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Healthcare in a rural setting

January 2005
Board of Science

Transportation and access to services
The limitations of public transport
Transport is important as a means of gaining access to good quality healthcare services. [go to reference 21] However, the lack of public transport in many rural areas means that residents have to rely on private transport, and car ownership is often higher in rural areas due to necessity. [go to reference 21] More than nine in 10 people living in rural areas use the car for their main food shopping trips and for travel to hospital; this compares with seven in 10 adults in urban areas. [go to reference 77]

Residents on limited income are less likely to have access to private transport, and a lack of public transport causes difficulty in travelling to healthcare facilities. In addition, people aged 16 to 24, and those aged 75 and over have more difficulty accessing services than the general population. [go to reference 77] As previously highlighted, the proportion of those aged 75 and over is greater in rural areas. In one-car families where the working parent uses the car to get to work, the remaining partner needing to travel to health facilities will be reliant on public transport if it is available, or taxicabs if they can be afforded and are available. [go to reference 21] Women are more likely than men to report difficulty in accessing a chemist, GP, post office or main food shop. This reflects the longer journey times they experience and their lower car use. [go to reference 77]

Improving rural transport is vital to improve accessibility of available services. The Countryside Agency has made special provision for public transport services in rural areas, to promote the social inclusion of people living in these areas by enhancing transport services and securing a long-term improvement in access to jobs, services and social activities. The Rural Bus Subsidy Grant Service was set up in 1998 and is provided by central government funding. These funds are to enhance existing services in rural areas, for example by extending evening services. The Rural Transport Partnerships Scheme supports community-based transport initiatives, including commercial and voluntary schemes. [go to reference 78] For example, Hampshire County Council used available funds to set up transport to Basingstoke Hospital from rural areas, as existing journeys were long and involved changing buses. This scheme operates two services three days a week to Basingstoke Hospital. [go to reference 79]

Unfortunately, the funding available for enhancing public transport services in rural areas is not fully able to meet health needs, as it is also used to increase opportunities for travel to work and training, and to retail and leisure services. There are also concerns about funding for transport schemes in the long-term, for example the Rural Transport Partnership scheme is currently only due to run until March 2006. Long-term funding dedicated to improving access to healthcare services for patients living in rural areas is required. The Countryside Agency has recently published research on the benefits of providing transport to healthcare in rural areas. The report recognises that there is currently little health sector funding for transport schemes and that the health sector, local authorities, Community Transport Association, Countryside Agency and Department for Transport need to be involved in providing solutions.
In addition, only limited funding is available for voluntary services such as community car schemes, which many rural residents rely on. Research by Hampshire County Council has suggested that some 70,000 health related journeys are provided countywide by voluntary car schemes, [go to reference 79] and it is probable that these provide a vital service nationwide. These schemes are necessary when patient transport services are not available, and for those who do not have private transport or cannot use public transport. Public transport is not the most appropriate transport option for sick people, because of timing, discomfort and lack of skilled support. [go to reference 80] However, many community transport schemes struggle for funding. Hampshire County Council suggest that an increase in the proportion of elderly people in the population will result in a much greater demand for such health-related transport schemes. [go to reference 79]

Emergency transportation
An infrastructure of transportation that responds to emergency calls is vital in rural/remote areas to ensure rapid access to effective pre-hospital and hospital care. Pre-hospital care is particularly important in rural/remote areas where specialist hospital care may only be available in urban centres with longer travelling times. Pre-hospital care can be effective for diseases such as myocardial infarction, where 91 per cent of cardiac arrest deaths in people under 55 years of age occur outwith hospital. [go to reference 81] Pre-hospital care therefore provides the greatest scope to improve survival. [go to reference 82] A study found that reducing ambulance response times increased the chances of survival from out of hospital cardiac arrest. A general improvement in response time results in more people with chest pain being reached by a healthcare provider with a defibrillator before the onset of cardiac arrest. [go to reference 82]

In-hospital thrombolysis is an effective treatment for myocardial infarction, providing treatment is received promptly. However, patients in rural/remote areas may not receive timely transportation to hospital.[go to reference 83] In response to research on thrombolysis in peripheral general practices in Scotland
by Rawles and Ritchie (1999), [go to reference 84] pre-hospital thrombolysis is now being developed in rural/remote areas to improve access to early treatment prior to reaching hospital.

A study in Scotland explored the effectiveness of pre-hospital thrombolysis after the closure of the coronary care facility of a small district general hospital. [go to reference 85] The closure meant longer journey times for rural/remote patients to the base hospital; rural patients were classified as those outside a 15km radius of the base hospital. Rural patients were divided into two groups for the study. Group one was outside the 15km radius but still considered for in-hospital thrombolysis. Group two was outside the 15km radius of the base hospital, in the area previously served by the district general hospital, and considered for pre-hospital thrombolysis. Paramedics with the Scottish Ambulance Service, with hospital-based support, delivered the treatment to group two patients. The median time from first medical contact to initiation of thrombolysis for group one was 125 minutes and for group two was 52 minutes. The pre-hospital treatment was found to be most effective in meeting the needs of patients from rural areas with a median time saved of 73 minutes.[go to reference 85]

Increasing the response times of emergency care in rural/remote areas is vital. In addition, all ambulance Trusts in the UK should be trained and equipped to provide appropriate pre-hospital care, including thrombolysis. In remote areas, it is also important to consider alternative forms of transport to road ambulances. For example, roads can become congested in summer months in rural tourist areas, [go to reference 86] making journeys longer and more unpredictable. For patients living on remote islands, ferry transportation is not always appropriate and is weather-dependant. Other forms of transport, such as air ambulances, must be considered in such areas.

Case study – The West Country Service: providing a range of transport services (UK)
The West Country Ambulance Service NHS Trust provides ambulance services for two strategic health authorities: Dorset and Somerset, and the South West Peninsula. In addition, the Trust works with 15 primary care organisations for ambulance matters and 18 for NHS Direct. [go to reference 86]

The Trust provides out of hospital care and transportation in response to 999 (emergency) or urgent calls (from doctors, dentists and midwives) within the counties of Cornwall, Devon and Somerset. There is an air ambulance available, which is particularly important in rural areas where roads can become congested in the summer months.

The Trust also has patient transport vehicles and provides transport to individuals who are unable, for medical reasons, to make their own way to hospital. This is non-emergency work including admissions and discharges from hospital and attendance at out-patient clinics. This service is provided by ambulance care assistants and provides opportunities to support and give assistance to those in need. Staff are extensively trained in basic life support skills and first aid. Voluntary car drivers are also used to drive non-urgent patients to and from hospital appointments.

The Trust also runs a responder scheme, where first responders answer life-threatening emergencies in advance of the ambulance's arrival in their local area, providing the best opportunity of survival for patients. First responders comprise of off-duty Trust staff, fire and rescue co-responders and community volunteers. The ambulance service welcomes applications from members of the public to become community first responders. The first responders are called at the same time as the ambulance, and usually arrive at the scene first due to their knowledge of the area, or their proximity to it, and can initiate treatment straight away.

Voluntary emergency services
Isolated rural communities have a tradition of self-help with voluntary emergency services such as Mountain Rescue, Lifeboat Service, Auxiliary Coastguard Teams and Fire Teams. The NHS needs to construct an organisational framework for voluntary participation in emergency healthcare situations, such as attending local road accidents or sudden collapses, for the whole of the UK. The involvement of voluntary participants within small communities will mean that issues of training, liability and indemnity will need to be addressed.

Recommendation 9
Improved coordination and planning of transport schemes is needed at local and regional level. Transport considerations should be integrated into any health service planning for rural/remote communities.

• A range of new innovative transport schemes is needed within rural areas, for example emergency transport, non-emergency hospital transport and transport to day centres, GPs, getting prescriptions and follow-up care.
• Need should be identified at local level. Local service providers (public, private and community-based) and communities should be involved in systematically identifying these transport needs. Funding specifically for health-related needs must be provided by the local authority for both voluntary schemes and non-voluntary schemes.
• An infrastructure of transportation that responds to emergency calls and ensures access to effective, rapid, pre-hospital care is vital in rural/remote areas. Rapid response times need to be ensured and the transportation adequately equipped to provide pre-hospital care. Different methods of rapid transportation must be available according to the different needs of a rural area.