REMOTE AND RURAL
When we use the term "remote and rural" we easily think of the "Highlands and Islands" but 14 of the 15 Health Boards in Scotland include GP practices classified as either remote or rural, so the problems of geographical remoteness and accessibility are widespread. Since the GMS contract came into effect in 2004, GP practices in most remote and rural areas have been allowed to opt out of responsibility for patients during out-of-hours periods. A few practices have either chosen not to opt out or have not been allowed to opt out by their Health Board in accordance with the terms of that same contract and those practices still have to carry on largely as they have been doing since 1948.
The difficulties of people in remote and rural areas, and the services required to meet those needs, are not fundamentally different from those in any other part of the country. Accessibility is a major issue. A recent survey commissioned by the Remote and Rural Areas Resource Initiative (RARARI) to look at out-of-hours care in Scotland [1] tells us that:
- 40% of services covered areas where nearly all the roads were single track;
- 66% of services had patients where the journey to reach them by road might take between 30 and 60 minutes; and
- for 42% the journey to the nearest district general hospital would be over 50 miles and would take more than one hour.
As stated earlier, it is important that a call-receiving organisation should take calls without delay. That becomes even more important when the call is from a remote and rural area. Call handling has to be prompt and efficient and, where it is thought appropriate, triage must follow on without any undue delay because, for the logistical problems outlined above, it might take up to an hour for a clinician to make the necessary home visit - and then, if necessary, perhaps a fairly similar length of time to get an ambulance to the home and yet another similar time to get the patient to the nearest appropriate hospital. There has also to be recognition of the fact that taking away one NHS "unit" (GP, nurse practitioner, emergency ambulance) can seriously reduce the resource then available for NHS assistance. Because relatively few GP co-operatives were established in remote and rural areas, for fairly obvious reasons, the impact of some of the consequences of the new OOH arrangements have probably been felt there much more than in urban areas. Populations covered by pre-existing GP co-operatives have experienced little change in service delivery but in remote and rural areas they have in effect gone, in one step, from practices that have continued relatively unchanged since 1948 to a quite new regime of Health Board and NHS 24 out-of-hours arrangements. That lack of familiarity probably led to some distrust of the new and that initial distrust has perhaps been exacerbated on occasion either by personal or third-party experience of the actual service. It is important that people in remote and rural areas gain, or re-gain, confidence that the new out-of-hours services can at least match what went before because, otherwise, there will be further demand on 999 and A&E services -not always appropriate. There are some indications that in some areas the role of NHS 24 was never properly explained and it does seem that there is fairly widespread lack of understanding of the new OOH arrangements. Health Boards and NHS 24 should agree ongoing local communication planning to better inform the local population about the NHS OOH services now available and how they can best be used.
It may well be that the current pilot "hub and satellite" model in Inverness will be relevant to the particular accessibility-type challenges of remote and rural areas. There is a lot of talk about "localisation" of services, almost as some sort of panacea. That might be part of the solution but much more important is that local circumstances are understood and taken into account when decisions are being made on the appropriate response - wherever those decisions are made. Again it is important that Health Boards and NHS 24 avoid the temptation to rush to make all things "local" for the sake of that alone.
If all that sounds a little negative, we think that there are the means available now to improve services for remote and rural populations. There is scope to have better and much more modern technological links available for community and district general hospitals (eg, variations of telemedicine linked up to specialist general hospitals). The Ambulance Service is currently capable of continuously satellite-tracking every single NHS on-duty vehicle fitted with a small, portable and inexpensive piece of equipment. Co-location of all out-of-hours services attached to a community or district hospital can provide the critical mass of medical, nursing, paramedical and allied health professionals that in turn allows advice giving and sharing across the whole team. In the future we should all have the benefit of our individual electronic patient records. These will surely be of very considerable help to speedy preliminary diagnosis and subsequent patient care. There seems to us to be no reason why, pending the development of a Scottish equivalent, NHS 24 and people calling in for more general information about their condition or about their general health etc should not tap in to the highly acclaimed NHS Direct health website.
There is also clearly more scope for innovative thinking across the whole of primary care in remote and rural areas - and following the 'Kerr' report that will become more and more relevant over the next few years. The voluntary sector and the people within the community - particularly in remote and rural communities - could well also prove to be part of the solution to the particular challenges - and opportunities - of primary care out-of-hours.
[1] 'Out-of-hours Care in Remote and Rural Scotland' - D. Heaney and S. Hall (July 2005)