The questionnaire hit our doormats in the middle of June. It was addressed to all adults in the Rannoch and Tummel community and was from the Centre for Rural Health. We local residents were asked to complete and return the form in a reply paid envelope to an address in Inverness. No date was given for the return of the questionnaire which can be viewed and downloaded at:
http://www.commentonline.co.uk/supplement/Questionnaire06.09KR.pdfÂ
Is this just another survey, which a lot of people will dutifully fill in to help academics in their research? It is a question worth asking, since the evaluation of Community First Responders, of which this survey is a part, has been commissioned by NHS Tayside. It was the Tayside Health Board which slammed the door on the repeated calls for the restoration of the local GP out-of-hours service. This was lost three years ago when the local doctor was allowed to opt out - against the wishes of Peter Bates, the then chairman of the Health Board.
Since August of last year, under the chairmanship of Sandy Watson, the Health Board has promoted First Responders as its preferred way of “enhancing emergency response.”
There are some worrying things about this particular questionnaire.
No Date for Response
First, and most basically, no date is given for the return of the questionnaire. Nobody filling in the form (and having no other information to go upon) can possibly know if they will miss the deadline if they delay for any reason, for example because they were away from home when the questionnaire came through the letter box. The researchers know the deadline. The respondents do not.
As is customary, the questionnaire has questions about both facts and opinions. There is no great difficulty in finding out the facts but discovering people’s opinions requires objectivity from the researchers rather than partisanship for one side or another side in a controversy.
Prior Commitment
We might ask ourselves, what happens if the researchers from the Centre for Rural Health, the ones who sent out the questionnaire, are already committed to a particular method of delivering health care, which is opposed to another method altogether - which a lot of local residents in Rannoch and Tummel actually support? ? And when there is local controversy on the issue?
This is exactly what has now happened in Rannoch and Timmel with this apparently so straightforward a request which, to recap, is to help a pair of independent researchers, Dr Heaney and Professor Farmer, to get a picture of what it is that local people want.
To know that the issues around GP out-of-hours are controversial you have to look no further than Comment’s website or the pages of the Courier for evidence of that. We are entitled to expect that Dr Heaney and Professor Farmer are reading the local press and so know that these are controversial issues. After all, it is now seven months since Sandy Watson told his Board that Dr Heaney would be helping NHS Tayside with the First Responders project in Kinloch Rannoch.
A Little Bit of History
Let’s pause a moment and go back a bit in time. This isn’t to be obsessed about the history of the dispute but to establish context for what is now being done by Dr Heaney and Professor Farmer as they receive the completed questionnaires in their offices in Inverness.
The controversy has been stoked by NHS Tayside which twice committed to local GP out-of-hours in Kinloch Rannoch before abruptly reversing this policy.
The first occasion when Tayside stood by the local community was when the incumbent GP wanted to opt out and the Health Board tried (but failed) to prevent him. The second occasion was when Tayside specified that cover at nights and weekends should be a “core component” of the new contract for the successors to the outgoing GP. Then, in the winter of 2007-08, Tayside changed its policy, trashing its own specification and appointing the only short listed GP applicant who would not do any out-of-hours.
Promoting first responders
Last August Mr Watson and his colleagues in the senior management team at NHS Tayside went a step further and started to promote a First Responder scheme for the area. At the crucial Board meeting on 13 November (agenda item 6.2) Mr Watson - at the outset of the hour-long discussion - first ruled out discussion about the lost GP out-of-hours service in Kinloch Rannoch as being water under the bridge. But then, a few minutes later as he presided over the meeting, he invited his Board colleagues to consider four options for “enhancing emergency response in Kinloch Rannoch.” One of these options was First Responders and another - GP out-of-hours!
Frightening the Non-Execs
The purpose of this sleight of hand was only too clear. It was to so frighten the Non-Executives on the Board with the supposed huge cost - over £½ Million a year - that they would recoil and choose the very cheap option, ie First Responders. In fact, GP cover for nights and weekends could be secured for very much less. And this was being done successfully in other mainland practices - seventeen of them in the summer of 2008. The Tayside officials must have known this very well, or they were stunningly incompetent.
A Curious Admission
Three of the Non-Execs wanted more time to examine the pros and cons of First Responders. This was denied even though Dr Heaney of the Centre for Rural Health admitted in a letter to the Board that there was no hard evidence for the effectiveness of First Responders. But he himself was an enthusiast for these schemes, having helped to set one up in his home village of Achiltibuie on Scotland’s north-west coast. And as a health policy researcher he had been advocating this kind of scheme, called “Community Resilience”, at least since 2005.
A Wide Range of Medical Emergencies
This was the unpromising start to the introduction of Community First Responders to Rannoch and Tummel. That is not, of course, the fault of the volunteers whose principal aim is to save a life if someone has a heart attack and to reach them in the crucial first few minutes. But this is not anywhere near what is needed, which is to have a doctor available locally to deal with a wide range of medical emergencies that can happen unpredictably and at any time, both in- and out-of-hours.
But this situation, in which residents have to rely upon the inadequate NHS24 out-of-hours service, is the fault of the senior managers in Tayside.
Health Care Planning
Now, after this excursion into the back history of the controversy, let’s return to Dr Heaney, Professor Farmer and their questionnaire.
This is not an evaluation of First Responders in the sense of being an objective and fair-minded way to understand how best to meet healthcare needs.
For the most part respondents will have had no prior experience with First Responders schemes. So how on earth can there be a valid evaluation, especially when there has as yet been no launch?
In any case, to evaluate the scheme decision-makers should be looking to the academic literature and empirical evidence regarding this type of programme and NHS organisation.
A loaded question
The questionnaire skirts around the broader issue of what kind of health care would be best for people in the area, containing a loaded question about people’s preference (or lack of preference) for GP out-of-hours cover. This is posed as representing a requirement that the present GPs would have to work around the clock when, as most people know, two of them live well away from the area. As perhaps fewer know, however, it is common practice in the Highland Health Board area to bring in locums for some at least of the weekends.
The Most Important Problem for the Community?
Of all the questions in this dodgy questionnaire perhaps the most misleading is Question 36, which reads: “Currently, I believe the provision of out of hours cover for emergency healthcare situations is the most important problem the Rannoch and Tummel community have to deal with.” (Strongly agree/ Agree/Neither agree nor disagree/ Strongly disagree)
Imagine that this question had been reworded to read: “… the most important healthcare problem the Rannoch and Tummel community have to deal with.” Then the answers might be very different and, of course, they would relate to the way in which campaigners for the restoration of local GP out-of-hours cover have actually been arguing.
This is not that restoring this service is all important for the community, but that it is one outstanding issue in terms of healthcare provision. The other such strongly felt issue, of course, is the restoration of the full ambulance service, staffed by paramedics. As it is, the way that the Centre for Rural Health academics have couched their question is likely to produce an artificially low figure for the “strongly agrees” and “agrees”.
First Responders’ Reference Group
Along with his colleague, Professor Jane Farmer, Dr Heaney is now on the First Responders Reference Group which was set up by NHS Tayside soon after their Board meeting last November. This group, which brings together representatives from NHS Tayside and the Scottish Ambulance Service with selected local representatives, has reportedly been periodically meeting in the surgery over the last few months. Have Dr Heaney and Professor Farmer consulted with them? Who knows.
A long time coming
Dr Heaney has been a long time coming. Back in June 2005 a report came out by Heaney and Hall, ‘Out of hours care in remote & rural Scotland: identifying sustainable strategies for change.’
This is an extract from the report: ‘The role of GPs in emergency care is also changing with paramedics taking on extended roles, again this may have an impact on rural general practice. The new service may also motivate people in rural communities to participate in emergency care by establishing first responder groups. The public will need to be educated about these new roles.’
This is such an interesting use of language. At that time there was a mass exodus by GPs from out-of-hours working. And it looks as though, four years later, Dr Heaney now has his opportunity. But people will need to be “educated.”
Change of Mind at the BMA
Things have changed since these words were written. Nowadays the people representing the doctors’ interests, notably the BMA, are desperate to regain GP control over out-of-hours services. As one of them told me only the other day, “the pendulum has swung too far against GPs doing OOH.”
This may not be the position of NHS Tayside’s Sandy Watson, or of our own GPs. But elsewhere more and more GPs are coming to believe that something must be done, given the multiple failures of NHS24, which costs far more than anybody ever expected and which causes distress - and even danger - to patients who may have to wait hours for a doctor to attend, if at all.
Dick Barbor-Might
Kinloch Rannoch
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