While the UK does not have the extremes of geographical remoteness found in some parts of the world, there are a number of areas – some with relatively sizeable populations – which have difficulty creating safe and viable services.
In some places, this is due to their distance from major hospitals; in others it may be the result of sparsely distributed populations with poor public transport links and low rates of car ownership.
What are the issues?
Getting the workforce right
A major issue facing rural and remote hospitals is the problem of recruiting and retaining the right number of staff with the right skills to do the job.
Standards and training requirements upheld by Royal Colleges and regulators often require minimum numbers of patients or a specific number of consultants – which in rural areas can be difficult, or even impossible, to meet. Even if the required numbers of staff could be recruited, the resulting rotas are often unaffordable due to relatively small numbers of patients.
Moreover, an increasing shift towards sub-specialisation within certain fields of medicine has created a skills gap and a shortage in general physicians and surgeons competent in dealing with a range of emergency patients. In rural areas this is especially prevalent – and it is difficult for trusts to acquire a critical mass of doctors who are able to cover all elements of care.
These gaps are also hard to fill with new doctors. The low volumes of work and isolation from other professionals in remote areas often make these positions undesirable for new trainees.
Other factors make recruitment difficult too. For example, Cumbria has more than 50 vacancies in a consultant workforce of over 200, with critical shortages in acute medicine, paediatrics and other key specialties. This means that its hospitals are highly dependent on locum cover, which may reduce the attractiveness of posts to permanent staff.
And in some cases, the right clinical professionals for rural hospitals are not just difficult to recruit; they may not even exist. For instance, in anaesthetics, some newly qualified consultants are not able to cover the intensive care unit.
Inflexible standards and regulation
There are certain specific challenges facing rural and remote services that are not acknowledged by regulatory standards, since some of the assumptions made by external bodies that regulate services were based on models from large urban centres. This is a particular issue when standards revolve around the number of staff and facilities in a trust, rather than the results of care for patients. The evidence that staffing standards and models are directly linked to outcomes is actually not very strong. The volume effect is not significant for all procedures.
It's also noteworthy that the relatively high fixed-cost element of running hospital services means services that see fewer patients tend to be disproportionately expensive, with little opportunity to attract additional activity to cover costs.
So what are some of the solutions?
New staffing models present many opportunities. For example, combining rotas of A&E, acute medicine and other disciplines such as geriatricians could create a single service for dealing with emergencies.
Likewise, dual training would create a larger pool of staff with a wider range of skills. Belford Hospital in Fort William uses dual-trained GP/consultant physicians for more common emergencies, plus surgeons with a broader range of skills. However, this solution may be elusive as there is no easy route to training these types of multi-skilled professionals.
The further development of advanced practitioners, to take on work currently done by trainees, could also be explored further. As our recent workforce report discussed, there are also particular opportunities to train non-medical staff to carry out specific procedures.
Area-wide clinical networks create opportunities to address workforce and training challenges – such as lack of generalist skills. Hub units can consolidate some procedures through a network – reducing the need for staff to be present at some locations. However, this is a model that still needs some further finessing to ensure the appropriate technology, infrastructure and accountability structures are in place.
Training and recruitment
Professional training in rural and remote settings offers benefits, giving trainees the chance to develop leadership skills and expertise as an autonomous practitioner. These abilities seem to be undervalued in the current system, leading to the placement of more junior trainees, who need to be closely supervised, in the smaller units, rather than making a virtue of giving more experienced trainees the opportunity to practice more autonomously.
Furthermore, there are opportunities to boost the appeal of roles in rural and remote hospitals. Providing trainees with roles in high-quality rural settings, with good accommodation, the opportunity to work with colleagues and opportunities to be buddied with larger hospitals in urban areas could all accentuate the benefits of these roles.
Revised standards and regulation
The question of how far standards should be made flexible enough to recognise context is a thorny one: while flexibility may be desirable, there comes a time when, in flexing so far, safety is at risk.
Nonetheless, it is important that regulators acknowledge that different geographies require different approaches without diminishing the need to deliver high-quality outcomes. It is clear that there is a need for more diverse ways of assessing quality. The regulatory regime, both professional and organisational, could be broadened out to new service and staffing models, subject to their delivering good outcomes.
Payment mechanisms and costs
Current payment mechanisms often do not reflect the additional costs of rurality. It is not always clear how far higher costs are the consequence of small scale, remoteness, or other factors, but they are evidently significant and must be taken into account. The payment-by-results (PBR) model is not a suitable vehicle for reimbursing these costs as they are not related to the number of patients seen. Any supplement for hospitals would either have to be paid as a top-up, or would need to be reflected in commissioners’ allocations.
There are a number of solutions available for the problems facing rural and remote hospitals, but some of them require changes in legislation, new models, the deployment of technology, and different approaches to creating and running networks.
As with any complex issue, it is also clear that more research and investigation is needed to fill in the blanks.
However, as a first priority, there are clear opportunities to mitigate difficulties faced in rural areas by developing more flexible and meaningful measures of quality, by prioritising more effective recruitment strategies and through investing in the development of generalist skills.
We will be working with the Academy of Medical Royal Colleges and NHS England to take forward some of our ideas.
We are planning a further forum for organisations interested in rural health care in London on 13 October 2016 to explore these and other issues about providing care in rural areas.
This blog is based on a seminar held by the Nuffield Trust and the Academy of Medical Royal Colleges in April 2016, which aimed to discuss the challenges of delivering high-quality health care in rural and remote settings. For more of the findings and recommendations that emerged from the session, please see the full working paper.
Edwards N (2016) ‘Making rural hospitals sustainable’. Nuffield Trust comment, 12 July 2016. https://www.nuffieldtrust.org.uk/news-item/making-rural-hospitals-sustainable