One of the biggest blows to hit remote and fragile communities in the last decade has been if/when their local GP(s) announce they are opting out of the responsibility for organising out-of-hours (OOH) cover, leaving it to their local health board.

The medical practice in North Harris is joining a long line of rural GPs, having announced their intention to do so last autumn. Now the area is to be covered in the same way as the whole of Lewis with all non 999 calls dealt with by NHS 24's on call GP or a nurse based in the OOH centre in the Western Isles Hospital in Stornoway. That's 36 miles from Tarbert but there are many more remote communities which will have to depend on this service.

A pilot scheme has been running since October 1 using this arrangement.

But a recent public meeting underlined the local concerns, many of which centred on the prospect of an emergency journey to Stornoway in the middle of the night over the 'Clisham', the hilly main road between Harris and Lewis, in bad weather. And what happens if the road is closed?

NHS Western Isles recognises this but says: "Activity in North Harris during the pilot was very low and clearly demonstrated that it would not be possible to sustain a practitioner OOH in North Harris.

"Feedback from those who had used the service was positive, in terms of clinical care. The main concerns raised at the meeting related to the safety of travel during adverse weather. When it is considered unsafe for patients to travel to hospital, there are arrangements in place whereby they would be collected from their home."

But Alasdair Morrison, former Western Isles MSP and Scottish Executive minister who is now prospective Labour candidate in the General Election, has already written to tell Health Secretary Shona Robison, more needs to be done: "I was shocked to hear from a lady who had to drive her daughter and sick grandchild, late at night, in treacherous winter conditions, over the highest roads in these islands to receive medical care in the hospital in Stornoway. This is a completely unacceptable and needs to be immediately addressed by you and your department.

"I would urge you to apply a simple test: is this a set of circumstances that you would accept for you and your family?

"As well as the obvious implications for those living in Harris, this also affects the health professionals based in Lewis who are expected to provide the additional coverage."

This has been happening across rural Scotland and it is doubtful any of the communities affected have welcomed the changes - unless of course their GP had been a notorious incompetent or chronic drunk.

It has been impossible for health boards to provide a model of provision as trusted as local GPs. Some would take turns of covering weekends across neighbouring rural practices.

But the supply of doctors willing to work in rural areas continued to slow significantly.

It all began with the new general medical services (GMS) contract which was introduced for general practices across the UK in 2004. One purpose was to improve recruitment and retention by re-shaping GPs' working conditions.

So the the contract provided the opportunity for GPs to opt out of the responsibility for organising OOH care. If they decided do to so they would forgo an average of £6000 per GP each year, representing 6.6 per cent of the average net profit for contracted GPs in Scotland in 2005-2006. By September 2006, 94 per cent of general practices in Scotland had opted out of providing OOH care. But many in the Highlands and Islands were reluctant to do so and were well represented in the remaining 6 per cent providing OOH. Indeed the GP in the South Harris practice still hasn't opted out even though he is single handed.

But others have found it impossible to resist. As one observed they were being offered a chance to trade something like 8 per cent of their income to get 40 per cent of their time back. 'No brainer' was the phrase that came to his mind.

It was not always easy for them, as another made clear some years ago "How can I be in the house watching a rugby international in the house on a Saturday afternoon and say I am off duty phone NHS 24, if a local man is having a heart attack up the road? I would expect the plumber to leave his telly and turn out if I had a burst pipe."

One thing is clear, little thought was given 10 years ago as to how health boards were to replace GPs opting out in the Highlands and Islands. And it has been made worse by the fact that, despite the freedom to opt out, the supply of doctors willing to work in GP remote practices has continued to slow significantly. So it is not easy for health boards to make alternative provision apart from through using locums who can be of uneven proficiency but all very expensive - NHS Highland spent more than £1m last year on locum cover in the Thurso practice alone.

Western Isles SNP MSP Angus MacNeil said this week:

"There is no doubt that patients who are registered with the North Harris Medical Practice are anxious about these changes, particularly given the topography of the islands. When medical assistance is required, a journey from Harris to Lewis is obviously daunting and I have raised these concerns with NHS Western Isles and the Cabinet Secretary for Health."

So he said he welcomed that the Scottish Government had recently announced a review on out-of-hours care in Scotland.

That review will have failed if it doesn't recognise the specific problems of health boards trying to provide adequate OOH cover in remote communities, and seek to address them.