It has long been acknowledged that there is a disparity in funding levels between urban and rural settings. Rural settings receive less funding per head, notwithstanding the additional costs involved in delivering care in rural areas.
There are many challenges involved in creating a health and social care model suited to sparse and elderly rural populations and the post-Brexit and post-COVID recovery is providing an opportunity to lobby Government for investment in rural areas as a means of stimulating the entire UK PLC economy. Systems-thinking and fair funding for rural settings will lead to rural regeneration, rural economic growth and support the Government’s plans for a green recovery.
Campaigning for change
In February, The Rural Policy Group invited MPs and speakers to discuss what these disparities look like in more detail. MP Anne Marie Morris said, ‘The first problem with developing a rural health and social care strategy is that the concept of ‘rural’ is not clearly defined. In this context, rural does not mean leafy Surrey villages. Rural applies to those parts of the British Isles which are remote and relatively isolated with poor infrastructure. There is not even a unified definition across Government departments, or even within them. The Housing Department is looking at rectifying that but only for its own Ministry.’
So, how do we rectify the lack of local provision in rural areas? MP Morris said the question itself raises the issue of measurement. Provision of health and social care is measured at too high a level – it needs to be more granular. So, we have problems with definition and measurement.
The widening gap
The financial settlement that comes into play on 1st April 2021 sees rural areas receive £11 less per head in social funding and 16% less per head for new social care grants. Urban areas will receive 61% per head more than their rural counterparts. Rural residents pay on average £96 per head more in council tax despite receiving 43% less than urban areas in Government-funded spending power. Rural residents will fund 69% of their local Government spending power through council tax compared with urban residents who fund 57%.
Due to a lack of Government funding, rural local authorities are much more reliant on income from council tax. Over the years, council tax in rural areas has increased to higher levels than urban areas, which has had a detrimental impact on rural communities. Despite paying more, rural residents receive fewer services and, on average, earn less than those in urban areas.
In addition, NHS allocations to Clinical Commissioning Groups (CCGs) in rural and urban areas receive similar funding per resident, which does not consider the older rural demographic. Health and care systems are not set up for rural care and hospitals that miss targets are often penalised with further reductions in funding creating a downward cycle.
A report conducted by Age UK calculated that by 2020/21, public spending for older people’s social care would need to increase by a minimum of £1.65 billion to £9.99 billion in order to manage the impact of demographic and unit cost pressure alone. It also notes that local authorities face additional pressures on their care budgets arising from implementation of the Care Act, National Living Wage and the costs of new requirements for care services. The impacts on individual rural council budgets from the growing demand for funded social care are troubling.
Increasing older population
Rural areas have a higher proportion of older residents and rural communities are becoming increasingly older. The proportion of older people within the overall population is increasing faster in rural areas compared with urban areas, especially for those aged 85 or over whose care needs tend to be more complex. The Office of National Statistics estimates that by 2039 nearly half of all households in rural areas will contain people aged 65 or over. Older residents place extra demand on NHS services due to chronic illness, disability and mortality.
The family care gap is growing as the number of older people in need of care is predicted to outstrip the number of family members able to provide it. Increases in female employment, smaller family sizes, increased geographical mobility and increasing complex needs leaves a large gap in the provision of elderly care from within the family.
The difficulties of providing home care are compounded by other factors such as obstacles in patients accessing health care services that are further away and harder to access by public transport. Rural residents face longer journeys to reach a GP surgery than their urban counterparts. Rural Services Network (RSN) figures show that local authorities in rural areas have less money available for buses, with urban councils spending five times that of rural councils on supported bus routes. From 2009-2019, funding for rural bus services has fallen 43% in real terms.
This has been illustrated in recent weeks with the rollout of the COVID vaccine; while there are vaccination sites in rural areas, many of those at the top of the list to be vaccinated did not have their own means of getting to them. As ever, the local community rallied around and a combination of community buses, cheap or free taxis and neighbours helping ensured people received their potentially life-saving jabs.
The lack of infrastructure including transport issues and poor connectivity leads to deprivation in rural areas. Patients struggle to get to hospitals and there is a lack of GP services. In Kent, rural areas are not terribly remote, but the public transport infrastructure means villages can be quite isolated in health terms as it is difficult to reach the bigger, more well-serviced hospitals without a car. Even with a car, the hospitals can be a long drive upwards of 30 minutes.
Care providers operating in rural areas face a variety of specific challenges related to demographics, service provision and costs. A lower population density makes economies of scale difficult, resulting in higher per unit costs for service delivery. Local authorities are keen to realise cost savings comparable with urban communities, without considering unique geographical conditions. Rural healthcare provision may benefit from more specialist-generalist practitioners as residents struggle to see multiple consultants and nurses. Improved training of medical and care workers would enable services to be delivered in tandem. There is a need to create new care pathways to address the shortfalls in training and rework the geriatrician role.
Recruitment of care staff remains a challenge for rural care homes. In areas with a smaller pool of potential local employees, low pay and zero hours contracts do not help to attract staff, especially with more attractive alternatives on offer from the hospitality and retail sectors. Before the COVID outbreak the care industry had over 120,000 vacancies.
According to the Rural Services Network (RSN), significant sums of public expenditure have been invested to extend the reach of superfast broadband networks into less commercial areas. This included match funding from rural local authorities (a cost not borne by urban authorities). However, there remains a noticeable gap between levels of connectivity in rural and urban areas. In England’s rural areas 11% of premises – households and businesses – are unable to access a broadband connection with a 10 Megabits per second (Mbps) download speed. Industry regulator, Ofcom, considers this a necessary speed for everyday online tasks.
In the most remote rural locations connection speeds can be significantly worse. A survey of its members by the National Farmers Union in 2017 concluded that half (50%) could not yet access a basic two Mbps connection. In view of local authorities heavily relying on the web to publish resources and to signpost to community groups, it’s of great concern that vulnerable groups could not be accessing the social care information they need to support their health and quality of life.
Older people being geographically separated from their families and in some cases living in isolation can become extremely independent and hesitant to being assisted by care professionals. Isolation in rural areas leads to higher levels of mental health challenges such as suicide, for example Devon has one of the highest levels of suicide in the UK. The farming community is also particularly affected by mental health problems. Nearly half of all calls made to The Farming Community Network’s support helpline (between July-October 2020) have related to mental health.
Technology to combat gaps
The advent of digital communications has provided a variety of innovations in health and social care that can improve service delivery, patient outcomes and wellbeing.
Social distancing rules in care homes have prompted staff to think of more inventive ways for residents to keep in touch with loved ones. The use of iPads, laptops, Zoom calls and Facetime have enabled people to communicate throughout the pandemic.
An exciting development for social care comes in the form of robotics and engineering. Robots that can hold simple conversations with residents have been found to improve mental health and reduce feelings of loneliness. Researchers at the University of Bedfordshire conducted a trial both in the UK and Japan and found that older adults in care homes who interacted with the robots for up to 18 hours across two weeks had a significant improvement in mental health.
However, many of these technologies are reliant on good digital connectivity, leaving behind those in areas without reliable broadband.
Level playing field
However, despite the emergence of new technologies, the impact of a global pandemic shines a light on the disparity of funding in rural areas. Fairer funding from Government is required to improve health and social care services for rural communities now and into the future.
Going forward we need to look at how we build resilience and sustainability into the system. How can we make sure we make the most of AI? How can we make the most of the volunteers? How can we do the most to make sure communities are self-reliant and resilient so when isolated locations are cut off entirely (e.g., by snow) they can continue to provide good care and support to residents? Ultimately, rural communities must be part of the levelling up agenda.