Talk of a "two-tier" healthcare system tends to mean one thing: the gulf between the private sector and the NHS.

But in countries like Scotland with large rural geographies, two-tier healthcare could also mean the difference between what is on offer to people living in large towns and cities versus the services available far from the Central Belt.

This urban-rural healthcare divide was highlighted in a report published on Monday following months of evidence gathering by MSPs on Holyrood's health committee.

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To some extent, the problem is neglected - however unfairly - because most people do live in large urban areas, or at least "accessible" small towns.

As of mid-2021, roughly 960,000 people in Scotland - approximately 18% of the population - were resident in areas defined as remote or rural.

The level of need within this population is comparatively higher, however, as over-65s tend to make up a larger share.

The overarching message of the report is that the shape of services in rural Scotland is not well-matched to its demographics.

In particular, MSPs have called for a "comprehensive audit of social, palliative and end of life care services in remote and rural areas" given that demand "is projected to increase significantly in the years ahead".

It noted: "The Committee heard many stories illustrating how a combination of increasing demand and diminishing supply is forcing a growing number of people to have to travel long distances from where they live to be able to access these services."

This was highlighted during a visit by MSPs to the Isle of Skye, where several rural care homes located within older buildings have closed in recent years because the operators could not afford to upgrade and run them to meet modern accommodation standards.

Most people in Scotland live in urban areas and 'accessible small towns', but most of the land mass is considered rural or remoteMost people in Scotland live in urban areas and 'accessible small towns', but most of the land mass is considered rural or remote (Image: ScottishParliament)

The problem was echoed by Dr Ross Jaffrey, a GP at the Croyard Medical Practice - which covers the Highland communities of Strathglass, Beauly surround and Muir of Ord - who noted that they have been left with "no cottage hospital or care home beds in the community to help support someone needing a bit more help, but would not be considered unwell".

This was resulting in "a number of unnecessary admissions and failed discharges due to a lack of home care support", he said.

Similar patterns are playing out across Scotland as the Health and Social Care Partnerships (HSCPs) responsible to delivering social care, but faced with finding tens of millions in savings, are closing council-run homes and small cottage hospitals.

There was a glimmer of hope on Thursday, as councillors in Dumfries and Galloway backed proposals by Pauline Drysdale, chair of the council’s social work services committee, to retain at least four beds each at the region's four cottage hospitals - Kirkcudbright, Moffat, Newton Stewart and Thornhill - to provide palliative and respite care.

All four have been closed to inpatients since before the pandemic, despite local opposition.

Campaigners have been fighting to save Kirkcudbright cottage hospital, which had been threatened with permanent closureCampaigners have been fighting to save Kirkcudbright cottage hospital, which had been threatened with permanent closure (Image: Colin Mearns/Herald&Times) The obstacles to providing adequate healthcare to rural populations have not been helped by one-size-fits-all funding formulae better suited to urban contexts.

The 2018 Scottish GP contract is a prime example.

At its core was a bitterly divisive funding allocation formula which relied on a calculation of 'demand' - how many appointments a surgery was carrying out in a day - to work out which practices would get an uplift.

Inevitably this skewed in favour of practices in affluent urban areas with large elderly populations (partly because living longer is a sign of wealth, and also because affluent elderly are much more likely than those in more deprived areas to go to their GP).

In rural areas - where GPs are covering a larger geographical area, sometimes in single-handed practices and often with a wider range of duties - appointments are a much less accurate gauge of "busyness".

The result: virtually no rural GP practice in Scotland received an uplift in its funding in 2018, while extra resources flowed disproportionately into the middle class suburbs of the Central Belt.

Skye has struggled with care home closures, GP recruitment, and providing round-the-clock hospital services on the islandSkye has struggled with care home closures, GP recruitment, and providing round-the-clock hospital services on the island (Image: NQ) Another key element of the 2018 GP contract was the promise to embed new multi-disciplinary teams of pharmacists, physiotherapists, and mental health workers within practices - paid for by the NHS, rather than GP surgery budgets - so that doctors could devote more time to complex patients.

Shortages of these allied healthcare professionals mean that this goal is still lagging behind where it should be at this stage, but the issue is most acute in rural beauty spots where a range of barriers - from childcare availability, to lack of affordable housing exacerbated by tourists and second-home owners, and more expensive transport costs - deter workers from settling in these areas.

In its evidence to the committee, Nairn Healthcare Group, noted that current funding models "take too little account of the additional costs to maintain and develop services in remote and rural settings" leading to the rise in GPs handing back their contracts to the health board "who are now forced to run services [with] estimated costs two to three times higher than before".

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And it is not just the GP funding formula which has come up for criticism.

The National Resource Allocation Formula (NRAC) used to work out how much health boards should get to fund hospital and community services as well as GP prescribing has long been said to disadvantage rural Scotland where population size is shrinking but the costs of filling posts to keep services afloat is usually rising.

As the Argyll & Bute Integrated Joint Board summed it up in evidence to the committee: "With a declining population, we have a declining share and increasing cost of delivery."

Dr Iain Kennedy, a GP in the Highlands and BMA Scotland chairDr Iain Kennedy, a GP in the Highlands and BMA Scotland chair (Image: PETER JOLLY NORTHPIX)

Perhaps one answer is to accept that a "two-tier" of rural and urban healthcare is inevitable, and start adapting our formulae accordingly?

As BMA Scotland leader, Dr Iain Kennedy, put it during his evidence to MSPs: "The formulas need to be rural proof, but none of them is.

"They tend to be suited for urban areas.

"One of my colleagues from NHS Grampian often talks about 'geographical narcissism' and 'urbansplaining', which are international academic terms describing how people in cities tell people in rural areas what is good for them.

"We have to stop doing that, and we must dig deep into the data in remote and rural areas, ensuring that formulas are fit for purpose or that some kind of adjustment is made once the formula is applied."