Providing good quality healthcare to remote and rural areas has always been a challenge. In 1911, Sir John Dewar was invited by Lloyd George to report on the (poor) health of the people of the Highlands and Islands of Scotland. The impetus for that enquiry was the difficulty in getting deaths in properly registered by a doctor, but the findings and recommendations of the Dewar Committee were of international importance.

The frontiers of rural general practice in 1911 were rapidly expanding due to the technological advances afforded by the car and the telephone, but there were simply not enough GPs to go around. It’s likely that the main factor limiting recruitment and retention of doctors was that it was impossible for a GP to make a living in a poor remote community.

Dewar’s solution was radical: the establishment of the Highland and Islands Medical Service which gave financial and technical support to doctors and nurses, one of the first examples of a state-funded health service in the world. The legacy of the Dewar Report was huge: the service was a key part of the blueprint for the NHS.

Things are not so different now. Rural general practice can’t recruit enough doctors (and clinicians more generally), the health service in many rural areas is on the brink of collapse, and yet the potential for broadening the quality and scope of remote healthcare is massive. To move things in the right direction we need to understand how we got here in the first place.

For 100 years after the Dewar Report, the bedrock of healthcare in the more remote parts of Scotland was general practice. Until the 1970s, practices were most commonly operated by single-handed GPs, usually men, operating from consulting rooms in their houses.

Their wives often provided reception and practice management support. GPs worked alongside publicly-funded community nurses, often “triple duties nurses” who were trained in district nursing, midwifery and health visiting, and sometimes quadruple duties nurses offered school nursing too.

The determination of nursing regulatory authorities to increase specialisation prevented training of new triple duties nurses and the last practitioners disappeared around 15 years ago to be replaced by specialist nurses. The wide catchment areas of these specialist nurses now means that many spend more of their time travelling than seeing patients, and the personal long-term relationship with families has been greatly diluted.

Important organisational factors have also played a role in the demise of the GP/triple duties nurse model. In medical and nursing education there has been an inexorable increase in specialisation. Generalism has gone into serious decline in both hospital medicine and community practice.

While there is no doubt that individual tasks can almost always be carried out better by specialists than generalists, generalism has the advantage of allowing a view of the “bigger picture” which is particularly important when people have multiple problems requiring an integrated approach.

One of the major problems in Scottish rural healthcare is the inability to recruit GPs. Over the last 30 years there has been a dramatic decline in the proportion of medical students planning to be GPs – some sources suggest a fall from 50 per cent to as little as 11% of medical graduates choosing this career as a first choice.

Low morale among GPs and the increasingly call centre-like nature of the work are some of the reasons. The number of full-time-equivalent GPs has inevitably declined and as a result health boards and practices have recruited other health professionals to fill the gaps in service.

Gradually, this necessity seems to have become an ideology and in health policy circles any mention of general practice is quickly rerouted into a discussion of the “multi-disciplinary primary care team”. There are of course many advantages to having a multi-skilled professional team, but a model involving many multi-disciplinary boots on the ground simply doesn’t work if you live on Unst or Barra.

The GP contract negotiated in 2018 between Scottish Government and the BMA has come close to being the coup de grâce for remote general practice. As well as giving a large cash injection to Central Belt practices with no allocation to rural practices, the contract offered to take responsibilities for many tasks such as vaccinations, medicines management and support for hospital treatments away from practices and to allocate them to health board employed teams.

Most urban practices have seen some reduction in their workload from multi-disciplinary team support but very few remote practices have seen any tangible benefit. So we have a perfect storm of an overall decline in numbers of GPs, inability to support the ones that are left in rural areas with other professional staff and much better remuneration in the cities. Not surprising then that some wonderful rural practices, which in the 1990s would expect to get dozens of applicants for a GP post, now get no responses to their advertising campaigns.

Patients living in more remote rural areas need to depend on their GP. These patients do not have the option of changing practice or using the A&E department. If they are involved in a serious road traffic accident, they expect their GP to be first on the scene.

Rural GPs need a huge skill set allowing them to diagnose and manage complex cases in the community, often with remote specialist advice, when similar problems in urban areas would be referred to hospital. Rural general practice should be the best job in the world for a young doctor who loves all of medicine and who relishes variety in their work, continuity of patient care and high levels of clinical responsibility, but sadly not many see it that way. What can be done?

A good first step would be to revoke the 2018 GP contract in rural areas. Only 28% of Scottish GPs voted for it (far more abstained), and I have not found a single rural doctor who did. A rural contract allowing practices to innovate according to local circumstances, to take on new services to patients and to get paid properly for them would be attractive to the kind of new doctor who likes challenge and responsibility.

The problem of professional isolation can be hugely mitigated by video-based case discussions between colleagues, an approach successfully pioneered in Orkney. Flexible posts with rotations between rural areas and hospitals are another good option.

Exposure of medical students and trainee doctors to rural healthcare is a proven way to attract new recruits. We need to find a way to boost the availability of student and trainee placements in rural areas. One way to do this, successful in other areas, could be to create joint academic/clinical posts where doctors have protected time to teach and research as well as to do their clinical work.

We need to celebrate and support generalism in rural health – in general practice, in community nursing and in the small Rural General Hospitals. This will require changes to training curricula and professional standards regulations.

Remote areas would benefit from a new generation of triple duties nurses, rural general hospitals could benefit from a new generation of general physicians and general surgeons, and all could benefit from a willingness to try new approaches and to examine rigorously how well they work.

Phil Wilson is Professor of primary care and rural health at Aberdeen University & acting chair of the Rural GP Association of Scotland