Debate on the Address

My Lords, I have a long-standing interest in the quality of life in rural England. With that in mind, I want to look today at the delivery of healthcare to our countryside. The reality is that delivery of all services to rural Britain suffers from many of the same problems.The first and most important of these is a misunderstanding of the deprivation that exists there. Such deprivation and poverty is very real but, unfortunately for the people concerned, they are sprinkled—often liberally—among people of means and even quite considerable wealth. The result is that, both in deprivation indices and health inequalities, such deprivation does not show on anyone's radar because the average statistics of the community hide the uncomfortable truth of its existence. The second major problem of rural delivery stems from the dispersed nature of the population. Transport, for instance, is a major and costly barrier to access. The distances involved often mean that twice the time and thus twice the cost is spent on the job, compared to carrying out the same job in an urban setting. It is not only a problem for GPs on home visits, for patients accessing A&E and other specialist treatment, but for carers and even for hospital visitors. I remember once on a visit to the east Midlands being told that a visitor to the nearest hospital in Lincoln on public transport was left with only a 25-minute turnaround at the hospital if they wanted to get there and back within a day. The sparsity of the population also results in extra fixed costs: the number of small outlets required means that the core costs of delivery are multiplied. Numerous small health centres and community hospitals are good examples of that. There was a recent National Audit Office report on the costs of out-of-hours cover needed for the new opt-out doctors’ contracts. We know from that report that out-of-hours cover costs more than 70 per cent more in rural areas than urban ones. I suspect that the same differential applies to cover for training and continued professional development. Indeed, I know that one problem that remote practices have is the time it takes to get to training. A few hours training can often take a whole day, or even a day and a half. Smaller rural practices also appear to have a problem attracting young doctors and other qualified staff to remote communities and to what they see as a possible career dead end. It is true that older doctors sometimes prefer rural practices, but of course they tend to be more expensive than young doctors. As a result of all these problems, it is interesting to note that, following the Scotland Office paper, Fair Shares for All, rurality adjustments have been made to the funding formula in Scotland, with some rural areas receiving more than 31 per cent of extra resources. Without this extra funding in England, it is unsurprising that, although the rural population is only 20 per cent of the total English population, last year half the PCTs in deficit were rural, while most of those in surplus were urban. My main point today, therefore, is that a specific and adequate rural weighting must be built into the proposed review of the health funding formula, which I gather is due to start next month. I shall touch on a few other aspects of rural healthcare. We have recently entered a new era. The average population of a PCT catchment area has increased from 65,000 to almost 1 million. I totally understand the economic reasons for this, but it gives me even more reason to be concerned about rural healthcare. The larger the area, the easier it is for poor rural statistics to be hidden within the better urban average. I have heard various stories about PCTs being able to meet their Treasury targets best by focusing all their efforts on delivering to their one or two large urban centres and abandoning healthcare delivery to the countryside altogether. Of course none of them will have done that, but I suspect that lesser versions of that thinking must always be there when targets are looming. In the new regime, and in next year’s Comprehensive Spending Review, it is therefore important that the Treasury sets targets that require a universal and high standard of delivery across the board. In other words, we must rural-proof Treasury targets. Furthermore, the Department of Health must rural-proof all its policies at both a national and local level. Having said that, the first requirement of rural-proofing is to produce specific rural data sets so that we know what is going on and whether we are delivering effectively to the 20 per cent of our population that lives in rural England. So far as I can find out, only the ambulance trusts currently monitor rural/urban differences in patient care. Apparently, other parts of the service could flag their rural data, but choose not to do so. A difference that probably should be monitored is that of unpresented needs in rural communities, which could have considerable future costs attached. Research indicates that rural folk access out-of-hours treatment less than their urban neighbours, and I suspect that that reluctance also applies to more regular healthcare, particularly when it is preventive. There is evidence, for example, that distance is a key factor in the uptake of breast-screening services, and that the utilisation rates of both general practice and hospital out-patient services decline according to distance from the service. The same is true of specialist services such as family planning, sexual healthcare, and even regular preventive dentistry. I do not know whether rural people are more stoical or simply feel disempowered, but one thing is certain: old people are less willing and sometimes less able to travel, and in remote rural areas 28 per cent of the population is over 60. Again, all this emphasises the likely extra costs of rural healthcare in the future. I welcome the recent reinvention, or falling back into favour, of rural community hospitals. Given the major difficulty of transport, they have a vital role to play in our countryside. I hope that they will continue to take on more diagnostics, more minor procedures, and more pre-operative and post-operative procedures and other consultations. I also hope that they will provide more walk-in clinics to help with the high costs of rural out-of-hours treatment that have already been mentioned. Community hospitals are much loved and, indeed, much supported. I visited Tenbury Community Hospital in the Malverns, which, with a local catchment population of only 12,000 people, manages to raise more than £300,000 per annum for the hospital. I am sure that similar examples of that could be given all over England. What is less welcome in the countryside is the whole competition debate. A rural catchment area is unlikely to be attractive to new private deliverers; as I have already explained, it costs more. At its best, this debate can be said to be meaningless to the rural population. But there is a real danger that a competition agenda, if taken to its logical conclusion, could undermine the vital partnership work that is essential for the best-value delivery of healthcare in rural areas. In conclusion, I re-emphasise my main point about having an adequate funding formula for rural healthcare delivery. It should be noted that the rural population is growing three times faster than the urban population, and much of this growth comes from elderly in-migrants, who by their very age are more likely to put pressure on the health service. The difficulties of serving this population will not go away. I have hardly touched on the existing problems of dental care in rural England. I recognise that, on the surface, the indications are that country folk have better health than townsfolk. But as I said at the start of my speech, such average statistics mean nothing to the 20 to 30 per cent of deprived rural people who have difficulty accessing 21st-century healthcare in rural England.