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Healthcare in a rural setting

January 2005
Board of Science

Bringing healthcare services to local areas
Many services are becoming increasingly centralised and withdrawn from local areas, particularly specialist secondary sector services. Primary care is therefore increasingly important in rural areas, allowing rural patients access to local healthcare facilities and avoiding transport limitations. In this section different ways of delivering a local health service are discussed.

Branch surgeries
If access to a practice is difficult for residents in rural areas, a limited service may be periodically provided locally in suitable accommodation. Branch surgeries are one way for patients in outlying villages to be able to see their GP. However, branch surgeries are now much less common than a generation ago. They vary enormously in scope and size, and may be identical to a main surgery or may be merely a room in a village hall. Equipment and staffing levels also vary widely. These surgeries tend to be popular with patients because of the easy access, but may offer a limited range of services and be a time burden for the GP. [go to reference 87] Additionally, under the new GMS contract, [go to reference 68] if branch surgeries where the premises are owned by the GP partners are open less than 20 hours per week, they will no longer attract funding for improvement and enhancement, money for computer equipment or other additional benefits, making it less financially viable. However, primary care organisations can still choose to fund them, if they are providing vital local services.[go to reference 88] Branch surgeries are an essential service that provides rural patients with access to GP facilities and it is important that such services are developed.

Case study – Branch surgery threatened with closure (UK)
Proposals to close the last remaining GP branch surgery in a north-east village in the UK caused concern among residents in November 2003. With the doctor running the branch surgery due to retire, her partners wanted to close the surgery as with one doctor fewer it would have been impossible for them to open the 20 hours a week needed to qualify for government funding. Instead, the 1,100 patients on the list would have had to transfer to the partners’ main practice three miles and two bus rides away. This would mean four bus rides in total for people already sick enough to need a doctor and would be practically impossible for elderly people and mothers with young children. [go to reference 89] Without a surgery the local pharmacy would become unviable. The North Tyneside primary care organisation decided that a surgery was needed in the village and helped the surgery recruit and pay for another doctor to run the service. [go to reference 88]

Case study – Sustainable nurse-led branch surgery (UK)
A branch surgery in the large rural village of Letham (in north-east Scotland) provides a weekly nurse-led clinic and is a successful adjunct to existing services. Running the branch surgery without heavily involving the time and input of the closest GP surgery, which is six miles away, has created a sustainable service.90
The clinic was initially open for patients over 65 years of age, but is now available for all age groups. It gives access to advice, medical care and health promotion for those living in a rural area. Many minor ailments are handled by the district nurse; other patients are handled by a GP using teleconsultation. The nurse screens the patient before the clinic to decide on suitability for teleconsultation and the GP is then sent a list of suitable patients. The GP can then request the nurse to perform follow-up investigations and actions. While some patients may prefer to visit the main surgery due to urgency or a need to use the chemist facilities, the clinic spares many rural patients the need to travel the six miles to the clinic on limited public transport. Challenges include the costs involved in training participants in the use of technology, in conducting effective teleconsultations and upgrading and maintaining technology.[go to reference 90]

Community hospitals
Community hospitals are at the interface of primary and secondary care. They provide more care locally and relieve pressure on the secondary sector. [go to reference 14] They are generally run by local GPs, many of whom have specialised skills to help provide medical services. The GPs can be aided by visiting consultants and good liaison is important because of the need to seek advice when the consultant is far away. Telemedicine can also link the Community Hospital with its local district general hosptial. [go to reference 87] About 10 per cent provide the majority of the hospital-based care for the populationsthey service, including acute medicine, surgery, terminal care and maternity care. Another 10 per cent of community hospitals provide extended nursing long-term and respite care in much the same way as well equipped nursing homes. The remainder provide care which lies between these two extremes, usually including a minor injury service, specialist out-patient clinics, X-ray facilities and physiotherapy. [go to reference 87]

Nearly 400 hospitals in England, Wales and Northern Ireland are represented through the Community Hospitals Association (Scotland is represented by the Scottish Association of Community Hospitals). The Association reports that community hospitals are now being promoted as a critical part of the new primary care led NHS and many are considering plans for expansions, upgrades and new developments. [go to reference 91] For example, consideration should be given to the expansion of hospital and day surgery or one-stop clinics; travelling radiology units providing MRI, CT and ultrasound scanning; outreach dialysis clinics; oncology services and mental health teams. [go to the reference 9] There is the potential to develop new variants of community hospitals that would act as community resource centres and provide locally accessible integrated care in one place. [go to reference 92]

Potential problems regarding the staffing of community hospitals should be addressed. With GPs being given the opportunity to transfer the responsibility for arranging provision of out-of-hours care under the new GMS contract, there is a concern that there will be inadequate staff to run community hospitals out of hours. It is important that the complexities of providing out-of-hours care in remote areas is fully understood and solutions are well thought out, adequately funded and safe for patients (see the previous section on the burden of duty). Staffing problems may also arise from the lack of a national framework for payment of those GPs who staff community hospitals. This can result in pay variations amongst community hospitals in the UK and can act as a disincentive to recruitment.

Mobile services
Mobile services can provide access to healthcare in a non-healthcare setting, making services geographically accessible for patients in rural/remote areas. For example, a pilot mobile wheelchairrepair service in the Highlands, funded by RARARI, had a huge impact on the quality of clients’ lives and should be continued. Mobile services can also make healthcare facilities culturally accessible. The existence of cultural barriers, such as self-reliance and fear of visibility and stigmatisation in small rural communities can result in poor uptake of services. [go to reference 21] These services also help rural communities to access information, employment, and education and training which influence wider determinants of health and wellbeing. [go to reference 21] Providing services in non-traditional healthcare settings, where patients can ‘drop in’, encourages use of those services.

Mobile services can act as an interface between primary and secondary care, providing ultrasound, CT scans and MRI scanning, as well as therapeutic interventions such as chemotherapy, dialysis and breast screening. [go to reference 9] They can also usefully provide other essential services such as family planning and STI clinics. Mobile services can provide access to health education information and healthcare in a non-threatening, culturally accessible format.

Case study – Improving access to healthcare for farming communities (UK)
Many farming communities are by their nature isolated from mainstream services, and have developed a culture of self-sufficiency and stoicism, yet evidence suggests their health needs are actually greater than in many other sectors of society. The two-year Farmers’ Health Project, which began in 1999, aimed to bridge this gap between healthcare need and service provision in the farming communities of South Lakeland and North Lancashire. [go to reference 52] Piloting involved nurse practitioner-led mobile outreach, including agricultural auctions and farm visits. The researchers examined the particular health needs of the farming communities. They addressed inequalities and created healthcare which crossed the boundaries of primary/secondary care, physical/mental health and health/social welfare provision.

The presence of the mobile clinic at agricultural gatherings created access to healthcare in a non-healthcare setting and encouraged health awareness. Nurses also became involved in farmers’ organisations such as Young Farmers and the Women’s Institute, partly to communicate what the project was offering and partly to create opportunities for health promotion. Networking was also important to build trust with the farming community, to ensure an uptake of the services.

Previous unmet need was addressed, with the vast majority (85 per cent) of patients selfreferring and using the nurse practitioner and the clinic van to drop in, if only for ‘just a check up’ (often with additional problems that they disclosed after time). The age range of patients was wide but 70 per cent of them were over the age of 50 and constituted the group the project wished to reach – older men likely to have health problems who only rarely found their way to their GPs’ surgeries.

The Farmer’s Health Project was an exploration of one method of addressing the healthcare needs of isolated communities. Evidence shows that this method of providing healthcare is effective, complementary to that of the GP, and demonstrates a multi-agency approach to addressing the complex problems found in this community. The recommendations of the project included establishing the principle of mobile outreach services in rural health provision, and developing the role and skills of nurses and other healthcare workers. [go to reference 52] Due to a lack of funding Morecambe Bay Primary Care Trust has run a much more limited farming community health service since 2002, which is due to run for three years. Services available include life style advice and blood pressure checks, and public health campaigns are regularly run with rural community groups such as the Young Farmers. The initiative is limited as a mobile van is not available for work and travel purposes, although local auction markets are visited on a regular basis.

Recommendation 10
Local, innovative healthcare services must be provided to allow patients to reach those services and have a choice in the facilities that they use. To deliver high standards of healthcare, the combination of services for a community should vary according to size and location, distance from alternative healthcare services, and community demographics. [go to reference 93]

In order to maintain these essential services:
• the incentives and discincentives of working in local services needs to be addressed to improve recruitment and retention
• the basis for funding needs to be reviewed and branch surgeries and community hospitals must be viewed as providing a vital local service.

Telemedicine
Telemedicine provides and supports healthcare when distance separates provider from patient, [go to reference 93] through the use of information and communication technologies such as interactive video, digital imaging and electronic data transmission.[go to reference 94] In rural/remote areas, where patients may have difficulty accessing healthcare services, and where GPs may not have access to consultations with specialists, this is vital technology.

Telemedicine allows consultations between patient and doctor where face-to-face contact is not possible. Live telemedicine allows the clinician and patient to communicate via a real-time live audio-visual link. Time-delayed telemedicine involves capturing a visual image of the patient and then transmitting it electronically to the clinician, for example, a picture of a pigmented skin lesion sent to a dermatologist. [go to reference 95]

Telemedicine also facilitates interaction between healthcare professionals and can enable a rural practice to link with a larger hospital, usually in an urban centre. [go to reference 93] In Canada telemedicine has been shown to be an effective way to reaccredit neo-natal resuscitation skills in remote practitioners on a regular basis. Providing telemedicine in rural areas presents particular difficulties (key issues 10).

Case study – Accident and emergency (A&E) teleconsultation (UK)
A study evaluated the success of an A&E teleconsultation service over a 12-month period. [go to reference 96] Fourteen community hospitals in north-east Scotland, with remote minor injuries units, participated in this service. The A&E department at the Aberdeen Royal Infirmary provided telemedicine advice on still images of wounds and radiographs. The majority of teleconsultations related to fractures or suspected fractures of the limbs.

Although this study was carried out in Scotland, its implementation could be widened across the UK. The telemedicine equipment can be used for many other purposes, so increasing its cost-effectiveness. Some possible uses are as follows.

• Expanding the range of clinical applications beyond accident and emergency services: for example, a US maternity services system could be adapted for the UK. The Fairview Ridges Hospital in Minnesota (which serves a surburban and rural area) uses telemedicine to connect patients and practitioners to the specialty care and services available in the central Minneapolis/St Paul region. The equipment includes an ultrasound scanner that is connected for viewing at the specialist centre, physiological monitoring equipment with remote access, videoconferencing equipment and electronic medical record equipment. This increases patients’ access to specialty providers and therefore improves patient assessment and care management, while maintaining patients within the local community. [go to reference 97]
• Televisiting: telemedicine technology has also been employed as an aid to overcome the problems of patient communication with family and friends. For example, a teleconferencing link was set up at the Royal Cornhill Hospital in Aberdeen, to allow long-term psychiatric patients from Shetland to communicate with family. [go to reference 6]
• Continuing professional development (CPD): telemedicine equipment can be used to widen access to CPD opportunities through an e-learning approach, for example by making videoconferencing possible (go to the previous e-learning section).

Case study – Telemedicine in the Falklands
Telemedicine has a major part to play in the Falklands, where outlying farms and settlements may be a 100 miles away from the medical services based in the capital, Stanley. For example, telemedicine is used to seek advice from colleagues in the UK. Radiographs and photographs of skin rashes are commonly emailed for advice. In 2003 the plan was to install new X-ray equipment to allow all radiographs to be reported on by a consultant radiologist. The main limiting factor in 2003 was the absence of ISDN lines or broadband communication. [go to reference 98] In addition, consultations are often completed by telephone and the patient may be advised to take medication from the ‘medicine chest’ that is provided. A replacement for the chest is then sent in the post. [go to reference 98]

Key issues 10: difficulties associated with providing telemedicine
• If patients in rural areas have difficulties accessing healthcare services, they may also have difficulties getting to where the telemedicine service is available. [go to reference 61]
• The quality of a consultation is very dependent on the quality of the system being used and a poor quality link may mean that images and sound are fragmented and distorted. [go to reference 95]
• In GP-patient teleconsultations, the patient cannot be palpated or subjected to physical examination by the GP. [go to reference 95] However, methods of addressing this difficulty can be considered, such as a nurse practitioner physically examining the patient.

Initially, many rural areas were less likely to have access to the necessary technology, such as broadband communication and NHSnet (a secure wide area network developed exclusively for the NHS and available from two service providers: BT and Cable & Wireless).[go to reference 99] This was due to the use of trigger levels, where a certain amount of local interest had to be expressed before broadband could be introduced. However, the initiative by BT to introduce broadband to more areas is most welcome, as is the discontinuation of the trigger level system. It is intended that most of the UK population will automatically be able to receive broadband by mid-2005. However, this would still leave some rural parts of Scotland and Wales without fast internet access. These areas should be able to be reached using a wireless broadband network similar to the one established in Northern Ireland. It is recommended that the introduction of broadband to rural/remote areas must be introduced as quickly as possible.

Recommendation 11
The use of telemedicine should be encouraged. It gives increased flexibility to healthcare service providers and allows them to expand the scope and quality of services.

While the initial consultation with a patient may need face-to-face interaction, follow-up consultations could usefully use telecommunication. As the distance to alternative healthcare services increases, telemedicine can become a more attractive option. [go to reference 93] Isolated rural GPs may particularly benefit from contact with colleagues. Funding is needed from the DH to subsidise the equipment necessary to provide telemedicine services.