The last of the true generalists

RPAS Inverness 2008Dr Malcolm Ward

Rural Practice Standing Group

The Rural Practice Standing Group was founded in 1993 to raise the profile of rural medicine in the United Kingdom through education, research and the dissemination of good practice in rural health care.

RPSG• Malcolm Ward chairman

• Gordon Baird Stranraer, past RPSG chairman

• John Wynne-Jones Director Institute Rural Health

• David Johnston N.I. RCGP chairman

• Paul Kettle GP Orkney

• Iain Mungall Northumbria, past RPSG chairman

• James Moore GP Devon

• Russell Walshaw GPC

• Aidan Egleston DDA

Current activity

• Quest for a Rural Faculty

• Submission to Faculty Strategic Review

• Response to Darzi interim report 12.07

• Response to Pharmacy White Paper PWP: response to proposals for legislative change

• Response to PCF consultation

• Clinical scenarios, literary review, web site

Key features of current 2005 NHS Pharmaceutical Services Regs (England)

• Controlled locality

• 1 mile/1.6km rule for patients

• New DD applications: 1.6km distance criterion surgery to nearest pharmacy

• Existing market towns protected

• Reserved locations

• Registration of Dispensing premises

• Amalgamations

PWP proposals-EnglandChapter 4 Dispensing:options

1. No policy change

2. Empower PCTs to commission dispensing in accordance with Pharmaceutical Needs Assessments

3. Distance criteria between GP surgery and pharmacy rather than patient to pharmacy

4. As 3 but where a second pharmacy within a given distance. Dispensing practices to dispense to whole list.

5. OTCs

Problem clinical scenarios

• Psychiatric emergencies, access to mental health services, alcohol/drug services

• Transport issues for hospital lab testing• Near point testing: INR,Troponin,

Biochemistry, FBC, D-Dimer (wide variation of use)

• Variation in availability of funding (LES)• Ambulance rural response times• Social services

The uneasy “gut feeling” cases

“ The best solution to those uneasy feelings is having access to good local consultant advice and the ability to arrange investigations without the consultant having to see the patient”

Susan Taylor

Threats to rural practice

• Last of the true generalists?: GPSI, NPs, ECPs

• Darzi Polyclinics• Privatisation by stealth• Loss of MPIG• Proposals to change Pharmaceutical Regs• NICE e.g. Minor surgery• Single handed GPs: OOH, recruitment,

political attitudes

Opportunities?

• Primary Care Federations• Practice Based Commissioning/increasing

range of services: near point testing (INR, D-Dimer, GTT, auto-analyzers) minor surgery, cryotherapy, counselling, advanced ear care, insulin initiation.

• Developing the skills mix

• LIFT, PFI

• Increased use of IT, video links with 2ndry care

Why a Rural Faculty?

RPSG• No constitutional

powers• No Council

representation• Lack of funding• Lacks democratic

infrastructure

Rural Faculty• Constitutional powers• Council

representation• Funding stream• Democratic

infrastructure

= empowerment

Key issues for rural patients

• Access to services• Threats to local services posed by centralisation policies

(Darzi report) • Poor public transport • Pharmaceutical services - GP dispensing• Community hospitals• Rural deprivation /mental health• Agricultural workers Health and Safety• Minor injuries and pre-hospital care as essential (rather

than optional) practice commitments.

Key issues for rural doctors• Professional isolation fuelled by difficulty in accessing educational,

Faculty, peer group and other meetings• Difficulty in getting locum cover• Broader range of skills required and maintenance there-of• The last true generalist• Patient management dilemmas: to admit or not to admit, refer or not

to refer, all the more difficult if the nearest DGH is inaccessible.• Problem of resourcing in house services ,diseconomies of scale • Dispensing• Community hospitals• Social & family pressures stemming from the GP being a key figure

in a small community off or on duty.• Most importantly the need to have these special demands

recognised for validation and accreditation.• Managing difficult patients with unreasonable demands: no sanction

of list removal

Geographical Faculties

Bedfordshire and Hertfordshire

Cumbria

East Anglia          

East Scotland

Essex

Humberside 

Leicester 

Mersey  

Midland 

North and West London          

North East London          

North East Scotland          

North of England          

North Scotland

North Wales

North Wales

North West England          

Severn 

Sheffield 

South East Scotland          

South East & South West Thames          

South East Wales          

South London          

South West Wales          

Tamar

Thames Valley          

Vale of Trent          

Wessex 

West Scotland 

Yorkshire 

Strategic Faculty Review Submission

• The case for a non-geographical rural faculty

• Endorsements

• Grass root survey of opinion1. Rural list server

2. DDA web site

3. (IRH website)

Faculty Objectives

• To promote good practice

• To promote and facilitate education and research relevant to rural practice

• To promote awareness of, and seek solutions to, key problems facing rural practice: access to services, OOH, rural deprivation, diseconomy of scale, professional isolation , holiday cover etc.

Rural Faculty Modelling:ideas for the pot

• Virtual Faculty

• Regional face to face meetings

• Locally elected representatives of regions/nations to attend UK meetings ? twice a year. ? 4 regions for England,1 or 2 reps per nation/English region

• Reps elect UK chair

• Seat(s) on UK council, national councils?

• Constitution

Faculty issues

• Dual membership? Rural + geographical?

• Split funding?

Benefits for College

• Engage existing members

• Gain new members

• Morale boost

• Pilot for widening concept of non geographical faculties

Risks for College if RF refused

• Further disengagement

• Membership losses

• Fragmentation: • Independent Rural College?• Intermediate Care College?• ???

RCGP gives green light for Rural Faculty!

28

Dispensing Stats 2003

England Scotland Wales N.Ireland UK total

Dispensing

doctors 4799 301 327 27 5454

Dispensing

patients3.37 million

0.275 0.188 ? 3.833