A pledge by the first SNP government to ensure all six rural hospitals in Scotland are staffed by three general surgeons "at a minimum" has not been met and may be threatening lives, a doctor has claimed.
A report in 2007 made a commitment that patients should only have to travel for specialised services that cannot be provided locally and Scotland's six rural hospitals should have a minimum of three surgeons.
Stuart Fergusson, a Rural Surgical Fellow at Aberdeen Royal Infirmary says only two; Balfour Hospital in Orkney and the Gilbert Bain Hospital in Shetland are currently operating at this level.
Mr Fergusson made the headlines in 2016 because he was the only junior doctor in Scotland preparing for a career in a rural hospital.
The University of Glasgow graduate is a specialist in colorectal surgery but is currently gaining skills in routine procedures to allow him to work in remote areas. After his fellowship ends in 2023 he will transfer to Shetland.
He raised his concerns about staff shortages at the recent Viking Surgeons Association conference in Skye, which gathers healthcare workers from across the UK and the Nordic countries who have an interest in rural surgical practice.
The Belford Hospital (Fort William), Caithness General Hospital (Wick), Lorn & Islands Hospital (Oban) and the Western Isles Hospital all, currently have fewer than three permanent general surgery consultants.
"The Scottish Government is not currently fulfilling their commitment to the provision of surgical services in rural general hospitals," said Mr Ferguson.
"Rural surgeons face unique challenges in providing a broad range of services in comparatively isolated environments.
"It is not possible to staff a small rural unit with every kind of specialist, so generalist surgeons have to widen their practice and often perform many different types of operation in small numbers.
"Many studies have described how rural practice requires a certain kind of 'clinical courage', where practitioners operate beyond familiar comfort zones in order to meet needs locally.
He added: "The capability to provide major elective (planned) surgery has been significantly eroded in some rural surgical units and I am concerned that this loss of expertise will also impact on the ability of rural hospitals to provide life-saving emergency surgery when required."
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NHS Highland said three new surgeons had recently been appointed to the Belford Hospital, who are due to start in the New Year which will take the complement to four.
David Sedgwick, former head surgeon at the Lochaber hospital says the medical profession "has to bear some of the responsibility" for staff shortages.
"It is maybe the case that medical and surgical advisers are drawn mainly from the city centre type of practise and will advise accordingly," he said.
"The ability of people from remote and rural areas to access routine general surgical and medical services will be compromised if there aren't general surgeons.
"Someone with acute abdominal pain, possibly appendicitis, may have to travel four hours to see a surgeon."
He said there is "real interest" from trainee doctors and said it was encouraging to see fifteen trainees at the recent rural surgery conference.
"That's the most we've seen but they need to see a pathway to a consultant post that will be supported," said Mr Sedgwick.
"There's been an expansion in the number of consultant posts but not a proportional expansion in the number of training posts and the encouragement to consider remote and rural surgery as a career.
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"Quite a lot of the trainers don't have experience of it and I think would find it quite daunting."
Mr Sedgwick, who is retired and is now involved in training, said he would encourage any medical student to consider rural work.
He said: "You have to a certain extent a degree of autonomy, you have a breadth of procedures that you can do.
"My main area was colorectal but I did quite a lot of care of patients with urological problems, with trauma and paediatric care and that gives a really interesting workload.
"It's a great place to live, all the rural hospital [areas] have good primary and secondary schools.
"Culturally, it's interesting - all our kids played musical instruments and you can work in collaboration with the super-specialists.
"For me, it was in Inverness and Glasgow and I had great support from the guys there."
A Scottish Government spokeswoman said:“The staffing issues faced by rural and island health boards were a central point of discussions during the Health Secretary’s visits across the county over the summer and we will continue to work closely with remote, rural and island boards where we know recruitment and retention challenges can be particularly acute.
"NHS Scotland staffing remains at historically high levels, up 2% on permanent staff the same time last year.
“This comes as part of 10 consecutive years of increases in staffing across our NHS. Consultants in NHS Scotland are the best paid in the UK with a basic salary at the top of scale of over £121,000.
“Boards have the power to offer various working patterns and flexibilities to attract candidates and are required to set out clearly in their workforce plans how they will continue to ensure safe and sustainable numbers of staff.”
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