Cold comfort care New pressures on health services in rural areas mean nurses have to go the extra mile to care for their patients. Alison Moore reports

nurses have to know the back routes to be sure they can get through. Animals – pets, farm and wild – can also be an issue. Ms Morgan knows one nurse who visited a patient at a remote house and found a cow inside. Nurses are keenly aware of the difficulties their patients face in accessing routine health care, she says. ‘For people in isolated communities, even getting a prescription filled is difficult.’ Community hospitals have a vital role in rural areas. ‘We take lots of direct admissions into our

SUMMARY

Wellies and a lifejacket can be standard equipment for community nurses in parts of Norfolk – just in case they are called to care for someone on a boat. In snow, the chief executive of Norfolk Community Health and Care Trust abandons his office to provide a 4x4 taxi service to get staff to patients. The trust’s director of nursing, quality and operations Anna Morgan says staff tend to carry a considerable amount of equipment and supplies in the back of their car – ‘If you drive out ten miles to see a patient you can’t just pop back because you have forgotten something’ – and sometimes travel in pairs to ensure there is someone to push the car if it gets stuck in snow. In the summer, as in many rural areas, the local population soars with tourists. Traffic jams on winding roads are common;

20  january 8 :: vol 28 no 19 :: 2014 

People living in remote rural areas often have  difficulty accessing healthcare services, and  community and primary care providers are set  to be even more important as hospital services  become centralised. Rural nurses demonstrate  high levels of skill, resilience and ingenuity in  bringing care to patients in their own homes.    Author Alison Moore is a freelance journalist

community hospitals – if some of these patients lived nearer an acute hospital, they would go into one,’ says Ms Morgan. But patients rarely consider moving to more convenient locations. ‘There is a culture across Norfolk where people don’t want to leave their homes. They want to continue living in their small communities.’ Public health adviser for the RCN Helen Donovan says nursing in rural communities has specific challenges – not necessarily greater than those for nurses in other settings, but different. Patients in rural areas are likely to be more reliant on primary and community health services, as a lack of public transport can mean getting to major hospitals is difficult. ‘Sometimes nurses in rural areas have to have a range of knowledge and skills,’ says Ms Donovan. Back-up support

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PUBLIC HEALTH FACES YEARS OF UNDERFUNDING

can be some distance away and nurses need great resilience and judgement to work on their own. Sallie Pilcher, professional head of adult and community nursing and patient safety at Cumbria Partnership Foundation Trust, says: ‘We try to ensure that if a nurse goes to an area she sees all the patients there – but she needs the skill set to deal with them.’ Nurses may have limited contact with their peers, she points out, especially if they use remote technology and have less reason to return to base.

Lone workers

Another issue in Cumbria is gaps in mobile phone coverage. Deputy director of nursing Esther Kirby says this has security implications for nurses working alone: ‘The district nurses are experienced and use all their skills and senses

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to make sure they don’t take unnecessary risks. We are hot on lone worker policies.’ Community nurses in rural areas may appear to have low caseloads, but they spend a great deal of time travelling and the patients they see often have complex needs. Research in Cumbria has found that the patients being supported at home and in care homes can be as ill and dependent as those in acute hospitals. Recruitment is another issue. Nursing workforces outside major cities tend to be more static. It can be hard to find agency nurses to cover shifts, and even being a few nurses down can make services unsustainable. One community hospital in Launceston, Cornwall, has recently reopened some inpatient beds after nearly a year of closure  because of staff shortages.

The Department of Health (DH) recognises that public health services in rural areas are often funded below their target allocation, which is the amount of money required to meet the level of need in their populations. Target allocations are based on advice from an expert committee to the DH. Rod Thomson, director of public health in  Shropshire, is concerned that progress towards  target allocations is slow, while allocations for some  overfunded areas are still increasing.  For example, his own county had a target of £33  a head and moved a little way towards that this  year when its grant from the DH increased from  £26 to £29 per head of population – but the target  allocation has also increased to £35.  In contrast, Kensington and Chelsea was funded  for £126 a head against a target of £45. But in  2013/14 it still received an increase – albeit only by   2.8 per cent – and by 2014/15 will still be funded  at nearly three times its target. ‘There is a question  here,’ says Professor Thomson. ‘Why does the  population of Kensington and Chelsea rate £100   a head more than Shropshire?’   It could be decades before local authority   areas meet their target levels – and, as rural  areas feature strongly among those that are  underfunded, this will limit what can be done to  improve their public health provision.  The allocations for 2013/14 and 2014/15 meant  that every area had an increase. ‘They tried to sell it  to us as everyone being a winner, but there are huge  discrepancies,’ says Professor Thomson.  He points out that rural areas often have pockets  of severe deprivation rivalling anything found in  cities. The government has accepted that the use  of the index of multiple deprivation – which looks at  several indicators of deprivation based on electoral  wards – misses much rural deprivation, which can  be more widely spread than in cities where it is  concentrated in specific areas.  Professor Thomson also questions whether  the full cost of providing public health services in  isolated regions is reflected in the funding system.  Economies of scale may not work for rural services  because there simply is not the concentration of  population within easy reach of a central service.  Shropshire has 17 market towns, with poor  public transport links between some of them, so  that a certain number of services will have to be  provided in every setting. In contrast, inner city  areas can offer services such as sexual health on  a single site, often with extended opening hours.  Professor Thomson adds that the extra travelling  staff in rural areas have to do also contributes  significantly to their costs. january 8 :: vol 28 no 19 :: 2014  21  

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Telehealth services

So what could change rural health care for the better? An expansion of telehealth services, reducing the need for face-toface visits, could be part of the solution; but less direct contact could increase isolation even further. For some older patients, healthcare workers are the only regular visitors they see. However, Nick Payne, who leads on rural health for the Rural Services Network, points to Scotland, where telehealth care has been used in remote hospitals successfully. Hospitals even have a link with New Zealand, where doctors will provide advice and read scans overnight, and Scottish doctors provide the same service back to areas of New Zealand during night hours there. 22  january 8 :: vol 28 no 19 :: 2014 

Community staff are also using IT to keep in touch with their base and access patient records. Tracker devices help pinpoint where lone workers are. The method of calculating funding allocations for different areas is being reviewed by NHS England. This review could bring increased money to areas with more older residents, which would benefit some rural communities. But the impact of any change is likely to be variable and other areas are concerned they could end up worse off. Professor Sheena Asthana from the University of Plymouth argues that the funding system

still puts too much emphasis on deprivation rather than age, with the result that funding is disproportionately given to urban areas, which tend to have relatively young populations. It could be argued that poorer access to services, including health, is part of the price rural residents pay for living in what can be beautiful parts of the country. But Mr Payne says: ‘In many instances they have made that choice much earlier on in life or have been living in that community since birth. The reality of modern life is that these services are being moved further away from them’ NS

‘RURAL SERVICE PROVISION COSTS MORE’ The national clinical director for remote and rural health care, Lesley Boswell (pictured), has spent much of her career providing and managing health care in some of England’s most rural areas, so she is well placed to voice rural issues at NHS England. Ms Boswell, who trained as a nurse  and health visitor, is also chief executive of  the Royal Cornwall Hospitals Trust, which  provides acute services across the county.  She is the fi rst nurse to be appointed to the  growing band of national clinical directors.  One of the most pressing issues is  rural ageing, she says. People in rural  areas are less likely to die prematurely  than urban residents, which  has an impact on the demand  for services.    Many examples of good  practice by rural healthcare  staff could be adopted  more widely, she suggests.  Ambulance staff, for  example, are skilled at  admissions avoidance,  saving patients and their  families the long journey  to an acute hospital.    Nurses, too, are  doing great work in  rural areas, says Ms  Boswell. Their skills  can keep people  out of hospital and  they make diffi cult  judgements on risk  that require good 

supervision and training. Nurses’ ingenuity  and skill can only be stretched so far, however. ‘We also have to accept that service  provision costs more in rural areas,’ says  Ms Boswell. Department of Health policy is  to bring care closer to patients’ homes and  the consequences of this in rural areas has to  be recognised. Her Cornwall trust recently  supported a home birth on St Agnes, the  remotest inhabited island of the Scilly Isles.  The national policy of centralising hospital  and specialist services also needs to be  applied sensitively in rural areas. Ms Boswell  points out that it is not always feasible for  someone living in a remote area to be taken  straight to a regional centre – a local  hospital might have to stabilise the  patient fi rst. Awareness of the pressures  on rural communities is  growing, Ms Boswell  says. ‘Perhaps previously  we had not really  acknowledged that  86 per cent of England  is rural and 20 per cent  of the population lives in  rural areas.’   

APEX

 In Norfolk, the community trust is working with the University of East Anglia to ensure that training equips newly qualified nurses with the confidence and skills to manage risks when working independently. Nationally there is a growing trend towards centralised acute services, with senior staff available around the clock; this is likely to have a disproportionate effect on rural areas. Smaller district general hospitals may find it harder to sustain consultant-led maternity and children’s inpatient services, and many have seen trauma services centralised already. In much of East Anglia, for example, staff rely on remote reading of scans to sustain acute stroke services. There are concerns that changes to the GP contract will mean financial support for small practices will eventually be phased out, forcing some to close. And with a significantly older population in rural areas than in urban areas, the impact of growing numbers of people with multiple comorbidities is likely to be felt there first.

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Cold comfort care.

People living in remote rural areas often have difficulty accessing healthcare services, and community and primary care providers are set to be even m...
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