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Healthcare in a rural setting

January 2005
Board of Science

The burden of duty
The excessive on-call commitment
A seminar on rural healthcare at the BMJ Careers Fair (2003) highlighted the fact that a main concern of potential rural GPs is being on-call for 24 hours a day. A study of all 13 permanent consultant surgeons working in remote/rural hospitals in Scotland in 2001 found a similar concern. Ten surgeons had encountered difficulty in finding locums to cover periods of absence and 10 had to cancel holidays and meetings because of difficulties in obtaining suitable surgeons to cover their work. All 13 felt that a centralised locum system in rural/remote areas would be beneficial. [go to reference 35] New research on attitudes and opinions about access to healthcare services in relation to location found that those living in rural/remote areas of Scotland expect GPs to fill the gap in A&E facilities out of hours. [go to reference 67]

The new General Medical Services (GMS) [go to reference 68] contract requires primary care organisations to provide out-of-hours services where feasible. Under their new contract GPs have the opportunity of joining co-operative out-of-hours organisations and of opting out of out-of-hours care entirely. However, remote areas will have difficulty, [go to reference 69] and some isolated single-handed GPs in remote areas are unable to opt out of out-of-hours care. It is important that the complexities of providing out-of-hours care in remote areas is fully understood and solutions are well thought out, adequately funded and safe for patients. [go to reference 69] One such solution is to provide a centralised locum system that practices in rural/remote areas can use.

Recommendation 7
An infrastructure for out-of-hours care needs to be put in place in rural areas. A centralised locum system is essential for the sustainability of isolated and remote GP practices and the remote communities in which they serve.

The European Working Time Directive (EWTD)
The EWTD came into force on 1 October 1998 for all senior hospital doctors; junior doctors were excluded. However, since August 2004 the EWTD also applies to junior doctors. The key points of the EWTD are:
• a maximum of 48 hours per week
• a continuous 11 hour rest in every 24 hours
• a continuous 24 hour rest in every seven days or a continuous 48 hour rest in every 14 days.

The EWTD is having a particularly large impact in rural/remote areas. Smaller patient numbers in rural areas make it difficult to provide services economically, while complying with working time restrictions. [go to reference 70] In addition, it is not unusual to find a small number of consultants covering the full number of hours each week in acute hospitals in these areas. [go to reference 71] The EWTD will, therefore, have an effect on the sustainability of both primary and secondary care services.

Flexible employment opportunities
Healthcare staff across the UK, in line with social trends and to comply with legal requirements such as the EWTD, will expect a more flexible way of working and reasonable working hours. [go to reference 14]

More flexible employment arrangements would:
• ensure a more responsive medical workforce better able to respond to service need
• support recruitment and retention
• meet individual doctor’s needs
• improve career development. [go to reference 14]
Flexible working is an especially important issue to address in rural areas where the burden of duty is seen as a particular disadvantage to recruitment and retention. However, there are opportunities for flexible working that are particularly relevant to rural/remote areas.
• Career breaks and sabbaticals give professionals an opportunity to experience different ways of working and apply good practice, maintain clinical skills and reduce isolation. This can help longterm retention. [go to reference 14] The opportunity to participate in shorter rural/urban exchange schemes should also be available. A two-week exchange would allow urban practitioners to experience rural practice and begin to develop new skills, and rural practitioners to experience different ways of working and access CPD opportunities.
• Flexible retirement options [go to reference 72] can help delay early retirement. These options include windingdown into part-time roles, stepping-down into less demanding roles, and return to work options.[go to reference 73]
• Flexible working that allows part-time work and the provision of child-care facilities is particularly valuable when recruiting those with families, and female practitioners, to rural areas. The increasing number of women doctors means that these issues will acquire increasing importance. [go to reference 14]
• A flexible approach to the NHS workforce requires easily identifiable and accessible systems that will allow a ‘safe trial’ of working in rural primary or secondary care, at various stages of a career, to encourage rural service. The GP Rural Training Fellowship in Scotland is designed to follow vocational training for general practice and has enabled young GPs to try rural practice without long-term commitment. Similar schemes could be put in place for older GPs nearing retirement and wishing to end their career in a rural location and for GPs returning to UK healthcare from abroad.

Recommendation 8
The provision of flexible employment opportunities is particularly important in rural areas to aid recruitment and retention. It is important to provide:
• part-time opportunities to reduce the burden of working unreasonable hours
• flexible retirement to prevent the crisis affecting some rural areas where the majority of healthcare professionals are approaching retirement age
• career breaks and sabbaticals, possibly on a recurring basis, and the opportunity to participate in two-week rural/urban exchange schemes
• a system that allows healthcare professionals to try rural primary or secondary care at any point throughout a career, without making a long-term commitment.

Remuneration
Rural GPs are increasingly frustrated by remuneration that does not adequately reward for the time, skill and responsibility associated with meeting patients’ needs in rural/remote areas. Remuneration must be sufficient to enable the recruitment of practitioners.[go to reference 38]

The new GMS contract [go to reference 68] specifically refers to supporting practices in rural/remote areas. The relevant section of the contract is reproduced in appendix A .

In addition, equitable funding needs to be considered. Services in rural areas can be more expensive to provide than similar services in urban areas, due in part to factors such as remoteness and population dispersal.g In England there is no clear formula to provide adequate funding for rural areas, and a review of the resource allocation formula is required. In Scotland, The National Review of Resource Allocation was established in December 1997 to advise on methods of allocating NHS resources between health boards. The results of this review, which was carried out by a Steering Group chaired by Professor Sir John Arbuthnott, are set out in the report Fair Shares for All.[go to reference 74]

Following consultation, a new method of allocating resources was adopted, which:
• is based on much better evidence
• reflects more accurately the influence of morbidity and life circumstances on healthcare needs
• takes into account more fully the influence of remoteness on the costs of delivering healthcare
• achieves a more equitable distribution of resources. [go to reference 74]

g An example given is that in North Cumbria a population of 330,000 has two general hospital sites 40 miles apart with consultants having to travel between them. The consequence of this is that costs are increased, as it costs more to provide services to 330,000 people spread over 2,000 square miles than it would do compared to where a population is concentrated in a conurbation.