Crucial operation: fight to keep our remote hospitals

For more than a decade, the future of Scotland's six rural general hospitals has been precarious. The Herald reveals details of a long-awaited plan to secure the future of emergency care in these centres.

It paves the way for consultants to be trained specifically to staff these hospitals for the first time.

But the battle is far from over, with pressures threatening centres which are a lifeline for many communities: THE PROBLEM As medical advances have made treatment increasingly complex, surgeons and physicians have specialised in narrower fields. The generalist who is prepared to cope with whatever arrives - rather than repeat the same procedure often and develop a niche - has almost vanished. This alone makes filling vacancies in small hospitals difficult. Health boards scrabble to find clinicians who have worked abroad or in the Army and still have the skill mix.

The number of evenings and weekends rural consultants spend on-call, because there are few people to share the rota, can deter recruits. Some say rural hospitals will always breach the European Working Time Directive.

These pressures have already burst out into the open. In 2003, Belford Hospital, Fort William and Lorn and Isles General Hospital, Oban, fought off plans to cut consultant services leaving no cover at night.

Under the scheme, patients from the two areas who fell seriously ill faced travelling to Glasgow or Inverness.

David Sedwick, consultant surgeon at Belford, compares this with a shopper struck by appendicitis in Sauchiehall Street being rushed to Carlisle.

Glencoe Mountain Rescue warned casualties could die if such plans are revived.

John Grieve, team leader of Glencoe Mountain Rescue Service, said: "We certainly take the view that our job is to get our casualties into the local hospital as fast as we can. That is why you generally need to get the top-level accident and emergency experts in the hospital.

"We had one particular case in the past where the helicopter decided to take someone against our wishes to Glasgow and the casualty deteriorated rapidly and had to divert to Oban. It could have been quite dire."

Amid protest by thousands, the proposals for Fort William and Oban were withdrawn but anxiety remains. Every time a consultant retires from a rural general hospital, services are at risk.

THE FUTURE Since 2005, a group of key players have been working on a "road-map" to safeguard emergency medicine in the Highlands and islands.

The process has not been easy. In his foreword to the finished report, group chairman Roger Gibbins says: "The challenge has been to identify common elements within the diverse aspirations." That is code for passionate disagreement.

There has been division about what kind of clinicians should man the front line. Does it have to be consultants or could it be family doctors with extra training?

On Orkney, GPs already act as physicians. But in Dunbartonshire, emergency care at Vale of Leven Hospital hangs by a thread because plans to put GPs in charge have sparked safety fears.

The final Remote and Rural Steering Group report, submitted to the Scottish Government, appears to back 24:7 consultant cover.

It says rural hospitals should have a minimum of three consultant surgeons, a three-strong anaesthesia team which should be "predominantly consultant-led" and three acute medicine specialists - who could be physicians or GP specialists.

To supply these staff in future, a curriculum to prepare consultants for rural work has been developed.

In addition, the report recommends hiring doctors to posts perhaps a year in advance so they can be trained specifically for the job in question, and it obliges bigger hospitals to help them maintain their skills.

With powerful medical bodies nervous about doctors' skills getting rusty if they see too few patients, this should help protect the quality of care.

The report lists the operations patients can expect from their rural surgeon and what they cannot.

Repairing perforated ulcers is ruled-in; other stomach surgery is ruled-out.

Finally, the need for better transport to rush sick patients to the right hospital is underlined.

When someone needs to be transferred, an anaesthetist may have to go, too, leaving an island, for example, with even less medical back-up. There has been talk for some time of running an emergency retrieval service, where medics travel from the bigger centres to collect the patients, .

Professor Andrew Sim, consultant surgeon in the Western Isles, says: "It is an important thing for us to get that sorted. We do have reasonably good retrieval and transport at the moment but we need them to be better than they are."

It is too early to say Scotland's rural hospitals are safe.

Professor Neil Douglas, chairman of the Academy of Medical Royal Colleges in Scotland, warns the report does not solve everything. "People going to live in rural situations are making a choice," he says. "They have advantages and disadvantages. There is nothing we can do to make the safety advantages of a patient in a remote setting the same as someone sitting next to Glasgow Royal Infirmary."

Scotland's rural general hospitals now have their place on a map.

Meet Alan Grant, volunteer country surgeon

ALAN Grant is the first person in the UK to train as a "rural" surgeon from scratch.

When his peers on the basic surgical programme start to specialise in different parts of the body next year, he will take an alternative path.

He intends to master key skills in a range of medical fields - orthopaedics, maternity, urology and more - so that in an absolute emergency, hours from a full-scale A&E, he can cope. He needs to be able to stabilise a driver badly injured in a crash and perform an emergency Caesarean section on a sick mother.

But as the first of a breed, Mr Grant, 31, is having to compile his own curriculum - at times a challenging task.

Some quarters of the medical profession regard a professorship in a university hospital as the measure of success, with jobs in quieter towns dismissed as boring.

Mr Grant said: "There's been quite a lot of pressure from various people to try to change my mind. There are very polarised views. Some people are supportive, others are perhaps a little bit worried about the future of remote and rural surgery in Scotland and tell me that I should head down the mainstream.

"I think some of them are a bit worried that the scope will not be fulfilling enough."

His aspirations developed only when he was posted by chance to Belford Hospital, Fort William, in 2002. He said: "It was true general surgery as you do not see in many places now because of the specialisation of doctors. I felt for the first time for a while we were providing a true service in the community, keeping the community going."

The need to work "on call" at nights and weekends more often than city doctors - which managers say makes it hard to recruit to outposts - doesn't worry Mr Grant.

He says he will be bleeped less frequently than urban colleagues, because of the smaller population. He says that surgeons where he trains and works, Aberdeen Royal Infirmary, are called about their own patients when they are off-duty because they want to hear about their progress.

"If you lose that ability to care about what's going on, then you have missed the point entirely," he said. "I do feel a lot of the changes are taking away that personal ownership of patients."

How the areas are served

LORN AND ISLES GENERAL HOSPITAL

Catchment population: 43,553. Built in 1997 to replace services previously provided by a number of small hospitals throughout the district, including A&E and mater nity.

CAITHNESS GENERAL HOSPITAL, WICK