Care

May 2 2021

If oral health matters, how can we prevent rural residents pulling their teeth out?

Everyone experiences oral health problems at some stage of their life; and the mouth and oral cavity is central to people’s wellbeing and identity. While oral diseases are largely preventable, they often remain untreated and persist. With the need to improve oral health impacted by COVID-19 yet recognised as a major public health issue, what is access to oral and dental care like for people living in rural places? Jessica Sellick investigates*.

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What is oral health?

It is a key indicator of overall health and wellbeing and is primarily concerned with teeth, gums and the mouth. It encompasses a range of diseases and conditions such as dental caries, periodontal (gum) disease, tooth loss, oral cancer, oral manifestations of the HIV infection, oro-dental trauma, noma and birth defects such as cleft lip and palate. According to the Oral Health Foundation:

66% of adults have visible plaque.
25% of adults do not brush their teeth twice a day with a fluoride toothpaste.
74% of adults have had a tooth extracted.
60 million people do not have fluoridated water.
3 million people suffer from regular oral pain.
8,722 people in the UK were diagnosed with mouth cancer in 2019. In the UK, one person every hour is diagnosed with mouth cancer. Mouth cancer accounts for just over 2% of all cancers. While mouth cancer is the 14^th most common cancer in the UK, 67% of all patients are male and amongst men making it the 9^th most common cancer.

Back in August 2019, the Royal College of Surgeons of England published a Position Statement on children’s oral health. This highlighted how tooth decay remains a prominent cause of hospital admissions for young children. Amongst 5–9-year-olds, tooth decay has been a leading cause of hospital admission in each of the last three years for which data is available (2015-2016 to 2017-2018). Acute tonsillitis was the second highest reason for hospital admissions amongst 5–9-year-olds but caused less than half as many admissions as tooth decay. In total, there were 102,663 hospital admissions due to tooth decay amongst children under the age of 10 years between April 2015 and March 2018.

How are NHS dental services commissioned and contracted?

The Department of Health and Social Care (DHSC) is responsible for making sure legislative, financial, administrative and policy frameworks are fit for purpose and work together. NHS England and NHS Improvement then have responsibility for commissioning dental services including specialist, community and out of hours dental services. The aim of a single agency is to provide consistent standards of care delivery across the whole country. The vast majority of NHS dental care is provided through the general dental service (GDS) and personal dental service (PDS) via contracts between director of commissioning operations teams (DCO teams) and primary care contract holders. Dental care is also provided by district general hospitals and dental hospitals through hospital contracts. NHS regional commissioners plan, commission and monitor dentistry services within their region. The Office of the Chief Dental Officer England sits within NHS England and represents the head of the dental profession, providing system-wide leadership and setting the strategic vision for oral health.

In addition to NHS England and NHS Improvement, multiple organisations are involved in the commissioning and delivery of NHS dentistry. These include:

Public Health England (PHE): provides clinical advice, data, information and resources to assist in the planning and delivery of local dental services. This includes supporting dental practitioners to improve oral health and reduce inequalities. In March 2021 the Government published a policy paper setting out its plans for public health reform. This includes proposals for current health improvement, prevention and healthcare public health functions of PHE to be transferred to new homes within the health system in 2021 (e.g. Office for Health Promotion).
The Review Body on Doctors’ and Dentists’ Renumeration (DDRB): makes recommendations to Government on the pay of doctors and dentists delivering in the NHS. The DDRB’s recommendations take account of the need to recruit, retain and motivate dentists; regional/local variations in labour markets; Government funding; evidence submitted by professionals and other bodies; and legal obligations of the NHS.
Local Dental Networks (LDN): groups of commissioners, clinicians, managers and patients that develop annual work plans based on the dental needs of their local population in line with national initiatives. While LDN’s vary from region to region, each network meets locally every three months, with two of their four meetings attended by representatives from PHE and Health Education England (HEE). Additionally, each LDN chair is encouraged to participate in four national assemblies hosted by NHS England the Office of the Chief Dental Officer.
Health Education England (HEE): submits evidence to the DDRB.

Defence Medical Services (DMS) is an umbrella organisation within the Ministry of Defence (MoD) which provides dentistry in the UK and overseas to service personnel (and, where appropriate, their dependents); and NHS England Health and Justice is responsible for commissioning dental services in detained settings (which includes prisons, secure facilities for children and young adults, and immigration removal centres).

Unlike other health and care services, Local Authorities and Clinical Commissioning Groups (CCGs) are not currently involved in commissioning.

Within the NHS national dental commissioning and policy team, current priorities of work include:

To reduce oral health inequalities and improve oral health in children under the age of 5 years.
Flexible commissioning.
To oversee national dental access and address area of weakest dental provision.
To ensure a consistent and fair approach to contract performance management is applied nationally to dental contracts.
Dental contract reform.

The current contractual arrangements have been in place since 2006. General Dental Services contracts are usually held in perpetuity, with a set number of associated Units of Dental Activity (UDAs). Most of the primary care dentistry budget is, therefore, predetermined each year unless new services are commissioned, or current contract holders terminate their contracts. Dental practitioners can transfer their NHS contract to another practitioner by the formation and subsequent dissolution of a joint partnership. This means that contract values held in perpetuity may be provided by a new dentist who has formed such a partnership. Primary care dentists are not NHS employees and act as self-employed under contract from the NHS, in a similar way to GPs and pharmacists. Dentists in direct NHS employment (for example, secondary care) or Foundation and Core training are paid on a national scale with rates set centrally following advice from the DDRB. A dentist can have multiple contracts within an NHS England and NHS Improvement region or across a number of regions.

The NHS Outcomes Framework (NHS OF) sets out the national goals that the Secretary of State uses to monitor the progress of NHS England and to account for the outcomes it delivers through commissioning health services. Back in 2014, dental health indicators were included for the first time – this includes an indicator measuring people who reported that they were successful in getting an NHS dental appointment when they tried in the last two years; and an indicator measuring people who reported their overall experience of NHS dental services as being ‘fairly good’ or ‘very good’. NHS Digital recently closed a consultation on changing the frequency of OF reporting, from quarterly to annually. The two dental indicators were not updated in the latest release due to the unavailability of data.

Since 2011, there have been various pilots and ‘waves’ of dental contract reform (known as the prototypes scheme). In essence, when the dental contract was first introduced in 2006 it renumerated dentists for activity, whereas the prototypes scheme – of which 102 dental practices are currently participating – has an increased emphasis on preventing dental disease (i.e., offering “full oral health assessments and self-care plans”, in addition to traditional treatments). An evaluation of the first year of prototyping (2016-2017) found:

90% of patients had reduced or maintained levels of tooth decay.
80% of patients had reduced or maintained levels of gum disease.
97% of patients said they were satisfied with the dental care they received.

In 2018, NHS England launched Starting Well Core, a commissioning approach that aims to reduce oral health inequalities and improve oral health for children aged 0-2 years. The approach has been made available to all NHS dental commissioning teams for local use and is being implemented across the country in alignment with local population needs and with other local child oral health improvement work.

The DHSC intends to publish the latest results and lessons learnt from the dental contract reform prototypes in summer 2021. This includes a review of the design and implementation challenges that have prevented wider rollout. In addition, NHS England is leading the next stage of dental contract reform, working with the British Dental Association (BDA) and Government to design implementable proposals that address the key challenges facing the delivery of NHS dentistry and to leverage changes in the wider primary care system. The latest reforms are expected to meet 6 key tests:

Be designed with support from the profession.
Improve oral health outcomes [or credibly be back on track to do so].
Increase incentives to undertake preventive dentistry – and reduce incentives to deliver care that is of low clinical value.
Improve patient access to NHS care – with a specific focus on addressing inequalities (particularly deprivation and ethnicity).
Demonstrate that patients are not having to pay privately for dental care that was previously commissioned NHS dental care.
Be affordable within NHS resources – taking account of dental charge income.

Building on the NHS Long Term Plan and its call for greater collaboration between partners in health and care systems, Integrated Care Systems (ICSs) are expected to include primary care leadership, including dentistry, and are currently being placed on a statutory footing.

Throughout COVID-19, NHS England has issued letters and guidance documents setting out contractual obligations. At the end of March 2021, NHS England sent a letter to primary care dental contract holders confirming dental contract reform arrangements expected to last for the first six months of 2021-2022. This includes contractual protection for practices unable to deliver normal contracted activity over this period due to COVID-19: “during this period clawback will not be applied to practices delivering at least 60% of contracted UDAs [it was 59% as of February 2021] and 80% of contracted UOAs [Units of Orthodontic Activity].

A new process of dental contracting is underway; one that is seeking to balance constraints in capacity due to COVID-19, with restoring patient access back to pre-pandemic levels and targeting local dental priorities. While much of this work seeks to make rapid yet modest changes at the earliest opportunity, how will these reforms and its commissioning take account of rural communities (e.g., access and take-up of dental services; promoting innovation and different delivery models in rural settings) and what data will we need to collect – and when – to measure the impact of these approaches (e.g., moving away from data on units of activity to data on access, quality, preventive outcomes)? Similarly, some of the organisations that support commissioning are themselves in a state of transition, how can we ensure rural oral health is on the agenda amid discussions on health inequalities?

Who provides dental services?

Dental care can be provided by a dentist, dental hygienist, dental therapist, dental nurse or dental technician. Some dental professionals specialise in different areas of the mouth or treat specific groups of patients. Key specialisms include oral surgery, orthodontics, paediatric dentistry, endodontics, periodontics, restorative dentistry, public health dentistry, oral and maxillofacial pathology, and dental and maxillofacial radiology. The training each profession undertakes to qualify and treat patients varies – for example, becoming a dentist takes at least five years’ study at dental school, followed by 1-2 years of supervised practice.

As of 31 March 2019 there were 24,545 primary care dentists contracted to provide primary care dentistry for the NHS – this includes those dentists also contracted to provide community dental services. There were 227 NHS Trusts and NHS Foundation Trusts providing secondary care dental care in hospital under a standard NHS contract and/or providing community dental services under a primary care contract.

Primary care dentistry is accessed by patients typically at high street practices. Urgent and emergency dentistry can be provided in primary care and secondary care settings – with patients accessing treatment via a high street practice, 111 and/or accident and emergency departments. Specialist care is usually provided in secondary care but depending upon the treatment required, can also delivered in a primary care practice. Dentists can provide NHS treatment, private treatment or both – and they can refer into primary and secondary NHS services.

According to the National Audit Office (NAO), the UK has relatively low numbers of dentists per head of population compared with other advanced European economies, and England has the lowest number of NHS dentists per head of population in the UK. The UK reported an estimated 35,000 practising dentists in 2018, which is 5.3 practising dentists per 10,000 people. The numbers are higher in France, Germany and Italy. The data the UK submits to the OECD includes primary care dentists and dentists employed in hospitals. This data excludes those who work only in private sector dentistry. The General Dental Council (GDC) reported that in March 2019 there were 32,501 registered dentists in England. Although some might not be practising (working instead in research or overseas, for example), this equates to 5.8 dentists per 10,000 population, which is higher than the ‘practising’ number provided to OECD but still below G7 European comparators. In Germany for example the figure is 8.5, in Italy 8.3 and France 6.5.

Health Education England (HEE) is a Non-Departmental Public Body that is sponsored by the Department of Health and Social Care (DHSC). HEE leads education, training and workforce development in the health sector. Back in 2017, HEE commissioned an Advancing Dental Care Review (ADC) to identify a future dental workforce model and the training required to deliver it. The ADC is divided into two phases. Phase 1 (2017-2018) scoped the training and model, producing 21 recommendations. Phase 2 (2019-2021) is now concentrating on modelling flexible education and training programmes for the dental workforce, informed by the evidence HEE has been able to gather and more focused engagement with stakeholders. SQW has been commissioned to carry out an independent review to test and evaluate the training initiatives that are being piloted. HEE is due to publish the findings of the ADC in 2021.

On 25 March 2020 NHS England and NHS Improvement announced that all routine, non-urgent dental care including orthodontics should be stopped and deferred until advised otherwise and that urgent dental care (UDC) hubs would be set up around the country. Dental practices began to reopen for some care from 8 June 2020. In August 2020, the General Dental Council (GDC) commissioned Ecorys UK to undertake a study to explore the impact and future implications of COVID-19 on dental professionals. 78% of dental business owners reported a decrease in current income compared to the same period in the previous year – at some practices income had decreased by 45% and projected to fall by a further 41%. In focus groups dentists and dental hygienists highlighted how the requirement to practice enhanced PPE had impacted on their visibility, dexterity and confidence when carrying out intricate procedures. They also expressed concerns about the marked increase in the provision of interim solutions for patients (non-AGP treatments) and increased lone working due to staff absence. Analysis undertaken in September-October 2020 on those who expected to be economically inactive, working outside of dentistry, or not registered as a dental professional, found that one-third of dentists (32%) and DCPs (38%) did not expect to be practicing in 12-months’ time.

What changes are needed to support oral health and dental practitioners recover from COVID-19? How will the ARC help attract, train, recruit and retain a dental workforce in rural areas as we recover from the pandemic and seek to restore dental services?

How much do we spend on dental services? And how much dental activity is taking place?

NHS dental charges were first introduced in 1951. Charges vary, with some people entitled to free NHS dental treatment if they meet certain criteria.

In March 2019, the Government announced that dental charges in England would increase by 5% from 1 April 2019. Charges are divided into bands, with fees determined by the course of treatment. They are as follows:

Band 1 (£23.80): This covers examinations, diagnosis, and preventative care.
Urgent dental treatment (£23.80): This covers emergency care.
Band 2 (£65.20): This covers everything listed in band 1, plus any further treatment such as fillings and root canal work.
Band 3 (£282.80): This covers everything listed in bands 1 and 2, plus crowns, dentures, bridges, and other laboratory work.

Some people are entitled to free NHS dental treatment. This includes if an individual is:

Under 18 (or under 19 and in qualifying full-time education).
Pregnant or if they have had a baby in the previous 12 months.
Being treated in an NHS hospital, with treatment carried out by a hospital dentist (although patients may still have to pay for any dentures or bridges).
Receiving low-income benefits, or if they are under 20 and a dependant of someone.

Some dentists and professional bodies have reported patients fail to show up for an appointment or do not complete a course of treatment because they cannot afford to pay for it. While help is available, dentists believe some patients were not aware they might qualify for free treatment, or how to access it; and some lower income households and older people may be struggling to pay for treatment across the different bands. A recent study of adult dental fee exemptions found fee-exempt patients in 2018-2019 accounted for 23.7% of all adult claims in NHS primary dental care. This percentage has decreased year-on-year since 2011-2012 (when it was 31.5%). In 2018-2019 there were significantly fewer band 1 claims (36%) but a higher number of treatment claims for bands 2 and 3 (49% and 30.8% respectively). Why has there been a decline in total numbers of fee-exempt adults and what accounts for these band fee differences? In a YouGov poll with a sample size of 1,878 adults (aged 18+ years) based in England, carried out for Healthwatch England just before lockdown in March 2020, more than 7 in 10 people (73%) felt that NHS dental treatment charges were expensive and more than 2 in 5 (42%) said they either struggled to pay or avoided any dental treatment because they could not afford the costs.

NHS Digital publishes a biannual report containing dental activity for England. Covering the period April to September 2020, and patients seen data for a 24-month period (adults) and a 12-month period (children) up to 31 December 2020; the report reveals:

19.7 million adults were seen by an NHS dentist in the 24-months up to 31 December 2020, equating to some 44.5% of the adult population.
3.6 million children were seen by an NHS dentist in the 12 months up to 31 December 2020, equating to some 29.8% of the child population.
2.8 million courses of treatment were delivered in quarter 2 of 2020-2021; a decrease of 7.04 million compared to the same quarter in 2019-2020.

NHS Digital notes how to limit COVID-19 transmissions, dental practices were instructed to close and cease all routine dental care from the 25 March 2020. The data recorded in the report, including activity and patient numbers, is therefore lower than expected due to a period of COVID-19 restrictions. NHS Digital published a supplementary report outlining the estimated impact of COVID-19 using data at a national level for NHS practices. This found, to the 30 June 2020, 876,000 (4%) fewer adult patients were seen in the previous 24 months to receive NHS dental treatment compared to the 24 months before February 2020. 758,000 (10.7%) fewer child patients were seen in the previous12 months to receive NHS dental treatment compared to 12 months to February 2020.

In September 2020, Healtwatch published a report on accessing NHS dental care. Covering the period July-September 2020 and based on feedback from 1,313 people in 142 Local Authority areas in England, more than 7 in 10 people (73%) had found it difficult to access help and support compared to just over 1 in 10 (11%) who could access care easily. More than half of the respondents (51%) expressed negative sentiments about dentistry compared to in in 25 people (4%) who said something positive.

With people finding themselves and members of their household out-of-work or with reduced hours and pay, and patients having increased treatment needs as a result of the deferral of routine and non-urgent treatment; how can we reduce the gap between fee-exempt and fee-paying patients? COVID-19 has clearly made it difficult for most people to access services and some are still struggling to access NHS dentistry because practices are either not taking on new NHS patients or have no available appointments – how can we end the despair of getting dental care?

How is dentistry regulated and quality monitored?

A range of regulations cover accreditation, the registration of dental and oral health practitioners, and practice oversight to ensure standards and quality care provision. This includes the NHS (General Dental Service) Regulations 2005, NHS (Personal Dental Service) Agreement Regulations 2005, and NHS (Primary Dental Services) Regulations 2016.

All dentistry providers must register with the General Dental Council (GDC). The Dentists Act 1984 gives the GDC powers to grant registration to dental professionals to practice dentistry anywhere in the UK, to set standards for providers of dental education and training and the conduct of dental teams, investigate complaints against dental professionals (fitness to practice process), and require dental professionals to keep their skills up-to-date through continuing professional development. In 2017, the GDC published ‘shifting the balance’, a document considering how the system of dental regulation could be more collaborative so that issues are dealt with in the right place and deliver the right outcomes for patients and the public. It contained four main proposals: (i) move upstream – putting a stronger emphasis on patient protection, learning, engaging with professionals and developing alternative approaches to CPD. (ii) First tier complaints – improving the handling of patient feedback, concerns and complaints. (iii) Working with partners and other regulators. (iv) Refocusing fitness to practice – being clearer on ‘impaired fitness to practice’. More recently, in 2020, the GDC published ‘moving upstream’ setting out progress made to deliver the proposals in shifting the balance.

The Care Quality Commission (CQC): holds a register of primary dental providers; and inspects and monitors dental services according to the requirements set out by Government regulations. The inspection approach is based on ratings and level of risk: if a provider is rated ‘outstanding’ or ‘good’ their services are monitored through the CQC’s transitional monitoring approach. If a provider is rated as ‘requires improvement’, ‘inadequate’ or has never been inspected, from April 2021 a new approach is being implemented.

The Dental Assurance Framework was developed for area teams at NHS England to engage with providers to secure and improve service quality. It is designed to be used with GDS and PDS contracts and agreements – and contracts with NHS trusts. The framework has four domains: (i) delivery – centred around UDAs and UOAs; (ii) patient safety; (iii) patient experience – based on data and complaints; and (iv) quality/clinical effectiveness.

While regulatory approaches are needed to set the standards, professional values, knowledge, skills and behaviours required of oral health and dental professionals, are the existing frameworks, with their national pattern of decision making and activity, flexible enough for rural practices where some issues are atypical?

What are oral and dental health services like in rural areas?

Existing research has sought to understand and map areas where children and adults experience dental decay and/or hospitalisation. In March 2021, PHE published a report providing a current picture of oral health inequalities and oral health services inequalities in England and ways to reduce them. This describes how poor oral health affects the most vulnerable and socially disadvantaged individuals and groups in society, with other dimensions related to socio-economic position, protected characteristics and geography [by region, Local Authority]. The document contains two references to rural: the first in a summary of the academic literature and the second in the reference list. PHE intends to publish a companion piece to the report, setting out in more detail what action is needed to address research gaps.

The report’s findings around geography and deprivation are echoed in previous work. This includes research from the Nuffield Trust and Health Foundation back in 2017 on dental health outcomes and activity. This found dental health to be generally better in the south and East of England, and poorer in the North of England. Children in the Blackburn with Darwen Local Authority area, for example, were four times more likely to have missing, decayed or filled teeth compared to children in South Gloucestershire in 2015: just 44% of children in Blackburn were free from decay compared with 86% in South Gloucestershire. In Yorkshire, hospitalisation for tooth extractions in children under 10 years of age was five times higher than in the East of England in 2015-2016 (845 per 100,000 population in Yorkshire compared with 160 per 100,000 in the East of England). More recently, in 2019 PHE’s National Dental Epidemiology Programme (NEDP) found 23.4% of 5-year-old children in England whose parents gave consent for participation in the survey had experience of dental decay. The severity of experience of dental decay in children who have experienced dental decay was 5 times higher in Norwich, Norfolk (5.4 teeth) than in Rushcliffe, Nottinghamshire (1.6 teeth). The overall prevalence of dental decay was higher in children from more deprived areas (34.3%) than in children from less deprived areas (13.7%).

Existing data is only available at a certain level of geography (e.g., the English Indices of Deprivation are available at Lower Super Output Area). Not all deprivation indicators are relevant for rural places: health outcomes in rural areas are normally, on average, better in rural areas; and housing, access to transport, distance to services (GP, dentistry) can be more important in rural areas. It is the aggregation of statistics that masks rural deprivation. Multiple witnesses giving evidence to the Parliamentary Inquiry into Rural Health and Care cited the joint PHE and Local Government Association (LGA) ‘Health and Wellbeing in Rural Areas case study report. Evidence collected throughout the Inquiry has sought to illuminate how and why to address the statistical gap in information collected about rural places. This includes the development of a Rural Deprivation Index – with further research underway by the University of East Anglia (Norfolk) and the University of London (Lincolnshire) facilitated by the National Centre for Rural Health and Care (NCRHC).

According to the British Dental Association (BDA) a growing number of dental practices are reporting problems filling core clinical vacancies. In March 2019, a survey of 358 BDA members found 75% of them had struggled to fill vacancies, with this figure rising to 84% amongst those with the highest NHS commitments. The survey also highlighted a practice in Barrow having permanent vacancies unfilled for 5 years, resulting in the practice operating at 25% capacity; and a recruitment agency that had been unable to fill any posts advertised in Cumbria over the past 12 months (as of March 2019). The following tables produced by the BDA, using NHS website and google maps data, shows journey lengths and times across England for new adult NHS dental patients as of March 2019:

NAO analysis of dentists per head of population within England highlighted the top 5 areas with dentists: Bradford City (12.6), Horsham and Mid Sussex (9.7), Crawley (9.2), Hammersmith and Fulham (8.8) and South Tyneside (8.6); and the bottom 5 areas: West Norfolk (3.4), North Lincolnshire (3.4), East Riding of Yorkshire (3.6), North Staffordshire (3.7) and South Lincolnshire (3.8).

Current data and information reveal a mixed rural picture. The number of dentists in rural areas appears to be varied – with some rural places having a high number of practitioners and others having a much lower number. In some rural and coastal places residents are having to travel between 20 and 90 miles to access an NHS dental appointment.

While research from other countries has found rural communities often lack access to oral health providers due to their geographic isolation and/or workforce shortages – and studies are underway in Scotland, Wales and Northern Ireland – more work is needed to properly understand and measure oral health and dental care in rural England (e.g., access to services – distance/transport, quality of interventions, and the outcomes achieved). We need to continue to unpick a widespread belief that people living in rural places are better off (both in monetary terms and in terms of health and wellbeing) compared to people living in towns and cities, for it masks pockets of significant rural deprivation and people experiencing poorer oral health outcomes.

Where next?

NHS England published a revised Standard Operating Procedure (SOP) for dentistry during COVID-19. While the SOP sets out a phased transition for dental practices to work towards resuming a full range of dental provision, services are not operating a pre-pandemic levels and dentists are still only able to see a significantly smaller number of patients (e.g., social distancing, infection protection control procedures, fallow time). A report published by Healthwatch in December 2020 signalled greater dental problems in the future and the pressure being placed on hospitals and GPs as a result of limited access to dental care. Similarly, the Health and Social Care Select Committee Inquiry on ‘delivering core NHS and care services during the pandemic and beyond’ described the substantial burden of untreated dental diseases and an overall worsening of the nation’s oral health as the UK emerges from the pandemic. Put simply, too many people patients are falling through the cracks and not seeking, or not able to access, appropriate dental care.

At the same time, there is a real opportunity for oral health and dental care practitioners to now come together to provide the access to those who need it and to tackle what are wholly preventable diseases. Tobacco use, alcohol consumption, sugary food, not practicing good oral hygiene daily exacerbate not only oral conditions but also impact upon general health and wellbeing. This requires oral health to have a stronger position within, and integrated with primary, secondary and community health services as well as other, wider, public services.

For too many people dentistry is currently unavailable, too distant, unaffordable, or inappropriate. What more can be done to better understand the oral health needs and dental diseases of rural residents and how can we make rural oral health more visible?

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National Smile Month is a charity campaign to champion the benefits of good oral health. In 2021 the campaign is taking place between 17 May and 17 June. More information Is available from the Oral Health Foundation here.

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Jessica is a senior research fellow at The National Centre for Rural Health and Care (NCRHC) and researcher/project manager at Rose Regeneration. Her current work includes supporting health commissioners and providers to measure their response to COVID-19 and with future planning; providing the secretariat for the Parliamentary Inquiry into Rural Health and Care; and evaluating two employability programmes helping people furthest from the labour market. Jessica also sits on the board of a Housing Association that supports older and vulnerable people.

She can be contacted by email jessica.sellick@roseregeneration.co.uk.

Website: http://roseregeneration.co.uk/https://www.ncrhc.org/

Blog: http://ruralwords.co.uk/

Twitter: @RoseRegen

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* This briefing seeks to provide an overview of NHS oral and dental health services from the perspective of a non-expert/specialist. It is not exhaustive and nor does it contain information pertaining to adults and children accessing private dental care.

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April 4 2020

Kindness is all around us – but what part should it play in policy making?

Kindness is a word we use in many forms – “X is such a kind person” or “Y is not very kind.” If we are kind, our lives and the lives of others are seen to change for the better. While kindness has a part to play in our everyday lives, when we think about public policy (not just what the strategic direction is, but how we implement it) where does kindness feature? Jessica Sellick investigates.

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Back in 1931 an American judge called Oliver Wendell Holmes described how the interpretation of constitutional principles must not be too literal in reminding us how “the machinery of Government would not work if it were not allowed a little play in its joints.” People’s views on public policy can oscillate between ‘harshness’ with policy makers seen as treating people worse than they deserve, or ‘generosity’ where policy makers are seen as treating people better than they deserve. Nowhere are such debates more prevalent than around social welfare policy where issues such as ‘need’, ‘entitlement’, who is or should ‘deserve’ benefits or how the system should ‘incentivise people to help themselves’ are prevalent. This can lead to trade-offs being made in how eligibility criteria is set and welfare support administered. In a rural context, debates persist over the funding formulas used to decide ‘what’ and ‘how’ public services are provided [are we distributing resources in a fair and equitable way for rural residents?] With ever-increasing demands being placed on public services, amid fewer resources and the rising expectations of some service users, can or should kindness help us navigate some of these debates and issues?

What is kindness?

Kindness is an elusive concept – we recognise it in our everyday lives and yet find it difficult to define.

The term derives from the Middle English word ‘kindenes’ meaning ‘noble deeds’ or ‘courtesy’. Its philosophy can be traced back to Aristotle and Book II of Rhetoric in which he defines kindness as “helpfulness towards someone in need, not in return for anything, nor for the advantage of the helper himself, but for that of the person helped.” Nietzsche considered kindness to be ‘curative herbs and agents.’ In religion, Buddhists view kindness as the act of ‘doing things for another person, without substantial motivation’. The Christian apostle Paul lists kindness as one of the nine traits considered to be the “fruit of the Spirit“. Judaism teaches that ‘the world is built on kindness.’ In literature, Mark Twain considered kindness as a “language which the deaf can hear and the blind can see.” While Charles Darwin’s work on evolution might at first suggest survival of the fittest required selfishness, he actually believed humans to be social beings seeking good.

In academic circles, researchers have been carrying out studies into the psychology and biology of kindness. Psychologists at the University of Sussex, for example, published a study about the ‘warm glow’ of kindness – with their findings based upon brain scans from some 1,000 people looking at what happens in the brain when they act out of genuine altruism and when there’s nothing in it for them.

A study by the Universities of Exeter and Oxford found that taking part in self-compassion exercises calms the heart rate and switches off the body’s threat response. 135 Exeter students were divided into five groups, and members of each group heard a different set of audio instructions. The two groups whose instructions encouraged them to be kind not only reported feeling more self-compassion and connection with others, but also showed a bodily response consistent with feelings of relaxation and safety.

Back in 2015 geographer Danny Dorling drew upon multiple sources of evidence to try to understand the reasons why the UK had become one of the most unequal countries when ranked alongside 25 other countries. He discussed how behind every unequal policy there is a lack of empathy, and that only kindness and respect will enable us to see each other as if we really are “all in this together”.

In the United States last year UCLA established the Bedari Kindness Institute. The Institute takes an interdisciplinary approach to the study of kindness – looking at the evolutionary, psychological, economic, sociological, and other factors that facilitate kind actions toward others. In developing its research programme the Institute aims to translate its work into real-world practices and engage with the public.

In everyday life kindness has come to the fore in the UK and around the world recently – with acts of kindness and solidarity burgeoning amid Coronavirus (COVID-19): from a postcard that you can drop off with neighbours who are self-isolating, offering your help with shopping or a friendly phone call; to supermarkets designating certain hours for vulnerable shoppers or NHS staff and frontline workers; the clap for our carers, the 750,000 volunteers signing up to support the 1.5 million people asked to shield themselves for three-months and the countless rainbows we see displayed in windows. Of course, much of it has also been going on behind the closed doors of hospitals and homes, anonymously and unsung.

Where does kindness fit in public policy?

Back in 2017 The Carnegie UK Trust invited Julia Unwin to explore kindness in public policy through holding a series of roundtables discussions, polling 5,000 people, and speaking at events and writing. In her report, published in November 2018, Unwin argued that kindness, emotions and human relationships are a blind spot in public policy. She argued that kindness matters and makes a huge difference: for without acts of kindness the ‘state’ and the ‘market’ would be incapable of functioning. Three drivers in public policy – (i) the technological power to manage information, (ii) the digital power to manage communication, and (iii) the economic force of austerity – have made it increasingly important to look at the role of emotions, and kindness in public policy. While policy makers are always engaging with emotional responses, feelings and relationships; kindness itself tends not to feature in public policy. Unwin’s work on kindness suggests it matters for those developing, managing and accessing services: “action on kindness in communities must be met by a new contract…a contract that recognises that public services are always about relationships and emotions. A contract that is written in the two lexicons of public service [rational and relational] and helps us all to be more bilingual. A contract that will build trust in public services, encourage engagement and make social change possible”.

Unwin’s work has stimulated further debate in this area. In September 2019 Simon Anderson and Julie Brownlie from the University of Edinburgh queried if kindness was a concept belonging in, or having much to say to, the realm of public policy – as part of discussions around how to enable and sustain what they called an ‘infrastructure of kindness’. Their report unpacks the conversations within policy and research circles in Scotland about how and why kindness has emerged as a focus for policy. Anderson and Brownlie describe how the National Performance Framework (NPF) has an internal focus in creating the conditions in which acts and relationships of kindness can flourish within organisations; and an external focus in creating the conditions in which acts and relationships of kindness can flourish between individuals in community settings. The NPF already signals a new approach being taken by civil servants and politicians – the national outcomes for children and young people, for example, sets out a challenge to not only ensure that young people grow up with equal opportunities, but also that they ‘feel loved, safe, and respected’.

In Wales, the Well-being of Future Generations Act requires public bodies to consider the long-term impact of their decisions, to work better with people, communities and each other, and to prevent persistent problems such as poverty, health inequalities and climate change. The art of the possible programme is intended to make the Act ‘real’ by challenging ‘business as usual’ to create public services that meet the needs of current and future generations. A Healthier Wales, for example, describes ‘a society in which people’s physical and mental well-being is maximised and in which choices and behaviours that benefit future health are understood’ – it further describes a need to ‘support people to act with compassion.’

Outside the UK, in a speech at the United Nations General Assembly in September 2018 New Zealand’s Prime Minister Jacinda Ardern called for kindness and collectivism as an alternative to isolationism, protectionism and racism. Since then the New Zealand Government has implemented a family tax package aimed at reducing the number of children living in poverty by 41% by 2021 and introduced a Child Poverty Reduction Act which contains further child poverty reduction measures. In his 2018 Christmas message the Canadian Prime Minister Justin Trudeau talked about “spreading kindness and light to each other”.

Back in the UK, on the 31 March 2020 the think tank Compass held an online event on ‘the ethics and emotions of the Coronavirus emergency.’ This looked at how the pandemic is forcing us to think and behave differently: how do we relate to each other socially and politically now? What are the right emotions and tone to adopt?

Many of these policy research discussions and dialogues have emerged as a result of seeing limits to the welfare state (be it a crisis in health care or child poverty); or global issues such as COVID-19, climate change or migration; and/or in response to populist political leaders. All of this is leading to reflections on if and where kindness, empathy and compassion fit into public policy.

Where does kindness fit into policy interventions?

The civil service competency framework sets out 10 competencies grouped into three areas (setting direction, engaging people, and achieving results) to indicate how civil servants are expected to work. From a HR perspective the framework is intended to be used for recruitment, performance management and staff development discussions and progression. Similarly, the capabilities plan for the civil service identified four priority areas for future development: (i) leading and managing change, (ii) commercial skills and behaviour, (iii) delivering successful projects and programmes, and (iv) redesigning services and delivering them digitally. Holders of public office should act in accordance with the 7 principals of public life: selflessness, integrity, objectivity, accountability, openness, honesty and leadership. While it is important that civil servants adhere to these frameworks and codes, does kindness require a behavioural shift that is not explicit in these existing documents? A shift that would lead towards more open and collaborative working – including a long term commitment from national and local policy and decision makers to understand, support, reflect and invest in organisations and communities?

Kindness could bring civil servants closer to communities – by being accessible and listening to what people are saying, including the voices of people who are not traditionally heard. Research has looked at repeated efforts to rationalise policy through processes, qualities, structures and politics. This can lead policy to be seen as responding to problems rather than identifying issues before they become problems in need of intervention. In business, for example, there is often a quality control process whereby any new products are trialled and stress-tested before they reach the marketplace. Policy makers can find it difficult to adapt to local and changing circumstances (i.e., they often focus on making things happen systematically). We also need a greater awareness of, and be able to measure, the intended and unintended effects of the implementation of policy (i.e., will the intervention disadvantage some rural communities?).

Kindness could open up a new dialogue about where, how and why policy makers should invest. At a macro level some of us spend time looking at the production, distribution, consumption and trade of goods and services and yet less time understanding the role rural residents and community organisations play in reducing isolation, loneliness and demand on acute health services and social care. Can we measure what we value – such as the value of befriending, improved mental health or savings from joint working? The Scottish Household Survey (SHS), for example, contains questions asking respondents about people who are kind and trusted in their neighbourhoods; other public bodies are using social value tools to measure the wider benefits and outcomes of their interventions.

Understandably, some commentators query if kindness should inform policy and decision making at all. They cite the need to ensure fairness, openness, clarity and transparency. Steven Pinker, a psychologist at Harvard University, describes our natural tendency to empathise more with our friends and relatives than with strangers – and he suggests that no amount of training can erase this difference. Similarly, we can focus on the ‘warm glow’ we get from being kind rather than thinking through whether it will deliver positive results (i.e., what are the upstream and downstream consequences? Does being kind lead us to focus on ‘us feeling good’ rather than implementing initiatives that actually ‘make people’s lives better?’?) Some commentators question how kindness fits into evidence based policy (EBP) in wanting to apply scientific standards of proof?

Nowhere is this discussion more illuminated than in health. NHS England’s Evidence Based Intervention Programme examined how to avoid variations in clinical interventions. And yet in ‘the Language of Kindness,’ former nurse Christie Watson explains how when she started her career some 20-years ago she thought of nursing as a combination of chemistry, biology, physics, pharmacology and anatomy, but gradually realised it to be much more about philosophy, psychology, art, ethics and politics. Similarly, the mum test developed by the Care Quality Commission (CQC) seeks to personalise the inspection regime – by asking if the service is ‘caring’ the CQC explores whether staff ‘involve and treat everyone with compassion, kindness, dignity and respect.’ Here the balance between scientific–technical and psychosocial elements of patient care [a biomedical model of medicine] and the humanisation of medical care [having empathy, compassion and being kind and sympathetic] come to the fore. In the United States, for example, physician-scientists Stephen Trzeciak and Anthony Mazzarelli have highlighted what they refer to as the systemic inhumanity within “patient-based” medicine. Referring to a “compassion crisis” in US health care; they argue that treating patients more kindly would improve health outcomes, reduce doctor burnout and reduce costs.

What makes a (rural) community kinder?

The Carnegie UK Trust and Joseph Rowntree Foundation have compiled evidence and undertaken action research with communities on kindness. They view kindness as important in both reducing social isolation, tackling loneliness and improving wellbeing; and in providing the building blocks for community empowerment through positive relationships and values. They have highlighted three factors that contribute to kinder communities: (1) welcoming places – by this they mean places that are free to use, have warm hospitality and are free from any agendas. (2) Informal opportunities – creating opportunities to connect and act in kindness. (3) Values of kindness – being kind to you, trusting people and celebrating kindness. Linked to these themes they suggest three actions lead to kinder communities: (i) thinking and talking about kindness to encourage us all to be kinder, (ii) leaders empowering people to act in kindness (particularly leaders of organisations that provide services), and (iii) Government removing barriers to kindness.

In July 2019 the Ministry of Housing, Communities and Local Government (MHCLG) set out its vision for stronger local communities – what they look like and what Government and local partners can do to support them. The vision focuses on four areas: (i) trust, connectedness and local pride; (ii) active citizenship and local control; (iii) shared community spaces; and (iv) shared prosperity. Building on activity taking place across departments, Government intends to hold conversations with communities across the country, establish Civic Deal pilots and publish a Communities White Paper. According to MHCLG stronger communities are built on people, place and pride and lead to improvements in health and wellbeing, local services, economic growth, decision making and the environment. The vision cites the Ennerdale Hub in Cumbria as an example of a strong community. Here residents came together to form a cooperative to develop and run ‘The Gather’, a community centre, shop, café, exhibition and event space in the heart of the village. The Hub developed this facility for the local community in response to the reduction and withdrawal of services in the area.

Between 2010 and 2015 the RSA worked with the University of Central Lancashire and London School of Economics to carry out research in seven neighbourhoods across England on connected communities. This longitudinal project focused on how communities can support themselves [where people are embedded within networks of social support in which people experience reduced social isolation and greater wellbeing] in ways that reduce pressure on public services. They argued that by investing in interventions that build and strengthen networks 4 types of divided will be shared by people in the community: a wellbeing dividend, a citizenship dividend, a capacity dividend and an economic dividend.

Whether it’s a non-profit organisation, national charity or Government department, what does all of this work mean for rural communities? I offer three points.

People: rural residents do things intuitively every day for others in their local community that are either taken for granted or that we rarely take the time to reflect upon (e.g. dropping a prescription off, providing a lift to get somewhere or checking in on a vulnerable resident). Existing work on kindness, connectedness and strength tends to focus upon individuals or community organisations (looking upwards or downwards) rather than at a whole community level (within). Who is doing what, when and why – and how might we encourage more people [living in rural and urban areas] to adapt some of these practices?
Place: RSN readers are well-rehearsed in the innovative ways that rural communities seek to overcome access to services difficulties – we are used to getting by with less in rural areas compared to our urban counterparts. In being kind to each other in rural communities do we reduce demand on public services? (E.g. we may notice when a vulnerable person we visit is deteriorating and support them to access help sooner so they do not present in crisis; we pick up the prescription to help a neighbour get and stay well). This opens up an important dialogue about ensuring policy makers do not leave rural communities to ‘get on with it’ [i.e., where services might be reduced or withdrawn] or that they seek to absorb what we do into their system with its strategies and processes. We need the relationship between rural communities and policy makers to be ‘bilingual’, can kindness build and strengthen links between rural communities and policymakers?
Outcomes: there are clearly societal benefits that come from acts of kindness (e.g. reduction in isolation and loneliness, improved health and wellbeing etc.) but we often find it difficult to identify, describe, quantify and measure these. In many instances we have not collated data or used it as part of an evidence base to make the case for investing in rural communities.

For me kindness is not grand, rather it is found in small everyday acts, something that you do for another unselfishly but from which your personal gain can also be unavoidable. While talking about kindness in a professional context has not always sat comfortably with many of us, amid COVID-19 it has brought it to the fore and for many of us offered warmth and support at a time of great need. How can we ensure the kindness displayed amid this tragic global pandemic continues and informs whatever our ‘new normal’ ways of working will be? How can we continue to talk about kindness in our work, in our lives and in our rural communities?

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Jessica is a researcher/project manager at Rose Regeneration. Her current work includes helping public sector bodies to measure social value; evaluating an employability programme; and working with 8 farming organisations across England on a Defra funded project on farmer resilience. 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

February 21 2020

Are rural residents ‘retirement-ready’?

Although the idea of offering a State Pension was first proposed in the eighteenth century it was not until the Government established two committees in the 1890s (the Rothschild Committee on Old Age Pensions in 1896 and a Select Committee on the Aged Deserving Poor in 1899) that the matter was fully explored. This led to the Old Age Pensions Act 1908 which resulted in the Government providing 5 shillings to those over 70 who had an income of less than 10 shillings a week. The first pension system was therefore a means of averting poverty in older age. Since then successive Governments have made many changes to pension provision – resulting in a system today which is both complex and multi-layered. What does the current pension landscape look like and what might future reforms mean? Jessica Sellick investigates.

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What is a pension? A pension is a form of income you can use in later life. The Department for Work and Pensions (DWP) is responsible for ‘providing a decent income for people of pension age and promoting saving for retirement’. DWP provides pensions, benefits and retirement information for current and future older people in the UK and abroad. The services they currently deliver include State Pension and Pension Credit, as well as Winter Fuel Payments, Cold Weather Payments, Carer’s Allowance, Attendance Allowance and Visiting Service. In 2018-2019 DWP spent some £182.5 billion on benefit payments from its Annually Managed Expenditure (AME) – with the majority of these payments, £101.1 billion, to older people. Of the £110.1 billion – £96.6 billion was spent on State Pension, £5.6 billion on Housing Benefit, £5.1 billion on Pension Credit, £2 billion on Winter Fuel Payments and £0.8 billion on other benefits (e.g. free TV licences for the over 75s).

Today there are several different types of pension schemes available to help people save money for their future. These schemes vary according to an individual’s circumstances – including how much they have or want to pay into them, and in how they operate. The amount an individual receives is dependent upon how much money they have contributed into their pension pot during their working life.

What is the pensions system in the UK like? According to The Pensions Policy Institute (PPI), the UK pension system has three tiers:

Tier 1 is provided by the state and consists of a basic level of pension to which almost everyone either contributes or has access. This provides every citizen with a minimum level of retirement income.
Tier 2 is also administered by the state and aims to provide pension income that is more closely related to employees’ earnings levels. Tier 2 is less redistributive (from higher-income to lower income) than Tier 1. Tier 1 and Tier 2 operate on a ‘pay-as-you-go’ contributory basis, through the National Insurance (NI) system.
Tier 3 is voluntary (private) pension arrangements that are not directly funded by the state. Private pension contributions can come from employers and/or employees and funds provide designated pensions for the individual. The primary aim of private pensions is to redistribute income across an individual’s lifetime, and not to redistribute income from higher-income to lower-income people. Tier 3 includes pensions arising from automatic enrolment, a policy requiring employers to enrol eligible employees into a qualifying workplace pension scheme.

These tiers are summarised in the diagram below:

PPI, pensions guide primer, 2019, page 2

For tier 1, State Pension entitlement is based on an individual’s NI contribution record. Any tax year in which an individual makes, or is credited with making, sufficient NI contributions is known as a qualifying year. There are 27 activities that can credit someone into the State Pension without them having to pay contributions (e.g. if an individual is receiving Statutory Sick Pay, Statutory Paternity or Adoption Pay, Carers Allowance, Jobseeker’s Allowance or Employment and Support Allowance). People can also make voluntary contributions to fill gaps in their contribution record. For people applying for State Pension on or after 6 April 2016, thirty-five years of NI contributions are necessary to qualify for a full State Pension – with a minimum of ten qualifying years necessary to get any new State Pension.

The Pensions Act 2014 includes a review of the State Pension Age (SPA) at least once every 5 years and is underpinned by an assumption that people should expect to spend a third or less of their adult life in retirement; where adult life is defined as starting at aged 20 years. The SPA – the minimum legal age at which State Pension can be claimed – has been increasing incrementally from age 65 to reach age 66 in October 2020. The SPA was scheduled to increase to 67 years between 2034 and 2036 and to 68 years between 2044 and 2046. However, Government brought forward the rise to age 67 years to take place between 2026 and 2028. In March 2017 the Independent State Pension Age Review was published. The Review recommended that the SPA increase to 68 years over a two-year period starting in 2037 and ending in 2039, to reflect changes in life expectancy.

There are three strands to tier 2 provision, which like tier 1 is also provided by the state: (i) Graduated Retirement Benefit; (ii) State Earnings Related Pension Schemes; and (iii) Second State Pension. These schemes are historic and people have not been able to build up entitlement for an Additional State Pension since 2016.

The third tier of provision is private pensions, including workplace pensions and individual pension schemes. These are not directly funded by the state. These schemes tend to be Defined Benefit (DB) or Defined Contribution (DC). With DB, contributions are varied in order to ensure that the level of promised benefits is reached; whereas with DC contributions are usually expressed as a percentage of salary or total earnings [where the DC could be a flat rate or tiered by age or length of service]. The Pensions Schemes Act 2015 introduced legislation to facilitate shared risk and collective benefit schemes and are based on the level or amount of pension benefits, with elements of DB, DC and/or Collective Defined Contribution (CDC) schemes.

Automatic Enrolment (AR) has resulted in more employees joining pension schemes. Employees aged between 22 years and SPA are eligible for automatic enrolment into a scheme chosen by their employer, with employees having the right to opt-out. AR began in October 2012 when larger employers (with 250+ employees) were required to auto-enrol eligible employees between October 2012 and February 2014. Medium employers (those with 50-249 employees) were required to auto-enrol eligible employees between April 2014 and April 2015 and small employers (those with fewer than 50 employees) to do so between June 2015 and April 2017. For employees who opt in to AR a minimum of 8% of their band earnings must be paid in – of this 3% is contributed by the employer and 5% is paid in by the employee. Employees have the right to opt out – and must revisit their decision every 3 years. A review of AR published by DWP in December 2017 made a number of recommendations from the mid-2020s including removing the lower limit on the salary for contributions [currently £10,000]; reducing the minimum age from 22 years to 18 years; and finding new ways to improve pension saving for self-employed people.

How much state pension do people receive? Between 1974 and 1979 the State Pension (tier 1) was increased annually by the greater of the increase in National Average Earnings (NAE) or the increase in the Retail Prices Index (RPI). Since 1979 annual increases have generally been linked to RPI. While the value of the State Pension increased in real terms, when compared to NAE its value has actually declined since 1979. From April 2011 State Pension has been uprated by the higher of the increase in earnings (Consumer Prices Index, CPI) or 2.5%. The full new State Pension is currently £168.60 per week – with the actual amount dependent upon your National Insurance record.

Are we paying ‘enough’ into our pensions? According to HM Revenue & Customs, £28.2 billion was contributed to personal pensions in 2017-2018; with the total value of contributions rising from £27.4 billion in 2016-2017. While the number of individuals contributing to a personal pension increased – from 9.4 million in 2016-2017 to 10.4 million in 2017-2018 [part of a sustained increase attributed to the introduction of AR in 2012]; the annual average contribution per individual has fallen – from £2,900 in 2016-2017 to £2,700 in 2017-2018. Annual average contributions per individual grew between 2006 and 2012 (peaking at £3,690 per individual). Gross pension tax relief for 2017-2018 is projected to be £37.8 billion, up from £37.1 billion in 2016-2017. Tax on private pensions has also increased, from £17.8 billion in 2016-2017 to £18.3 billion in 2017-2018. This data reveals how the net cost of pension tax relief is increasing. Indeed, over the past five years pension tax relief has increased by 30%.

As the pension system has become increasingly expensive commentators have discussed a need to reform the existing structure in order to control costs and free up cash for Government to use to deliver public services. It has also opened up debate on who benefits most from the current system – with opponents suggesting the current system favours wealthy individuals as higher rate taxpayers gain the biggest tax relief on contributions and proponents pointing out how some high earners have spent years on low incomes with little spare household income – and now they are earning more they are prohibited from saving more than £10,000 a year into a pension even though their time earning a higher income may be a small part of their overall working life.

Numerous studies have suggested millions of us are not saving enough to give us the standard of living we are hoping for when we retire. A survey in 2019 carried out by Willis Owen found just over one-third of women do not have a pension plan compared to 17% of men. Of the female respondents, 17% said they had no intention of saving into a pension scheme until they reach 40 years, and 9% intended to delay saving into a pension until they are at least 50. In the same survey 35% of respondents said they had stopped paying into a pension scheme during the past year citing how they were no longer afford to make contributions.

A survey of 1,500 millennials (25-35 year olds) from Royal London reveals how the amounts young people are saving towards their pension are less than 5% of their income (an average of 4.6%). This is below the level of pension contribution Royal London recommends (which is 12-15% of your income) to help achieve a reasonable income amount in retirement.

Figures from the Office for National Statistics (ONS) show that 4.2 million self-employed workers are not saving into a pension scheme. At the same time the number of people estimated to be self-employed has increased by 162,000 a year to almost 5 million.

What is clear from many of these surveys is that some people need money for now to meet their financial responsibilities – from trying to get on the property ladder, through to paying for education and caring responsibilities. Indeed, many of us are putting off paying into a pension because the amount we can afford to pay in is deemed too small to be worthwhile; or because these savings are inaccessible until we retire.

On the other hand, some older people already have enough to live on – either because they carry on working or have other income to live on – leading them to delay accessing their pension pot beyond their selected retirement date or their pension scheme’s normal retirement date. A Freedom of Information request (FOI) submitted by Canada Life revealed not only how more than 14,000 opted to stop receiving their State Pension (tier 1) in the 2018-2019 tax year, but also how people can only opt to suspend and re-start their pension on one occasion after it is in payment. Andrew Tully from Canada Life explained how “This [opting not to receive State Pension] could be for a number of reasons, most likely is the simple fact they didn’t need the income and were looking to manage their tax liability, either because they returned to work or continued in paid work, or possibly because they received an inheritance. This sort of flexibility is common in the private pension sector, where people are able to turn income on and off from pensions using the right products, but is not a well understood part of the State Pension system.”

To help you consider how much you should be saving into a pension, the Money Advice Service has a pension calculator. This works out your SPA and State Pension income amount, asks you about the amount of income you’d like in retirement, looks at your current contributions and other sources of income and identifies any shortfall and suggests ways to improve this. The Money and Pensions Service is delivering a pensions dashboards programme which, in the future, will enable people to see all their lifetime pension savings in one place. The programme is currently working on designing, testing and building a consumer facing dashboard.

For me, whether or not we are paying enough into our pensions highlights four issues:

We are living longer, some of us will want to continue working full-time or part-time or begin a new career, some of us may retire early because of health issues; some of us may face redundancy and struggle to find another job.
When we retire some of us may want to increase our spending (e.g. to travel or start a new hobby) while others of us will want to reduce our spending (e.g. moving to a smaller property).
For some RSN readers retirement feels some way in the distance and you have more pressing financial goals (mortgage, saving for your children’s education).
Some of us are not sure how pensions work and that the benefits of saving sooner could mean a larger pension pot when we eventually retire.

All of this makes it difficult to identify how much money we need to save for retirement let alone coming up with an actual plan to do it!

Are people living in rural areas paying enough into their pension pot(s)? According to Defra’s Statistical Digest of Rural England:

Rural areas have a higher proportion of older people compared with urban areas. In 2018, the peak age group in rural areas was 50-54 years (8% of the rural population), while the peak age group in urban areas was 25- 29 years (comprising 7.3% of the urban population).
The percentage of people living in relative and absolute low income is lower in rural areas than in urban areas. The percentage of working-age people in rural areas in relative low income was 13% before housing costs and 16% after housing costs. In comparison, the percentage of working-age people in urban areas in relative low income was 15% before housing costs and 21% after housing costs. The percentage of pensioners in rural areas in relative low income was 17% before housing costs, and 14% after housing costs. In comparison, the percentage of pensioners in urban areas in relative low income was 19% before housing costs and 18% after housing costs. The dashboard shows that in rural areas, between 2016-2017 and 2017-2018, relative income for children, working-age people and pensioners increased; and absolute low income for working-age people and children also increased before housing costs. These figures reveal how many thousands of people living in rural areas are in households below average income (HBAI) and how these numbers may be increasing.
In 2018 there were 1,031,000 home workers in rural areas, accounting for 21% of all workers living in rural areas. This compares to 31% of all workers living in urban areas (some 2,888,000 home workers). Home workers are defined as those who usually spend at least half of their work time using their home, either within their grounds or in different places or using it as a base. Home workers will include both those who are employees of organisations and those who are self-employed.
In 2018 median workplace earning in predominantly urban areas (excluding London) were £23,300 – for predominantly rural areas this figure was lower at £21,900. In 2018 median residence-based earning in predominantly urban areas (excluding London) were £23,500 and slightly higher in rural areas at £23,700. Average residence based earnings differ from workplace based earnings because people living in rural areas sometimes work in urban areas in higher paid jobs.

Researchers in the United States looked at how working age residents in Michigan’s rural Upper Peninsula were engaging in retirement planning. The researchers found rural residents were less likely to make maximum contributions compared to their urban counterparts – which they attributed to rural areas having smaller populations, lower medium incomes, higher unemployment rates, and seasonal and short term work. The researchers called for easier retirement plan participation and public service campaigns to notify individuals of the tax and personal advantages.

In comparison, work in the UK has tended to focus on looking at people growing old in or retiring into rural communities – from housing and access to services, to transport, health and care and community activities – rather than focused on when, why and how much they are saving for their retirement. In low-income households, and those living and working in rural areas (including self-employed), how much are they contributing into a pension and saving for their retirement?

For those who have retired or are looking to retire figures from the Financial Conduct Authority (FCA) and The Pensions Regulator (TPR) suggest that 42% of pension savers, equating to some 5 million people, could be at risk of falling victim to pension scammers. The likelihood of being drawn into one of more scams increased to 60% among those who said they were actively looking for ways to boost their retirement income. The FCA and TPR believe pension cold-calls, free pension reviews, claims of guaranteed high returns, exotic investments, time-limited offers and early access to cash before the age of 55 years could all tempt savers into risking their retirement income.

While the principal focus of this briefing has been on the pension arrangements of individuals, there has been much discussion around the deficits of some schemes: this is the gap between how much a pension is required to pay out versus how much money is available to pay out and occurs when there isn’t enough money to pay. For example, in February 2020 BAE systems agreed a deficit recovery plan with The Pensions Regulator after a valuation revealed a deficit of £1.9 billion. At the same time, analysis of Councils in London found a combined total pension deficit of £17.98 billion for the period 2018-2019, representing a 7% rise on the previous 12-months. According to analysts, the situation has been exacerbated by legal rulings against the Government including the McCloud case, relating to the shift from final salary schemes to less generous pension arrangements based on average salaries. The Government announced a pause to the cost control part of the valuations of public service pension schemes and has estimated that the ruling could add up to £4 billion a year to the cost of funding public sector pensions.

RSN readers will be aware that sometimes changes to pension arrangements have unforeseen consequences. According to research from UCU a typical member of the Universities Superannuation Scheme (USS) will pay £40,000 more into their pension pot but receive £200,000 less in retirement. In the NHS, for example, we have seen how fewer clinical and non-clinical staff are seeking promotion, taking on leadership roles or doing additional shifts as a result of pension taxation rules – while Government announced an interim solution for clinical staff in December 2019 this does not apply to non-clinical staff.

Many of us want to save enough money to be able to retire but struggle to understand what, when and how we can become ‘retirement-ready’. For people in rural areas this has particular implications around job security, wage levels, housing and living costs and access to services (e.g. transport, care). The next independent pension review is due in 2022 – what should our ‘rural asks’ be?

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Jessica is 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 drug and/or alcohol addictions. She is also a senior research fellow at The National Centre for Rural Health and Care (NCRHC).

December 6 2019

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).

June 3 2019

‘Working at scale’ – what do Primary Care Networks mean for rural communities?

Primary care services ‘provide the first point of contact in the healthcare system, acting as the front door of the NHS.’ It includes general practice, community pharmacy, dental and optometry services. It is also the route by which we most commonly access secondary parts of the NHS (e.g. planned hospital care, rehabilitative care, urgent/emergency care, out-of-hours/NHS 111, community health services, mental health services and learning disability services) as well as tertiary care (e.g. specialised treatment such as neurosurgery, transplants, forensic mental health services). Primary care has a pivotal role to play in Government ambitions for safe, personalised, proactive out-of-hospital care for all. This includes the establishment of Primary Care Networks (PCNs). Since April 2019 individual GP practices have been able to establish or join PCNs covering populations of between 30,000 and 50,000. What are PCNs and what do they mean for rural areas? Jessica Sellick investigates. ………………………………………………………………………………………………..

What are Primary Care Networks (PCNs)? While GP practices have been finding different way of working collaboratively for many years, the NHS Long Term Plan and NHS GP contact have placed a more formal structure around some of these ways of working.

According to NHS England, experience from around the country has shown that practices working collaboratively and more formally together at scale become more resilient, improve work-life balance for staff by deploying a wider team and are more effective at meeting the holistic needs of their patients and populations.

PCNs involve staff from practices and other local health and social care providers working in close partnership, as one team. They operate as a network, designing and delivering services collectively that best meet the needs of their local communities. The majority of care will continue to be based around general practice and GP surgeries – but PCNs provide a means of offering additional services that are either too big to be in every practice and/or that do not need to be delivered in a hospital setting.

The core characteristics of PCNs include:

Practices working together and with local health and care providers ‘around natural local communities that make sense geographically, to provide coordinated care through integrated teams.’
Providing care in different ways to match different people’s needs – including flexible advice and support and multidisciplinary care for people with complex conditions.
Focus on prevention, patient choice and self-care – supporting patients to make choices about their care and connecting them with statutory and voluntary services.
Use of data and technology – to assess population health needs and inequalities, and to inform the design and delivery of different care models.
Making best use of collective resources across practices – leading to greater resilience, more sustainable workloads and access to a larger range of professional groups.

PCNs are intended to be small enough to maintain the strengths of general practice (e.g. continuity of care) but large enough to support the development of integrated teams made up of several professional groups.

The diagram below illustrates the difference between the current way primary care operates and how it will do so under PCNS.

The exact size of PCNs is determined locally. PCNs can be structured in a number of ways, with the decision on how a network operates down to an agreement between the general practices in membership.

PCNs are intended to build upon ‘primary care home’ (PCH). This is a model developed by the National Association of Primary Care (NAPC) to bring together a range of health and social care providers to work together to provide enhanced personalised and preventive care for local communities. PCH initiatives have been running for three years. NAPC has been supporting the development of PCNs, through both organisational development and offering a Diploma in Advance Primary Care Management to support staff to manage primary care at scale.

Why have they been set up? The NHS Long Term Plan contained proposals to establish PCNs to ‘provide flexible options for GPs, and wider primary care teams’ as part of an extra £4.5 billion of investment to fund community multidisciplinary teams. As part of a set of multi-year contract changes, individual practices in a local area will enter into a network contract – as an extension of their current contract – and have a designated single fund through which all network resources will flow. Most Clinical Commissioning Groups (CCGs) have local contracts for enhanced services and these will normally be added to the PCN contract. Expanded neighbourhood teams will include staff such as GPs, pharmacists, district nurses, community geriatricians, dementia workers and Allied Health Professionals (AHPs) e.g. physiotherapists and podiatrists/chiropodists, who will be joined by social care and the voluntary sector providers. Within the Long Term Plan, PCNs are to be offered a new ‘shared savings’ scheme so that practices benefit from reductions in avoidable A&E attendance, admissions and delayed discharge, and the streamlining of patient pathways to reduce avoidable outpatient visits and over-medication. The Long Term Plan also sets out a desire for stronger links between PCNs and local care homes, emergency services, local community services (e.g. frailty services) and social prescribing (providing patients with links to local groups and activities). PCNs are also expected to support early diagnosis, as well as to find and treat people with high risk conditions.

PCNs also build upon the findings of the GP partnership review. In recognising how the average size of individual practices is increasing, the number of salaried (employed) GPs is increasing and the move towards more part-time and flexible working; the review made seven recommendations. They were: (1) reducing the personal risk and unlimited liability currently associated with GP partnerships; (2) increasing roles and funding for General Practitioners; (3) increasing the range and number of healthcare professionals to support patients in the community; (4) increasing the time medical students spend in general practice through primary care partnerships; (5) ensuring practice are more sustainable through the establishment of PCNs; (6) ensuring general practice has a representative voice at a system level; and (7) enabling practices to be more efficient through IT and innovative digital services.

NHS England and the British Medical Association’s (BMA) General Practitioners Committee (GPC) have agreed a five-year GP (General Medical Services) contract framework from 2019-2020. The contract increases general practice funding by £978 million per year by 2023-2024 and introduces a PCN contact from 1 July 2019 as a Direct Enhanced Service (DES). The 2019-2020 Contract Agreement includes additional funding for general practices to engage and participate in a PCN. Should a practice not wish to engage in the DES, the respective practice will not qualify for the additional monies and the rest of the network will take responsibility for the provision of network level services to that practice’s patients. The DES is being phased in over the next five years and will eventually cover seven service areas (medication, health in care homes, anticipatory care, personalised care, early cancer diagnosis, cardiovascular disease and inequalities).

Also referred to as the Primary Care Network Contract, the Direct Enhanced Service (DES) is designed to support practices to develop and implement PCNs by working with neighbouring practices in their areas. The DES consists of a network agreement specifying the governance and financial structure of the PCN along with details of funding, workforce and a timetable. In signing up to a DES, PCNs will need to make a submission to their Clinical Commissioning Group (CCG) including details of member practices, the PCN list size, a map showing the PCN area, a single practice that will receive funding on behalf of the PCN and a named Clinical Lead. The deadline for submissions was 15 May 2019.

According to The King’s Fund, PCNs are being established to respond to three challenges facing the NHS: (i) to address workforce recruitment and retention – by targeting specific professions including pharmacists and physiotherapists to start with; (ii) to properly ensure the voice of general practice is part of, and fully integrated with, community and other services; and (iii) to improve population health – covering a whole range of issues from preventing coronary heart disease to tackling neighbourhood health inequalities.

In the meantime, NHS England has produced a Reference Guide, frequently asked questions (FAQs) podcasts and details about events and webinars for health and care professionals to find out more.

From a patient perspective, people should experience more joined up services, access to a wider range of professionals and diagnostics in the community, different ways of getting advice and treatment (e.g. digital and face-to-face services), shorter waiting times and greater involvement in decisions about their care within a PCN. Within local communities, PCNs are intended to increase the focus on prevention and helping people to take charge of their own health.

From a general practice perspective, clinicians should experience more efficient use of resource leading to greater resilience (staff, buildings); a more sustainable work-life balance; a more satisfying workload; greater influence on decisions made elsewhere in the health system; and the ability to provide better and more timely treatment to patients.

For other health and care partners, including Local Authorities, PCNSs are expected to lead to greater cooperation across organisational boundaries and a wider range of services being made available in local communities so patients do not have to default to the acute [hospital] sector.

How do they work? NHS England has developed a ‘maturity matrix’ for PCNs as part of a recognition that networks will progress at different rates. The matrix covers:

Foundations for transformation: develop a plan, engage with primary care leaders and other stakeholders, provide headroom to make change and ensure you have the people skills and financial commitment to fulfil primary care transformation.
Step 1: identify PCN partners, analyse outcomes and resource use between practices, understand population groups and their resource use, integrate primary care teams with social care and the voluntary sector, standardised state models of care, take steps to ensure operational efficiency, and ensure primary care has a seat at the table for system strategic decision making.
Step 2: have a defined future business model, function interoperability within the network, ensure shared access to information and decision making, new models of care in place for most population segments, networks can see their impact on system performance, and play an active role in system operational decision making.
Step 3: the business model is fully operational, IT / workforce / estates fully interoperable, systematic population health analysis, new models of care in place for all population segments, collective responsibility for available funding, and providers are full decision makers of Integrated Care Systems (ICSs) and working in tandem with other partners allocating health and care resources.

The primary care model being developed by each network fits with Sustainability and Transformation Partnerships (STPs) and Integrated Care Systems (ICSs) in operating at three system levels: (1) neighbourhoods – with PCNs providing multidisciplinary care; (2) places – with PCNs integrating care between hospitals and Local Authorities; and (3) systems – with PCNs participating as an equal partner in decision making. STPs/ICSs must include a primary care strategy – they will be developing their strategies in autumn 2019 in response to the Long Term Plan.

The PCH has produced some examples, NHS England published some case studies and the BMA a handbook all illustrating what a PCN may look like in practice.

What do they mean for rural areas? PCNs, by their very voluntary nature, suggest a mixed approach to their formation and delivery will emerge. So what might PCNs mean for rural residents? I offer three points.

Firstly, the term ‘working at scale across practices’ which can be traced back to the General Practice Forward View, takes on renewed significance with PCNs as NHS England is committed to 100% geographical coverage of the Network Contract DES by 1 July 2019. It is NHS England’s intention is for practices to work together ‘around natural local communities that geographically make sense, to provide coordinated care through integrated teams.’ NHS England anticipates that practices will work together in ‘geographically coterminous areas, rather than because of historic performance.’ PCNs are intended to have a defined patient population of at least 30,000 and not to exceed 50,000. The Long Term Plan suggestion of 30,000-50,000 registered patients as the desired size originates from the findings of the PCH model. According to the BMA handbook, ‘while there is no maximum size of a PCN, and commissioners can sign off on PCN proposals that go over 50,000, it is at around this size that networks will best keep the features of traditional community-based general practice, combined with the benefits of integrated working across a locality…Only in exceptional circumstances will networks be allowed to cover a population smaller than 30,000; for example, in rural areas where reaching a 30,000+ population causes geographic problems.’ It is not anticipated that PCNs will cross CCG boundaries.

It is expected that funding will vary by the population covered by the PCN (BMA handbook page 16):

Research by Nuffield in January 2019 found evidence of the additional and unavoidable costs of delivering health care in rural settings and highlighted the implications of this ‘funding gap’ on wider quality and sustainability issues.

The way the NHS funding model currently works is based upon economies of scale. While providing all patients with equal access to its services at the same level of quality; how will PCNs take account of different types of rural and coastal populations and places? What does ‘traditional community based practice’ look like in rural areas – and how can PCNs support it? Where are there gaps in coverage and why?

Secondly, will PCNs lead to better recruitment and retention of the health and care workforce in rural places? All PCNs must have a named clinical director – but how that post is filled is determined by each PCN. Their role is to provide appropriate leadership to establish and develop a successful network. The DES provides workforce reimbursement for the network covering a number of specified health professions and is designed to allow the PCN to build up an expanded primary care team. In year 1 this will include funding for a clinical pharmacist (funded 70% by NHS England and 30% by the PCN) and a social prescriber (funded 100% by NHS England). The majority of the workforce that will be introduced into PCNs over the next five years will normally be set at a 70/30 NHS England / PCN funding split. This could include roles such as physician associates, physios and community paramedics.

PCNs are expected to form the basis of people themselves being the best navigators of their care. The personalised care operating model sets out the infrastructure role of PCNs in supporting local social prescribing schemes, with every GP practice having access to a link worker – which will see the recruitment of 1,000 social prescribers by 2020-2021 and up to 900,000 people benefiting from the support they provide by 2023-2024.

PCNs will also be expected to work alongside other voluntary and community sector organisations to help alleviate workload pressures on practices and allow GPs to concentrate on the most complex patient cases.

In October 2018, the National Centre for Rural Health and Care (NCRHC) published the findings of a study into rural workforce issues in health and care. While securing staff to deliver high quality health and care in rural areas (now and in the future) is crucial, the research revealed 9 challenges affecting the recruitment and retention of staff:

Rural areas are characterised by the disproportionate out-migration of young adults and in-migration of families and older adults.
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.
Relatively high employment rates and low rates of unemployment and economic inactivity mean that the labour market in rural areas is relatively tight.
There are fewer NHS staff per head in rural areas than in urban areas.
A rural component in workforce planning is lacking.
The universalism at the heart of the NHS can have negative implications for provision of adequate, but different, services in rural areas.
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.
Rural residents need access to general services locally and to specialist services in central locations to provide the best health and care outcomes.
Examples of innovation and good practice are not routinely mapped and analysed which hinders sharing and learning across rural (and urban) areas.

For me, the research highlighted the lack of a spatial component in workforce planning. 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. 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.

In May 2019, the Nuffield Trust, assessed the number of GPs compared to the size of the UK population over time. The analysis revealed how the number of GPs relative to the size of the population has fallen in a sustained way for the first time since the 1960s. For the overall number of GPs to have kept pace with the number of the people in the UK since 2014 we would have needed some 3,400 more GPs.

Will PCNs provide a way of addressing existing recruitment and retention challenges in primary care? Or will they find it difficult to do so as they are already running and trying to change / reorganise whilst getting on with the demanding day job? How can (and will) PCNs address some of these rural issues they face, particularly through working with the voluntary and community sector and local groups in the design and delivery of primary care services? For rural residents, in theory, PCNs offer the potential to provide a mix of proactive and preventative support, emergency and rapid support and ongoing support (for complex conditions) but this will only happen if existing and new staff can be both attracted and retained.

Thirdly, will PCNs provide a better means for ensuring the voices of rural communities and clinicians are heard and acted upon at a system level? NHS England wants patients and the public to be involved in the work of PCNs in a meaningful way. It’s guidance on patient and public engagement sets out web based resources and best practice for both greater shared decision making between patients and clinicians and for engaging the public in a discussion about services. Healthy Conversation 2019, for example, precedes PCNs and is a discussion across Lincolnshire about what (and how) we need to change to ensure that our health, and health services are fit for the future. PCNs are expected to engage with STPs and ICSs to shape their strategic direction and align population care on a wider scale. PCNs are also expected to focus on prevention and personalised care – delivering a set of seven national service specifications. Five will start by April 2020: structured medication reviews, enhanced health in care homes, anticipatory care (with community services), personalised care and supporting early cancer diagnosis. The remaining two will start by 2021: cardiovascular disease case-finding and locally agreed action to tackle inequalities.

The health care system already collects an enormous amount of data and feedback from patients at local and national levels. Do PCNs provide new opportunities for the health system to think differently about how it listens and acts on insights from residents and patients? Where will their voices be, for example, in the development of local system plans? How can PCNs make this – and their work with voluntary and community sector organisations and local groups – essential to how they operate? Will there by capacity and capability in this new system to share learning and practice?

Where next? The current model of health care has been focused on hospital-based care and treating diseases and illnesses. There is now widespread acceptance, within the system, that this model is not sustainable and that coordinated, integrated and multidisciplinary care at the local/neighbourhood level is needed to prevent ill-health. PCNs offer a means of doing this. Practices have been meeting to discuss forming PCNs since January 2019 and the networks themselves are expected to go live in July 2019. Are we giving PCNs too much to do – and too soon – or do they provide an ambitious response to address the challenges that general practice faces, particularly in rural areas? 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 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; and evaluating a series of community safety and crime reduction projects.

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

June 9 2018

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

March 19 2018

What more can be done to prevent suicide in rural areas?

In March 2017 the House of Commons Health Committee published its final report to accompany its suicide prevention inquiry. While the report recognises the Government’s focus on suicide prevention and mental health, clear messages also emerged around the preventability of suicide; how the current rate of suicide is unacceptable; and how the current rate is likely to under-represent the true scale of this loss of life. What more is and can be done to reach out to people who are at risk in rural areas? Jessica Sellick investigates.

For many people suicide is hard to broach, cloaked in silence and difficult to understand or make sense of. There’s no easy way wither or writing about it. While perceptions and attitudes towards mental illness are gradually changing suicide all too often remains taboo. What is the scale of this avoidable loss of life, how can we reach people at risk of suicide (and support their family, friends and communities) and do rural areas present particular challenges or opportunities for suicide prevention? I offer three points.

Firstly, what is the scale of this loss of life? In December 2017 the Office for National Statistics (ONS) published its latest statistical bulletin on suicides in the UK. This records registered deaths from suicide by age, sex, area of usual residence and method. In the UK, in 2016, 5,962 suicides were registered – three-quarters of suicides were amongst men, in persons aged 40-44 years of age (with this age group having a suicide rate of 15.3% per 100,000 population) and the most common method hanging. The bulletin highlights a 3.6% reduction in registered suicides between 2015 and 2016; with registrations in England falling a significant amount, Wales and Northern Ireland falling slightly and Scotland increasing by a small amount. According to Emyr John at ONS “the fall in suicide rates from 2015 to 2016 is the largest decrease in 20 years. It fell for both males and females in the UK…It’s interesting to note that between 1981 and 2016, the male suicide rate among the 75 and over group has more than halved.”

It is thought these figures under-represent the true loss of life because of the ‘standard of proof’ required to register suicide. Part 1 of the Coroners and Justice Act 2009 places a duty on a coroner to investigate a death where they are made aware that the body is within that coroner’s area and they have reason to suspect that the deceased died a violent or unnatural death; that the cause of the death is unknown; and/or the deceased died while in custody or state detention. Where an inquest is held the outcome are known as ‘conclusions’ and may be short form or narrative and include one or more of the following type: accident or misadventure, alcohol/drug related, industrial disease, lawful/unlawful killing, natural causes, open, road traffic collision, stillbirth or suicide. From these conclusion types the standard of proof required for unlawful killing and suicide is the criminal standard of proof ‘beyond reasonable doubt.’ For all other types of conclusion the standard of proof is the civil standard of proof ‘on the balance of probabilities.’

The standard of proof has raised debates around whether coroners are reluctant to reach a verdict of suicide and/or whether the current arrangements mask the true number of suicides. Analysis from Bournemouth University, for example, suggested if coroners used the civil standard of proof (rather than criminal proof) there would be a 30-50% increase in recorded suicides. Professor Colin Pritchard, who led the study, describes how “when a death occurs, coroners have to decide whether the death was suicide – which could be hurtful to the family – or whether it was an accident or give an open verdict because they could not decide which. It is then categorised by the World Health Organisation (WHO) stats as an Undetermined Death (UnD) and it is amongst UnD that under-reported suicides are more likely…the UK had a disproportionately higher UnD in every age band than any other country.” In its final report the Health Committee noted its disappointment that in the third progress report on the suicide prevention strategy no reference made to changing the standard of proof.

In addition to overall figures we do know that some groups more at risk than others. Maternal suicide, for example, is the third largest cause of direct maternal deaths occurring during or within 42 days of the end of pregnancy. However, it remains the leading cause of direct deaths occurring during pregnancy or up to a year after the end of pregnancy, with 1 in 7 women who die in the period between 6 weeks and one year after pregnancy dying from suicide. Figures compiled by the Ministry of Justice show 119 people killed themselves in prisons in England and Wales in 2016 – an increase of 29 people (32%) on the previous year. In 2017 the Samaritans published a report setting out why socioeconomic disadvantage is a key risk factor for suicidal behaviour – revealing suicide rates to be two to three times higher in the most deprived neighbourhoods compared to the most affluent. In 2017 ONS published data on suicides by occupation – this revealed males in the lowest-skilled occupations had a 44% higher risk of suicide than men as a whole (with the risk among labourers three times higher) and for women the risk of suicide was found to be 24% higher among professionals. Male and female carers both had a higher risk of suicide than average.

In England, it is difficult to get statistics differentiating those at risk from suicide living in rural areas compared to that of urban areas. In March 2017 the Local Government Association (LGA) and Public Health England (PHE) published a report on health and wellbeing in rural areas. This described how the risk of suicide and undetermined injury may be higher in farming communities due to various factors related to isolation and ease of access to the means of suicide such as guns and poisons. The map on page 32 of the report shows higher suicide rates in areas that are rural and sparsely populated; although some deprived urban areas also have higher than average rates. PHE also publishes a Suicide Prevention Profile – this provides publically available data on suicide, risk factors and service contact by Local Authority or Clinical Commissioning Group geography. In January 2018 ONS provided raw data on farmer suicides in England and Wales between 2000 and 2017.

In other countries more data is available on the scale of the loss of life in rural areas. In the United States, for example, data compiled by the Centers for Disease Control and Prevention (CDC) found rural counties consistently had higher suicide rates than metropolitan counties. Between 2001 and 2015 suicide rates for rural counties was 17.32% per 100,000 people compared to 11.92% in large metropolitan counties. Over the same period the suicide rate increased by more than 20%. States with the highest suicide rates include Alaska, Montana and Wyoming and those with the lowest rates New Jersey and New York. The University of Washington found people who die by suicide are frequently experiencing undiagnosed, undertreated or untreated depression. Research from Mental Health America suggests the availability of treatment may be an issue in rural states – with Alabama having one mental health worker for every 1,200 people compared to one health worker per 420 people in New York. Studies have also shown that rural dwellers have more guns than their urban counterparts – with 51% keeping a gun at home in rural areas compared to 25% in urban areas. 86% of suicide attempts using guns end in death, compared to just 2% of attempts using drugs.

Suicide can affect anyone and while we should not concentrate on the numbers, having timely and accurate data – particularly for rural areas – could enable us to respond more quickly (which initiatives are working well and less well? Where are the gaps?)

Secondly, what is Government doing to reduce deaths by suicide?

In September 2012 the Coalition Government published ‘preventing suicide in England: a cross-departmental outcomes strategy to save lives.’ This sought to reduce the suicide rate in the general population and provide better support for those bereaved or affected by suicide. It contained six areas for action: (1) reduce the risk of suicide in key high-risk groups, (2) tailor approaches to improve mental health in specific groups, (3) reduce access to the means of suicide, (4) provide better information and support to those bereaved or affected by suicide, (5) support the media in delivering sensitive approaches to suicide and suicidal behaviour and (6) support research, data collection and monitoring. Since then, three strategy updates have been provided: in 2014 (which included a focus on what local areas could do to reduce suicide), in 2015 (which highlighted an increase in self-inflicted deaths of prisoners and increases in suicides among young people); and in 2017 (which follows the Health Committee’s inquiry and sets out how the Government intends to strengthen its response). Suicide prevention strategies are also published in Scotland, Wales and Northern Ireland.

The Five Year Forward View for Mental Health, issued in February 2016 by the Independent Mental Health Taskforce, set out a number of objectives for the whole health system in England on suicide prevention. This includes a commitment to reducing the number of people taking their own lives by 10% by 2020-2021 compared to 2016-2017 levels and improving the seven day crisis response service across the NHS. In July 2016 an implementation plan was published. This lays out a blueprint for the view’s delivery over the coming years to 2020-2021. Under suicide prevention this includes a commitment for all Clinical Commissioning Groups (CCGs) to work with local partners to develop and deliver suicide prevention plans. These local plans are intended to focus on evidence-based preventative interventions that target high-risk locations and high-risk groups in ways that draw upon localised real time data. Government has committed £25 million to help CCGs and their partners implement their activities and actions from 2018-2019.

Since 2012 with the establishment of Health and Wellbeing Boards (HWB) Local Authorities have been responsible for developing local suicide action plans. According to the Local Government Association (LGA), by the end of 2016 95% of areas had plans in place or were in the process of drawing them up. The LGA produced a suicide prevention guide for Councils – this includes a set of good practice case studies from Lincolnshire, Cheshire and Merseyside, Warwickshire and Torbay.

The task of Local Authorities now, and the Government’s ask, is to take practical steps to reduce suicides.

In a health context, an approach known as ‘zero suicide’ has emerged. The concept can be traced back to Detroit which in 2001 became the first place to adopt the idea of becoming a ‘zero suicide city.’ Poverty and high unemployment were contributing to high rates of depression and high rates of suicide. Here mental health professionals began to focus on preventative care – tackling the stigma around mental illness and using identifiers to highlight cases of crisis or potential crisis. Patients attending health clinics are now routinely screened for depression and mental health issues and those identified as being ‘at risk’ can be referred to a mental health specialist. A central recording system means patients are traceable and information coordinated among health and non-medical practitioners. By 2005 the suicide rate among the patient population had fallen by 75% and by 2008 had been eliminated altogether.

In the UK, learning from the United States has informed four zero suicide pilot initiatives covering the East of England (Bedfordshire, Cambridgeshire & Peterborough), Merseyside and the South West (e.g. Somerset, Cornwall, Devon, Dorset, Gloucestershire, Wiltshire). In November 2017, the Zero Suicide Alliance was launched at the House of Commons; a collaboration of NHS Trusts, businesses, organisations and individuals committed to suicide prevention, it aims to raise awareness of and promote free suicide prevention training which is accessible to all. In January 2018 the Secretary of State for Health and Care, Jeremy Hunt, outlined plans for mental health trusts to draw up detailed plans to achieve zero suicides, starting with those in inpatient settings. It is intended organisations will learn from the pilot schemes – improving suicide risk assessment, improving staff training and improving access to crisis care around the clock.

The zero suicide approach is underpinned by the belief that suicide is preventable and that it is not inevitable for people in crisis. However, the Health Committee in its inquiry flagged that though Local Authorities have suicide prevention plans there is currently little or no information about the quality of plans – and the assurance process to monitor their implementation currently lacking. Where the resources to deliver will actually come from (and whether the £25 million allocated by Government in 2018-2019 is enough) have also been highlighted.

Thirdly, what can we do in rural areas to reach out to people who may be at risk?

The Health Committee’s inquiry recommended that to reach out to those in distress we need to offer non-traditional routes to help people who are unlikely to access mainstream services. If early intervention is important, and supporting people in non-clinical settings is important (including people who are not in contact with any health services), what does this look like in a rural setting?

Back in 2016, NHS Health Scotland published a planning tool and a guide to suicide prevention in rural areas. While no single pattern emerges in rural areas these documents highlight particular risk factors in rural areas (e.g. isolation, declining incomes, the stigma associated with mental health, culture of self-reliance, poor service provision, availability of lethal means and occupational groups such as farmers, vets and doctors); an approach to reviewing [rural proofing] interventions within a suicide prevention strategy; and focussing on what is missing from current interventions.

At a national level charities such as ‘MIND’ – which seeks to address the challenges and stigma faced by those living in rural communities as part of its core activities – through to Farming Help (which runs a helpline and provides other support services for the farming community) provide support. At a more local level there are a plethora of examples of good practice. There are groups that provide mutual support and advocacy – HUG represents the interests of users of mental health services across the Highlands of Scotland and ‘You Are Not Alone’ (YANA) provides a confidential helpline for those feeling isolated, depressed or unable to cope. In some rural areas mental health services are provided using custom-built vehicles (e.g. Doris, the Vale of Clwyd Mind’s mobile outreach vehicle); and/or or using existing community venues (e.g. nurse and farmer health checks at auction mart; and Reading Well). Some Rural Community Councils (RCCs) provide Suicide Awareness Training for frontline workers in areas such as care, family support, housing, children’s centres schools, police, social workers, diocese, probation and youth offending, foster carers, job centres and the general public – for example: Derbyshire, Leicestershire and Rutland,

In the United States, the Suicide Prevention Research Centre recommends educating primary health and care providers on how to assess and manage suicide risk (including reducing access to lethal means among vulnerable individuals) and using telepsychiatry and mobile crisis teams to support individuals at risk. The Rural Heath Information Hub holds a repository of suicide prevention rural project examples. The Winston Churchill Memorial Trust has a suicide prevention, intervention and postvention award category – with fellows funded in 2014 and 2018 spending time in the United States and Canada where extensive amounts of work in the field have already been done and support structures have been put in place.

For some of us, sharing our personal experiences of bereavement or suicidal crisis takes enormous courage. Suicide leaves families, friends and communities distraught. Many people find it difficult to talk about suicide and it is difficult to write about. But rather than walking away I believe we need to talk about suicide and suicide prevention in ways that help those that are suffering and those that so desperately want to help them.

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If you are concerned about someone who may be suicidal or are at risk yourself the following helplines are available 24 hours a day unless otherwise stated: Samaritans 116 123; Campaign Against Living Miserably (CALM) for men 5pm to midnight 0800 585858; Papyrus for people under 35 weekdays 10.00am-10.00pm weekends 2.00pm-10.00pm 0800 0684141 or text 07786 209697; Childline for young people under 19 0800 1111 the number won’t show up on your phone bill; or the Silver Line for older people 0800 4708090. If you have lost a loved one support is available from Cruse 0808 8081677.

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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. Her current work includes supporting a Lottery programme to help people into paid work; research for the NHS on rural workforce issues and a project looking to deliver higher level technical education and skills in rural areas. In her spare time Jessica volunteers for a farming charity which aims to prevent things from getting to the desperate stage. 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/

December 19 2016

Are rural carers overwhelmed by need?

Carers or caregivers not only reduce demand on health and social care systems but they often do so with very little (if any) support. How can we better understand the role that carers and caregivers play – and what more can be done to recognise and support them, especially in rural areas? Jessica Sellick investigates.

Most days carry announcements and articles about social care – and of a crisis in social care. Many of the discussions are framed around reform (of health and social care systems), funding (how many millions do we need now and how many billions by 20 something), the need for early intervention and preventive work (to maintain independence and reduce demand), involving users in the design and delivery of services (e.g. the Involvement Hub) and sustainability (44 STP footprints). This is accompanied by a plethora of organisations: CCGs, HWBs and PHE; and a maze of clinical, critical, care or integrated care pathways. Forgotten or hidden away within many of these discussions and debates are people who are carers and caregivers.

Back in June 2015, NHS England’s Director for long term conditions, Dr Martin McShane, wrote a blog describing how carers “make a critical and underappreciated contribution not only to loved ones, neighbours and friends, but to the very sustainability of the NHS… [NHS England is an active member of Carers UK/Employers for Carers UK]…Is that enough? Of course not…What we can try to do at the centre is make it easy for people to say ‘we have done this because of the system, not despite the system’.”

In September 2015 the King’s fund published Home Truths. The report sets out three trends that will continue to have an impact on carers and caregivers. Firstly, social care providers are under unprecedented pressure as a result of grant reductions from local authorities, workforce shortages, higher regulatory standards and the introduction of the National Living Wage. Secondly, the social care system is surviving by relying on people who can fund their own care and by local authorities funding support to protect the most vulnerable older people with the highest needs. This means access to care increasingly depends on what people can afford to pay– and where they live – rather than on what they need. Thirdly, Government and local authorities want older people to be independent and remain in their own homes for longer by drawing on the resources of their families and communities. This means carers and caregivers may be expected to do even more.

Between March and July 2016, the Department of Health published a survey to capture the views of carers, those who have someone care for them, businesses, social workers, NHS staff and other professionals that support carers on how a new Government strategy for carers can do more – one which reflects the health and financial concerns they have, and gives them the support they need to live well whilst caring for a family member or friend. Alongside this, the Communities and Local Government Select Committee has been carrying out an Inquiry into adult social care – examining whether the funding available is sufficient.

While alleviating pressure on the social care system now gains public and policy attention, a cocktail of factors are predicted to put the system under even greater pressure in the future. IPPR’s report ‘Generation Strain’ describes a ‘family care gap’ – where from 2017 the number of older people in need of care will outstrip the number of adult children for the first time. Carers UK and Age UK’s report ‘Caring into later life’ found a 35% rise in those caring aged 65+ years in England, while the number of carers aged 85 years and older in England has doubled over the last ten years.

For me, the plethora of reports, blogs, commentaries and inquires provide evidence of how our capacity to care is being overwhelmed by need. But what do we actually mean when we talk about ‘care’, who are the carers and caregivers, what’s the cost of care, and what are the implications of Home Truths for rural areas? I offer four points.

Firstly, what do we mean by care?

Social care is framed around the provision of social work, personal care, protection or social support services to children or adults in or at risk; or adults with needs arising from illness, disability, old age or poverty. The definition can be tied back to the National Health Service and Community Act 1990 which describes supporting the ‘activities of daily living’; with provisions such as the establishment of Personal Medical Services (1997) and structure of the NHS in England (2006) enacted since then. As a concept social care can be traced all the way back to the Elizabethan Poor Law of 1601.

According to Age UK, social care means help and support – both personally and practically – which can enable people to lead as independent a life as possible. In practice, it covers a wide range of services, both private and public, and can include anything from help getting out of bed and washing through to care homes and drop-in centres.

Health care on the other hand, is concerned with the treatment, control or prevention of a disease, illness, injury or disability and supporting the after care of a person with these needs. This is set out in the National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care.

According to the NHS, the kind of support you get depends on your needs i.e., the type of condition you have or the severity of your disability. For example, if you have trouble walking you may require some equipment to maintain your mobility and independence.

Care Conversations describes different types of care: in-home care, adult day care, respite care, assisted living, skilled nursing care, medical care, nursing and rehabilitative care, personal care, dementia care, veterans care and hospice care.

In practice, many carers and caregivers find themselves in dialogues with assessors about whether the person they care for has health care needs or social care needs and the type(s) of care they require. If an individual requires some degree of ‘nursing care’ is that a health care need or a social care need or both? This distinction is important because the NHS (health care) is free at the point of need, while payment for home support and care homes is means-tested (social care).

Much work is underway to try to join up these organisational and delivery structures. The Barker Commission on the Future of Health and Social Care in England, for example, recommended a simpler pathway for service users to replace the current health and social care maze. Current examples of this include the Better Care Fund (encouraging financial integration between health and social care services); New Care Models (led by NHS England with 3 vanguards covering integration between health and social care); Integrated Primary and Acute Care Systems (joining up GPs, hospitals, community health and mental health services); and Multispecialty Community Providers (testing new ways to move specialist care out of hospitals and into the community).

While integration may move us towards a more person-centred, coordinated and place based approach to care; for carers and caregivers the dedication and scale of commitment of the tasks and activities that they perform (often on a daily basis) needs to be recognised, valued and supported.

Secondly, who are the carers or caregivers?

The Department of Health defines carers as ‘people who look after a relative or friend who needs support because of age, physical or learning disability or illness, including mental illness’; and informal carers (also calling them unpaid carers) as “people who look after family members, friends, neighbours or others because of long-term physical or mental ill health or disability, or care needs related to old age. This does not include any activities as part of paid employment.”

According to the Carers Trust a carer is ‘anyone who cares, unpaid, for a friend or family member who due to illness, disability, a mental health problem or an addiction cannot cope without their support”. The Trust estimates there are around seven million carers in the UK (equating to 1 in 10 people) and that three in every five people will be carers at some point in their lives in the UK. Carers UK carry out an annual survey of carers to build a picture of the state of caring in the UK. They believe 1 in 8 adults (around 6.5 million people) are carers – with 6,000 people taking on a caring responsibility every day.

In May 2015, the UK Government’s Foresight Future of Ageing project published its report on volunteering, informal care and paid employment in later life. Data for England revealed more than one in six men and a quarter of women aged 50-69 years had provided informal care to someone in the past week. The report suggests informal caring roles are likely to have a negative impact on both participation in paid work and on wellbeing – but that informal care is an increasingly important complement to formal care.

The Carers (Recognition and Services) Act 1995 defines a young carer as ‘children and young people (under 18) who provide or intend to provide a substantial amount of care on a regular basis’. In February 2016, the Department for Education published a report on the lives of young carers in England. This identified 166,000 young carers in England, revealing how while caring was seen to be a very rewarding role by the majority of young carers – regardless of age or length of time spent caring – it also had adverse effects: linked to anxiety, stress, tiredness, strain within family relationships, restrictions in social activities and under-engagement in education.

In academic circles, different types of carers have been identified and typologies developed. Research into Alzheimer’s disease and Parkinson’s Disease reveals three management styles carers adopt concerning the’ burden of care’: adapters, case managers or struggler. In dementia care, three types of caregiver have been identified: ‘role-shift’, reflects care-giving where cognitive deterioration results in changing roles and uncertainty; ‘consumed by care-giving’, refers to those caring for persons with dementia-motor decline that greatly increases worry and isolation; and ‘service use’ where formal support is needed to help caregivers cope with daily responsibilities and behaviour changes.

Within these definitions and numbers it is important to remember that people are often thrown into their caring role, with little time to think about what it involves or how to seek help and support. Carer/caregiver and those they care for may be reluctant to recognise these roles. Some people may be anxious or hesitant to disclose their caring responsibilities to others in their school, workplace and community.

With the implementation of the Care Act 2014 and Children and Families Act 2014, there is now a need for local authorities to identify and assess the support needs of carers, regardless of the type of support they provide.

Section 10 of the Care Act 2014 makes provision for any carer to have a carer’s assessment. The assessment looks at any assistance that the carer requires to continue to provide care, even if the recipient of their care refuses an assessment for themselves. Section 20 of the Act places a legal duty upon local authorities to meet carers needs if these fall within national eligibility criteria. To meet the costs of these new rights, Government has provided over £100 million to local authorities in 2015-2016, rising to around £300 million by 2019-2020.

Feedback on carers’ assessments suggests 1 in 5 carers received little or no helpful information or advice and felt they did not know where to go for support with caring; but 35% of carers who had received an assessment in the last year felt that the support they needed to look after their own mental and physical health alongside caring was properly considered. 8 out of 10 carers buy or receive some form of practical support with their caring role such as equipment, technology, a break from caring or help from family and friends; while 1 in 5 carers who provide 50 hours or more of care each week receive no practical support at all.

Friday 25 November 2016 was Carers Rights Day, this brought organisations across the UK together to help carers in their local community know their rights and find out how to get the help and support they are entitled to. On the same day, Carers UK released new research highlighting how carers are missing out on support.

Many RSN members are aware of national and local organisations providing information, advice, support, services and campaigning on behalf of carers and caregivers. For example, Rethink Mental Illness – a national mental health charity – has been running a “Hidden Carers Campaign” with 300 carers living in Cambridgeshire and Peterborough making contact with voluntary carer support groups. Cornwall Rural Community Council provides a Carers Time Out Grant; and Rural East Suffolk Carers Action Network provides social/recreational and educational activities for carers supporting people primarily with learning disabilities.

Thirdly, what is the cost of care?

According to Carers UK, less than 1 in 10 carers have been asked to pay for support services for themselves, although over a quarter of those receiving social care have been asked to pay for it – with nearly half of those being asked to make a financial contribution saying they are struggling to afford to pay for it. The State of Caring 2016 report found the value of unpaid care carers give in the UK is worth approximately £132 billion – equivalent to the value of health spending in the UK (estimated at £134 billion).

The Adult Social Care funding: 2016 state of the nation report produced by the Local Government Association (LGA) reveals how between 2011-2012 and 2015-2016 councils had to manage a £5 billion funding gap in social care. This led to net spending staying constant – it was £14.5 billion in 2011-2012 and £14.1 billion in 2015-2016. While Government has made additional funding available for social care (e.g. improved Better Care Fund, iBCF), the LGA argues much of it is back-loaded, based on an ambitious set of assumptions that cannot be guaranteed (e.g. that all councils will use the precept to the maximum amount) and needs to be contextualised by wider pressures on council funding overall which is bringing the system to crisis point. Even using the Government’s full set of assumptions, the LGA estimates that adult social care faces a funding gap of £1.3 billion by the end of the decade as part of a £5.8 billion funding gap facing local government overall.

The Autumn Statement contained no new funding for social care or health. On 15 December 2016, Communities Secretary Sajid Javid announced a £240 million dedicated social care grant for Councils from 2017 and plans for them to have the flexibility to increase the social care precept by up to 3% next year. In response, Sarah Wollaston, the chair of the health select committee, said: “I’m not convinced that the local government settlement is new money, it brings some of it forward but doesn’t grasp the seriousness of the shortfall. Rising unmet need for social care will not be resolved without genuine cross-party working to find a long-term solution to funding.”

The impact of the shortfall is already being felt by carers and caregivers. In May 2016, the New Policy Institute undertook an analysis of the Family Resources Survey 2013-2014. The analysis shows 2.1 million informal carers are in poverty in the UK – the poverty rate among carers is 22% but this varies considerably by age, care intensity and relationship to the recipient. The poverty rate appears to increase with the number of hours of care they provide (particularly after 20 hours a week) which leads to a lack of time and capacity to also be in the workplace. The employment rate among working-age carers is 64% – this compares to an employment rate for non-carers of 74%. Despite the challenges of combining care with employment, 400,000 people are doing a full working week alongside providing 20 hours of more of care.

The so called ‘cash benefits’ for carers that meet the eligibility criteria consists of ‘Carer’s Allowance’ worth approximately £62.10 a week and the ‘carer premium/addition’ which is means tested and worth up to £34.60 per week. Carers UK estimate 366,000 people (or 35% of all carers) are not claiming the Carer’s Allowance to which they are entitled, leaving £1.13 billion unclaimed every year. Universal Credit and the under-occupation deduction from Housing Benefit (commonly referred to as the bedroom tax or spare room subsidy) are also having an impact on carers’ benefits.

Besides stating the costs of providing care, few of these analyses explore the financial implications for a carer or caregiver on their participation in work, education and learning and social activities. For the recipient of care, the financial cost of providing them with support is not linked to housing, transport and other services that underpin their care.

Fourthly and finally, what are the implications of Home Truths for rural areas?

a)Funding for social care in rural areas is under unprecedented pressure. Back in 2014, LG Futures undertook a piece of research for the Department for Environment, Food and Rural Affairs (Defra) and the Department for Communities and Local Government (DCLG) to establish to what extent rural authorities faced additional and unavoidable costs in delivering services compared to urban authorities. As a ‘needs based service’, differential provision in social care was not considered to exist (i.e., urban and rural dwellers have the same expectations for services) and there was a tendency for more rural authorities to have a lower proportion of agency staff costs and a lower proportion of expenditure on out of area placements. However, the research found rural authorities had higher travel claims per officer, a higher cost of travel downtime, a residential care premia linked to market factors, location and incidence of self-funders and a domicillary care rate premia of 5-11%. Rural authorities also receive 17-19% less income than their urban counterparts for day care.

In April 2016, the RSN carried out research for Rural England. This found the additional costs associated with sparsity were not being reflected adequately in social care funding leading to unmet care needs in the countryside. The study found rural residents presented later and/or required more urgent and complex crisis-point interventions. Issues around finding and paying for packages of care for very isolated rural residents, the implications of cost cutting in care homes and the increasing pressure on local voluntary and community sector organisations to ‘fill the gap’ where public and private sector providers couldn’t deliver were also highlighted.

b) The social care system in rural areas continues to get by because residents support vulnerable people in their communities. Research from Glasgow University in 2014 found that rural dwellers had greater access to informal networks of care, including family, friends and neighbours, which decreased their reliance on the social care system. The findings showed that, even after adjusting for age, sex, health and living arrangements, the rate of care home admission in rural areas was only 75% of that in urban areas. The study found it was less common for older people in rural areas to live alone, with 25% living with other family members, compared to 18% in urban areas.

c) If people are to remain independent and in their own home for as long as possible, there are a set of obstacles specific to rural areas that need to be addressed. These include personalisation, housing market, fuel poverty, transport, and isolation.

While the needs of carers and caregivers (independent of the needs of those they are caring for) have been recognised by policy and decision makers, the huge contribution that they make to sustaining others who would otherwise need health and social care services – often to the detriment of their own social, physical, emotional and financial wellbeing – is not always valued. According to Nadra Ahmed, chair of the National Care Association, “we are now beyond the crisis point. We really are at the edge of the cliff now.” So if carers and caregivers are not able to carry on – or unable to provide even more – ‘who will care?’

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The terms ‘carer’ and ‘caregiver’ are used throughout this article in recognition of forum discussions about the use of language. Some people prefer the term ‘carer’ rather than caregiver, believing it reflects the support they provide to a loved one with whom they have an emotional bond; while other people prefer the term ‘caregiver’ because it reflects both how they care for the person they are supporting and how they give to them. I do not think it is possible to find one word that fully encapsulates everything a carer and caregiver does. I also think whichever word people choose to use it shouldn’t negate the other roles that the carer/caregiver also fulfils.

October 4 2015

Growing challenge of the rural elderly

One in five elderly people in the UK feels they have no-one to turn to, according to the Campaign to End Loneliness. So what can be done to tackle loneliness in older people in the countryside? Jessica Sellick investigates.

Back in 2013 Defra published its Rural Ageing Research Findings.This profiled how older people in the countryside use services and highlighted examples of good practice. The study found while 18% of people live in rural areas (compared to 82% in urban areas), there are proportionately more people aged 65 years and over in rural areas than in urban areas: 24% in rural compared to 76% in urban.

Between 2011 and 2021 the number of older people is forecast to increase by 29% in rural areas, compared to 20% in urban areas. While older people in rural areas were found to have some socio-demographic advantages over their urban counterparts (e.g. above average income and education levels) they were unlikely to be proactive in terms of arranging the support they needed to help them continue to live there.

Here, two of the key challenges around service delivery that are well-rehearsed among RSN members, namely (1) lower population densities impeding economies of scale resulting in higher unit costs and (2) the penalty of distance and higher travel costs now converge with another challenge (3) lack of ability to forward plan services as older people present at critical moments.

A landmark report is Ageing in the Twenty-First Century: A Celebration and A Challenge’ published by UNFPA and HelpAge. While the report celebrates the contributions of those aged 60 and over as caregivers, voters, volunteers and entrepreneurs; it also sets out a series of challenges facing older people, particularly around income security, access to services and affordable housing.

On 30 September 2015, the World Health Organisation (WHO) launched its world report on ageing and health. This uses the term ‘functional ability’ in calling for a transformation of health systems away from disease-based curative models to providing integrated care. The Global Age Watch Index 2015 ranks 96 countries, covering 91% of the world’s population aged 60 and over. In the overall ranking the UK is tenth – behind the United States, Japan, Iceland, Netherlands, Canada, Germany, Sweden, Norway and Switzerland (ranked first).

With nearly 24% of its population over 60 years, Switzerland has a range of policies and programmes on active ageing, promoting capability, health and the enabling environment for older people. At the other end of the scale, Afghanistan, with 4% of its population aged 60 years and over, has few local or national policies to promote the wellbeing of older people. HelpAge International has called on all Governments to redouble their efforts to make ageing visible and to listen to, include and hear the voices of older people.

With renewed international focus on ageing populations, are we asking and listening to the voices of older people in rural England? I offer three points.

First, while many people dream of a rural retirement, the reality can be one of isolation, loneliness, fuel poverty, limited incomes and falling through the cracks in Government policy.

Amid the Government agenda of productivity, jobs and growth much of the current dialogue is around modernising the State Pension as part of wider attempts to improve the income security of older people.

On one hand, having a larger proportion of older people could mean slower growth and (because older people need to draw down their wealth to live) less saving; leading to higher interest rates and companies disincentivised to invest. On the other hand, some older people are deciding to work for longer dispelling the myth that no one works after the age of 65 years.

The Government’s UK Advisory Forum on Ageing (UKAFA), using data from the Department for Work and Pensions (DWP), found one in six men and one in four women who had recently reached State Pension age hadn’t worked since at least age 55.

An average earner retiring ten years early could see their pension pot shrink by a third. For each extra year in work an average earner could have around £25,000 extra income and increase their pension pot by around £4,500 (or 4%).

Carried out by NIACE, research on the labour market found (i) most older people want to work for longer – for identity/status, intrinsic interest, social engagement and/or financial reasons; (ii) working longer is good for individuals, firms and the economy; and (iii) the labour market is much less efficient for people over 50 – from this ‘mid-life’ point age discrimination rises, health problems cause premature exit, caring responsibilities peak, career progression stops and retirement beckons.

In 2013 the Department for Business, Innovation and Skills (BIS) funded NIACE to run a Mid-Life Review Project to provide people aged 50+ with access to impartial, expert advice on work issues to prevent them from leaving the workplace early.

The pilot provided very local and specific practical careers sessions to older people, with 3,600 sessions delivered to 2,994 clients across England.

The pilot was welcomed by clients who rarely discussed careers issues with anyone and by providers / careers advisors who welcomed the opportunity to build up their offer and work in partnership with other agencies.

For NIACE, the project was seen as important in addressing four main policy changes around discouraging premature retirement, reducing underemployment in hours and use of skills, encouraging lifelong learning, and ensuring a well-managed retirement.

In a recent article for the New York Times, sociologist Anne Karpf described how older people are more likely to be seen as a burden and drain on resources rather than a resource in themselves. She argues terms such as ‘dependency ration’, ‘agequake’ and ‘demographic time bomb’ enshrine dubious assumptions about who will be financially dependent on whom.

In current policy discussions around productivity and growth I do not think older people – as rural entrepreneurs, caregivers and volunteers, who remain vital and present and make a contribution to local economies – are always recognised.

In rural areas there are relatively lower levels of benefit claimants despite low wages.

This suggests the operation of a more informal economy with people undertaking a variety of activities to ‘get by’. People of all ages in rural communities often juggle more than one job to generate an income for their household.

The Rural Productivity Plan, with its welcome focus on education and training, apprenticeships, enterprise zones, planning, housing and availability of childcare often attends to fulfilling the economic potential of younger people in the countryside.

We need to fully consider how ageing influences the economy – the workforce, productivity/growth, savings and investments – and how this differs in a rural context (where the proportion of older people will increase more than in urban places). How can we then use these insights to ensure economic independence and reduce poverty in old age?

Secondly access to services. Many older people are lonely as a result of a partner’s death, disability, chronic illness, reduced or unstable income, and loss of vision or hearing, frailty, fear of falling and/or fear of forgetting.

How can we ensure older people in rural areas can access preventive, curative and long-term health and care? And encourage ageing in place by enabling older people to maintain their independence and social networks, such as transport and technology?

Much of the current discussion tends to be around the funding and criteria used to determine ‘from whom’ and ‘what’ health and care is provided for older people.

Care is funded through Government funds allocated to local councils, council tax revenues, individuals’ contributions to their local authority care package, and/or to services arranged independently.

The voluntary and community sector also provide and subsidise a range of care services. Health is funded directly from taxation. We are consistently informed that the health and care delivery systems have not kept pace with the needs of an ageing population.

And while much has been made around partnerships between NHS bodies and local authorities, vanguards for the development of new care models, person centred integrated care remains under-development.

At the same time, local authorities are calling for sustained and substantial extra funds to help older people. In its ‘don’t cut care’ campaign, Age UK argues the Government should invest £1 in social care for every £27 spent on the NHS.

RSN members clearly recognise the challenges of rurality with regard to providing services for older people and are grappling with the best ways to manage increasing pressures and demands. This includes providing innovative, user centric services that reflect local context.

Norfolk Swift Response, for example, provides help, support and reassurance if an older person has an urgent, unplanned need at home but doesn’t require the emergency services.

The Lincolnshire Wellbeing Service provides a range of interventions and support to access community based services to promote confidence in living independently. These schemes try to forward plan and prevent older people presenting at critical points in need of acute care.

Rose Regeneration has developed a ‘village companies’ model. Here, day care support is provided to vulnerable older people in a cluster of proximate villages. The company is professionally managed but influenced and ultimately owned by the relatives of those served and the communities in which they live.

Each village company is funded through a mix of direct payments, local authority contracts and self-funding arrangements.

Financial modelling has shown that a cluster of fifty clients with an average drive time of five miles to each appointment would enable twenty-two people in the locality to be employed; with visits of at least 30 minutes at least three times a day provided to clients; and a guaranteed, hours based employment contract, covering training, mileage and holiday provision given to every employee at a figure close to/or at the living wage.

Such a model not only enables older people to ‘age in place’ but also provides opportunities for people to live and work in a rural community.

Thirdly, how can we offer a wider range of housing options in rural communities for all age groups?

Back to Switzerland – ranked first in the Global Index – some analysts believe the solution is to build more nursing homes. Apparently 60-120% more older people will be cared for in Swiss nursing homes by 2040 than is the case today.

This requires 53,000 additional nursing beds.

Already the number of employees in this labour-intensive sector has increased more strongly than other sectors of the Swiss economy. By 2040 it is predicted 48,000-71,000 nursing FTEs will be required in nursing homes. However, the working population is currently stagnating and economists are not certain if this need can be met.

Taking a different approach, the American Planning Association promotes multigenerational planning. This considers the needs of all age groups throughout all stages of planning (from needs assessment to visioning, plan making, design, implementation, and evaluation) and how government policies, zoning, and building codes can be changed to ensure generational equality and access.

Examples of multigenerational housing communities include Hope Meadows and Rancho Mission Viejo.

In England much of the focus has been on extra care housing or assisted living communities. While these developments have a reputation for being able to accommodate people who would otherwise be frequent users of acute services, largely because their housing is unsuitable for them to self-care, how can we get policy-makers, planners and developers in rural areas to think more holistically?

With an ageing population surely housing projects catering for older people in rural areas is an investment hotspot for developers? How can we develop housing that enables older people to remain active and/or continue to work? Some older people do not want to live in a retirement setting – in the words of one older person “in those places [retirement communities], everybody is old, and you don’t see young faces”.

It is certainly an interesting time to be thinking about the effects of the ageing process on rural communities and economies. In May 2015 Archbishop Desmond Tutu in backing a UN campaign to reduce poverty described how: “As we get older our rights do not change. As we get older, we are no less human and should not become invisible. I am 83 and I am for people of all ages”. For those that want to, how can we support older people to have a stake and stay in the countryside?

To explore these issues further, the RSN is organising a seminar on ‘Tackling the Challenges of Ageing – Fuel Poverty and Services for Older People’ on 18 November 2015.

Hosted by Costwold District Council, speakers include: Alice Woudhuysen (Senior Campaigns Officer, Age UK), Jon Bright (CEO, Oxfordshire Rural Community Council ) and Holly Sims (Corporate Affairs Manager, Calor Gas Ltd). The seminar is free to attend but places are limited to 50. To book your place please contact the RSN by email events@sparse.gov.uk or telephone 01822 813693.

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, whichaims 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.

For more information about Village Companies please contact Ivan by email ivan.annibal@roseregeneration.co.uk

Website: http://www.roseregeneration.co.uk/ Twitter: @RoseRegen

September 29 2014

A healthcare settlement for rural England?

In 2013, The King’s Fund established the ‘Commission on the Future of Health and Social Care in England‘. Chaired by Dame Kate Barker, the Commission explored what a new settlement for health and social care might entail at a time of growing demand and constrained resources. With the Commission’s final report published in September 2014, what “hard choices” do we have to make and how can we ensure debates on the future of health and social care are not consigned to the ‘too difficult basket’, especially in rural England? Jessica Sellick investigates.

It’s almost impossible to pick up a newspaper or turn on the news without finding something about the NHS and/or social care. Launched in 1948, the NHS has grown to become the world’s largest publicly funded health service. It now employs more than 1.7 million people, including 39,780 GPs, 370,327 nurses, 18,687 ambulance staff and 105,711 hospital and community health service staff. Funding for the NHS comes directly from taxation and for the period 2012-2013, the NHS had a budget of £108.9 billion. NHS England publishes statistics on a range of health and care subjects. An initial trawl of the database revealed some staggering figures:

* Weekly information compiled by NHS England shows in one week alone (8-14 September 2014) there were 427,076 attendances at A&E departments in England.

* Provisional 2013-2014 Social Care Activity Statistics show the number of contacts from new clients in 2013-2014 was 2,157,000 (up 4% from 2012-2013 and up 6% from 2008-2009). Of these, 994,000 required a further assessment or commissioning of ongoing service (an increase of 3% from 2012-2013) while 1,164,000 were dealt with at the point of contact (a rise of 5% from 2012-2013).

* Quarterly performance analysis by Monitor found 147 foundation trusts (which make up two-thirds of all NHS trusts) failed to meet a number of national targets including waiting times, routine surgery and cancer services. For the first time, the sector as a whole posted a deficit: £167 million against a planned deficit of £80 million.

* The latest Ambulance Quality Indicators available up to July 2014 show of Category A Red 1 calls in England, the proportion of ambulances arriving within 8 minutes was 70.8%; and of Category A Red 2 calls in England, the proportion of ambulances arriving within 8 minutes was 68.7% = both figures failed to meet the NHS England standard of 75%. Only the West Midlands (77.7%), South Central (75.5%) and Isle of Wight (85.3%) met the Red 1 standard and only the Isle of Wight (75.6%) met the Red 2 standard. The figures themselves are compiled from the 803,820 emergency calls presented to the ambulance switchboard in July 2014 (equating to some 26,000 calls per day).

* NHS Dental Statistics for England 2013-2014 show 29.9 million patients were seen in a 24 month period ending June 2014; a 1.8 million (or 6.3%) increase from the March 2006 baseline. And 39.8 million Courses of Treatment were delivered in 2013-2014, a rise of 440,000 (or 1.1%) from the previous year.

These figures reveal how the NHS and Councils with Adult Social Services Responsibilities (CASSRs) in England are assessing and treating more people and having to do so amid the continuing need to make cost savings.

The latest tranche of research reports makes further uncomfortable reading with the Alzheimer’s Society Dementia UK study estimating there will be 850,000 people living with dementia in the UK by 2015, at a cost of £26 billion a year; and ‘the Ready for Ageing Alliance’, a group of major national charities, warning in its report ‘getting ready for ageing‘ that services for older people are now on the verge of meltdown. Indeed, the NHS Financial Temperature Check carried out by the Healthcare Financial Management Association (HFMA) indicates only a tenth of provider trusts (12%) were confident they would be able to achieve their financial targets for 2015/2016.

What these figures and studies bring to the fore is how health and social care systems rub up against each other: while the NHS is free at the point of use (from cradle to grave), the social care service is means-tested and free only for those with very severe needs; while funding for health is shared across all taxpayers and ‘protected’, for social care funding comes from local budgets which are not ring fenced. In practice, this leads to distortions. For example, cancer and dementia often place the same type of care burdens on the patient and their family, yet cancer care is funded by the health service and dementia care is not.

The Commission on the Future of Health and Social Care in England, led by economist Kate Barker, has unveiled a new and radical plan to extend free at the point of need care into social services. Rather than looking at the statistics and figures collated above, the panel was influenced by evidence from users and carers – and their distress, despair and sense of unfairness of the current situation. The final report (published September 2014) is littered with personal experiences that make upsetting reading: from Sally Ann’s account of her father’s end of life care (were his needs a health or social care responsibility?) or Becky whose father has complex needs and whose condition fluctuates backwards and forwards across the health and social care boundary requiring him to have 3 different assessments and initially moved to a home 22 miles from his local area requiring his wife and daughter to spend 2 hours on a bus each way changing 3 times on each journey).

These accounts led Barker and her team to look for a new pathway built around the individual patient and their carer/s as well as to investigate how far social care costs should be funded by those in need and their families, and how far they should be shared across society (thus addressing the arbitrary distinction between health and social care).

The Commission’s report proposes patients have a single, comprehensive multidisciplinary assessment for all their needs, providing a care pathway rather than the current maze. A single local commissioner with one care budget would then provide critical social care free at the point of use. Free provision for less serious needs could be added as the economy improves. In Barker’s pathway if social care needs classed as substantial and critical – including end of life care – were provided free, care costs of around £5 billion a year would be shifted from patients to taxpayers by 2025. The commission suggests this money could be raised by a range of means, including:

* £1.4 billion from introducing means testing for free TV licenses and winter fuel payments currently provided universally to over 75s.

* £1 billion a year by removing the current exemptions on NHS prescription charges but reducing the charge from £8.05 to £2.50 and maintaining a cap on charges to ensure a maximum medicines bill of £104 a year per person.

* £475 million by requiring people working past state pension age to pay National Insurance at a rate of 6%. This group is currently exempt from National Insurance contributions.

* £200 million by introducing means-testing for NHS Continuing Healthcare accommodation costs.

The commission rejected calls for a ring fenced NHS tax on the grounds that it would soon lose visibility while locking the system into an inflexible funding regime (although see comments from David Nicholson – former head of NHS England – on introducing an NHS tax). Extending NHS charges was also discounted because they would either be too small to make a difference or large enough to distort access.

Upon publication of the report, Barker concluded “as others have before us, that our system is not fit to provide the kind of care we need and want. We propose radical change, greater than any since 1948, that would bring immense benefit to people who fall between the cracks between means-tested social care and a free NHS. This includes people at the end of life and those with dementia or other conditions where too often there is a conflict about who pays at the expense of what people need…Our proposals would continue a system where costs are shared between the private individual and the state but with the taxpayer carrying a heavier load of that cost than at present. The cost of a more generous settlement, though large, can be afforded if phased in over time.”

While the Barker report has been broadly welcomed; some commentators point to the Commission’s failure to address the existing funding crisis in the NHS; suggesting that whilst the financial costs contained in the report itself may seem modest and affordable, they cannot be considered in isolation from the growing deficit already in the NHS.

Within these statistics and the Barker Report there are few (if any) references to rural. Yet now more than ever the issues they raise around access to services and funding are illuminated across rural England. If we need to redesign and adapt services in ways where quality is not compromised there are some good rural examples: the ‘supporting with confidence‘ scheme led by Surrey County Council; the ‘Rural Coffee Caravan Information Project‘ in East Anglia; or the ‘Village Agents‘ scheme which operates in rural areas across England.

At a national level, the Better Care Fund (a £3.8 billion 2-year programme supported by NHS England, the Local Government Association and Department of Health) creates a local single pooled budget to incentivise local authorities and the NHS to work more closely together. Five plans have already been approved covering: Nottinghamshire, Sunderland, Greenwich, Reading and Wiltshire. Nottinghamshire, for example, is aiming to cut emergency admissions by 3.7% and save £7.8 million while Wiltshire is expecting to deliver a cut of 3.7% and savings of some £2.1 million. While the ambition to cut emergency admissions and integrate health and social care is to be applauded it may be difficult to demonstrate what the Fund delivers: there are many factors which influence emergency admissions (which may be outside the remit of the funding itself to tackle); whether people can be assessed in their own home rather than in hospital or when/how they are admitted to a care home will deliver savings; or whether any savings from any reductions in emergency admissions and from people staying in their own home (rather than hospital or a care home) will increase costs for other community services remains unclear.

Similarly, the Nuffield Trust has set up a Cavendish Group for chief executives from small and medium sized hospital trusts to share new solutions to major challenges such as growing demand for health services and the continued funding squeeze.
When the Barker Report was discussed at the LGA/RSN rural conference on 9 September 2014, there was a conversation about ‘healthy rural communities’ and the need for ‘mixed’ and ‘balanced’ communities if rural settlements to be sustainable. At the same time, Members and Offices from multiple Councils said they were becoming so concerned about funding models, some could foresee situations in the near future where Councils may be forced to set up and run GP and dental practices (alongside the NHS) to provide rural residents with access to local health and care.

While many people agree that maintaining the status quo and/or doing nothing would mean more rural residents would find themselves unable to access health care and social care; more consideration needs to be given to how to join up delivery, how to fund it and crucially how to bring together policies from Government alongside bottom up delivery models developed by rural communities themselves to better meet their needs. Will Barker’s recommendations be implemented? Watch this space.

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. Jessica has undertaken a variety of projects on services, including research for Defra on alternative service delivery and local level rural proofing. In 2013 she organised an event for the RSN on inequalities and deprivation and in 2014 participated in the LGA/RSN conference workshop on health and well-being. More information about the RSN’s work on health can be found here. Jessica can be contacted by email jessica.sellick@roseregeneration.co.uk or telephone 01522 521211. Website: www.roseregeneration.co.uk Twitter: @RoseRegen