Historically the rural practitioner in Spain had been working in isolation and was the only person responsible for his own population health. In those times, up to thirty years ago, the lack of diagnostic tools in rural areas and the isolated environments, made the rural doctor mainly responsible for almost all the therapeutic activities of rural populations.
General practitioners working in rural environments had a very wide range of activities and in very few circumstances; patients were referred to a specialist. This issue made the rural doctor to achieve a highly respected status inside rural communities. An important circumstance for that is that who alsrural doctors used to be on call 24 hours a day and 365 days a year.
On the other hand the rural general practitioner became a very isolated professional who was many times increasingly more unaware of the continuous changes and vertiginous improvements in medicine over the last 30 years.
At the same time this was happening, the improvement in infrastructures on rural areas could made unethical for patients not to be able to take advantage of medical new developments.
Some times rural doctors became 'burnt out' and also lost interest in medicine due to the increased emphasis in diagnostic techniques which were in many circumstances unavailable in their own environment. So, the role of the solo rural doctor changed a lot and sometimes the prestige was lost as the workload of rural doctors was being reduced to act only for banal conditions.
All this brought about a feeling of mistrust in the community and also from other medical colleagues. All those issues, and the increasing loss of self esteem of rural doctors made many good doctors to leave rural environments, giving the chance for their positions of work to be covered by newly-qualified practitioners lacking of experience and prestige that were working on sites where no one else wanted to go. For some of these circumstances, 'rural doctor' became a pejorative job in the medical world.
As a result of that, budgets for health care in rural areas became higher and higher as the referral rates increased a lot for specialist care in towns.
As a solution to this problem, the idea of establishing 'team work' in rural areas came about. The idea for this was helping rural doctors to cope with their situation leaving a situation of isolation and sharing basic technology available with other colleagues in rural communities. An important issue on that was to improve relationships among rural practitioners and specialists.
Spain is on of the largest country in Europe as far as extension is concerned, but the population is just 39 million people. About 20% of Spanish population is living in rural areas in small communities of less than 2000 people.
Geographical division of Spain into different autonomies made also possible the distribution of the country in different 'basic health areas', where doctors and nurses (on ratio 1:1) shared the work in a health center. This is how our new Primary Care System was established in the early 80s.
Size of each 'health area' depends on geographical conditions and demographic dispersion. The usual population for a basic health area would be between 5,000 and 25,000 inhabitants.
By law, it should take on longer than 30 minutes to get to the health center by car. Usually, the in the largest village of the rural area the health center is established.
From time to time specialists attend meetings on these centers to train the team in their own specialty. Also, basis diagnostic techniques, such as ECG, x-ray, Spirometer and basic lood test are usually available at the health center.
A normal working day starts at 9am and ends at 5pm. In this period rural doctors have to travel to the villages where patients live. Every small village has its own surgery. Usually there are about 1,500 people on the practitioner list. After the afternoon work, 2 or 3 team members have to stay during the rest of the afternoon and night at the health center on call to guarantee continuity of care of the area population.
This reform that began its development more that 15 years ago, has continued to grow in a progressive way until present times, which includes 90% of the rural doctors.
During these years rural doctors and nurses have achieved not only an important improvement on their working conditions but also important aspects as research in rural areas. This scientific research has revealed: