Consider extending review to other rural services

11. We accept this recommendation in principle. NHS England are establishing Vanguard sites to explore how new models of care can address the challenges faced by services that are rural, geographically isolated or difficult to recruit to. 12. The Investigation highlighted some of the problems that can affect services provided in remote or isolated areas, where poor practice becomes entrenched and low staff turnover and low numbers of procedures can lead to a lack of clinical experience and reduced opportunities for learning. 13. The NHS Five Year Forward View11 set out a way forward for the NHS that includes new and different care models to meet the health needs of the population in the future. Through these new care models, care will often be focused more in community settings than in hospitals, will be more joined up to recognise the need of people with multiple conditions, and will be more patient-focussed. For example, integrated community teams will be community based (including in rural districts) and where clinically appropriate will utilise tele-health to support effective, safe and quality care. 14. One of the main areas of focus for the new model of acute care collaboration will be on the question of how to maintain local access to a range of safe, clinically and financially sustainable acute services - in particular for services with low volumes of patients or where there are national or local staff shortages. 15. Changing how care is provided is an ambitious and lengthy task. To start this process NHS England has established some Vanguard sites which will test whether these models work for patients. NHS England has selected areas that address these challenges in both rural and urban settings. Lancashire North, which covers the population of Morecambe Bay, is one of the nine Primary and Acute Care Systems Vanguard sites that will receive national, regional and local support to develop new care models joining up GPs, hospitals, community and mental health services. 16. Examples of best practice and shared learning from these Vanguard sites will be made available to the wider NHS as soon as possible. 17. NHS England, Monitor and the NHS Trust Development Authority have also recently announced the first locations to enter into the Success Regime, in which the tripartite partners will jointly oversee a package of challenge and support for some of the most challenged health economies. The regime will be tailored to local circumstances, building upon existing interventions and working with providers, commissioners and other local stakeholders to diagnose key underlying issues and develop and implement the solutions to address both short-term performance and long-term strategic issues. 18. The aim of the Success Regime is to create the conditions within health economies to enable them to become high performing in the future. It will differ from other interventions in that it will focus on identifying and addressing issues across whole health systems as opposed to simply dealing with individual providers or commissioners

The Thirlwall Inquiry has noted action taken in response to this recommendation.

Extensive engagement during the Better Births review (see recommendation 20) made it clear that a single model for maternity services in rural areas was not feasible due to significant local differences between units. Having considered the Kirkup recommendation, NHS England therefore concluded it would not be appropriate to review requirements in the way proposed.

There are significant differences across rural areas in terms of provider landscape, workforce availability, catchment area geography, and broader infrastructure (including road networks and broadband reach), meaning that a single service model is not feasible or desired. This perspective was echoed in ongoing engagement with providers and published reviews into rural health, including the Parliamentary Inquiry into Rural Health and Care published in February 2022. Further, analysis by NHS England in 2023 found that outcomes in rural areas varied considerably, for example with some experiencing worse A&E performance and waiting times for elective surgery than the national average and others better performance. Moreover, a single model stands in contrast to NHS England’s operating model supporting flexibility for place-based decision making.

Support for rural services

NHS England continues to support improvements in service delivery in rural/remote areas, such as changes to recruitment and training approaches, as part of wider objectives. The NHS Long Term Workforce Plan, published in June 2023, set out 3 priority areas to improve the training and retention of the NHS workforce, and reform to improve productivity by working and training in different ways. It states that “Work is already underway within pilot Integrated Care Systems (ICSs) as part of the rural and coastal workforce transformation programme to implement education, training and workforce transformation solutions, aimed at improving attractiveness of jobs and retention of the healthcare workforce in these locations.” NHS England “will work closely with systems to consider the best approaches to reviewing geographical distribution of training posts for wider professional groups.”

In terms of funding for rural providers, there are a range of adjustments made in the core Integrated Care Board (ICB) allocations formula that account for the fact that the costs of providing health care may vary between rural and urban areas. Target allocations include four adjustments that specifically support remote or sparsely populated areas:

• the emergency ambulance costs adjustment to reflect longer travel times in sparsely populated areas

• a travel time adjustment to the community services formula to reflect longer travel times in sparsely populated areas

• an adjustment to remove from the formula supply induced demand in urban areas where people live close to a hospital • the adjustment for unavoidable small hospitals, to support continued provision by hospitals with 24/7 A&E services that are remote from the wider hospital network and have unavoidably higher costs.

Some of the differences between rural and urban areas, such as the tendency for rural populations to be older, are naturally captured in the formula.

Safe staffing and quality surveillance

Evidence-based decision-making on safe and effective staffing is a requirement for all NHS organisations. The National Quality Board sets out expectations for nursing and midwifery staffing to help NHS provider boards make local decisions that will deliver high-quality care for patients within the available staffing resource.

ICSs were legally established in July 2022 to enable local partners involved in care to create better services based on local need.

The NHS Standard Contract requires that providers ensure that there are sufficient appropriately registered, qualified, and experienced medical, nursing, and other clinical and non-clinical staff to deliver services and have regard to applicable staffing guidance (GC5). Service Specifications may set out further requirements around staffing levels.

Quality Surveillance Groups (QSGs) were set up by the National Quality Board in 2013 to provide a forum in which quality concerns could be raised and dealt in a coordinated way, and to enable improvement. QSGs have since operated locally, regionally, and nationally, and been supplemented by enhanced assurance activity (including Risk Summits) when recurrent or serious risks have required focussed attention. In line with the establishment of ICBs, QSGs are now known as ‘System Quality Groups’ to reflect the shift to greater engagement, collaboration, and learning. National guidance was published in January 2022.

Broader work is underway across NHS England to build the realities of rural service delivery into national policy decisions, including bringing rural hospitals into strategic national discussions. Recent initiatives that have the potential to address sustainable service delivery in rural areas include:

• Trialling new competency-based workforce approaches and intake models in A&E
• Funding pilots into rural medical recruitment via the Medical Education Reform Programme
• Accelerating the spread of innovative practice via peer learning networks and (e.g. rural local maternity network)

New and expanding telehealth approaches improving access to specialist input.

The NHS Long Term Plan included a commitment to “develop a standard model of delivery in smaller acute hospitals who serve rural populations”.

The National Maternity Review report, ‘Better Births - Improving outcomes of maternity services in England, A Five Year Forward View for maternity care’ reviewed maternity services across the country including in rural and isolated areas.

In the 2016/17 clinical commissioning group allocations, NHS England made a change to the allocation funding formulae for remoteness. In part, this funding recognises that services in remote areas, including maternity services, have unavoidably higher costs because the level of activity is too low for services to operate. Further, we know that the challenges faced by services in remote areas are broader than funding which is why we committed in the NHS Long Term Plan to develop new operating models for rural hospitals, as well as to reduce geographical and specialty imbalances in medical posts. As part of this, NHS England and NHS Improvement is working with 35 smaller acute hospitals and local systems leaders to identify and accelerate the spread of new delivery models through peer learning and in partnership with national stakeholders, including the Care Quality Commission and Royal Colleges.

Department of Health response (July 2015):

“NHS England are establishing Vanguard sites to explore how new models of care can address the challenges faced by services that are rural, geographically isolated or difficult to recruit to. (p. 68)

[…]

The NHS Five Year Forward View set out a way forward for the NHS that includes new and different care models … be more community-based. (p. 68)

[…]

NHS England, Monitor and the NHS Trust Development Authority have also recently announced the first locations to enter into the Success Regime, in which the tripartite partners will jointly oversee a package of challenge and support for some of the most challenged health economies.” (p. 69)