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
    areas.

    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
    communities. 

    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
    accommodation.(1)

    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
    supermarkets.

    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
    neighbours. 

    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
    people.

    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
    Direct.
    * 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
    providers.
    * 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
    approach.

    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
    professionals.

    Abstract
    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
    services.

    References
    (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,
    1997
    * 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
    J.Glasby@bham.ac.uk

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