23/91 - Improving the Organisation and Quality of Health and Social Care Services in Rural and Coastal Areas of the UK - commissioning brief

Scope

The Health and Social Care Delivery Research (HSDR) Programme wants to fund high-quality research about the quality, accessibility and organisation of health and social care services in rural and/or coastal areas. These remote regions have been highlighted as in need of specific attention due to pronounced health inequalities around access, experiences and outcomes of care.

The HSDR Programme is particularly interested in funding ambitious studies evaluating responses to addressing the challenges, including flexible or generalist workforce models, mobile, remote and outreach services as well as whole-system solutions. Studies should include careful definitions and sampling across rural and/or coastal areas from a number of sites to generate national learning. Small-scale evaluations are considered out of scope.

Please note this topic is also of interest to other NIHR Programmes including the Public Health Research (PHR) Programme. If your proposal solely concerns population based, non-NHS interventions then please contact phr@nihr.ac.uk.

Background

The number of people living in rural and coastal locations is increasing, with 17% of people in England residing in these areas, and includes high numbers of vulnerable older people with complex health and social care needs. Significant deprivation exists in rural and coastal areas – with seasonal working, educational inequalities and poorer quality housing all contributing to deprivation. The Chief Medical Officer’s 2021 report ‘Health in Coastal Communities’ identified small coastal towns as having some of the most deprived areas, and suggested that improving the health of people living by the sea would reduce the long tail of lower life expectancy in England.

In terms of the challenges to health and social care services, dispersed populations mean that users often have to travel further to access services, which are in themselves sparse, and digital solutions may disadvantage older or deprived individuals and exacerbate digital exclusion. The quality of services are affected by workforce challenges, given difficulties in recruitment, training and retention of health and care staff in rural and coastal regions, which have 14.6% fewer medical trainees, 15% fewer consultants and 7.4% fewer nurses per patient. Workforce challenges and difficulty in utilising economies of scale contribute significantly to the higher costs of delivering health and social care services in these remote locations.

Identified Research Need

Research is needed to improve the organisation, quality and accessibility of health and social care services in rural and coastal areas, taking into consideration the experiences of service users and the workforce. Deprivation and poor health in rural and coastal areas is often masked by a lack of small area data; analyses of granular data capturing accurate outcomes will build a better understanding of the needs of rural and coastal communities and the problems they face. Strategic solutions range from deployment of generalists and schemes to attract and deploy staff more flexibly; system-wide solutions on transport, planning and shared resources; digital, outreach and integrated services; new kinds of primary and community services and others.

Ongoing and completed studies of interest in the NIHR portfolio (with greater or lesser direct relevance to rural and coastal communities) include:

• Community First Responders' role in the current and future rural health and care workforce;
• Primary care Networks;
• ‘Come and work here!' Exploring the role of local community-led initiatives to improve recruitment and retention of healthcare staff in remote and rural areas’;
• Understanding the role of adult community health services in avoiding hospital admissions;
• Mapping underdoctored areas: the impact of medical training pathways on NHS workforce distribution and health inequalities’;
• Identifying multi-agency, trauma-informed and integrated solutions for unmet need of individuals experiencing homelessness in Northumberland and North Tyneside;
• Sustaining locally-driven social care for those affected by dementia: A realist evaluation of successful Meeting Centres’

Further relevant background information to this call is provided in the supporting information.

Areas of Interest

The HSDR Programme is interested in funding high quality research that provides evidence on how best to tackle inequalities in rural and/or coastal regions to improve health and social care service quality and outcomes for users. Studies will need close engagement with rural and/or coastal service users and workforce in all relevant parts of the health and social care system, as well as community and third sector organisations. Evaluations of new ways of working and service models, or adaptation of existing services should be designed to allow for wider learning and for generalisability to other rural and coastal settings. Applicants should consider the availability and quality of routine data and of data linkages across health and local government on costs, experience, use and outcomes of services. In addition, analysis of higher granularity data may allow for a better understanding of needs and activity.

The following areas are of particular interest to the HSDR Programme, though other questions may be proposed with appropriate justification:

• Organisation of care, including what is the impact of service centralisation on access and quality? How can the workforce be better organised in rural and coastal areas to deliver health and social care? What forms of outreach, or mobile services, are viable or worth testing and scaling up?
• Innovative models of care that have been developed in less densely populated regions that exhibit system flexibility and that might draw upon rural and/or coastal strengths and assets across the wider community, including social prescribing approaches.
• Models of care to streamline delivery, accessibility, engagement with and coordination of services in rural and/or coastal areas, with particular attention to complex and frail populations with multiple conditions, as well as identified in-need services, including emergency, mental health and cancer care services.
• Strategies to recruit, train and retain the workforce in rural and/or coastal areas, with a view to improve service access, organsiation, delivery and experience. Particular attention to the experiences of staff from ethnic minority groups and wider exploration of workforce diversity is welcomed.
• Ensuring that services are inclusive by improving access for vulnerable populations, including older people, children and young people, and people from ethnic minority groups. What are their experiences of health and social care services? Which measures can be used to promote greater engagement with these services?
• Understanding digital poverty in rural and/or coastal areas, how accessible are digital interventions to these populations and do they deliver the same quality and outcomes as in urban areas? Providing insights into the current impact on service organisation and delivery, both positive and negative, and using learning to unlock new possibilities for service organisation and delivery.
• What is the environmental impact of changes in delivering health and social care services in rural and/or coastal areas?

Rural and Coastal Definitions

There are no nationally accepted definitions on what constitutes ‘rural’ or ‘coastal’ areas. As such, a range of definitions have been used, some of which are outlined in the CMO Report 2021 appendices. In the PHE report ‘An Evidence Summary of Health Inequalities in Older Populations in Coastal and Rural Areas’, ‘coastal’ is defined as any settlements (excluding coastal cities) within a local authority area whose boundaries include foreshore. The report also uses the ONS definition of ‘rural’ areas, which refers to areas outside settlements with more than 10,000 resident population.

Applicants should include robust definitions of what they consider to be rural and/or coastal areas, providing justification for their sampling strategy, as well as an awareness of the strengths and weaknesses of their proposed approach. HSDR are open to a wide range of appropriately articulated and sourced sampling definitions.

Research Inclusion

The NIHR is committed to creating a diverse and inclusive culture, as outlined in our Equality, Diversity and Inclusion strategy 2022-2027. We therefore encourage applications from people from all backgrounds and communities. We are committed to having leadership and teams that contain diverse skills and experiences.

All NIHR research proposals need to demonstrate that they have met the requirements of the Equality Act (2010). Researchers should consider being diverse and inclusive in the design, planning, conduct, impact, and dissemination of their research study.

NIHR also welcomes partnerships between research active and other less active institutions and those located in geographical areas of deprivation. Applicants are also expected to pay attention to populations that have been underserved, to conduct research in locations where the need is greatest.

General Guidance

The HSDR Programme supports applied research with the aim of improving both health and social care services across the nation and is open to any appropriate methodological approaches to answer the proposed research question(s). The approach must be fully explained and justified.

To enhance the success of a research proposal, a clear theory of change and pathway to impact, with links into the NHS and social care services delivery, is suggested. It is useful to consider in the research study design how outcomes could be scaled up to maximise impact and value for money across the NHS and social care services – the focus is on applied research with tangible impacts that improve the quality and organisation of health and social care services. This includes stakeholder engagement and the development of processes, tools, and guidelines to strengthen workforce capacity. Please see the HSDR Programme webpage for further general information.

Research proposals should be co-produced with national organisations, professional bodies, health and social care service professionals, and service users. Links with health and social care planners and professional bodies are required to ensure impact and scaling up of research findings to benefit the wider health and social care system.

The COVID-19 pandemic is having a significant impact across the health and social care system. As this research may be conducted during the COVID-19 response and recovery period, applicants should consider how the impact of the COVID-19 response and recovery may affect the deliverability of their research.