Please note that the following is intended to provide further background information on this call but does not constitute an exhaustive literature review.
Background
A high proportion of rural and coastal populations are vulnerable older people who are more likely to experience multiple long-term conditions, which place a great demand on rural and coastal services. Moreover, there are other vulnerable demographics who have specific and often unmet service needs, and do not follow the general trend of out-migration from rural and coastal areas, in particular children, young people and migrants.
Average minimum travel times to hospital were reported to be approximately double in rural compared to urban areas, and rural social care workers travel 2.4km further to get to work compared to urban social care workers. Organisation of services are typically modelled based on urban needs, and approaches such as service centralisation which are beneficial in urban areas may not suit service delivery in rural and coastal areas . The COVID-19 pandemic accelerated the deployment of digital solutions to deliver services remotely, however a lack of digital infrastructure alongside lower rates of digital literacy in an older population still provide barriers to implementation. The pandemic also exacerbated pre-existing rural and coastal challenges including longer hospital waiting times and workforce issues. Despite having vulnerable demographics, there are important problems with the recruitment, training and retention of health and social care staff in rural and coastal regions.
Identified Research Need
Due to the sparse nature of services and communities in rural and coastal areas, the Rural Health & Care All-Party Parliamentary Group (2022) recommend service model flexibility to meet local needs, service integration to provide coordinated holistic care, and for generalist skills to be ingrained in the clinical workforce to allow staff to treat patients presenting with a range of problems. An investigation into generalist care in smaller hospitals showed that generalism is appropriate in this setting, yet patients and subsets of doctors preferred models of specialist care. This work highlighted a need for further understanding of the relationships between the workforce, models of care and organisational culture, along with a need to address workforce challenges including difficulty recruiting and retaining appropriated trained staff to delivery a quality service based on local needs, and to prevent service closures.
To address health and social care workforce inequalities in rural and coastal regions, Health Education England have implemented policies to redistribute medical training placements and key specialties, as well as to provide recruitment incentives for trainee GPs to work in remote locations and workforce-wide educational opportunities. Potential benefits of Primary Care Networks, including promoting resource sharing and giving users flexibility in service access, appear not to have been fully realised in rural areas. A rapid evaluation of Primary Care Network development reported that rural Primary Care Networks felt that policy had been produced based on experiences of urban service delivery, and that policy did not consider established collaborative ways of rural working. The South West Care Collaborative – in which over 500 rural care homes support each other and share learning – is a successful example of utilising rural cooperation that improves the organisation and quality of service provision. Research is needed to assess novel approaches to delivering health and social care in rural and coastal areas, with an emphasis on community based innovations and those that offer flexibility in the organisation of care within an Integrated Care System.
Distance and limited public transport provision are specific issues in rural and coastal areas that particularly impact access to and experiences of health and social care services. One solution is to offer services closer to users, from outreach maternity clinics in rural settings to mobile breast cancer screening units. Despite the established clinical benefits of initiatives such as routine screenings for some cancers, there is limited UK-based evidence evaluating how mobile and outreach health and social care services are organised within the wider system, and the impact they have on rural and coastal communities. Likewise, community and patient transport services can improve access to health and social care services. Research should evaluate the value of transportation care services to users in rural and coastal areas, as well as consider the wider experiences of users and staff who need to travel, for instance staff who work across distant sites in a rural Primary Care Network.
Digital solutions such as electronic consultations and remote monitoring tools circumvent the need to travel. There is a need to understand the perspectives of service users in rural and coastal areas to better tailor these resources to communities. Furthermore, as most research examined short-term outcomes due to the recent uptake of these technologies, there is a need for long-term studies to fully assess the impact of digital solutions on health and social care services.
Emerging approaches to improve health and wellbeing leverage the existing supportive community networks in non-urban areas and encourage connections with tranquil natural environments through green social prescribing. Compassionate Frome is a complex primary care intervention which combines person-centred planning and social prescribing, and has shown promising indications of reduced emergency admissions across the total population. Grounded in knowledge that social factors influence health, this personalised approach – which is particularly helpful for people struggling with mental ill-health – identifies individuals needs and helps build relationships with healthcare professionals and supportive members of the community through social prescribing. Whilst there are no overall differences in wellbeing between rural and urban populations, on an individual level the sparsity of rural communities can contribute towards loneliness, and there is a need for research into innovative approaches of service delivery that employ social strategies .
In rural and coastal areas, deprivation and poor health often go unnoticed due to a lack of small area data, which is typically only available at low levels of granularity, such as at local authority or Integrated Care System levels. In some regions, areas of affluence may mask pockets of deprivation, preventing an accurate understanding of specific needs; there is a need to deconvolute existing data and analyse higher granularity datasets to unveil and answer service level questions of particular relevance to rural and coastal service users, especially underserved users (CMO Report 2021; Rural Health & Care APPG Report 2022).