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Healthcare in a rural setting

January 2005
Board of Science

Rurality and healthcare
Research is beginning to show that there are rural-urban differences in health outcomes, and challenges the belief that rural patients have a health advantage over their urban counterparts. [go to reference 11] Different approaches to healthcare provision may need to be taken in rural and urban areas, as often those that work well in urban areas do not translate to a rural situation.

Recognition of the benefits of specialised cancer care, for example, has led to the reshaping of cancer services in the UK. This has resulted in a move towards centralisation, which has implications for those living in rural areas. [go to reference 12] A Scottish study investigated whether survival from cancer differed for patients resident in a rural and an urban area. It was found that patient distance from the nearest cancer centre can affect cancer survival. [go to reference 11] More remote patients are less likely to have their stomach, breast and colorectal cancer diagnosed, and have poorer survival after diagnosis for prostate and lung cancer.[go to reference 11] Another study [go to reference 12] lends support to the theory that remote/rural patients may be disadvantaged in the early diagnosis of cancer.

Health outcomes for patients in rural areas compared with patients in urban areas needs to be more fully researched as there is a paucity of evidence. The joint GPC/IRH report suggests that this reflects the relatively recent development of health research in rural areas and the use of varying definitions of rurality. The report suggests that a consensus definition of rurality is needed to help develop this evidence base. [go to reference 3] However, it is very difficult to identify a definition that encompasses the many facets of rurality relevant to primary and secondary care.

What is rurality?
This section discusses the characteristics of a rural area and examines the different methods of measuring rurality and rural deprivation. For the purposes of this report we are particularly interested in defining rurality and rural deprivation in a manner that is relevant to healthcare. More detailed discussion of the wider debate can be found in the joint GPC/IRH report. [go to reference 3]

Rural areas account for over four-fifths of the UK landmass and include up to a quarter of the population. Rural areas are heterogeneous and the differences between rural areas in terms of social, environmental and economic challenges are arguably as great as the differences between urban and rural areas. [go to reference 13] The definition of rurality is, therefore, far from straightforward.

Population
In remote/rural areas, the proportion of older people in the population will be higher than in the general UK population. [go to reference 14] Many rural areas have experienced migration patterns that have led to an ageing population, with the outward migration of young people and the inward migration of older, retired people. [go to reference 15] This may mean that healthcare practitioners in rural areas need to deal more often with chronic diseases that increase from the middle years of life into old age, such as heart disease, stroke and mental illness. [go to reference 16] In addition, older patients may have more difficulty accessing services than the general population. Many rural areas also experience changes in population density, with the fluctuating population of temporary residents, many of whom are tourists.

Loss of services
Research has suggested that the core services essential to maintain a sense of community are a shop, primary school, general practitioner (GP) and community hall. [go to reference 17] A local post office could also be considered essential. However, many rural areas are now suffering a decline in these local amenities, resulting in the need to travel longer distances to access services. It is suggested that service decline impacts most on poor people and the elderly. [go to reference 18]

Remoteness
Rural areas that are also remote are challenged by the greater inaccessibility of urban centres and sparser infrastructure than less remote rural areas. [18 - go to the reference] Remote areas may also have fewer economic opportunities. For example, remote/rural areas of Scotland such as the Highlands and Islands area, is one of the most sparsely populated in the European Union (EU).[go to reference 18] This area has a population density of 9.5 people per square kilometre compared with an EU average of 116 people in 1998. Thirty per cent of the population live on more than 90 inhabited islands. While more accessible areas within the Highlands are flourishing, the population of the island and remote areas is declining and ageing. Average weekly earnings in the Highlands area are lower than the Scottish average and there are high rates of long-term unemployment. The cost of living is higher than in more accessible parts of Scotland. [go to reference 18]

Remote islands in particular experience difficulties in providing healthcare services. This results from:

• having to provide a certain standard of service for a small population

• the need to cater for the fluctuating population of temporary residents

• high proportions of elderly residents

• the cost of transporting goods

• the need to pay incentives to recruit and retain healthcare professionals. [go to reference 19]

Deprivation
Rural deprivation has been largely ignored in the post-war period, partly due to the image of the ‘rural idyll’, which has been difficult to counteract, and also due to the focus on urban deprivation. However, there are people experiencing disadvantage throughout rural areas, and they often live in close proximity to people with very different circumstances. [go to reference 20] This results in small pockets of deprivation existing within relative affluence. [go to reference 21] Deprivation in a rural context involves a complex interaction between factors associated with income, social circumstances, access to services and choice. [go to reference 22] Those with resources can access a range of services using private transport, while those with lower income have restricted access to services, limited choice and high living costs. [go to reference 17]

It is suggested that rural areas experience particular forms of deprivation to a greater extent than urban areas.

These include:
• household deprivation: low incomes and lack of housing opportunities
• opportunity deprivation: decline in services and employment
• mobility deprivation: difficulties in obtaining access to jobs, services and facilities.

Deprivation and poverty are important determinants of health and disease, [go to reference 23] and various aspects of deprivation such as poor quality housing have been the subject of previous Board reports.24 Researchers are now beginning to examine relationships between health and life circumstances in rural areas. [go to reference 22] Deprivation needs to be appropriately measured if resources are to be targeted at local health inequalities. [go to reference 22] However, existing measures of deprivation are inappropriate for use in rural areas. This is partly because they may be more suitable for urban areas and partly because they do not allow for the heterogeneous nature of rural areas. Small pockets of deprivation are, therefore, missed. [go to reference 22] An appropriate measurement also relies on an understanding of the extent to which urban and rural deprivation differ. In recent years there have been attempts to develop rural specific indicators, which now need to be evaluated in the context of rural healthcare. [go to reference 3]

Measuring rurality
The lack of an agreed definition of rurality means that there is not one preferred method of measurement. [go to reference 7] Different methods of measuring rurality, stressing different rural characteristics, fit different purposes. [go to reference 25] The Countryside Agency uses settlement size to delineate rural areas. It defines rural wards and postcode sectors as having a population of less than 10,000.3 Due to the demand for a better definition of rural settlements, a new project has developed more detailed classifications for rural areas. [go to reference 26] However, there is a lack of international consensus on settlement size thresholds. [go to reference 27]

Healthcare researchers have tended to use definitions that focus on distance from key healthcare facilities. [go to reference 28] For example, a review of the Scottish Medical Workforce approached the definition of rurality by using drive time to services. [go to reference 14] It was found that 89 per cent of the population in Scotland live less than 30 minutes drive-time from an acute hospital accepting acute admissions while 1 per cent live more than 120 minutes away. Eighty-four per cent live less than 30 minutes drive-time from a hospital with a major accident and emergency unit and 3 per cent live more than 120 minutes away. [go to reference 14] The more rural and remote the area, the greater the drive-time and the greater the risk in emergency and acute conditions. The Accessibility/Remoteness Index of Australia uses a geographical information system to bring together information on distance, roads, locality and services. Rural areas are then rated on a five-part scale of highly accessible, accessible, moderately accessible, remote and very remote. [go to reference 22]

Further indicators for the measurement of rurality include the following.

• Population density/sparsity is the most widely used measure of rurality which, in addition to distinguishing urban from rural areas, can be used to discriminate between different rural areas. However, the distribution of the population must also be taken into account. [go to reference 7]

• Accessibility to services measures nearest neighbour distance and concerns the physical availability of services and facilities. It is useful to show if populations are widely dispersed. [go to reference 7] The Scottish Executive Health Department (SEHD) defines rural areas as ‘accessible rural’ and ‘remote rural’. Accessible is defined as being within a 30 minute drive of an urban settlement of 10,000 or more people. [go to reference 29]

• Land use allows rurality to be defined in terms of economic activity, such as a percentage of the population involved in agriculture. [go to reference 7]

• Measures using multiple variables overcome the problem that single measures cannot adequately capture the heterogeneous nature of rurality. For example, rurality can be defined around the combined measurement of sparsity and remoteness.

Measuring rurality in relation to healthcare should incorporate an array of variables, in addition to geographical features, to reflect the heterogeneity of rural areas and the perceived differences between urban and rural areas. [go to reference 3] Research by the IRH and the University of Glamorgan, reported in the joint GPC/IRH report, set out to develop a consensus definition of rural healthcare based on the perceived differences between rural and urban general practice (key issues 1). [go to reference 3]

Key issues 1: factors distinguishing rural from urban general practice
Four factors distinguish rural practices:
• increased emergency/minor casualty work
• difficulties associated with distance and travel
• specific rural illness, for example zoonoses
• difficulties in obtaining cover for absence and out-of-hours work.

Further factors found to be important are:
• a wider range of clinical skills needed
• in general, smaller list sizes and larger geographical areas
• personal/family implications, such as social isolation
• professional isolation.

Source: Deaville [go to reference 3] (2001).