Health, Social Care and Sport Committee

Meeting date: Tuesday, November 21, 2023

Official Report 661KB pdf

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Healthcare in Remote and Rural Areas

The second item on our agenda is the first oral evidence session of the committee’s inquiry into healthcare in remote and rural areas. We will hear from representatives of the Scottish Government and NHS Education for Scotland. I welcome Stephen Lea-Ross, deputy director of health, workforce planning and development, and Siobhan Mackay, interim deputy director of primary care capability, both at the Scottish Government. Dr Pam Nicoll is associate director of medicine and leads on the national centre for remote and rural health and care at NHS Education for Scotland. We are expecting Professor Emma Watson, the executive medical director of NHS Education for Scotland, to join us. Dr Nicoll is joining us remotely. Thank you and welcome.

We will move straight to questions.

I am keen to hear how the work of the Scottish Rural Medicine Collaborative informed the plan for the new centre and what additional areas the centre will cover.

The development of the rural centre is very much the product of lots of discussion about the implementation of the 2018 general practitioner contract. Hearing and responding to the concerns about implementation of the contract in rural areas, a rural working group was set up, chaired by Professor Sir Lewis Ritchie, to explore that and try to find solutions. It covered a range of issues that were informed by lots of engagement across rural communities, within the health and social care workforce and with users of services.

One of the working group’s recommendations was the development of the rural centre, which NHS Education Scotland has now been commissioned to take forward. In scoping the centre out, NES has built on the original engagement that took place in Sir Lewis’s work and will continue to engage broadly with a range of rural interests, the workforce and users as that work progresses. Sir Lewis Ritchie said previously that he hoped that the centre will be an international example in that space, and that it will pick up many of the issues that the working group’s broader report looked at, including recruitment and retention, education and training, research and evaluation, and leadership and good practice. I will hand over to Pam Nicoll at this point and she can give a bit more context from NHS Education for Scotland’s perspective as it moves forward.

We have worked closely over many years with the Scottish Rural Medicine Collaborative and we are a member of it. We will take forward and build on all the learning and the outputs from its work in our work within the national centre.

Part of the aim of the national centre is to work in a very streamlined manner, bringing under one virtual roof all the work from the Scottish Rural Medicine Collaborative and a variety of excellent programmes of work carried out across Scotland to address health and care in remote and rural and island areas over many years.

As Siobhan Mackay has highlighted, this allows us to work across all four priority areas in a co-ordinated and streamlined manner, but very much building on the work that has come before and particularly on our work within the Scottish Rural Medicine Collaborative.

I should mention my entry in the register of members’ interests—I am a registered mental health nurse.

When I was reading through the work of the Scottish Rural Medicine Collaborative and its final bulletin to members, I was struck by how medically dominated it was. There was a lot of talk about GPs—Siobhan Mackay referred to GPs—and even the workstreams seemed to be very focused on doctors and on the need for recruitment and retention in that area. How will you ensure that the centre does not focus solely on medical staff and that the scope is widened out to include nurses, allied health professionals and so on?

I will kick off and then bring Pam Nicoll back in.

Part of the discussion around the 2018 contract was on some of the challenges around the establishment of the multidisciplinary team and full implementation of the contract in relation to that. That was very much in the scope of the discussions around the rural working report and the rural centre. I know that the rural centre will be looking at the broader scope of professions across the health and social care workforce.

We are very much focused on the multidisciplinary workforce. Our chosen way of working is to focus on the rural team in order for it to be as inclusive as possible across community services and primary care services. From an NES perspective, we have been working for the past 16 years on remote and rural and island education, supporting workforce development in that area. We have taken a multidisciplinary approach to that in all cases, to good effect.

We find that there is learning to be gained from specific professional groups and when we achieve something in a specific professional group, we are keen to look at where it is possible to transfer that learning across to other groups.

From the national centre perspective, all the evidence that we have—and all our success in the past, particularly around remote and rural and island education and training—has been around supporting a multidisciplinary approach and we will be taking forward that approach across the national centre work plan.

It would be helpful to see some more detail around that work plan because that certainly was not what I was getting from the reading that I did in preparation for the committee meeting.

Good morning, everybody, and good morning to Pam Nicoll online.

I am interested in issues around the impact of the national centre for remote and rural healthcare. I am thinking about actions, the delivery of the strategy and plans. We have had previous papers, including papers from the remote and rural areas resources initiative and the review of the 1912 Dewar commission paper, for example. Professor Jason Leitch has spoken about the Nuka system of care in Alaska, which is about community-owned delivery of healthcare rather than it being done to people. I remind everybody that I am a nurse—I remember Professor Jason Leitch talking to us about rural healthcare in the late 1990s.

I am interested in how NES will ensure that the work of the centre focuses not only on strategy development but on actions, delivery and impact.

I will come in first agai, then hand over to Pam Nicoll.

If we are to consider what success looks like, our ambition for the centre is that through its work we see an improvement in the sustainability, capability and capacity of rural and island primary care and that we increase capacity in the multidisciplinary community-based workforce across rural and island communities, so that more people can get the right care at the point of contact. We want improved outcomes for people in such communities.

Thank you for that question. We are very aware of Scotland’s strong history of addressing and identifying the health and care challenges of our remote, rural and island communities.

We worked on an extant policy on delivering remote and rural health and care—we led on the education and training work on that. During the decades since, there has been a range of very helpful programmes of work and initiatives, as Emma Harper identified, that highlight the needs of remote rural and island communities and the challenges of addressing service delivery issues and supporting the workforce in such areas.

In 2008, the Scottish Government supported the establishment of the first permanent team—the NES remote and rural health care education alliance—and for the past 16 years we have been delivering education, training and workforce support. However, we are very keen to also be able to leverage the expertise of partners across Scotland who have expertise in remote and rural research and evaluation, in the development of leadership skills and good practice and also in recruitment and retention.

We do a great deal of work with our international remote and rural partners, and we have a great deal of evidence of programmes of work that have been practically implemented in other countries, as well as across parts of Scotland, that we want to take forward.

The outcome of all that is that our delivery plan is very practically orientated. We are heavily focused on specific programmes of work that are now bringing all those elements together. That means that although we may previously have worked on education and training but not necessarily been able to back that up with appropriate impact evaluation and practical research into whether it works, how it works, where it works and for whom, in order to be able to take that to areas in Scotland, we can now do that. We will be able to leverage expertise across all those areas using practical programmes of work that address the priority needs that the centre has been set up to support.

I thank you for that question, because we are very determined that our work—particularly around recruitment, retention, research and evaluation—will be incredibly practically orientated and that it will be focused on getting the results out and sharing them with our workforce as quickly as possible.

You mentioned monitoring and evaluating whatever is implemented. We have had a permanent group looking at rural healthcare for 16 years. How are we monitoring and evaluating that?

I will roll that in with my final question. How will the centre work with integration joint boards and local authorities to ensure that the work is delivered directly at the point that it is needed, which is in our remote and rural areas—fae Shetland tae Stranraer, for instance?

I will come in again, briefly, and then I will hand back over to Pam Nicoll.

There is a commitment to evaluate the centre. The centre is funded with around £3 million until 2026 and evaluation will take place after year two to look at the impact that the centre is having and to consider its future.

Initially, as proof of concept, the centre is focusing on primary care, and NES might want to speak about the broader scope that it would like it to have. We see the centre as a hub of support for health boards and health and social care partnerships. Pam might want to talk about how it is linking in with those.

Although the centre is focusing on primary care, the aim is that the work that it is doing and what it achieves will be a learning opportunity and that it will be replicable in other settings beyond primary care.

09:30  

Yes, absolutely. I will follow up on that aspect. We will be heavily reliant on establishing excellent collaboration with our health board, primary care and local authority partners and a range of other agencies across Scotland in order to deliver on that and really achieve an impact.

From a NES perspective, on the first part of your question, it is reasonable to say that, over the past 16 years, we have become world leaders in Scotland in delivering and designing remote, rural and island education and training and supporting our workforce. We have a happy history of requests for visits from other countries that want to understand what we are doing and how we are delivering it. There is still more work to be done.

Over the past 16 years, that work has been measured in NES through our own governance process, reporting to the NES board, for example, and then back to the Scottish Government in our role as delivery partners on behalf of the Scottish Government with regard to that work.

After today’s meeting, I would be happy to share the track record that we are building on and bringing into the national centre. We acknowledge that there is more work to do, but we have a great deal of expertise already in Scotland upon which to build and take this work forward. We are very much in partnership with people in our communities, local authority partners and a range of partnership agencies in order to deliver and make an impact.

I remind those in the room that you do not need to operate your microphones; broadcasting will do that.

My questions are to Stephen Lea-Ross and Siobhan Mackay. Earlier this year, I attended a round-table meeting with the Royal College of Nursing, which focused on student finance. There was an example from one of the students who had got a placement on the Isle of Skye. She had found accommodation but it had to be registered with the council. Due to housing availability in such a remote location and the cost being prohibitive, she had to withdraw from that placement. What is the Scottish Government doing to support student nurses who want to train in rural and remote areas?

I can pick that up first. The Scottish Government continues to offer all student nurses across all programmes an annual bursary of £10,000 in addition to support with tuition fee costs. There are additional costs. I do not have the figures to hand but, if the committee would like, I can enumerate the additional financial support in relation to additional out-of-pocket expenditure that is related to placement activity across the country.

That combined package of financial support is the most advantageous that is offered anywhere in the United Kingdom, but it is being reviewed in line with the evidence that we are taking as part of the nursing and midwifery task force, which was commissioned on the back of the 2023-24 agenda for change pay offer. That task force is looking expressly at attraction, selection and the package and offer of support that is available to nurses in training as well as to attract graduates to posts across the country; in particular, it is looking at the rural and island infrastructure component that poses an additional burden.

I have nothing to add to that.

Stephen, can the RCN follow that up with you and share its experiences?

Yes, of course. The RCN is part of the task force and a leading voice around that table of partners.

Thank you.

My second question is to Dr Pam Nicoll. In the north-east, we are seeing a proliferation of 2C GP practices being run by health and social care partnerships, what with the difficulty of recruiting GPs outside the central belt. Indeed, a recent example of that is what has happened at Braemar. What is the Scottish Government doing to address the GP recruitment crisis in remote and rural areas of Scotland?

I can tell you what the national centre is doing with focus work in that area, and my Scottish Government colleagues can give an overview of all the work that the Government is undertaking to improve the situation.

We have talked a lot about the delivery plan for the national centre as a practical example. Some of our priorities for the first 24 months are focusing on a streamlined approach to keeping the GPs that we have and attracting more of them into practice.

We have already begun two key pieces of work. First, we are working to improve support and training for remote and rural dispensing practices. We know that dispensing causes considerable stress for staff, and we know, too, from evidence that some GPs who are attracted to remote and rural practices have concerns about supporting full dispensing functions. That is an immediate priority for us, and we have already begun work to develop education, training and support packages in that respect.

Secondly, we are working to introduce community training hubs in our practices for the first time in Scotland, and we are keen to support 2C practices in that first of all. I will explain a little bit about why that will be helpful. We have had feedback and evidence on the burden that GPs feel with regard to providing training in their practices and yet we know that, to attract more GPs, we have to expose them to positive experiences both during their training and throughout their career in practice in remote and rural areas if we are to achieve a real improvement in recruitment rates.

For a long time in Scotland, a large amount of our training, particularly for our medical colleagues, has been carried out in acute settings in hospitals, and through the national centre, we are now working hard across the country to develop a package of support, education, training, guidance and protocols that will allow remote and rural practices to become what are termed community training hubs. That will attract more GPs in training to remote and rural practices, and we will also have more doctors in training coming through remote and rural practices as part of their training, without increasing the burden on existing staffing.

We intend to do that across the rural practice multidisciplinary team, so pharmacists, nursing staff and advanced practitioners will be included. That work is already under way, and we have chosen specific practices that are geographically spread across Scotland to be involved in it.

How much of a priority is that for you? Is it in the top three of your priority list?

Improving recruitment and retention and supporting our existing staff are our top priorities.

In its evidence, NHS Dumfries and Galloway has described vacancies as

“a staggering challenge that is on par with the financial issues.”—[Official Report, Health, Social Care and Sport Committee, 2 May 2023; c 29.]

Can you provide further detail on the extent of vacancies in rural areas and on what can be done to attract people to such roles?

I am happy to pick up that question. Since 2019, we have seen across Scotland overall an upward trajectory in the number of vacancies in the principal job families of nursing, midwifery, medicine, dentistry and AHP. However, although the number in each family has risen precipitously in that time, we have also in the past 12 months seen a drop in vacancies in nursing, midwifery and AHP roles.

Overall, there has been an upward trend in vacancies in medicine and dentistry in our rural and island board areas such as the Borders, Highland, Orkney and Shetland—although for Shetland, Western Isles and Orkney such fluctuations are nominal—while vacancies in nursing and midwifery and AHPs have been on a downward trajectory for the past 12 months, including both staff in post and advertised vacancies. That picture is likely to reflect recent recruitment efforts. For example, about £18 million-worth of funding has been provided to recruit international nurses, midwives and AHPs, and so far that funding has successfully recruited staff for around 1,250 such posts. It also reflects a shift in the configuration of job families following the Covid pandemic.

As they stand, the trends also reflect the pre-pandemic pattern of there being, comparatively speaking, more of a challenge with recruiting to medical and dental posts in rural and island settings than to nursing and midwifery posts, which is the inverse of the position in our urban areas.

Thank you for outlining those trajectories. I would just highlight the underlying pressures in the domestic workforce, though. I recently joined a round-table meeting with representatives of the Royal College of Nursing Scotland, at which students cited examples of their wanting to do placements in rural areas and on islands but being unable to do so, because of financial constraints on their student bursaries. Could more work be done to support and incentivise rural placements so that the significant financial cost would not be detrimental—or a complete disincentive—to students participating in placements in such locations?

As I have said, the attractiveness of placements in rural and island settings is being actively considered through the work of the nursing and midwifery task force. We are aware of a financial element to that, which has been raised by the RCN and other colleagues.

There is clearly an infrastructure element, too, which we have been considering directly with colleagues on the island boards. For example, we have been exploring the availability of accommodation for both placement activity and peripatetic appointments in such settings, and working with colleagues across Government to release funding to increase accommodation capacity. For example, NHS Shetland’s board was recently supported by the Government in purchasing a guest-house facility and repurposing it to house peripatetic and placement students.

In short, we are aware of a direct financial component to the situation as well as a broader infrastructure element, and the two aspects need to be considered in tandem.

What other efforts are you putting into developing housing capacity? Are you just purchasing existing stock, or is there potential to develop more housing around clinical sites?

In our engagement with colleagues across Government who are leading on the rural development plan, we have picked up the question of key worker housing. By that, I mean not just providing housing for placement and peripatetic staff, but increasing housing availability more generally as part of the effort to attract staff to live and work in the communities that they serve, which includes both local or domestic and international recruitment efforts. Off the top of my head—I would have to double-check the figure—I think that the commitment is around £30 million-worth of investment, as part of the Scottish Government’s broader housing strategy commitment to invest in new housing to support key workers across the country.

I want to ask a direct question about the 2018 GP contract. Was the Scottish Government told that the GP contract would negatively impact rural and island GP and primary care settings?

I will come in on that. I cannot comment specifically on what might or might not have been told to the Government at that time. However, I am aware that concerns were raised, and since then, work on the matter has been on-going through Professor Sir Lewis Ritchie’s group and discussions with the British Medical Association on moving towards the phase 2 commitment to continuing to take account of the needs of rural communities.

We have talked about the centre, which is very much the product of that discussion—

09:45  

We have talked about all of those things, but I asked a very direct question. If you do not know the answer to it, perhaps Stephen Lea-Ross does. Was the Government told back in 2018 that the GP contract would negatively affect rural and island communities?

I am afraid that I am not aware of that.

There was certainly a lot of discussion at the time—and at this point I should declare an interest, not just as a practising NHS GP, but as someone who sat on the BMA Scottish general practitioners committee at the time of the contract. I know that rural GPs were making a lot of noise about the contract negatively affecting those areas. How much of a gap was there between the introduction of the 2018 contract and the putting in place of all the things that Siobhan Mackay mentioned?

My understanding is that the rural working group, which was very much focused on implementing the GP contract in rural and island areas, was established in 2018 and reported in 2020, making a number of recommendations, as you have rightly mentioned. We have already covered the national centre, and many of the recommendations in Professor Sir Lewis Ritchie’s report will be picked up there. Other recommendations included ensuring that no GPs in rural communities or elsewhere lose out, so the incentives guarantee—as I think it is called, if I remember correctly off the top of my head—will be continued. I think that that was worth about £23 million, and it has been uplifted. There is a range of other funding initiatives to support rural communities, and work on dispensing practices is actively on-going and will be picked up in guidance and training materials from the centre.

The work to respond to the concerns has been going on since 2018 and is continuing. As we approach phase 2, there is, as I have said, a commitment to continuing to engage on what the rural dimension looks like.

As for the establishment of the MDT, our GP colleagues have made it quite clear that services should be handed over to the NHS boards only when it feels safe to do so. If GPs want to continue to deliver some services, we are by no means opposed to that.

In terms of implementation—

I am sorry, but can I pick you up on that? What if there were, say, a vaccine delivery system that lots of GPs in the Highlands would like to take on, but the health board said that they were not allowed to? Are you saying that they would be allowed to deliver that vaccine programme?

My understanding is that the health board and the GPs can have that conversation, and services should be handed over only when it is felt that it is safe and appropriate to do that. I am happy to pick up the specific issue of vaccines with my GP colleagues and to provide more information on it, if that would be helpful.

That would be very helpful. Thank you.

My next question is for Stephen Lea-Ross. Tess White asked about numbers. What are the numbers of physician associates in primary care in the Highlands or in other rural settings?

I am not directly aware of the number of physician associates working in GP settings in the Highlands and Islands, but I can say that, overall, a comparatively low number of physician associates work in NHS Scotland, both in GP settings and in health board settings. The overall number is in the low 200s to 300.

But that number is growing.

Yes, but nominally, compared with growth in other disciplines.

What is the role of a physician associate in primary care?

As has been set out, the role is to support the delivery of primary care services, and they can undertake broad-based activities relating to the delivery of healthcare—providing, of course, that they are appropriately trained and supervised. We also specified in a direction letter in 2016, I think, how we expect that to be communicated and enumerated to patients receiving services, too.

My final question about physician associates is really important. If you look at some material that is coming out, physician associates are talking about being GPs. Undifferentiated patients are being seen by physician associates, who, although they have a degree and two years of training, do not have what a senior nurse, such as an advanced nurse practitioner, who has done many years to be at the point where they are seeing someone, would have.

With the difficulty in recruiting in rural areas, are we in danger of seeing a two-tier health service, where compared to people in better-off areas, people who live in rural or deprived areas are more likely to see a physician associate than to see a general practitioner?

I do not believe that that would be the case in the context of the trajectory that we are on within the NHS in Scotland and the commitments that have been made by the Scottish Government. In connection with general practice, there is an outline commitment to increase the number of GPs by 800 by 2027. We have seen record increases in the number of undergraduate medical places, alongside record increases in the number of GP specialty training places, with a commitment to deliver a further 100 places over the next three years. We have also expanded our Scottish graduate entry medicine programme—ScotGEM.

We train comparatively small numbers of physician associates domestically. There is a small programme within the University of Aberdeen of about 40 per annum. As I said a moment ago, we have broadly 200 to 300 physician associates working across the service. We have committed to looking at the role of physician associates, along with that of other medical associate professionals, over the next couple of years by independently evaluating that in line with recommendations that came from a report that we commissioned from NES on the role that medical associate professionals can play within and across our health service. We have committed, pending that evaluation, to only modest increases in training numbers across the suite of professionals.

Emma Harper has a supplementary question before we move on.

I will pick up on ScotGEM. I recently met the chief executive officer of NHS Dumfries and Galloway, Jeff Ace, who said that the retention of ScotGEM graduates in Dumfries and Galloway was excellent.

I have an article here that says that 55 people have completed the first four-year graduate entry to medicine programme, which is unique to Scotland. My colleagues in Ireland, as part of the British-Irish Parliamentary Assembly, are looking to Scotland to learn about ScotGEM so that they can maybe implement it elsewhere.

I am interested in your findings regarding ScotGEM. Is it successful? Has it proved to be supporting rural recruitment for general practice across either side of the central belt?

In one sense, it is a little bit early to do the final analysis because we have had only the first group of graduates. In relation to those 55 graduates, we can see that there has been successful retention on to foundation training programmes. We anticipate a further 40-odd graduates this year. We have expanded the programme in line with our broad expansion of undergraduate medical places. The intake for ScotGEM for this year was 70.

We are seeing that it is delivering, certainly in relation to the vast majority of the clinical and pre-clinical training activity as part of the degree programme in Highland, Dumfries and Galloway and also on the east coast, with indications from the students that their intention to pursue a career within medicine in Scotland and to remain in the locality in which they were trained is at a higher rate than that of other groups of undergraduates.

That is fine. That was a good enough answer—thank you.

I will ask about palliative care in rural areas. In the chamber last week, we debated inequality at end of life, so it will be fresh in members’ minds. The most recent evidence to the committee from Marie Curie, which was on the national care service, highlighted inequity in accessing palliative care in rural areas. What role could the national centre have in making sure that our citizens in rural and remote communities know what palliative care is and how to access it?

I will come in before handing over to Pam Nicoll for some thoughts on palliative care. As we have said, the national centre is focused on the primary care setting. I cannot speak in a lot of detail about palliative care, but the primary care team who support the person who is receiving palliative care will have a role. I am sure that thinking about how the primary care team connects with specialist services, the third sector and beyond to provide support for people who are in remote, rural and island settings will be in NES’s sights.

One of the national centre’s priorities is the need to support our staff to be as skilled as possible to deliver as much care as possible as close to home as they can for the wide range of communities across our remote, rural and island areas. From NES’s perspective, palliative care, the provision of high quality mental health support and paediatric care continue to be very high priorities and areas where there is a significant and on-going need to continually update staff knowledge and skills. The national centre will have the ability to understand varying needs across different remote, rural and island communities, working with citizens through stakeholder networks to understand where the gaps exist and how we can use our expertise to address them.

Within NES, we have experts on palliative care education and training who already work across the multidisciplinary team. Our job is to understand where the gaps exist across the remote, rural and island workforce and to provide support to address the gaps in skills, capability and capacity. In that way, we will work to increase the access to good quality, skilled support for the citizens who live within those communities, now and into the future.

I am finding the session very focused on staff, which, in many ways, is understandable. However, I am particularly interested in patients. Pam Nicoll spoke about the gaps in services. Could you give some specific examples of gaps that you have identified and how those will be plugged? We would all be keen to see that the folk in rural communities whom we represent are afforded the same choices at the end of their lives, whether that is to end their life in a hospice or to be at home. Those two things will have unique challenges, depending on where in Scotland someone is based.

We work closely with remote and rural communities from an education and training perspective to understand changing needs—that has been our history. There is no one-size-fits-all approach; each community has a different range of needs and each rural team will have a different skillset. We have developed an understanding of how to identify specific gaps where we can marry up what is already being provided within communities. For example, we will identify excellent hospice work across remote and rural areas and will work with those teams to look at delivering educational support or supervisory support for staff so that they can feel confident and competent to deliver excellent palliative care within their local areas.

If it is appropriate to step away from palliative care for a moment, I will provide other some examples of gaps that we have identified. Scotland has not had a specific training programme to train our growing group of practitioners in rural areas who are working at advanced practice level. We expect that workforce to continue to grow and to work alongside the other members of the rural team. We have now developed the first rural advanced practice programme in the UK, which means that health boards and primary care practices no longer have to take on that work individually.

10:00  

We are currently funding the first cohort of those practitioners to go through the programme. There are priority areas in which rural practitioners need to have increased skills, and an increased range of skills, to deliver that type of care in their local area—

Sorry—I will jump in there. It is difficult when you are appearing remotely—if you were here, I would be trying to catch your eye rather than interrupt you.

Can you speak to what that would look like for a patient? What difference do the improvements that you have made mean for patients?

Certainly. We will measure what the impact of changes and improvements on patients is by, for example, looking at a specific remote and rural or island setting where the healthcare practitioner will have an increased range of skills that are, increasingly, matched to the local community health needs as we go forward.

One of the ways in which the national centre will be different is that it will be using and gathering more data, gaining more understanding and engaging more closely with local remote and rural and island communities across Scotland, in order that we can fulfil that commitment.

As we talked about earlier, we will measure the impact of that in a practical way, by asking whether the approach is making a difference on a regular basis and ensuring that we are delivering measurable change that has an impact on patients. It will be making an impact by supporting service delivery, which we will do through supporting the workforce capability and capacity to deliver an improved service. In addition, there will be a difference in that we will be measuring the impact in a very practical and on-going way.

I will press you a little on that one final time. What would that measurable difference be? Would it mean that somebody does not have to travel to get treatment, or that they will get treatment more quickly? What will it mean for a patient?

Where it is possible to have increased service delivery, or if that is the improvement that is required, and there are staff in the local area whom we can support to deliver that care, that would be one example of what improvement would look like.

I will ask about alcohol services. When the committee put out a call for views, some of the biggest respondents talked about alcohol services. Obviously, you will be aware—as everyone is—of the large number of alcohol deaths in Scotland. What increases or improvements have there been in alcohol services in rural areas?

I do not have a lot of detail on that, but I can say that the Scottish Government continues to be committed to addressing the high levels of alcohol harm in Scotland. It is working collaboratively with alcohol and drug partnerships across Scotland in order to understand and to help to resolve issues, and to support partnerships in identifying ways to improve waiting times.

There has been increased investment from the national mission on tackling drug-related deaths, which is being used by ADPs across Scotland to support people who are dealing with alcohol and drug abuse. In 2022-23, £106.8 million was made available to support local and national initiatives that are overseen by ADPs, thereby ensuring that local services—

I am sorry. Forgive me, but I am asking specifically about rural areas. What is there in rural areas to help people with alcohol addiction issues specifically?

We do not have material specifically on rural areas, but what I have described will be supporting rural activity. We could certainly follow up on that with the committee.

Absolutely. It would be great if you could let us know what is available and what increases and improvements have been made in respect of alcohol services. If you could do that for each year, including information on alcohol brief interventions, beds that are potentially available for people who want to detox and waiting times, that would be fantastic. Thank you.

I am interested in how we might change to a more preventative model in the NHS and how we support that essential work to help people in our communities and the population generally. On reform in that direction, are the challenges in rural areas different? We talk a lot about the demographic changes in the rural population and the rural workforce. Are you looking at how we can ensure that that reform happens in remote and rural areas?

I am happy to make a start on that question. I will answer it in reverse order. The demographic challenge is more pronounced in our rural and island communities because of the twin effects of ageing and depopulation in those communities. In the context of the broader community-based prevention agenda, that situation exacerbates the total burden of long-term chronic illness that we anticipate managing with regard to demand for healthcare.

We are considering specific things in the context of bringing forward the remote and rural workforce recruitment strategy, under the auspices of our national workforce strategy, which considers the skills mix that is needed for rural and island working, particularly where there are lone practitioners and smaller multidisciplinary teams of community-based practitioners.

However, with regard to our public health and prevention agenda, it is also clear that there will have to be a growing role in matching the availability of workforce and service provision with the national and international demographic challenge that we face as a result of having an ageing population across the west. That is a key focus of the care and wellbeing portfolio and of the proposal to bring forward a further suite of activity to consult on how to sequence preventative action in relation to messaging, public knowledge and people being in control of understanding their own health needs and dealing with the fact that, given the burden-of-disease projections, we will be managing more chronic ill health in the community.

That speaks to colleagues’ earlier questions about the types of skills in areas—rural and island settings—where we would focus on building up the skills mix of staff. Those would include skills in palliative care, respiratory conditions, long-term conditions that are associated with obesity, diabetes management and things of that nature.

Will the development of the national centre help with looking at that for remote and island communities?

There is absolutely scope for the centre, once it has been embedded, to reach out to pick up the broader long-term cross-disciplinary focus on preventative healthcare that will be needed. As things stand, it has four workstreams in the activity that it has been commissioned to deliver, some of which is about increasing recruitment and retention capacity and diversifying the skills mix. Therefore, there is a natural synergy and there is a longer-term decision for ministers to make about how the role of the centre could be broadened.

Siobhan—do you have anything to add?

I probably do not have much to add. The chief medical officer published the “Value Based Health and Care: Action Plan” last month to support the delivery of realistic medicine. In that action plan, he talks about the fact that every healthcare contact is an opportunity for preventative activity. I go back to Carol Mochan’s point about the role of the national centre in that. Pam Nicoll might have some reflections on working in a rural and islands context and the importance of growing MDTs—the growing local primary and community care workforce—and ensuring that they have the skills, confidence and tools to drive forward the approach in which every contact is an opportunity for preventative activity.

Pam, is that something that you feel the centre will be able to help with?

Yes. That is a really excellent question. We are focused not just on addressing our existing priorities but on supporting, training and shaping our practitioners to be fit for meeting our population’s future needs, and on understanding the demographics in a range of rural and island settings, because, of course, they are all quite different.

However, the approach is already having a significant influence on how we are designing our education programmes across medicine, as well as our healthcare training programmes and our recruitment and retention work. Perhaps I can give you a little example of what I mean by that. We have strong evidence from the World Health Organization and from other rural geographies that the more we recruit from remote rural and island settings across Scotland, the greater the retention rate of staff will be. In other words, where staff come from a remote, rural or island area and have access to training and good-quality support, retention rates go up accordingly. That is work that we still have to invest in and evaluate across Scotland.

There are untapped resources in that respect. We know that we are facing a decline in population in many of our remote and rural areas, but we still have work to do to increase access and ensure that we recruit as many people as possible into healthcare professions, so that we have the capacity to deliver for the needs of remote and rural communities. We are working with our academic institutions and our training establishments to try to develop modern and accessible routes to becoming a healthcare practitioner of the future, and we are also seeking to influence the curriculum to ensure an emphasis on preventative care, for example.

It has recently been said that 50 per cent of school leavers in the Western Isles leave the islands and do not come back—or if they come back, they do so much later in life. There are, therefore, related areas that include education and training, increasing access to qualifying routes and a positive recruitment strategy in which we welcome all people to come and work in Scotland.

In particular, we want to increase the number of people who have been brought up in remote and rural areas who are attracted back and retained in health and care careers. As a result, there is a tie-in with what we actually train people to do and whom we attract as our practitioners of the future, so we will begin to have an impact with regard to preventative care and providing the types of healthcare and social care that meet the population’s needs now and into the future.

Thank you.

I call Gillian Mackay.

Thanks, convener, and good morning, panel.

Given the changing demographics that we are seeing, how can we continue to move more services towards the community—not just into primary care but into some of our smaller hospitals in remote and rural locations? They are often much closer to communities than, for example, Raigmore is to Sutherland.

I am happy to pick up that question.

From a workforce perspective—which is, I think, the perspective that I speak predominantly from—I would say that the issue with delivering more care in the community is in how we create the enabling conditions that will allow it to happen. Pam Nicoll and other colleagues have talked extensively about skills and capacity. That is partly about the professional skills and competences that are involved in lone working, and some of it is about professional decision making. Alongside that, though, we would highlight how we have improved our service terms and conditions to promote flexibility in the service offering and, as a result, to allow staff to be better dispersed in community settings.

I will highlight another two enabling conditions. One is about how we create, or invest progressively in, the technology and infrastructure that will allow staff to work in a more dispersed way and to be connected. That would involve staff getting support for collective clinical decision making and being able to use the tools that will—as we know from looking at innovations in medical and other clinical services delivery around the world—allow them to give supported diagnoses for conditions through advances in artificial intelligence and other technological innovations.

10:15  

The second condition is about how we create the leadership capacity to allow more dispersed network management of staff. There is a service design and patient safety element to that—we have to design services that are delivered in a clinically safe way. Some aspects of specialist and acute care will still require a certain throughput of patients in a given service within a given locale in order for that care to be safe, effective and efficient. That will also continue to be the case for some advance care planned treatment.

As was talked about briefly earlier, we will have a significant focus on creating the enabling conditions that I have just laid out, along with a focus on capacity and skills.

That is great. Pathways are sometimes opaque, to say the least, even when you live in the central belt and go to a major hospital for out-patient treatment. When there are extra complexities of distance, as there are with some of the smaller hospitals, things are even more challenging to navigate.

What work is going on to ensure that the populations that we are talking about have transparent pathways that suit their needs, and to ensure that ageing populations know where, when and how far they have to go for their treatment?

That is, and will continue to be, an on-going challenge as services evolve. Obviously we have to commit in the broadest sense—as the committee would rightly expect—to continuing to signpost access to services, and to continuing to evolve our digital infrastructure and our expectation that health boards and partnerships, even down to practices, communicate directly with patients regarding access to and delivery of services. As I said, we will have to continue to pay attention to that.

Finally, we know that feedback from patients is essential to on-going service delivery and evolution, but in some communities the doctors and nurses on whom people are giving feedback are their neighbours, and are much more closely related to the community than they might be in more populous areas. Is there active work being done on seeking views from people, so that their feedback on changes can be taken into account? People might be apprehensive because of that close relationship.

Yes. We recognise that, and there are objective mechanisms for seeking feedback, including getting feedback about people’s experience of receiving treatment through anonymous fora such as the Care Opinion website and so on.

In addition, in the context of our on-going work to develop the rural recruitment and retention strategy under the national workforce strategy, we have, as well as doing the standard literature review work, visited NHS Western Isles alongside the WHO, and have done some engagement work with staff and service users.

We will continue to undertake outreach work as well, through on-going mechanisms in relation to the nursing and midwifery task force, and by engaging with service users via our tripartite working structures in the NHS.

We also take cognisance of the fact that a number of individual service users have written in response to the committee’s inquiry, and we will pick up on those submissions in the next stage of development of the strategy.

Good morning, panel.

When we talk about remote and rural healthcare, we often look at it through the same lens as we look at healthcare elsewhere. We consider that, for various reasons, healthcare in rural areas is not as good as we would like it to be in comparison with the rest of the country, and we look at how we can improve its standing.

That is hugely important, but I want to flip that around and look at the subject through another lens—in relation to digitisation, remote healthcare, telehealth and so on. There are clearly opportunities for us not only to get ahead of the curve in how we deploy those technologies at scale in rural communities and drive up health outcomes as a consequence, but to position Scotland as a leading global player in those technologies. I know that we have done a lot of that already, and that there are great examples of it in the Highlands and Islands and elsewhere. To what extent do you see the national centre focusing on such opportunities, as it does on the many existing challenges that we have discussed?

In a broader sense, we have the digital health and care strategy. However, to home in on the work of the centre, I note that the idea of using digital technology to support delivery of primary care services was a feature of the report of Professor Sir Lewis Ritchie’s rural general practice working group back in 2020. According to the report’s four pillars, digital will be a theme of the centre’s work—in respect of how it connects with the healthcare and social care workforce across rural and island areas and with service users to seek their views on training, support and other features, which will be done very much with international examples in mind.

Pam—do you want to elaborate on that?

Thank you, Siobhan.

I agree that it is integral to our work that we be innovative with our community members through the work of the centre, in considering ways in which we can harness our existing digital technology skills to improve access to services and the quality of those services. We already have a track record of pioneering increases in our staff and workforce in remote and rural areas, and in raising their confidence and competence in using technology to conduct their own learning at a distance. Our training programmes increasingly include digital confidence and competence among the range of skills that our rural practitioners have now, and will have in the future. That is therefore very much part of the work of the centre now and into the future.

We are keen to highlight, through our work, the fact that remote, rural and island areas have often been leaders in showing others how to use technology. We want to continue that pattern by using all available technologies, artificial intelligence and low-tech and high-tech solutions to good effect, in order to achieve improved impact in how we deliver services and how patients experience that delivery.

Have you specific examples of technology and digitisation having been deployed in rural areas in advance of that happening elsewhere in the country, or are there plans in which that is in train?

Again, NES’s experience on that has been in education and training and using technology. We were early adopters of technology. More than 10 years ago, we set up our at-distance healthcare education networks, which have now been running for about 10 to 12 years using available technologies to deliver education in priority areas of need for a wide range of multidisciplinary staff.

In response to need, we also developed a technology-enhanced learning programme for our learning and development staff in health boards in remote and rural areas. Again, that was first delivered for those staff and is now a rolling programme that they implement themselves, in which they design, for their own staff, high-quality education and training that make excellent use of available technologies and emerging ones.

Does anyone have further comments on that?

I add that we see further opportunity in rural and island communities for using the two digital technologies that are already in use.

The committee will be familiar with NHS Near Me in relation to video consultation, and Connect Me, which focuses on wellbeing and allows two-way communication with service users, in that they feed in information about their wellbeing and how it is going, outwith a consultation via text message or app. It also allows them access to a library of services. There is an aspiration to target, through Connect Me, 80,000 folks in relation to supporting a variety of blood conditions, including hypertension, by 2025. There is a focus on rural and island communities in the roll-out of those two programmes.

I have a question for Siobhan Mackay. The number of GP practices in rural areas has declined by 7 per cent in the past 10 years—it has gone from 188 to 175. What is the Scottish Government doing to reverse that decline?

We have the nationwide commitment to increase the number of GPs in Scotland by 800 by 2027. Stephen Lea-Ross has already mentioned that we are making good progress on that at the national level, with record numbers at the moment.

The number of GPs working in rural practices—

I am sorry, but my question was about GP practices, not GPs. If you do not have the figure let us know, then answer the question. It is a massive concern that the number of GP practices is declining. Is that decline going to be reversed? If it is, what is the Scottish Government doing?

We will get back to you specifically on the number of GP practices.

That would be very helpful for the committee.

I have a final question, which is specifically for Pam Nicoll. We have heard a lot this morning about the workforce, staff retention and so on, but I have not heard where the patient’s voice is in respect of development of the new national centre, or how patients’ voices will be heard in following iterations of the centre and their development.

We have talked a lot about improving services through our support for the workforce, which is a large part of the work of the centre. The other very significant part of the centre’s work is what we term our “community accountability”, which is about patients and citizens. We are establishing stakeholder networks that will take different shapes and forms. The intention is that, rather than having sporadic consultations of citizens and patients, we will establish on-going dialogue, particularly under the four areas that the centre has been set up to support. We will establish networks that will aim to be inclusive and have appropriate representation around the table from a range of communities—north, south, east, and west. They will include patient groups and wider groups of citizens.

In relation to the model of delivery that we are taking forward with the national centre, we are very much adopting the terms “socially accountable” and “community accountable”. That, by merit, requires us to demonstrate how we are maintaining dialogue, how we are influenced by and how we are guided by the needs of communities and patients, and the impact that we are having within communities and with patients. That will be a very important part of the centre’s work.

In addition to having a strategic programme board, we will establish early next year a range of stakeholder networks—as we have called them at the moment—that will be completely focused on being inclusive of patient representative groups and community members, as well as other stakeholders.

That answers part of my question, in relation to what will happen going forward, but where has the patient’s voice been in the development of the proposals and the work programme for the centre?

We have taken our lead from the work that the Scottish Government has described, which was done in preparation for addressing the need to develop the centre in the first place. It has been a long time in the planning. Throughout that planning process, we have considered all the information that we have had from a variety of sources and a variety of reports, as well as having considered the matter from an NES perspective. Our on-going engagement within communities and remote and rural island communities up and down Scotland over the past 16 years or so has all been taken into account in shaping the delivery plan that we have for phase 1 of the national centre.

I am sorry—I am maybe not being clear enough in what I am asking. Has there been direct consultation of patient groups and patient representatives in remote and rural settings during development of the work plan for the centre and its priorities? I hear what you are saying about how that will happen going forward, but has there been engagement so far?

We have not had a recent series of specific engagement with patient groups in relation to the national centre, but it is in our plan to continue that work. We had established a programme of work for that last year, but we had to put it on hold temporarily while we were waiting to understand whether funding would be established in 2023 for the national centre. We understand that it is a priority, and we will address that early next year within the phase 1 delivery plan targets and objectives.

Okay. Thank you.

I thank the witnesses for their attendance at committee this morning. We will briefly suspend.

10:30 Meeting suspended.  

10:41 On resuming—