How health service was made in the Highlands
Project set up 35 years before NHS provided perfect template.. but challenges remain
THE Highlands showed the rest of the UK how a state-funded health system serving a whole community could work.
The Highlands and Islands Medical Service had been established 35 years earlier than the NHS.
HIMS was a unique social experiment formally set up in 1913 with a Treasury grant of £42,000 in the wake of a report by Sir John Dewar’s committee.
He chaired a Treasury commission to investigate medical and nursing attendance in the Highlands and Islands and make recommendations to improve the situation.
Highland GP and former chairman of the Scottish Committee of the Royal College of General Practitioners, Miles Mack, said: “It looked at the state of medical services in the Highlands and Islands, which was basically crofting communities.
“The report had shown there were areas of the Highlands where there was no medical attention at all. Forty per cent of the deaths in Ross-shire weren’t even certified as there was no doctor at the time of someone’s death.
“The main problem was that the National Insurance scheme – which entitled all workers to a doctor – was completely unfit for the Highlands as it didn’t cover crofting areas.
“The key evidence came from Lachlan Grant, in Ballachulish, who provided medical attention to his own community and also Ballachulish Slate Company.
“They began a model – similar to one in the Welsh valleys for mineworkers – to give GPs an income. In 1903, he was dismissed for advocating for workers and they went out on strike for 18 months until he was reinstated. He advocated a state-funded comprehensive medical service. A great deal of his proposals were incorporated in HIMS.”
Doctors struggled to make a living in
sparsely populated areas and depended on tourists having accidents or taking ill on holiday for cash.
But in the Highlands, the GP was given an income and entitled to a house, a phone and a car or motorboat as well as allowances for other expenses like new technology – which included the phone – and locum cover to allow them to undertake study.
But while rural practice was an attractive option back then, the problems of recruitment are recurring almost 100 years later.
Mack said: “We have shown repeatedly our model works everywhere in Scotland but the urban solutions come unstuck in rural areas.”
He believes this has been ignored in the much-lauded new GP contract, which will have services previously done by GPs, such as vaccinations, carried out elsewhere.
He said: “Rural GPs’ concerns are that patients have to travel long distance for additional services across rural Scotland.
“In the central belt, we forget the distances that are travelled. Even in my practice, which is not the most remote, we have patients who have to take one-and-a-half hour round trips.
“We don’t know what vaccination model we will be looking at in the Highlands. Parents won’t want to travel to get childhood immunisations.
“Some groups are difficult to reach. It has always been a challenge to get pregnant women to get a flu vaccine.
“People suffering from multiple morbidities and health inequalities are the most vulnerable and the people we are keenest to get to.
“One of the biggest concerns is a move towards a purely bio-medical model which potentially underplays the problems of people’s psychology and overall health. The people I look after I’ve already had a relationship with on smaller stuff. When they come to me with serious stuff, there is trust built up.
“It is a different case when the first time you have contact with a person is to have a difficult conversation.
“GPs are expensive but we have always proven to be cost-effective. What vexes me in celebrations for NHS 70 is the lack of understanding and recognition of the key role the GP has played.”
Additional Treasury funding in the 30s provided surgeons to Stornoway, Wick, Shetland and Orkney. By 1935, they introduced their first air ambulance with HIMS. The HIMS proved so successful that in 1936 their adoption was recommended throughout Scotland. The Beveridge Report then used it as the blueprint for the National Health Service in 1948.
The advent of World War II saw a hospital building programme in Scotland. It had been deemed necessary as there was expected to be thousands of civilian casualties in air raids.
Seven new hospitals were built – Raigmore in Inverness, Stracathro near Brechin, Bridge of Earn in Perthshire, Killearn in Stirlingshire, Law in Lanarkshire, Ballochmyle in Ayrshire and Peel in Selkirkshire – under the Emergency Hospital Service.
The building work caught the attention of the German air force and Law and Stracathro were mistaken for military barracks on Luftwaffe maps.
In addition to the new hospitals, annexes were built at existing hospitals, with hotels purchased to provide convalescent beds.
However, the expected casualties did not materialise and the hospitals instead were given over to specialities – seven orthopaedic centres with 2000 beds and further 1300 for plastic surgery, eye injuries and psychoneurosis and neurosurgery among others.
A pathology lab service was established and a Scottish Blood Transfusion Association set up.
From severe pre-war bed shortages, by 1948, Scotland had a relative abundance and 15 per cent more per head of population than in England and Wales, plus 30 per cent more nurses and better resourced GPs making it better equipped to cope with the demands on free services.