Scotland’s independent think tank
Scotland’s independent think tank

The future of the NHS in Scotland: Don’t ignore the challenges of rural hospitals – Paul Cooper & Kevin Fox

Rural Hospitals are under threat in many countries, with the same recurring issues.

Recruitment and retention of medical and nursing staff and Allied Health Professionals is inconsistent and unpredictable, leading to shortages of key workers and the reliance on (usually more expensive) locum and temporary staff. Whilst it is possible to create an appropriately skilled and resilient body of interested clinicians, it can be difficult and expensive and time-consuming.  A recent article in the British Medical Journal highlighted the consultant recruitment problem in Scotland, with many advertised Consultant posts in rural hospitals receiving no applications.

The problem of recruiting and retaining a sustainable workforce is multi-faceted.

Training is overwhelmingly based in urban centres and in units offering specialised care. Each speciality focuses on their own training requirements and recruitment needs, and where referring patients is straightforward and advice from other specialists is readily available, the role and skills of a generalist have been minimised. There is evidence that centralisation and specialisation has improved outcomes in some clinical conditions, for instance stroke and trauma, but these conditions are only a small proportion of acute presentations to rural hospitals.

With education and training being focussed on urban centres, there are strong incentives to remain once training is completed. Established cultural interests and social connections may not be so readily available or duplicated in the smaller, dispersed rural community. Employment opportunities for partners, who may also have professional qualifications, are more varied and accessible in an urban environment. Travel to visit friends and relatives is much more straightforward (and cheaper) and children may be in a happy, stable school and social environment. Families and individuals are understandably reluctant to move when there are so many and varied reasons not to relocate.

There are also professional issues that affect rural recruitment.

  • There may be the lack of generalist skillset that gives clinicians the confidence to see a mix of clinical presentations and problems. They may be required to manage conditions and provide care that will be  at the limits of (or occasionally outside)  their usual scope of practice and comfort zone. This has been labelled ‘clinical courage’.
  • Due to small numbers, the burden of frequent on call responsibilities.
  • The lack of a clinical community of peers to provide support and advice when needed.
  • Difficulty in accessing educational opportunities – many rural areas suffer from poor broadband and the logistics of travel, locum cover and expense make attending meetings problematic.
  • Concerns over ‘clinical drift’, where the clinical practices of a small, relatively isolated group can deviate from newer changes to standard clinical practice , exacerbated by lack of significant turnover in staff and problems accessing educational and updating opportunities.
  • Small client groups with high demands will be relatively more expensive to maintain and thus are not provided for.
  • When individual clinicians with specific additional skills are working in a rural hospital it may be possible to support a ‘special interest’ as an alternative to patients being sent to larger hospitals for some parts of their clinical journey. However, agreeing funding arrangements, governance, integration  and  appropriate support staff for  what may end up being  a one-off site-specific pathway can be problematic.

Offering flexible working (weeks on-weeks off arrangement or  an annualised contract) may be an attraction for some. However, this can bring additional issues. Audit, governance, education, formal management roles and other professional and administrative  activities can be difficult to support in an irregular or intermittent  commitment. Travel can be time-consuming and expensive and for Scottish islands, subject to significant disruption in the winter. Finding and funding satisfactory  accommodation that will be used intermittently can be difficult.

In the current situation regarding recruitment and staffing, being an ad-hoc locum, frequently through an Agency, offers more flexibility (if that is an important consideration) and more money (if that is important consideration) and more varied work (if that is important consideration), when compared to a more fixed ’flexible working’ arrangement.

But the problems facing rural hospitals aren’t just about individual recruitment and retention.  

To make a hospital an attractive place to work will rely on there being a ‘critical mass’ of activity to maintain and develop appropriate knowledge and skills. Specialities are often inter-dependent and problems with staffing one service can often have knock-on effects on the provision of other services –for example  problems in providing paediatrics can have repercussions in emergency department, maternity , and community services. There is a ‘critical mass’ of clinical work and colleagues that can make a hospital an attractive place to work. The danger when co-dependant specialities are removed is that the hospital enters a ‘death spiral’ where an increasingly struggling hospital finds it difficult to recruit, which leads to services being withdrawn, which makes it harder to recruit.

If a rural hospital does recruit an individual with more specialist skills, it can prove difficult to create the environment where those skills can be utilised, to the benefit of clinicians, hospital and  community. Patients would have to travel less and for the hospital improving the range of what is on offer and can provide additional educational  opportunities and experience. However, funding and resource issues, governance and integration with the existing service can be difficult problems to solve, for what may end up being appropriate only to a single site.

Hub-and-spoke arrangements, where a larger, urban hospital provides resources (usually  visiting senior staff) to the spoke (rural) hospital have evolved as provision of care has become more specialist-based and centralised. Such relationships can operate with the issues, services and needs of larger central  hub remaining the priority rather than  maximising the potential of the rural hospital to create an active and attractive environment for work and recruitment that serves the  community.

Any possible ‘economies of scale‘ available in administrative, estates and other essential functions do not exist, and in a geographically dispersed population  services mean staff spend more time unproductively in travelling. Because of distance and transportation difficulties with travel (ferries, B-class roads) and the much smaller scale of operations, logistics arrangements and supply will be more expensive.

Although the primary activity of a hospital is the provision of secondary care, in rural environments hospitals can  contribute to the provision for the community of many other services and functions.  This has been described by the Health Foundation as the role of an ‘Anchor institution’ within the community. The social determinants of health refer to the social, cultural, economic, commercial and environmental factors that influence the conditions in which people live and thereby influence their health. In rural environments hospitals can contribute to the health and well-being of the community in many  ways. Hospitals provide secure and stable employment, not just in medical and nursing areas, but in ancillary support services –for example Estates, management, IT and catering. Education and training opportunities can be provided for individuals who would be unable to travel or relocate. The addition of distance learning supported by brief secondments to other units, rather than longer term placements,  can greatly increase the scope of what can be offered.

Procurement strategies can support and encourage the development and sustainability of local services and make a significant contribution to the local economy.

Clinicians and many in the community accept that provision of some aspects of care can be impracticable at small scale. But the response to financial or clinical problems in small hospitals is frequently to close units or scale back services. In recent years this has been most obvious in the provision of rural obstetrics, where Units providing surgical obstetric care have been replaced by midwife units and patients are required to travel , often large distances, to receive care. The effect of forcing patients to travel is to transfer risks and problems from the Institution to the patient. Patients receiving care at remote institutions are deprived of family and social support and frequently suffer disjointed care when transferred back to their community. And when closure of Units and down-grading of hospitals occurs it is to solve a problem which is not of the communities’ making, and such closures can make access to appropriate  care harder for an already disadvantaged group and can worsen health inequalities in the rural population

In most societies, the principle of equitable access to good quality health care for all the population is accepted. Due to distance and time involved in travel and infrequent public transport links, accessing appropriate healthcare can be more difficult for a rural community where the population tends to be older, more deprived with more co-morbidities and hence greater health needs. In Scotland, the allocation formula , calculated by the National Resource Allocation Committee  (NRAC) and Technical Advisory Group on Resource Allocation (TAGRA), developed between 2005-2007 takes into account age and sex profile of the NHS board population, additional needs based on morbidity and life circumstances (including deprivation),excess costs of providing community services to different geographical areas, and excess costs in rural areas of ‘hospital costs’, together with Service Level Agreements for work that cannot be carried out locally.

The current funding arrangements do not recognise the difficulties in recruiting and retaining appropriately skilled and interested staff and is not flexible enough to allow rural hospitals to take advantage of serendipitous opportunities to improve services when they arise  to the benefit of patients. Such flexibility  would also contribute to the sustainability of services and increase educational opportunities and work experience for all staff working there. An active sustainable hospital can play an important role in the community as an Anchor Institution, addressing social determinants of health and  funding jobs, opportunities and training  that can contribute  to the stability, resilience, economic sustainability and attractiveness of rural communities as  places to live, contribute to the community, and  work. This important, wider societal role should also be reflected in any funding settlement .

Paul Cooper is a bank locum Consultant Anaesthetist with NHS Orkney and NHS Highland; Kevin Fox is a consultant physician with NHS Orkney and a Consultant Cardiologist with Imperial Healthcare NHS Foundation Trust.

1 comment

  • Hilary MacPherson

    Many thanks to you both for summarising this issue so accurately and comprehensively.
    Thinking of recruitment, there are also many benefits to living and working in a rural setting which are often not apparent until you get there, e.g. the quality of life, environment and community.
    My own experience of working with you both in Orkney for over 7 years was remarkable after a career in large teaching centres in the Central Belt. Care delivered mainly by trained staff, consultants, decision makers; regaining skills and knowledge you last used as a “house officer”; using all the skills and experience gained over a long career; the hospital team as your peers and colleagues rather than your own specialty; more autonomy over how you work and what you do – less people to convince of the small change you want to make.
    The pressures are different. While throughput is low, the challenge of working at the edge of your comfort zone, exercising the “clinical courage” you describe, adds a different dimension and doesn’t make for an easy life! But it is a human and humane way of working in small teams that is life affirming, brings great appreciation, and satisfaction.
    Scottish Government could do far more to support clinical staff to sample rural life and work, through inclusion in training programmes, supporting secondment and sabbaticals, funding of the serendipitous opportunities that can place a cardiologist from Imperial College and an intensive care and cardiac anaesthetist from North Tyneside, at the Balfour Hospital, Kirkwall. The potential benefits to patients, reduced travel and reduced costs of care are significant if the individual skills that turn up are utilised. Managers also need to be able to exercise clinical courage to recognise and grasp these opportunities.
    The numbers of health care staff and clinicians needed are very small in relation to large urban centres and only a few need to be smitten by the joy of rural life to begin to address the recruitment issue.

    The hospital as an “anchor institution” is critical to community sustainability. Good transport, good health care, including maternity care, and good schools enable families and the community to thrive. Scottish Government failure to support rural hospitals fails the whole community and will erode our Scottish and UK heritage of rural and island life, at the uniquely precious northern and westerly reaches of the British Isles.

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