Friday FAQs: Malcolm Alexander

For this edition of Friday FAQs, we spoke to Dr Malcolm Alexander about the challenges of rural health care. He is a recently retired GP who now lives on the island of Bute in Scotland. His recent book, "Close to Where the Heart Gives Out: A Year in the Life of an Orkney Doctor", describes his previous experiences as a GP in the remote setting of Eday.

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Published: 11/12/2020

You’ve written about your time as a doctor in Eday in the Orkneys, and that you gave up your job in Glasgow to move there. What are the particular challenges of island health care?

The thing that hits you first is that you’re on your own. If something happens, there is no ambulance. That isolation is still what a lot of people can’t handle.

You are never off call because you are an inherent part of the community. That concept of having to be the doctor, all day, every day, it’s in the back of your head.

There was a time I was on call 24 hours a day for six months, doing almost everything, including the police work. Occasionally, I looked after animals too. You were expected to look after anything that was living.

How much of a risk is it that more remote areas like Orkney might be left behind when it comes to the quality of care?

Transport issues affect quality of care, more than the skill or will of the professionals on the ground to deliver it. It is geography that will defeat you unless you plan for it not to.

Many conditions can be treated remotely with good telemedicine links to major centres. It’s time-critical specialist care episodes, such as vascular incidents or major trauma, that are the challenge.

Confident caregivers, well supported by links to professionals in larger centres, are often able to deliver excellent and more personalised care in the smaller remote and rural communities.

Is it therefore understood that the islands in Scotland which are closest to a big city by air time are less risky health wise to live in?

People don’t think like that. I think they accept that the local economy has health resources that can be accessed, and then there are specialist resources that are further away. There are pros and cons to both. You’re certainly not going to suffer from air pollution up in the Western Isles!

There’s almost an unconscious deal that people make with themselves. They’ll think, “this is definitely a better place to live, it may just take a little longer to get to specialist care”.

With regard to health care, do you feel that urban areas have benefited more from the response to Covid-19 than remote areas?

I don’t think urban areas have fared better than rural ones. My daughter is an anaesthetist in a metropolitan area of England, and she had to source her own FFP3 mask to work in ICU. My sense is that rural health care teams have coped well, once they adapted to the new infection control measures. The different way of working was not easy, but small teams are very flexible. Their vulnerability is exposed when one member has to self-isolate or is affected by travel restrictions.

Difficulties arose with patient transfer where additional infection control measures, including the need for a negative Covid test before transfer, limited the available resources. The reduction of specialist inpatient facilities will similarly have created greater problems for rural hospitals, which have had to hold on to patients they would routinely have transferred. Travel to outpatient appointments by sea and air also became more difficult with some patients electing not to attend. The Near Me video consultation equipment was already in use in many rural areas of Scotland and is well accepted by patients.

The real challenge is now starting to bite as primary care faces an increased number of delayed presentations on non-Covid illnesses. Mental health issues are also dramatically on the increase across all segments of society. Limited mental health resources in rural areas to meet this demand will put pressure on the rural health care systems.

Thinking more broadly, what are the biggest changes you’ve seen within general practice during your career?

The range of diseases and available treatments today means your generalist has to have a much broader knowledge base. The range of activities that a GP is expected to undertake is quite considerable now compared to when I began.

The other significant change that I notice is in relationships. When I started as a GP, I would have a relationship with several specialists within the hospital. In those days, we still had domiciliary visits, so you could ask a specialist to come out and see a patient at home. These days you don’t know who’s looking after your patients. You can track down the consultant leads, but it can take a huge amount of time. Patients don’t always fit into pathways of care, and the system doesn’t recognise that.

What do you think is the biggest risk to continuity of care in general practice?

I have seen fragmentation within the practice teams. Some small teams have managed to remain tight, still meeting to discuss patients in their group. Other teams are now becoming so big that they are just not able to have those conversations. I feel that’s where we are losing continuity of care – there’s a loss of personal conversations between the professionals.

What’s the biggest change you would like to see in health and social care?

As a patient, I should be treated as a valued customer who you want to see again. Most of the time, the system is built to discharge us rapidly.

I’ve been through three different clinical systems in Scotland now. What was done by each clinical service was perfect, but I didn’t know what was happening as I went through the various steps. Information needs to match pathway steps – tell me why this step is next.

What’s the hidden danger that you can see bubbling up in health care in the next few years?

We continue to treat illness, which we’re good at, but we don’t start early enough through public health interventions to fix the cause of the problems – the real danger is our inability to understand the early phases of disease. The Covid pandemic has brought that issue sharply into focus.

Take the recent research on diets, and how a healthy body struggles with high levels of carbohydrates. We need to tackle this problem to protect ourselves from the next bulge of health care issues, which are going to be driven by diabetes and obesity. The recent government paper advocating an advertising ban on junk food is a start. Still, we are going to have to go much further if we don’t want to see the whole system overwhelmed by unnecessary illnesses.

Dr Malcolm Alexander is a recently retired GP and the author of Close to Where the Heart Gives Out: A Year in the Life of an Orkney Doctor, which is available in both hardcover and paperback. 

Photo by Michael Boyd.

FAQs 16/11/2018

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