On 23 February 2023 the House of Lords is scheduled to consider the following question for short debate:

Baroness McIntosh of Pickering (Conservative) to ask His Majesty’s Government what plans they have for the delivery of health care in rural areas.

1. What challenges does the delivery of health care face in rural areas?

A significant proportion of England’s population lives in rural areas. In mid-2020 population estimates, the government estimated that 46.9 million people in England (82.9%) lived in urban areas and 9.7 million people (17.1%) lived in rural areas. Of those living in rural areas 5.2 million lived in ‘rural town and fringe areas’ and 4.4 million in ‘rural village and hamlet’ areas. Within rural areas, 0.5 million people lived in ‘sparse settings’. Rural health statistics published by the Department for Environment, Food and Rural Affairs (Defra), state that average life expectancy is highest in ‘mainly rural’ areas and that “on average, people born in ‘mainly rural’ areas in 2018–20 are expected to live two and a half years longer than people born in ‘urban with minor conurbation’ areas”.

Speaking in a debate in the House of Lords on ‘Primary and community care: Improving patient outcomes’ on 8 September 2022, Baroness McIntosh argued that “there is a rural and urban aspect to health policies, which is often overlooked”. She cited specific challenges faced by rural areas, for example that “poor broadband and mobile signals hamper delivery of the service and make remote consultations almost impossible”.

These challenges have also been identified by several other organisations and observers, including the House of Lords Select Committee on the Rural Economy, which considered rural health services as part of its 2019 inquiry into the rural economy. Amongst its findings, the committee’s report, ‘Time for a strategy for the rural economy’, published on 27 April 2019, said challenges included:

  • Older populations. The committee found that the average age of the population in rural areas was nearly six years higher than that of urban areas. A quarter (24.5%) of the rural population was aged over 65 and the committee stated that “statistics also indicate that the number of over-65s is increasing much more sharply in rural areas (37% between 2001 and 2015) than in urban areas (17%)”. The committee said that the older population in rural areas presented a specific challenge to the delivery of health services and that it “inevitably” did so “owing to greater incidences of chronic illness, disability and mortality”.
  • Funding challenges. The committee stated that the Rural Services Network (a special interest group of the Local Government Association) said that rural areas received slightly less funding per resident under NHS allocations to clinical commissioning groups (CCGs), despite their older populations. The committee said funding was also raised on a visit to Herefordshire. It was told by “local leaders and business groups” that a “one size fits all” approach to health care did not work for local areas and that “the local NHS trust was in considerable debt, through inadequate funding rather than poor financial management”. Since the 2019 report, CCGs have been replaced by integrated care systems (ICSs) under the Health and Care Act 2022. In a November 2022 written answer, the government stated that integrated care boards (ICBs) (which form part of ICSs) are responsible for making appropriate provisions to meet the health and care needs of local populations. It has said that the core ICB allocations formula is adjusted to allow for differences in the costs of providing health care between rural and urban areas.
  • Access to services. The committee said this was a particular challenge, with the remoteness of some populations making access to health services more difficult. The committee stated that whilst community transport schemes did exist, “they are not able to respond at short notice to assist all patients in need of transport, meaning many people are dependent on taxis”.
  • Poor connectivity. The committee said that digital services could address some challenges in rural health care provision. The committee cited evidence from the District Councils’ Network, which said “the digitisation of public services offers an important opportunity to support sustainable local services in more remote district council settings and overcome the barriers of sparsity”. However, it also said benefits were dependent on having the correct digital infrastructure in place. The District Councils’ Network said that whilst the government was planning to invest £4.2bn in digital health, these services would be more difficult to use in rural areas because of poor connectivity.
  • Issues of isolation and loneliness. The committee identified isolation, loneliness and “associated physical and mental health challenges” as key issues in rural communities. It said it was particularly important that policy solutions were “rurally oriented” to take account of sparsely populated locations.

A resolution submitted by the Royal College of Nursing’s (RCN) North Yorkshire branch at its 2019 congress set out rural health challenges, many of which reflected the findings of the House of Lords Select Committee on the Rural Economy, as follows:

Rural health challenges are well documented. People living in rural communities have issues relating to accessing health and social care, general practice, domiciliary care, medicines, shopping and transport. The response times of health care staff are longer and domiciliary care may be limited. Access to physical activities and leisure services can also be limited, which makes it much harder for health professionals to support people to take preventative measures in regard to their health. In addition, the effects of loneliness and poverty have significant impacts on health. Nursing staff working in rural settings have also reported challenges around access to technology and broadband, and the implications of this on patient care.

In addition, the Nuffield Trust’s briefing ‘Rural, remote and at risk: Why rural health services face a steep climb to recovery from Covid-19’, published in December 2020, argued the health care service problems faced in rural areas had been made worse by the Covid-19 pandemic:

Rural and remote areas experienced problems that differentiate them from their more urban counterparts even before the Covid-19 pandemic. However, the pandemic has both exacerbated some of these challenges, as well as thrown up new ones.

The Nuffield Trust stated that “it had long been recognised” that rural and remote services faced particular challenges for a range of reasons, including:

  • workforce challenges, including recruitment and retention difficulties and higher overall staff costs
  • larger distances leading to higher travel costs and unproductive time spent by staff having to travel
  • challenges related to size, such as difficulties in realising economies of scale
  • access to certain resources being more expensive or difficult, such as telecommunications, training and consultancy

The Nuffield Trust said that quantifying the impact of these issues was challenging. It argued that some health services may not be able to provide the same services as others:

If insufficient adjustment or compensation is made for the unavoidable costs involved, it is likely that some health services will not be able to afford to provide their population with the same access to, and quality of, care that others do.

The All Party Parliamentary Group on Rural Health and Care published a ‘Parliamentary inquiry’ on the issue of health care in rural areas in February 2022. The report made recommendations under different areas, including building an understanding of the “distinctive health and care needs of rural areas” and delivering “services that are suited to the specific needs of rural places”.

Specific recommendations included:

  • Rurality and its infrastructure must be redefined to allow a better understanding of how it impinges on health outcomes.
  • “Rural health proof” housing, transport and technology policy.
  • With the Royal Colleges and NHS England, review the match between the existing health and care professional structure and the skill needs of today to meet health and care demands with a view to creating a wider variety/diversity of health and care professionals with shorter training courses.
  • Empower the community and voluntary sector to own prevention and wellbeing.

The OECD has also considered the delivery of health services in rural areas amongst its member countries in its March 2021 report ‘Delivering quality education and health care to all’. The OECD said that rural health was a “key component” of high-performing health systems. It noted this was “not only because rural regions host around 30% of the OECD population but also because inequalities in provision are more likely to happen in rural places”. It said that tackling the challenges of rural health care delivery required understanding of both health issues and the structure of health systems:

Implementing effective policy relies not only on understanding the health issues facing rural populations but also how rural health fits new health systems organisation and measurement trends. The trade-offs between quality, access and costs are inseparable from the spatial organisation of health systems and call for a territorial approach to the management of health care provision.

The OECD argued that ‘place-based’ approaches to improving health system performance could help adapt to the greater, and increasing, demand for health care in rural areas:

Place-based policies focusing for instance on improving primary care in areas with low accessibility can have positive trickle down effects on the health system through reduced needs for more complex and costly interventions. From a national perspective, while investments in rural health must be aligned with potentially competing health system goals, place-based policies can not only help reducing inequalities, but can also represent cost savings for the health system at large.

2. What is the government’s policy on rural health care?

The UK government is looking at the issue of health care in rural areas as part of its wider levelling up agenda. The ‘Levelling up’ white paper, published in February 2022, was set out around 12 ‘missions’, including health.

In March 2021, the Department for Environment, Food and Rural Affairs (Defra) published its report ‘Rural proofing in England 2020’. The term ‘rural proofing’ describes when policy makers and analysts in government consider how to achieve their policy objectives in rural areas. The report was published in response to recommendations made in the House of Lords Select Committee on the Rural Economy’s report, ‘Time for a strategy for the rural economy’. The government’s formal response to the committee was published on 2 July 2019 (Ofcom also responded on 25 July 2019).

The foreword to ‘Rural proofing in England 2020’ said that it aimed to “improve transparency and accountability by illustrating how rural proofing is planned and coordinated across government, and by demonstrating the various innovative ways in which rural needs are being successfully identified and met”.

Defra’s second report on rural proofing, ‘Delivering for rural England’, was published on 3 September 2022. Part of the report looked at the delivery of health care services in rural areas, including in the context of the government’s levelling up polices.

The government’s levelling up mission for health is that:

By 2030, the gap in healthy life expectancy (HLE) between local areas where it is highest and lowest will have narrowed, and by 2035 HLE will rise by five years.

Defra’s report ‘Delivering for rural England’ sets out the ‘rural position’ as follows, which reflects the findings of other organisations:

  • In 2018 in England, the average life expectancy was 79.6 years for men and 83.2 years for women. Life expectancy is slightly higher in rural than in urban areas.
  • The rural population is older than the urban population and its average age is increasing faster with implications for health and social care needs.
  • Distance can mean that some health services are less accessible. The average minimum travel time to a hospital is approximately one hour in rural areas, compared with approximately half an hour in urban areas.
  • Delivering community-based care can be more expensive in more sparsely populated rural areas.
  • It can be more difficult to recruit health care professionals to rural areas.

The report, published in September 2022, noted that the government had a number of measures in place to address challenges of delivering health care in a rural setting:

  • Pharmacy access scheme. This £20mn scheme provides funding to support pharmacies to stay open to provide accessible primary care. The government has said that there are 1,230 rural pharmacies in England and 46% of these qualify for support under the scheme. The scheme will remain in place “until at least the end of 2023”.
  • NHS community pharmacist consultation service. This scheme, launched by NHS England in October 2019, enables patients to get same-day appointments with a community pharmacist for minor illnesses or the urgent supply of a regular medicine. The government has said that this improves access to services and provides convenient treatment closer to a patient’s home. The service includes referrals from general practice and the government has said that it is looking at whether the approach could be further expanded.
  • Targeted enhanced recruitment scheme. This scheme funds a £20,000 salary supplement to encourage trainee GPs to work in areas where training places have been unfilled for a number of years. The government has said this includes rural communities. The government has been increasing the number of places on the scheme. There were 550 in 2021 and ‘Delivering for rural England’ said the government would fund 800 places in 2022. The government has also said that trainees on the scheme “usually stay after training, helping to sustain the GP workforce in rural areas”.

‘Delivering for rural England’ also considered health care in rural areas as it is impacted by other factors. On transport, Defra said that rural areas typically suffered from poor connectivity. It said that the Department for Transport’s forthcoming ‘Future of transport: Rural strategy’ would “guide local authorities, transport operators, and the private sector towards a future transport which maximises the benefits of new technologies and business models for rural and remote communities”. The report said this would make it easier for people to access health care. A written answer given on 9 February 2023 said that the ‘Future of transport: Rural strategy’ was “soon to be published”.

In a November 2022 written answer, the government stated that integrated care boards (ICBs) are responsible for making appropriate provisions to meet the health and care needs of local populations. It has said that the core ICB allocations formula is adjusted to allow for differences in the costs of providing health care between rural and urban areas.

2.1 Responses to Defra’s ‘Delivering for rural England’

The Rural Services Network’s (RSN) report ‘Rural lens review’, published in September 2022, provides its response to Defra’s ‘Delivering for rural England’ report.

In its ‘Delivering for rural England’ report, the government had said that an additional benefit of its ‘targeted enhanced recruitment scheme’ was that “trainees who are attracted to these areas by the scheme usually stay after training, helping to sustain the GP workforce in rural areas”. The RSN said that “some data as to actual numbers of trainees staying in rural areas (compared to urban) would be helpful”.

The RSN was also critical of what it described as a lack of discussion about social care in Defra’s report. Referencing the government’s proposals for a care cap and arranging care for self-funders, the RSN said “rural proofing of these proposals and the funding support from government to councils is a huge concern for rural social care authorities”.

On the wider issue of funding for rural residents, the RSN argued that rural local authorities were not getting enough funding. Referencing the 2022–23 local government finance settlement, the RSN stated that:

  • Rural areas in 22/23 will still receive some 37% (£105) per head in settlement funding assessment grant less than their urban counterparts.
  • Rural residents will pay, on average, 21% (£104) per head more in council tax than their urban counterparts due to receiving less government grant.
  • Rural residents will get 14% per head less in social care support overall.

The RSN said that “rural residents pay more, receive fewer services and, on average, earn less than those in urban areas and that is inequitable”.

3. Read more

Cover image by Ian Taylor on Unsplash.