Defining characteristics of 'rurality'
It is important to first set out our definition of ‘rurality’. Generally, we are taking this to refer to a combination of lower population density and size than urban centres, and lengthier travel times to reach hospitals, compared to trusts in urban areas (Nuffield Trust, 2019).
The NHS Providers rural trust learning network includes trusts which serve different rural populations. For these trusts, a significant section of their service user population is widely dispersed across rural areas, with considerable distance to travel to access health and care services. Smaller acute providers are also more likely to be located further away from other providers, and deliver a smaller range of specialist services to patients based in rural areas.
Trusts operating in rural areas often treat a greater proportion of elderly people than those based in urban areas. This is partly caused by the migration of young people away from rural areas. Frailty and complex comorbidities amongst elderly populations can present major challenges to the delivery of care in rural settings – particularly in isolated, small communities.
Public health initiatives can also often fail to reach certain sections of the population in rural areas given their remoteness and sparsity: only 55%of rural households are based within 8km of a hospital compared to 97% of urban households (Local Government Association, 2017). Moreover, broadband connectivity is often poorer in rural areas – particularly in seaside towns – compared to other parts of the country. The availability of solid broadband coverage is inconsistent across localities in England, and more comprehensive provision is required to ensure patient access to their electronic records. As NHS Digital (2021) have highlighted, people living in rural areas are more likely to be 'digitally excluded' than others.
Public health initiatives can also often fail to reach certain sections of the population in rural areas given their remoteness and sparsity: only 55%of rural households are based within 8km of a hospital compared to 97% of urban households.
Workforce constraints
Rural trusts running acute services often struggle to attract junior doctors who are seeking opportunities in medical specialty training. Young doctors are often more inclined to work in urban centres to train in specialties via large teaching hospitals. Cities are also perceived to offer a greater range of social and cultural opportunities, and more convenient and cheaper transport links. There are also difficulties in attracting trainee doctors because of the lack of financial incentives that support relocation to rural areas.
National difficulties in filling vacancies in acute specialties are amplified for many trusts operating smaller sites in rural areas. Gaps in clinical rotas also lead to a reliance on expensive locum and agency staff. Perceptions about a lack of high-end specialist provision attractive to clinical staff hoping to build expertise, exacerbate retention and recruitment difficulties.
Research has shown that recruitment of both consultants and middle-grade staff is difficult for smaller hospitals (Future Healthcare Journal, 2020). Aware of their geographical isolation, and limited proximity to urban centres, there is a real push for these trusts to ‘grow’ their own workforce. Community and mental health trusts can often struggle to recruit to particular disciplines – such as nurses specialising in learning disability. These workforce pressures and local of an available pool of recruits is then exacerbated in a rural area.
The pandemic has also shone a light on the implications of staff sickness and absence across rural remote services (Nuffield Trust, 2020) due to staff sickness and absence. In rural settings, remote services often comprise of smaller teams than urban-based services, and therefore gaps in rotas can cause relatively greater disruption to healthcare delivery.
National difficulties in filling vacancies in acute specialties are amplified for many trusts operating smaller sites in rural areas. Gaps in clinical rotas also lead to a reliance on expensive locum and agency staff.
Structural financial issues
Delivering services in rural settings tends to attract cost pressures that are not properly reimbursed by existing funding models. It is therefore important to acknowledge that some rural acute trusts face 'structural deficits', caused by factors outside of a trust’s control and which are not amenable to management action. For example, rural acute providers have had to provide the same level of quality as larger, urban-based trusts in services where they may not deliver the levels of activity required to attract sufficient funding in the context of payment-by-results payment models.
Trusts across all sectors face an inflated cost-base when operating in rural areas. As the Nuffield Trust (2019) has demonstrated in its review of the impact of rurality on the costs of delivering healthcare, there is a need for higher spending in rural areas given the higher spending on agency and locum staff, due to the difficulty of recruiting to remote hospitals. Not only do trusts incur higher workforce costs, they are also likely to face broader operational costs and productivity challenges given their geographical isolation. The costs of providing multidisciplinary care for small client groups with complex needs who are highly dispersed is expensive for acute, mental health and community trusts, and there are higher costs for ambulances in rural areas to meet response standards as it takes longer to convey patients.
Operating across dispersed populations often involves working from multiple sites or within a patient’s home, therefore reducing the opportunities of economies of scale or service consolidation. While many trusts, particularly in the mental health and community sectors, are used to grappling with these issues, a very dispersed population within a large geographical area, can exacerbate existing structural challenges for rural trusts. These hidden costs aren’t properly reflected in the national tariff payment system or other funding mechanisms, and trusts often make a loss on the delivery of services to more rural populations.
Operating across dispersed populations often involves working from multiple sites or within a patient’s home, therefore reducing the opportunities of economies of scale or service consolidation.
Delivering care to patients whose access to services is limited
The geographical spread of rural trusts often requires providers to deliver community services in hard to reach settings. The difficulty lies in efficiently delivering this care to a relatively small population across a large geographical area. As we have shown in our Provider voices (2018) series, it can be difficult for patients in certain geographies to access some types of care because of their rurality. In these cases, there is greater need to integrate with local community and primary care services. Multidisciplinary working is vital, and these providers have to coordinate effectively to ensure acute clinicians can deliver care to patients in remote areas.
There is a strong link between scale of challenge for a hospital trust and its geographic location. As rural hospitals usually deliver on a smaller scale than acute providers based in urban centres, these providers often deliver services on a ‘hub and spoke’ basis. This integrated model involves a central anchor service – for example, an acute hospital providing highly specialised treatment or major trauma centres – which run integrated pathways with ‘spoke’ services delivering a broader range of less specialist care. These are often based on peripheral sites and are run by community care teams.
There is also a challenge for trusts which are not ‘rurally focused’, and which have more urban-based patients than rural ones. For example, acute trusts which also operate district general hospitals (DGHs). The issue here is how to best serve a widely dispersed elderly population, while also running these services as part of the same organisations which provide more complex tertiary activity, such as operating major trauma centres in both urban and rural settings.