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Nicky Marr: Are we heading to ‘rich v poor’ health system again?

By Nicky Marr

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Nicky Marr. Picture: James Mackenzie.
Nicky Marr. Picture: James Mackenzie.

As the rest of the nation celebrates 75 years of our NHS, here in the Highlands and Islands we’ve been looked after for longer than most. Because our beloved NHS, founded on July 5 1948, was based on the much earlier Highlands and Islands Medical Service (HIMS).

Here we should be celebrating 110 years of being cared for, thanks to the Dewar Report, which was published in 1912, and created the HIMS the following year. And as we celebrate, we should consider where we’ve come from, and where we are heading.

Before 1913, private doctors, hospitals and asylums cared for the wealthy, leaving charitably funded institutions to scoop up the poorest and most needy. Dunbar’s Hospital in Inverness opened as a poor house in the 1660s.

But in 1913, the HIMS was ground-breaking in terms of ambition, equality and delivery. It became the world’s very first, state-funded, comprehensive health service. Although treatment wasn’t completely free, fees were set at minimal levels, and some could access free treatment if they were unable to pay.

The Dewar Report – the original is held in Inverness’s Highland Archive Centre – exposed poor health and deeply inadequate medical and nursing provision among crofting communities, and recommended the ground-breaking establishment of state funded medical services.

Crofters, by the nature of their way of life, had little or no regular income. When illness or injury struck, they couldn’t afford to pay for a doctor, nurse, or midwife, so – as Dewar disclosed – they relied on traditional remedies and superstition.

A lack of medical care, combined with poverty, poor housing, and a sketchy understanding of hygiene, meant Highlanders and Islanders had lower quality of health than the rest of the population.

It was a Catch 22. If patients didn’t have regular income to pay for medical help, doctors couldn’t afford to live and work here. The whole system had to change.

The report’s solution was to guarantee doctors a minimum salary if they would agree to visit all those who needed help and to assist with public health education too. And so the transformation of the health of Highlanders began.

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Raigmore Hospital, April 2023.
Raigmore Hospital, April 2023.

In time, the HIMS expanded nursing services, created hospitals, paid for specialists, and bought ambulances. It launched the first air ambulance too, serving the Western Isles from 1936.

The success of the HIMS was phenomenal. It became the blueprint for Nye Bevan’s ‘free at the point of delivery’ National Health Service in 1948, and for other health services across the world.

But looking now at some of the details of the Dewar Report, there are parallels with today’s NHS Highland. Compounding the poor health of Highlanders and Islanders were real challenges in attracting doctors, nurses, and midwives to work in remote and rural areas. Take one look at the vacant posts at Raigmore and other Highland hospitals, and in GP practices across the region, and it’s clear that similar challenges exist today.

We all know of healthcare workers who are leaving, crippled by insurmountable workloads, limited resources, an ageing population with increasingly complex needs, and a crisis in mental health. Their departure puts additional pressure on colleagues who stay, and the situation spirals.

The closure of rural GP practices for lack of staff means many rural communities find themselves – again – without medical cover.

Personally, I can’t fault the care and treatment I’ve received, during childbirth and minor ailments, through broken bones and the occasional mental health wobble. My family has been well served too. But it’s clear the service is in crisis. We need Dewar Mark II.

We’ll never be in such dire need – fingers crossed – as we were 110 years ago, but free universal care isn’t sustainable if it’s not properly funded. Are we heading back to where we were in the 1910s, with a two-tier ‘rich versus poor’ system? We simply can’t allow that to happen.

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