Hansard

One theme that came out of just about every evidence session at our committee, and again in the cabinet secretary’s response to our report, is that one size does not fit all, and out-of-hours cover needs to be tailored to the needs of each individual rural community, yet in reality some NHS boards seem to attempt to do precisely the opposite. Like the ugly sisters in the fairy tale, who try to squeeze their feet into shoes that manifestly do not fit, NHS boards try to force out-of-hours medical services that are designed to work in urban areas on to the countryside, where they patently do not meet the health needs of the different community.

I will take as an example what happened in Kinloch Rannoch. I do that not because that rural area represents all other rural areas—to claim so would be to fall into the one-size-fits-all trap—but because much of the evidence that the committee heard focused on that community and the petition that we received. I do not intend to go into every detail of the concerns of those who live there; I will draw out some relevant themes.

Because of a collapse in the existing out-of-hours arrangements, which we have heard about, NHS Tayside set about providing an alternative. Local people, not unnaturally, wanted the re-establishment of local GP cover, but they did not get it. NHS Tayside argues that suitable GPs did not come forward to offer a more local service and, in any case, the health board decided that it was impractical, because it would cost a staggering £556,468.77 per year, according to health board officials. That is more than half a million pounds, even if we forget the 77p.

One can understand how board members could come to a decision not to go ahead with such a service, given that figure, but let us look a bit more closely at how that figure was reached. The officials estimated that Kinloch Rannoch would require the services of four full-time equivalent drivers, as it is the board’s policy not to allow unaccompanied visits. Perhaps that is good policy when the GP who is on call has to make regular visits to tough housing estates, but it is a little bit over the top when we are talking about 800 hardy rural souls who usually generate no more than one out-of-hours call every three weeks or so. The truth is that no drivers are needed in any other rural areas, so why should they be needed in Kinloch Rannoch?

The board then said that the service would need 3.8 full-time equivalent doctors to cover an out-of-hours service because of the European working time directive and NHS employment policy. Again, that might be appropriate for an urban area, but is it required for a handful of requests per year? The board must be joking.

It seems as if someone at NHS Tayside was determined that a local GP out-of-hours service would never see the light of day. It is not as if many health boards, including NHS Tayside, show the same concern about the working hours of the doctors who staff the out-of-hours services that they run in busy urban areas. I found out from NHS Tayside that it employs GPs for that purpose without any knowledge or apparent concern about how many hours they have worked that week in their own practices. As the GPs are self-employed, they fall outwith the scope of the European working time directive, and there seems to be no desire to ascertain that information before allowing them to put in a shift or shifts for the health board. If the health boards can use those GPs—who might be working 50 hours a work in their own practices—to staff extremely demanding on-call rotas, why can they not devise a scheme to do something similar in places such as Kinloch Rannoch, where the workload is minuscule in comparison?

How might that be done? Our committee heard evidence on GPs in the Highlands who are contracted satisfactorily for an agreed lump sum, many times lower than that mentioned by NHS Tayside, to provide out-of-hours cover. They run a rota among themselves. Boards could devise innovative rotations of young doctors or pre-retirement doctors to cover needs in suitable areas. Telemedicine and the use of highly trained, locally based community nurses—whom we have talked about already—both have enormous potential if used wisely and with the on-going support of all concerned.

Advertisements for such posts could be made 10 times more attractive to potential applicants. Many of our rural areas are most beautiful and provide opportunities for country pursuits and an escape from the urban rat race, but those benefits need to be sold positively, not just by a tiny anonymous advertisement in the British Medical Journal.

Indeed, one size does not fit all, and a solution for one area will not always work elsewhere. The important thing is that the health board looks for a solution and takes on the local community as a partner in the search.

Having a locally based out-of-hours service also saves money and misery as a doctor who knows the patients can often avoid expensive ambulance journeys and hospital admissions. He or she knows what treatment a patient needs, what treatment they have had in the past, and what works and what does not work.

In summary, let me quote the two last sentences of the report:

“NHS boards should be given the responsibility for devising—and should be enabled to deliver—specific, sustainable, and often innovative arrangements whereby out-of-hours services meet the needs of individual communities. This should be delivered in consultation with those communities.”

Give them the responsibility and tell them to get on with it.

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