We are experienced clinicians and medical managers, with a history of working with patients in rural and remote communities and 2 councillors.
We have submitted and published papers showing the effects of unnecessary travel for cancer patients; and showing that travelling negatively affects access to inpatient care. We have also met repeatedly with senior health officials, to raise these issues and obtained numerous undertakings to address the inequalities.
It seems that there is a gap between government agencies, who quite properly state a reluctance to interfere with operational matters, and health boards who often see matters from a provider perspective. There is therefore not an agency or body to advocate for remote communities with adverse consequences for patients. Whether unrecognised or ignored the effect is negative, and the processes and procedures for resolution unsatisfactory, and certainly ineffectual.
This petition proposes that an agency is created, which will ensure that policy implementation by health boards is both “fair” and “reasonable” (both of which are statutory requirements) for rural and remote communities, as well as for those who live in more urban areas.
The role of the agency could be advisory whereby the facts of a policy and its possible impact are established, to ensure that parties understand the nature of the compromise and have clarity about the consequences.
The agency should have an ability to influence management thinking, a responsibility to ensure facts are relevant and valid, and best evidence considered within the management process.
It could also disseminate examples of best practice to ensure equity on a national scale, and to give comfort to boards facing the uncertainty of change. In the longer term this could encourage a better and more constructive dialogue, through context-specific management processes with rural and remote communities. The process would therefore focus on engendering mutual respect, rather than as now, confrontation.
The centralisation of complex services such as cardiology, neurology, oncology, obstetrics, paediatrics and others are essential to support a structure that will deliver consistent high quality and cost-effective care. Inevitably and appropriately, these are based in areas of high-density population. Being focussed on specific conditions and outcomes they require highly structured team management to perform as well as they do.
However, structural inequality can occur when the fabric of organisations, institutions, governments or social networks contain an embedded bias which provides advantages for some members and marginalises or produces disadvantages for other members.
When the structure is balanced, for example by someone or a body that is responsible for representing the end user (in this case the patient), inequalities lessen. The agent could be the clinician, traditionally the general practitioner, a Health Board or politicians. In 2004, however, Scotland placed NHS Trusts (primarily a structure status) within Health Boards. The inevitable conflict between agency and structure fell more in favour of structures (as the managers had always been primarily providers). In the new set-up, the board non-executive is responsible for oversight, acting as an agent and being responsible to government.
In an urban setting, centralisation creates fewer conflicts; the benefits of travel (often a minor inconvenience) are clearer and the deficits smaller. Communications between professionals and user organisations are easier. Committees rarely have rural representatives, due to access issues: that includes agency organisations such as the British Medical Association, professional Colleges and Academics, as well as patient representatives.
Poor national data
Structures drive policy and management through available data. Deprivation is closely associated with health outcomes and current deprivation indices do not favour the rural deprived. For example, car ownership may be a rural necessity but is an indicator that reduces deprivation scores. The Scottish Office Department of Health Acute Services Review Report of 1998 highlighted a lack of rural research, a situation that still exists. These data issues were highlighted in the academic press such as the British Journal of General Practice The effect of “distance decay”, where the uptake of specialist services is reduced by the need to travel, is widely recognised. A further Editorial in the British Journal of General Practice hypothesised that the effects of distance decay should be regarded as deprivation in its own right. The lack of good rural data remains an issue.
Common sense and Compassion
However compelling the data, managers should be driven by common sense and compassion, a value that should above all underpin any public service. Both of these have a contextual element and a personal awareness, and data is usually heavily biased towards specific (in this case urban) groups. Even then, a healthy BMW owner lacks context for what a cancer patient’s 10-hour journey on hospital transport really means, and the victim of that policy, vulnerable through illness, deprivation and exhaustion, is unlikely to wish to confront the providing authority. An agency can inform this process, either independent or embedded within the management structure. The appendix reveals the lack of agency in a rural health board.
Poor local data
Even in the most rural boards, the primacy of managing for population centres is widespread. Rural middle management can be excluded from decision making, often inadvertently. Confusion between consultation and engagement, underpinned by you “don’t understand the big picture”, and “must expect to travel” mean that rural provision is not critically examined, and lying at the edge of “outreach” services, rural becomes underserved.
Lack of agency
The board should serve a region equitably, but inevitably the urban majority dominates, and rural issues fall off the agenda. Advocates are frequently seen as troublesome and disruptive, while “groupthink” encourages a belief in the moral superiority of the group, and marginalisation of critical evaluation. This can be demoralising to caring professionals because—
“managers' approach could have been moderated by an understanding of frontline care work. However, on the whole, they had never worked in healthcare. This culture clash, coupled with the managers’ limited repertoire of (mostly technical) ‘hard skills’, meant that aspects of healthcare that are difficult to quantify – for example, providing care to people who are frightened, agitated or in their final moments of life – were overlooked. Over time, the differences between the two professional groups contributed to a deep divide, underpinned by mutual suspicion and labelling. This provided fertile ground for some managers to impose a top-down control regime in an attempt to gain the desired organisational results”.
The effects on staff and patients
Throughout Scotland, staff who raise issues encounter a number of barriers. Managers are people too; vulnerable to unconscious bias fuelled by lack of contact with periphery, pressures to deliver, and a focus on the immediate and local problems. The expeditious solution is to marginalise these minority issues, using tactics that may be construed as bullying, but may also be due to poor information (qualitative and quantitative), or poor interpretation which may be explained by a culture supporting structural inequality.
Summary
In a perfect world management would resolve this by creating an agency that would inform the board of unintended consequences of policy, but it is clear from issues in Galloway, Grampian, Argyll & Clyde and others that such issues cannot be raised centrally without resistance and inevitably confrontation. It is no coincidence that many of these issues arise in rural areas.