The struggle to recruit doctors to work in rural and remote parts of Scotland will be the subject of a special government workforce strategy – but not for at least two years.

In the meantime, a unique programme that offers graduates of all backgrounds the chance to train as doctors, coupled with a training bursary in return for a commitment to work in Scotland’s NHS, has been recognised by the health secretary as a “critical component” of alleviating the challenges facing rural practice.

At this year’s NHS National Education for Scotland (NES) conference, delegates heard from Professor Jon Dowell, the Director of Scotland’s first graduate entry medical programme, about how the ScotGEM course offered jointly by the Universities of Dundee and St Andrew’s is “on track to meet its mandate”.

A nationwide shortage of qualified nurses, doctors and specialist consultants in many fields is well documented across the UK but is perhaps most keenly felt in the most rural and remote areas. In these areas, additional challenges in finding accommodation, higher costs of living and a more intense patient-practitioner relationships can make it even harder to recruit staff.

With these extra challenges in mind, the Scottish government has commissioned the ScotGEM four-year medical course – the first postgraduate medical degree offered in Scotland - which looks to develop the next generation of generalist doctors working in under-served rural areas. The health secretary told the Scottish parliament’s Health and Care Committee in March that the course is “absolutely key” to challenges faced by rural practice and that he was looking for opportunities to expand it further “because of the value seen even in its early years”.

The ScotGEM curriculum has a ‘generalist’ focus and hopes to ‘enthuse graduates’ to consider becoming generalist practitioners with experience in rural health care. Professor Jon Dowell, the Director of ScotGEM, told conference attendees that “nudging” students toward this career destination is key to the future of Scotland’s NHS:

 “In total, it’s only 32% of Scottish medical graduates who pursue general practice training in Scotland [in seven years after they complete their medical degree], which is obviously not the statistic which would support a healthy workforce development given 50% of the workforce is general practitioners.”

The Scottish government, in its workforce plan, highlighted growing Scotland’s community-based workforce as a key priority, describing ScotGEM as producing doctors that are ‘more likely to choose a career in General Practice’.

Professor Dowell explained the course’s “unique structure” is an important aspect of this:

“[In ScotGEM] 50% of all clinical education across the four years either in or led by GPs. Specifically GPs form a team of dedicated so-called ‘generalist clinical mentors’.

“Our delivery system is very dispersed, with almost half of our teaching happening in Dumfries and Galloway and Highland. And there is also a focus on service development and healthcare improvement activities, rather than research and traditional academic study.

“That distributed learning changes minds. Because we force people to spend a minimum of six weeks in Dumfries, they come back and say, “that’s made us change what we want to do”.”

Early, partial analysis of ScotGEM students’ desired career destinations shows this approach could be working. Among the 77% of current ScotGEM students surveyed, a higher expressed interest in a general practice career than is the norm amongst UK medical schools was found, as well as a greater desire to work in rural or remote areas:

“Overall, 89% of the ScotGEM students said they wanted to either be a GP working in Scotland or in a rural setting and only 6% declared themselves as clearly having another career interest,” Professor Dowell said.

“The key findings for our purposes is that 37% expressed they wanted to be GPs, 23% consultants and 40% remained undecided. General practice was the most popular single career destination. But interestingly and strikingly in comparison with other studies, emergency medicine – another generalist career – had a lot of interest among our students.”

This generalist focus of the ScotGEM course sets it apart from standard undergraduate medical degrees, far surpassing the General Medical Council’s challenge to all medical schools to deliver 25% of clinical education in primary care.

No students have had to resit an OSCE assessment – situational tests of clinical skills and knowledge - since the course began, which Professor Dowell says is “notably testament to those GP generalist mentor tutors”. These are trusted, senior clinicians who students have access to throughout their programme, in a master-apprentice type approach.

He says the unusually low attrition rate of ScotGEM and an exam pass rate similar to that of undergraduates at the University of Dundee means he is “broadly reassured about the quality” of the course.

Currently 55 places are available at ScotGEM annually, with students spending their first year based at the University of St Andrews. However, from their second year, students are expected to spend periods living and studying in rural areas of the Highlands and Dumfries and Galloway.

To support them in this, students can apply for a ‘return of service bursary’ up to a maximum of £16k over the four years as long as they commit to working in Scotland’s NHS for at least four years after graduation.

Professor Dowell says this extra incentive has likely contributed to all final year ScotGEM students including Scotland Deanery in their foundation programme applications.

A national centre for remote and rural health and social care is in its scoping stage, confirmed the health secretary last month, and is expected to be operational by next spring. This will look to ‘foster and promote innovation and excellence within Scotland and internationally’.

Scotland is not the only country to be facing challenges in recruiting appropriately-skilled doctors to its rural and remote areas. In fact, the ScotGEM course is informed by a teaching model already in place at the Northern Ontario School of Medicine in Canada.

Despite recruitment challenges, GPs in rural areas are some of the most popular medical professionals with their patients in the country: research by the University of Aberdeen has shown rural residents are happier with their GP service than those in urban areas, with patient-centred care and continuity of care cited as the main reasons.

Though workforce implications of ScotGEM are yet unknown, with the first cohort of students set to graduate this year, Professor Dowell says the team is “fairly confident, based on the evidence we’ve got to date, that we are about to meet our mandate”.

When pressed on how confident he is that student intentions to train as rural generalists will translate into reality upon graduation, Professor Dowell told delegates that evidence is lacking but he is hopeful the true impact of the course on Scotland’s workforce will be understood soon:

“We don’t have any good evidence on that in the UK – and indeed, internationally, the number of follow-up studies that are done are very limited, particularly ones that link the student information to the postgraduate outcome.

“We now, in the UK, have a database capable of achieving that. One of the intentions with this survey data…is that we will link this into UKMed and in five years’ time we will be able to answer that question.”

 

If you are interesting in studying ScotGEM, the University of St Andrew’s is holding a virtual information event on Thursday 19 May at 5pm.

 

 

Read more: Insight: A new route for NHS staff into medicine; Insight: Why I chose psychiatry; Government misses GP link worker target

 

 

 

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