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Around 15% of Scotland's population live in rural and remote areas, but what kind of healthcare service are they getting?

The issue has been under scrutiny over the past few weeks as MSPs from Holyrood's health and social care committee gather evidence on everything from general practice to maternity care in rural Scotland.

Urban bias

Dr Stephen Makin, a consultant geriatrician based in Wick, Caithness, told MSPs that there was a "tendency to forget that healthcare has to be delivered differently in a rural hospital" because most of the medical academics devising new initiatives work in urban hospitals.

Dr Makin, who specialises in stroke research, pointed to the example of thrombectomies – a potentially life-saving and disability-avoiding procedure where blood clots are physically removed during emergency surgery.

Scotland is working towards having three thrombectomy hubs, in Edinburgh, Dundee and Glasgow.

"I practise in Caithness, and the nearest place where a thrombectomy can be done is Dundee, and it has to be done in six hours," said Dr Makin.

"How do we even select the right patients to go to Dundee and when? We are operating in an almost evidence-free zone."

The shift towards more remote consulting on NHS disadvantaged rural communities, he added: "When I try to do a video clinic, the broadband that most of my patients have is not good enough for a video call, so we just end up talking on the phone, which negates the whole point of the service – it is not the same. By moving our service to video calls, we are exacerbating socioeconomic inequalities."

He noted that the centralisation of vaccinations from GP surgeries to the health board "has not worked well" in remote parts of Highland.

"We have heard of people driving for three hours to get one vaccination."

The Herald: 'I practise in Caithness, and the nearest place where a thrombectomy can be done is Dundee, and it has to be done in six hours''I practise in Caithness, and the nearest place where a thrombectomy can be done is Dundee, and it has to be done in six hours' (Image: NHS)

Depopulation

The number of older people in Scotland's rural communities is increasing, but they are also losing large numbers of young people due to a lack of jobs and affordable housing. The committee heard that 50% of young people from Western Isles leave and do not return.

Outsiders settling in picturesque rural, island and coastal communities upon retirement are also pushing up house prices and demand for healthcare, making it harder for people to return to care for elderly parents or grandparents because they have been "priced out".

This creates a situation whereby older people living in rural areas are more likely to spend longer in hospital as a "delayed discharge" following a minor illness, because they have no family in the area to support them at home.

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The committee heard the example of a student nurse who had to give up a training placement on Skye because she could not afford to stay on the island, and was told that the number of GP practices in rural Scotland had fallen over the past decade from 188 to 175.

Stephen Lea-Ross, deputy director of health workforce for the Scottish Government, told MSPs that – over the past 12 months – there has been an "upward trend in vacancies in medicine and dentistry in our rural and island board areas", particularly in the Borders and Highland.

It is a "little bit early" to say what difference the ScotGEM initiative will make, he said. The postgraduate medical degree – which is geared towards careers in rural general practice – has just generated its first 55 graduates, with another 40 in the pipeline this year.

The "intention" of this cohort to stay on and work in the same area they trained "is at a higher rate than that of other groups of undergraduates", said Mr Lea-Ross.

Maternity

There is "still a lot of resentment and anger" over the decision to downgrade the maternity service at Caithness General hospital to a midwife-led unit in 2016 "without any consultation", said Dr Makin.

The decision, made on safety grounds amid obstetrician shortages, means most first-time mothers and anyone with a higher risk pregnancy has to travel 100 miles to Inverness to give birth.

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Dr Makin said he was aware of some mothers planning to turn up to A&E in Caithness instead when their labour is too advanced for them to be transferred by ambulance.

"I am the consultant on call who would be resuscitating their baby – I am a geriatrician – and that terrifies me."

Shetland, he said, spends an "eye-watering" amount to have a consultant obstetrician on the island.

"If we are going to reintroduce full maternity services to rural general hospitals, should we accept that there is a risk to babies, or do we spend a vast amount of money?"