Richard Smith: Dumfries and Galloway NHS 7—Services in Stranraer are still presenting difficulties

richard_smith_2014Richard 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.

It is never going to be easy to provide health services in a small town that is 73 miles by a slow and dangerous road from the main town. Stranraer has been a problem to the health board ever since I first visited in 1980.

In those days a local GP did surgery, including emergency surgery, in the small hospital, and provision of surgical services was controversial for 20 years after he retired. Now the people and the counsellors of Stranraer have accepted that it isn’t possible to provide emergency surgery to an acceptable standard. Day surgery does, however, continue in the new hospital that cost £12.5 million and was opened in 2006, although it seems that the lists are small. Surgeons and anaesthetists travel from Dumfries, but surgeons seem reluctant to perform operations that might need emergency surgical follow-up.

Doctors in Stranraer put it to me that some patients from Dumfries might be brought to Stranraer for operations like cataract removal. “Stranraer patients have to travel to Dumfries for appointments and procedures, why shouldn’t Dumfries patients come here.” The hospital would then be better used, but it seems unlikely to happen. Dumfries seems remote and rural to people from Glasgow, but Stranraer seems like “the back end of nowhere,” as one local doctor put it to me. (Many people in London, I find, can’t place Dumfries and Galloway on a map.)

The new hospital, the Galloway Community Hospital, was described to me as “a miniscule DGH” and “a kind of a hospital.”

Emergency medical services are provided by the hospital—by GPs or locums. The locums are mostly GP trained as they can take full responsibility for patients, whereas junior doctors cannot. Patients with heart attacks are thrombolysed, as are patients with thrombotic strokes after they have had CT scans. “It’s a bit like being a houseman again, you have to do everything,” said one of the doctors, with more satisfaction than resentment. Nursing support is strong, and the doctors in Stranraer consult the physicians in Dumfries if they are unsure of what to do. Patients sometimes have to be transferred to Dumfries.

The hospital does have an accident and emergency department run mainly by locums. The department has two resuscitation rooms, and there is always an anaesthetist on call. These too are mainly locums, and if no anaesthetist is on call then the department has to be downgraded to a minor injuries unit.

At night there is only one doctor on call for the whole hospital, covering accident and emergency and the medical wards and medical admissions. Usually this is enough, but there is obviously a chance of several sick patients presenting at once. Other doctors can be called, and one doctor described an episode where several sick patients presented at once and the “whole hospital helped.”

The results of the accident and emergency department are good, but exactly who is responsible for its services and anaesthetic services is unclear. It is presumably the clinical directors in Dumfries, but they feel that they have limited influence over what happens in Stranraer.

People in Stranraer attend the accident and emergency department more than twice as often as patients from towns that are far from the departments in either Stranraer or Dumfries. Indeed, across the region—as across Britain—there is a clear correlation between attendance at and proximity to the departments. “Half the population of Stranraer seems to visit A and E each year,” observed one doctor from another town that has an old community hospital.

I took part in several discussions about whether people in rural and remote communities like Stranraer are more resilient or more dependent than their urban counterparts. I heard people confidently support both views.

Most of the services in the hospital in Stranraer used to be provided by local GPs, but now the GPs have little to do with the hospital, although their large health centre, which contains three practices, is next door. Most of the GPs are in their 50s, and yet it is proving almost impossible to recruit GPs to Stranraer. Three years of advertising by one practice produced only one applicant (who didn’t join the practice), and another practice had only two applicants—“And I had to ring the GMC about one of them,” said a GP.

In 2002 there were 17 GPs; now there are nine—and four advanced nurse practitioners. As everywhere, the workload and the complexity of the patients has increased, but the GPs have coped by abandoning some services—like working with drug users and some contraceptive services—and doing more sessions. But another GP is about to retire, and one practice may have to close.

A crisis is clearly pending, and it’s the health board’s responsibility to provide services. One of the GPs pointed out that the practices in the west of Dumfries and Galloway are historically rather than logically positioned, and that hubs in Stranraer and Newton Stewart with spokes in smaller places would be more logical. The practices are, however, independent contractors, and the health board can’t rearrange them against their will. One GP argued that the health board doesn’t understand the business of general practice.

One of the GPs recently met with local people and counsellors and tried to lower expectations of what can be provided in Stranraer. Local people look at the brand new hospital and expect better services, but they don’t always grasp that the staff are more important than the building and that there are severe recruitment difficulties. (After writing this I went to a meeting in London where an NHS manager described a survey asking people in Cornwall what they thought happened in their community hospital: most thought it did heart surgery.)

As it has always done until now, the NHS will muddle through with providing services in Stranraer—perhaps by employing more advanced nurse practitioners, offering golden handshakes to GPs, or providing GP services from the hospital—but it’s a long term problem.

Richard Smith was the editor of The BMJ until 2004.

Competing interests: Nothing further to declare.