Out in the field

Service providers are struggling to meet the needs of people in
rural areas. There is a legacy of under-investment in rural
services as public money has been diverted towards higher profile
needs in urban areas. But there are also the  problems of providing
services in sparsely populated, rural areas including poor
transport, geographical isolation, rural poverty, ageing
communities, and the closure of vital local services. For far too
long these issues have been overlooked, with few people
acknowledging the complexity of delivering services in rural

Against this background, Harper Adams University College,
Shropshire, set up the Convalescent and Recuperative Environment
project (Care) in 2003. The aim of Care is to explore the
possibility of using farm accommodation for the provision of health
and social care, and to help rural communities be part of a
solution to the difficulties of providing rural services. Harper
Adams also commissioned the Health Services Management Centre at
Birmingham University in 2004 to support the work of Care in acting
as a broker between health and social services and rural

In late 2004 and early 2005, interviews with senior managers in
health and social services in rural areas across England were
conducted by Care and the Health Services Management Centre. These
were chosen from social services departments that are members of
Sparse, a national network of rural councils. Participants were
often directors or chief executives, or other senior managers
recommended by these people. They were asked about the difficulties
of providing services in rural areas, ways forward and the role of
a project like Care in acting as a broker between rural communities
and rural service providers.

Nationally, health and social care are facing  staff shortages that
are challenging their ability to deliver services and forcing them
to consider ways of tapping into new labour markets. This is
particularly the case in rural area because of the exodus of
potential younger recruits, less availability of specialist
training opportunities, long travelling distances in community
services, difficulties with workers’ partners finding employment
after relocating to rural areas and expensive

In Care’s study, similar concerns emerged from rural services, with
recruitment and retention identified as a major difficulty. In some
areas there is a thriving tourist industry that can lead to
seasonal difficulties in recruiting care workers. With wages low
and the cost of living often high, social care staff cannot afford
to live in the local area on public sector salaries. In one
council, a social services director explained how private care home
owners were having to rent properties to people from Eastern
Europe, whose rent would cover the cost of the property and who
were employed in the care home. Elsewhere, a Butlins had a big
impact in one area on competing for local staff, and some
authorities were not able to match the wages offered by local

Closely linked to this issue is the difficulty and cost of covering
large, sparsely populated areas. Whereas home carers in a city can
visit two people who may live in the same street, a rural worker
may have to travel many miles between visits, and this is both
time-consuming and expensive. Unfortunately, these costs were not
felt to be adequately reflected in current funding formulas, with
rural areas unable to secure the same economies of scale as urban

Participants spoke about the need to invest in preventive services,
and to work together across agency boundaries in such situations.
This was particularly the case in terms of partnerships between
health and social care, although other key partners include
sheltered housing and local voluntary and community groups. At the
same time, the wider health and social care literature suggests
that a typical response is to use new technology to facilitate
communication between rural service users and centrally based
specialist services; to develop one-stop shops; to develop a range
of accessible transport services to bring people to central
locations; or to employ peripatetic workers who travel to the
communities concerned and offer mobile outreach services (see
panel, left). As the then health secretary, Frank Dobson, said in
1998: “When someone is ill [in a rural area] they get professional
treatment in two ways. Either they travel to the treatment or the
treatment travels to them.”

But another approach would be for projects such as Care to work
with local communities, and health and social care to develop local
services and extra capacity. In social care, this could include the
promotion of direct payments, the development of accessible holiday
accommodation for short breaks, and the stimulation of a range of
low-level preventive approaches such as befriending schemes for
older people or people with mental health problems, practical
support for new parents and visiting services for people with
long-term conditions.

In the Care interviews, this approach was supported by a range of
participants who felt that such a role could help improve rural
services, while also building social capital, aiding the
diversification of farming and supporting the rural economy.
Crucially, this could offer an alternative to the two options
outlined by Frank Dobson: rather than bringing the service to the
person or the person to the service, a rural broker such as Care
could work to ensure that services are available locally, managed
by service users themselves and provided and staffed by local

Jon Glasby is head of health and social care
partnerships and a senior lecturer at the Health Services
Management Centre, University of Birmingham.

Existing rural services

Services that reflect the current doctrine of taking
patients to the service, or the service to the patient
* 24-hour access to professional health advice via NHS
* Use of webcams and video links to link patients with doctors in
central settings.
* Use of volunteer driver schemes to bring people to appointments.
Other techniques include paying for taxis, hiring minibuses,
sponsoring driving lessons and arranging transport with other
* Use of outreach and mobile clinics to deliver primary care, run
mother and baby clinics and offer mobile day care.
* Use of mobile play, early learning, health and family support
services in rural Sure Start programmes.
* Use of existing community facilities to provide a one-stop shop

Training and learning
The author has provided questions about this article to
guide discussion in teams. These can be viewed at www.communitycare.co.uk/prtl
and individuals’ learning from the discussion can be registered on
a free, password-protected training log held on the site. This is a
service from Community Care for all GSCC-registered

This article looks at the difficulties and costs in
providing services in rural areas and possible ways forward in
tackling them, including new technology and local communities
helping themselves by working with providers to develop local

(1)  R O’Connor, “Idyll or nightmare?”, Nursing Standard,
18 (11), 14-15, 2003

Further reading
* J Cox, “Rural general practice: a personal view of
current key issues”, Health Bulletin, 55(5), 309-315,
* J Cox, and I Mungall, (eds), Rural Healthcare, Radcliffe
Medical Press, 1999
* J Glasby, H Lester,  J Briscoe, M Clark, S Rose and L England,
Cases for Change in Mental Health (emerging areas of
service provision booklet), Department of Health/National Institute
for Mental Health, 2003
* FW Rennie, W Greller, and M Mackay, Review of International
Best Practice in Service Delivery to Remote and Rural Areas
TSO, 2002
* Countryside Agency, Delivering Services to Children and
Families in Rural Areas: the Early Lessons from Sure Start
Countryside Agency, 2003
* Also, visit www.careinthecountryside.net

Contact the author

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