All trusts act as 'anchor institutions' creating economic and social value for their communities, as a major employer, a provider of key services and advice and often as a supporter of local businesses and voluntary sector organisations. This is all the more pertinent in a rural community where there are few other public service institutions and key employers playing a similar role.
It is vital that policy makers are attuned to the wider value that trusts operating in rural environments provide to their patients, staff, and local communities in the emerging COVID-19 landscape. Beyond ensuring operational frameworks adapt to support multi-site DGHs or small acute hospitals operating in isolated rural areas, it is also important to consider the broader examples of best practice and innovation for providers in rural settings across the acute, mental health, community and ambulance sectors.
The value of the care and treatment delivered in rural settings must be considered in the development of national policy across system transformation, workforce, and in the design of the new NHS financial architecture. Below we have highlighted the specific rural offer to the workforce in these trusts; their use of digital; their effectiveness in integrating with
primary, social and community care services and their value as 'anchor' institutions.
Economics and social contribution to local communities
It is vital that the economic and social value of rural trusts to their local communities is recognised by national policymakers. Rural providers can also act as major drivers of employment within regional economies and have a local 'multiplier effect’' A report from the Health Foundation (2019) explains this concept, highlighting how trusts can shift more of their spend locally, and embed social value into their purchasing decisions to benefit local communities. This can involve prioritising local catering suppliers, and identifying what proportion of spend can stay within a trust’s region. For example, Sussex Community NHS Foundation Trust offers nursery places in three sites for NHS and emergency staff, and Cambridgeshire Community Services NHS trust has opted to work with a locally owned café rather than a large national chain while rebuilding a community hospital.
Rural hospitals often act as community hubs which are not just about health, but also act as local anchors for social cohesion. They can help limit social isolation for elderly patients, particularly in areas which may have seen the loss of post offices or libraries, for example. These institutions are critical in terms of their partnership with local government to reduce health inequalities in the broader sense, and not just in relation to population health management.
The closure of smaller hospitals leads not only to an exodus of clinicians and other allied health staff, but also dissuades younger families to move to these areas, and makes it more difficult for low-skilled workers who lose their hospital-based jobs to find alternative sources of employment (Future Healthcare Journal, 2019). Communities can therefore collapse as towns become unviable and incumbent residents face further social isolation.
Rural areas as attractive places to live and work
Trust leaders highlight how deeply rooted staff often feel, maintaining a strong connection with the communities they are serving. As we have highlighted in our briefing on system approaches
(2019) to workforce challenges in the NHS, trusts operating in rural areas are keen to promote their local areas as good places to live. While vital to promote the NHS as a good employer, national and regional campaigns can often fail to advertise the specific living benefits that rural areas have to offer. Providers have carried out their own successful overseas recruitment campaigns, including encouraging new staff who want to stay and build their lives in largely rural areas.
It is important to acknowledge the cultural appeal of working within rural trusts. Trust leaders highlight how some clinicians prefer to work in smaller, discrete teams. Given the smaller size of these bases, clinicians and nurses are more deeply embedded within the community.
Integration with community and primary care across hard to reach areas
Providers delivering services in rural areas collaborate with primary and community care services through integrated hubs to treat patients in hard to reach areas, and to ensure these services are sustainable for the long run. As we explored in a briefing last year, primary care networks (PCNs) are building blocks for integration, and alongside neighbourhood teams play a vital role in providing care and treatment to patients in their homes. Dorset County Hospital NHS Foundation Trust has integrated teams working with social services to provide 'virtual wards', allowing patients to be treated in their own homes.
These integrated teams include GPs, primary and social care workers, and professionals across independent and third sector, providing services such as community rehabilitation, palliative care, and intermediate care to support people to be as independent as possible. Where access to hospices can be limited in rural areas, there is more of a need for GPs and neighbourhood teams to deliver palliative care to patients.
Quality of services
It is important to highlight that studies have shown (Monitor, 2014) that the quality of care delivered in these smaller hospitals is equivalent in terms of outcomes to services provided by larger acute providers. However, as patients may have limited access to acute services in rural areas because of difficulties in travelling to hospitals, there is a greater need for systems to look at how specialist clinicians in acute settings can advise community teams outside of hospitals. (Rural Services Network, 2020).
Trusts operating in rural settings are resourceful in ensuring their patients can receive care and treatment from acute clinicians. In some areas, the relative lack of care homes can often mean that discharge rates from acute settings to community hospitals is unsustainably high.
To help manage this, some providers have recruited medics who are dual qualified as GPs and emergency department consultants. This can bridge the divide between acute and community settings and increases the number of high acuity patients that can be cared for at home rather than in hospital settings.
The offer to staff
The fact that these providers often face amplified workforce challenges means they have developed innovative means to recruit and retain junior medics, middle-grade clinicians, consultants and nurses to work on site in more rural settings.
Facilitating generalist training pathways
Providers operating in rural areas are particularly well-equipped to provide junior doctors with generalist training, and to facilitate working with multi-disciplinary teams within trusts. They provide accessible training for integrated pathways, and the younger medical workforce is often better suited for their development needs by this training, as they can develop a wider range of learning experiences. Moreover, given the growing ageing population in England, there is a greater needed to equip doctors with the skillset to treat older patients with multiple comorbidities.
Research from the National Centre for Rural Health and Care (2018) identifies the opportunities available to rural providers to secure their workforce supply, given their provision of generalist training opportunities. The varied roles and opportunities available for career development mean that rural areas are attractive for clinical staff who are looking to develop a broader training portfolio.
Indeed, Health Education England recently launched its Future doctor programme (2020). This is a new recruitment framework accompanying the launch of new generalist training schools for junior doctors.
Providing 'centres' of excellence in specialties
There is also ample space for developing ‘centres of excellence’ in certain specialties that are attractive to potential staff. While rural hospitals may have a less extensive range of specialist services, small rural hospitals often develop expertise in clinical practices reflecting local circumstances, and these trusts can offer training opportunities in specialist services. For example, East Kent Hospitals University NHS Foundation Trust has a specialist centre delivering radiotherapy.
Collaborating with educational institutions
Working with universities and further education colleges is vital for providers operating in rural areas to enhance the capacity of their own local workforces. Where there are shortages of junior doctors to work in acute centres or DGHs, rural trusts have partnered with local universities, putting forward proposals to build more enhanced junior doctor accommodation. Other examples include rural providers working with universities to create placements and pathways to support their technology and AI development. Others have developed business cases to build new medical schools which stretch across different counties.
Composite workforce approaches
Community trusts in rural areas can have limited medical staff with few junior doctors compared to large acute providers, and these trusts are often nursing-led. Many providers offer nursing associate roles as a route to growing their own workforce, with evidence that these individuals are more likely to stay. This role helps bridge the gap between health and care assistants and registered nurses, providing clear pathways to develop professionally.
For rural trusts providing community care services to patients across large, dispersed areas, there is a vital need for ‘interoperability’ across systems, ensuring that patient records can be
shared with other organisations, including local authorities. Trusts providing services in rural areas were in many ways better placed to deliver care remotely in response to COVID-19. The pandemic has put greater weight on the need to provide remote care for ‘hard to reach’ groups, particularly rural patients, and the expansion of trusts’ digital capacity has helped them cope with demand through the use of virtual appointments. For those whose access to health services is constrained by their geography, remote care delivery models have improved the ways in which these patients access care.
Many trusts already had the infrastructure in place to push forward the digital agenda prior to the pandemic. For example, as we have detailed in our Digital boards programme, (2020), ambulance trusts have worked to implement fleetwide electronic patient records, and have established online and telephone self-assessment services to treat patients with influenza.