Primary and community services are central to NHS reforms, which place a growing emphasis on out-of-hospital care, plan for further service integration and adopt more of a place-based approach. The NHS Long Term Plan for England seeks to remove “the historic barrier” between primary and community health services. GP practices and other health professionals are expected to work together in Primary Care Networks, that typically cover an area with 30,000 to 50,000 patients. Reflecting these reforms, the annual budget for primary and community health care is being increased in England by £4.5 billion over the five years to 2023/24.
These reforms have potential to improve primary and community health care provision in rural areas, depending how they are implemented. Challenges could include the large area of Primary Care Networks in sparsely populated geographies, expectations that specialist health professionals can serve such large areas and ensuring that health centres or health hubs remain accessible. In addition, service demands may reflect the (typically) older age profile found in rural areas, which may mean more patients with multiple morbidities.
The following questions are intended to help improve rural service planning and design:
- How far do the Clinical Commissioning Group funding priorities match locally identified priorities at the Primary Care Network level? What effort has been made to ensure that these, in turn, incorporate the needs of the area’s rural communities?
- How large are (planned or implemented) Primary Care Network areas on the ground? Is there a justifiable operational case, in one of more localities, to drop below the expected 30,000 lower limit for patient numbers? Could operational concerns be monitored and addressed in other ways?
- What scope exists to expand the range of services delivered locally at medical centres, health hubs or community hospitals, to meet local needs and avoid patients travelling to main hospitals? For example, for minor procedures, diagnostics, oncology blood tests, in-patient rehab, baby clinics, re-enablement and end of life care.
- How easy do members of locality or hub-based multi-disciplinary teams, especially those who hold more specialist roles or who visit patients in their homes, find it to cover needs across the whole locality including any outlying areas?
- Are there any proposals for GP surgery alliances, mergers or relocations? How are these likely to affect local access to surgeries and the services or clinics they host? If the proposals leave any local gaps in provision, how could these be addressed?
- What public transport options exist to help patients travel to GP surgeries, community hospitals and other health facilities? Do those transport options serve the smaller rural settlements? Might community transport providers or schemes (such as volunteer car schemes) help to plug gaps?
- What are the travel costs and downtime for health visitors, district nurses, etc if they are regularly visiting patients with long term conditions in their own homes in outlying areas? Is any additional burden from such travel accounted for in resource and workload planning?
- What scope exists to offer and facilitate virtual consultations (by phone or online) for patients who may otherwise face difficult journeys to reach a traditional consultation? Similarly, could digital be used at surgeries or health centres to access advice from specialists based elsewhere (perhaps thereby obviating a hospital visit)?
- What is the location of community pharmacies in the area and how adequately does that serve the dispensing needs of residents from rural settlements? Is there a role for dispensing surgeries to fill any particular gaps in provision?
- What support services are provided to those who are living with a chronic condition or a disability and who self-care? What might improve the support and its delivery to those patients living in outlying areas?
- When commissioning community health services what scope exists to do so from local providers or in ways that improve service availability in rural areas? Could this include an enhanced role for local voluntary and community sector organisations?
- What collaboration or networking challenges arise, if any, for primary and community health professionals and managers where they are working across a geographically large rural area? Are there working practices which could alleviate these challenges?
Case studies [not yet available]:
- Health Connector project of enhanced primary care in Frome, Somerset
- Supporting high intensity users of NHS services in Cornwall
Other solutions to rural service delivery challenges could include:
- Mapping primary care services in the area (General Practice, dentistry, pharmacies, etc) to understand their distribution in relation to rural populations and transport networks.
- Deploying other trained healthcare professionals to undertake selected tasks that were previously carried out by a GP.
- Having pharmacy prescriptions delivered to village shops that agree to act as local collection points for residents, especially those who cannot easily travel.
- Engaging with any local projects which help people, especially from vulnerable groups, to enhance their online skills, so more patients can take-up the option of virtual consultations.