Rural health turned upside-down

With over half of the world’s population living in cities and towns, one of the great challenges of the 21st century is to define and deliver effective and affordable health and social care to urban populations. In the United Kingdom, this is nowhere more apparent than in the deprived parts of its great metropolitan areas. Here, the ratio of general practitioners to population numbers is significantly lower than the national average, there are more solo-doctor practices, and these practices frequently lack the critical mass required to support a full range of services. Overall, inner-city general practice has been a running sore for the National Health Service. To make matters worse, many of the principals of these practices are within cooee of retiring.

The looming crisis in metropolitan medical manpower has thrown into focus a general difficulty in attracting health professionals of all kinds to work specifically in primary care, but also in other parts of the NHS serving the big cities. As ever, London is the most extreme case, but it is not unique. The combination of low wages, expensive accommodation, and difficulties in out-of-hours travel (underground trains stop soon after midnight and buses are then infrequent) leaves one far short of Dr Finlay’s idyllic country practice, as depicted in A J Cronin’s books and the TV series. If you are a general practitioner in Harris, in the Outer Hebrides, your nearest specialist in a particular discipline might be in Aberdeen, on the other side of Scotland, but your life and work will have other personal and professional compensations, starting with a beautiful environment, neighbours you know and a stable population of patients.

In 2001, the UK government launched a program of “teaching” primary care trusts (PCTs), eventually conferring this status on one trust in each of the 25 strategic health authority areas in England and Wales and making equivalent arrangements in Scotland. Curiously, the background documents for this initiative stressed not education but recruitment and retention of health professionals to work in primary care. Although this seemed a non sequitur, eventually the penny dropped — metropolitan medicine in the UK is, in effect, rural health in Australia turned upside-down. Many of the difficulties faced by practitioners in the two settings are virtually identical: long working hours, often in solo practice; lack of suitable pre-placement training; limited locum cover for holidays and professional development activities; and major concerns about housing, education for children, jobs for partners, and transport.

What is not the same is the systematic effort and investment to make a virtue out of necessity. Going beyond early experiments in protected quotas for students from country areas, many Australian medical schools have created departments of rural health, and there are vibrant undergraduate student societies supporting this interest. There are now dedicated postgraduate training schemes for both GPs and specialists seeking a career in the bush, and the profile of the Australian Journal of Rural Health is growing steadily. While medical schools worry that a mismatch between political enthusiasm and dollars invested has increased competition for limited resources, and outer metropolitan areas struggle to attract doctors, country practitioners in Australia from all health disciplines have a growing sense of pride in themselves and their work and are rediscovering the independence and ingenuity that the nation holds as central to its self-image.

The UK badly needs to revitalise metropolitan medicine in the same way, but, apart from some dedicated appointments of GPs made under a new system of contracts, this is not happening. The “teaching” budgets of the teaching PCTs are tiny and time-limited, and the university-affiliated hospitals of the biggest cities have one eye on solving the problems referred by their local district general hospitals and the other on research. Any sense of serving a “patch” is much more about defining the geographical boundaries of legitimate referrals than mutual “imprinting” between institution and community. Providing primary care services to their local, inner-urban populations via accident and emergency departments is an inherited responsibility descended directly from giving alms to the poor — a form of noblesse oblige. The features of urban populations that make metropolitan practice exciting — their youth, mixture and mobility — are seen as a source of complication, not stimulation.