Recruitment and Retention of
Health Care Providers in
Remote Rural areas
Status report for Highland Region
Authors:
Pam Nicoll
Isobel Madden
David Heaney
Gillian Galloway
[March 2012]
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1
Table of Contents
2
INTRODUCTION
4
3
GEOGRAPHY
4
4
DEMOGRAPHY
6
5
THE ORGANISATION OF HEALTHCARE SERVICES IN HIGHLAND
11
6
HEALTHCARE PROFESSIONALS IN NHS HIGHLAND
13
7
URBAN COMPARISON AREA
14
8
TRAINING AND EDUCATION
18
9
RECRUITMENT AND RETENTION:
20
10
SUMMARY
20
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2
Introduction
This report provides baseline information about the NHS Highland area. It forms the basis for
comparisons in the area of recruitment and retention of Healthcare providers. The report includes
general information about the NHS Highland area including; geography and demography, the
organisation of the health services and staff. The figures in this report are based on the NHS Highland
boundary which includes both the Highland and Argyll and Bute Local Authority areas.
3
Geography
NHS Highland covers an area comprising the largest and most
sparsely populated part of the UK and represents more than 40%
of the land mass of Scotland. From the Southern to the Northern
tip is more than 300 miles. Much of the landscape is mountainous,
interspersed with sea lochs along the coast and fresh water lochs
inland. The west coast of the region is long in comparison to the
regions size, with many inlets and islands.
The Highlands have a temperate climate, warmed by the ‘North
Atlantic Drift’, with higher temperatures than other countries on
similar latitude. Average temperatures vary with the affects of
proximity to the coast and topography, but average annual
temperature at low altitude is 7-8°C, with a lowest recorded
temperature of -27°C in Altnahara and a highest recorded of
32.1°C in Onich. The mountainous scenery of the Western
Highlands results in high rainfall with Fort William averaging
4000mm of rain per year. However, in the east of the region, near the Moray Firth, rain fall is
considerably lower, averaging 700mm/year. Snowfall is usually confined to the months November to
April, but with snow cover rarely prolonging at low altitude. Upland areas, however, may retain snow
cover for around 7 months of the year1.
The Highlands are reached via road and rail from the other regions in Scotland and via air from across the
UK and Europe. The region is served from the South and East by trunk roads, carrying significant road
traffic particularly in the summer months, but many parts of Highland are linked by a series of single
track roads mainly in the West of the region. Bad weather in the winter can result in road, rail and air
disruptions and closures.
Seventy five percent of the Highland population live in areas classified as remote or rural compared to
twenty percent in Scotland as a whole2. The Highland region has a population density at 9 persons per
1
Met Office
2
Scottish Government 8-Fold Urban-Rural Classification Scheme
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km2 fallen to only 2 persons per km2. The Scottish average is 67 persons per km2.3 These remoteness and
sparsity factors, in addition to the regions geography and transport infrastructure place obvious
challenges in delivering health services particularly where the focus of government policy is to provide
care as near to the patient as possible. This remoteness has also contributed to the difficulties in
attracting healthcare professionals to work in these areas. The implications of such factors for the
population’s health are felt in terms of accessibility of services and also in other direct impacts on a
person’s health arising from the economic vulnerability and social isolation of their remote-rural
situation.
These challenges are felt much less in the regions urban areas. The region’s capital, the city of Inverness,
has a population of around 60000 and is one of Europe’s fastest growing cities. The city is a thriving place
to live and work and is considered to have a high quality of lifestyle. The city accommodates the District
General Hospital, the Executive Office for Scotland’s newest university; the University of the Highlands
and Islands and is the main transport hub for locations across the region and to the Islands. However,
Inverness, too, can suffer from a perception of remoteness from the other main urban areas in Scotland,
which in itself can impact the attraction of students and professionals to the city.
3
General Register Office Scotland
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4
Demography
Demographic trends have a clear impact on workforce planning and population health needs both
through the overall changes in population size and in the age/gender composition. The 2010 population
served by NHS Highland is 310830 and accounts for 5.9% of the total population for Scotland. 14.7% of
the population are aged 16 to 29, lower than for Scotland at 18.7 %. The population aged 60 and over
make up 26.1% of the population; higher than for Scotland, at 23.1%4. Overall, the Highland population
has been rising since 1984 and is predicted to continue to rise. By 2033 the population is predicted to be
343348, an increase of 10%. The Scottish population as a whole in predicted to increase by 7.3% in the
same time frame5.
Projected percentage change in population (2008-based), by NHS board area,
2008-2033
25
20
Percentage change
15
10
5
0
-5
4
General Register Office for Scotland
5
National Records of Scotland
Lothian
Borders
Forth Valley
Grampian
Orkney
Highland
Fife
Tayside
SCOTLAND
Lanarkshire
Dumfries & Galloway
Ayrshire & Arran
Greater Glasgow & Clyde
Western Isles
Shetland
-10
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From the profile below it is apparent that the projected growth in population by 2033 will come
predominantly from the 65+ age groups. There is also significant growth in the population surviving to 91
and older.
Highland Population Profile
Age
91
male
81
female
71
61
51
41
31
2033
21
11
1
6
4000
4
2000
2
0
-2
2000
-4
4000
-6
number
Migration
The main influence on population growth has been inward migration rather than an increase in births or
reduction in deaths. In 2010 the net inflow of people was 1003 with the biggest movement of people
occurring in the 16-29 age group at an average 1327/ year. However, the population of Argyll and Bute
has fallen by 1.7% over the last 10 years6. Inward migration from Eastern Europe has accounted for
substantial changes in the ethnic minority population in recent years. However, the ethnic minority
population only accounts for 0.5% of the population.
6
General Register Office for Scotland
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Life expectancy
Life expectancy at birth in the Highland region for latest period is above the national average for both
men and women. Women have a life expectancy of 81.5 years compared to men with 76.4 years7.
However, men’s life expectancy in the region is improving more rapidly than women’s. On average,
there are 3500 deaths in NHS highland each year. The commonest cause of death is heart disease and
stroke (34%), cancers (28%), respiratory disease (11%) and dementia (6%)8.
: Life expectancy at birth, 95% confidence intervals for NHS Board areas, 20072009 (Males and Females)
SCOTLAND
Borders
Grampian
Dumfries & Galloway
Lothian
Highland
MALE
Tayside
FEMALE
Shetland
Forth Valley
Fife
Orkney
Ayrshire & Arran
Lanarkshire
Western Isles
Greater Glasgow & Clyde
68
70
72
74
76
78
80
82
84
86
Years
7
National Records of Scotland
8
The Annual Review of the Director of Public Health 2010
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Socio-economic challenges and Rural Deprivation
The Scottish Index of Multiple Deprivation (SIMD) 2009
identifies the most deprived areas across Scotland. It is
based on 31 indicators in the six individual domains of
Current Income, Employment, Housing, Health,
Education, Skills and Training and Geographic Access to
Services and Telecommunications. Overall, the indicators
of deprivation show that Highland residents fare better
than the average Scot, although there is significant
variation in the detail between Highland communities.
Geographical barriers contribute to the areas remoteness
and socio-economic aspects such as low income and poor
transport links result in areas of disadvantage contrasting
with other areas of rapid development and associated
better quality of lifestyle. These inequalities present a
challenge for those designing and delivering health and
social care. Those rural areas with greatest levels of
deprivation in terms of income, employment and
accessibility are shown in the map.
Household Income
The average annual household income for the region is
£31360/yr slightly below the Scottish average of£33207/yr.
Employment status
Employment rates are higher than in Scotland as a whole. Sectors such as agriculture, tourism and
construction are important to the region but by far the biggest employer is the public sector accounting
for more than a third of the workforce. Employment rates over the course of a year are affected by the
seasonal nature of many of the areas jobs particularly in tourism. The unemployment rate is 2.8% and of
those employed, 12.3% are regarded as income deprived9.
Health Impacts
There are a number of population healthcare impacts facing the NHS Highland arising from a
combination of our ageing population, remote geography and lifestyle. Life expectancy is different
according to your socio-economic status; boys born in the most deprived areas of Highland will live an
average of 7 years less than boys from the least deprived areas, while the difference in girls is around 5
9
Scottish Index of Multiple Deprivation (SIMD)
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years10. As with Scotland as a whole, the region expects to see an increase in those living with chronic
disease as a result of an ageing population and lifestyle resulting in escalating costs for those providing
health and social care.
Patients with Long Term Conditions in NHS Highland
Long term condition
Number of patients Prevalence (per 100 patients)
CHD (Coronary Heart Disease)
14,754
4.58
COPD (Chronic Obstructive Pulmonary Disease) 5,353
1.66
Asthma
19,469
6.04
Diabetes
13,845
4.30
Dementia
2,563
0.80
Data source: QOF Calculator Database, as at 18th July 2011, plus notifications of adjustments from NHS Boards.
10
The Annual Review of the Director of Public Health 2010
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5
The Organisation of Healthcare Services in Highland
Community Health Partnerships (CHPs) were established across the NHS in Scotland from 2004. Each
CHP covers a defined geographical area. There are four CHPs in NHS Highland (see map11):


North Highland CHP (Caithness & Sutherland)
Mid Highland CHP (Ross & Cromarty, Skye &
Lochalsh, and Lochaber)
South East Highland CHP (Inverness, Nairn,
Badenoch & Strathspey)
Argyll & Bute CHP


Community Health Partnerships are responsible for:

Supporting the improvement of the health of
local communities.
Providing health services for local people.
Involving local people, health and social care
professionals, voluntary and independent
organisations, in decisions that affect the
planning and delivery of health care and health
services for their communities.
Co-ordination of the planning, development and
provision of health services.



The Community Health Partnerships are directly
responsible for providing a wide range of local and
community based services including local hospitals,
community mental health teams, community nurses,
midwives and health visitors, therapy teams such as
physiotherapy, speech and language therapy, occupational therapy, nutrition and dietetics,
podiatry/chiropody, and a range of specialist practitioners such as Macmillan nurses. Some specialist
services are hosted by the CHPs and include NHS Dental Services, Acute Mental health and Learning
Disability Services and the Out of Hours service.
Raigmore Hospital is the district general hospital based in Inverness and is an acute general hospital and
has existed on the site since 1941. The hospital has a total of 577 beds and employs approximately 3200
staff and consists of 5 directorates; medical, surgical, woman and child, clinical services and facilities.
There are 3 rural general hospitals based in Wick, Fort William and Oban and a further 21 community
hospitals across the region. The rural general hospitals undertake management of acute medical and
surgical emergencies and are the emergency centre for the community, including the place of safety for
11
http://www.nhshighland.scot.nhs.uk/CHP/Pages/chp.aspx
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mental health emergencies. It provides more advanced levels of diagnostic services than a community
hospital and will provide a range of outpatient, day-case, inpatient and rehabilitation services. Secondary
psychiatric care is based in New Craigs in Inverness. There are 102 general practices across the region
with 409 general practitioners.
Dental service
Dental Services in the Highlands are managed by NHS Highland, and are made up of the General Dental
Services, with independent practices working in either the NHS, private practice or a mixture of both,
and the Salaried Dental Service. Secondary care is delivered in Raigmore Hospital, Inverness, Caithness
General Hospital, Wick, Lorn and the Isles Hospital, Oban, Lochgilphead Community Hospital and smaller
units in community facilities.
There are 67 dental practices in total, supporting 128 practitioners and salaried service health centres
situated in all the Health Boards, with 110 dental practitioners employed.
Salaried Dental Service Centres
North Highland
Mid Highland
South East Highland
Argyll & Bute
Inner Hebrides
Golspie
Portree
Inverness (3 practices)
Campbelltown
Isle of Coll
Helmsdale
Kyle
Nairn
Dunoon
Isle of Collonsay
Lairg
Dunvegan
Fort William
Oban
Iona
Lochinver
Aviemore
Lochgilphead
Mull
Alness
Granton on Spey
Furnace
Tyree
Invergordon
Lochgoilhead
Islay
Dingwall
Tighnabruich
Jura
Tain
Helensburgh
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6
Healthcare Professionals in NHS Highland
Whole time equivalent data is not routinely available for staff
employed by General Practices. The following table provides an
estimate of staff employed by General Practices across Highland.
Staff in Post at
Sept 2011 (wte)12
Healthcare Staff Group
Medical (not including GPs)
470.5
Dental
79.7
Medical & Dental Support
225.1
Med & Dental Total
775.3
Nursing & Midwifery (Band 1 -4)
759.6
Nursing & Midwifery (Band 5+)
2324.5
Nursing & Midwifery Total (wte)
3084.1
AHP (Band 1-4)
108
AHP (Band 5+)
429.9
AHP Total
537.9
Other Therapeutic Service
172.5
Personal & Social Care
29.2
Health Science Services
246.8
Support Services
811.9
Admin Services
1243.2
Management (Non AFC)
Staff group
WTE Estimate
2009
GPs
295
Practice Nurses
87
Healthcare Assistants and Phlebotomists
25
Employment %
medical and dental
nursing and midwifery
6% 11%
2%
AHP
11%
0%
healthcare science
1%
admin services
42%
67.9
3%
Other Total
2571.5
TOTAL
6968.8
management
17%
personal and social care
therapeutic services
7%
support services
general practice
Gross Joiner and Leaver trend for All staff -
NHS Highland
400.0
350.0
Joiners
300.0
Leavers
Headcount
250.0
200.0
150.0
100.0
50.0
Q1
12
Q2 Q3
2006/07
Q4
Q1 Q2 Q3
2007/08
Q4
Q1
Q2 Q3 Q4
2008/09
Q1
Q2 Q3
2009/10
Q4
Q1
Q2
Q3
2010/11
Q4
Q1
2011/12
ISD NHS Scotland Workforce September 2011
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7
Urban comparison area
The Urban area for comparison is the area served by NHS Grampian.
Grampian was a local government region of Scotland from 1975 to
1996 but is now divided into the unitary council areas of: Moray,
Aberdeenshire and the City of Aberdeen. Grampian continues to
have a joint police service, fire service and electoral, valuation, and
Health boards.
Map Source:
Employability
in Scotland
Highland
Grampian
Aberdeen City is the 3rd largest and one of the most densely
populated cities in Scotland, with a population density of 1,151
persons/sq km. Population density within Aberdeenshire sits at 36
persons/sq km with approximately 63% of the population living in the
main towns. This reflects the rural nature of the region.
Demography
The estimated population for Grampian 2009 was 544,980, an
increase of 1% from 539,630 in 2008. The population of Grampian
accounts for 10.4% of the total population of Scotland. The population currently has a relatively high
proportion of under 20s and fewer over-65s compared with the Scottish average, reflecting
employment-driven in-migration in recent decades.
Area
2008
2009
% Change
Scotland
5,168,500
5,194,000
0.49%
Grampian
539,630
544,980
0.99%
Aberdeen City
210,400
213,810
1.62%
Population Projections 2008 to 2033
By 2033 the population of Grampian is projected to be 605,307, an increase of 12.71% compared to
2008. The population of Scotland is projected to increase by 7.27% between 2008 and 2033.
Area
2008
2033
% Change
Scotland
5,168,500
5,544,410
7.27%
Grampian
539,630
605,307
12.17%
Aberdeen City
210,400
219,630
4.39%
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Health care services
NHS services for the Grampian region are provided by NHS Grampian, and are overseen by one single
NHS Board. NHS Grampian covers an area of over 3,000 square miles of city, town, village and rural
communities.
The Board is supported from headquarters at Summerfield House in Aberdeen. Senior managers for the
functions which cover the whole of Grampian are based here, including financial overview, corporate
planning, and central responsibility for protection and promotion of public health.
NHS Grampian consists of acute services, corporate services and three Community Health Partnerships
(CHP) and works closely with the local authorities. NHS Grampian is also very closely linked with both
the University of Aberdeen and The Robert Gordon University, especially in the fields of research,
workforce planning and training. Care is provided throughout Grampian in 9 main hospitals, a 17
community hospitals, 84 GP Practices and various other specialist care units.
Hospitals:








Aberdeen Royal Infirmary is NHS Grampian's largest hospital, situated at Foresterhill, Aberdeen.
Royal Aberdeen Children's Hospital and Aberdeen Maternity Hospital are also housed at the
Foresterhill site.
Woodend Hospital caters for many patients, including the elderly.
Royal Cornhill Hospital provides inpatient and community support for mental health services.
A large number of outpatients are seen at the Woolmanhill Hospital in the city centre.
Roxburghe House is a new purpose-built unit providing palliative care for terminally ill patients.
Dr Gray's Hospital is the district general hospital based in Elgin, Moray.
Children with special needs are cared for at the Raeden Centre jointly with Aberdeen City
Council.
The Oaks is another purpose-built unit which provides specialist care and support for people
with cancer and other progressive illnesses in Moray.
Community Hospitals:
Community hospitals are hospitals where most patients are admitted, and cared for, by their own GPs.
They normally deal with:




Acute medical care where patients cannot be cared for at home, but where the expertise and /
or the specialist diagnostic facilities of a major specialist hospital are not required.
Post acute care including rehabilitation.
Casualty services.
Palliative care.
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They may also have:





Diagnostic facilities (such as x-ray, ultrasound, sigmoidoscopy, cardiac assessment,
telemedicine).
Therapeutic facilities (such as physiotherapy, occupational therapy, minor surgery, day hospital).
Facilities for joint teams (such as community nursing teams and social work / care management
teams).
Specialist outpatient clinics.
Intermediate care clinics.
NHS Grampian Staffing
NHS Grampian Current Staffing (wte)
Total
10885.20
Administrative Services
1726.20
Nursing/Midwifery
4967.50
Allied Health Profession
874.80
Other Therapeutic
291.20
Healthcare Sciences
438.40
Personal and Social Care
77.90
Medical and Dental
627.60
Senior Managers
127.20
Medical and Dental
Support
203.60
Support Services
1550.80
Note: the above Medical and Dental figure excludes training grades and GP sessional
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The following Table is a breakdown of Medical and Dental Staff. (Headcount)
Total
1330
Associate Specialist
48
Career Start GP
11
Clinical Director
3
Asst Clinical Director
1
Consultant
447
Dental Officer
36
Dental Trainee
6
FTSTA
15
FY1
108
FY2
105
Limited Specialist
1
Medical Director
1
Para 94
9
Salaried 2C GP
40
Salaried GP
4
Salaried OoH GP
23
Senior Dental Officer
13
Salaried GDP
11
SHO
5
Specialty Doctor
51
SPR
63
Staff Grade
4
STR
275
STRCT
50
In addition to the above there are approximately 123 GPs carrying out sessional work within
Community Hospitals.
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8
Training and education
Changes to services required and way in which services need to be delivered will consequently have an
impact on the training of healthcare staff and the ability to attract and retain staff able to live and work
in the region, particularly in the remote and rural areas. There is a perceived difficulty in ensuring
sufficient access to training, education and research opportunities within the remote and rural areas.
This in turn contributes to reducing the ability to attract to certain posts which may not be considered a
positive career development in comparison with similar posts in urban settings.
Undergraduate Medical Education
The University of Aberdeen has its Highland Medical Education Centre based in the Centre for Health
Science in Inverness where around 80 medical undergraduate students are based at any one time. 18 of
these students work through a rural option, providing specialised teaching for application in remote and
rural medicine.
Undergraduate Dental Education
The University of the Highlands and Islands (UHI) in collaboration with NHS Education for Scotland and
the Health Boards in Highland, Western Isles and Dumfries and Galloway provide BSc degree level
education in Oral Health Science for 14 students per year. This degree allows graduates to register with
the General Dental Council as Dental Hygienists / Therapists.
Outreach training for final year Dental students (BDS) is provides at the Inverness Dental Centre, Centre
for Health Science for the University of Dundee Dental School and at the Spynie Dental Centre in Elgin for
students from the University of Aberdeen Dental School.
Vocational training schemes are organised for dental graduates working across the Highlands, with 20
Vocational Dental Practitioners currently working in dental practices across the region. These are
graduates in their first year post-qualification, who have supervised clinical experience in general dental
practice for a year, with supported learning carried out at the education centres in Inverness and the
peripheral centres.
NES also supports training for dental nurses, dental administrators and dental practice managers.
Undergraduate and Postgraduate Nurse Education
Stirling University Highland Campus is sited within the Centre for Health Science in Inverness and also in
the Western Isles. The University delivers pre and post registration nurse training. On average there
around 400 students being taught from this campus with placements offered across the region.
Other Undergraduate Education
Other types of health care education can be studied across Scotland and the United Kingdom;
placements for students are available in many of the Allied Health Professions in NHS Highland. Most of
the health care professionals are trained at a university level and take a minimum of 4 years at Bachelor
level. Students undertaking these degrees are based out with the Highland area in Glasgow, Edinburgh,
Dundee or Aberdeen.
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Postgraduate Education and Training
NHS Education for Scotland (NES) is responsible for the design, development, commissioning and
provision of post graduate healthcare training in Scotland. The delivery of postgraduate healthcare
training requires a partnership approach between Deaneries, NES, universities and local Health Boards.
NHS Education for Scotland (NES) hosts the Remote and Rural Healthcare Education Alliance (RRHEAL).
RRHEAL coordinates and delivers education to meet the specific needs of the multidisciplinary remote
and rural healthcare workforce. RRHEAL works to increase access to remote and rurally relevant
education and training for the remote and rural workforce.
There are four Deaneries in Scotland – the North Deanery is responsible for 5 Health Boards: Western
Isles, Orkney, Shetland, Grampian and Highland. All North of Scotland Deanery Foundation Programmes
(134 posts) offer as a minimum 4 months in a remote or rural placement, Aberdeen-based with a
placement in one of the 6 Rural General Hospitals (RGHs).
Postgraduate Dental Education and Training
NES provides funding for general dental practitioners working in the remote and rural areas of Scotland
who wish to undertake postgraduate training to Masters level. The Scottish Dental Postgraduate Rural
Training Fellowship has been in place for eight years, and has a high record of retention of participants in
the remote and rural areas. Fellows undertake a part-time Masters degree in a relevant clinical subject at
one of the three participating Scottish University Dental Schools, whilst working in either the General
Dental Service or the Salaried Dental Service of the NHS. They are financially supported with payment of
university fees, travel and subsistence to university teaching days and a percentage of their salary is paid
by NES. Currently there are nine Postgraduate Rural Fellows, working in Grampian, Highland, Argyll and
Bute, Western Isles, and Dumfries and Galloway.
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9
Recruitment and Retention:
Recruitment and retention of staff continues to be an issue for NHS Highland particularly in the rural
locations of the region. In addition to overcoming the rural challenges, a number of changes to the NHS
in the region have had a significant impact on the workforce. Two of the biggest of these have been the
‘Shifting the Balance of Care’ agenda13 and the integration of health and social care services with the
Local Authority. The former of these has seen a shift in care delivery to a community setting, treating
patients at or closer to home, relieving pressure on acute services, reducing travel in the region or
enabling patients to remain at home for longer. The latter of these is a joint undertaking between the
Highland Council and NHS Highland with plans to integrate health and social services across the two
agencies form 1st April 2012. The Highland Council will lead the integration of children’s services and NHS
Highland will lead the integration of adult services. Both of these initiatives have seen significant changes
to service delivery with a need to provide education and training to support changes in roles and ways of
working to deliver integrated health and social care service.
There is also a need to redesign the workforce who provides care in rural general hospitals as current
models are considered to be largely unsustainable. Issues that contribute to the vulnerability of the rural
general hospital workforce also have an impact across rural community services and workforce. There is
a need to develop new and adapted roles to support redesign of the rural hospital workforce. This
requires high standard education and ongoing training programmes to be accessible and affordable.
The areas listed below outline the key issues for Highland:



Recruitment – There are difficulties in attracting sufficient applicants for posts which results in a
lack of availability of appropriately skilled staff. Therefore there is a need to ensure staff have
the range of skills required to deliver care across breadth of practice required in remote and
rural settings.
Placement issues – There is a lack of availability or exposure for Scottish undergraduates to
remote and rural working. Remote and rural placements may have to be self funded by some
professional groups while others are supported to meet rural placement costs.
Retention/ staff turnover - There is a higher level of locum use within remote and rural hospital
settings. This results in increased costs and high turnover of staffing. There are difficulties in
identifying longer term work for partners of new recruits.
10 Summary
Attracting professionals to work in Highland is a challenge for the region in many health disciplines and
the continued retention of staff in a fulfilling and rewarding career is central to many of the teaching and
13
http://www.shiftingthebalance.scot.nhs.uk
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training initiatives established in the region. The development of rural undergraduate courses will go
some way to encourage these graduates to stay and practice in rural areas with the assurance of access
to high quality CPD (Continuous Personal Development) training. There is a role for other sectors in
ensuring professionals locate to/ remain in Highland through the provision of, for example, schooling,
housing, leisure activities and other employment opportunities for spouses. The region is looking to
further develop the use of digital technologies in health, which will improve access to healthcare for
those living remotely and also to education and training for health professionals. The use of
communications technology will reduce professional isolation for these workers also.
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