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NHS HIGHLAND: Highland healthcare model designed for remotest areas was blueprint for NHS

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The Highlands and Islands Medical Service was established as the world’s first state-funded comprehensive health service, says our columnist.
The Highlands and Islands Medical Service was established as the world’s first state-funded comprehensive health service, says our columnist.

As the NHS celebrates its 75th birthday I realise I started as a medical student almost 40 years ago and have been working as a partner in general practice for 30 years.

We feel the NHS has always been there, and although that is obviously not true, a form of state-funded health service did exist in the Highlands from 1912.

In 1912, healthcare was very different. In towns and cities doctors were able to maintain viable medical practices from private practice and most hospitals were funded by public subscription.

But the crofting counties were in crisis and so a commission was set up, chaired by Sir John Dewar, to investigate.

This group toured 17 of the remotest communities of the Highlands and Islands and their resulting Dewar Report startled and horrified politicians.

Beset by poor transport and rural poverty, many people had no meaningful access to healthcare, with the new National Insurance Act often only covering the doctor, teacher and minister. Many communities were unable to support a doctor’s salary. In Ross-shire, in the 10 years previously 47 per cent of deaths went uncertified, rising to over 80 per cent in some parishes.

The Dewar Report was published in December 1912, detailing how poor living conditions led to bigger problems with infectious diseases such as tuberculosis and diphtheria.

Provision was unplanned and random, often reliant on individual and haphazard charitable donations. The report details the barriers to doctors settling in rural areas, such as lack of housing, poor pay and fears for the opportunities for their family.

But it also made a revolutionary recommendation: a state-funded service should be set up in these areas. This was much influenced by the evidence supplied by Dr Lachlan Grant, a GP in Ballachulish.

He had seen how the “medical club” in existence for the slate quarry workers there had allowed the provision of a doctor and he exhorted that this model could be expanded to the whole population, at reasonable cost and to great effect.

The following year, the Highlands and Islands Medical Service was established as the world’s first state-funded comprehensive health service. After a shaky start, more and more doctors and nurses were appointed and by 1936 the Cathcart Report stated: “This service has revolutionised medical provision in the Highlands. It is now reasonably adequate in the sense that for all districts the services of a doctor are available on reasonable terms.”

Other areas of Scotland looked on with envy and when the NHS White Paper was published in 1944 it was the only model quoted as an example of how the NHS would work.

So, a model designed to deliver healthcare to the remotest areas of the UK was the blueprint for the NHS as we know it, and has become central to the British identity.

Healthcare outcomes are envied across the world and it is still seen as the most cost-effective of health services. This is a legacy of which we should be proud and Dr Grant’s vision should be celebrated.

Populations in the remotest areas are right to demand reasonable access to basic healthcare and should demand better when solutions from urban areas lead to sometimes catastrophic gaps in services.

We need a renewed generation of doctors, nurses and others with multiple roles, embedded in communities. These individuals will be true lifesavers to these populations but will also have the skills to care for people with the complex multiple problems, which increasingly result from our lengthened life expectancy.

With the right support and vision, solutions that are developed and refined in the remotest areas have the potential to again provide the blueprint for new models. Perhaps in the future, other less rural areas will again petition that they are rolled out more widely and as a result, like Lachlan Grant’s initiative 100 years ago, a reinvigorated NHS will be in place to face the new challenges of our times.

Dr Miles Mack is a GP at Dingwall Medical Practice.

Dr Miles Mack.
Dr Miles Mack.

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