A new G.P. contract implemented on the 1st April 2018 places rural and remote areas at a severe disadvantage in relation to the provision of medical care, and compromises the viability of sustainable communities. There are actions which need to be taken urgently to protect rural and remote practices and ensure the communities they serve experience health equality. There is to be a remote and rural short life working group Short Life Working Group (SLWG), which acknowledges the need for action.
Official Consultation.
The public consultation for the new G.P. contract began in February 2018, only 2 months prior to its implementation on 1st April 2018. Of the events publicised 6 were in cities with one being held in Portree. Patient pressure led to facilitation packs so rural and remote groups could hold meetings and submit their views, although there was insufficient time for many rural and remote communities to organise their own facilitated groups. An additional video event linking a number of communities in town hubs was also arranged at the last minute, but this was not done in open video format, so did not allow access to all rural and remote patients.
The events did not provide full details of the new G.P. contract and did not explore in the detail needed the detrimental impact it would have on small rural and remote communities. At the time of the engagement the new G.P. contract was already a foregone conclusion and the 'consultation' therefore a meaningless exercise. Unfortunately however it was disingenuous in raising patient expectations of quick access to numerous health professionals, which is far from what will happen in rural and remote communities given the complexity of the issues in these areas. We are still awaiting the final report and Governmental response to this 'engagement' a month after the consultation ended, so unfortunately are not able to include their findings. This demonstrates the woeful speed with which rural and remote issues are being addressed, it is hoped that this petition will be met with a more timely action.
Grassroots Action and Activism.
Because of the lack of notice and poor engagement by the Scottish Government a Facebook page (Rural and Remote Patient Group) and Twitter account (@RuralPatients) were set up to try to establish contact between rural and remote communities and inform them what was happening. Since they have been set up the page has had over 4.1k post reach, 1.5k post engagement and has been shared in Mull, Skye, Benbecula, Lerwick, Dingwall, Ullapool and Fort William, to name a few areas. As a result there is some communication between widely dispersed rural and remote populations, this continues to have a ripple effect as increasing numbers find out the implications of the new G.P. contract.
There has also been considerable interaction by email, telephone and in person from patients who are not on social media, and the issue has been covered in rural and remote local printed media, T.V and community forums as a result. Meetings have been held in small communities; Carradale held a meeting with well over 100 residents attending and subsequently the MSP came to a meeting about the issue, again attended by over 100 people. Luing, Kilmelford, Oban, Conell etc. have all held meetings which have been as proportionately well attended. There is a 'big picture' which the Scottish Government are failing to take into account.
Response to concerns raised by remote G.P.s and patients.
To date, engagement from the Scottish Government has been felt to be defensive, seeking to deflect enquiries and dismiss concerns. The standard of replies and engagement people are experiencing is very poor, demonstrating a lack of understanding of the complexity of issues and the urgency with which it needs to be addressed. For example, politicians are repetitively insisting to their constituents that core funding will stay the same, but are either ignoring or are ignorant of the fact that the changes will affect enhanced service funding very early in the process, and the core funding subsidy is due to end with phase one, thus undermining provision.
Underpinning Issues.
In January 2018 the Scottish G.P.committee and the Scottish Government agreed a new G.P. contract. Despite being hailed as having strong backing and consent of G.Ps only 39% of G.Ps voted and of this only 71% voted in favour of the contract, which means that only 28% of G.Ps voted for it. The contract will have severe detrimental consequences for rural and remote practices, already under represented in patient numbers and always at a disadvantage compared to urban areas.
The BMA have not given the Rural G.P. Association of Scotland (RGPAS) or patients detail about regional breakdown in voting so, in the absence of data, they conducted their own survey. Of 115 members there was a 65% response rate (74 responded) and 89% of the RGPAS voted no. This information, used in advance of implementation would have triggered the need for an impact assessment and demonstrated risks to communities. People, already disadvantaged in many aspects of their lives because of where they live are now faced with the consequences of serious inequalities in health care provision.
RGPAS has released data which demonstrates the impact the contract will have on specific areas (https://fusiontables.google.com/DataSource?docid=13SLV8fjU8S5LvhiMcmbUWpK8imuntSf2f1f1r_g7#map:id=3). The Scottish Government classifies every postcode on how rural and remote it is and a patient has mapped this against the heat map and confirmed that every one of the 73 very remote and rural practices will see a reduction in funding (see below) which will be balanced by a subsidy only in phase one. Urban areas are however receiving increased funding and resources in phase one.
GP contract Heatmap data
See Table 1 of the additional data provided by the petitioner
The Workload Allocation Formula and The Way Forward.
This negative effect is due to the Workload Allocation Formula (WAF) which, with surgical provision, targets rural and remote practices and the communities that make up 20% of the population, by reducing their funding. There is something very wrong with a resource allocation system that does not work for one fifth of the population, a concern already raised by Prof. Phil Wilson, an expert in care and director of the Centre for Rural Health at Aberdeen University. However, these concerns have not been addressed by the Scottish Government. The contract itself is a very urban centric model that will work well where there are economies of scale, good transport links, housing employment opportunities etc, but undermines the provision of primary care that has been specifically and individually tailored to meet the demand of rural and remote communities in challenging geographic areas.
Rural and remote G.Ps, patients, Practice nurses and Teams, HSCP and IJBs can already see the obvious pitfalls occurring with implementation of the contract (although in some cases IJBs have been racing ahead with plans, contrary to what the Scottish Government has promised).They also have expressed serious reservations about the use of the WAF in rural and remote areas, so it is disappointing that the BMA and Scottish Government are not acknowledging the difficulties, and the BMA are not paying sufficient attention to RGPAS. The patient groups have demonstrated a groundswell of public support which we trust will not be ignored due to political inertia.
Praise and Petitioning.
Urban and rural practice are necessarily very different from one another. There is a lack of acknowledgement of this reality in the new contract. It appears that the idea is to turn the lights out on the rural and remote communities that support and sustain our countryside and food security, by removing the key services that sustain them, including the G.P. Doing this means it won't be long before everyone suffers, including those who live in urban areas - we all need a vibrant countryside, farming and fishing sector to support communities and attract tourism.
The Scottish Government is to be commended for securing a contract which benefits so many citizens, but the table below indicates just how many of the population registered with a practice and living in rural and remote areas, will experience severe health inequality as a result of a decrease in their practice's funding.
No of patients on list Change under new GP contract
See Table 2 of the additional data provided by the petitioner.