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The NHS was founded in 1948 on three key principles: it should meet the needs of everyone; it should be free at the point of delivery; it should be based on clinical need and not on the ability to pay. 75 years later and our beloved NHS is creaking and is struggling to ‘meet the needs of everyone’ as other factors influence our ability to access services, particularly in our rural communities.
Our ageing rural population places additional demands on the delivery of services in rural areas. Furthermore, our social care services are facing significant challenges to recruit and retain a workforce to meet these needs.
Is it possible that a longer-term approach of concentrating on fairer funding could help to resolve these issues?
Almost a fifth of our population in England live in rural communities; however, Government policy, which is designed to meet the needs of all, is so often failing to deliver for our rural residents. Migration patterns show that young people are relocating to urban centres whilst older people are often retiring to rural areas, leaving an increasingly ageing population in our rural communities. Official population projections show that the share of the population in predominantly rural areas that is aged 65 or over is expected to rise to just over 30% by the year 2043. This proportion of older residents can place more complex and more expensive demands on health and care services.
The State of Care in County and Rural Areas report, published by the County Council Network and the Rural Services Network in 2021, found that county and unitary councils received 49% of all service requests in 2019/20. Nationally, 71% of service requests were from those aged 65 and over; but in rural areas, this figure was disproportionately higher at 75% compared to other parts of the country.
Public services in rural areas have long suffered from underfunding by successive governments. In the 2023/2024 local Government finance settlement, urban local authorities will receive some 38% (£135) MORE in Government-funded spending power per head compared to rural authorities. Rural residents will also receive 13% less per head in social care support overall. This is despite it costing more to deliver services in a rural context. These lower levels of funding, therefore, result in rural councils having a smaller budget to start with and, once they have budgeted for statutory services, they then have a much smaller pot of funds available to spend on discretionary services. This can include things like public transport, libraries, public toilets and youth services.
The All-Party Parliamentary Group for Rural Health and Care highlighted in its inquiry that ‘alongside funding, workforce capacity is perhaps the greatest impediment to the delivery of equitable health and social care in rural areas.’ It continues, ‘Staffing for social care which currently at operation level competes with food factory jobs and other sectors, also pay the premium wage leading to a significant instability of workforce.’
A perfect storm is hitting rural communities, with an ageing demographic, higher service costs and an underfunded system to meet those needs, along with some fundamental hurdles to attracting and retaining a workforce to help deliver social care in rural areas.
There are two basic elements that a workforce needs: somewhere affordable to live and transport to travel to work. It is becoming increasingly difficult for rural areas to achieve both elements, especially given the current cost-of-living crisis.
A supply of affordable housing helps to ensure there is a workforce, particularly for jobs that typically attract a modest pay rate.
Overall, wages earned in rural areas are lower than those in urban areas and figures published in 2020 by The Department of Environment, Farming and Rural Affairs (DEFRA) show them as almost 10% lower. Worryingly, excluding London, the average sale price of housing is £112,300 higher in rural areas than it is in urban areas.
As a result of this, plus relatively low local wages, housing is less affordable in rural than in urban areas (excluding London). This remains true for those buying at the cheaper end of the housing market. The housing affordability index measures the cost of bottom quartile housing as a multiple of bottom quartile annual earnings. In 2021, that multiple or ratio was:
The number of social rented homes in predominantly rural areas has reduced further with the Right to Buy Scheme, where barely any homes are built in the same settlements to replace those sold. Figures are available for affordable homes built and/or added to the housing stock in predominantly rural areas (of which small settlements are a part). Also, a notable feature is that very few of these affordable homes added in predominantly rural areas are for social rent, for example, the most affordable tenure category. In 2020/21, social rent homes comprised just 10% of new affordable homes. The rise in short-term holiday lets, particularly in tourist hotspots, has further reduced the available housing stock and the Government has recently launched a consultation on introducing planning criteria to limit this approach in new build housing.
In short, finding somewhere to live that you can afford in rural areas is particularly challenging when you consider the low wages earned in rural areas. Rural local authorities can play a key role in helping to enable the delivery of affordable housing; however, limited resources can impact on the success they can achieve.
Getting from A to B
Getting to work is difficult when you consider the limited public transport in rural areas. Budgeted spend on public transport per head (excluding concessionary fares) for 2022/23 in urban areas was five times that of rural councils. Despite the Government’s piecemeal approach to funding public transport through the Bus Service Improvement Fund, huge areas of rural communities are lacking in a comprehensive network of public transport that would enable residents to access employment. As a result, rural residents often rely on having a car. This leaves them more at risk of rising fuel costs, as seen particularly in the summer of 2022. In many rural areas, the lack of adequate broadband adds to access/connectivity issues.
Despite the challenges, there are organisations helping to ensure a supply of care workers in our rural communities by helping those communities themselves to set up organisations to help.
Case Study – Community Catalysts
Community Catalysts is a member of the Rural Services Network and is a social enterprise, working across the UK to ensure that people can get the help and care they need in ways, times and places that suit them. They are trying to find solutions to the crisis in maintaining a care workforce, by supporting local people to use their energies and talents to establish their own small enterprises. The aim of these groups is to deliver sustainable care and health services for other local people, by creating jobs and volunteering opportunities. One enterprise they supported was Social Support Suffolk, which involved a lady wanting to set up her own community enterprise helping people close to her. The support provided by Community Catalysts enabled Social Support Suffolk, and the care worker/community enterprise leader Helen, to get one-to-one support with areas such as policies and procedures and getting everything in place to deliver a high-quality offer.
Helen, the driving force behind Social Support Suffolk, said, ‘These first few months have been amazing! I am so glad I found you and Community Catalysts to get me up and running. I am now starting to feel that I am actually making a difference to people’s lives and in a positive way.’
The road ahead
Whilst providers can take steps to entice workers into the care industry and reduce turnover, until thorny challenges such as the availability of affordable housing are fixed, there will continue to be challenges in recruiting to our care industry in rural communities. The risk for our ageing population in not having the workers to care for them in future years is growing, purely because they can’t find a home.
The Rural Services Network is the national champion for rural services and campaigns for fair funding. We know that there are limited public funds available, but they must be fairly distributed to ensure our services can meet the needs of their communities. The very foundation of the NHS means this must happen to ensure the survival of our rural communities.
A fairer distribution of funds will result in solutions for some of the wider challenges facing rural communities – the lack of affordable housing, development of the rural economy and public transport – which will ultimately help to deliver solutions for the difficulties in recruiting and retaining a social care workforce.
Care Management Matters - Fairer funding for rural communities
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