Fortnight Publications Ltd.

Down on the PharmacyAuthor(s): Mark ConwaySource: Fortnight, No. 301, Supplement: Proceedings of a Conference Organised by theFortnight Educational Trust, Benburb, Co Armagh (Dec., 1991), pp. 16-17Published by: Fortnight Publications Ltd.Stable URL: http://www.jstor.org/stable/25553215 .

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Jfgp*Bft WORKSHOP REPORT 7

Itjfl Rural -iflflflBBBfll' -I'

^m emplovment RURAL PERSPECTIVE8B ^"^ ^ l^~ ^ B^^ "^ ^^^ ^W

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Chair: Avila Kilmurray (Regional Women's Organiser, Amalgamated Transport and General Workers' Union)

THIS WORKSHOP COVERED a wide range of issues concerning rural employment and a

number of development schemes. Many felt

that the problems faced by people in rural areas

were not being taken as seriously as they should be, and that rural employment statistics

were being hidden amongst urban statistics,

and so their importance was lost. An agreement was reached that the problems faced by people in rural areas required special measures due to

their uniqueness. A number of members also voiced the

opinion that current government policies were

largely ineffective in tackling the problem of

rural unemployment. Many felt that

government schemes had been designed largely to suit the government system, rather than

solve the problem. Some felt that government

policies may even have added to the problem. One reason for this ineffectiveness, it was

felt, was that rural development was regarded

by many as merely 'flavour of the month', due

to the availability of grants from Brussels.

Many thought that individuals and

organisations with little or no idea as to a

solution, had jumped on this band-wagon,

basically for financial reasons. This was

regarded as being the 'cheque-book' approach, and of limited effect. A call was made to

encourage local residents of rural areas to

bring forward their own ideas as to what would

be of benefit to their own community. This last point raised the notion of a 'one

stop shop' where such ideas could be developed. Such a shop would be staffed by either rural

co-ordinators or development officers and

provide information and advice on the pit-falls of developing such schemes and gaining

government support and grants. These officers

would be familiar with the procedures involved

and the various departments of government. Co-ordinators and development officers would

also act on behalf of local residents when

negotiating with government departments. The

reasoning behind this was that a recognised official would receive a more sympathetic ear

than a group of local residents, who were

perhaps ignorant of the workings of government and maybe ran the risk of being seen as a

pressure group. The group also stressed the need for long

term development as any changes which may

occur would take many years before having a

noticeable effect on the community. A need

was also expressed to avoid the mistakes of

previous policies and schemes, which had

proved more damaging than beneficial.

Youth featured largely in the discussion

also, as many felt that the key to success was

winning the youth over. If they see a town

with little or no prospects, they are unlikely to

remain living in it, and this depopulation would add significantly to the problems of

rural decline. Development is required which

will stimulate the growth of rural towns to the

degree that they become attractive once more,

and encourage young people to stay, as well

as skilled people to return. In order to achieve

this, long-term local development is required, as the change will take many years to complete. But given time and the right kind of aid and

support changes could be achieved.

Report compiled by DECLAN M. KEENAN, Irish World, Dungannon

Down on the pharmacy

MARK CONWAY is not entirely convinced

by health service reform in the sticks

I WOULD LIKE TO make clear from the

beginning the perspective I am starting from:

firstly, primarily and most importantly we

have to start by setting what the rural context

is, because I think for too long in this world

people, for example in the health service, have

been inclined to say 'Here is our health service

in all its glory, here is what it does, here is what

it is, here is its structure/its layout. Now how

can the rural world fit in to that'.

I think it should be done the other way

round, you should say 'Here is the rural world.

Here is the context. Now what sort of a health

service do we need to fit that?'

What is the rural world in Northern Ireland?

As far as I am concerned, it is made up of

people who are physically and geographically

dispersed. They are usually isolated from

each other, physically isolated, sometimes by a hundred yards, sometimes by miles, but they are isolated. They are virtually all owner/

occupiers, and by that I mean they own the

house they live in, or they own a wee bit of

land, or a big bit of land. That idea of ownership is extremely important-be it the house, be it the

bit of property, be it the land. Because of this,

one of the key features of Northern Ireland's

rural world is the attachment to place-it is

extremely important. The response to the rural world for the last

thirty years can be summed up in one word

centralisation: centralisation in all its forms.

This has been the bane of Northern Ireland for

the last three decades. It first appeared with

the Mathew Plan in 1963, and this more or less

identified Northern Ireland primarily as the

city region of Belfast. There were six key centres-and then the rest. Reading it now, one

gets the impression that 'the rest' was like

those areas on medieval maps designated by ' HERE BE DRAGONS'. This is the area which

has been brilliantly and ironically described as

?'the passive backdrop against which the

important events in the Belfast City Region would take place'.

In the 1990s, as far as health provision goes

with regard to GPs, we are better off here than

the rest ofthe UK: in Northern Ireland, one GP

16

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Concentrating on the greatest needs: a patient in Downshire hospital

deals with on average 1,800 patients; in

England, one GP deals with 1,950 patients. In

Northern Ireland, there is one pharmacy for

every 3,000 patients; in England, there is one

pharmacy for every 5,000 patients. Now, this

indicates that here things are a bit more

decentralised: though I am not sure that is the

case. These figures might simply mean that we

have a whole lot of pharmacies in Belfast and

none anywhere else. However, on the face of

it, looks as if we are not doing too badly as far

as that goes. A few specific steps have been taken to

come to terms with rural Northern Ireland.

The first of these is the Rural Practice Scheme.

What this scheme tries to do is that for any

general practice with 10 per cent or more of its

patients living more than three miles from the

surgery, there are extra payments made to the

people in that practice to accommodate their

extra costs-assuming that they actually go out

and see these people. This is a very laudable strategy: it is the sort

of thing that tackles one ofthe basic problems of Northern Ireland, which is remoteness and

inaccessibility. The only problem with this is

that 75 per cent of GPs qualify for this, including an unspecified number in the Belfast urban

area. So, certainly, it might mean that if you are

a GP in east Belfast and you have a patient in

the west of the city, you will get your money for going out there to see them, and I assume

that is not what the scheme was created to

address. Some refinement is needed..

The small pharmacy scheme is based on the

same principles as the Rural Practice Scheme,

and this time it is for pharmacies which produce less than 1,300 prescriptions per month, and

are at least two miles from another pharmacy.

Again, there is financial assistance available

for those pharmacies-they are literally subsidised. Again, this is good in theory, but

the problem is that apparently only 17

pharmacies qualify for this or have applied for

this, which is only three per cent of pharmacies in Northern Ireland. Once more, there are

refinements needed.

'Dispensing Doctors', like the other two, is

a policy which allows doctors to dispense

drugs to people who would have difficulty in

getting to a pharmacy, again because of the

classic rural problems of access etc. The last

available figures show 33 practices which came

within this remit and they cover 53,000 patients that is quite impressive. Clearly there is a lot of

good work being done there.

The first thing?and I think the most

important thing?is this idea of 'Care In The

Community' People First?the White Paper which covered the NI initiative, states clearly the principle which underpins the whole

system: ?'To enable people to live as full a

life as possible in whatever setting best suits

their needs.'

The first basic principle of community care

is 'flexibility and sensitivity' and by that

government means it is now looking at the

needs of individuals and of their carers. A

range of options would now be offered, and

this is extremely important, especially in the

area of mental health. What this means is that, at last, we can get away from centralisation.

The second principle is 'Fostering

independence'?I know that this seems

extremely Thatcherite. But the reality is in

rural life that fierce independence is a fact.

When we talk about 'fostering independence', there are a lot of rural people's eyes lighting up.

Finally, there is a commitment to

'concentrate on greatest needs'. Again, because

a lot of rural Ireland is extremely deprived and suffers from very high levels of

deprivation, I think this idea is grist to the mill as far as the rural constituency is

concerned.

At long last in the health area, we are

getting to a position where the people who

deliver health care are saying 'If you have a

problem out there, we will bring our solution

out to you'. One of the big complaints we have all had

is the lack of integration between government and rural areas. We might have a great planning

service, we might have a great housing

executive, we might have a great education

and library board?but they are all great on

their own. They are all working independently and one might be doing one thing and another

doing something JP^IHttfl^fe) which is contrary to 'I Jll^B^^^fl

The health service .1^iHflH > reforms have started I flfljl to open up and have

^ MH1 allowed us to spread ^^^^^^^BlB' out into rural areas. I ^^^B^jp think that the

A^fi^I encouragement of / ; / fl

nursing homes is HRAL

PEPSPECTlvE,flj

generally beneficial for two reasons. In our

area, 16 elderly people are now able to live in

the middle of a rural environment whereas

before the options open to them were to go either to the only state home in Cookstown or

to geriatric wards in Magherafelt or

Dungannon. The scheme is also providing

jobs there, and jobs for a section of the rural

community which has been badly catered for

up until now-women.

Like everybody else, of course, I have

worries about the NHS. Will we be given the resources we need to match the rhetoric? Will

they be able to do all these wonderful things they are planning to? For example, in our unit,

we have 700 in-patients who suffer from mental

illness. Our intention would be to have the vast

majority of those people back in the community as soon as possible. Our unit has a budget of

around about ?18 million?we spend almost

95 per cent of that on 700 in-patients and the

other five per cent goes to 10,000 out-patients. Now can we redress that balance? That is in

management, work and organisational terms.

'Care in the Community' is all about getting

people out of institutions and back into the

community. In rural areas, in particular, we

must have worries about the housing supply

problem. Do we have the housing supply to

meet the demands of care in the community? I am doubtful that we in the health service

actually have the information systems to be

able to implement care in the community initiative. Research in England into community

mental health centres has shown that people who were previously being catered for very well in hospitals were now not coming forward

to the centres.

Finally, within the health service, the culture

we are faced with is one of 'internal market'.

There are the two awful words that appear on

many documents: 'income generation'. For

example, it is in my unit's best interest to

generate as much income as possible from

elsewhere-because the more income we can

get into our unit, the more we can spend on

services. Therefore, services will be sold to

anyone who will buy them.

My big worry is that, in a few years' time,

people may not be prepared to stand up and say what they are doing in their unit: a reluctance

to give free information. If this happens in

rural areas, it is the rural people who will suffer

and I am extremely wary of this.

For too long, providers in rural areas,

whether health boards or other statutory

agencies, have been inclined to go into the area

were the light is?where it is easier to do the

job, rather than get to the place were the job has

to be done.

MARK CONWAY is Business

Manager with the Western Health and Social Services Board.

17

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