Skip to main content

Language: English / Gàidhlig


Chamber and committees

Meeting date: Thursday, February 18, 2021

Meeting of the Parliament (Virtual) 18 February 2021

Agenda: Portfolio Question Time, Citizens Assembly of Scotland (Report), Decision Time, Men’s Sheds Movement, Highlands and Islands Medical Service


Highlands and Islands Medical Service

The Deputy Presiding Officer (Linda Fabiani)

The final item of business is a members’ business debate on motion S5M-23483, in the name of David Stewart, on the Highlands and Islands medical service. The debate will be concluded without any question being put. Members who wish to speak in the debate should put an R in the chat box.

Motion debated,

That the Parliament celebrates the Highlands and Islands Medical Service, which was set up in August 1913; notes that it was established following the National Health Insurance Act 1911, which provided workers with health insurance but did not cover crofters and great swathes of the Highlands and Islands; recognises the exemplary research that was carried out by the Dewar Committee, which was chaired by Sir John Dewar and comprised of men, women, doctors, teachers and others who travelled the length and breadth of the region and whose recommendations included standardising the cost of doctors’ visits regardless of distance, creating a minimum wage for doctors, funding more district nursing associations and increasing communication channels for doctors, and recognises that it was the first state-provided health service in the world and is generally considered to be the model for the NHS, which was established 35 years later.


David Stewart (Highlands and Islands) (Lab)

[Inaudible.] I thank all members who have signed my motion. To those who have not, I say that I warmly welcome all sinners who care to repent.

The establishment of the medical service in 1913 was, in my view, the greatest achievement in the history of the region. Picture the scene: nurses riding pushbikes and motorbikes, cutting across some of the most difficult terrain in the country; and doctors, with their sleeves rolled up, putting their strong arms to the oars and moving from one scattered rural population to another, navigating from place to place in simple rowing boats. That was all part of one great effort to bring care and treatment to people in what would later be recognised as the world’s first provision of state-funded healthcare.

The service brought medicine, creams and, critically, medical expertise to the super-rural—[Inaudible.]—no care at all. Its practices and principles were to become the bedrock—the very foundation—on which our health service was created.

The Highlands and Islands medical service came into being after it was discovered—[Inaudible.]—exempt from the National Health Insurance Act 1911—

The Deputy Presiding Officer

Excuse me, Mr Stewart. Your sound is very bad and we are finding it difficult to pick up what you are saying. I suggest that you turn your camera off, which may improve your sound.

David Stewart

Thank you, Presiding Officer.

Chaired by Sir John Dewar, the Dewar report of 1912 sought to understand the impact—[Inaudible.]—on the region. That was no armchair exercise. His large team travelled across the Highlands and Islands, engaging with and listening to communities in Inverness, Orkney, Shetland, Lewis, Skye, Oban and many other settlements. It is difficult to exaggerate the enormity of that task, with the inadequate transport infrastructure that was available in the early part of the 20th century. Doctors, crofters, fishermen and others were consulted across the region.

It was found that the geography of the Highlands and Islands was problematic, both for doctors in reaching people, and for patients—[Inaudible.]. Diets were poor, homes were damp and disease, spreading from livestock, was rife. Many people died needlessly.

Here is an extract of the evidence given by Dr James Reardon—[Inaudible.]—to the Dewar report:

““What do you blame? To begin with, there is no foundation for the children. The mothers don’t nurse their children, and at the age of three months they are supposed to be able to take porridge and sops. The reason for that is that the milk of their cows is given to the calves, and there is no milk for the children. It is a case of the survival of the fittest.”

The Dewar report was to change lives for the better. Its philosophy was that income, class or geography should not be barriers to receiving—[Inaudible.]. It recommended the establishment of a minimum wage for doctors, funding for more district nursing associations and standardisation of the cost of doctors’ visits, regardless of distance.

Parliament approved those recommendations, and the Highlands and Islands medical service was swiftly established in August 1913 and handed and annual grant of £42,000, which is worth more than £1 million today—good value for money.

The service was a rousing success. The grant provided accommodation, transport, further study and holidays for healthcare workers, and the standard of healthcare began to exceed—[Inaudible.]. Those successes were detailed in—[Inaudible.]—a review of the state of Scotland’s healthcare systems. It said:

“On the basis of the family doctor, there has been built up a flexible, central administration and a system of co-operative effort embracing the central department, private GPs, nursing associations, voluntary hospitals, specialists, local authorities and others to meet the medical needs of the people.”

Additional funding from the Treasury in the 1930s led to a further expansion of the service. Stornoway and Wick now had surgeons, followed by Shetland and Orkney in 1934. In 1935, the first air ambulance service was established, with the first patient, fisherman John McDermid, lifted in 1933. He was in urgent need of a stomach operation and could not wait to travel by sea or road. An hour after he was lifted off Islay, Mr McDermid arrived in the—[Inaudible.]—where he was treated. By 1948, the air ambulance service was carrying 275 patients a year across the Highlands and Islands.

[Inaudible.]—half of Scotland’s land mass were able to—[Inaudible.]—which improved their quality of life, social mobility and community spirit.

By the time that the national health service was established in 1948, by the Atlee Labour Government, the Highlands and Islands medical service had been running for 35 years. The rest of the United Kingdom was able to learn from the successes of communities across the Highlands and Islands.

The early pioneers of 1913 deserve our praise, admiration and recognition. I have no doubt—[Inaudible.]. Nye Bevan—[Inaudible.]—concept of a national health service that would be free at the point of use. Not for the first time, the Highlands and Islands provided inspiration and leadership, with a philosophy that it is better to light one candle than to forever curse the darkness.

The Deputy Presiding Officer

Thank you very much, Mr Stewart. We made out most of what you said, but it was quite difficult at times. If you have the basis of your contribution digitally, please email it through and we will ensure that all members who are participating in the debate and the official reporters have a copy of it.

We move to the open debate. Speeches should be of around four minutes, please.


Dr Alasdair Allan (Na h-Eileanan an Iar) (SNP)

Thank you, Presiding Officer. I will switch off Outlook to avoid any undue irritation.

I thank David Stewart for bringing the motion to the chamber. It is one that is worthy of discussion. I feel the need to preface my words with a health warning of sorts, in that I am not a medical expert.

In reading through the 1912 Dewar report into health in the Highlands, which is the subject of our debate, I readily identified with one witness above any other—the crofter on North Uist who fainted while holding up a tallow candle for a visiting doctor who was operating on his neighbour’s strangulated hernia. That episode and others that were recorded in the remarkable report to the United Kingdom Parliament give us a perspective on the huge geographical challenges that health services had then, and have even now, to overcome in that part of Scotland.

As others have pointed out, the challenges also serve to remind us that the Dewar report led to the then unimaginably radical conclusion that only a health service that was free at the point of need would ever work. That led to the creation of the Highlands and Islands medical service, which 35 years later provided, arguably, the model for the national health service itself.

To say that the Highlands and Islands in 1912 were poorly served by health services is a fairly monumental understatement. As David Stewart set out, the Dewar report exposed what had been a chronic political failure to deal with the problem at any point throughout the famines and clearances of the preceding century.

The report describes a time, only just beyond living memory, when large areas of the Highlands and Islands had neither roads nor telephones. The few doctors there were so poorly paid that they had to charge fees to cover their frequent need to hire boats and horses. One doctor in Lewis described trying to serve the scattered population of 7,000 people in his district on foot. Given that, at that time, the average income, after rent, of a crofter in the Western Isles varied from place to place from £10 to £26 per annum, doctors were, for appreciable reasons, often only called on when it was too late.

Many people on the islands testified to the inquiry into such injustice, including—memorably—Father Macneil on Eriskay, who complained about the lack of medical care on the island. He pointed out that the schoolmaster was having to attend the births of babies with the aid of a medical dictionary.

Another witness testified that in parts of the Hebrides people were walking 30 miles just to search out the powers of a seventh son of a seventh son, for want of any medical option.

The Dewar committee’s recommendations were enacted not long before a global pandemic. Its main recommendation was radical indeed: the establishment of a health service that should be free at the point of need. The committee’s ideas were implemented in the Highlands and Islands and 35 years later formed the basis of the national health service in Scotland. It is right that we mark that historic anniversary, and how it transformed the lives of people in my constituency and elsewhere.

This is an opportunity also to recognise the unique challenges that health services face on islands and other areas that have scattered populations, and to pay tribute to the work that health and care services continue to do today, sometimes in challenging circumstances, to make Dewar’s hopes a reality.

The Deputy Presiding Officer

Edward Mountain has been having connectivity problems, so I call Stewart Stevenson, who will be followed by Lewis Macdonald.


Stewart Stevenson (Banffshire and Buchan Coast) (SNP)

I have bypassed my domestic broadband failure by being out in my car and using my phone to connect. That will work perfectly well, but more fundamentally, I sit looking out at the very last of the sun over the Moray Firth to the Highlands and the area from which my father came. He was born and brought up in the Black Isle.

My main hobby these days is genealogy. Therefore, I look at many certificates, particularly death certificates, of my ancestors and the ancestors of friends. What is remarkable from looking at the cause of death for many people in the Highlands into quite modern times, is that the certificate will simply say: “General debility—no medical attendant.” In other words, there were no medical people to tend to people at the end of their life and—as I know perfectly well—at other points in their life.

The Highlands and Islands medical service was a remarkable and visionary attempt to right the wrongs of poor access to proper healthcare, which had been wholly absent all across rural areas of Scotland. One of the early appointments was a community nurse being sent to Hirta—St Kilda—just in time for the first world war to break out.

The world into which my father was born in 1904 in the Highlands was a fundamentally different environment from that of today. Every decade has seen the health service and health provision in the Highlands, and across Scotland and beyond, change. My first dentist, for example, had no medical qualifications whatsoever, so he could not prescribe or give anaesthesia when he was working on the teeth in people’s mouths.

The Highlands and Islands medical service was a remarkable and visionary step that came from the Liberal Government of the time, which also introduced the national insurance system that provided people with pensions for the first time. In one of the imaginary tales that were written more than 100 years ago, Para Handy talks about pension farming and about medical provision in the Highlands and Islands, from the point of view of the coastal trade in which he and his crew sailed around our coasts.

I particularly congratulate David Stewart on bringing the debate to Parliament. He, as I and others are, is coming to the end of his parliamentary career, so this will probably be the last debate that he leads. If that is so, there is no finer way for a parliamentarian of his considerable distinction to go out—albeit that I have not agreed with him on every subject—than on a high, by bringing an important topic to Parliament for debate.

Today, we have a health service that is modelled on the experience of the service. Without it, we would probably not have had what we now take for granted in the NHS in Scotland today.

The Deputy Presiding Officer

Thank you, Mr Stevenson, for showing your commitment by going out to sit in your car.


Lewis Macdonald (North East Scotland) (Lab)

I, too, congratulate David Stewart on securing the debate, and I echo the remarks that were made by Stewart Stevenson towards the end of his speech. David Stewart won his first parliamentary election 24 years ago, albeit to a different Parliament, and in all that time his commitment to the Highlands and Islands and to campaigning to improve public health have been plain for all to see. The topic is very apt for a members’ business debate in his name, because the story that we celebrate today is one of public service and of promoting public health in the Highlands and Islands.

We should never forget that the creation of the Highlands and Islands medical service was a result of the absence of a cash economy and the challenge for doctors to make a living in the crofting counties at that time. Clearances and emigration had created some of the most sparsely populated areas in western Europe.

Crofters had gained the vote for the first time in the 1880s, and the Crofters’ Party sent members of Parliament to Westminster and crofting land rights were secured. That ended the clearances, but crofting remained a subsistence economy—as Alasdair Allan said, not one in which patients could readily lay their hands on cash to meet medical fees.

As the Edinburgh Medical Journal put it in 1911:

“The districts are enormous, the population very thin and very poor, and means of communication are few”,

and as Morrice McCrae wrote in 2003 in his history “The National Health Service in Scotland: Origins and Ideals, 1900-1950”:

“No doctor in the Highlands could easily afford to buy a car or a motor boat, although in many cases he needed both.”

Victorian and Edwardian Britain’s reliance on the market to provide medical services was a classic case of market failure. Private practice could not sustain general practitioners in the Highlands, and the very limited services that were funded by local ratepayers or by charities could not hope to fill the gap. Once the law provided every British citizen with a right of access to medical services, under the National Insurance Act 1911, the only way to deliver that in the Highlands and Islands was to set up a public medical service.

My father and his brothers grew up in the Hebrides in the 1920s and 1930s. Those were hard and often hungry times. Traditional remedies that had sustained people for generations could still be found, but the Highlands and Islands medical service had begun to bring modern scientific and medical knowledge to the service of even the most remote communities.

By the end of the 1920s, the number of GPs in the Highlands and Islands had increased from 100 to 165. They were now on secure incomes with, as David Stewart said, a minimum guaranteed. The service also funded jobs and homes for nearly 200 district nurses, often with small hospices attached to the house and with bikes or motorbikes for doing their job of going from home to home across vast rural areas.

The next decision was to go beyond primary care and to invest state funds in what had previously been charitable or cottage hospitals. From 1924, a full-time consultant surgeon in Stornoway was funded by the Highlands and Islands medical service. During my father’s childhood, it became possible for the first time for crofting families to access both out-patient and in-patient services as a matter of course without leaving the Western Isles, which provided huge benefits for all, from the cradle to the grave.

The Highlands and Islands medical service served its region for a generation. The next generation built the national health service on the same principles and with the same transformational impact on public health. As we celebrate the NHS today for all that it continues to do, David Stewart has done us all a service by reminding us where it all began.


Gail Ross (Caithness, Sutherland and Ross) (SNP)

The debate has certainly been—unintentionally—entertaining, so far.

As others have done, I thank my colleague David Stewart for bringing the motion for debate. At a time when the value of our NHS is so dearly felt, it is appropriate that we reflect on the pioneering work that was carried out in the Highlands and Islands 35 years before the creation of the NHS in 1948. I also recognise the contribution that David Stewart has made to the Highlands and Islands over many years, and I wish him well in whatever he chooses to do next. He has certainly been a source of advice and information for me.

To go back to the topic at hand, we owe so much to those who campaigned for, lobbied for and created a service that brought affordable healthcare and support to clinicians and communities alike more than a century ago. I believe that their work had a massive influence on the creation of what we now take for granted in healthcare. Many others have mentioned the Dewar report, which led to the creation of that pioneering service.

I will focus on the legacy that the service has left in many of our communities. In many communities throughout the Highlands and Islands, some homes are still referred to as the nurse’s house or the doctor’s house. Although very few of those remain homes for medics, they stand as a testament to the recognition that healthcare in remote rural Scotland has many requirements that are different from those in urban settings. Housing was identified as a key factor in retaining and supporting medical practitioners. That is still relevant today. In my home county, Caithness, and throughout the constituency of Caithness, Sutherland and Ross, good-quality affordable housing for healthcare professionals remains a key issue. Although steps are being made in the right direction to address that, it shows how thorough and forward thinking the Highlands and Islands medical service was.

Another legacy is the funding and creation of many small hospitals. For example, in 1920, the cottage hospital in Invergordon was acquired from the Royal Navy and repurposed as an infectious diseases hospital. It is now the county community hospital and is a vital part of the health and social care infrastructure in Easter Ross, which is borne from the legacy of its predecessor. In the early part of the 20th century, more than 60 small hospitals throughout the mainland Highlands provided a range of services.

Public health and healthcare in general have come a long way during the past century, as we all know. It is almost hard to believe that hospitals had to be constructed specifically to deal with outbreaks of disease. For example, a smallpox hospital had to be built in Wick and it operated for almost 30 years. I am happy to report that smallpox is not an issue in the town any more.

Our population is far healthier than it was in the past. Science and technology have improved healthcare immeasurably. However, questions about the provision of service remain and the question that is continually being scrutinised is whether centralised units are better able to care for patients or whether patients from remote rural communities should expect more of their treatment to be delivered closer to home.

To this day, the Highlands and Islands are continuing their tradition of pioneering service. The NHS Near Me digital technology was created and developed in NHS Highland and is now used to support and treat patients throughout the country. Without it, many of us—even some in the Parliament—would have been unable to attend medical appointments during the pandemic. The Highlands and Islands have been pivotal in transforming our NHS in many ways over the years.

The debates about funding and resources for remote rural healthcare that were begun by the pioneers of the Highlands and Islands medical service continue to this day, and I suspect that they will for some time to come. However, one thing that is certainly not in question is that the NHS is still supporting, caring for and helping our communities. For that it deserves our heartfelt thanks.

The Deputy Presiding Officer

We were trying very hard to be able to hear Edward Mountain’s contribution—as was he. However, it seems as if that is impossible, because there are connectivity problems from his location, so I am afraid that I will have to go straight to the minister. I am sure that we are all very upset not to hear from Mr Mountain.


The Minister for Public Health, Sport and Wellbeing (Mairi Gougeon)

I thank David Stewart for the debate. It has been enjoyable to listen to everyone’s contributions, and I thank everyone who has taken part. It has been fascinating.

It is important that we reflect on and celebrate the innovation of Scotland and its people. The Dewar committee’s report led the way in establishing a new model for health and healthcare provision in the Highlands and Islands and, as others have said, the Highlands and Islands medical service model for the NHS is poignant at this time. The world-class care that the NHS in Scotland is providing during the pandemic demonstrates how far the healthcare system has progressed since the Dewar report. The report set solid foundations for the provision of healthcare for people living in remote and rural areas. Those foundations have continuing relevance today and provide the basis on which we have responded to the Covid-19 pandemic.

I hope that the Dewar committee would have welcomed the fact that the latest budget will support the safe and sustainable recovery of the NHS with record funding in excess of £16 billion—an increase of more than £800 million in core health and sport funding to allow investment of £11.9 billion in health boards. That includes £1.9 billion for primary care, and a spend in excess of £1.1 billion for mental health services.

Not only has much changed in the provision of health and healthcare services since 1912, much has changed since this Parliament marked the centenary year of the report in 2012. I highlight the commitments that the Government has made in three key areas of remote and rural healthcare: general practice, technology and the national islands plan. Since the agreement of the GP contract offer in 2018, we have significantly expanded recruitment incentives for rural GP posts across Scotland. We have increased GP relocation packages and widened their eligibility to cover all remote and rural practices. We want to make general practice an even more attractive career option, so we have funded bursaries for GP specialty trainees who take up posts in remote and rural areas in Scotland. The bursaries have helped to distribute trainees more evenly across Scotland.

Since 2016, we have supported the Scottish Rural Medicine Collaborative to develop recruitment and sustainability measures. That has included our support to the rediscover the joy in general practice project, which has so far led to the recruitment of 33 doctors to work up to 18 weeks a year in remote and rural areas. In addition, Scotland’s first graduate entry medicine programme—ScotGEM—focuses on careers in general practice and remote and rural working.

We could argue that the Scottish Government’s remote and rural working group, which is chaired by Sir Lewis Ritchie, is our modern-day Dewar committee. The group was established to consider how rural GP practices can best be supported to deliver the new GP contract and to strengthen their sustainability. Sir Lewis published his report of the group’s work in January 2020, and the Cabinet Secretary for Health and Sport had no hesitation in accepting its recommendations, including the establishment of a national centre for remote and rural health and social care, to foster and promote innovation and excellence in Scotland and internationally.

Digital technology was, of course, unknown when John Dewar and his committee colleagues wrote their report. The use of digital technology to support people to remain independent, or to manage their condition from home, has been a priority in Scotland for a long time, and it was key to our Covid response. The NHS Near Me virtual appointment system has been crucial in ensuring that people could access healthcare during the past year. Its use has increased significantly, from 300 consultations per week to 21,000 per week. Feedback on the service has been positive, and we expect it to be a core part of delivering modern health and care services.

Information technology challenges remain a significant issue—we can see that, given that not everyone was able to take part in the debate—which affects our ability to deliver digital health and care services. The connecting Scotland programme aims to support 50,000 of the most vulnerable people in Scotland to access digital services and devices, learning and skills and connectivity.

We know that good-quality healthcare underpins life on Scotland’s islands, as it does life in rural mainland communities, and many good examples of excellent provision are set out in the national islands plan. Health and wellbeing is at the heart of the plan, which is why we have committed to work with NHS boards, local authorities and health and social care partnerships to ensure that there is fair and accessible healthcare for those who live on our islands.

The fact that we are debating a report from 1912 demonstrates the continuing influence and impact that Sir John and his colleagues have had on Scottish healthcare. Remote and rural healthcare has improved immeasurably since that time. As we emerge from the Covid pandemic, our vision for world-class healthcare in Scotland remains. We will continue to protect the NHS and to provide the necessary investment and planning to ensure that our healthcare system goes from strength to strength.

Meeting closed at 18:13.