The market town of Insch sits in a sheltered howe in the rural heart of Aberdeenshire. It is the smallest settlement having its own station on the Aberdeen-Inverness railway line, and has expanded greatly in recent years, while losing a number of shops and all three of its banks. What was once a junior secondary school is now primary only, but bursting at the seams due to the large number of new houses that have been built.
 
Just along from the school lies the pride and joy of the community, Insch and District War Memorial Hospital. After World War One, the villagers decided that rather than simply erect a war memorial to the fallen of the six parishes that surround it, they would build a hospital. The driving force behind this was an innovative local doctor, George Mitchell, one of a long-established medical family in the area. With extensive fundraising, his vision soon became reality, and the new facility opened in 1922.
 
The hospital has continuously served the surrounding extended community for almost 100 years, offering a wide range of services, including at one time relatively complex surgery such as appendectomies, and, until about 20 years ago, a maternity unit. Over the decades it has evolved, and the large site now includes a health centre housing a GP practice that still provides the hospital’s medical director. The practice maintains a tradition of innovation and integrated working with social services and volunteer groups.
 
The community self-help operating model long-established at Insch would appear to offer a viable solution to the major challenges facing future health and social care provision. Given the impact on services demand by an increasingly elderly population, it would seem that Insch Hospital was well placed to ease the strain, and provide a safe clinical environment in reassuring surroundings. The hospital was closed in March this year, ostensibly due to the coronavirus pandemic. Subsequently, it emerged that this was intended to be permanent.
 
In a crisis situation, quick action is likely to be required, and normal procedures, such as consultation, abandoned. The trustees of a local charity, the highly active Friends of Insch Hospital and Community, were told it was about to happen at very short notice, and asked not to go public on it. As is inevitable, especially in small communities, the news leached out anyway. It has also emerged that Aberdeenshire Health and Social Care Partnership (AHSCP) are cutting community hospital beds across the shire from 230 to 169. There has been no public consultation on this.
 
Any objective assessment of the performance of the joint boards set up several years ago between health authorities and councils to integrate the running of health with social care provision would indicate general failure. The whole process has given rise to a new layer of management and a culture of budget hoarding. Creation of these boards, which function with little public scrutiny, was an acknowledgment of the problem but they are proving to be an ineffective solution. Their approach to the hospital closure in Insch can only be described as one of stealth.
 
The community has spontaneously challenged this, with one initiative being the erection of roadside WW1 soldier silhouettes before Remembrance Sunday with small posters alongside stating: 'Built in 1922 in my memory'. The memorial inside the hospital entrance commemorates many Gordon Highlanders, and former members of the regiment have expressed their wholehearted support for the hospital's retention as a living reminder of their sacrifice. Media attention extracted a public statement from the AHSCP which provided a little more information, but raised more questions about their plans.
 
The Beveridge Report published in 1942, in the midst of war, laid the foundations for the NHS, but that was only created in 1948, after the National Health Service Act of 1946. The proposals had been debated and subject to parliamentary scrutiny over four years, with a further two years for implementation. Interestingly, Beveridge wanted the NHS run through local health centres and administered regionally, whereas Aneurin Bevan made it state run following Labour winning the 1945 'khaki' election. The consequence of this is that the only effective means of independently challenging management decisions is through parliamentarians. NHS Scotland is a separate institution, with control currently fully devolved to Holyrood.
 
In another corner of Scotland, Galloway Community Hospital Action Group recently lodged a petition to the Scottish Parliament seeking the creation of 'an agency to ensure that health boards offer "fair" and "reasonable" management of rural and remote healthcare issues'. The background information submitted with it cites 'centralisation of complex services' and the occurrence of 'structural inequality'. It refers to the Scottish Government placing NHS Trusts within health boards in 2004, thus giving more powers to management, and relentless centralisation following that.
 
Rural dwellers may live in a healthier environment, but apparently one that is increasingly unsafe in terms of healthcare compared with their urban counterparts. In light of demographic changes, AHSCP policy is 'Home First' to reduce hospital bed occupancy. The most recent term they have coined is the 'Frailty Pathway', simply a period of intensively supported home care, something that has actually been happening for decades. The Insch practice has a history of developing healthcare initiatives which have included trialling keeping ill folk in their homes, termed the 'virtual ward', and assessing its effectiveness. Professional advice is that this simply will not work in many instances, as nursing cover cannot possibly be provided 24/7. In closing community beds now, AHSCP are putting the cart before the horse in not having a realistic, functioning, proven alternative in place.
 
In response to a comment that NHS/AHSCP policy appears to change direction every five years, one GP said that policy may change, but 'what we actually do remains the same'. To do that adequately they need local GP hospital beds, not ones 12 miles away from their surgery in opposite directions. In looking after the healthcare needs of a diverse and expanding community, they have plenty to keep them busy locally rather than spend time travelling between hospitals 24 miles apart to see their patients.
 
There needs to be an immediate moratorium on community hospital bed closures, regardless of the purported basis for these. The Insch Hospital closure is now being represented as 'mothballing', along with a blanket refusal to carry out any essential maintenance work or improvements despite the opportunity temporary closure offers. Having funded and built the facility in 1922, trustees ran it successfully for the following 26 years until nationalisation. Did Bevan get the formation of the NHS, with its centralised structure, fundamentally wrong?

Photo at top of page by Bryan Stuart

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