Funding

hospital

What does integrated care mean for rural communities?

Public spending on health care is driven by the needs of the population, the resources available and national priorities. Health services are facing unprecedented financial and operational pressures, with many NHS organisations in deficit and key performance standards missed. At the same time, some people require support from both health and social care services and there are longstanding calls for them to be integrated – putting patients at the centre of how their care is organised and saving money by cutting down on emergency hospital admissions and delayed discharges. Integrated Care Systems (ICSs) are bringing together NHS organisations and Local Authorities to work in partnership to improve health and care in their area. NHS England has acknowledged that transitioning to ICSs is ‘complex’, requires a ‘staged implementation’ and they make take several years to fully form. What are ICSs, how are they developing, and what do they mean for rural residents? Jessica Sellick investigates.  ………………………………………………………………………………………………..

Health and social care services in England have traditionally been funded, administered and accessed separately – with health provided for free at the point of use through the National Health Service (NHS) and social care through means-testing carried out by Local Authorities. Successive Governments have sought to better integrate health and social care by focusing on providing care as close to the patient as possible (i.e., in their home or community rather than in hospital). This move towards integration has led to the creation of Health and Wellbeing Boards, the Better Care Fund and Sustainability and Transformation Partnerships (STPs). 

Integration is now a central goal of the NHS – referenced in both the Five Year Forward View (October 2014) and the Long Term Plan (January 2019). In September 2019 the NHS set out legislative proposals for a new NHS Bill to implement the Long Term Plan and enable parts of the NHS to work with partners more easily. The Bill would replace the current NHS procurement framework which is seen by some health commissioners and providers as a barrier to integrating care at scale. Integrated Care Systems (ICSs) are one of the emerging models of integrated health and social care. 

What is an Integrated Care System (ICS)? The NHS Long Term Plan contains an ambition that every part of the country should be an ICS by 2021. An ICS ‘brings together local organisations to redesign care and improve population health, creating shared leadership and action…They are a pragmatic and practical way of delivering the ‘triple integration’ of primary and specialist care, physical and mental health services, and health within social care’.  This emphasis on ‘working together’ is not new and the origins of ICSs can be traced back to 2016 and the establishment of Sustainability and Transformation Partnerships (STPs). STPs are five-year plans covering all aspects of NHS spending in England. STP leaders generally come from clinical commissioning groups (CCGs), NHS trusts or foundation trusts or local government. There are 42 STP areas – with their geographical footprints varying from 300,000 to 2.8 million people.  The Long Term Plan envisages that by April 2021 ICSs will cover the whole country, growing out of the current network of STPs. 

NHS England and NHS Improvement have highlighted three areas at which decisions will be made within ICSs: 

  1. Neighbourhoods (populations circa 30,000 to 50,000 people) – served by groups of GP practices working with NHS community services, social care and other providers to deliver more coordinated and proactive services, including through Primary Care Networks (PCNs). 
  2. Places (populations circa 250,000 to 500,000 people) – served by a set of health and care providers in a town or district, connecting PCNs to broader services, including those provided by Local Authorities, community hospitals and voluntary organisations. 
  3. Systems (populations circa 1 million to 3 million people) – all health and care partners in different sectors come together to set the strategic direction and to develop economies of scale. 

According to research by the King’s Fund, ICS leaders have suggested that 70-90% of work within an ICS should occur at the place and neighbourhood levels, with the remainder carried out at the system level. 

There are two other forms of integrated care: (a) Integrated Care Partnerships (ICPs)– these are alliances of NHS providers that work together to deliver care by agreeing to collaborate rather than compete; and (b) Accountable Care Organisations (ACOs) – these are established when commissioners award a long-term contract to a single organisation to provide a range of health services to a defined population following competitive procurement. There are a number of important differences between ICSs, ICPs and ACOs. For example, ICSs are characterised by ‘integration by collaboration’ whereas ICPs as ‘integration by contract’; ICSs involve an ‘alliance agreement’ by the bodies involved whereas ICPs require a single contract held by a single body.   

How many ICS are there? In line with STPs, the size and geographical footprint of ICSs is expected to vary from area to area. Since 2018, 14 areas have been designated as an ICS. They are: (1) South Yorkshire and Bassetlaw, (2) Frimley Health and Care, (3) Dorset, (4) Bedfordshire, Luton and Milton Keynes, (5) Nottinghamshire, (6) Lancashire and South Cumbria, (7) Buckinghamshire, Oxfordshire and Berkshire West, (8) Greater Manchester, (9) Surrey Heartlands, (10) Gloucestershire, (11) West Yorkshire and Harrogate, (12) Suffolk and North East Essex, (13) The North East and North Cumbria, and (14) South East London. These areas cover rural and urban geographies; different population sizes (ranging from 528,000 in Gloucestershire to 2.7 million in West Yorkshire and Harrogate); and different system complexities (with 2 areas having devolution agreements in place: Greater Manchester and Surrey). One-third of England’s population is now covered by a developing ICS. 

NHS England and NHS Improvement’s regional teams will work with ICSs to agree system-wide objectives and performance against these objectives. 

What will ICSs do? Every ICS will need to have: 

  • A partnership board, drawn from commissioners, trusts, PCNs, Local Authorities, voluntary and community sector organisations and other partners. 
  • A non-executive chair (locally appointed but subject to approval by NHS England and NHS Improvement) and arrangements for involving non-executive members of boards/governing bodies. 
  • Clinical and management capacity drawn from constituent organisations to enable them to implement system-wide changes. 
  • Full engagement with primary care – including through a named accountable clinical director for each PCN. 
  • A greater emphasis by the Care Quality Commission (CQC) on partnership working and system-wide quality in its regulatory activity. 
  • All providers within an ICS will be required to contribute to ICS goals and performance – including in relation to (a) population health and (b) system objectives. 
  • Clinical leadership aligned around ICSs to create clear accountability to the ICS – with cancer alliances, clinical senates and other clinical advisory bodies coterminous with one or more ICS. 

ICSs are expected to incorporate learning from existing initiatives including the 50 vanguards that tested and refined new care models. 

From a clinical perspective ICSs may reduce barriers between services and competition between providers leading to improved patient care. Clinical input is central to the development of ICSs and ensuring that the views of health and care staff and their representative bodies are actively sought as ICSs develop may help to address some of the barriers that the health and care systems face (e.g. recruitment and retention of staff, funding, resources etc.)  

From a local government perspective, ICSs will have a key role to play in working with Councils at ‘place’ level with commissioners making shared decisions with providers on how to use resources, design services and improve population health. This means every ICS is expected to have streamlined commissioning arrangements to enable a single set of decisions to be made at a system level. As part of this CCGs are expected to become leaner and more strategic and support providers to partner with local government and other bodies on population health, service redesign and Long Term Plan implementation. Ultimately ICSs are expected to replace STPs by 2021. 

 From a patient perspective, ICSs will have a new accountability and performance framework which will measure the extent to which the local health service and its partners are genuinely providing joined up, personalised and anticipatory care. 

In September 2018, the King’s Fund published a review of ICSs during their first year. They found most ICSs were making progress in developing their capabilities to work as systems, and organisations were working more collaboratively to manage finances and performance in a way that was not happening previously. There were some early signs of progress in delivering service changes, particularly in relation to strengthening primary care, developing integrated care teams and reviewing how specialist services are delivered. 

A British Medical Association (BMA) briefing on ICSs has also identified some common themes across the 14 ICSs established to date: 

  • ICSs have a specific focus on enhancing the role and scope of primary and community care services. This is revolving around the development of Primary Care Networks (PCNs) and Multi-Disciplinary Teams (MDTs) . NHS England sees PCNs are central to the provision of at-scale primary care – encompassing GP surgeries, community and mental health trusts, pharmacies and voluntary and community sector organisations. 
  • ICSs are prioritising improving the overall health of their population to prevent ill-health – this includes looking at the wider determinants of health and the use of social prescribing.  
  • The current and future workforce has been highlighted as a major issue – with some ICSs prioritising the use of new clinical roles to support their work. 
  • ICSs are focusing on better use of data, technology and innovation to improve care and support prevention – this is centred on improving IT interoperability and the sharing of patient records.
  • Several ICSs are exploring possible service reconfiguration – including centralising specialisms at certain sites and/or trust mergers. Any service reconfiguration should be led by clinicians, based on clinical evidence, rather than driven by financial pressures. 
  • Clinical Commissioning Groups (CCGs) are changing as ICSs are developing – with a single CCG covering an ICS, although in some areas ICSs are not coterminous with CCG boundaries. Commissioning is also changing, with providers increasingly taking responsibility for some day-to-day functions rather than CCGs. 
  • ICSs will be taking collective responsibility for the resources and financial performance for the whole system – this will include arrangements for risk sharing and decision making on how services will be paid for.  
  • The move to system-wide working is changing regulation – with NHS England suggesting ICSs will be subject to a new form of regulation that focuses less on the performance of individual organisations and more on the system. 

How will they develop? NHS England has produced a ‘maturity matrix’ [pages 9-11] for ICSs. This outlines the core characteristics of systems as they develop and is intended to provide a consistent framework for all regions and systems across the country. There are four stages a system is expected to follow: emerging, developing, maturing and thriving.  For a system to be formally named an ICS it is expected to meet the attributes of a maturing ICS. The matrix cover: (1) system leadership, partnerships and change capability; (2) system architecture and strong financial management and planning; (3)  integrated care models; (4) track record of delivery; (5) coherent and defined population; (6) oversight; (7) finance; (8) planning; and (9) support.  

NHS England describes the matrix as a ‘journey rather than a series of binary checklists’ in recognising that systems will not develop across all domains at the same pace. 

What do they mean for rural communities? Integrated health and care is pertinent to rural communities, which experience poorer access to services than their urban counterparts. The way the health system is currently organised and funded is based upon economies of scale. While ICSs aim to provide patients with equal access to its services at the same level of quality, how will they take account of different types of rural and coastal populations at a neighbourhood, place and system level?  

A briefing published by the Nuffield Trust in November 2019 looked at why the different models of integrated care that have emerged so far had not produced the expected results of reduced hospital admissions. They identified a number of reasons why this may be happening: 

  • The model may be poorly designed, targeting the wrong population, not listening to patient preferences and/or containing a large number of complex work streams. 
  • The model experiences difficulty when it reaches the real world i.e., getting multidisciplinary teams to work well, effectively involving primary care, and the likelihood of uncovering undiagnosed pathology are all issues that have caused problems.
  • The expectations of those designing the models about the outcomes that are likely, and the speed that they can be achieved, are sometimes higher than can be achieved in the often short periods allowed for evaluation. 

NHS England’s maturity matrix for the development of ICSs sets out how a thriving ICS should have a  meaningful geographic footprint that respects patient flows; be contiguous with local authority boundaries (or have clear arrangements for working across local authority boundaries; and cover an existing STP of sufficient scale (1 million population or more). With one-third of the population now covered by an ICS and 70-90% of the work expected to happen at place and neighbourhood levels, how will ICSs listen to, and act on, insights from rural residents and patients? Where will their voices be in the development of local plans and allocation of resources?

Currently there is no clear statutory basis for the development of ICSs leading to concerns around their accountability and oversight. Clinicians, local government officers, Elected Members and the public are unsure how to challenge the direction of travel or decisions taken within an ICS. In 2019, Luton Council withdrew its support from the Bedfordshire, Luton and Milton Keynes ICS; Nottingham City Council temporarily suspended its involvement in the Nottinghamshire ICS; and in Berkshire West neither the South Central Ambulance Trust nor Local Authorities were participating in their ICS. Concerns about a lack of transparency and democratic oversight in the ICS planning process were cited. Research conducted on delivering integrated mental health support for older people in South Australia, for example, identified three structural barriers to integration: (1) fragmentation of Governmental responsibility, (2) funding shortfalls, and (3) the centralisation and standardisation of service delivery. Where do the flexible, informal and self-sufficient relationships that typically underpin integration in rural communities fit within an ICS? 

To date, the experience of local government and the NHS working together has been variable. Legislation can remove obstacles to integration, but it does not necessarily lead people and organisations to collaborate more effectively. Should legislation specify the level of involvement of Local Authorities, or other non-NHS bodies, in ICS arrangements? What will be the future of existing forums for promoting joint working, such as Health and Wellbeing Boards? Greater sharing of responsibilities across health and care may mean that regulation needs to change. Some of this is already happening, with the Care Quality Commission now reviewing local systems, as well as individual providers. Legislation can help avoid legal uncertainty – for example, clarifying what might happen if the decision of an ICS conflicted with the statutory duties of its member organisations. However there is concern that while ICSs are intended to overcome and remove existing organisational barriers; the models that are developing often appear dominated by NHS Trusts – how can they ensure the plans they are drawing up involve primary care [GPs], public health and social care [Local Authorities]? Evidence from Switzerland and Italy, where local hospitals were converted into health centres [as part of attempts to coordinate health and social care resources within and closer to rural communities], highlighted the importance of (i) creating a new legal entity or specific organisational unit to focus managerial attention on the need to coordinate health; and (ii) having enough internal resources to support the professional development of staff.  

Cuts to Local Authority funding have already stretched budgets in the areas of public health and social care. At the same time many NHS Trusts are in deficit. How will ICSs deliver system-wide change when the capacity of services it seeks to integrate are already under so much pressure? For me this underlines the need to have a dialogue about how much it costs to meet health and social care needs in rural areas (for children, young people and adults) and how to pay for integration (before provision collapses).

In November 2019 the Local Government Association (LGA) and the Social Care Institute for Excellence (SCIE) published a joint resource to support local systems to integrate. The document prioritised 15 actions, drawn from the UK and what works from international research. A number of core principals underpin these actions – here integration is not an end goal but a means of achieving the goal of better, joined up care; and should support the building of community capacity for prevention, early intervention and place based care and support.  In Herefordshire and Worcestershire, for example, it is difficult to deliver acute care because of the rurality of the area and the distance patients have to travel. The STP is looking at how acute specialist clinicians can work with community teams outside of hospitals, including providing advice and guidance to neighbourhood teams. In designing neighbourhood teams in Worcestershire the STP/ICS went to see the Buurtzorg Nederland and the Norrtaelje model in Sweden to learn how they could empower clinicians to ensure care is patient centred. 

Many STPs are not yet in a position to become ICSs – and may not be for some time. For change cannot happen overnight– and needs to be married with some realism about the scale, complexity and resources needed to truly deliver integration. If ICSs are the future of the NHS – if they are intended to lead to stronger health and care systems across the country – how can we ensure systems think rurally? 

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Jessica is a senior research fellow at The National Centre for Rural Health and Care (NCRHC). The NCRHC is a Community Interest Company, national in scope with a Headquarters in Lincolnshire, that focuses on four principal activities: data, research, technology and workforce. 

Jessica is also a researcher/project manager at Rose Regeneration. Her current work includes helping public sector bodies to measure social value; evaluating an employability programme; and reviewing a project that supports parents committed to recovering from, drugs and/or alcohol addictions.

She can be contacted by email jessica.sellick@roseregeneration.co.uk or telephone 01522 521211. Website: http://roseregeneration.co.uk/https://www.ncrhc.org/ Blog: http://ruralwords.co.uk/ Twitter: @RoseRegen 

Wind farm

How far do Community Benefit Schemes reach into rural areas?

Much of our renewable energy infrastructure is located in rural communities. From wind farms, and nuclear power stations, to tidal and solar, all have wide ranging implications for host localities. It has become increasingly common for renewable energy projects to make financial or in-kind payments to local communities. Often described as “benefits payments”, “compensation schemes” “incentive payments” or “added value”; the level of payment made and how it is used for ‘community’ ‘benefit’ varies greatly. What do renewable energy community benefit schemes offer rural communities? Jessica Sellick investigates. ………………………………………………………………………………………………..

On 1 April 2012 the Planning Inspectorate became the Government agency responsible for operating the planning process for what are known as ‘Nationally Significant Infrastructure Projects’ (NSIP). NSIPs are projects such as new roads, power generating stations or harbours which require a type of consent known as ‘development consents’ under the Planning Act 2008. 

A search of energy projects on the National Infrastructure Planning (PINS) website on 2 December 2019 revealed 99 projects. Of these, 31 were at the pre-application stage; 3 at the pre-examination stage; 5 at examination stage; 2 at recommendation stage; 4 at decision stage; 52 at the decided stage and 1 project had been withdrawn. 

The Planning Act 2008 streamlined the decision-making process for these major infrastructure projects; with the purposes of making it a fairer and faster process for both communities and applicants. In March 2016 Government published its first National Infrastructure Delivery Plan – setting out plans for economic infrastructure, housing and social infrastructure over a 5-year period.  This 2016-2021 plan focuses on ensuring the right projects are delivered well; determines the proprieties and project/programme milestones that Government should focus upon; and aims to get the right (public and private) investment in place. The delivery plan sets out a range of policy mechanisms to support the transition to an affordable, clean energy system – with the priorities to 2020-2021 centred around new nuclear investment, gas power stations, large-scale offshore wind; as well as projects relating to interconnectors, smart meters and transmission and distribution.  

Of the projects currently listed on the PINS site the majority of entries (23 projects) are related to wind, followed by grid lines (11 projects), gas (6 projects), nuclear (5 projects), tidal lagoons (4 projects), biomass and solar (2 projects respectively). While in a policy context this move to improve the planning and delivery of infrastructure by increasing investment and accelerating project delivery is gearing us towards a more productive economy; these large projects can sometimes be controversial because they have wide ranging implications for the communities hosting them. In response, a range of new procedures, processes and methods for their assessment and management, including widening impact assessment and the use of Community Benefit Schemes (CBS) have emerged. 

Impact Assessments – such as EIA, SIA, SEA, SA, HIA, HRA sometimes include special procedures for subsets of major projects through the examination system operated by PINS. Community Benefit Schemes (CBSs) refer to agreements between the various stakeholders involved in a project – in particular, between the developer and the host community. The schemes can include financial incentives, infrastructure and community empowerment measures and are drawn up in recognition of a community’s participation in an activity that is perceived as being in the ‘national interest’. 

CBSs are different from project designed-in measures which seek to minimise adverse local impacts at the early stage of planning; and they are also different from mitigation and enhancement measures which may evolve during the assessment and decision making process. 

Why have Community Benefit Schemes? Views range from developer philanthropy and corporate social responsibility through to mitigating the anticipated and/or adverse impacts of construction or operations [through preventive or ameliorative actions]; compensation for actual damage; rewarding communities for assuming non-local cost or risk; and participating in an activity which is deemed to be in the national interest. 

The United States has been a long history of CBSs. Here CBSs are legally enforceable contracts signed by community groups and developers in which the developer agrees to shape the development in a certain way or to provide specified community benefits. Examples include: the Lakers Stadium and Los Angeles Airport expansion. Of the $500 million community benefits for LAX expansion, $230 million was allocated to soundproofing local schools and homes. 

In France, the Government pays compensation as part of its Grand Channtiers programme. Here the level of CBA funding varies from 1-10% of project value and is used to fund a wide range of activities, particularly affordable housing. 

Back in the UK, the wind energy industry has been at the forefront of the development of CBSs. A toolkit published by the Centre for Sustainable Energy back in 2009 aimed to make meaningful community benefits such as being a good neighbour; paying compensation for impacts on local amenity and the inconvenience caused by the construction process; and sharing the rewards from wind as a ‘common’ which nobody owns more routine and systematic in UK wind energy projects. 

The completion of Sizewell B nuclear power station back in 1995 led to a package of ‘ameliorative measures’ such as village hall improvement projects in recognition of the pressure placed on local facilities by the project. More recent examples include the Copeland Community Fund (CCF), an agreement negotiated with the Government to recognise the service Copeland provides to the nation by hosting the Low Level Waste Repository (LLWR) close to the village of Drigg; and EDF energy’s £20 million Community Fund to improve the social, economic and environmental wellbeing of communities affected by the development of Hinkley Point C. 

While the justification for CBSs varies considerably between countries, project types and over time; the benefits of large energy projects tend to contribute to national and sometimes global objectives. 

How is the payment calculated? Payments can be linked to the capacity of the development – with a one-off payment made by a company during the construction period (e.g. £5,000/MW); they can be related to the profitability of the development (i.e., the surplus profit that a project will generate); or they can be at the discretion of the developer (drawn from the Corporate Social Responsibility budget or described as a ‘goodwill contribution’). Payments can be ad hoc and discretionary or are guaranteed by Government using statutory powers on behalf of communities.  They can comprise single donations or annual contributions and they may have conditions attached (such as the money has to be spent over a set period of time or returned to the company). 

Local Authorities often play a vital role in negotiating the level of payment; often acting on behalf of the community in liaising with developers and/or in collecting and distributing the payments. In the case of the Copeland Community Fund, the Low Level Waste Repository provides the Fund with £1.5 million a year for every year that the repository is operating; in addition to an initial endowment of £10 million. The CCF is supported by Copeland Borough Council and Cumbria County Council [which acts as the Accountable Body for the funding]. East Riding of Yorkshire Council is responsible for a number of community funds linked to energy related developments – the Burton Pidsea Community Wind Farm Fund, for example, receives an annual donation from the wind farm owner EnergieKontor UK Limited. The amount of the donation is based on a formula of £2,000 per megawatt of the wind farm to a maximum of £20,400 per annum.

While early examples of CBSs for energy projects in the UK were relatively small – the number, their scale and size of payments has increased over time.  

In Scotland, over the last 15 years the scale of benefits has increased from £1,000 per MW size of the project over the working lifetime of the project (normally 25 years) for early projects to at least £5,000 per MW for more recent projects. For a wind farm of 20 MW, the annual benefit is estimated at £100,000. 

In England in 2011 the renewable energy industry (Renewables UK) agreed a protocol to provide community benefits in connection with eligible on-shore wind schemes of no less than £5,000 per MW per year or benefits in kind to an equivalent value [the protocol was updated in 2013]. The annual contribution is index linked and commences within 12 months of a project making its first commercial export of power and applies for the operational lifetime of the scheme.  

For solar, the benefits are often less than for wind; with some community benefit negotiations based on a minimum of £1,000 per MW of installed capacity for a period of 20 years, linked to the Retail Price Index (or a pro-rota single upfront community benefit payment). In Dorset, for example, the majority of solar farm developments in Dorset have offered a community benefit fund to host communities, often through the local Parish or Town Council. 

The UK Nuclear Decommissioning Authority (NDA) provides a Community Fund for communities at Drigg in Copeland (West Cumbria) and at Dounreay in Caithness (Scotland) which have storage facilities for low level nuclear waste. 

For shale, the energy industry provides community benefits of £100,000 per swell site when a test well is drilled plus a 1% share of revenues from any resultant gas production. This is in addition to provisions for Local Authorities to retain all business rates paid by developers and for energy firms to make direct payments to local residents and/or set up trust funds to be managed by local communities. 

For remote off-shore locations, until recently community benefit payments have been more ad hoc and pro rota compared to on-shore locations. However a recent £10 million CBS initiative by the Danish energy company Dong, in relation to its Hornsea One and Race Bank wind farms, will distribute approximately £0.5 million pounds a year to help local initiatives over the next 20 years through the East Coast Community Fund. 

In March 2019, Cumbria County Council (CCC) formally granted planning approval for the development of the Cumbrian Metallurgical Coal Project – to be known as Woodhouse Colliery. It is anticipated that site work will commence in Spring 2020, with coal production commencing around 24-months from the start of construction. Once in production, WCM will create a Community Fund to support local charities and organisations with projects that echo our desire to promote health and well-being, local amenities such as footpaths and cycle ways, as well as a plan to secure the future of the old Haig Mining Museum building.

Across these examples, community benefits for energy projects can broadly be divided into three  categories: (1) financial incentives – either an annual payment or lump sum or both; a share in local tax revenues, reduced utility fees and/or paying shares into a local community organisation. (2) Social benefits in kind where a developer may provide for a community facility or local environmental improvements. (3) Community empowerment measures – with local participation in decision making. In practice, community benefits can often be an integrated package across all three categories – and these can be shaped by local community preferences (e.g. for reduced utility bills), or technical and regulatory factors. 

At a local level community benefits can be very sensitive issues. Some residents perceive it to be providing a means for developers to take forward a project that is not wanted by the local community while other people view it as a means of sharing in the rewards of a development. 

How do rural communities benefit from the payments? Information on individual CBSs on the PINS website is limited because these agreements are not a material consideration in the planning process. This also makes understand the relationship between community benefits, the planning process, environmental assessment procedures and a series of impact assessments difficult.

On a practical note, a nationally negotiated scheme usually takes a legal approach meaning the scale, type and preconditions of benefits are largely determined beforehand in legislation. In contrast, a locally-negotiated approach involves discussions between developers, local communities and other stakeholders (e.g. Local Authorities) with the agreement reached usually followed by some form of formal written agreement. 

A key issue that often emerges in negotiations is how to define the ‘community’ that will ‘benefit’ from a scheme. Is the relevant community determined spatially (i.e., by geography and locality) or by interest? Should the community that benefits be nearest to the site or the area affected most by disturbance or nuisance? What happens if a scheme covers more than one Local Authority area – is it decided by population on a pro rata basis? How is the community defined for off-shore projects – do coastal communities benefit? In 2005 Dumfries and Galloway Council developed a Wind Farms Community Benefit Governance Framework which established two tiers of benefit: (i) 60% of the community benefit funds from any one wind farm would go to communities 15km from the outer edge of the wind farm with the remaining 40% ring fenced for a region-wide fund for renewable energy or energy efficiency projects. The framework was superseded in 2015 by Windfarm Community Benefit Guidelines which removed the 60:40 split and the 15km measurement of host communities. In Northern Ireland and Wales there have also been discussions around whether the purpose of having a community benefit scheme is to recompense the impacts on the nearest communities or should apply to communities over a much wider area.   

Back in 2014 the then Department for Energy and Climate Change (DECC) published best practice guidance  to showcase good practice and sets out expectations for developers, Local Authorities and communities in the provision of onshore wind developments. The document brought together a set of principles (i.e., timely, transparent, constructive, inclusive, fair, unconditional), with a process for establishing community benefits through the wind development process (preparation phase, planning phase, post-consent phase and operational phase). 

A further issue that emerges is the timing of community benefits – should it come early as part of the planning and development processes or staged, perhaps related to project milestones? For financial payments, should a lump sum be paid (up front or at the end) with smaller sums paid on an annual or quarterly basis? 

More recently, there have been discussions around the types of communities that are benefitting from CBSs. In April 2018, for example, the Centre for Sustainable Energy published its research into community renewable energy projects in low income areas. The researchers found that the skills, knowledge, time, resources and links to useful people and organisations were not as readily available in low-income communities compared to their more affluent neighbours. They often lacked existing community development and regeneration organisations and Local Authorities had reduced capacity to engage in community energy. As community energy projects in low-income areas seldom emerge directly from the grassroots, with intermediary organisations – locally based and with a community development focus – often acting as the catalyst for energy activity to benefit the community – the authors highlighted the need to bolster the community’s project capacity and resilience (through funds, mentoring and capacity building).  

In relation to energy projects, CBSs have become increasingly commonplace over the last 20 years. While CBSs initially focused on on-shore wind projects; they have since expanded to include nuclear, solar, tidal, and shale gas. However, to date, little work has been undertaken to collate the different types of CBs and the community benefits that arise from individual schemes. Mapping what community benefit schemes they are, where they are located, the scale of payments, a description of the benefits they provide (types of initiatives) and measuring the outcomes and impact they achieve for local communities (legacy and sustainability) would provide a better understanding of the collective. And while current attention around CBSs is focused on renewable energy, could it be applied to other types of infrastructure (e.g. flood defences, broadband/mobile connectivity, roads or airports)? 

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Jessica is a researcher/project manager at Rose Regeneration. Her current work includes evaluating two veteran support projects (in Cornwall and North Yorkshire); supporting public sector bodies to measure social value; and reviewing a project that supports parents recovering from drugs or alcohol addictions. She is also a senior research fellow at The National Centre for Rural Health and Care (NCRHC).  

She can be contacted by email jessica.sellick@roseregeneration.co.uk or telephone 01522 521211. Website: http://roseregeneration.co.uk/https://www.ncrhc.org/ Blog: http://ruralwords.co.uk/ Twitter: @RoseRegen 

Outer space

What does the new ‘space age’ mean for rural communities?

On 4 October 1957 the Soviet Union launched the first artificial earth satellite (Sputnik 1) from a spaceport known today as Baikonur Cosmodrome. Since then launch vehicles have reached orbit from 27 spaceports around the world. With the rate of space launches expected to grow exponentially in the coming years, the Government here wants the UK to be a leading player in the global space industry, capturing 10% of the global market by 2030. But what does being at the forefront of a new commercial ‘space age’ mean for rural communities? Jessica Sellick investigates.  ………………………………………………………………………………………………..

Data collected by satellites impacts upon our everyday lives – from navigation and weather reports to broadcast television, mobile communications and financial services. They are often described as an “invisible utility”. The decreasing cost of small satellites and launch services combined with the increased application and use of satellite data is creating more demand and requiring more capacity for satellite facilities. Further, with the development of re-usable spacecraft and horizontal launch capabilities, space travel and space tourism are now a reality. With the world becoming ever more dependent on satellites and the space industry, the Government’s ambition is for the UK to be a leading player in this global industry.  But what does this mean for rural communities? I offer four points. 

1. How big is the UK space industry?  

The UK Space Agency (UKSA), an executive agency of the Department for Business, Energy & Industrial Strategy (BEIS), is responsible for all strategic decisions on the UK civil space programme. Every 2 years the UKSA surveys organisations in the UK who supply and/or make use of space or satellite services – spanning commercial and non-commercial activities. The latest in a series of ‘size and health of the UK space industry’ studies was published in January 2019. Carried out by London Economics, the study covers the period 2015-2016 and 2016-2017 and is based upon an analysis of 948 space-related organisations (comprising 276 survey responses) and desk-based research of more than 600 organisations. The facts and figures presented reveal how: 

  • Total UK space industry income grew to £14.8 billion in 2016-2017, a growth rate of 3.3% per annum. This is equivalent to 5.1% of the global space economy (2016-2017). Income is forecasted to grow 4.8% to £15.5 billion in 2017-2018. 
  • The upstream grew strongly to £2.4 billion, though the downstream still dominates at £12.4 billion. Space Applications is the largest segment with 69% of income, of which 48% is Direct-to-Home (DTH) broadcasting. This is followed by Space Operations (15%), Space Manufacturing (13%) and Ancillary Services (3%). 
  • Across all activities, Broadcasting dominates (51% of total income) followed by Communications (19%), Position, Navigation and Timing (12%), Defence (which has grown to 8%), and Earth Observation (3%). 
  • The UK space industry now comprises 948 organisations, with 39 new entrants per year since 2012. Income growth from 2014-2015 to 2016-2017 (+£924 million) can be divided into: organic growth (+£794 million), new entrants (+£357 million), less attrition (-£226 million). 
  • Growth is concentrated amongst very large enterprises (56% of overall growth) and larger SMEs (28%), with the latter growing particularly fast (31% per annum, compared to very large enterprises at 2% per annum). 
  • The industry is commercially-focused, with 82% of income from sales to consumers and businesses. However, the public sector share of income has increased from 14% (2014-2015) to 18% (Space Agencies 4%, Government 14%), but remains marginally lower than the global average (20%). 
  • Exports grew to £5.5 billion in 2016-2017, or 37.4% of total income. This is up from 36.4% in 2014-2015 and this export intensity is one third higher than the UK economy. 
  • The industry directly contributed £5.7 billion of Gross Value-Added to UK economic output (0.29% of UK GDP, up from 0.27% in 2014-2015), and a total of £13.0 billion (including supply chain effects) in 2016-2017. 
  • Employment in the UK space industry increased at a rate of 4.3% per annum to 41,900 jobs in 2016-2017. This is equivalent to 0.13% of the UK workforce (up from 0.12%). 
  • The space industry workforce is exceptionally highly-skilled, with 3 in 4 employees holding at least a primary degree. This is higher than any sector covered by ONS Census data for England and Wales. 
  • It is estimated that wider UK industrial activities representing over £300 billion of UK non-financial business economy GDP (15.3%) are supported by satellite services as follows (not mutually exclusive): 

GNSS (positioning, navigation and timing) satellite services support £264 billion of GDP (13.4%). 

Meteorological satellite services support £159 billion of GDP (8.1%). 

Telecommunication satellite services support £117 billion of GDP (5.9%). 

Earth Observation satellite services support £92 billion of GDP (4.7%). 

As well as benefitting the space industry itself, these investments are seen to result in new knowledge, expertise and technologies that benefit wider economy. Termed ‘spillovers’, the lag between investments in space-related work and the benefits accruing to groups outside of these initial activities is 3-5 years. Spillovers are often focussed around technology transfers (e.g. products, processes and knowledge that can be copied and used in other settings). It is argued that without Government support, private companies would be likely to under-invest in activities with positive spillovers because they could not fully capture all the benefits of these activities. Conversely, in the absence of Government intervention, private companies are likely to over-invest in activities generating negative spillovers because they do not fully bear the costs. Both these cases of market failure are used to make the business case for Government intervention.

2. Why do we need spaceports? 

In July 2018 the Government published a brochure promoting the UK as an attractive destination to grow commercial markets for small satellite launch and sub-orbital flight services.

Small spacecraft (SmallSats) focus on spacecraft with a mass less than 180 kilograms – about the size of a large kitchen fridge. More than 1,300 smallsats were launched between 2012 and 2018 – with 2018 seeing six times as many launches compared to 2012. In 2018, 36% of smallsats were launched from the United States (US) – 80% of them manufactured by US companies. The US deployed the most Government smallsats between 2012 and 2018 (120) followed by China (44 smallsats) and Russia (43 smallsats). 

A paper from Frost & Sullivan commissioned by the UKSA assessed the potential UK market share for dedicated launch services.  With the number of small satellites launched in 2017 increasing by 157% compared to 2016 combined with modelling showing likely supply (launch capacity) and demand (satellite operator constellation plans) to 2030 – the paper highlights an opportunity to invest in a spaceport in the UK. 

As part of efforts to grow the UK’s spaceflight capabilities, Government has been funding a range of industry-led projects. This includes a £1.3 million investment in spaceport plans in England, Scotland and Wales. As part of the spaceflight programme, ‘Launch UK’, Government has contributed to a funding package to establish the UK’s first spaceport in Sutherland (Scotland). Called Space Hub Sutherland, the project is being led by Highlands and Islands Enterprise (HIE) and will see the development of a vertical launch site for a new generation of small rockets to launch micro communication and earth-observation satellites at The Moine, on the Melness Crofting Estate near Tongue. The launch site is expected to create around 40 highly skilled jobs. At a regional level, HIE estimates this figure will multiply to 400 jobs by 2023, with launch activities in Sutherland making the site the hub of a significant new space sector. The HIE project team has identified community benefits around tourism and local supply chain development and diversification. In October and November 2019 HIE organised a series of public events and community engagement activities. HIE then hopes to submit a formal application for planning consent to the Local Authority. 

The UKSA and Cornwall Council are working with Virgin Orbit to develop facilities and operational capabilities that would enable small satellite launches from Cornwall in the early 2020s. The funding package consists of approximately £12 million from Cornwall Council, £7.85 million from the UKSA and £0.5 million from the Cornwall and Isles of Scilly Local Enterprise Partnership (CIOS LEP). Spaceport Cornwall will use an existing airport, Cornwall Airport Newquay, and a modified Boeing 747 to offer launches. The spaceport also aims to act as a catalyst in attracting more high-value companies (from all sectors) into Cornwall. It is estimated that 150 direct and 282 indirect jobs will be created and £200 million of GVA generated over the next 5-years.   

Other Government investments include a new National Satellite Test Facility in Harwell, Oxfordshire and a new National Propulsion Facility in Buckinghamshire. Additional funding has been provided to support plans for small satellite launch and sub-orbital flight from aerodromes in the UK – including to Snowdonia Aerospace for the Snowdonia Spaceport Development Plan, which aims to create a centre for space R&D, training and satellite launch; and to Machrihanish Airbase Community Company (MACC) for a spaceport cluster plan in Argyle, Scotland. 

The RAF will be launching a satellite as part of the Ministry of Defence’s £30 million space programme. Eight military personnel will also be joining Operation Olympic Defender to work alongside allies at the Combined Space Operations Centre in California.

Back in May 2018 the Government published its ‘Prosperity from Space’ strategy – setting out its vision for enhanced growth in the UK space sector over the next decade. The strategy focuses on four areas: (i) earth navigation services; (ii) connectivity services; (iii) in-space robotics; and (iv) low-cost access to space. The strategy aims to double the value of space to wider industrial activities from £250 billion to £500 billion, generate an extra £5 billion in exports, attract £3 billion of inward investment and interact with 1 million young people a year to increase interest in STEM careers [science, technology, engineering and mathematics]. Developing space launch sites in the UK is one of the priorities to take forward the goals of the strategy. 

In August 2018 Government suggested the UK could compete to launch 2,000 satellites by 2030 – having a competitive advantage to compete for a more substantial share of the market owing to the UK’s location, regulatory framework, private sector strategy and space ecosystem. Existing ‘rideshare’ small satellite launches [where small satellites piggyback on larger missions] are capable of meeting less than 35% of the total demand thus revealing a significant gap in commercial small satellite launch provision for which future UK spaceports could deliver.

The UK’s geography is also well suited for launch sites. Our northern latitude provides access to specific types of orbits around the earth – such as polar orbits, which are useful for earth observation. Also, the neighbouring Atlantic means launches can take place over the ocean and sparsely populated areas. 

The Space for Smarter Government Programme (SSGP) is a strategic, national, programme established in 2014, led and funded by the UKSA. It is delivered in collaboration with the Satellite Applications Catapult to drive the uptake and use of space products, data and services across Government departments. The programme aims to increase the public sector’s use of space as an enabling technology to stimulate innovation and growth whilst at same time making Government more efficient and ‘smarter’. 

On the one hand, the development of spaceports is viewed seen as providing a means for the UK to build a global reputation for manufacturing and launching small satellites (drawing on skilled engineers in the aerospace, electronics and software industries); of attracting companies from across the globe to invest in the UK; fully integrating the sector supply chain; boosting local economies in the communities surrounding sites and more widely (e.g. well-paid careers, inspiring the next generation); and increasing links to academic institutions and the research community. On the other hand, concerns have been raised about the lack of public consultation and the potential environmental impact of spaceports. 

Alongside these developments Government is intending to establish a new National Space Council to inform UK space strategy and governance. Government is also focusing on international cooperation and has signed a Memorandum of Understanding (MoU) with Australia to exchange information, technology and personnel between the two countries. 

3. How are they being regulated? 

In the UK, the Space Industry Act 2018 provides the regulatory framework for the expansion of commercial space activities and the development of spaceports; covering orbital and sub-orbital activities and horizontal and vertical launches. In most cases, the Civil Aviation Authority (CAA) will regulate sub-orbital activities and the UKSA will regulate space activities. The exception is where the UKSA will regulate all spaceflight activities involving the use of rockets; regardless of whether they are involved in sub-orbital or space activities.

The licencing framework is not fully in place yet with details to be set by secondary legislation. The Government has issued guidance for prospective licences (for any launch, procurement of launch operation or return vehicles capable of operating above the stratosphere, some 50km) and anticipates publishing and consulting on detailed regulations in 2019. So far there has been one call for evidence on liability, insurance and charging.

Government has also been looking at health and safety legal requirements that may need to be implemented by a spaceport to minimise the risks to populations nearby from the storage and use of hazardous fuels.

The infrastructure spaceports need will require permission from the local planning authority.  

4. How will rural communities benefit from ‘lift off’? 

Launch UK is focusing its attention on Prestwick, Western Isle, Shetland, Sutherland, Campbeltown [Scotland]; Snowdonia [Wales]; and Newquay [England] – i.e., rural and remote areas. 

The initial selection to qualify as a location suitable for a spaceport was based on a CAA assessment of a wide range of criteria from meteorological to environmental and economic factors. Criteria also included having an existing runway that could be extended to over 3,000 metres in length; the ability to accommodate dedicated segregated airspace to manage flights safely; and a reasonable distance from densely populated areas in order to minimise impact on the uninvolved general public.

For some rural residents the development of commercial spaceports is viewed as an opportunity to create highly technical jobs, upskill local people and generate income for the local economy. Other rural dwellers are less supportive – with spaceports seen to threaten the solitude and tranquility of where people live and have adverse environmental impacts (on landscapes and wildlife). Moreover, there have been discussions around whether spaceports are being imposed upon some rural communities and do not represent the kind of infrastructure they actually need. With Local Authorities responsible for the provision of an extensive range of services (e.g. planning, housing, highways, environment, economic development) how is/will Government support them to increase spending on these core services in spaceport areas? 

If space matters – every time we go to work, turn on the television, make a phone call or do our banking; how can we ensure the benefits from our satellite and space programmes flow back to rural communities? For if the UK is to truly realise its potential of becoming a spacefaring nation it is dependent on rural places to do so.  

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Jessica is a researcher/project manager at Rose Regeneration. Her current work includes evaluating two veteran support projects (in Cornwall and North Yorkshire); supporting public sector bodies to measure social value; and evaluating a series of community safety and crime reduction projects. She is also a senior research fellow at The National Centre for Rural Health and Care (NCRHC). In her spare time Jessica sits on the board of a housing association. 

She can be contacted by email jessica.sellick@roseregeneration.co.uk or telephone 01522 521211. Website: http://roseregeneration.co.uk/https://www.ncrhc.org/ Blog: http://ruralwords.co.uk/ Twitter: @RoseRegen 

Rural Healthcare

What more can be done to address the “unavoidable smallness due to remoteness” of delivering health care in rural areas?

That it costs more to deliver health and care in rural areas is well-rehearsed among RSN members. But how much more does it actually cost to deliver in rural areas and are these costs recognised in current funding formulae? Jessica Sellick investigates. 

How much funding is available for the NHS and where does it come from? 

The vast majority of funding for the NHS comes from taxation, with a small amount from National Insurance contributions. Some funding is also generated from charges from prescriptions, dental treatment and spectacles – although these user charges amount to less than 1.1% of the budget. The NHS also generates some income itself (e.g. through parking charges). 

The Government publishes a Mandate for NHS England before the start of each financial year. This document  sets out what the Government wants NHS England to deliver over a given year with the money it receives. In 2018-2019 NHS England is receiving some £114 billion mandate funding. Of this total, £75.6 billion is being allocated to Clinical Commissioning Groups (CCG), £17.7 billion to specialised services, £8.1 billion to General Practice, £6.7 billion to other direct commissioning, £2.5 billion to the Provider Sustainability Fund, £1.1 billion to transformation, £0.7 billion to NHS England programmes, £0.5 billion to NHS England running costs, £0.4 billion to a Commissioner Sustainability Fund, £0.4 billion for drawdown and £0.3 billion for other services/activities. 

The running costs for NHS England for 2018-2019 have been set at £508 million. From this figure, £215 million is being allocated to operations and information, £73 million to transformation and corporate operations, £64 million to primary care support, £43 million to depreciation, £30 million to finance, £18 million to NHSE Core Contracts, £17 million to specialised commissioning, £11 million to strategy and innovation, £8 million to nursing, £6 million to medical, £1 million to board and chief executive and £22 million to other activities.  

In March 2018, NHS England and NHS Improvement announced some key steps to bring the two organisations closer together. While the statutory framework prevents these organisations from formally merging, functional integration (i.e., of regional teams led by a single Regional Director) and increased alignment of national programmes and activities will be undertaken to improve integrated working. These charts illustrate the new national and regional management structure. In May 2018, NHS England and NHS Improvement held their first joint board meeting. The financial changes presented and discussed included both bodies introducing a single financial and operational planning process for the health system and the appointment of a new Chief Financial Officer to ensure ‘effective use of national resources at areas of need.’

In  Budget 2018, the Government set out its commitment to increase NHS England’s budget by £20.5 billion by 2023-2024. This equates to a 3.4% increase per year, on average. This figure includes an additional recurrent £1.25 billion on top of a core revenue increase to cover NHS employer pension contributions. All of this means, in practice, that NHS England’s 2018-2019 budget of £114 billion will rise to £149 billion by 2023-2024.  

On 7 January 2019 Simon Stevens, Chief Executive of NHS England launched The NHS long-term plan. Over the next 10 years, the plan aims to save half a million more lives through taking practical action on major physical health conditions (e.g. heart attacks, strokes, respiratory conditions, cardiac care, and cancer) alongside investment in mental health services. The plan includes a renewed focus on using the latest technology and ‘prevention’ to help people live healthier lives so that they do not develop life threatening or limiting conditions. 

While the NHS is expected to be in balance in 2018-2019 [by this Government means health providers and commissioners will have eliminated deficits]; the long-term plan contains a commitment for NHS providers to be in balance by 2020-2021 and for all NHS organisations to be in balance by 2023-2024. To achieve this, the plan sets out proposals for NHS Improvement to ‘deploy an accelerated turnaround process in the 30 worst financially performing trusts’, the creation of a new financial recovery fund, and initially £1.05 billion provided to trusts in deficit that sign up to control totals with NHS Improvement. The joint board meeting between NHS England and NHS Improvement in September 2018 included a work stream on ‘finance and efficiency’ to ensure a shared 20% efficiency commitment and establishing a finance operating system for both organisations.  

From looking at all of these figures what is emerging here is a shift in financial support for the NHS – with a focus on annual efficiency gains, improvements in productivity, of meeting (population) demand more appropriately through prevention and providing care closer to home (freeing up hospital beds) and integrated working (across and within organisations at local, regional and national levels). 

(How) is ‘rural’ taken into account in funding formulae? 

The Advisory Committee on Resource Allocation (ACRA) is an independent committee that ‘makes recommendations on the preferred, relative, geographical distribution of resources for health services.’ Set up in September 1997, ACRA is a successor body to the Resources Allocations Working Group (RAWP) which dates back to 1976. ACRA makes recommendations to both the Secretary of State and the Chief Executive of NHS England. This includes making recommendations on the ‘weighted capitation formulae’ which sets target shares of the national budgets for local areas – focusing on reflecting the best estimates of (i) the relative need for health services and (ii) the relative unavoidable differences in the costs of providing these services. ACRA also seeks to review evidence and develop statistical models of need for health care. ACRA does not advise on the size of health budgets, which is determined by Government. 

In 2015, ACRA analysed the potentially higher costs faced by hospitals which are ‘unavoidably too small to achieve full economies of scale.’  The technical term ‘unavoidable smallness due to remoteness’ applies to hospitals which serve a population of under 200,000 people [the minimum population required to achieve economies of scale]; and for these hospitals, the proportion of the population they serve for whom the next nearest hospital is more than 60 minutes driving time away [the maximum travel time for clinical safety reasons for emergency care].  The analysis identified 12 hospitals which fitted the unavoidable smallness criteria: St Mary’s Hospital (Isle of Wight), North Devon District Hospital (Barnstaple), Furness General Hospital (Barrow), West Cumberland Hospital (Whitehaven), Pilgrim Hospital (Boston), Hereford County Hospital (Hereford), Cumberland Infirmary (Carlisle), Scarborough General Hospital (Scarborough), Hexham General Hospital (Hexham), Dorset County Hospital (Dorchester), Royal Shrewsbury Hospital (Shrewsbury) and Friarage Hospital (Northallerton). Cornwall and North Norfolk did not feature in this list and ACRA undertook further analysis of these two areas. North Norfolk has providers located in Norwich and Kings Lynn (served by Norfolk and Norwich University Hospital and the Queen Elizabeth Hospital in Kings Lynn); and in Cornwall the majority of the 420,000 population are able to access Treliske Hospital in Truro or Derriford Hospital in Plymouth in less than one hour. However, if the ‘unavoidable smallness due to remoteness’ reduced this journey time from 60 minutes to 45 minutes, while it has relatively little effect on which providers serve a remote population it does have a significant impact on the proportion of the population that is remote. ACRA cite Furness Hospital where the proportion of the population considered remote would increase from 60% at 60 minutes to 90% at 45 minutes and 100% at 30 minutes.  

In 2016-2017 seven CCGs covering eight remote hospital areas received an additional £31.2 million to take into account their unavoidable smallness. This figure will increase by 6% to £33.1 million in 2018-2019. The allocation of this funding amongst the eight remote areas ranges from £2.8 million in Scarborough and Ryedale CCG to £8.9 million in North Cumbria CCG. The largest single adjustment is a 2.8% increase for the Isle of Wight. 

In October 2018 NHS England and NHS Improvement set out proposals to change the payment system in 2019-2020. This included proposals to update the Market Forces Factor (MFF). The MFF estimates the ‘unavoidable cost differences between healthcare providers based on their geographical location’ and has not been updated in 10 years. The main changes in the MFF relate to: using travel to work areas (TTWA) rather than primary care trust (PCT) areas to estimate the non-medical-and-dental staff component; introducing business rates as a new component; and using a more consistent method to combine components into a single index. However, MFF is not seen as the most appropriate mechanism for costs relating to ‘rurality/remoteness’. Instead the recommendation is that “these costs should be compensated via local arrangements to reflect the existing national rurality adjustment to CCG allocations” (page 30). 

In autumn 2018 the Nuffield Trust was commissioned by the National Centre for Rural Health and Care (NCRHC) to explore the impact of rurality and sparsity on the costs of delivering rural health care. This review looked at the key factors for calculating health allocations to local areas: with adjustments in funding made for population need, unmet need/inequalities, costs and financial stability. The key determinant here is population and demographic needs within a given area. A further adjustment is made for the higher costs of running hospitals with 24-hour A&E departments in remote areas. Funding from CCGs to rural areas makes adjustments for (i) the extra cost of ambulance provision and (ii) an allowance for remoteness. However, these two factors are outweighed by a further two factors (iii) market forces and (iv) health inequalities. The impact of iii and iv sees the total budget for core services move around £600 million of funding from predominantly rural areas to urban and less rural areas. Nuffield’s analysis further reveals how six rural hospital trusts carry a quarter of England’s health service’s funding deficit. 

Data provided to the Nuffield Trust by NHS Improvement suggests that, to November 2018, 17 trusts had applied for local modifications. Of these applications, the majority (11 applications) are for rurality (or sparsity/economies of scale); with the remainder consisting of rationale relating to case-mix complications (2), Private Finance Initiatives or estates (2), A&E services (2), and clinical negligence scheme costs (1). To date, only one trust, Morecambe Bay, has been successful in its request for formal compensation for higher costs due to rurality. 

Indeed, when CCGs make any adjustments for the actual amount of funding an area receives they follow a ‘pace of change policy’ in their allocation formulae. This is a determinant of how far CCG areas are moved closer to their target allocation each year through differential growth – and it intended to provide stability in funding for all organisations with those moving furthest under target closer towards their target. This policy is set by NHS England for NHS allocations. While the policy is intended to support a place based approach to commissioning, in practice it can also lead funding to be moved from rural to urban areas.  

The NHS Long-Term Plan contains one reference to  ‘rural’ on page 23. Section 1.32 states: “we will develop a standard model of delivery in smaller acute hospitals who serve rural populations. Smaller hospitals have significant challenges around a number of areas including workforce and many of the national standards and policies were not appropriately tailored to meet their needs. We will work with trusts to develop a new operating model for these sorts of organisations, and how they work more effectively with other parts of the local healthcare system.” 

The implications of the long-term plan for rural communities highlights trade-offs between the centralisation and/or localisation of services; having a health and care workforce and meeting required safe staffing levels; specialist versus generalist staff; and face to face provision and the use of technology.  

The authors of the Nuffield Trust review conclude that “the way the NHS distributes funding between local health services is unclear, unfair and fails to fully compensate remote and rural areas for the extra costs they face”. 

Moving from (acute) hospital settings to (preventive) community care?

For me, in trying to unpack and understand the funding formulae’s for NHS services what remains missing is: (1) a joined-up dialogue about funding for social care in rural areas, and (ii) a joined-up dialogue about prevention in rural areas. 

In March 2017 the Government stated its intention to publish a Green Paper on social care in order to allow a public consultation to be held. Since then, the publication of the Green Paper has been delayed several times – most recently following the announcement of the NHS long-term plan. 

The purpose of the Green Paper is to look at the sustainability of the care support system in its broadest sense (taking into account workforce, technology, health and other services). In December 2018 the Rural Services All-Party Parliamentary Group (APPG) published the findings of its inquiry into the future funding of adult social care in rural areas. This reveals how there are 4,615 requests per 100,000 residents for new support from clients aged 18 years and over: 16.5% greater than in urban areas (3,960 requests per 100,000 population). The gross current expenditure on support in predominantly rural areas is £210,982 per 100,000 adult population: 20% greater than urban areas (£175,877 per 100,000 adult population). The hourly rate for home care in predominantly rural areas is £16.43 per hour, 11% greater than the hourly cost in urban areas of £14.81. For many rural Local Authorities the current care support system is not sustainable. 

These figures, provided by RSN members, suggests ‘unavoidable smallness due to remoteness’ is also an issue that affects the provision of audit social care. 

However, these figures – and the Government’s Green Paper – do not include requests, expenditure or the costs of providing children’s services. According to the Local Government Association (LGA), in 2017-2018 there was a £816 million overspend in Council’s children’s social care budgets – with the largest overspends in the areas of looked after children and child protection. While overall spending by Local Authorities was down by £447 million on the previous year (2017-2018), spending on children’s social care increased by £368 million; meaning authorities have to divert money from other services to meet the costs of providing vital services to children and young people. The LGA estimates that children’s services are facing a funding gap of approximately £3 billion by 2025 just to maintain services at their current level. 

For me this work underlines the need to have a dialogue about how much it costs to meet social care needs in rural areas (for children, young people and adults), where integration happens in delivering health and care in rural areas, and how to pay for it (before provision collapses). 

The NHS long-term plan contains a substantive section on strengthening the NHS’s contribution to prevention – including programmes to cut smoking, reduce obesity, limit alcohol-related A&E admissions and to lower air pollution. In 2019, the Government will also be publishing a Green Paper on prevention. This will seek to shift health services from acute settings to community and primary care settings. Currently, £97 billion of public money is spent on treating disease and £8 billion on preventing it. The Green Paper will set out how this shift from treating single acute illnesses to promoting the health of the whole individual will be undertaken – with a mission to improve health life expectancy so that by 2035, people enjoy at least five extra years of healthy, independent life. Of particular interest to RSN members, the plans are thought to include reducing loneliness and social isolation as well as the provision of specialist mental health services. At the same time, many RSN members will be familiar with reductions in the public health grant given to Local Authorities (averaging 3.9% a year to 2020-2021) which may lead to a reduction in the quantity and quality of services available and place increased demand on treatment services.  For me, this underlines the need for a dialogue about what kinds of public health intervention are needed in rural areas, how they integrate with health and care, and where any future investment will come from. 

Where next? 

In April 2019 NHS England will be reviewing how allocations are made to local areas in line with its next mandate from Government. This may include seeing if the needs of rural areas are better captured through estimating the need for community services and using population data which better reflects seasonal workers. Will this result in additional allocations for rural areas? 

At some point in 2019, HM Treasury will be carrying out Spending Reviews for public services. This will, ultimately, set the level of NHS funding provided by Government. This will set health funding for the 2020-2021 financial year and may possibly extend over the two following financial years as well.  

We also eagerly await the Green Papers on social care and prevention. 

While there is a clear thread emerging here for providing more integrated, place-based and holistic/whole person health and care – and to getting all NHS organisations into balance – what will the resultant financial allocations mean for rural residents? Will future funding formulae offer equal access to everyone or will the financial costs of doing so in rural areas mean the same economies of scale for which we are judged against cannot be achieved? Watch this space…   

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The term ‘unavoidable smallness due to remoteness’ derives from NHS England’s Advisory Committee on Resource Allocation (ACRA) and provides estimates on the unavoidable costs associated with providing health care services in remote areas.  

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The Nuffield Trust research report – Palmer B, Appleby J and Spencer J (2019) Rural health care: A rapid review of the impact of rurality on the costs of delivering health care – can be downloaded from the NCRHC website here. 

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Jessica is a senior research fellow at the National Centre for Rural Health and Care (https://www.ncrhc.org/) which commissioned the research from the Nuffield Trust.  

The NCRHC has joined with the Rural Services Network (RSN) to launch the affiliated Rural Health & Care Alliance – a membership organisation dedicated to providing news, information, innovation and best practice to those delivering and interested in rural health and care across England. More information about the RHCA – and how to join – can be found here: https://www.rsnonline.org.uk/page/about-the-rhca 

Jessica is also a researcher/project manager at Rose Regeneration. Her current work includes evaluating two veteran support projects (in Cornwall and North Yorkshire); supporting public sector bodies to measure social value; evaluating a hospital avoidance service; and undertaking a piece of work on migration. 

In her spare time Jessica sits on the board of a housing association. 

She can be contacted by email jessica.sellick@roseregeneration.co.uk or telephone 01522 521211. 

Website: http://roseregeneration.co.uk/ 

Blog: http://ruralwords.co.uk/ 

Twitter: @RoseRegen 

Food poverty

Hidden hunger – how can we tackle food poverty and insecurity in rural areas?

When we think of the word ‘hunger’ we often think about starving children in developing countries. Yet unfortunately this type of hunger is very much a reality for some people living in the UK today. Figures suggest 1 in 6 adults has skipped a meal because they couldn’t afford it and 1 in 12 has gone a whole day without eating. School holidays make up 13 weeks of the year – this means children and young people spend a quarter of their year not in school. This brings additional costs and challenges for families – with some 3 million children at risk of hunger during holiday periods. For too many children and adults the food runs out. Because it’s harder to spot in the UK it can be difficult to convey hunger exists. How many children and adults have hunger as their most constant companion? What causes household food poverty and food insecurity?  And what more can be done to respond to this urgent need? Jessica Sellick investigates. 

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How many children and adults are going hungry? 

The Food Standards Agency’s working definition of food poverty is ‘where the constraints are such that it is not possible for individuals or households to consume a nutritionally adequate diet, they could be considered to be in food poverty.’This is where an individual or households isn’t able to obtain healthy, nutritious food, or can’t access the food they would like to eat – forcing people to eat what they can afford rather than what they want. Some commentators draw on Peter Townsend’s concept of relative poverty in defining food poverty beyond these nutritional concepts to ‘the social functions that eating serves i.e., being able to modestly eat out once in a while, have friends over to eat or celebrate special occasions.’  

The Food and Agriculture Organization (FAO) defines food insecurity as ‘a situation that exists when people lack secure access to sufficient amounts of safe and nutritious food for normal growth and development and an active and healthy life. It may be caused by unavailability of food, insufficient purchasing power, inappropriate distribution or inadequate use of food at the household level…Food insecurity may be chronic, seasonal or transitory.’ 

According to UNICEF, in 2017, 10% of children in the UK were reported to be living in households affected by severe food insecurity [defined by UNICEF as ‘experiencing hunger’]. According to figures published by End Hunger UK, in January 2018 16% of adults in Great Britain either skipped or saw someone else in their household skip meals; 14% of adults worried about not having enough food to eat; and 8% of adults had gone a whole day without eating because of a lack of money during the last 12 months. Parents whose children were aged 18 and under were found to be particularly food insecure, with 23% either skipping or seeing someone in their household skipping a meal due to a lack of money; 23% worried about not having enough food to eat; and 13% had gone without eating for a whole day in the last 12 months. Parents with primary school-age children (aged 5-11 years) fared even worse: with 27% either skipping or seeing someone in their household skipping meals to make ends meet. 

“I work—two jobs—and my husband works full-time. We should be able to afford good, nutritious food. We should be able to afford food. The reality, though, is multiple days when dinner has been a tin of chopped tomatoes, some value dried mixed herbs, and 20p pasta; we have to regularly feed our family on around £1.50 for the entire meal—not per head. By the time our rent is paid, money put on the gas and electric keys, the bills paid…there’s nothing left. We drink water, we eat the cheapest food, but we struggle to afford even that.”

“It [Christmas] was a festival of all the things we couldn’t have. Adverts on telly show families spending loads of money and you’re just bombarded with it everywhere you go – this faux festivity and cheer. My worst year, I didn’t have a tree, didn’t have any decorations, I couldn’t buy any presents, I had unplugged the fridge, turned the heating off, taken out the light bulbs…I sent my son to his father’s for Christmas and I just sat on my own and got drunk on cheap lager on the couch and didn’t tell anyone.”

According to academics at Northumbria University, holiday hunger is a ‘condition that occurs when a child’s household is, or will, become food insecure during the school holidays.’ When there is no school there is no Free School Meals (FSMs). Eligibility for Free School Meals (FSMs) extends to all children in England and Scotland who are in Year 2 and below. For pupils in other years FSMs is means tested. According to the Institute for Fiscal Studies (IFS), in April 2018, there were some one million children receiving means tested FSMs, with two-thirds of these children living in the lowest income fifth of households with children. A change to the rules governing FSMs led by the Department for Education (DfE) is now taking place due to the introduction of Universal Credit (UC). The IFS estimates that this will lead some 210,000 extra children will be eligible for FSMs after the rollout of UC. However, 160,000 children who are currently entitled to FSMs will lose out under the new system – meaning an overall increase of 4% or some 50,000 pupils in receipt of FSMs. In many cases, school dinners can be the main source of nutrition for children and young people living in low income households.  

Research by Feeding Britain suggests 3 million children are at risk of hunger during school holidays; and that the loss of FSMs during the holidays costs a family, on average, £30.00-£40.00 per week. Work in Glasgow by the Child Poverty Action Group (CPAG) has highlighted some of the cost pressures facing families during holiday periods – with many parents reporting falling into debt or borrowing money to pay for heating, eating and uniform for new the new school term.  

A survey funded by Kellogg’s found more than six out of ten parents with household incomes of less than £25,000 said they were not always able to afford to buy food outside of term time [this figure increased to 73% for parents on incomes of less than £15,000]; and that one-third of parents had skipped a meal during the school holidays so that their children could eat.   

No parent cuts out meals for themselves or their children through choice; they do so because they have no choice. But it is difficult to tell how many children and adults have hunger as a constant companion because there is no standard measures or data collection for measuring this across the UK.  

The FAO, for example uses the Food Insecurity Experience Scale (FIES) to measure food insecurity through people’s experiences. The FIES asks individual respondents for themselves or their household as a whole during the last 12 months is there a time when – because of lack of money or other resources – they: (1) were worried they would not have enough food to eat; (2) were unable to eat healthy and nutritious food; (3) ate only a few kinds of foods; (4) had to skip a meal; (5) ate less than they thought they should; (6) ran out of food; (7) were hungry but did not eat; and (8) went without eating for a whole day? Responses to these eight questions are then transposed onto a scale from mild food insecurity (i.e., worrying about the ability to obtain food); through to moderate food insecurity (i.e., reducing quantities, skipping meals) and severe food insecurity (i.e., experiencing hunger). 

The United States Department of Agriculture (USDA) collates data and information on ‘hunger’, ‘food security’ and ‘food insecurity’ as part of Government attempts to identify the economic and social factors that may lead to hunger.     

When it launched new research into destitution in 2018, the Joseph Rowntree Foundation (JRF) described what it means to go hungry. By ‘destitute’ the researchers asked respondents if they, or their children, had lacked two or more of the following six essentials over the past month because they could not afford them: (i) shelter, (ii) food, (iii) heating, (iv) lighting, (v) clothing and footwear and/or (vi) basic toiletries.

How can we draw on some of these definitions and measures to develop some baseline data (and ongoing information) about children and adults experiencing hunger, on the verge of hunger, and at risk of hunger (including the nutritional and social functions of food) across the UK? 

Why are people hungry – what is causing household food budgets to become so restricted? 

The report of the All-Party Parliamentary Group on hunger in the United Kingdom ‘a strategy for zero hunger’ describes how:  

“something fundamental is happening in advanced Western economies which throws into doubt the effectiveness of a national minimum below which no one is allowed to fall. It is the erosion of an effective national minimum that has led to the existence of hunger and the rise of the food bank movement in its wake” (page 9). 

The report illuminates the multifaceted reasons for hunger. These include: a reduction in real wages; benefits levels and changes (delays/errors in processing claims, benefit sanctions); juggling the budget for food, housing and utilities (which for some people means going without food in order to avoid becoming homeless or the utilities being turned off); people being overwhelmed by a sudden budgetary crisis; and/or the absence of FSMs. The APPG also identified some underpinning reasons including the size of debt which many families are struggling with and addiction (including addiction funded by debt).  

A Rapid Evidence Assessment (REA) carried out for Defra back in 2014 asked food aid organisations who accesses their support and why. Food aid organisations identified immediate problems such as a sudden reduction in household income (job losses or benefits payments) as well as ongoing circumstances (continual low household income and indebtedness). The REA also revealed how people who struggle to manage their food needs adopt a variety of strategies to avoid having to ask for food help (e.g. cutting back, changing eating and shopping habits, juggling budgets, turning to family and friends). When they do turn to food aid – often as a very last resort – they are likely to draw upon as much assistance (food and non-food support) as they possibly can.   

More recently, in January 2018, the APPG on Hunger published its report into the ‘hidden’ problem of elderly hunger in the UK. This revealed more than 1 million older people at risk of malnutrition caused by social isolation (e.g. due to bereavement, illness, immobility or loss of driving licence) and cuts to public services. The report found malnutrition costs the NHS approximately £12-13 billion a year and this is being exacerbated by reductions in social care packages, cuts to meals on wheels services and local shop closures. 

‘Food aid’ is an umbrella term that encompasses a range of large and small scale local activities aimed at helping people to meet their food needs, often on a short term basis (during crisis or immediate difficulty). 

Food banks are one example of food aid. Foodbanks in the UK are typically run by charities, community groups, voluntary sector organisations and faith groups. People are usually referred to a food bank from an agency or body such as Citizens Advice, Jobcentre Plus, GP, social worker or school from whom they receive a voucher to take to a food bank where they receive 3 days’ worth of food. 

Since February 2017 the Independent Food Aid Network (IFAN) has been mapping the number of independent foodbanks outside of those operated by the Trussell Trust. So far, researchers at the IFAN have identified 801 independent foodbanks. This equates to 39.3% of the total number of UK food banks, with the Trussell Trust’s network currently extending to some 1,235 foodbanks. 

Between 1 April 2017 and 31 March 2018, Trussell Trust foodbanks provided 1,332,952 people with three-day emergency food supplies – a 13% increase on the previous year. Some 484,026 of these emergency food supplies went to children – whose foodbank use increased 6% on the previous year. The top four reasons for referral to one of the Trussell Trust’s foodbanks were: being on a low income (28% of referrals), a delay in benefits (24%), changes in benefits (18%) and debt (9%). 

An animation, ‘Hunger by the Sea’, made by Bournemouth University contains first-hand accounts from people accessing support from a foodbank. The foodbank used to develop the animation was situated by the sea and this was used to produce images to accompany participant’s narratives about how they are struggling to keep their heads above water. The Trussell Trust also provides narratives of people using its foodbanks. 

The UK Government does not collect data on the number of foodbanks in operation, the number of people accessing them and the circumstances that lead them to do so. This would undoubtedly build a fuller picture about the ‘national minimum’ below which people should not be allowed to fall.  

How many people are hungry in rural areas – and how many people are struggling to access healthy and affordable food? 

An Evidence Review for the All-Party Parliamentary Inquiry into Hunger looked at the extent and geographical spread of hunger and food poverty. The review included a section on ‘rural hardship’ which identified several factors which may worsen the ability of low-income households in rural and coastal areas to be able to afford food. These factors included: struggling with the higher costs of heating their homes, higher costs of transport, distance to work or Jobcentre Plus and low-paid and seasonal employment. Evidence submitted to the review found some rural residents were living some distance from lower-cost supermarkets and could not afford the bus fare to travel to town to shop. The insecure and short-term patterns of employment in some rural areas led some residents to not be able to accrue savings or resources to provide resilience during difficult times; and how property costs are higher and comprise proportionately more of the family income which means families can be more vulnerable to shocks in their household budget. 

Food deserts are defined in the US as ‘parts of the country vapid of fresh fruit, vegetables, and other healthful whole foods, usually found in impoverished areas.’ 

A report published by the Social Market Foundation in October 2018 found about three-quarters (76%) of food deserts in England and Wales were in urban areas, with the remaining 24% in rural areas. While a quarter (24%) of urban super output areas are “food oases”; this is the case for 7% of rural super output areas. Overall, 95% of food oases are in urban areas and 5% in rural areas. Rural areas were found to have more restricted choice of food stores than urban areas; and for rural residents without access to a car, or with restricted mobility, accessing a range of food stores in a rural area was a challenge. 

Much is written about what happens when a supermarket opens up in an area but less is written about the consequences when a supermarket closes – particularly in a rural area which can lead to a reduction in the local community’s access to fresh food.  

Defra’s Statistical Digest of Rural England  (December 2018) monitors ‘accessibility to key services’ by looking at the time taken to travel from a rural place to a service location. Generally, people living in rural settlements have lower overall levels of accessibility to key services compared with people living in urban places – with people living in sparse rural settings having the lowest overall accessibility. For travel by public transport, the average number of key service locations accessible to people living in rural areas is highest for primary schools and food stores, with 9 available within a 60 minute journey time. 

Approximately 28% of UK food banks are located in rural areas, but their distribution varies across different rural districts. Even where there is a foodbank in a rural area some remote residents may struggle to access it (or get a referral from an agency) because of the distance and cost of transport. Research has further highlighted how the stigma often associated with using foodbanks can take on additional prevalence in rural areas where this is often a strong ethos of ‘making do’. 

Back in 2015 Hannah Lambie-Mumford and Carolyn Snell investigated the ‘heat or eat’ dilemma in rural areas, interviewing clients from Trussell Trust foodbanks in Cornwall. The report’s findings suggest neither fuel nor food is sacrificed for the other, but instead those with the lowest income ration both. The quantity and quality of food is reduced, whilst the use of fuel for cooking and lighting is often prioritised over warmth. 

Is it possible to collect data on the number of foodbanks in operation, the number of people accessing them (or not able to access them) and the circumstances that lead them to do so? 

Importantly, is it also possible to map sources of ‘affordable’ and healthy food in rural areas – not only taking into account distance to a food store  and number of stores available in a given area; but then overlaying this information with other indicators such as average household income, deprivation and availability of public transport? 

What is being done to address hunger?  

In March 2018 the Government announced a £2 million ‘Holiday Activities and Food Programme’ for new and existing holiday clubs to explore how to help disadvantaged children benefit from healthy meals and enriching activities. In November 2018, the DfE published management information about the children and young people attending the holiday clubs.  This revealed, of the seven organisations funded by the DfE to provide healthy food and enriching activities, 18,200 children and young people had received support. 

Holiday clubs provide free meals and activities during the school holidays for children who may otherwise go without and are often operated by charities, community groups, youth groups or Local Authorities. In 2017, the estimated 593 clubs across the UK provided over 190,000 meals to more than 22,000 children and young people during the summer holidays and October half-term. But their geographical coverage is patchy which means they are not reaching all the children who need help during the holidays.

Under the strapline ‘no child too hungry to learn’, Magic Breakfast provides breakfast food and expert support to schools. The DfE provided funding to Magic Breakfast to support schools to set up and run breakfast clubs in schools with over 35% of the pupils eligible for FSMs which had no existing breakfast club. The evaluation of the scheme found the delivery model worked well – with 184 schools recruited and 96% of schools continuing to provide a breakfast club after Magic Breakfast’s contract with the DfE ended. As well as reducing hunger, breakfast clubs were perceived to improve concentration and behaviour in class and to improve punctuality for some pupils. In March 2018 the DfE announced £26 million [funded through the soft drinks industry levy] towards a National School Breakfast Programme. To be delivered by Family Action in partnership with Magic Breakfast, the Programme aims to help improve breakfast for pupils in more than 1,700 schools by 2020. In addition to providing the National School Breakfast Programme, Magic Breakfast is continuing to provide nutritious breakfasts to more than 31,500 children during school term time. In the 2017-2018 academic year, Magic Breakfast provided 2,884,512 bagels, 2,016,727 bowls of cereal, 1,765,446 glasses of juice and 242,705 bowls of porridge.  

The Healthy Start Scheme is Government funded and provides vouchers for pregnant women or parents with children under the age of four years on benefits for them to spend on healthy foodstuffs such as milk, fruit and vegetables.  

Other non-Government initiatives include Fare Share’s, the UK’s largest food charity, campaign ‘feed people first’ which is working with manufacturers, processors, packers and retailers so that surplus food can be collected by local charities. Many foodbanks have joined the ‘more than food programme’, becoming community hubs and providing people with support people tackle debt and financial issues, get through and out of fuel poverty and providing holiday clubs for children when FSMs are not available.   

What more can be done? 

The Fabian Commission on Food and Poverty looked at how a fairer food system could be built that works better for people on low incomes. The Commission’s recommendations included a new cross-department minister with responsibility for eliminating household food insecurity in the UK; action to reduce acute household food insecurity caused by sanctions, delays and errors in the benefits system; an inquiry to remove poverty premiums for key living costs such as food, utilities, housing, household appliances and transport; and called for Local Authorities to establish food access plans that address physical barriers to affordable, nutritious food in their area. 

Other organisations are also calling for a coordinated Government strategy to tackle household food poverty and food insecurity (e.g. End Hunger UK, Feeding Britain, Church Action on Poverty and partners).  

The Poverty and Inequality Commission was tasked with looking at the Child Poverty Delivery Plan 2018-2022 by the Scottish Government. The Commission’s recommendations included: that the Scottish Government introduce an additional cash benefit during school holiday periods that at least matches the equivalent costs of school meals; that the Scottish Government and Local Authorities should work together to take a strategic approach to funding a package of school holiday support that address the full range of pressures faced by low income families; and that existing holiday club provision should be used to provide food as a core element of their work. 

Much of this work draws attention to some of the themes outlined above – particularly in calling for more government leadership [e.g. strategy, data, welfare reforms]; recognising the important work undertaken by local, regional and national charitable (food) organisations; and helping people to earn a decent wage. In addition to this strategic approach; another strand of work is seeking to encourage people who are struggling with food insecurity to feel more able to seek assistance without the stigma of shame or failure. This strand recognises the assets and resources that communities already have and how these might be built upon. 

What more can be done to support people in rural communities? We need to listen to people with first-hand experience of hunger in our rural communities and use these experiences to provide immediate and longer-term support. this means we shouldn’t just focus on food (nutrition and social functions) but should be much more holistic and wide ranging (e.g. work/wages, social inclusion etc.) No one should have hunger as their constant companion. As Sir Winston Churchill (1943) reminds us ‘healthy citizens are the greatest asset any country can have.’ 

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Jessica is a researcher/project manager at Rose Regeneration. Her current work includes evaluating two veteran support projects (in Cornwall and North Yorkshire); supporting public sector bodies to measure social value; evaluating a hospital avoidance service; and undertaking a piece of work on migration. 

She is also a senior research fellow at the National Centre for Rural Health and Care (https://www.ncrhc.org/). 

In her spare time Jessica sits on the board of a housing association. 

She can be contacted by email jessica.sellick@roseregeneration.co.uk or telephone 01522 521211. 

Website: http://roseregeneration.co.uk/ 

Blog: http://ruralwords.co.uk/ 

Twitter: @RoseRegen 

Rural NHS

How can we build a rural health and care workforce?

The NHS tuned 70 on 5 July 2018. This year has seen celebrations and appreciation of the vital role that the service plays. As the NHS ages the pressures and demands it faces are very different to those of 1948 – with the workforce under considerable strain to provide services. How can we plan, fund, recruit, train and retain health and care workers in rural areas that meet people’s (clinical and wellbeing) needs and the (professional/lifestyle) aspirations of staff? Jessica Sellick investigates.

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NHS England employs some 1.2 million people – in more than 350 different roles: from 140,000 doctors and 300,000 nurses and midwives through to physiotherapists and dieticians. Despite these numbers it is apparent to all that the NHS just doesn’t have enough staff. There are some 50,000 vacancies in different clinical areas, with a 5.9% shortfall between the staff needed and the staff in post. 

In November 2018 the National Institute of Economic and Social Research (NIESR) prepared a report for the Cavendish Coalition on the health and social care workforce (H&SC) in all parts of the UK – highlighting trends over time and across regions and job roles – and providing a number of simulations on the workforce in the next few years. By examining the pattern of leavers and joiners to the NHS over the year prior to June 2016 and the year post June 2016 the model suggests the UK may have an additional shortage of around 2,700 nurses. Projecting this shortfall over the remaining period of Brexit transition to 2021 suggest there may be a shortfall of 5,000-10,000 nurses in addition to current vacancies. While challenges around developing a sufficient workforce supply pre-date the Brexit referendum, and Government reforms to education and training routes, the report calls on Governments to urgently review their workforce planning approach.

What do these shortages mean for rural health and care staffing?

In July 2018 I was part of a research team commissioned by United Lincolnshire Hospitals NHS Trust (ULHT), funded by Health Education England (HEE), to apply a rural lens to the workforce challenges facing the NHS in England.  The research involved: 

  • Applying the Rural Urban Classification – an official statistic used by Government to distinguish rural and urban areas – to the different units that health and care as a system is organised into.    
  • Analysis of economic and labour market data: using the Rural Urban Classification to produce a demographic profile for different rural areas, their trends in employment and unemployment, qualifications, occupations and earnings data.
  • An evidence review of academic, health and care charities, national and professional bodies that made reference(s) to rural health and care workforce matters.
  • Analysis of a survey about adult social care involving 13 rural first tier Local Authorities commissioned by the All-Party Parliamentary Group (APPG) on Rural Services.
  • A series of one-to-one interviews and focus groups with 20+ NHS staff in Cumbria, Northumberland, Lincolnshire, Herefordshire, Worcestershire, Kent and Cornwall.

The findings of the research were triangulated with a reference group. The group comprised individuals with different perspectives on workforce development at local, regional and national levels (e.g. representatives from rural general practice, acute care, clinical commissioning groups, professional clinical bodies, Local Authorities, charities and community groups). 

The golden thread running through the research is that securing staff to deliver high quality health and care in rural areas (now and in the future) is crucial.  The research identified the following 9 challenges around recruiting and retaining staff in rural areas:

  1. Rural areas are characterised by the disproportionate out-migration of young adults and in-migration of families and older adults.
  2. This means that the population is older than average in rural areas – this has implications for demand on health and care services and for labour supply.
  3. Relatively high employment rates and low rates of unemployment and economic inactivity mean that the labour market in rural areas is relatively tight.
  4. There are fewer NHS staff per head in rural areas than in urban areas.
  5. A rural component in workforce planning is lacking.
  6. The universalism at the heart of the NHS can have negative implications for provision of adequate, but different, services in rural areas.
  7. The conventional health service delivery model is one of a pyramid of services with fully-staffed specialist services in central (generally urban) locations – which are particularly attractive to workers who wish to specialise and advance their careers.
  8. Rural residents need access to general services locally and to specialist services in central locations to provide the best health and care outcomes.
  9. Examples of innovation and good practice are not routinely mapped and analysed which hinders sharing and learning across rural (and urban) areas.

The research also identified 9 opportunities to maximise the supply of staff in rural areas: 

  1. Realising the status and attractiveness of the NHS as a large employer in rural areas (especially in areas where there are few other large employers). 
  2. This means highlighting the varied job roles, opportunities for career development and need for generalist clinical skills in rural areas. 
  3. This means developing ‘centres of excellence’ in particular specialities or ways of working in rural areas that are attractive to workers.
  4. This requires developing innovative solutions to service delivery and staff recruitment and retention. 
  5. This may provide opportunities for people who need or want a ‘second chance’ – perhaps because the educational system has failed them, or because they want to change direction; their ‘life experiences’ should be seen as an asset.
  6. Finding new ways to inspire young people about possible job roles and careers in health and care.
  7. Drawing on the voluntary and community sector, including local community groups, to play a role in the design and delivery of services.
  8. Promoting local solutions to foster prevention and early intervention.
  9. Using technology so face-to-face staff resources are concentrated where they are most effective and needed.

Inherent in addressing these challenges and realising these opportunities are a number of trade-offs. These concern balancing centralisation and localisation (in the way health and care are organised); balancing the flexibility that the workforce desires with filling rotas (to meet required safety standards); balancing the number of clinical specialists with expert generalists; and balancing the use of technology with face-to-face provision.

The research report was published in October 2018. A copy of the report is available from the National Centre for Rural Health and Care (NCRHC) here.  There are three overarching points emerging from the research that may be of particular interest to RSN members: (1) spatial component, (2) staffing and (3) funding.

Firstly, the research highlights the lack of a spatial component in workforce planning. In 2016 the NHS and Local Authorities came together in 44 areas covering all of England to develop proposals to improve health and care. Called ‘Sustainability and Transformation Partnerships ‘(STPs) they have been set up to run services in a more coordinated way, agree system-wide priorities, and to plan collectively how to improve residents’ day-to-day health. NHS Shared Planning Guidance led to the publication of a document setting out how these 44 STP footprints should be formed. This highlighted five factors: (i) geography, (ii) scale, (iii) fit with existing footprints of change programmes, (iv) the financial sustainability of organisations in the area, and (v) leadership capacity and capability to support change. Since 2016 STPs have been publishing plans setting out proposals for how they will achieve these aims – with some STPs evolving into Integrated Care Systems (ICS).

The rural workforce research found 22 of the 44 STPs have a population share equal to, or greater than, the England average (of 17%). The research analysed 10 STP plans in detail – with these areas chosen because they have at least double the share of rural population than England as a whole. Across these 10 plans there are fewer than 50 references to ‘rural’. None of the plans makes a clear link between the rural area they cover and the workforce challenges that they face. That said, some of the plans do highlight how rurality impacts more generically on service delivery (e.g. time, cost and distance) – but these tend to be introductory and contextual remarks rather than integral to the documents. While RSN members recognise and champion the heterogeneity of rural areas– geographically and socioeconomically – this spatial component is not always taken into account in health workforce planning.

Secondly, the research highlights how there are fewer NHS workers per head of population in rural areas compared to urban areas. NHS Workforce Statistics publish monthly numbers of NHS Hospital and Community Service (HCHS) staff groups working in Trusts and CCGs in England (excluding primary care staff). This data on headcounts is compiled and published by NHS Digital. The research looked at the statistical bulletin published in April 2018 which included monthly headcount figures from January 2018. The headline figures show: 

  • The headcount was 1,205,949 in January 2018. This is 7,711 (0.6 per cent) more than the previous month (1,198,238) and 21,068 (1.8 per cent) more than in January 2017 (1,184,881).
  • The full time equivalent (FTE) total was 1,064,810 in January 2018. This is 6,910 (0.7 per cent) more than the previous month (1,057,900) and 19,252 (1.8 per cent) more than in January 2017 (1,045,559).
  • Professionally qualified staff make up over half (54.0 per cent) of the HCHS workforce (based on FTE).

Analysis of this data reveals an overall difference in the ratio of NHS staff per head of population (excluding regional ambulance services) in the 11 most rural STP areas compared to England as a whole of 45%. This means compared to the national average rural areas have 45% fewer workers per head of population. And this picture does not appear to be improving despite the increase in headcount in some staff groups. In rural areas there are 10 key staff groups with shortages. They are: professionally qualified clinical staff, doctors, consultants (including Directors of Public Health), staff grade, specialty registrar, core training, foundation doctor year 1, midwives, scientific/technical and property/estates.

The research found recruitment poses a greater challenge than retention in many (but not all) rural areas. Achieving an optimal balance between mobility and immobility is important – some churn is valuable in stimulating new ideas, but too much churn is problematic. A segmented approach to recruitment is needed to focus on what makes rural areas attractive to different staff groups.

The research also highlights the need (in rural and urban areas) to think of workforce development in terms of an employment pathway: get in, get on and go further. For rural areas this could mean “grow your own”, i.e., finding ways to recruit, develop, cultivate and retain individuals from the local community to enter healthcare careers to help provide a long-term solution to addressing workforce challenges. For rural areas it could also mean thinking about health and care careers in terms of a ‘climbing frame’ rather than a ‘ladder’ because a career could include side-steps, changes in direction, entry into related or new specialisms and/or working for longer. For rural areas it could mean developing more innovative health and care service delivery models. For example, The Buurtzorg Nederland (home care provider) Model is based on small, self-managing teams of community nurses who have access to coaches for ongoing support and spend at least 60% of their time with patients – could a similar approach work in rural England? 

Thirdly, health and care funding formulas do not take into account the additional costs of delivering services in rural areas. From speaking with clinical and non-clinical staff the research identified additional costs associated with: staff joining towards the end of their clinical career rather than towards the start or middle (leading to higher wage bills); a lack of nearby acute centres to divert patients to if your own centre is full;  staff distance from training and continuing professional development and higher education opportunities; and poor road network (affecting ambulance response times, staff travel time).  In October 2018 The National Centre for Rural Health and Care (NCRHC) commissioned the Nuffield Trust to carry out ‘a rapid review of the impact of rurality on the costs of delivering healthcare’.  The review is considering how the NHS takes account of rurality in its funding allocations (e.g. unavoidable smallness due to remoteness). The Nuffield funding review will be available on the NCRHC website in December 2018. Given the announcement of an extra £2 billion for mental health services and £650 million grant for Local Authorities struggling to cope with rising care bills for 2019/2020 contained in Budget 2018 [NB: the budget for day-to-day running costs for NHS England is £114.6 billion for 2018-19]; it will be interesting to consider how the findings of the workforce research and the Nuffield review can be harnessed to inform future funding allocations to improve the ‘provider to population’ ratio?

Perhaps what this research reveals is the need for rural proofing in the funding, planning and delivery of health and care services. I am aware that Defra is looking at the guidance it provides to policymakers. There is also interest in rural proofing health and care policies in Northern Ireland and Wales. This also means understanding, in some detail, the character of rural populations and the health issues facing them (which are often masked by official statistics); and thinking through how we promote rural [as offering professionally fulfilling and rewarding careers with high quality of life] to health and care professionals. Can we do this? Watch this space…

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Jessica is a senior research fellow at The National Centre for Rural Health and Care (NCRHC). The NCRHC is a Community Interest Company, national in scope and with a Headquarters in Lincolnshire, and focuses on four principal activities: data, research, technology and workforce.

The NCRHC is providing the secretariat for a new Parliamentary Inquiry into Rural Health and Care.  The Inquiry is being led by the All-Party Parliamentary Group on Rural Health and Social care and is co-chaired by Ann Marie Morris MP and The Rt Revd and Rt Hon Dame Sarah Mullally. Eight key issues will be considered by the Inquiry over the next two years:

1) What are the needs of rural communities and how are they different from their urban counterparts?

2) How are rural health and social care needs currently met?

3) What is not working in rural communities and why?

4) Workforce challenges and opportunities

5) Education and training challenges and opportunities

6) Structural challenges of fitting current delivery models into a rural setting with different needs and challenges

7) Technology opportunities and challenges

8) Integration opportunities and threats

The first key issue was considered at a session on 30 October 2018 held in the House of Commons. Updates on the Inquiry and how to participate will be available on the NCRHC website and/or by emailing the Operations Director for the NCRHC Ivan Annibal via enquiries@ncrhc.org    

When Jessica’s not working at the NCRHC she is a researcher/project manager at Rose Regeneration. Her current work includes helping public sector bodies to measure social value; evaluating a hospital avoidance service; and undertaking a piece of work on migration.

In her spare time Jessica sits on the board of a housing association.

She can be contacted by email jessica.sellick@roseregeneration.co.uk or telephone 01522 521211. Website: http://roseregeneration.co.uk/ https://www.ncrhc.org/ Blog: http://ruralwords.co.uk/ Twitter: @RoseRegen

Procurement

How can we “think rural” in public procurement?

Public procurement is the process by which public organisations buy and rent services or functions rather than provide them internally. If the over-riding requirement is that all public procurement must be based on value-for-money and achieved through competition (unless there are compelling reasons to the contrary); how can we ensure procurement has a positive impact on rural communities? Jessica Sellick investigates.

How do public bodies undertake procurement? There are three policy purchasing responsibilities placed on public bodies. Firstly, to offer value for money, defined as “the best mix of quality and effectiveness for the least outlay over the period of use of the goods or services bought”. The process normally comprises a competitive tendering process; whereby a public body says what it wants to buy and various organisations provide competing offers to supply those goods, works or services. Secondly, to ensure compliance with legal obligations under UK, EU and international agreements. There are three elements to the current legislative framework covering procurement: (a) EU Treaty principles – these set out general requirements such as advertising opportunities and opening these up to suppliers located in other Member States; (b) EU Directives and the UK regulations that implement them – these provide procedures and thresholds in line with the Treaty; and (c) UK-specific procurement legislation – including The Public Contracts Regulations 2015 which contains UK specific rules intended to make public sector procurement more accessible to small businesses. Thirdly, to follow Crown Commercial Service (CCS) policies and standards on public procurement.

For public bodies these regulations set out the money thresholds that apply and procedures to follow during the procurement process. These include: (i) the open procedure – a one stage process during which parties submit a written tender and a supplier is chosen. (ii) The restricted procedure – a two stage process comprising initial selection (using a selection questionnaire), followed by an assessment of technical capability [an Invitation to Tender] which may include an interview. (iii) Competitive procedure with a dialogue and rounds of discussion and submission of information. There is also flexibility for public bodies to use other procurement routes including competitive procedure with negotiation, competitive dialogue and/or an innovative partnership.

How much do we spend on public procurement? The UK Government spends £251.5 billion per year on outsourcing and contracting – this is equivalent to 13.7% of UK GDP or one-third of all public spending (excluding utilities). Expenditure on gross procurement increased by 5.2% in 2016-2017 compared to 2015-2016; and gross capital procurement increased by £1.3 billion (3.8%) over the same period. Since 2010 central Government has moved to a system which buys common goods and services once on behalf of the whole of Government rather than individual departments. The CCS provides documents to assist public sector buyers to think through and identify the most appropriate procurement route for their requirement as well as supplier support, including different ways to sell goods or services to the public sector.

What does ‘good’ procurement look like? HM Treasury offers guidance on how to manage public funds. Around value-for-money this includes ensuring that the organisation’s procurement, projects and processes are systematically evaluated to provide confidence about suitability, effectiveness, prudence, quality and good value (judged for the Exchequer as a whole). Where feasible, procurement through multi-purchaser arrangements, shared services and/or standard contracts to drive down prices is also encouraged. The Government Commercial Function (GCF) is a cross-government network comprising some 4,000 civil servants procuring (or supporting the procurement of) goods and services.  Activities are coordinated by the Government’s Chief Commercial Officer (CCO). The GCF sets commercial standards for Government, ensuring ‘effective and consistent commercial delivery, and to drive continuous improvement of that commercial capability’. The standards cover workforce/resources, planning, identifying a senior officer to oversee the process, early analysis of options, maximising competition, contracting, contract management and supplier relationships.

In this policy context the focus of public procurement is on driving competitiveness and innovation in ways that lead to efficiency in public spending.

The National Audit Office (NAO) estimates that when Carillion collapsed it had 420 contracts with the public sector – while the Local Government Association (LGA) calculated that 20 Local Authorities and 220 schools were directly affected by the collapse. In 2017 Carillion was the sixth largest supplier to the public sector. In June 2018, the East Coast rail service was temporarily renationalised (as LNER) when Virgin and Stagecoach could no longer meet payments as part of their £3.3 billion contract with the Government. In September 2018 Grant Thornton published its audit report following the identification of a significant fraud committed by a former member of staff at Regional Enterprise Ltd, a company set up by a Local Authority and Capita.

These instances remind us that when public sector organisations let contracts or set up arm’s length companies it does not dissolve them of responsibility – they do not outsource the risk. Indeed, if the supplier is unable to deliver the contract the risk goes back to the public sector organisation responsible for ensuring the service is delivered. This means public sector bodies need systems in place to track and manage performance under the contract to avoid such situations from emerging – or to mitigate them should they arise.

These instances remind us that procurement is often a document based exercise – with those who procure services not necessarily involved in the services that are being used or sought. On the one hand, there is no formal training required for people assessing bids. On the other hand, if the process is solely overseen by people who specialise in procurement they may not understand, in practical delivery terms, what is needed? This underlines, therefore, the importance of involving different departments, teams, service areas, officers and elected members in the procurement process. This also underlines the importance of understanding supply chains (and the behaviours of large, medium and smaller suppliers up and down the chain).

The use of online procurement portals for organisations to express an interest in bidding, download documents, submit documents, ask questions and/or be notified of the outcome can also lead to the exclusion of some potential suppliers – particularly in a rural context with a higher number of small and medium sized enterprises and poor broadband coverage in some areas. 

Overall, there are some trade-offs emerging here: should you disaggregate a larger contract into smaller contracts? Who should be involved in procurement within the public body and at which steps of the process? Should a public body procure on cost and how/where does quality fit?

If public bodies were to use procurement for rural good, what might this look like? The challenges of providing public services in rural areas are well-rehearsed among RSN members: rural areas receive some 49.2% (£123) per head in Settlement Funding Assessment grant less than their urban counterparts;  yet rural residents pay approximately 20.17% (£91) per head more in Council Tax even though they earn less than their urban counterparts and receive fewer services.  While procurement cannot overcome some of these central decisions about local government funding; for me there are four steps that could be incorporated into the process to more fully recognise rural circumstances. Firstly, choice: developing procurement mechanisms that fit the needs and desires of rural localities (sparsity) – acknowledging that there may be fewer providers wanting or able to deliver in rural areas. Secondly, design: there is a long standing tradition of rural communities taking action to provide a wide range of services that in urban areas would be provided by the market or by the state. The procurement process should seek to involve rural residents in the process (what are their perspectives and preferences)? This also means recognising market failure and identifying alternative models which fit rural circumstances. If the procurement process is often influenced by the type of service to be offered and the level of resource available (cost) in a rural context it means thinking through different and innovative options. Thirdly, delivery: this means having robust processes and monitoring in place to measure the impact and effects (including ‘rural proofing’). Fourthly, assessment: is the intervention that has been procured any good (what is working well and what is working less well in rural areas) and if the service isn’t benefitting rural communities what can be done to improve the offer?   

Where next for procurement? In June 2018 the Government announced changes to extend the scope of the Public Services (Social Value) Act 2012. Designed to rebuild trust after the collapse of Carillion, the package of measures proposed are designed to reform public sector outsourcing so that central Government bodies must not only consider social value when procuring public service contracts – but that they must specifically evaluate social value. Other proposals include: challenging suppliers to publish data and action plans on equality and diversity; requiring suppliers to develop ‘living wills’ setting out contingency plans should the business fail; improving the training given to Government purchasers and implementing enhanced measures to protect suppliers from cyber-attacks.

The real debate needed now is not whether outsourcing or insourcing is good or bad, but about which services, goods and works should be kept in-house and which should be external?  Above all, how can the procurement process help us deliver locally responsive services that fit rural circumstances – and in ways that balance cost, efficiency, quality and outcomes?

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Jessica is a researcher/project manager at Rose Regeneration and a senior research fellow at the National Centre for Rural Health and Care. Her current work includes helping public sector bodies to measure social value; evaluating a hospital avoidance service; and undertaking a piece of work on migration. In her spare time Jessica sits on the board of a housing association. She can be contacted by email jessica.sellick@roseregeneration.co.uk or telephone 01522 521211. Website: http://roseregeneration.co.uk/ https://www.ncrhc.org/ Blog: http://ruralwords.co.uk/ Twitter: @RoseRegen

Global Health

Why global health matters to rural England

In bringing together domestic and international health concerns ‘global health’ criss-crosses geographical, cultural, economic and linguistic boundaries. But what exactly is global health? Why does it matter? And how might it benefit rural communities across the UK? Jessica Sellick investigates.

What is ‘global health?’ According to the Government ‘global health’ relates to “the range of health issues influenced by factors that extend beyond state borders…This includes preparedness for pandemic influenza and emerging infections, climate change, international development and a worldwide healthcare industry” (page 3).

Academic Jeffrey P. Koplan, describes it as an area of study, research and practice that places a priority on improving health and achieving health equity for all people worldwide; whereas for Ilona Kickbusch the term provides a new context, awareness and strategic approach to matters of international health.

International organisations and charities explanations vary from where ‘everyone has access to comprehensive healthcare services delivered by highly trained and compassionate medical professionals in well-equipped facilities’ (Global Health Foundation) through to ‘providing prevention, treatment and care services to hundreds of millions of people, helping to revitalize entire communities, strengthen local health systems and improve economics’ (The Global Fund). For The World Health Organization (WHO), which coordinates international health within the United Nations system (working with some 194 Member States), global health is concerned with ‘combating diseases – communicable diseases like influenza and HIV, and non-communicable diseases like cancer and heart disease…We ensure the safety of the air people breathe, the food they eat, the water they drink – and the medicines and vaccines they need.’ ‘Grand Challenges’ concentrates its efforts on 14 major scientific challenges that, if solved, could lead to key advances in preventing, treating and curing diseases in the developing world.; and The World Bank is working with Governments to achieve universal health coverage by 2030.

This plethora of definitions varies from a concern with the broad determinants of health through to the threat of individual diseases. Taken as a collective they open up debates around where the boundaries lie between global health and ‘other’ disciplines (e.g. international health, public health and tropical medicine); between population-wide health interventions and individual health interventions; and the relationships (and interrelationships) between high, middle and low income countries.

If there is no international consensus on what, how and when to take a global health approach, why does it matter?

In September 2014, Public Health England (PHE) published its Global health strategy. This sets out PHE’s approach to global health from 2014 until 2019. In the strategy PHE describes how ‘health is a global public good, and that we should have the skills and expertise at our disposal to contribute towards addressing the global health challenges that we face and to reducing global health inequalities. In doing so we achieve our own domestic priorities, while contributing to the public health priorities of others. We will adopt the principle of co-development in our international activity, working in genuine partnership and recognising our shared learning and shared future’ (page 4). PHE has five strategic global health priorities: (1) improving global health security and meeting responsibilities under International Health Regulations; (2) responding to outbreaks and incidents of international concern; (3) building public health capacity in middle and lower income countries; (4) developing its focus on international aspects of health and wellbeing including non-communicable diseases; and (5) strengthening UK partnerships for global health activity. In 2016-2017 PHE launched the Public Health Rapid Support Team, established a Field Epidemiology Training Programme, supported the development of infrastructure (e.g. disease surveillance in Pakistan, Ebola laboratories in Sierra Leone) and provided technical advice to the United Nations and other bodies.

The mandate for much of this work comes from an Outcomes Framework developed by Government in 2011. The Framework focused on three areas for action: (a) global health security, (b) international development, and (c) trade for better health. Ten guiding principles underpin the Framework. Notably this includes a principle to ‘protect the health of the UK proactively, by tackling health challenges that begin outside our borders,’ and to ‘learn from other countries’ policies and experience in order to improve the health and well-being of the UK population and the way we deliver healthcare’ (page 5). Progress on achieving the twelve outcomes was to be monitored through Government Department’s own delivery plans.

More recently Defra has been working with the Department of Health and Social Care, PHE and the Veterinary Medicines Directorate to slow the growth of antimicrobial resistance; and with PHE to support the diagnosis, management and epidemiology of avian influenza; and produce a new One Health Report.

The All-Party Parliamentary Group on Global Health recognises the interdependency and interconnectedness of health issues and has carried out evidence based reviews of global health issues and provided briefings and reports on emerging global health issues: from overseas volunteering through to measuring the UK’s footprint on health.

In June 2017 Public Health Wales launched its International Health Strategy. The strategy contains three priorities: (1) to maximise applied international learning and support innovation for public health; (2) to develop globally responsible people and organisations; and (3) to strengthen Wales’ global health approach. The strategy was developed through a consultation process, literature review and mapping international work and collaborations across the organisation. In 2018 Public Health Wales is developing an implementation plan for the strategy.

The Scottish Global Health Collaborative (SGHC) is a multidisciplinary network chaired by Scotland’s Chief Medical Officer that works with the Scottish Government and partners in the wider health community to ‘promote effective and coordinated health sector involvement in global health.’ The network has been mapping Scotland’s global health work and consulting on a Scottish Global Health Framework.

In Northern Ireland, Queen’s University Belfast convenes an annual global health symposium, undertakes research and provides a taught postgraduate course.

Healthcare UK is an initiative of the Department for International Trade, Department of Health and NHS England that promotes the UK healthcare sector to overseas markets and supports the development of partnerships between the UK and overseas providers. Launched back in 2013, the initiative is currently focusing on identifying international opportunities for healthcare providers in clinical services, education and training, infrastructure, digital health and healthcare systems.

From these country policy perspectives global health matters because communicable and non-communicable diseases do not respect national/administrative boundaries; the threats, impact and response are truly global. Importantly, the UK has leading scientific expertise, data and insights in fields such as data, technology, surveillance and laboratory services which can be harnessed to work with high, middle and lower income countries. The Global Burden of Disease (GBD), for example, collects and analyses data on premature death and disability from more than 300 diseases and injuries in 195 countries. This information has been used by PHE to develop a Health Profile for England and to focus on areas which help people in early life and middle age so they have the best chance of living a longer and healthier life. At both individual and population health levels the outcome being sought through each of these strands of work are the same: to improve health outcomes for people. Finally, as a signatory to the WHO International Health Regulations 2005 (IHR) we are legally obliged ‘to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.’

Why does global health matter to rural communities?

Despite what may appear to be huge differences between low, middle or high income countries (developed and developing) we share common challenges and issues in providing health care in rural areas.

According to the Statistical Digest of Rural England (April 2018 edition), people born in mainly rural areas in 2013-2015 are expected to live two years longer than people born in urban with minor conurbation areas. Potential years of life lost (PYLL) from all causes of death was lower in predominantly rural areas than predominantly urban areas: the highest rate of PYLL was in urban with major conurbation areas at 475 years of life lost per 10,000 population and the lowest rate in mainly rural areas, at 372 years of life lost per 10,000 population (2012-2014). While some of the data suggests people living in rural communities live longer and are healthier, the Digest also reveals how people living in rural areas have lower overall levels of accessibility to key service locations compared to people living in urban settlements: 41% of people living in rural areas do not have access to their nearest hospital within one hour travelling by public transport, compared with 6% of users living in urban areas; and people living in rural areas have (on average) access to four GPs within a 15 minute car journey compared to nine GPs for people living in urban areas.

There is considerable variation in the average home-to-hospital distances by local authority: 1.6 miles for the London Borough of Camden and 21.3 miles for people living in the Eden District of Cumbria.

Defra’s Single Departmental Plan (updated on 23 May 2018) cites work with the Department of Health and Social Care to improve access to health provision in rural areas, including on distance and time parameters used for service delivery (section 4.2).

Similarly for mental health, the literature reveals a number of factors specific to rural areas (e.g. demography, access to services, social exclusion, deprivation) that may contribute to stress, anxiety and depression; highlights how some rural occupations – including farming – have high suicide rates; and how those that develop mental illness in rural areas seem less likely to seek treatment compared to their urban counterparts.

There is also the rural premium that exists in providing services (i.e., sparsity) that is not always recognised in funding arrangements.

These issues around funding, access to services, transport, distance and sparsity are well-rehearsed among RSN members but also common in rural areas in other countries.

While not every country has a Rural Urban Classification, there are commonalities framed around geography, remoteness and population density/community size. For example, Australia has an Accessibility/Remoteness Index; Canada has a four-fold definition that includes all territory lying outside population centres,; and in the United States the Census Bureau, Office of Management and Budget and U.S. Department of Agriculture all have definitions based on demography to fit programmes. While in other countries such as South Africa there is no standard statistical definition of rural.

Regardless of whether and how rural areas are classified (for they are not homogenous), similar issues around access to health care emerge.

In Australia, for example, there are 58 GPs and 589 registered nurses per 100,000 population in outer regional and remote areas compared to 196 GPs and 978 registered nurses per 100,000 in major cities. 23% of people living in outer regional and remote areas felt they waited longer than was acceptable for an appointment with a GP (compared with 16% of those living in major cities), with people in these areas four and a half times more likely as those living in cities having to travel over one hour to see a GP.

The National Center for Health Workforce Analysis (NCHWA) assesses health surveys and data on the supply, use, access, need, and demand for health workers across the United States. This includes data on the distribution of practitioners in 32 health occupations across urban and rural areas. This reveals how there are proportionately more providers in occupations that require fewer years of education and training i.e., there are more EMTs and paramedics per capita residing in rural areas compared to urban areas, and more physicians and surgeons per capita in urban areas as opposed to rural areas. Two sectors have proportionately fewer providers in rural areas regardless of education and training: oral health (i.e., dentists, dental hygienists and dental assistants) and behavioural health (i.e., psychologists, social workers and counsellors). Academics at the Gillings School of Global Public Health are evaluating inpatient care in rural areas in the United States through tracking rural hospital closures (some 81 of the 2,200 rural hospitals have closed since 2010) and looking at solutions for areas with a dearth of hospitals and other health providers (e.g. rural freestanding emergency centres).This is part of a recognition that rural residents have further to travel to hospital compared to their urban counterparts and changes in acute hospital configurations (closure, downgrading) can have bigger impacts.

More broadly, the Economist Intelligence Unit’s Global Access to Healthcare Index measures how healthcare systems across 60 countries are working to offer solutions to the most pressing healthcare needs of their people. The Index seeks to answer the key question: ‘in a country, do people have access to appropriate health services?’ The EIU’s report not only reveals the 6 top performers (the Netherlands, Germany, Australia, the UK and Canada) and bottom 6 performers (Cambodia, Ethiopia, Uganda, the Democratic Republic of Congo and Afghanistan) but also how income levels are not a precursor to success in providing health: with middle-income countries such as Cuba, Brazil, Thailand, Colombia and Kazakhstan ranked ahead of some high-income countries. The report also highlights how public health providers have less of a presence in rural areas and limited resources.

If access to healthcare in rural areas is a key topic of discussion worldwide, these statistics open up debates around how the ‘provider to population ratio’ varies between rural and urban areas; how to recruit, retain and develop the health workforce in rural areas; the relationship between universal coverage and universal access; the level of investment needed in (rural) healthcare systems; and how the health infrastructure that exists in rural areas relates to health outcomes for rural residents.

If the rural health issues in different countries are similar, there may be good practice and collaboration that can be taken up to improve the health of all rural residents.

The term ‘frugal innovation’ has been used by academics for some time to describe the development of sustainable products and services that are ‘appropriate, adaptable and accessible solutions’. The term brings together the idea that more can be done for less for many more people, globally. It is viewed as a means of leveraging new approaches to offset escalating health expenditures and to improve health outcomes. Some successful examples include GE’s MAC 400 and Narayana’s $1500 cardiac surgery. The term ‘frugal technologies’ refers to cost effective technologies that are developed to cope in local conditions. A report by Nesta considered India’s potential as a laboratory for frugal innovations and the knock-on effects this could have in the UK and globally: from crowdsourcing drug discoveries to the Keralan approach to palliative care.

The term ‘reverse innovation’ is concerned with translating innovation in lower income countries into higher income country health systems. Some recent examples of this in the United States include: The Brazilian Family Health Strategy around community health workers; Singapore-based GeriCare@North use of telemedicine and Brazil’s Saude Crianca community involvement and citizenship programme. This thought paper from The Health Foundation also explores what the UK could learn from India – from the provision of clinical data to physicians in real time through to the Care Companion Programme to help patients recover in their local community.

While RSN members may not be taken with the terms frugal innovation and reverse innovation, they do open up dialogues around the relationship between innovation and need; the relationship between cost and frugality (low/no frills versus access); and the relationship between health care coverage and scale. What can we learn from approaches to rural health in low, middle and high income countries that could be applied to rural England (e.g. what medical devices, technologies, diagnostics, workforce and other services integral to health such as transport, pharmacies are used in other rural settings that could work in the UK)?

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Jessica is a researcher/project manager at Rose Regeneration and a senior research fellow at the National Centre for Rural Health and Care. Her current work includes undertaking research on the health workforce landscape in rural areas; helping public sector bodies to measure social value; and evaluating a mobile sensory project. In her spare time Jessica sits on the board of a housing association. She can be contacted by email jessica.sellick@roseregeneration.co.uk or telephone 01522 521211. Website: http://roseregeneration.co.uk/ Blog: http://ruralwords.co.uk/ Twitter: @RoseRegen

Mind the [rural] funding gap

Many community groups, parish and town councils, charities and social enterprises have relied upon grants programmes at one time of another to help them do something to improve their local community and the lives of residents most in need. This funding may have been from a Local Authority, Government, a non-departmental public body or charitable trust or foundation. Yet the landscape is changing, with less funding now available and/or eligibility criteria changing, are rural communities feeling the pinch? Jessica Sellick investigates.

In June 2015 Rob Wilson, Minister for Civil Society, set out the Government’s vision for a ‘bigger stronger society’. Mr Wilson described this as “a society where everyone has the chance to contribute to their community, and where those communities are self-confident and civically engaged. It is a world where people ask what they can do for their community not only what their community can do for them”.

This seems to chime with the ‘Big Society’ theme where people in their everyday lives would no longer always turn to Local Authorities or central Government for answers to the problems they faced, instead helping themselves and their own communities. At the same time the Government continues to change the way public services are delivered – thus opening up delivery to providers from public, private and/or community and voluntary sectors.

In practice, there are three rural issues that are often overlooked here. The first relates to recognition of the sheer number of rural residents already actively involved in their local communities before the Big Society/Bigger Stronger Society was invented.

The second and connected issue is that a more ‘open market-based approach’ for the delivery of services needs to acknowledge just how much rural residents already do (often informally and on an ad-hoc, responsive basis) to support their local community and the extent to which they want / are able to become more active partners in the planning and delivery of rural services is in doubt.

The third issue is one that is well rehearsed among RSN members, namely the ‘rural premium’ or additional costs of delivering services in the countryside. Provisional figures for 2015-2016 show that spending power per head is £73 per head less than in urban areas yet Council Tax is £81 higher per head for rural residents compared to their urban counterparts.

With a further Comprehensive Spending Review due on 25 November, local authorities will discover this autumn what they will have to spend in the next four years – from April 2016 through to March 2020.

In July 2015, the Chancellor wrote to the heads of all central government departments that do not have ring-fenced funding, asking them to model two scenarios of 25% and 40% of real-terms savings by 2019–2020.

Whatever announcements are made all public services are under pressure and the trajectory of finding further cuts and ‘doing more with less’ seems likely to continue. This will undoubtedly affect rural communities who rely upon the public sector not only for the delivery of services but also to help them with projects (e.g. will free information, advice and support be available to communities from planners, community development workers, health professionals, environment officers etc.?)

Outside of public sector funding and support, rural communities are finding the ‘other funders’ (i.e., the charitable trusts, foundations and non-departmental bodies) are also changing what, where and how they award money.

In March 2015, Dawn Austwick (Chief Executive, Big Lottery Fund) launched the Fund’s new Strategic Framework 2015-2021: “No bells or whistles. No dancing horses. No fanfare of trumpets. The Big Lottery Fund’s new strategic framework is a rather modest two pages and will quietly gather pace over the next few months. It’s more of a statement of intent than a detailed set of directions, a jumping off point for future choices… in a nutshell it’s: ‘People in the Lead’. From this everything else flows: we want to start with what people bring to the table, not what they don’t have; and from the belief that people and communities are best placed to solve their problems, take advantage of opportunities, and rise to challenges. Our job is to support them in doing so.”

The Lottery is now implementing the Strategic Framework, with a ‘blended funding model’, the interplay between different funding approaches across the organisation’s portfolios, and it is the Fund’s intention to get closer to communities and work more effectively with other local funders, such as community foundations.

Similarly, in March 2015 the Esmee Fairbairn Foundation published its five-year Funding Strategy. While the Foundation expects the austerity drive to continue with statutory provision retrenching it does not believe philanthropic funding will fill the merging gap and short-term crisis cannot be the long term strategy.

At the same time, the Strategy describes how communities are ‘crying out for space, time and faith to re-design and innovate. Crucially under the themes of art, children and young people, environment, social change and food the Foundation is looking to fund projects that have outcomes with a lasting impact beyond the lifespan of the funding provided.

In the current economic climate, all funders are under pressure to ensure that they make the best use of resources in pursuit of clear but realistic goals. So if you’re a rural community looking for funding what might you need to consider?

Firstly, don’t chase funding – or you may find yourself on a treadmill of making and/or fulfilling grant applications that may not be relevant to what you actually want to do. It’s about your idea, what it is you want to do, whether other members of your local community are on board, and if this is the right thing for your community or if there are other issues that mean a different solution might be needed.

And it is from this ‘idea to plan’ stage which your business plan and potential funding streams come from. This prevents communities from spending lots of time filling in forms for grants which don’t match what they want to do.

Secondly, ask yourself if you are ‘investment ready’. The terminology that many funders are using is changing with applicants that have the attributes that make them an ‘investible proposition’ more likely to secure the finance they are seeking. Are you investment aware? Could you receive investment but are not seeking it? Or are you seeking investment but at the wrong time or without proper preparation?

Are you business like in how you operate – have you got a strong board and staff/volunteer base, built investment into your business plan, manage opportunities and risk as well as have a risk register and contingency plan to help you manage your income?

Thirdly, in addition to the targets and outputs in your funding agreement which will be monitored by the funder; what are your outcomes, impact and sustainability that are a result of the funding you have received? Ensuring you can tell funders, stakeholders and the people in your community about the difference you are making (in terms of data/measurement and through case studies) will demonstrate the value you offer.

As funders grapple with increasing volumes of applications they want applicants to fully consider their exit strategy, legacy and sustainability – some funders do not want to be viewed as ‘giving grants’ and being ‘a revolving door for communities’. Of course many projects may require some ongoing grant support but ‘co-mingling’ or mixing income generation so applicants generate some funds themselves (e.g. by charging for some services, offering consultancy) or use other means appropriate to their project (e.g. Crowd funding) to complement traditional funding approaches are becoming more commonplace.

Finally, I think it is important for funders to ‘think rurally’. With exceptions such as The Prince’s Countryside Fund t is disappointing that over the last five years many charities, foundations and non-departmental public bodies have ended their rural grants programmes. On the one hand, this is part of attempts to mainstream, to get groups to come forward with good ideas and follow a ‘no wrong door’ to ensure it succeeds and gets funding.

Some funders focus on deprivation and measure it in a way that favours urban rather than rural areas. On the other hand, how can we get funders to consider rural issues in the planning and delivery of grants? For example, could rurality be one of the metrics they use when considering applications? How can funders be clear on the level and type of demand there will be in the countryside and how can rural communities respond to funding opportunities?

If funders want to be ‘demand led’ not ‘grant led’ as part of an overall movement away from seeing communities as having problems/being in deficit to wanting to do things for their community, and with grey areas emerging for some funders who now support services that would have been provided by the state such as supporting victims of domestic violence, what funding and support will be available for rural communities in the years ahead?

One thing is clear, a call for more money and a return to the previous status quo are both out of the question.

Jessica is a researcher/project manager at Rose Regeneration; an economic development business working with communities, Government and business to help them achieve their full potential.

She has undertaken a mid-term evaluation of a Wellbeing Service, which aims to reduce hospital admissions and the need for long term residential care by putting in place a community package of support (e.g. equipment, adaptations, TeleCare) and recently completed a European project on ‘social value’.

Jessica’s public services work includes research for Defra on alternative service delivery and local level rural proofing. In her spare time Jessica volunteers for a farming charity that offers a 24/7 advice and support service for farmers, their families and the wider community with the purpose of ‘preventing things from getting to the desperate stage’. She can be contacted by email jessica.sellick@roseregeneration.co.uk or telephone 01522 521211. Website: http://www.roseregeneration.co.uk/ Twitter: @RoseRegen

What’s (not) in the rural productivity plan

The government says its Rural Productivity Plan reaffirms its commitment to rural communities. But is it focusing on the right issues? And will it be supporting all rural communities? Jessica Sellick investigates.

Back in September 2012 and under the strap line ‘new contract to give rural communities power to hold Government to account on rural growth’, the Rural Statement 2012 was launched by then Environment Secretary Owen Paterson. This eagerly awaited document was intended to reaffirm a then Coalition Government commitment to rural England. Positioned as the ‘Government’s Rural Statement’ not ‘Defra’s Rural Statement’, it described existing projects and policy commitments (with some new initiatives too). However, the ‘rural contract’ in it was never binding; it was unclear where responsibility would lay for its implementation and evidence submitted to the EFRA Select Committee revealed there was no intention to update it.

During summer recess 2015 two documents have been published which again seek to reaffirm the Government’s commitment to rural communities: (1) the Rural Productivity Plan and (2) ‘what will rural communities look like in the future’ roundtable paper.

On 20 August, the Rural Productivity Plan was launched. This sets out government action for strengthening productivity in England’s rural areas. Described by the Chancellor of the Exchequer and Secretary of State for Environment, Food and Rural Affairs as “focusing on ten specific areas we believe could make a real difference to productivity. It is wide-ranging and will require efforts across government, as well as close working with others outside of government, to deliver. It is central to our offer and ambition for England’s rural areas. We will monitor progress closely”. The ten points cover broadband, mobile communications, transport, education and training, apprenticeships, enterprise zones, planning, housing, availability of childcare and devolution.

In a previous analysis examining how a productivity plan might invest in all rural places, I signalled the need to take a broader economic development agenda: one that helps people to find a job where they live (retaining rather than losing young people, provides local opportunities to undertake training and skills development); improves access to services (health, adult social care, transport, leisure and entertainment) and leads to 100% mobile and broadband connectivity. While the ten points touch upon these issues, in many instances the Plan re-presents existing announcements and initiatives – schools becoming academies, neighbourhood plans etc. While the Plan recognises the role rural areas play in the national economy, and how rural and urban England have a similar sectoral structure, it does not explore the impact of place on the operation of rural businesses. Indeed, some of the ten points hinge on decisions to be taken in the Spending Review (due in November).

The Plan has certainly opened up dialogue and debate among rural dwellers and organisations. On housing, there is uncertainty if the Plan will help provide homes for all who need them in rural places. How many landowners, for example, will actually sell their land to provide affordable rented housing at £10,000 a plot when they can achieve much higher values at 80% of open market value? How many young rural residents will be able to buy a home at 80% of open market value?

The RSN is calling upon the Government to consider the wider implications of its housing proposals. Starter Homes, for example, could be built on rural ‘exception sites’ – sites which are usually used to provide social housing rather than houses that can be sold on the open market. Given local government’s role as local housing, planning, social care and public health authorities, is the Productivity Plan – and the spending cuts yet to come – are we limiting the ability of Local Authorities to provide social housing?

On transport, the Plan sets out a £15 billion Road Investment Strategy which includes four schemes that will better connect rural areas: the A303 expressway in the South West, upgrading of the A1, dualling sections of the A453 near Nottingham and improving traffic flow on the A11 in the East. The Department of Transport will be publishing a list of fifteen proposals for newly supported passenger air routes as part of its Regional Air Connectivity Fund (citing improvements already made to the Newquay-London route). Small airports/regional air routes aside, will the Plan help address concerns voiced by RSN members around reductions in bus services, households running a car (sometimes 2 cars) out of necessity not choice (and the associated fuel costs) and the future of initiatives such as Wheels To Work? With improvements to public transport viewed as an ‘absolute’ priority by many RSN members, does the Plan help identify transport solutions for rural communities (including buses, community transport) and make decisions about whether we should take people to services, services to people, or both?

On mobile connections, will superfast broadband of at least 24Mbps be delivered to 95% of UK households and businesses by 2017? And will access to what the Plan calls “standard broadband” (i.e., at least 2Mbps) be available to everyone by the end of 2015 through the option of satellite broadband? The Plan also states the Government will work closely with industry to support further improvement to mobile coverage, and extend permitted development rights to taller mobile masts. Given previous Governments have failed to meet broadband targets and much of the work of the Mobile Infrastructure Project (MIP) is archived, will the Plan “fully connect” rural areas to the wider economy? It would have been good to highlight examples where communities have successfully taken action themselves and delivered broadband in their area, with the Plan then setting out what Government will do (finance, technical skills and resources) to help other communities take action.

The second document to emerge from Government during recess is ‘what will rural communities look like in the future?’ This paper was prepared following a Cabinet Office roundtable which took place under Chatham House rules. Defra has therefore been unable to provide the names/organisations of those “leading industry, academic, voluntary sector, permanent secretaries and chief scientific advisors” in attendance. The ‘visions for rural communities’ put forward by attendees include: how rural areas are simply the commuter belt for cities; that rural areas should focus on environmental sustainability and/or that rural areas ought to be competitive and diverse economies. RSN members have individually contacted Defra querying the research from which this short paper and visions were drawn with one practitioner-researcher describing it as having “one saving grace: that it is not a statement of Government policy”.

In terms of where next for Government rural policy, Defra has appointed a global financial advisory firm to look at where/how they can make 25-40% cuts called for by the Treasury. This work will include proposals to consolidate several executive non-departmental public bodies sponsored by Defra into the Department itself. At its most extreme this could be a wider reaching consolidation than that in Wales where a single and separate body to manage natural resources was established to replace the Countryside Council for Wales, Environment Agency Wales and Forestry Commission for Wales. Defra is also currently working on the Government’s response to Lord Cameron’s review on rural proofing, which they are aiming to publish in September 2015.

What do the Plan, Roundtable, 25-40% cuts and rural proofing response mean for rural communities?

Firstly, I wonder if the OECD Rural Policy Review of England and associated New Rural Paradigm (NRP) are more relevant than ever. The Review was carried out by Professor David Freshwater (University of Kentucky) back in 2011. He found England had a highly centralised government structure and had adopted ‘evidence based policy making’ where quantitative data was favoured but not readily available at a local level for rural communities to use. Freshwater identified policy implementation issues around defining the role of Defra, unpacking the relationship between mainstreaming and rural proofing, and persuading other Government departments to “follow through” on their responsibilities. In 2011 the OECD Review suggested Defra had too few staff and too limited a budget to monitor agencies and influence decision making. The Review contained five main recommendations: (1) introduce a distinct rural component to the Regional Cities strategy, (2) enhance mainstreaming to ensure better service delivery, (3) strengthen the rural economy by joining up housing, planning and economic strategies, (4) expand rural connectivity by strengthening networks, and (5) continue efforts to strengthen governance networks. How can the Rural Productivity Plan and Cabinet Office horizon scanning take up these recommendations?

Secondly, all of these documents in some way speak to transparency. If the Government want the public to assess the effects of policies and reforms, how can we ensure communities and their views inform their development? For the measurable points in the Rural Productivity Plan, how will implementation be monitored, when and by whom?

Thirdly, Government priorities mean that Defra is not alone in relooking at where/how it spends its money. Asked for savings of 25-40% will undoubtedly present challenges for rural people and places: will future cuts lead to rurally considered policies and championing or centralised policies imposed from Whitehall?

Above all, I wonder if there is enough “thinking rurally” among policy and decision makers. If we want the countryside to be somewhere people can live and work is a positive ‘new’ agenda for change emerging or are we failing to address the opportunities, barriers and priorities that rural communities face? Reading the OECD Review back in 2011 left me with a sense that England was lacking a long term coherent rural strategy, four years on perhaps it is time to address this and make rural voices heard.

Jessica is a researcher/project manager at Rose Regeneration; an economic development business working with communities, Government and business to help them achieve their full potential. She is currently preparing an economic baseline for a Local Authority; supporting the Big Lottery Fund to deliver Village SOS; involved in projects to help older people remain independent and in their homes for as long as possible; and completing a European project on ‘social value’. Jessica’s public services work includes research for Defra on alternative service delivery and local level rural proofing. She can be contacted by email jessica.sellick@roseregeneration.co.uk or telephone 01522 521211. Website: http://www.roseregeneration.co.uk/ Twitter: @RoseRegen

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