Richard Smith visited and wrote about the NHS in Dumfries and Galloway in 1980, 1990, and 1999, and this series of blogs describes what he found in 2016. A feature article provides a summary. 

England has an urban health system with some rural areas, whereas Scotland has a rural system with some urban areas, observes Jeff Ace, the chief executive of Dumfries and Galloway Health Board. The observation on Scotland may not be true in population terms, as most of the population lives in urban areas, but it’s certainly true in geographical terms: nowhere in England is 73 miles from a district general hospital as is the case for Stranraer. Other places in the Highlands and Western Isles are even further from hospitals.

I haven’t seen any sign that the surfeit of medical schools in Scotland has responded by producing graduates suited to rural practice. But during my week in Dumfries I heard that Dundee medical school (now regarded as the best medical school in Scotland) has developed a programme together with the Dumfries and Galloway Health Board to produce graduates for rural practice.

Ace has three main concerns about the health system in Dumfries and Galloway.

The first is responding to the aging of the population. People over 60 are 31.5% of the population compared with 24.2% for the whole population, and the region now has the oldest population in Scotland. The young are thus underrepresented, and there is net emigration of the young and net immigration of older people.

Ace’s second—and biggest—concern is recruitment to the right model of care, which might be caricatured as fewer specialist consultants and more social and care workers. One cause of recruitment problems is structural and across the whole of the UK in that there aren’t enough doctors to continue with the present models of care. Britain leaving the European Union may cut off the flow of doctors from Europe. Workforce planning hasn’t responded to the needs of the service, and there is a net flow of young doctors out of the UK.

But some of the recruitment problems are specific to Dumfries and Galloway, which has a low-wage economy based mainly on agriculture, forestry, and tourism. A comment on D and G Online http://www.dumfries-and-galloway.co.uk/facts/info.htm points out that: “By far the largest contribution to the region’s economy comes from the taxpayer who funds the salaries of the public sector employees in health, education, social work, police, etc. And, I might add, the taxpayer funds a great deal of ‘agricultural’ income too.” One consequence is that it’s difficult for the partners of doctors moving the region to find employment unless they too work in the public sector. Most of those I spoke to thought that young doctors from “the Central Belt” (as everybody called it) are reluctant to move to a rural and remote area because they have flats and friends in Glasgow and Edinburgh. Plus, as Ace put it, the region lacks “overall vibrancy,” which I take to mean nightclubs, theatres, and the facilities that are readily available in Edinburgh and Glasgow. Specialists like neurologists, especially if they have a particular interest in, for example, epilepsy or stroke, are likely to find themselves the only one, which hinders professional development.

On the plus side the area is outstandingly beautiful, the schools are good, houses are cheap, and people are friendly and supportive. Then a small town like Moffat (population 2500) has dozens of societies covering every interest.

I asked Ace what the response might be to the problem of recruitment, and he answered that discussion is underway in Scotland about reducing the number of health boards from the current 14. One possibility is that there would be just one, but three is more likely—for the West, East, and North. Recruitment in Dumfries and Galloway would then become the responsibility of managers in Glasgow.

The third concern of Ace, who was once the board’s finance director, is money. The service is being kept afloat by spending the seed corn. Ace thinks that there needs to be an open engagement with the public about what can be afforded and what can’t.

Richard Smith was the editor of The BMJ until 2004.