'It is too soon to call rural recruitment scheme a failure'

Drs Andrew Strain, Sinead Hutchinson and Andy Barlow share their experience of working with the ‘failed’ rural recruitment scheme in Scotland

It’s hard to find anywhere more rural than the far north west of Scotland. Of course, there are parts of Wales and northwest England where rurality is a significant challenge – but for the most part, you’d be hard pushed to find a GP practice that was two and a half hours drive away from their nearest referral center, like we are.

Our practice serves a population of around 6,500 patients. Various terms get bandied around for the type of medicine we do, but it is fair to say it goes over and above normal general practice. We are the holders of a GMS contract, but as a partnership we are also holders of a separate business to business contract with our local health board to provide urgent, emergency and community hospital care. We are the medical cover for our rural hospital A&E, which serves a population of around 10,000 spread over 500 square miles.

But we are also a training practice. Not only that, but for the past five years we have taken on students from the Scottish Graduate Entry Medicine (ScotGEM) course. The scheme was introduced in 2018 with the aim of addressing ‘the shortage of NHS doctors in Scotland’, with a focus on primary care and remote and rural medicine. The scheme has recently been criticised for only producing two rural GPs so far, and branded a failure.

In our minds, this is not that simple.

Firstly, setting up a medical training program with the aim of only creating rural general practitioners was never realistic. In the same way that not all students who train in a tertiary Cardiology Center will go on to become interventional cardiologists, not every student who trains in general practice will go on to be a GP. You are never going to get everyone who comes from a particular training pathway to come and stay here permanently – it is just never going to happen.

What’s more is that rural general practice and recruitment are a completely different ballgame. The type of medicine we do requires a specific type of person. The majority of doctors who become GPs do so because they want to see patients in a clinic room setting in a controlled environment, Monday to Friday, and not do out-of-hours. So the concept of what we do (trauma-related and acute medicine) terrifies a lot of GPs; they are GPs because they don’t want to be hospital doctors. So when we, and indeed other rural practices, are recruiting we are holding out to find the right person – the niche group of doctors who want to do both.

Of course there are other factors to consider. Rural areas require a particular type of lifestyle and that extends to family members. By the time people have gotten to the stage of being a GP, having enough qualifications to be a rural GP, they might be married with children. You’ll want a job for the partner and a school for the kids. Regarding the former, there is a possibility that they will have to commute for an hour or more for a job. And with the latter, rural schools are not funded as well as those in the central belt so are not as appealing for parents. It has been an issue for us in the past, having people who are dead keen on the job but the other factors don’t fit into the lifestyle.

That’s part of the reason we are enthusiastic about ScotGEM. Because it is a graduate programme, it usually brings in slightly more mature students. These are people who have a bit more experience under their belt, thought a little bit more carefully about what they’re wanting to do with their careers and where they want to practice etc.

There’s been a lot of talk over recent years about longitudinal integrated clerkships and similar models of training that involve embedding students within clinical teams for the duration of their medical student training. The ScotGEM programme is probably one of the best, or most formed, examples of that. We have our ScotGEM students here for a year at a time and they become fully immersed in rural primary care and understand how it works. The feedback we receive from our students (anonymously) is largely positive: one in four will say that it wasn’t for them – they felt isolated. But the majority report back that they loved it and embraced not just the professional side, but the lifestyle aspects too – joining rugby teams, hiking clubs or going trail running to build communities.

Calling ScotGEM a failure is premature. A full cycle would be: four years training; two in foundation; and then three in GPST – that’s nine years. The criticism is based on the first cohort going into their speciality and that just isn’t enough time to fully see the results. We have not even seen a full cycle of people come out the other end as a GP and potentially come back to us.

We feel really strongly that ‘what you can’t see, you’re unlikely to be.’ If people aren’t exposed to something, then they won’t view it as an option. We want to get students in this very formative part of their training, and the very first few years where we can mold and influence them. Many of these students won’t end up in general practice, let alone rural general practice, but they will go out into medicine. They will talk about how they trained, where they trained, and we hope that we give them a positive experience of that. They’re then able to pass on that positive experience to other people in the wider medical environment and the country.

And then maybe, when we are trying to recruit years down the line someone might remember a conversation they had with an ex-student of ours: ‘I had that friend who I was an F2 with. She said she trained in this area, and it was really good.’ For us, it is about building that recognition of the medicine that we do and the place that we live so that we can kind of bring people in that way, with a sort of ‘soft power’.

Those who do come to rural general practice don’t leave quickly. They stay until they retire: once they’re here, you get stuck in. It’s so holistic and fulfilling. You feel like you’ve made a real difference at the end of the day to a community to which you fully belong.

Drs Andrew Strain, Sinead Hutchinson and Andy Barlow are GP partners at Lochgilphead Medical Centre. Dr Strain is also chair of the Highland LMC and Dr Barlow is Clinical Lead, Mid-Argyll.