The NHS Long Term Plan for England cites a number of clinical priorities where service improvement should make the greatest impact on health outcomes. They are cancer, cardiovascular disease, stroke, respiratory disease, diabetes, maternity and neonatal, and young people’s care. Naturally, main hospital services must play a crucial part in addressing these priorities. That said, there is a clear expectation that, in future, more services will be available outside a main hospital setting and that fewer patients will need to attend them for treatment.
Main hospital estates and their emergency and elective services are being reconfigured and, in some cases, centralised into specialist units. Irrespective of the merits, one challenge this brings is how to ensure that main hospitals remain accessible to those from outlying rural areas who may have long or complex or costly journeys, be they patients, visitors, carers or staff.
The following questions are intended to help improve rural service planning and design:
- If assessing options for reconfigured or new acute and elective services (including A&E and out of hours services), what can analysis show about travel times and transport options to main hospital sites from settlements across the area served? What is considered a reasonable travel time?
- What transport options to main hospital sites exist, including from smaller or more outlying settlements? What are the implications for those who do not drive, do not have access to a car or who are too ill to drive? How far does transport service frequency limit the ability of patients to attend hospital outpatient appointments through the day?
- What scope is there to collaborate further with the community transport sector, who manage volunteer car schemes and minibus services, and who may be able to bring patients to health appointments, especially those without access to a car? How widely are non-emergency hospital transport services available as an option for rural users?
- What scope is there to provide some (until now) main hospital services safely at a more local level or at outreach clinics within urgent treatment centres, community hospitals or care hubs? For example, minor procedures, diagnostics, in-patient rehab, baby clinics, re-enablement and end of life care.
- What scope is there to offer outpatients greater choice, with options where they can go to receive treatment or care? Could further collaboration with neighbouring health authorities or providers enable such cross-border options or pathways?
- How might the number of visits that patients are required to make to a main hospital be reduced for those travelling from outlying areas? Could more examinations and tests be carried out during the same hospital visit or more common tests be carried out locally?
- What opportunities might be pursued to offer digital or online consultations and advice, to reduce the need to travel to outpatient appointments? Could this include local health centres having access to online advice from hospital-based specialists?
- How sufficient is provision for low-volume and high-risk specialities in geographies where population numbers are relatively small? (An example might be intrapartum care for childbirth involving high risk.) Could regional networks and cross-site working be strengthened?
- What are typical response times for ambulance and paramedic services, when attending calls from rural and outlying areas? Could clinical emergency protocols take better account of rural needs, where time-critical intervention is necessary e.g. stroke, heart attack? How well distributed are resources such as ambulance bases, first responders and paramedics?
- What is known about the location of public access defibrillators and those trained to use them, especially in rural settlements more distant from quick response services? Equally, how sufficient is air ambulance and rescue service cover to deal with time-critical cases which happen at remote locations or in coastal and mountainous settings?
- What resilience planning is in place to work with the other first responder emergency services when incidents occur such as flooding and wild fires? Should this be reviewed?
- Could public and patient engagement, by organisations such as the local Healthwatch, be used to gather feedback from service users who live in rural areas? How could this be used to generate useful lessons for service planning, design and implementation?
Case studies [not yet available]:
- Community Gynaecology Service – a one stop service delivering 3D ultrasound diagnostics in community settings in rural Surrey. Won the Women’s Health Initiative award 2018
- NHS Near Me service – access to (mainly) outpatient services through virtual consultations at home or at rural clinic rooms in Highland region, Scotland
Other solutions to rural service delivery challenges could include:
- Taking the service to the patient, by holding outreach clinics at local health centres or community hospitals, with visiting consultants or specialists from main hospitals.
- Upskilling and equipping GPs or Primary Care Teams to carry out some specialist services locally, which are traditionally delivered at more centralised sites e.g. memory clinics.
- Ensuring sufficient training is available for locally based healthcare workers in rural settings, so they can support patients returning home quickly from hospital and avoid others needing to go into hospital.
- Establishing a team of community-based paramedics, who can more quickly attend emergencies and provide a first response in hard-to-reach locations.
- Upgrading air ambulances so they are made capable of night flying, to reach emergencies at remote locations around the clock.
- Using Geographic Information Systems (GIS) to model and analyse typical travel times from different locations to main hospital sites and other service facilities.
- Maintaining a rural risk register, as part of a plan or strategy, to identify and monitor issues which need managing and addressing or mitigating.