Recruitment and Retention of Health Care Providers in Remote Rural areas

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Recruitment and Retention of Health Care Providers in Remote Rural areas

Status report for Highland Region


Pam Nicoll

Isobel Madden

David Heaney

Gillian Galloway

[March 2012]

Table of Contents

Introduction 3

Geography 3

Demography 5

The Organisation of Healthcare Services in Highland 10

Healthcare Professionals in NHS Highland 12

Urban comparison area 13

Training and education 17

Recruitment and Retention: 19

Summary 20


This report provides baseline information about the NHS Highland area. It forms the basis for comparisons in the area of recruitment and retention of Healthcare providers. The report includes general information about the NHS Highland area including; geography and demography, the organisation of the health services and staff. The figures in this report are based on the NHS Highland boundary which includes both the Highland and Argyll and Bute Local Authority areas.


NHS Highland covers an area comprising the largest and most sparsely populated part of the UK and represents more than 40% of the land mass of Scotland. From the Southern to the Northern tip is more than 300 miles. Much of the landscape is mountainous, interspersed with sea lochs along the coast and fresh water lochs inland. The west coast of the region is long in comparison to the regions size, with many inlets and islands. scotland-north

The Highlands have a temperate climate, warmed by the ‘North Atlantic Drift’, with higher temperatures than other countries on similar latitude. Average temperatures vary with the affects of proximity to the coast and topography, but average annual temperature at low altitude is 7-8°C, with a lowest recorded temperature of -27°C in Altnahara and a highest recorded of 32.1°C in Onich. The mountainous scenery of the Western Highlands results in high rainfall with Fort William averaging 4000mm of rain per year. However, in the east of the region, near the Moray Firth, rain fall is considerably lower, averaging 700mm/year. Snowfall is usually confined to the months November to April, but with snow cover rarely prolonging at low altitude. Upland areas, however, may retain snow cover for around 7 months of the year1.

The Highlands are reached via road and rail from the other regions in Scotland and via air from across the UK and Europe. The region is served from the South and East by trunk roads, carrying significant road traffic particularly in the summer months, but many parts of Highland are linked by a series of single track roads mainly in the West of the region. Bad weather in the winter can result in road, rail and air disruptions and closures.

Seventy five percent of the Highland population live in areas classified as remote or rural compared to twenty percent in Scotland as a whole2. The Highland region has a population density at 9 persons per km2 fallen to only 2 persons per km2. The Scottish average is 67 persons per km2.3 These remoteness and sparsity factors, in addition to the regions geography and transport infrastructure place obvious challenges in delivering health services particularly where the focus of government policy is to provide care as near to the patient as possible. This remoteness has also contributed to the difficulties in attracting healthcare professionals to work in these areas. The implications of such factors for the population’s health are felt in terms of accessibility of services and also in other direct impacts on a person’s health arising from the economic vulnerability and social isolation of their remote-rural situation.

These challenges are felt much less in the regions urban areas. The region’s capital, the city of Inverness, has a population of around 60000 and is one of Europe’s fastest growing cities. The city is a thriving place to live and work and is considered to have a high quality of lifestyle. The city accommodates the District General Hospital, the Executive Office for Scotland’s newest university; the University of the Highlands and Islands and is the main transport hub for locations across the region and to the Islands. However, Inverness, too, can suffer from a perception of remoteness from the other main urban areas in Scotland, which in itself can impact the attraction of students and professionals to the city.


Demographic trends have a clear impact on workforce planning and population health needs both through the overall changes in population size and in the age/gender composition. The 2010 population served by NHS Highland is 310830 and accounts for 5.9% of the total population for Scotland. 14.7% of the population are aged 16 to 29, lower than for Scotland at 18.7 %. The population aged 60 and over make up 26.1% of the population; higher than for Scotland, at 23.1%4. Overall, the Highland population has been rising since 1984 and is predicted to continue to rise. By 2033 the population is predicted to be 343348, an increase of 10%. The Scottish population as a whole in predicted to increase by 7.3% in the same time frame5.

From the profile below it is apparent that the projected growth in population by 2033 will come predominantly from the 65+ age groups. There is also significant growth in the population surviving to 91 and older.

The main influence on population growth has been inward migration rather than an increase in births or reduction in deaths. In 2010 the net inflow of people was 1003 with the biggest movement of people occurring in the 16-29 age group at an average 1327/ year. However, the population of Argyll and Bute has fallen by 1.7% over the last 10 years6. Inward migration from Eastern Europe has accounted for substantial changes in the ethnic minority population in recent years. However, the ethnic minority population only accounts for 0.5% of the population.

Life expectancy
Life expectancy at birth in the Highland region for latest period is above the national average for both men and women. Women have a life expectancy of 81.5 years compared to men with 76.4 years7. However, men’s life expectancy in the region is improving more rapidly than women’s. On average, there are 3500 deaths in NHS highland each year. The commonest cause of death is heart disease and stroke (34%), cancers (28%), respiratory disease (11%) and dementia (6%)8.











Greater Glasgow



Western Isles







Forth Valley














: Life expectancy at birth, 95% confidence intervals for NHS Board areas, 2007-

2009 (Males and Females)
Socio-economic challenges and Rural Deprivation

The Scottish Index of Multiple Deprivation (SIMD) 2009 identifies the most deprived areas across Scotland. It is based on 31 indicators in the six individual domains of Current Income, Employment, Housing, Health, Education, Skills and Training and Geographic Access to Services and Telecommunications. Overall, the indicators of deprivation show that Highland residents fare better than the average Scot, although there is significant variation in the detail between Highland communities. Geographical barriers contribute to the areas remoteness and socio-economic aspects such as low income and poor transport links result in areas of disadvantage contrasting with other areas of rapid development and associated better quality of lifestyle. These inequalities present a challenge for those designing and delivering health and social care. Those rural areas with greatest levels of deprivation in terms of income, employment and accessibility are shown in the map.

Household Income

The average annual household income for the region is £31360/yr slightly below the Scottish average of£33207/yr.

Employment status

Employment rates are higher than in Scotland as a whole. Sectors such as agriculture, tourism and construction are important to the region but by far the biggest employer is the public sector accounting for more than a third of the workforce. Employment rates over the course of a year are affected by the seasonal nature of many of the areas jobs particularly in tourism. The unemployment rate is 2.8% and of those employed, 12.3% are regarded as income deprived9.

Health Impacts

There are a number of population healthcare impacts facing the NHS Highland arising from a combination of our ageing population, remote geography and lifestyle. Life expectancy is different according to your socio-economic status; boys born in the most deprived areas of Highland will live an average of 7 years less than boys from the least deprived areas, while the difference in girls is around 5 years10. As with Scotland as a whole, the region expects to see an increase in those living with chronic disease as a result of an ageing population and lifestyle resulting in escalating costs for those providing health and social care.

Patients with Long Term Conditions in NHS Highland

Long term condition

Number of patients

Prevalence (per 100 patients)

CHD (Coronary Heart Disease)



COPD (Chronic Obstructive Pulmonary Disease)












Data source: QOF Calculator Database, as at 18th July 2011, plus notifications of adjustments from NHS Boards.

The Organisation of Healthcare Services in Highland

Community Health Partnerships (CHPs) were established across the NHS in Scotland from 2004. Each CHP covers a defined geographical area. There are four CHPs in NHS Highland (see map11):

  • North Highland CHP (Caithness & Sutherland)

  • Mid Highland CHP (Ross & Cromarty, Skye & Lochalsh, and Lochaber)

  • South East Highland CHP (Inverness, Nairn, Badenoch & Strathspey)

  • Argyll & Bute CHP

Community Health Partnerships are responsible for:

  • Supporting the improvement of the health of local communities.

  • Providing health services for local people.

  • Involving local people, health and social care professionals, voluntary and independent organisations, in decisions that affect the planning and delivery of health care and health services for their communities.

  • Co-ordination of the planning, development and provision of health services.   

The Community Health Partnerships are directly responsible for providing a wide range of local and community based services including local hospitals, community mental health teams, community nurses, midwives and health visitors, therapy teams such as physiotherapy, speech and language therapy, occupational therapy, nutrition and dietetics, podiatry/chiropody, and a range of specialist practitioners such as Macmillan nurses.  Some specialist services are hosted by the CHPs and include NHS Dental Services, Acute Mental health and Learning Disability Services and the Out of Hours service.

Raigmore Hospital is the district general hospital based in Inverness and is an acute general hospital and has existed on the site since 1941. The hospital has a total of 577 beds and employs approximately 3200 staff and consists of 5 directorates; medical, surgical, woman and child, clinical services and facilities. There are 3 rural general hospitals based in Wick, Fort William and Oban and a further 21 community hospitals across the region. The rural general hospitals undertake management of acute medical and surgical emergencies and are the emergency centre for the community, including the place of safety for mental health emergencies. It provides more advanced levels of diagnostic services than a community hospital and will provide a range of outpatient, day-case, inpatient and rehabilitation services. Secondary psychiatric care is based in New Craigs in Inverness. There are 102 general practices across the region with 409 general practitioners.

Dental service

Dental Services in the Highlands are managed by NHS Highland, and are made up of the General Dental Services, with independent practices working in either the NHS, private practice or a mixture of both, and the Salaried Dental Service. Secondary care is delivered in Raigmore Hospital, Inverness, Caithness General Hospital, Wick, Lorn and the Isles Hospital, Oban, Lochgilphead Community Hospital and smaller units in community facilities.

There are 67 dental practices in total, supporting 128 practitioners and salaried service health centres situated in all the Health Boards, with 110 dental practitioners employed.

Salaried Dental Service Centres

North Highland

Mid Highland

South East Highland

Argyll & Bute

Inner Hebrides












Inverness (3 practices)


Fort William


Granton on Spey









Isle of Coll

Isle of Collonsay






Healthcare Professionals in NHS Highland

Whole time equivalent data is not routinely available for staff employed by General Practices. The following table provides an estimate of staff employed by General Practices across Highland.

Staff group

WTE Estimate 2009



Practice Nurses


Healthcare Assistants and Phlebotomists


Healthcare Staff Group

Staff in Post at Sept 2011 (wte)12

Medical (not including GPs)




Medical & Dental Support


Med & Dental Total


Nursing & Midwifery (Band 1 -4)


Nursing & Midwifery (Band 5+)


Nursing & Midwifery Total (wte)


AHP (Band 1-4)


AHP (Band 5+)


AHP Total


Other Therapeutic Service


Personal & Social Care


Health Science Services


Support Services


Admin Services


Management (Non AFC)


Other Total




Urban comparison area



Map Source: Employability in Scotland


The Urban area for comparison is the area served by NHS Grampian. Grampian was a local government region of Scotland from 1975 to 1996 but is now divided into the unitary council areas of: Moray, Aberdeenshire and the City of Aberdeen. Grampian continues to have a joint police service, fire service and electoral, valuation, and Health boards.

Aberdeen City is the 3rd largest and one of the most densely populated cities in Scotland, with a population density of 1,151 persons/sq km. Population density within Aberdeenshire sits at 36 persons/sq km with approximately 63% of the population living in the main towns. This reflects the rural nature of the region.


The estimated population for Grampian 2009 was 544,980, an increase of 1% from 539,630 in 2008. The population of Grampian accounts for 10.4% of the total population of Scotland. The population currently has a relatively high proportion of under 20s and fewer over-65s compared with the Scottish average, reflecting employment-driven in-migration in recent decades.




% Change









Aberdeen City




Population Projections 2008 to 2033

By 2033 the population of Grampian is projected to be 605,307, an increase of 12.71% compared to 2008. The population of Scotland is projected to increase by 7.27% between 2008 and 2033.




% Change









Aberdeen City




Health care services

NHS services for the Grampian region are provided by NHS Grampian, and are overseen by one single NHS Board. NHS Grampian covers an area of over 3,000 square miles of city, town, village and rural communities.

The Board is supported from headquarters at Summerfield House in Aberdeen. Senior managers for the functions which cover the whole of Grampian are based here, including financial overview, corporate planning, and central responsibility for protection and promotion of public health.

NHS Grampian consists of acute services, corporate services and three Community Health Partnerships (CHP) and works closely with the local authorities.  NHS Grampian is also very closely linked with both the University of Aberdeen and The Robert Gordon University, especially in the fields of research, workforce planning and training. Care is provided throughout Grampian in 9 main hospitals, a 17 community hospitals, 84 GP Practices and various other specialist care units.


  • Aberdeen Royal Infirmary is NHS Grampian's largest hospital, situated at Foresterhill, Aberdeen. Royal Aberdeen Children's Hospital and Aberdeen Maternity Hospital are also housed at the Foresterhill site.

  • Woodend Hospital caters for many patients, including the elderly. 

  • Royal Cornhill Hospital provides inpatient and community support for mental health services.

  • A large number of outpatients are seen at the Woolmanhill Hospital in the city centre. 

  • Roxburghe House is a new purpose-built unit providing palliative care for terminally ill patients.

  • Dr Gray's Hospital is the district general hospital based in Elgin, Moray.

  • Children with special needs are cared for at the Raeden Centre jointly with Aberdeen City Council.

  • The Oaks is another purpose-built unit which provides specialist care and support for people with cancer and other progressive illnesses in Moray.

Community Hospitals:

Community hospitals are hospitals where most patients are admitted, and cared for, by their own GPs. They normally deal with:

  • Acute medical care where patients cannot be cared for at home, but where the expertise and / or the specialist diagnostic facilities of a major specialist hospital are not required.

  • Post acute care including rehabilitation.

  • Casualty services.

  • Palliative care.

They may also have:

  • Diagnostic facilities (such as x-ray, ultrasound, sigmoidoscopy, cardiac assessment, telemedicine).

  • Therapeutic facilities (such as physiotherapy, occupational therapy, minor surgery, day hospital).

  • Facilities for joint teams (such as community nursing teams and social work / care management teams).

  • Specialist outpatient clinics.

  • Intermediate care clinics.

NHS Grampian Staffing

NHS Grampian Current Staffing (wte)



Administrative Services




Allied Health Profession


Other Therapeutic


Healthcare Sciences


Personal and Social Care


Medical and Dental


Senior Managers


Medical and Dental Support


Support Services


Note: the above Medical and Dental figure excludes training grades and GP sessional

The following Table is a breakdown of Medical and Dental Staff. (Headcount)



Associate Specialist


Career Start GP


Clinical Director


Asst Clinical Director




Dental Officer


Dental Trainee








Limited Specialist


Medical Director


Para 94


Salaried 2C GP


Salaried GP


Salaried OoH GP


Senior Dental Officer


Salaried GDP




Specialty Doctor




Staff Grade






In addition to the above there are approximately 123 GPs carrying out sessional work within Community Hospitals.

Training and education

Changes to services required and way in which services need to be delivered will consequently have an impact on the training of healthcare staff and the ability to attract and retain staff able to live and work in the region, particularly in the remote and rural areas. There is a perceived difficulty in ensuring sufficient access to training, education and research opportunities within the remote and rural areas. This in turn contributes to reducing the ability to attract to certain posts which may not be considered a positive career development in comparison with similar posts in urban settings.

Undergraduate Medical Education

The University of Aberdeen has its Highland Medical Education Centre based in the Centre for Health Science in Inverness where around 80 medical undergraduate students are based at any one time. 18 of these students work through a rural option, providing specialised teaching for application in remote and rural medicine.

Undergraduate Dental Education

The University of the Highlands and Islands (UHI) in collaboration with NHS Education for Scotland and the Health Boards in Highland, Western Isles and Dumfries and Galloway provide BSc degree level education in Oral Health Science for 14 students per year. This degree allows graduates to register with the General Dental Council as Dental Hygienists / Therapists.

Outreach training for final year Dental students (BDS) is provides at the Inverness Dental Centre, Centre for Health Science for the University of Dundee Dental School and at the Spynie Dental Centre in Elgin for students from the University of Aberdeen Dental School.

Vocational training schemes are organised for dental graduates working across the Highlands, with 20 Vocational Dental Practitioners currently working in dental practices across the region. These are graduates in their first year post-qualification, who have supervised clinical experience in general dental practice for a year, with supported learning carried out at the education centres in Inverness and the peripheral centres.

NES also supports training for dental nurses, dental administrators and dental practice managers.

Undergraduate and Postgraduate Nurse Education

Stirling University Highland Campus is sited within the Centre for Health Science in Inverness and also in the Western Isles. The University delivers pre and post registration nurse training. On average there around 400 students being taught from this campus with placements offered across the region.

Other Undergraduate Education

Other types of health care education can be studied across Scotland and the United Kingdom; placements for students are available in many of the Allied Health Professions in NHS Highland. Most of the health care professionals are trained at a university level and take a minimum of 4 years at Bachelor level. Students undertaking these degrees are based out with the Highland area in Glasgow, Edinburgh, Dundee or Aberdeen.

Postgraduate Education and Training

NHS Education for Scotland (NES) is responsible for the design, development, commissioning and provision of post graduate healthcare training in Scotland. The delivery of postgraduate healthcare training requires a partnership approach between Deaneries, NES, universities and local Health Boards.

NHS Education for Scotland (NES) hosts the Remote and Rural Healthcare Education Alliance (RRHEAL). RRHEAL coordinates and delivers education to meet the specific needs of the multidisciplinary remote and rural healthcare workforce. RRHEAL works to increase access to remote and rurally relevant education and training for the remote and rural workforce.

There are four Deaneries in Scotland – the North Deanery is responsible for 5 Health Boards: Western Isles, Orkney, Shetland, Grampian and Highland. All North of Scotland Deanery Foundation Programmes (134 posts) offer as a minimum 4 months in a remote or rural placement, Aberdeen-based with a placement in one of the 6 Rural General Hospitals (RGHs).

Postgraduate Dental Education and Training

NES provides funding for general dental practitioners working in the remote and rural areas of Scotland who wish to undertake postgraduate training to Masters level. The Scottish Dental Postgraduate Rural Training Fellowship has been in place for eight years, and has a high record of retention of participants in the remote and rural areas. Fellows undertake a part-time Masters degree in a relevant clinical subject at one of the three participating Scottish University Dental Schools, whilst working in either the General Dental Service or the Salaried Dental Service of the NHS. They are financially supported with payment of university fees, travel and subsistence to university teaching days and a percentage of their salary is paid by NES. Currently there are nine Postgraduate Rural Fellows, working in Grampian, Highland, Argyll and Bute, Western Isles, and Dumfries and Galloway.

Recruitment and Retention:

Recruitment and retention of staff continues to be an issue for NHS Highland particularly in the rural locations of the region. In addition to overcoming the rural challenges, a number of changes to the NHS in the region have had a significant impact on the workforce. Two of the biggest of these have been the ‘Shifting the Balance of Care’ agenda13 and the integration of health and social care services with the Local Authority. The former of these has seen a shift in care delivery to a community setting, treating patients at or closer to home, relieving pressure on acute services, reducing travel in the region or enabling patients to remain at home for longer. The latter of these is a joint undertaking between the Highland Council and NHS Highland with plans to integrate health and social services across the two agencies form 1st April 2012. The Highland Council will lead the integration of children’s services and NHS Highland will lead the integration of adult services. Both of these initiatives have seen significant changes to service delivery with a need to provide education and training to support changes in roles and ways of working to deliver integrated health and social care service.

There is also a need to redesign the workforce who provides care in rural general hospitals as current models are considered to be largely unsustainable. Issues that contribute to the vulnerability of the rural general hospital workforce also have an impact across rural community services and workforce. There is a need to develop new and adapted roles to support redesign of the rural hospital workforce. This requires high standard education and ongoing training programmes to be accessible and affordable.

The areas listed below outline the key issues for Highland:

  • Recruitment – There are difficulties in attracting sufficient applicants for posts which results in a lack of availability of appropriately skilled staff. Therefore there is a need to ensure staff have the range of skills required to deliver care across breadth of practice required in remote and rural settings.

  • Placement issues – There is a lack of availability or exposure for Scottish undergraduates to remote and rural working. Remote and rural placements may have to be self funded by some professional groups while others are supported to meet rural placement costs.

  • Retention/ staff turnover - There is a higher level of locum use within remote and rural hospital settings. This results in increased costs and high turnover of staffing. There are difficulties in identifying longer term work for partners of new recruits.


Attracting professionals to work in Highland is a challenge for the region in many health disciplines and the continued retention of staff in a fulfilling and rewarding career is central to many of the teaching and training initiatives established in the region. The development of rural undergraduate courses will go some way to encourage these graduates to stay and practice in rural areas with the assurance of access to high quality CPD (Continuous Personal Development) training. There is a role for other sectors in ensuring professionals locate to/ remain in Highland through the provision of, for example, schooling, housing, leisure activities and other employment opportunities for spouses. The region is looking to further develop the use of digital technologies in health, which will improve access to healthcare for those living remotely and also to education and training for health professionals. The use of communications technology will reduce professional isolation for these workers also.

1 Met Office

2 Scottish Government 8-Fold Urban-Rural Classification Scheme

3 General Register Office Scotland

4 General Register Office for Scotland

5 National Records of Scotland

6 General Register Office for Scotland

7 National Records of Scotland

8 The Annual Review of the Director of Public Health 2010

9 Scottish Index of Multiple Deprivation (SIMD)

10 The Annual Review of the Director of Public Health 2010


12 ISD NHS Scotland Workforce September 2011


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