The last of the true generalists

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The last of the true generalists

• RPAS Inverness 2008
• Dr Malcolm Ward

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Rural Practice Standing Group

• The Rural Practice 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.

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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

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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

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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

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PWP proposals-EnglandChapter 4 Dispensingoptions

• No policy change
• Empower PCTs to commission dispensing in
  accordance with Pharmaceutical Needs Assessments
• Distance criteria between GP surgery and pharmacy
  rather than patient to pharmacy
• As 3 but where a second pharmacy within a given
  distance. Dispensing practices to dispense to
  whole list.
• OTCs

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Problems 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

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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

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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

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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

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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

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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.

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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

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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 

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Strategic Faculty Review Submission

• The case for a non-geographical rural faculty
• Endorsements
• Grass root survey of opinion
• Rural list server
• DDA web site
• (IRH website)

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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.

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Rural Faculty Modellingideas 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

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Faculty issues

• Dual membership? Rural geographical?
• Split funding?

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Benefits for College

• Engage existing members
• Gain new members
• Morale boost
• Pilot for widening concept of non geographical
  faculties

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Risks for College if RF refused

• Further disengagement
• Membership losses
• Fragmentation
• Independent Rural College?
• Intermediate Care College?
• ???

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RCGP gives green light for Rural Faculty!
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