is to help GP practices pay for their staff expenses and their non-staff expenses, which are much greater in rural areas because of the excess cost of supply.

We will be coming on to recruitment, so I will not venture into questions about that.

I want to ask about optometry. We have got some fantastic examples in Lanarkshire and in Glasgow of people being able to go directly to their opticians to get help with their eyes, to be referred to the hospital and to then pick up prescriptions. They can have that wonderful dialogue without going to their GP. Quite frankly, opticians are better at eyes than I am as a GP. Why has that not been rolled out across the country? What are the barriers to that happening?

It has been a question of funding. There has been a shared care roll-out of the glaucoma scheme across Scotland, which has allowed us to see glaucoma patients with a low risk. We have been able to see glaucoma patients within community eye care practices.

For the anterior eye—the front of the eye—there is the eye health network in Grampian and also in Lanarkshire, as you mentioned, but that is happening only in pockets at the moment. The issue is funding. We have spoken to the Government about that. In the background, we have developed pathways that would enable us to do that more widely, but the process is being held up because of funding. If we had the funding, that would allow us to see certain conditions within community eye care practices across Scotland.

My final question is for Laura Wilson. Looking specifically at our rural population, pharmacy first is a great initiative, which allows people to go and get help very quickly when they need it from somebody who is skilled and who knows what they are doing—it is really important to stress that the pharmacists involved are trained to provide such help. However, are there enough pharmacists in rural areas and is there enough time for them to be able to do that fantastic work, or is there a slight difference between what we see in the urban areas and the rural areas?

Yes, there is definitely a variation in the number of pharmacists that are available in remote and rural areas, as there will be with GPs, optometrists and so on.

On the provision of the pharmacy first service in rural areas, a number of issues arise, such as access to training. For a one-day training session, a pharmacist from a remote and rural area might require two days of travel. Training is very centrally located, and it is important to recognise the impact that even just accessing that training has on people. What would be helpful for us would be support for those pharmacists to undertake that training closer to home so that they can provide those services. Once they have qualified and they are providing those services, on-going support would be good, because they can be isolated, and we want them to flourish in those roles and to provide those services.

It is a question of identifying the pockets where those services are needed and gathering data that would allow us to see where they are and are not provided. We could then target people and offer them support to undertake the training to provide those services. I know that access to records has been one of the themes; access to records would be massively helpful in expanding those services and enabling them to be used to their fullest. That would allow us to continue to provide those services and to expand them as appropriate for remote and rural communities and the population as a whole.

Good morning. My question probably leads on from what Laura Wilson was talking about, as it is about the models of training for staff in the NHS. For a lot of professions across the NHS, we have a very university-based style. We have heard a lot of evidence about that and about how we encourage people in remote areas to train and stay in their own area, in order to build a workforce that cares a lot about that community.

I would be interested to hear from each witness, when it comes to their profession and the wider NHS, what models they think that we could use, or what the universities could do, to get a better balance for people.

The pharmacy course is very university orientated. At the moment, it is a science degree, not a health degree, so it is important to have university input. That degree is provided by two universities in Scotland—one in Aberdeen and one in Glasgow. People from remote and rural communities therefore do not necessarily see pharmacy as an option for them, because they would have to leave home to study it.

Support needs to be provided for people in such areas. Different models have been trialled. For example, in the Highlands, a person would be almost sponsored to attend university—their travel back and forth was paid for, so that they maintained their links with the community—but that is a high cost burden for one person, with no guarantee that they will go back at the end of their course and stay in the remote and rural community. That approach has been tried, but that cost cannot be borne for many students.

If we get people from such areas to go to university to become pharmacists, we need to think about how we maintain their links with remote and rural communities while they are at university. We need to allow them to get the experiential learning there. We must make sure that they get the experience, because if they have never experienced it, they will not know whether they like it. We also need to think about how, once they have qualified, we encourage and support them to go back to those areas and take up the places that are available.

I am sorry to interrupt, but do you have any good examples of where that has happened, or is it something that still needs to happen?

It is something that we need to look at. Different models of education could be provided. Those could involve the provision of supported travel to and from university or a completely different model that maintains the structure and integrity of the university course while also allowing the remote and rural connection to be maintained. That is important, and we would support its being looked at.

Mhairi Templeton, I do not know whether you have any examples.

Unfortunately, due to timescales, I have not been able to gather the information that I needed to deliver today, but it is interesting to hear all the feedback, and I am willing to take that back to the board and feed back next time.

That would be great—thank you.

Do we have any good examples of what is working in optometry?

Up until two years ago, Glasgow Caledonian University was the only university in Scotland that offered optometry, but in the past two years, the University of the Highlands and Islands has started an optometry course, in the hope that students will graduate and stay in the NHS Highland area and that awareness of the profession will be raised in the area. It is more of a blended programme, whereby students will come out into community eye care practices. That has not happened before.

In the United Kingdom in general, the optometry course has been completely overhauled, so that will change over the next two years. In Scotland, the idea is to embed independent prescribing, so that optometrists will come out qualified and be able to prescribe medication. That will be a blended course through both universities. At the moment, it is unclear how those placements will be supported and how that will look from a funding point of view, but that will all change in the next couple of years.

That is lovely, thank you. I put to Dr Kennedy the same general question about models of training. I am also interested in the extra medical training places that have been provided. Was the remote and rural aspect part of the process of working out what medical training was needed?

09:30  

I will quickly declare a couple of conflicts of interests: I was born and bred in Inverness, and my wife is a lecturer at the University of the Highlands and Islands.

We do not have a medical university in the north of Scotland, and the five medical schools that we have drain people away from the area. That includes me: I trained in Edinburgh.

We know that people are more likely to work in a rural area if they are born and bred there. I am an example of that. I did not plan to go back to a rural area, but it happened.

We need to grow our own and actively recruit people from remote and rural areas of Scotland. That means getting involved with them when they are at school. An example would be to get pupils into care homes. It is good culturally to get intergenerational interactions, so it would be good to get school pupils exposed to that at a young age.

I think that you were perhaps alluding to an apprenticeship training model. The BMA does not support that, although there are pilots in parts of England that might be worth watching in the years ahead.

On your specific question around the 200 extra medical students, a senior doctor and I were talking last night about the fact that we have not managed to fill those places. For some reason, school pupils in Scotland are not choosing to go into medicine; they are choosing engineering or science degrees. We need to ask ourselves why that is.

I will give you a specific example on training, although it is not at undergraduate level. I am doing a little bit of work with the new national centre for remote and rural health and care at the moment. Three training hubs are being developed across Scotland, in GP practices, to train advanced nurse practitioners, advanced clinical pharmacists and perhaps practice nurses and healthcare assistants. One of the hubs is at my main practice in Inverness, and the others are in Stonehaven and Galashiels. That approach adopts the grow-your-own model in which people are trained where they will work.

Lovely.

Good morning, everybody. I have a quick question for Dr Kennedy about the Scottish graduate entry medicine programme before I move on to my theme. ScotGEM is unique to Scotland and has been created to address rural healthcare needs. Basically, it is a graduate entry medical programme to train people who, for example, already have a degree in healthcare. My understanding is that the programme has been quite successful in Dumfries and Galloway. What is the perception of ScotGEM in your world?

The BMA in Scotland, and colleagues more widely, have a very positive perception of ScotGEM.

I highlight another conflict of interests: my practice trained the first batch of ScotGEM students in Inverness. I can remember groups of six students coming in. We had one of our GPs freed up for a full two days every week purely to train ScotGEM students. The students are highly motivated, mature and brilliant.

One concern is whether the students come back to work in rural areas. However, ScotGEM is regarded as a success. I think that we should try to emulate the bursary that those students get for undergraduate medical students at our universities, so that they can be funded to go to rural areas, which obviously attract much greater costs.

Okay—thank you.

I am interested in picking up issues to do with continuing professional development such as additional training. It is challenging if, as Laura Wilson said, you have to travel for two days to get to your place of education. Is there a role for delivering more multiprofessional CPD in rural areas directly, such as through the clinical skills managed education network’s mobile skills unit? Is that something that we could look at doing better?

Yes. We would support any training that can be done more locally, that does not take pharmacists away from their practice for longer than is necessary and that allows them to build up skills.

Also, the pool of senior pharmacists who can provide peer review and support is far more diluted in remote and rural areas. It would be more than welcome if attempts were made to encourage them to take part in those things and to provide them with support and training to do so.

I probably need to declare an interest, as a former clinical educator for nurses in remote and rural areas. Are there more digital opportunities for pharmacists in particular? Online learning could be the way to deliver education.

Yes, and pharmacists do a lot of online learning. For the clinical skills that Dr Kennedy mentioned, a hands-on approach is necessary, and it is vital to provide that closer to home. However, pharmacists do quite a lot of online learning through NHS Education for Scotland and other organisations such as ours. Organisations provide learning online and pharmacists undertake it, which is great because they can do it during their working day and are not taken away from their practice.

Nothing beats hands-on clinical skills training, whether it is a simulation with mannequins or something else.

Education budgets are often the first to be cut, and clinical educators are then disposed of. Is there a way to take a standardised approach to certain clinical skills or methods of training so that the same course can be delivered for different professionals? I know that pharmacists, dieticians, physiotherapists and GPs have completely different roles, but is there an opportunity for some education to be standardised for multiple professionals?

Yes, there is to an extent. Certainly, when I did clinical skills training, we learned about ears, nose, eyes, chest and all those kinds of things. We have to make sure that people are going to use those clinical skills, because there is no point in training people if they are not going to use them—otherwise, they will lose them. I could not listen to a chest now, because it has been too long. A general approach would allow more people to be trained, but we would need to evaluate whether it was worth training them in everything, if it is not all applicable to their practice. However, those are always useful skills to have, and they certainly are well learned. The issue is whether people will keep up the skills and maintain that competence in the future.

Is there enough time for education? I put this question to Dr Kennedy as well. Some GP practices close for half a day for continuing professional development, for all the staff in the area. Is there enough time in the day to do the education that is needed for continuing professional development?

Unfortunately, protected learning time in general practice in Scotland has gone. The resource has been removed from NHS 24, so GPs no longer have that. Last night, I was speaking to a hospital doctor who works on Skye, and he appealed to me to ask for resource to be built into hospital doctors’ contracts and GP contracts to provide continuing professional development in remote and rural areas. Clinicians in those areas require a much greater range of skills than those in the city. A far greater breadth of skills is required, but those clinicians are not funded in any way to do that.

On the remote online learning idea, a good example of where you absolutely need to be in the room or in the field is basics training, or pre-hospital emergency care training. That involves doctors and nurses from across primary and secondary care—it is multidisciplinary learning. Some of that can be done online as well, so there is a mixed approach.

However, rural doctors tell me, “Please don’t have us doing remote consultations with our patients and remote learning—remote everything is not the solution.” There is nothing like seeing patients and your colleagues face to face.

To add to what colleagues have said about training, when you are working in a remote and rural area, it can be very isolating and difficult. Once healthcare professionals have qualified, as well as needing on-going support while living in such areas, by working together, they can learn from and support each other in that.

Another point, which one of my colleagues touched on, is that we need to have face-to-face placements available in hospitals in rural locations to be able to upskill the professionals who work there.

Thank you.

My question is about multidisciplinary team work. It would be helpful for the committee to understand how well multi—it is a very hard word to say this early in the morning—multidisciplinary team working is being implemented. Do you have examples of where that has worked well, or of where there have been challenges, that would help our understanding? Laura Wilson, you are nodding, so I will come to you first.

The pharmacotherapy service that Dr Kennedy alluded to is a good example of pharmacists and pharmacy technicians becoming embedded in a multidisciplinary team. We had a fantastic example of a pharmacist and a pharmacy technician who, by working with a patient’s usual prescriber, reduced a patient from being on six or seven medicines, housebound and unable to take part in any social activities to now appearing as Santa at a local children’s hospital, after undergoing a polypharmacy review. That began with the pharmacy technician, who referred the patient to the pharmacist for on-going support and consideration of his medicines. By working with his usual prescriber within the practice, they were able to completely change the patient’s life.

Did that happen because they were located in the same place or because of a differently structured way of working?

They had well-defined roles, a good mix of skills and an understanding of each team member’s role and of how they were going to interact. They worked well together. Each one knew their own limitations and was able to call on the support and help of someone else within the team. It was a collective effort.

Were they literally in the same building, or were they part of a virtual team?

They were together most of the time. The pharmacy technician covered two sites. The pharmacist worked for one practice and the GP prescriber was there too. They were not always physically together, but they spent more time together than was usual in the past.

Iain Kennedy do you have anything to add?

If you say MDTs, as I am going to do, that is far easier than saying multidisciplinary teams.

Okay.

I have quite a lot to say about MDTs. They are crucial in remote and rural areas, where sharing a common purpose and having good relationships makes a good team.

I am told that it is sometimes possible to recruit MDTs but difficult to retain them, because of issues with housing, childcare and schooling. We spoke about the 2018 GP contract, the whole idea of which was to deliver MDTs to GP practices across Scotland. That has not been implemented and it did not work well for rural areas because the resources simply did not provide the number of MDT staff required. Lots of practices in the Highlands have very few pharmacists, mental health nurses, physios or other staff in additional roles.

My own practice in Inverness is a good example, although it is not quite rural.

I was going to ask you about that, because you described Inverness as rural and I was not really sure about that.

My own practice is not really rural, but I can use it as an example. We have four practices, two of which are rural. We have a training hub for the MDT and then team members go out to Cromarty and Foyers. There are also training hubs in Stonehaven and Galashiels. NHS Education Scotland is very much behind the idea that the whole purpose of those hubs is to build multidisciplinary teams within the workplace.

That is the way ahead. We must incentivise MDTs—not just doctors but the whole team—to live and work in rural areas. That might require adding 20 per cent to their pay, so that we can get those people in and so that they will stay.

I will come back to talk about housing and other structural issues.

Two weeks ago, Derek Laidler from the Chartered Society of Physiotherapy told the committee about the challenges of being located in general practices and reported that there was some pushback from GPs about hosting people physically in their premises. Will you tell us a bit more about what your members say? Why might that be the case? What are the difficulties?

09:45  

It is very much about space and rooms. If there are not enough rooms, there is an opportunity cost to having a physio or a mental health nurse in a room that a GP might need.

Sadly, over the past two decades, we have invested very little in primary care premises. The focus has been on hospitals. In Scotland, as is the case in most western countries—the issue is not unique to Scotland—the quality of the primary care estate has gone down. General practices in Scotland simply do not have the necessary number of rooms to accommodate MD teams. I am lucky that my practice was extended recently, so I can fit people in, but many of our smaller rural practices struggle with space.

In the Ayrshire constituency that I represent, one general practice in an urban setting has co-located in a community hub. The staff are not there all the time, but they go in and out. Could such a model work for multidisciplinary teams in rural areas?

I have probably worked in about 30 rural practices in Scotland. I am trying to picture all the village halls, some of which were quite close to the practice, but I cannot really visualise that sort of accommodation. I do not think that it exists.

The community hub was a new build. When we look at renewing community facilities, is there an opportunity to consider wider needs?

Absolutely. The model that you have described sounds very attractive. The way forward involves increased accommodation and co-working with the community.

Does Mhairi Templeton have anything to add?

Not specifically—I would need to ask for feedback in order to get more answers.

Okay. Does Julie Mosgrove want to come in on the issue of multidisciplinary teams?

I have nothing specific to add.

Do you want me to leave my next questions until later, convener?

Thank you. Sandesh Gulhane has a supplementary question.

I have a couple of very quick questions. MDTs include not only our physios and pharmacists but people who work in schools, for example. I recently worked in NHS Fife, and children in schools there cannot be given basic medication such as Calpol unless a GP has prescribed it. Dr Kennedy, how is that helping our primary care services?

I have not come across that issue personally, nor have I heard members mention it recently, although it has been a feature in the past. I think that most GPs in Scotland would push back if they were asked to do that. I would be concerned about that, and BMA Scotland would certainly be willing to take up the matter if you gave us more details.

The Fife local medical committee said that that was the case and that it had been struggling for a year to get schools to change their minds.

My second question also relates to NHS Fife. Those of us who work in primary care want to try to keep people out of hospital—I love to be able to do that as much as possible. In NHS Fife, people who work in primary care are not able to order pretty routine tests, such as a brain natriuretic peptide test for heart failure. Why are there such differences across the piece? There are some basic things that we can do, and I do not understand why it can be said that it is not acceptable for someone who is trained to order an examination that will keep someone out of hospital.

A BNP test—which, as you know, is a test for heart failure that can be done in the community—can be done in my practice in NHS Highland, so I am not sure why it is not possible to do that in Fife. We want to minimise that sort of variation. Following the GP contract, NHS Fife was relatively well resourced compared with health boards that cover remote and rural areas, but Fife is one of the areas in Scotland that is really struggling to recruit GPs, so there are particular pressures there—that is for sure.

I have a quick question for Dr Kennedy about the NHS Scotland resource allocation committee—NRAC—formula. I was at the NHS Borders update on Friday, and Ralph Roberts, the chief executive, was talking about how the NRAC formula works for the funding of remote and rural areas. Do you think that the NRAC formula needs to be revised or altered in any way?

None of those formulas, including NRAC, is perfect. For the GP contract, the Scottish workforce allocation formula certainly had its flaws. We need to examine those formulas, and we need to look at the data as it is now. We know that, in remote and rural areas, we attract the older patients in the population, as they tend to go out to rural areas. There is therefore much greater frailty in those areas, with all the comorbidities that go with age. The formulas need to be rural proof, but none of them is. They tend to be suited for urban areas.

One of my colleagues from NHS Grampian often talks about “geographical narcissism” and “urbansplaining”, which are international academic terms describing how people in cities tell people in rural areas what is good for them. We have to stop doing that, and we must dig deep into the data in remote and rural areas, ensuring that formulas are fit for purpose or that some kind of adjustment is made once the formula is applied.

Good morning. What benefits could be realised in remote and rural areas from having improved sharing of information technology systems such as electronic prescribing, single patient records and more joined-up access to patient information?

We have long advocated for access to patient data, particularly for community pharmacists. As we mentioned earlier, we could expand pharmacy first plus and pharmacy first services, creating far greater equity of access to treatments that are available in the community, rather than having to identify them, with patients—particularly those in remote and rural areas—having to travel long distances to their GP to get treatment that it would be appropriate for a pharmacist to provide. Single shared patient data would be transformative for the whole of community pharmacy, particularly in remote and rural areas, where it would prevent a lot of unnecessary travel for patients and would allow them to access care closer to home.

The electronic patient record is reasonable in primary care in Scotland, although our systems are quite out of date—they need to be updated. In secondary care and in hospitals, there is no electronic patient record. Having such a record would offer a huge improvement, particularly for clinical governance and learning. There is a big gap there.

SystmOne is used in England, and it has been very successful, but I understand that we cannot afford it in Scotland. An electronic patient record is a must, however. We should have had it decades ago; it would certainly improve patient safety and the patient journey, and it would absolutely improve clinical governance.

Do colleagues online have any thoughts?

To reiterate what has already been said, it is a matter of getting a lot of information. In prescribing medication to patients, we need to understand their general health conditions, what medications they have and any complications. As colleagues have already said, it is also about safety and the amount of time that it takes to get information, which can hold up the process for the patient and the clinician. There is a need to improve the patient journey, safety and governance.

Are there specific data gaps in the information that is available in relation to rural health services? If so, what are they, how do we make things better and what impact do those gaps have on service planning?

There are huge data gaps. The lack of data is probably one of our greatest infrastructure problems in Scotland. We need data on our patients, their comorbidities and their health needs, and we must do proper needs assessments for our remote and rural populations. However, we also have an absence of data on workforce. The ageing demographic affects not only patients but the workforce, generally as regards people aged over 50.

Laura Wilson is nodding, so I will come to her next.

In pharmacy, we need data on where our students come from and where they go back to. We need to know where the gaps are so that we can try to plug them and find solutions. We do not have workforce planning for pharmacy in the way that we do for medics and nurses, so we do not know what the gaps are. If we do not know that, we then struggle to get the right number of people in the right places.

Every year, we train hundreds of pharmacists, and the workforce plan contained a commitment to provide additional funding to do so, but we are still short by about 70 places. We therefore train 70 people in Scotland who gain experience in remote and rural areas, have the chance to go and see those places, and then leave—more than likely to go to England or Wales—to practise and do their foundation year. We need the basic data on workforce, and we also need the patient data to be accessible.

I put the same question to Julie Mosgrove.

We have very much the same challenges. There is definitely a lack of information on workforce, work patterns, behaviour, planning for the future, the students that are coming through, how many optometrists we need across Scotland, and also patient information. Many different systems are being used, but not all of them talk to one other. Therefore, although there is a lot of information out there, it is not easily shared among the different professions.

Thank you, convener.

Can I come back to Dr Kennedy on one point? I might have misheard you when you were talking about electronic patient records, but what about the EMIS system?

EMIS is one of the systems that is used in primary care in Scotland. In Practice Systems Ltd’s Vision is the more commonly used one, but EMIS is used purely in general practice and not in hospitals.

No, it is not. Here I should declare an interest as a registered mental health nurse. I was using EMIS on Friday in a community addiction team, so I can say that it is used in other parts of the NHS. I am pretty sure that it is used in mental health in-patient services, too.

Thank you for educating me. That system is not used in Highland so I am not familiar with it in that context.

I just wanted to clarify that.

Dr Kennedy mentioned SystmOne, which is used in England. Of course, there are constraints that you described as financial. I have been in contact with GPs in my area in Glasgow who described any improvement to services or deployment of new technology being constrained by a practice’s capacity to take itself offline to deliver any new system or to train staff. Do you see such constraints as being an issue in rural settings as well?

Yes, absolutely. In my career, I can remember there being two IT changes, which were hectic, chaotic and stressful. Putting in the software and the infrastructure is often done at weekends. If that can be done, it always helps. However, practices and hospitals in Scotland could do with a lot of support the next time a major change happens such as learning a new system.

What support would be practical and useful? It might be hard to describe it precisely, but in general, what additional resource could be supplied by health boards or by the Government directly?

The issues are all the things that would happen with any change management project. IT systems tend to land on our desks literally on the day, and we have to get on with it. However, we do not introduce changes in that way for anything else that we do. We would normally have preparation, planning and support throughout. There should also be on-going support in the form of people being either physically in the building or quickly accessible online to help when glitches occur. However, I agree that we need to invest in that area.

Are there any supplementary points on that?

10:00  

Yes. Pharmacy systems can change, but, in the community, a change is usually implemented by the contractor. As Dr Kennedy has said, support is usually provided to do that. If it is planned for, it is usually manageable, and if it is for the better, teams will work through it.

Is there a feedback loop whereby practitioners describe a problem and a solution is developed and co-designed with them, or are changes dumped on you and you just have to deal with the adaptation?

It is probably different for community pharmacy because independent contractors decide themselves what system to use, then implement it. There is usually a conscious decision to go with a different system and they undertake the change themselves. It is not usually a block change as such.

If there is fragmentation, does that introduce problems with interactions with other healthcare services?

There is no interaction with community pharmacy systems and other healthcare systems, including IT systems.

If there were to be a desire to integrate in the future, would it be challenging because of the fragmentation?

Yes. One of the challenges is the interoperability of the systems and the variety of systems that are out there.

We move to Tess White, who is joining us remotely.

Dr Kennedy, you raised the issue of the closure of care homes. You said:

“The closure of care homes and the ongoing recruitment struggles in the care sector have created a crisis.”

You gave the example of Broadford hospital, which was left in limbo. In Aberdeenshire, the closure of smaller care homes in rural areas causes a huge issue with delayed discharges. Will you say a bit more about that, please?

I am trying to recall the quote that you gave there. Perhaps it is something that has gone out via BMA Scotland in advance of today’s meeting.

I am certainly aware of care homes closing across Scotland, which is a huge concern, as is the whole of social care. Recently, at the Scottish GP conference, the cabinet secretary set out his vision of, first, the patient, then social care, then primary care and then secondary care. That is a good model. Obviously, care homes are very much part of social care, so, given the ageing population, it hugely concerns me when I hear about care homes closing across Scotland. It is an issue in rural areas. I mentioned my practice in Cromarty earlier; the one and only care home in Cromarty closed last year.

In relation to the location of clinics, could you talk about the difficult balance to be struck between having the economies of scale that arise from centralisation in high-population areas and trying to deliver for rural areas?

Yes. In Scotland, we have a completely unique geography with a very dispersed population and not enough hospital consultants to work in all those areas, so we have some decisions to make. Should consultants travel out to Orkney, Shetland, the Isle of Skye, Fort William or wherever and therefore spend 30 per cent of their paid time on the road not seeing patients, or should we have them working in the centres but seeing patients remotely on NHS Near Me or by telephone? At the moment, we probably have a mix, and I think that some patients really appreciate remote consulting and being able to avoid those 100-mile journeys to see specialists.

However, there are huge concerns coming from primary care that patients are often being seen on screen by the consultant and are then being told to go and see their GP, because a particular examination needs to be done or because something gets picked up that needs to be addressed the same day. However, it is inevitable that we will need to provide a variety of methods from face-to-face clinics to the use of technology.

Thank you. Convener, would you like me to cover demographic challenges now?

I have a quick supplementary and then I will come back to you, Tess.

My question is specifically for Mhairi Templeton. I am keen to hear about some of the issues in dental health. We have heard a lot in other sessions about the impact of travel time on accessing services. What is the impact of that on people accessing dental health services in remote and rural areas and what impact might it have on health inequalities?

One thing that I can say is that there are no consultants in orthodontics down at the Borders general hospital, and because of that, a group of us travel down at the weekends to do the clinics on Saturdays and Sundays. We are taking time out of our personal lives to travel down there and to try to get through all the clinics. We are doing a good job in that respect, but we do not know when there will be a consultant to continue with that care.

Having worked with NHS Borders prior to coming to NHS Lothian, I know that you have to cover a great area to get to Kelso, Coldstream and Galashiels. I was spending a lot of time getting to those clinics, and the patients would have to travel, too. Also, if they needed an emergency appointment and you could only offer them an appointment with a general practitioner in Eyemouth so that they could get seen, they could, if they were coming from, for example, Hawick or Peebles, spend the whole day travelling. Because some of them did not drive, they had to access buses, trains and taxis, but some could not afford to do that. I do not know whether the solution is as easy as getting more dentists down to rural areas such as the Borders.

Does that have an impact on existing health inequalities with regard to oral health?

For dentistry, I think so, because we cannot get NHS patients seen by our public dental service and general dental practitioner practices.

I will hand back to Tess White.

Thank you, convener.

Dr Kennedy, we know that patient numbers in remote and rural areas can change significantly. The RPS has said that when cruise ships come into ports, the population can go up by as much as a third. You are based in Inverness, and I have been highlighting the example of Braemar. How is the impact of tourism taken into account in funding and workforce planning?

It is not really taken into account at all. Invergordon gets 100 cruise ships a year, I think, and places such as the Isle of Skye, because of certain TV programmes, get lots of tourists from across the world. It is very difficult to get moving in parts of Skye in the summer.

I know from doing locums in rural areas that the summer months are extremely busy, with a lot of road traffic collisions. That is one of the things about rural areas: as a doctor, you get involved in everything, as do other healthcare professionals. It is scary work; indeed, we know from research that a lot of city doctors do not go to rural areas, because it is quite frightening and the skill set that you require is massive.

Therefore, the busiest times of the year in remote and rural areas are often the summer months, when the tourists are there. Whether they come from a UK city or from abroad, tourists have no idea about the difficulty of providing healthcare in remote and rural areas, and they expect the same immediacy of service that they are used to in their own areas. The situation is very demanding and, other than having the provisions for temporary residents, we do not do much at all to take account of the excess numbers of patients and the fluctuation that occurs in the summer months in particular.

That was helpful.

My second question is different and relates to the ageing population.

Tess—

Earlier, you talked about there being much greater frailty. You know of the example from the Highlands and Islands, and from Inverness, in particular, and I would also highlight the fact that, in Aberdeenshire, the ageing population will be increasing by around 28 per cent over the next seven years. That is huge. The question is: how will such steep increases be factored into budgets, forecasting and workforce planning?

Tess, I think that Julie Mosgrove wanted to come in earlier.

I am sorry, but going back to the previous question, on tourist areas, I would point out that an increase in tourism can also have an impact on accommodation. We are trying to get clinicians to areas where accommodation can be difficult to find and where hotels and bed and breakfasts can be very expensive. Sometimes it can be hard just to get a clinician into a remote and rural area.

Wow! Thank you, Julie. It is good to hear you reinforce that point, because it is something that is coming across loud and clear in the inquiry.

To go back to the ageing population, Dr Kennedy, I highlighted the whopping figure of 28 per cent. Have you any thoughts on that? Is it just a crisis waiting to happen?

We knew that it was going to happen, and we have not prepared for it.

You mentioned the Grampian area. My members in Grampian, particularly in general practice, have expressed serious concerns. Of course, we have a lot of rural GP practices in the Grampian area, but we are also hearing concerns about vacancies from doctors in the hospitals there.

Primary care doctors in Grampian are calling for direct investment in GP practices. The resource for delivering the MDTs that were meant to have been provided under the GP contract has not been used and the GPs in Grampian are asking—pleading—for it. I think that £10 million should have come their way but it has not done so. The GPs in Grampian are pleading for that resource to be directly invested in their GP practices. It is by investing in primary care that we will address the issue of the ageing population. By the time patients get to hospital, it is too late; we then run into difficulties with getting patients out of hospital, because of our problems with social care.

Of course, for an ageing population, social care provision is probably more important than healthcare. That will come down to resource. We have to pay our social carers a decent wage—it might be £15 an hour—so that we get the social carers that we need to look after our frailer patients. I should also point out that there is an ageing demographic not just among our patients but among the workforce, too. That is of huge concern to the BMA in Scotland.

You have covered a couple of themes, and I will drill down into them.

One GP in a practice in Aberdeen told me that they have to hand money back, because they cannot recruit people into the multidisciplinary teams, but they need that funding to provide GP cover. They talked about an imbalance in the formula that you described earlier. Does the Scottish Government need to look again at that formula to ensure that it addresses the needs that GPs talk about?

Yes. As I have said, all formulae are flawed, and there is no doubt that the Scottish workforce allocation formula was flawed, too. The situation that you have described with regard to the inability to provide the MDT team is what I was alluding to. Obviously, the GPs who are appealing to you are having to do the work that would have been done by the MDT teams, but they are not being given the resource. The resource is there, but we need to rethink and maybe move on that issue, so that we can make greater healthcare provision in general practices in areas such as Grampian.

10:15  

Finally, you have used the phrase “geographic narcissism”, which I have not heard before. Do you want to say a couple more words about it? It is quite a loaded term.

It was a new one to me, too, on 1 December, when I first heard it mentioned by Dr Samantha Fenwick, the LMC medical director in Grampian. She was speaking to all the GPs across Scotland, and she made quite a challenging statement about geographical narcissism, which is often called urban narcissism.

You have also heard me use the phrase “urbansplaining”. It is what happens when professionals—not just healthcare professionals—say to rural professionals, “When are you coming back to the city?”, as if going out to a rural area would be something that a professional would do only on a temporary basis. I have also been aware of people who have never worked in rural areas telling those of us who do how things should be done. It is something that is known internationally—geographical narcissism is part of the human condition.

Thank you, Dr Kennedy.

We have been talking about sustaining the MDTs and the wider infrastructure challenges in that respect and, in the inquiry, we have been hearing quite a lot about the specific issue of housing. Previous panels have given us some examples. When nurses on the Isle of Bute were doing their training, workarounds were found with hotels or colleagues providing digs, such as spare rooms; obviously, though, that is not a long-term solution, and it is not likely to attract qualified professionals.

Iain Kennedy, I notice that you were previously with NHS Highland. Are the health board and the local authority having conversations about what a whole-system fix might look like? Are there examples of more sustainable solutions to the issue of housing? I know that the college on the Isle of Skye provided land to a housing association, which shows that the shortage of housing affects not just medical staff but everyone across the board. If discussions have been had on housing, have there been any ideas for solutions?

I was a non-executive director of NHS Highland from 2011 to 2014, so it was a wee while ago, but I have spoken very recently to doctors on the Isle of Skye and rural doctors across Scotland about housing, and the message that they have given me is quite clear: we need to invest in permanent healthcare staff.

The housing problem is not some temporary rent issue; the question is whether people can go in and buy a house. I make it absolutely clear that this will require paying healthcare professionals, whether they be doctors, midwives, pharmacists or physios, a decent wage so that they can afford to buy a house and live permanently in remote and rural areas.

I just want to press you a little bit on that. We have heard that some of the challenge is to do with the availability of housing. I appreciate that affordability might be an issue for individuals, too, but this is literally about the supply of housing across the country in rural areas. I have to say, though, that Skye is an area I am familiar with.

Availability is often cited, and Airbnb and holiday homes are mentioned as the reasons for those houses not being available or affordable.

I have been asked to continually mention the importance of continuity. We know that the best outcome for patients occurs when they get continuity with a healthcare professional and that seeing the same healthcare professional will do more for the health of patients in remote and rural Scotland than anything else. The evidence of that is largely there with regard to seeing the same GP, so we need continuity of care with the remote and rural GPs in Scotland. That will mean attracting GPs and resourcing them so that they can move with their families and stay in the area for a generation.

Do you and your members feel that there is a place for health boards, local authorities and the Government to work together to provide that infrastructure and housing, or to find solutions to how they get built?

I am thinking about the times I have worked across remote and rural areas. Sometimes I would stay in health board accommodation next to a practice, or even within the practice. It is not the most attractive thing to think of doing over the long term. I suspect that health boards and local authorities could not afford to do that now, and even if they could, I do not think that it would attract individual healthcare professionals to move there with their families on a long-term basis.

That is interesting, but we might be thinking about different things. I am thinking about the land that some health boards have and which is not being used. Are there solutions for how boards might dispense with it—and not necessarily for the type of health accommodation that you have described? You have given us an image of some hostel-type thing that might not be attractive to permanent workers. Just to be clear, you are saying that you did not have that kind of whole-system housing and that childcare was not mentioned in your conversations with the board.

It was mentioned often. The issues that we are discussing today have been discussed for decades.

Yes, but are there solutions to them? Do health boards have a part to play in getting to those solutions?

Again, the solutions that we are talking about are similar, but it often comes back to investing in healthcare professionals and giving them the necessary resources to commit to an area for the long term.

Does anyone else have anything to add?

We have certainly heard more about the cost of things from pharmacists. I know of somebody who was going to work in a remote and rural area, but when they found out that the rent was somewhere between £800 to £1,000 a month, they declined.

The challenges definitely exist. We talk about London weighting and using that to offset the cost of additional accommodation as well as the additional costs of accommodation but, from what we are being told, we are now seeing the same thing happening in remote and rural areas. As Dr Kennedy has said, it forces a challenge on everyone to try to address it.

Okay. Thank you.

There are also challenges facing dentistry in remote and rural areas. For a start, there is a crisis with the lack of dentists in Dumfries and Galloway. Is there a role for dental nurses to step in at some level to support good oral hygiene, especially in children and young people? Childsmile has been quite a success, but is there a role for dental nurses to help support people through our dental crisis?

We have a lot of extended duties courses that we can put the dental nurses through, from radiography to impression taking and photography, to try to take the pressure off dentists. However, they are pretty expensive—they are usually set at around £1,000. Can each person afford to pay that themselves, or does the NHS fund it for them? I am not too sure. I self-funded my radiography course, because the general practice that I was in could not afford to pay for it.

Now that I am in the British Dental Institute, I am not able to use my skill set as I would like to, because radiographers come in to us from NHS Lothian. I feel that I will lose my skill set in radiography, but we have a lot of extended duties that dental nurses can carry out. It is about finding the time to put the nurses through the courses. A lot of it is about time and whether we have enough nurses to cover clinics with the dentists. If we had enough trained nurses, I am sure that we could try to take the pressure off any orthodontic needs in general practice or the public dental service.

Dental nurse work is taking place in a range of locations. It could happen at an NHS hospital—indeed, you mentioned Borders general earlier—as well as in dental practices, so there is a wide range of opportunities to implement those skills. Is that right?

Yes. I trained in general practice, having left school after sixth year. A lot of dental nurses train after school, or as a second career, and some go on to do dental therapy and oral health science at universities across Scotland or down south.

I thank the committee witnesses for attending today. Just for clarity, and to put it on the record, I must declare an interest: I hold a bank nurse contract with NHS Greater Glasgow and Clyde.

We will briefly suspend while we change panels.

10:26 Meeting suspended.  

10:40 On resuming—