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IntroductionRural Proofing for Health is a new approach to ensuring that health policies and models of service delivery are rurally sensitive. It can be defined as a systematic methodology to ensure that rural sensitivity is embedded into policy-making in order that health services meet the needs of people living in rural and remote communities. The Institute of Rural Health (IRH) is developing a Rural Proofing for Health toolkit which will be a resource for Primary Care Organisations (PCO) to help deliver services that are rurally sensitive. The purpose of this article is to outline the policy context in which rural proofing was developed, and to explain why Rural Proofing for Health has an important role to play in ensuring equity of access to health services is achieved for all people living in rural communities.
The National Health Service (NHS) in the UK is based on the premise that all citizens have equity of access to services that are appropriate to their needs, and is free at the point of delivery. The NHS is funded through general taxation and administered locally through PCO and hospital trusts. The broad ambitions, policy and strategic direction for health care services and public health are set at a national level in each of the four nations of the UK. A policy statement for England, published by the Department of Health, maintains that it is vital to put patients and staff at the heart of the decision-making process1. The document places great emphasis on choice and access to services, and the introduction of National Service Frameworks (NSF) ensures that all patients have equality in the standards of care that they receive and the quality of that care1,2. There has been a considerable increase in the resources that have been made available to the NHS in recent years with reductions in waiting times, access to GPs within 48 hours and the development of a telephone triage/information service ('NHS Direct'). Despite some tangible improvements, there are still inequalities in health and inequities in health service provision that persist among different sections of the population. This includes parts of the population who live in rural areas and who may not have the same ready access to as broad a range of services as their counterparts in urban Britain. Examples of inequities of access to services can be the centralising of services in urban centres3 and the decline in the numbers of branch surgeries.
Institute of Rural Health
The Institute of Rural Health is the only organisation with a UK-wide remit to research issues of rural health. The IRH, a charitable foundation, was established in 1997 and is working for the sustainable health and wellbeing of people and communities in rural areas through three key areas of activity: research, education and policy development and analysis. The IRH is a membership organisation and is well connected with individuals and organisations working to tackle health and the wider determinants of health in rural communities across the UK, as well as engendering strong partnerships with other academic units with an interest in rural health internationally. The IRH also provides the secretariat for EURIPA. The IRH is well connected with local and national policy makers in the UK through its policy work and in particular through the Rural Health Forum which is a partnership initiative of the IRH. The Rural Health Forum is a partnership of representatives from both the statutory and voluntary sectors whose interest is to promote the health and wellbeing of rural communities. An important area of development that has evolved out of the policy work and also drawing on IRH's research expertise, is the Rural Proofing for Health project.
What is rural proofing?
The concept of 'rural proofing' was initially developed by the Countryside Agency as a result of the Governments' Rural White Paper for England4,5. The Rural White Paper outlined the Governments' commitment to ensuring that policies take account of the specific needs of rural areas. Rural proofing is a requirement at government department level and is part of Regulatory Impact Appraisal. The Countryside Agency has responsibility for monitoring that all departments take account of the impact of their policies in rural communities. The mandatory process means that there is a systematic methodology to policy development, which should ensure that policies are appropriate in a rural context. Where policies are shown to be likely to have different impact in rural areas then those impacts should be assessed and the policy adjusted accordingly. Rural proofing should be applied to all policies and should be built into programme and policy design prior to implementation.
A checklist has been developed for this purpose, which outlines the key aspects of the rural proofing process. The checklist consists of a list of questions and subjects for agencies to address when taking decisions with regard to policy to ensure that the needs of rural communities are taken into account. The checklist can be found on the Countryside Agency's website. Since the development of the rural proofing tool there has also been a requirement for all government departments to produce an annual report about their approach to rural proofing, and an annual assessment of the rural proofing process is published by the Countryside Agency. This annual report highlights each departments' strengths and weaknesses in incorporating rural needs into their policies and implementation plans.
As well as the requirement for all Whitehall departments to rural proof their policies, there is an obligation for the process to be adopted in the Government Offices for the Regions in England. These regional offices are expected to work with other local agencies to ensure that policy implementation is equitable in rural communities.
The IRH published a document 'Think Rural Health'6 which encouraged PCO to consider the needs of people living in rural and remote areas. The work was carried out in collaboration with the Countryside Agency and, because they have been the department responsible for the development of the methodology of rural proofing, it seemed natural for the Institute to progress towards Rural Proofing for Health as an initiative.
Rural proofing for health
The Rural Proofing for Health project has been funded by the Department of Health and Defra (Department for the Environment, Food and Rural Affairs). The project has been carried out over 2 years and has consisted of three stages. The aim of the project has been to produce a resource to help PCO consider the needs of people living in rural communities when determining service delivery priorities which can result in services which are rurally sensitive. The project team developed a robust methodology to develop the toolkit and a scientific paper will be written and published.
The toolkit will be available as a guide to help identify the health needs of residents living in rural areas so those needs can be incorporated into policy making at a strategic level. A parallel project, funded by Defra, has been to develop a database of good/innovative practice to highlight and disseminate effective rural service delivery models, and this is available at www.ruralhealthgoodpractice.org.uk. This website will also host the finished toolkit and will provide links to appropriate examples of good practice for each section. Rural Proofing for Health will ensure that, at all levels, models of service delivery that are rurally sensitive can be employed appropriately according to local need. This methodology will ensure that rural communities have the same equity of access to health services as their urban counterparts.
Engaging with policy
The broad ambitions, policy and strategic direction for healthcare services and public health are set at a national level in each of the four nations of the UK. Across the UK, there is a growing awareness of the complexities of ensuring good health outcomes for populations and the inter-connectedness of a range of factors in ensuring optimum levels of health and wellbeing. The recent publication of separate public health White Papers in England and Wales both highlight the fact that health is not just the responsibility of health service providers and that there needs to be a multi-sectoral approach to taking responsibility for actions that impact on health and well-being. These can include ensuring decent income levels, safe working practices, access to services, planning, housing and transport.
Clearly, many responsibilities for health and wellbeing lie outside the traditional role of healthcare provision and, therefore, engaging with policy-makers at all levels of governance is critical to ensuring good health outcomes for rural communities. For example, by engaging with transport planners and providers, rural health service providers can have a stake in the development of public transport policies which can help to improve accessibility to a range of health services. In England, at a local level, Local Strategic Partnerships (LSP) have responsibility for coordinating and planning across a range of key government services, including health, and this is proving to be an effective vehicle for local health agencies to engage and work in partnership with other parties to influence a range of emergent policies and practical initiatives. This approach has enabled broader health ambitions to be considered.
It is important to engage senior officials in the rural proofing process in order that the initiative is cascaded down through the system, and so there can be a champion of rural affairs within each department. It is also important that rural proofing is seen as an aid to policy development to ensure appropriate implementation in rural areas, and is solutions and outcomes focused, and not just a tick-box process.
Influencing emerging policy and commenting on new initiatives means that the needs of rural communities are not overlooked. Initiatives such as rural proofing offer an opportunity to assess the impact of policy and service delivery models on rural communities before they are implemented.
International aspects
Achieving optimal health for all requires collaboration and partnership working across different sectors; an integrated vision can provide the basis on which to build healthy communities.
Rural Proofing for Health has already attracted considerable interest and attention outside the UK. The nature of rurality may differ throughout the world, yet the majority of rural communities experience similar problems in relation to access to care, resource allocation, health inequalities and deprivation. Some countries, such as Australia and the USA, face significantly more obvious geographical contrasts, while other developing countries have larger rural populations where the majority live well below the poverty line. The WONCA Working Group on Rural Practice in its collaborative WHO rural health action plan HARP (Health for All Rural People) recognised the importance of developing the rural proofing for health methodology when building health services and systems in the developing world7. EURIPA have also recognised the importance of Rural Proofing for Health.
Conclusion
The concept of Rural Proofing for Health is attractive in that it offers a systematic approach to rural health policy development, which is measurable and accountable. The rural proofing process may need to be adapted to meet local conditions and structures. International use of this methodology will ensure that this approach develops credibility as a respected tool with which to meet rural needs and hold government and other public bodies accountable to their rural populations.
References
1. Department of Health. Shifting the balance of power: the next steps. London: HMSO, 2001.
2. Department of Health. The NHS improvement plan: putting people at the heart of public services. London: HMSO, 2004.
3. British Medical Association. Healthcare in a rural setting. London: BMA Board of Science, 2005.
4. Department for the Environment, Transport and the Regions. Rural England: a discussion document. London: The Stationery Office, 1999.
5. Department for the Environment, Transport and the Regions. Our countryside: the future - a fair deal for rural England. London: The Stationery Office, 2000.
6. Deaville J, Mitchinson K, Wilson L. Think rural health. London: Countryside Agency, 2000.
7. Wonca. Creating Unity for Action - An Action Plan for Rural Health. Online (2003). Available: http://www.globalfamilydoctor.com/aboutWonca/working_groups/rural_training/actionplan.htm (Accessed 2 May 2005).