Against the rural penalty

As the Prime Minister keeps on reminding us, most of the country is not actually very much like London. What he may have forgotten is that a lot of the country is not particularly like Manchester either. While residents of Manchester benefit from impressive — and highly taxpayer subsidised — public transport, a choice of good medical facilities within easy reach, and a ready supply of medical graduates from local medical schools, the reality in much of rural and coastal England is very different.

From Clacton to Cornwall via Cowes, large parts of the country are already finding their health services relatively badly funded compared to cities. They are more likely to see their  local medical practices close or merge, will have less choice over when or where they receive treatment and there’s a better chance that their local hospitals will be struggling to recruit or retain the best staff.

Policy Exchange’s latest report, The Rural Penalty, co-authored by Joe Robertson MP (MP for Isle of Wight East), Dr Emma Watts (The Chair of the Royal College of GPs Rural Form) and an expert team of professionals from within the NHS has found extensive evidence of these problems and warns that the situation could get a lot worse if the Department of Health does not recognise them as part of the planned shift in the 10-Year Health Plan.

Current NHS funding formulas are weighted according to the population in any area and other factors such as age, deprivation, health needs and some adjustments for cost. Some of these formulas do not recognise additional costs associated with rural and coastal areas at all, while others only make limited allowances for them. By contrast urban areas tend to benefit more from weightings associated with modelled costs and deprivation.

Rural deprivation and the particularly pronounced health needs of some rural communities are not properly reflected in these costs, nor are other factors such as the limited economies of scale which can be achieved in more remote areas or the reduced opportunities to share staff and facilities.

In addition, many rural and coastal areas have significant seasonal changes in population as large numbers of people migrate in for parts of the year either for tourism or for work. For some practices this can represent a very significant additional strain at peak times.

Urban areas also benefit when it comes to recruitment. Medical graduates are already more likely to favour working in urban areas having gone through medical schools in cities and as they are more likely to have had most of their early practice experience there and limited if any exposure to the different challenges and opportunities of rural practice. This challenge is then aggravated by London in particular benefitting from additional pay weightings for staff working in inner or outer London. This can cause a brain drain and leave rural providers struggling to recruit, making it even more likely that they will close or merge.

The overriding strategy of the Government when it comes to health, which has been retained from the Starmer administration, is the 10-Year Health Plan for England.

On the face of it this plan should be encouraging for local areas. There is a strong strain of localism and devolution throughout the plan and it envisions more areas of healthcare being delivered on a neighbourhood basis.

While this direction is welcome in principle, the challenge emerges when considering what “neighbourhood” means.

In rural settings this risks meaning additional costs being transferred into already relatively under-funded healthcare systems and “efficiencies” being sought by combining services into “neighbourhood” health centres which could be considerable distances away.

A “neighbourhood” of 50,000 people (the definition of a Single Neighbourhood used in the Government’s Neighbourhood Health Framework) can be a compact and easily travelable area in somewhere like Manchester, comprising only a few miles. In other parts of the country it could represent an area hundreds of times that size.

In coastal areas this can be a particular challenge due to relatively limited transport links and remoteness from other population centres.

Another definition used in the Government’s framework in which certain services would be clustered in “Multiple Neighbourhoods” would mean that in areas such as the Isle of Wight residents may have to take the ferry to Portsmouth or Southampton for more services.

Obviously there are inevitably going to be additional challenges associated with delivering healthcare in rural and coastal settings but the answer to these lies in building on the genuine localism which is already working in some areas.

The flipside of having fewer choices of doctor to see is that the chances of seeing the same GP over a number of years are often greater in the countryside, thereby allowing patients to benefit from more continuity of care: if a doctor knows their patients better then they may be better able to spot subtle health or behaviour changes.

Over a fifth of English constituencies find themselves in the situation we describe in our report

These GPs can be supported to do more.Our report proposes making it easier for GPs to provide more services, such as dispensing prescriptions, and to recognise that the preventative and community value they bring can significantly offset the loss of economies of scale they inevitably represent.

Over a fifth of English constituencies find themselves in the situation we describe in our report – far too large a part of the country to be ignored.

For the NHS to abide by its promise of being a comprehensive service available to all, and for the localising devolving rhetoric of the 10-Year Health Plan to succeed, the Government must accept that one-size cannot fit all when it comes to neighbourhood health: it must tackle The Rural Penalty.