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Rheumatology is understaffed and under-resourced, with patients facing the consequences. Dr Rosemary Hollick of NHS Grampian covers an area the size of Belgium, with a population of c.1 million. She's looking at innovative solutions to halt the postcode lottery of care, and tells us here about taking services on the road, initiatives to retain staff and designing services that create equitable access to care for all.

What's your area of interest?

I’m an academic rheumatologist based at the Aberdeen Centre for Arthritis and Musculoskeletal Health. I spend half my time on clinical work and the other half researching how we can design and deliver equitable access to care for people with rheumatic conditions.

I’m passionate about addressing geographical inequalities and access to care. Adequate staff and resources are a key part of that. Our rheumatology workforce has a huge area to cover in Grampian, so we’re always adapting and working to find ways to make the best use of our limited resources.

What impact has COVID-19 had?

As we’re remobilising, all rheumatology services are in a unique place, which gives us a real opportunity to make changes, and importantly evaluate the impact of these changes on care. Rheumatology services look after people with complex conditions and high care needs. We work hard to keep them out of hospital, and we need the resources to do that. Locally, we’ve been looking at new models of working to provide more equitable access to care.

What are some of the answers to the workforce issue?

There are many reasons why we’re in this position – our response must be multi-pronged. For a start, we need to be promoting careers in rheumatology. For doctors, if they don’t get a good taster at medical school, they won’t choose rheumatology. In Grampian, as an outpatient-based specialty we don’t have a ward, so nurses don’t get the exposure to rheumatology like they do in other specialties.

Our nursing team pushed hard to get student nurses rotated through our rheumatology service; it was suspended when COVID-19 happened, but it provided a good experience and a potential opportunity to bring new people in. We did the same in our osteoporosis service, enabling trainee radiographers to rotate through the bone density scanning service.

It would be great if access to initiatives such as the Glasgow Specialist Nurse Training Programme could be widened out across Scotland, and potentially to other healthcare professionals. This one-year programme recruits nurses on a secondment basis and includes both clinical and academic training.

How do you retain people?

Using remote consultations means you can have staff based anywhere. We’ve been using them  for a long time to support the delivery of rheumatology services to the islands of Orkney and Shetland. NHS Highlands has a rheumatologist based in Alaska!

It’s also about thinking outside the box. Providing healthcare for people in remote and rural areas is particularly challenging because of difficulties recruiting and retaining healthcare staff. I’m currently involved in a study looking at how we can improve the recruitment and retention of doctors working in rural areas.

What’s coming out of that is that you’re not just selling the job, you’re selling the community. There have been some successful initiatives where the community as a whole has made a concerted effort to recruit healthcare professionals to their area. When someone moves to a new job, they often bring family with them, and more needs to be done to support their partners to move with them.

If you’re looking to fill a vacant post and persuade someone to move, think about the possibility of creating or filling a role for their partner too if they are in the medical profession. That way people can move as a family. You’re taking services out on the road to each older and frailer patients.

Some of our remote patients have to take a 500-mile round trip from the islands to have a bone density scan, so we set up a mobile bone density service to cover rural Aberdeenshire and the islands, working across three health boards. Two radiographers go out in our ‘bone bus’ and deliver not just a scan but a comprehensive assessment on the doorstep. We’ve been doing this since 2014 and it’s been successful in reaching older and frailer patients at risk of fracture who we were missing before.

However, the structure and organisation of the NHS doesn’t make it easy to set up and sustain a service across three health boards. In order to create innovative solutions, there has to be buy-in and support and local, regional and national level to facilitate this.

What’s your advice to others around developing services?

One size doesn’t fit all. Every area is different, so focus on what matters to meet the needs of local people. Areas can have similar issues, for example, digital exclusion, but with very different underlying problems, and therefore solutions. As services remobilise and reconfigure post-COVID-19, there's a unique opportunity to take a fresh approach. Look around you and see what others are doing and learn from them.

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