Despite growing up in industrial North Lanarkshire, I knew from my early teens that I wanted to become a remote rural doctor. It is what I went to medical school to do and, after 7 years of postgraduate training, I took up a post as a relief doctor for the islands of Islay and Jura in 1995 before moving on to a partnership in Portree, Skye in 1996.
I became aware almost immediately of what I regarded as a looming rural healthcare recruitment and retention crisis. In 1999 I received funding from the Scottish Executive and the Royal College of General Practitioners to spend a month in New Mexico to look at how they had addressed their own extant rural recruitment and retention crisis. On the back of this mini sabbatical I wrote two reports – one looking at alternative models of primary care provision in remote communities, the other looking at measures to address recruitment problems.
In this second report I made a number of suggestions – identifying and mentoring school pupils showing an interest in rural healthcare; allowing preferential admission to medical school for students from rural areas; developing an undergraduate medical curriculum which is student-centred, problem-based and community-orientated with a strong emphasis on the primary care setting; seeing rural healthcare as a separate speciality and developing a specialist postgraduate training programme for rural health instead of just lumping it into standard general practice training; offering financial incentives to rural working in the form of signing on fees and terminal bonuses; addressing rural infrastructure issues (roads, public transport, internet access, mobile phone signal); protecting rural primary schools; ensuring employment opportunities for the partners and spouses of health workers; providing adequate childcare; looking at affordable housing; asking communities themselves what they can do to attract and keep hold of key workers; and so on.
Fast forward 25 years and I am now a member of a number of email groups to do with primary care, some of which are world-wide in their reach. The rural recruitment and retention crisis has hit rural Scotland hard, just as I predicted it would. But what quickly becomes clear from my involvement with these ‘virtual’ email groups is that in almost every other developed country the problems with recruiting and retaining rural doctors are just as bad as if not worse than the situation in Scotland. That is certainly the case in England, Wales and Northern Ireland but what about things elsewhere?
Across the Irish Sea the situation in the Irish Republic is no better. In rural Ireland 25 – 50% of GPs are at retirement age. Speaking in 2017 Dr Padraig McGarry, then Chairman of the Irish Medical Organisation’s GP Committee, said “The loss of general practice in rural areas is similar to the loss of many services in rural Ireland. We have an increasingly older population of GPs facing retirement and young GPs are not prepared to come in under present circumstances of excessive hours and poor supports. There is a very real threat that GPs in the worst affected counties will not be replaced. We might have areas in rural Ireland, particularly west of the Shannon, where they will not be able to attract GPs.”
In Ireland a reduction in funding has been highlighted as a key issue – specifically the Financial Emergency Legislation of 2009 which saw funding to many rural practices cut by as much as a third or more.
The rest of Europe is fairing little better. In Germany, for example, one third of rural GPs are over 60 and the majority are struggling to find anyone to replace them when they retire. And in many parts of neighbouring Austria rural GPs have all but disappeared. In 2020 the European Commission reported a shortage of doctors, nurses and healthcare assistants in almost every European Union country and in 2022 the European Public Services Union put the figure for these shortages at around 2 million workers.
In September 2022 the World Health Organisation published a report entitled Health and Care Workforce in Europe: Time to Act, which found that 40% or more doctors in one third of all European and Central Asian countries were close to retirement age. The highest rates were seen in Italy at 60% and Latvia at 50% and overall across the EU the average rate was 30%. The figures for nurses were only marginally better.
In Sweden, despite it being a wealthy country with a long tradition of state-funded healthcare and welfare, they cannot recruit rural GPs either and rural hospitals are being closed because they cannot staff them and rural social services cannot be delivered for the same reasons.
In rural north Iceland there are waiting times of up to six weeks to see a GP in Akureyri, by no means an isolated social or cultural backwater. In June 2018 Jón Helgi Björnsson, the director of the Health Care Institution of North Iceland said “What we are struggling with is the difficulty of enlisting doctors to work here. There are simply too few doctors for the clinics we have. It’s maybe a little easier in Akureyri, but generally speaking, it’s just really difficult to hire a doctor to work in the countryside.”
In Portugal doctors are opting to work in private healthcare leaving vacancies in the National Health Service there unfilled. In Eastern European countries like Bulgaria, Romania and Serbia the emigration of medical graduates has left those countries with severe shortages.
Writing in Politico in November 2022, Sarah-Taissir Bencharif reported on the situation in the rural town of Le Vigan in France’s Massif Central. Here in the face of three GPs reaching retirement age they had tried to future-proof the local healthcare services by building and creating a new multidisciplinary healthcare centre in the hope of attracting younger doctors. But after 5 years of looking no potential replacements came forward. She goes on to point out that 44% of French GPs are reaching retirement age and 7 million French people have no access to a referring GP and nearly one third of the entire French population lives in a region with poor access to GPs.
Just last month I received an email from a contact in Belgium which stated “I am a GP and health activist in Antwerp, and we have a huge shortage of staff in Belgium”
On the other side of the Atlantic both Canada and the USA are also facing major problems.
Rural Canada is witnessing large gaps in rural GP service provision. In British Columbia, for example, it is estimated that 700,000 people (15% of the population) have no family doctor.
In 2018 the US National Rural Health Association estimated that rural America would be short of 45,000 rural doctors (mainly family physicians) by 2020. James Dickson, CEO of the Copper Queen Community Hospital in rural Arizona, describes the rural areas he serves as “the new inner cities because we have the same shortages and lack of access to care.”
In Australia, despite what appear to be the lucrative packages on offer (at least on paper) they cannot find enough doctors to work in rural communities. Again cuts in funding are cited as at least one possible factor. The Australian Government froze Medicare payments in 2014 and since then some rural doctors have lost as much as 40% of their incomes as a consequence. Further south in New Zealand the rural GP vacancy rate is currently running at 20 – 25%.
So what is the underlying issue? In essence Governments don’t generally look for ways to do things better. Rather they look first and foremost for ways to do things cheaper. This is true wherever you look in the developed world where there has been a persisting and consistent underfunding of primary care in general and rural healthcare in particular for many, many years.
The new Scottish GP contract of 2018 was yet another example of this trend. Yes, more money was going into primary care as a whole but almost all rural practices were to receive no real uplift to their finances and most would become dependent on a form of ‘income support’ known Minimum Practice Income Guarantee (MPIG) for their very survival.
However it’s not just a matter of adequate finance, important though that is. And it’s not just about doctors either. There are shortages of nurses, midwives, health visitors, mental health workers, physiotherapists, radiographers, social workers, home carers, and school teachers. In addition, too often the debate becomes localised to regions (like Highland) or nations (like Scotland) with lots of ire directed at local healthcare managers or national politicians but no recognition that this is an international problem and there has been no real attempt by anyone – politicians, academics or the professions – to ask why that is so.
Solutions are often proposed – but these are often just the same solutions that have been proposed more than once before, as I did for the Scottish Executive in 1999 and the Dewar Committee Report did before me in 1913. We fail to distil the origins or essence of the crisis.
When faced with apparent complexity, as seems to be the case with rural recruitment and retention, it sometimes helps to use a heuristic approach such as ‘Occam’s razor’. The theory of Occam’s razor is that when faced with a very complex problem the solution may well be the simplest, most straightforward one.
I believe that the fundamental issue we are facing is the ‘Westernisation’ of our society which explains why we see consistent patterns of rural recruitment and retention crises across the developed world. In its current iteration this Westernisation has seen a huge shift towards urbanisation – unmatched since the original industrial revolution in each of those countries.
Urban towns and cities are expanding rapidly. At the same time rural populations are dwindling and ageing.
This results in young people, and especially young professionals, preferring (on the whole) to make their lives in urban or suburban communities rather than rural areas. These young people in particular value what might generally be termed amenity – good broadband and mobile signals; fast and reliable transport links; affordable housing; easy access to a wide variety of activities both for themselves and their children; an acceptable work/life balance that keeps their working hours down; schools offering the best range of educational opportunities; nice shops and cafés to walk round or hang out in; and so on.
Unless and until we can provide similar levels of amenity in our rural areas we will struggle to fill our vacancies. So we need to stop asking “What is about this job that no-one is applying?” and start asking “What is about our community that young professionals do not want to live and work here?”
As things stand, and given the current financial crisis we face, I see no way to sufficiently address these amenity issues and reverse this societal shift so that we will, once again, be able to attract key workers to rural areas and allow rural communities to become sustainable and to flourish.
Stephen McCabe is the Clinical Director of Primary Care with NHS Highland. He graduated from medical school in Edinburgh in 1988 before undertaking GP training in the Scottish Borders, gaining MRCGP in 1993. Stephen worked on Islay and Jura in 1995 as an Associate GP before becoming a GP partner in Portree in 1996. He became a Fellow of the Royal College of GPs in 2013 and was also for a while the remote rural representative for RCGP Scotland. In 2018 Stephen became a salaried GP in Inverness then in 2023 took up the role of Clinical Director of Primary Care with NHS Highland with the remit of supporting primary care services in Caithness and Sutherland.
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