THE Lochgilphead Practice has written to NHS Argyll and Clyde and to the Scottish health minister expressing our support for the Clinical Strategy. We believe it is the only way to sustain and improve the quality of services in Argyll and Clyde and especially in mid-Argyll. It gives a refreshingly honest and blunt assessment of the frighteningly precarious position the service is in, and describes the rather difficult, but only feasible way out of the hole we are in.

How bad is it? Very.

Demographics: The birthrate has fallen significantly and life expectancy has increased dramatically. This is uncharted territory. How does a modern first-world state with these demographics actually work?

Sub-specialisation: For example, from general orthopaedic surgeons has evolved hand surgeons, surgeons who only do work on the knee joint. They get a lot of experience in a very specific area and so they get better results. The downside of this is that they are lost outside their area of expertise and so must work in teams in very large units. This creates a strong centralising force.

European Working Directive and new deal for junior doctors (maximum of 56 hours per week now and 48 hours per week later): Hospitals will need extremely more consultants and junior doctors to see the same number of patients. This is a very expensive way for lots of junior doctors to get not very much experience; even if there were enough junior doctors to go round, which there are not. Of course, a big hospital can get round this on-call out-of-hours by having cross-cover of junior doctors between specialities. This is a strong centralising force.

Trends in gender of medical workforce: Girls are cleverer than boys are and over the past 20 years the percentage of female graduates has increased. However, female doctors are much more likely to seek part-time employment, so of course you have to produce many more doctors. Unfortunately we didn't do that.

Litigation: In the US the doctors' response to being sued all the time is to put their prices up. This enables them to afford to be sued regularly and everyone is happy. Unfortunately, in the UK we are not allowed to do this. So we came up with a better plan. If making decisions gets you sued, don't make any decisions. Just refer everything on and on and on, so all being well eventually there will be so many doctors making so few decisions, it will be impossible to blame any one person for anything. The catch is you really can't afford that option.

Democracy: This is obviously good but one downside is that the NHS is a very big ship and it takes a lot longer than one electoral cycle to change direction in any meaningful way.

The Royal College: This body exercises enormous power over the NHS by controlling the training requirements for specialist doctors and therefore the way training money flows, and whether anyone will work in your hospital or not. Big teaching hospitals can afford the libraries, training facilities, tutors, etc, necessary to be part of this club. The catch here is that service provision isn't the college's problem. Many years ago the Royal College of Obstetricians withdrew training accreditation for the Vale of Leven Hospital, with immediate financial and recruitment implications. A slow steady chain of events ensues and 10 years down the line even offering to pay (pounds) 60 an hour won't entice a paediatrician locum to work there and the service implodes.

The new GMS contract (out of hours): This kicks in in October, the mother of all sticking plasters. This enables GPs to walk out of their on-call commitments completely. You will be relieved to know that the penalty for this will easily be made up by meeting certain ''targets''. Meanwhile, you have the option to opt in again to on-call sessions in a primary care treatment centre and for (pounds) 75 an hour you can sort out all the ear infections and tummy bugs while next door for a tenth of that hourly rate, the emergency nurse practitioner helps sort out the road traffic accident and the heart attacks. No, we can't work that one out either.

The Clinical Strategy is controversial as it doesn't duck any of these issues and is a major departure from how things have been done in the past. It acknowledges the inevitable centralising influences and develops one large acute centre which by the economics of scale will have all the training facilities, equipment, staffing and cross- cover for a modern training hospital.

This is counter-balanced by developing intermediate care, keeping all the care that can sustainably be provided locally, in a network of community hospitals. Most acute as well as long-term chronic disease management

will be provided locally by a multi-disciplinary team of extended-role GPs, allied health professionals, emergency nurse practitioners and nurse specialists.

Central to the success of this is persuading enough GPs to become involved, and in the future recruiting medical students on to tailor-made training programmes. There certainly is an appetite for this kind of work among medical students who have attachments with our practice, so there is cause for some optimism for the longer term.

Dr A D Ward, Dr M J Simpson, Dr C S Mackie, Dr J K Phillips, Dr R D Sloan,

The Surgery, Lochgilphead, Argyll.