Nuffield Trust: Pandemic will leave rural health services facing a steeper climb to recovery without targeted support

A briefing from the Nuffield Trust warns that national measures put in place at the outset of the pandemic to boost NHS capacity will likely disproportionately benefit trusts in urban areas.

Press release

Published: 11/12/2020

Hospitals in remote and rural areas face a steep climb to recover waiting lists if national pandemic measures continue to overlook long-stated workforce and capacity challenges.

A briefing from the Nuffield Trust warns that national measures put in place at the outset of the pandemic to boost NHS capacity, including the creation of seven ‘urban-centric’ Nightingale hospitals in England, the £10m deal to block-book independent sector hospital beds and additional support to reconfigure services will likely disproportionately benefit trusts in urban areas.

All of these national measures eat up much of the additional funding to support the NHS through the pandemic, so a lack of tailored support could leave many rural trusts, GPs and social care services struggling to catch up.

Analysis in Challenges that Covid-19 presents for rural health services finds that although rural areas have seen fewer Covid-19 cases overall, they have seen a more dramatic impact on patient access to services than in some urban areas. By comparing data from around March to June, during the first wave, with the same data for the year previous, it identifies:

  • There was a larger fall in the number of patients that were seen for their first consultant appointment for cancer in rural trusts (-66%) compared to a decline of 58% in urban areas.
  • In April 2020 this has left over 10,000 fewer patients in rural areas seeing a cancer specialist.
  • There was a fall in the number of patients admitted for emergency care of 57% for rural trusts compared with 45% elsewhere. 

Long-standing challenges and the starting position of trusts in rural and remote areas have put them under increased strain. These challenges include:

  • Rural sites typically have less unoccupied floor space and arguably flexibility. 8% of floor space in non-rural sites is unoccupied compared with a lower level – just 5% – in rural areas making it more challenging to reconfigure services to cope with increasing Covid admissions. 
  • Ahead of the pandemic, rural services had a higher level of occupied beds across their services (93%) compared with other urban areas (89%).
  • Remote and rural services have pre-existing workforce issues. They have a greater spend on agency staffing (8% of budget) compared to other areas (6%) meaning staff absences have a greater impact on the delivery of care.
  • While the number of hospital and community health staff increased by 7% nationally in the year to June 2020, the workforce of remote trusts grew by only 5% over the same period.
  • The underlying financial position of remote services was worse than the position of more urban trusts before the pandemic started and has historically been less likely to get a fair share of additional NHS national funding.

The briefing urges that learning from the first wave of the pandemic should inform support for rural and remote services going into a busy winter period as the service continues to battle a second spike in infection rates.

Nuffield Trust Senior Research Fellow Dr Billy Palmer said:

“There is no denying that the Covid-19 pandemic was a game-changer across the whole health and care system. Health and care services face a tough battle ahead to recover growing waiting lists and support their staff who are working heroically against this ongoing crisis.

"In the early stages of the pandemic, we saw the NHS put in national measures to help the service to brace itself for a surge in Covid-19 patients. These responses should have been tailored in a way which supports local teams to meet the care needs of the communities they serve.

“Yet our research has found that many of these national policies inadequately considered the needs of rural areas and reflect the long-standing workforce, financial and capacity issues of rural and remote services. Rural services are far less likely to benefit from ambitions to use either the urban-centric Nightingale hospitals or the independent sector to clear waiting lists.

“Because of this starting position, rural areas face an ever-growing steep climb to recover from the pandemic without the growing resources, support or capacity available in more urban areas.”

Notes to editors

About the research:

The scope of this research is limited to NHS services. It is also important to note that non-urban trusts include a diverse range of providers, and while they face some similar challenges, they also have individual challenges. In this report, we sought to look at rural and remote services separately.

Rural trusts are defined as the 10% with the highest proportion of patients admitted to hospital from rural areas, and clinical commissioning groups and local authorities were defined by Office for National Statistics' 2011 rural-urban classification. Remote trusts are those considered to face higher costs due to their small size and location far from the next nearest service.

The full list of defined rural and remote NHS trusts is[1]:

Rural trusts:

Cambridge University Hospitals NHS Foundation Trust

Cornwall Partnership NHS Foundation Trust

Dorset County Hospital NHS Foundation Trust

Lincolnshire Community Health Services NHS Trust

Lincolnshire Partnership NHS Foundation Trust

Norfolk and Norwich University Hospitals NHS Foundation Trust

Norfolk Community Health And Care NHS Trust

Royal Papworth Hospital NHS Foundation Trust

Royal Cornwall Hospitals NHS Trust

Royal Devon and Exeter NHS Foundation Trust

Royal Surrey County Hospital NHS Foundation Trust

Salisbury NHS Foundation Trust

Shrewsbury and Telford Hospital NHS Trust

Shropshire Community Health NHS Trust

Somerset NHS Foundation Trust

Taunton and Somerset NHS Foundation Trust

The Queen Elizabeth Hospital, King's Lynn, NHS Foundation Trust

The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust

West Suffolk NHS Foundation Trust

Yeovil District Hospital NHS Foundation Trust

Remote trusts:

Isle of Wight NHS Trust

North Cumbria University Hospitals NHS Trust (merged in October 2019 to form North Cumbria Integrated Care NHS Foundation Trust)

Northern Devon Healthcare NHS Trust

United Lincolnshire Hospitals NHS Trust

University Hospitals of Morecombe Bay NHS Foundation Trust

Wye Valley NHS Trust

York Teaching Hospital NHS Foundation Trust

About the Nuffield Trust:

  • This research was commissioned by the National Centre for Rural Health and Care (NCRHC)
  • The Nuffield Trust is an independent health think tank. We aim to improve the quality of health care in the UK by providing evidence-based research and policy analysis and informing and generating debate.
  • For more information or to arrange an interview, please contact Simon Keen on 07805 217935 or

[1] For Accident & Emergency data, only acute trusts were included in our definition.