IT is said that the very blueprint for the NHS emerged from the dilemma of providing a medical service to the Highlands and Islands (HIMS) at a time when most doctors shunned the region, put off by the difficulty of making a profit in an area of widespread poverty and low population.

The solution - the Highlands and Islands Medical Service - was revolutionary in 1913 by providing a taxpayer-funded salary to GPs at a time when healthcare in the UK was still private.

When the NHS was created, a new model - the Inducement Practice Scheme - continued to incentivise GPs to work in rural Scotland by guaranteeing an income equivalent to 75 per cent of the median for Scottish doctors.

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More than a century after HIMS and 70 years into the NHS, there is a growing disquiet among rural GPs that the cornerstone of these early models - closing the gap between rural and urban general practice - has been lost in Scotland's new GP contract with its highly controversial workload-based funding formula.

Professor Phil Wilson, director of the Centre for Rural Health at Aberdeen University, said: "To my mind, this new GP contract is completely unfit for rural practice."

To put the current frustration into context, it is worth going back to 1910 when the UK Government commissioned a report that would eventually inspire the NHS.

Prof Wilson said: "The itch that needed scratching was that less than 50 per cent of all the deaths in the Highlands and Islands were certified, and the Edwardians really didn't like that administrative messiness.

"They weren't that bothered about the health of the people - but they were bothered about the fact that their deaths were not recorded properly.

"So they established the Dewar Committee and they came up with this fabulous report which really became the blueprint for the NHS.

"One of the really interesting things picked up in the report was that doctors in the Highlands and Islands stopped work in August, and they stopped work in August because August was the only time that doctors in a lot of areas of Scotland could make any money at all, and they made their money from the aristocrats who came up with their shooting parties.

"Essentially what they found was that it was just not possible for a doctor in the Highlands and Islands to make a living in the private medical environment that existed at the time. It was not possible because their patients were poor, and thinly spread."

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As a result of the Dewar Report, HIMS was formed and a system known as the 'imperial grant' paid GPs in the region a salary as well covering other expenses, such as providing a car.

As a result, patients were charged only a basic fee to see a doctor.

HeraldScotland: The GP practice in Portree, Skye is struggling to recruit a new GP

The early years of the NHS continued its ethos with the Inducement Practice Scheme used to iron out some of the inherent disparities between rural and urban at a time - from 1948 until 1966 - when GP practices were paid according to the number of patients on their list.

Prof Wilson said: "There was intense competition [for patients].

"But of course if you're on Tiree you can't have more than 700 patients because that's how many patients there are on Tiree."

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Prof Wilson added that from the beginning of the NHS, and before, there was a recognition that "there had to be a different solution for rural general practice".

This, according to Prof Wilson and other critics of the new Scottish GP contract - implemented in April this year - is now missing.

One the one hand, the new contract envisions GPs becoming 'expert medical generalists': still the linchpin of the practice, but supported by a team of practice nurses, physiotherapists, and pharmacists based within the surgery but directly employed by the health board, rather than the GP practice.

The idea is that this relieves some of the workload for GPs, allowing them to concentrate only on the patients who really need to see a doctor.

Meanwhile, the responsibility for delivering immunisation would also pass from GPs to a health board team.

But with health board's finances under pressure - Highland is among the boards requiring emergency government loans to break even - there are fears the the model will fail in remote and rural areas, even if practices could attract the extra staff.

"It's now become very clear indeed that particularly in rural areas that health boards simply haven't got the budget to employ these staff," said Prof Wilson. "Then idea of providing immunisation on Barra, for example, sending out a team of people to do it - logistically it's a complete nightmare.

"The consequence of that is that either children don't get immunised in these areas, or general practices are going to be pressured to provide the service for free."

An arguably thornier issue is funding. The new contract's Scottish Workload Allocation Formula (SWAF) calculates each practice's core allocation based on the number of available appointments.

Since remote and rural practices are generally smaller and employ fewer GPs, many saw their allocations slashed - up to 88 per cent in one case. Meanwhile, urban and suburban practices - especially in affluent areas with high elderly populations - saw their allocations increase by up to 63 per cent.

Critics argue that this fails to take into account the additional work rural GPs undertake which their urban colleagues can refer to hospitals.

While the Scottish Government is providing top-ups in the form of income support to those practices losing out under SWAF so that their funding can be maintained at previous levels, the point for critics is that the gulf in earnings between rural and urban GPs is now wider than ever.

Dr Stephen McCabe, a GP in Portree, Skye, whose practice lost around 20 per cent of funding under SWAF said income support "feels like being on the dole".

"It just sends a message that rural practices are second best," said Dr McCabe. "That the only way we can sustain rural practices is effectively to put them on 'benefits'.

"If people choosing between a career in an urban or suburban practice which is having a fairly decent uplift and a rural practice that is basically dependent on handouts to survive, it's not difficult to see there might be a challenge there in recruitment.

"What really irks me is that the BMA knew all this and pressed ahead anyway and when challenged basically said that rural is 'too difficult to deal with'."

The practice has already seen its resources eaten away thanks to the boom in tourism on Skye.

The seven-partner practice is paid extra 'temporary resident' cash based on historic estimates that it would handle 300 additional patients a year due to visitors. In 2017, the actual figure was more than 1000.

"We basically saw 700 people who we weren't actually getting resourced for," said Dr McCabe, who is leaving in September for a new job in Inverness.

He notes that when he applied for the GP post on Skye in 1996 he was one of 40 applicants; this time, there have been none.

Dr David Hogg, chair of the Rural GPs Association Scotland: "Rural practice is in a really difficult position at present with the implementation of the new contract.

"It's frustrating to us - and causing anxiety amongst rural communities - that despite clear opportunities existing in rural GP teams to build and sustain current realistic rural medicine, that the work and innovation of rural practices has been sidelined and devalued as a result of the new contract."

BMA Scotland, who led negotiations on the new contract with the Scottish Government, has repeatedly insisted that it will reduce workload and improve recruitment and retention in general practice.

The trade union has also stressed its other benefits, such as a setting a minimum income for GP partners and shifting responsibility for premises away from GPs, and points out that 71.5% of GPs backed it. 

Dr Alan McDevitt, chair of the BMA’s Scottish GP Committee, said: "The new contract offers income stability and reduced business risk to individuals.

"It protects the funding of every practice in Scotland while addressing the relative underfunding of practice workloads associated with elderly and deprived populations.

“I truly believe that this contract offers something to GP practices in every part of Scotland.”