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Healthcare in a rural setting

January 2005
Board of Science

Recruitment and retention of healthcare professionals
There continues to be a shortage of GPs in the UK. For example, in 2000 there were 1.8 practising GPs per 1,000 population, compared with an average of 3.3 among European countries. [go to reference 30] The DH General Practitioner Recruitment, Retention and Vacancy Survey,31 highlights the dramatic decline in the average number of applicants per GP vacancy in England and Wales (table 1). There was an average of 8.5 applicants per vacancy in 2000, compared with 3.3 applicants in 2003. Urban deprived areas attracted fewer applicants on average than any other type of area.

Table 1: average number of applicants per vacancy by self-defined area in England and Wales (2000-03)

Area served	Overall average number of applicants
Year	2000	2001	2002	2003
Urban deprived	5.9	4.7	3.6	2.4
Urban	8.5	6.4	4.7	3.3
Mixed urban/rural	9.5	8.3	4.1	3.7
Rural	10.6	8.1	5.6	3.6
Not defined	4.6	2.7	-	-
Overall average	8.5	6.9	4.4	3.3

Source: Adapted from Government Statistical Service (2003). [go to reference 31]

Although these figures suggest that, in general, the recruitment and retention of GPs is less problematic in rural areas than urban areas in England and Wales, this picture is deceptive once the heterogeneous nature of rural areas is taken into account. Statistics from the whole of the UK confirm that some rural areas are more difficult to recruit to than others. Pockets of recruitment difficulty exist, for example, in remote rural areas and deprived rural areas. Healthcare practitioners other than GPs may also be more difficult to recruit in some rural areas than in others.

In Scotland, the percentage of vacancies open more than three months in 2003 for allied health professions illustrates the vulnerability of services in remote/rural areas. Statistics from the Information Services Directorate, Scotland show that in some rural areas vacancies are more longterm in comparison to the urban areas of Lothian and Greater Glasgow (table 2). [go to reference 32] Long-term vacancies are a major concern in remote/rural areas, particularly in one or two person practices. Carrying a vacancy will be very different in a five- or 10-person practice, compared with a one- or two-person practice where it will make significant differences to the ability to maintain workload; in some cases resulting in a complete loss of a service. [go to reference 33] The figures also reveal a high vacancy level in the remote Highlands.

Table 2: the number of vacancies for allied health professions in selected health board areas of Scotland in 2003. Data expressed as a percentage of total positions and the number of these filled within three months

Health board	Vacancies as percentage	Percentage of vacancies of total positions filled within 3 months
Rural areas
Orkney	9.0	0
Shetland	7.8	Not available
Western Isles	2.5	0
Highlands	10	4 38
Borders	4.4	82
Dumfries and Galloway	8.0	74
Urban areas
Lothian	6.3	52
Greater Glasgow	9.7	65

Source: Information Services Directorate, Scotland. [go to reference 32]

The number of dental practitioners involved in NHS treatment in Scotland also reveals recruitment difficulties in remote/rural areas, [go to reference 33] with figures showing a general shortage in these areas as compared with the urban areas of Lothian and Greater Glasgow (table 3). [go to reference 32]

Table 3: the number of dental practitioners providing NHS treatment per 100,000 population in selected health board areas of Scotland in 2003

Health board	Dentists per 100,000 population
Rural areas
Orkney	15
Shetland	13
Western Isles	25
Highlands	32
Borders	26
Dumfries and Galloway	33
Urban areas
Lothian	44
Greater Glasgow	44

Source: Information Services Directorate, Scotland. [go to reference 32]

The impending retirement of healthcare professionals in rural areas must also be examined. For example, communities in the deprived South Wales Valleys are facing a GP recruitment crisis. Many non-UK trained doctors who emigrated to the UK in the 1960s and 1970s, and fill almost three-quarters of the posts, are now nearing retirement age. Therefore, some communities face the possibility of not having access to a GP in the near future. [go to reference 34] A study of all permanent consultant surgeons practising in remote/rural Scotland in 2001 (13 in total) found that the majority were over 50 years of age (figure 1). [go to reference 35]


Figure 1: ages of all 13 permanent remote/rural consultant surgeons in Scotland in 2001
Source: Sim [go to reference 35] (2001).





The attitudes of medical students are important and could also reveal future recruitment difficulties in rural areas. For example, in 1996 a US study found that only 2.2 per cent of medical school graduates planned to practise in rural areas or small towns. [go to reference 36] This suggests that newly qualified practitioners may choose to live and work in an urban area, leading to a shortfall in the rural medical workforce. There is a pressing need to define the career intentions of UK medical students as part of the need to address the recruitment and retention of healthcare professionals in the UK.

Many strategies designed to improve recruitment and retention in rural/remote areas emphasise raising awareness of the incentives for working in such areas (key issues 2). It is also recognised that in order to recruit and retain these individuals, the disincentives to becoming a healthcare professional in a rural or remote area need to be addressed. The disincentives of working in a rural/remote area as compared with urban areas are highlighted below (key issues 3).

Key issues 2: incentives/benefits for working in a rural/remote area
GPs
• A rural practice is likely to provide a range of specialist services that most urban practices do not. Rural GPs can therefore gain new skills, for example in minor surgery and more specialist treatment of minor injuries, a range of ‘hands on’ clinical work and experience in dealing with emergencies.
• A rural GP is more likely to be able to practise traditional family medicine.
• A rural practice offers the chance to contribute to the holistic care of a community.
• A rural practitioner is likely to be regarded as an essential leading figure in a community.

Surgeons
• There is the opportunity to perform a wider range of surgery, have greater clinical autonomy and provide a more personalised service with greater patient contact.
• A rural surgeon can take a more holistic approach to the care of a patient.

General
• Rural healthcare professionals are likely to enjoy a good quality of life (for example outdoor pursuits) and an ideal environment in which to raise a family (generally safe communities with low crime levels).
Sources: Gillies [go to reference 37] (1998), McCabe [go to reference 38] (2002), Sim [go to reference 35] (2001).

Key issues 3: disincentives of working in a rural/remote area
• New medical graduates do not always see working in a rural area as a positive career option and are not always encouraged and appropriately trained to work in a rural area.
• Professional isolation, including lack of opportunities for continuing professional development due in part to difficulties in obtaining locum relief.
• Social isolation for the professional, partner and children and potentially fewer job opportunities for the spouse.
• Lack of personal privacy in a small community and lack of access to personal healthcare outside of the local practice.
• Greater burden of duty, including excessive on-call commitment and living and working in a small community with corresponding pressures on working hours.d
Sources: Buckley [go to reference 33] (2003), Dewar [go to reference 1] (1912), McCabe [go to reference 38] (2002), Sim [go to reference 35] (2001).

d It should be noted that it is also possible for the intensity of workload to be less, though the on-call commitment might be greater, so that there can be trade-offs between availability and intensity, which may be attractive compared to the high intensity of working in a more densely populated and busy urban setting.

In the following sections ways of addressing the disincentives to working in a rural/remote area, which affect recruitment and retention, are discussed and possible solutions and actions are highlighted.