Summary of the impact

Dr Annie Tindley's research on long-term changes in welfare in the Highlands and Islands during the later nineteenth-century and the Dewar Commission of 1912 supported the formation of the Dewar Centenary Group, a pressure group which included historians, Highland GPs, members of the Royal College of General Practitioners, and other stakeholders. The Group employed the historical example of the Dewar Commission to lobby the Scottish Government and NHS Highland to bring about key targeted reforms in medical training and healthcare policy. These include new GP benchmark tests and an innovative programme of rural training fellowships in general practice.

Underpinning research

Historical and archival work on poverty and welfare in the Scottish Highlands and Islands between 1845 and 1950 carried out by Tindley (Lecturer and SL in History 2006-13) highlighted the role of landowners, clergy, schoolmasters and the state in the relief of poverty and ill-health. By the early twentieth century there was consensus among both local and central government that the system of private practice in healthcare provision had largely failed the population living in the Highland region. A majority of people in the region were either too poor to pay for private medical care or not poor enough to qualify for available medical relief. Crofting and other poor families could obtain little healthcare. Private and charitable efforts were largely ineffectual in the region and the government was obliged to take exceptional measures. In 1912, a royal commission was appointed under Sir John Dewar (MP for Inverness-shire) and by 1913, in a show of remarkable political consensus, the Highlands and Islands Medical Service was established.

Originating research by Tindley (2011) focused on poverty and health amongst crofters and other poor families on the Sutherland estates during the second half of the nineteenth century. The research examined how the Highland Famine, reforms to the Scottish Poor Law, and charitable, medical club and landowner provision affected remote communities. Tindley's subsequent research and public engagements were supported by a series of grants from the Wellcome Trust. A community workshop in Ballachulish (2011) exchanged key research findings with stakeholders and discussed how Highland communities wished to shape future research in the field. The Dewar Centenary Group was created out of this engagement with a remit to use the historical example of the Dewar Commission to promote change in the professional and political agenda affecting Highland health. The engagement with professionals and stakeholders resulted in an article by Tindley and Kehoe in the Journal of Scottish Historical Studies (2012).

Tindley's research on the long-term problems of poverty and ill health in the Scottish Highlands and Islands and her work with the Dewar Centenary Group showed that the Highlands had always experienced chronic and particular challenges in relation to healthcare outcomes. These were determined largely by the region's topography, demography and socio-cultural composition. The relevance of the 1912 report to current health policy in the Highlands and Islands was stressed in open discussion groups, policy meetings and later in official documents from NHS Highland and the Scottish Parliament, where the group's findings received cross-party political support and debate. The research and engagement brought to the attention of policy makers the importance of historic factors relating to rural and remote healthcare in the region and led directly to changes in policy by the Scottish Government and to a re-design of rural health services with regard to the recruitment and training of GPs.

References to the research

Tindley, A., Wellcome Trust Research Expenses Grant. `Health and health care in the Scottish Highlands, 1850-1950', WT085430AIA (2008) £1,515. [Research Grant]

Tindley, A., Wellcome Trust Research Expenses Grant. `Dr Lachlan Grant of Ballachulish: the unintended roles of the medical practitioner in the Scottish Highlands, 1871-1945': WT095208MA (2011) £3,600. [Research Grant]

Tindley, A. (PI) and The Royal College of General Practitioners (RCGP), Wellcome Trust People Award. `The Dewar Commission and the Highlands and Islands Medical Service: 100 years of state health services', Wellcome Trust People Award: WT099803AIA (2012). £5,200. [Research Grant]

Details of the impact

Summary, including nature and extent
Tindley's research and engagement activities revealed that a private market model of healthcare had largely failed the Highlands and Islands region in the late-nineteenth and early twentieth centuries and that many of the historic problems were still relevant. The Dewar Centenary Group successfully used the momentum of the centenary years of 2012 and 2013 to lobby the Scottish government and NHS Highland to re-design healthcare and training processes.

How the research led to the impact
The historical work on the Dewar Centenary Group was the subject of a debate in the Scottish Parliament (10.5.12 - source 6 below). The Group was thanked by speakers and congratulated by Nicola Sturgeon (Cabinet Secretary). The "inspirational principles" of the Dewar Report were highlighted, as was "the right of every individual in society to local, accessible, healthcare; the responsibility of the state to provide healthcare to every individual, regardless of ability to pay; and the importance of delivering good quality, well-organised, and satisfactory health services." Ms Sturgeon spoke directly to the Group seated in the public gallery throughout the debate. The MSP for Skye, Lochaber and Badenoch later chaired a meeting (7.9.12) where he stated that the Dewar Group's project had led to a "willingness to think differently." The Chair of NHS Highland Board attended and stated "We have many vacancies in remote and rural areas and we know the way we structure practices needs to change in order to make these jobs more attractive and to meet the demands of modern care." It was agreed "to put a proposal to the Cabinet Secretary, Alex Neil, that there should be a specific piece of work focusing on remote and rural health and care services, to build on the legacy of Dewar." (sources 5 and 7 below). This led to the establishment of new Rural Training Fellowships in General Practice (source 8). An NHS Education for Scotland (NES) Board Paper (source 9) noted: "The `Dewar group' ... gained significant media and political interest recently in proposing not only that there is important learning in the way the Dewar Committee carried out its work in the early 20th century, but also that the resulting recommendations remain relevant" (p. 4)

Details of beneficiaries

1. Medical professionals and general practitioners in remote and rural Scotland.
Medical staff and general practitioners in remote and rural areas benefited through an improved programme of continuing professional development. The research raised awareness of these issues amongst NHS Highland, the Rural Practitioners Association of Scotland, the RCGP (Scotland) and NES and promoted a dialogue within and between the professions and government to attempt to resolve problems of remote and rural healthcare. A programme of Rural Training Fellowships in General Practice was made available. An agreement with the Scottish Government's Director for Health and Health Improvement led to the implementation of the Group's benchmark model of `Four Dewar Tests' to support rural practice. These consisted of (1) The Mind Map (2) Benchmark Testing (3) Environmental Assessment and (4) the `Dr Who' Test. The tests currently form the basis of good practice in remote and rural areas under NHS Highland (source 2).

2. Stakeholders and consumers of healthcare in the Highlands and Islands.
The Group was able to operate as an independent broker between communities, politicians and health administrators and disseminated the Dewar model widely amongst Highland communities. A workshop (`An Afternoon with Dewar') was held in the Highland Archive Centre (23.5.12) to launch the Dewar Report Centenary Exhibition (source 3) and moved subsequently to Lochaber Archive Centre (Jun 2012) and Inverness Museum and Art Gallery (Jul 2012), having been earlier previewed in a reception in the Scottish Parliament (10.5.12) and reported on BBC Radio Scotland (9.6.12).

3. Politicians and other policy makers in Scotland.
The Group brought to legislators hitherto unknown information about the long-term development of the NHS in Scotland (source 6), providing a model for policy action. A dedicated policy workshop was hosted by the Group in Fort William (Apr 2013) to which senior NHS executives, general practitioners, paramedics and midwives discussed the future of health policy in the light of the Group's key outcomes. A further policy workshop was also held in Inverness in Apr 2013 which debated the core outcomes of the group. A summary of what was learned can be found at http://www.ruralgp.com/wp/2013/05/dewar-2013-what-have-we-learned/.

Details of nature of impact
Cuts to services and difficulties with the recruitment and retention of medical staff are of the utmost concern to remote and rural communities. The work of Tindley and the Dewar Centenary Group directly informed Highland health policy and led to major changes in policy and practice which benefited both healthcare professionals and stakeholders. Evidence of impact exists in the records of exhibitions and conferences held, in the Scottish parliamentary record, media reports, and various reports on the RuralGP.com website.

Dates when impact occurred
May 2012 to July 2013

Sources to corroborate the impact

1. The Dewar 2012 web-site at RuralGP.com:
   http://www.ruralgp.com/wp/dewar2012/
2. Outcomes of the Dewar Centenary Group including the "Four Dewar Tests" can be found here:
   http://www.ruralgp.com/wp/2013/10/dewar-2013-outcomes/
3. `An Afternoon with Dewar', at the Highland Archive (23.5.12)
   http://www.ruralgp.com/wp/dewar2012/dewar-conference/
4. The `Dewar 2013' conference and clips from the web-cast
   http://www.ruralgp.com/wp/2013/04/success-at-dewar-2013-conference/
   http://www.ruralgp.com/wp/dewar2012/dewar-2013-webcast/
5. Details of the reception of the Dewar model by the Cabinet Secretary for Health, and the Dewar Group's statement as to the fragility of remote and rural healthcare can be found at:
   http://www.nhshighland.scot.nhs.uk/News/Pages/HighlanddoctorstoapproachnewCabinetSecretaryonremoteandruralcareservices.aspx
6. Scottish parliamentary motion and debate, May 2012 (text version)
   http://www.scottish.parliament.uk/S4_BusinessTeam/pm-v1n71-S4.pdf
   (televised version)
   http://davethompsonmsp.org/index.php?option=com_content&task=view&id=381&Itemid=14
7. Newspaper article (Herald Scotland, 7.11.2012) reporting success of the Dewar Centenary Group in prompting policy review.
   http://www.heraldscotland.com/news/health/step-forward-in-plans-to-overhaul-rural-health-care.19346292
8. Details of the rural GP fellowship scheme can be found at:
   http://www.nes.scot.nhs.uk/education-and-training/by-discipline/medicine/careers-and-recruitment/scottish-general-practice-training/gp-fellowships.aspx
9. NHS Education for Scotland (NES) Board Paper on Remote and Rural Healthcare (2013).
10. Joint letter from general practitioners from the Royal College of General Practitioners, North Scotland Faculty, highlighting the underpinning importance of Tindley's research and her central role in the Group.