Social care in rural areas: developing an agenda for research, policy and practice
Problems for rural areas are moving rapidly up the policy agenda for government and other public bodies.
Issues of funding, declining transport and employment opportunities, the growing awareness of rural deprivation and the withdrawal of basic services, such as banks and post offices, are now being hotly debated. Fresh fields contributes to that wider debate, focusing in particular on the difficulties surrounding the provision of good quality, affordable and appropriate social care for older people and disabled people in Britain's sparsely populated areas.
It draws on a wide-ranging literature review, a reanalysis of data collected during research on local government reorganisation, and on a telephone survey of rural authorities, to set out agendas for research, policy and practice of those concerned with the provision of rural social care. It shows that many of those responsible for service provision still only give lip service to the needs of rural dwellers, with much policy overlooking the particular and different responses required for sensitively addressing the needs of rural areas.
Current interest in rural concerns needs to take on board issues relating to the organisation and provision of social care. Gary Craig and Jill Manthorpe from the University of Hull have carried out a study of initiatives and debates in this area. They found that:
- Rural areas are sometimes associated with high levels or pockets of deprivation and social exclusion. Difficulties with access, low levels of service provision, isolation, higher costs and lack of choice or quality all contribute to health and social care problems.
- Despite increasing argument, there is still no firm agreement about the fair allocation of resources to meet the distinctive needs of rural communities. A variety of ways of bringing in funding are used, patchily, to help with resource problems.
- Many of the difficulties associated with the planning and provision of rural social care are faced by other services, most notably health. Joint approaches and shared thinking appear limited yet potentially fruitful.
- Within the UK there are major differences between rural areas. These variations need to be explored: needs and responses may be different, for example, between islands, other more remote areas, and those areas close to urban centres with good communication links.
- There is already considerable rural research; calls for more activity in this area need to focus increasingly on specific questions or to bring together disparate evidence to inform the development of best practice. Evaluations of initiatives appear to date rarely to influence thinking and policy development.
- Policy development in many areas does not incorporate a clear and explicit rural dimension. Some local authorities and organisations are making progress: others involved in social care appear to operate at a more limited level of understanding. Little is known of what training and support effectively equips social care providers to operate in rural areas.
- The voices of those living in rural areas, particularly those receiving social care services or groups needing specialist attention in policy development, are rarely heard; much remains to be learned from them of their experiences and ways of coping.
The upsurge of interest in rural matters is beginning to have an impact on the commissioning and delivery of social care. This project reanalysed data from a recent study of local government reorganisation and collected new data to explore service provision and problems in rural areas. It also reviewed recent literature and current activity in rural-based social care, particularly drawing on evidence which is just emerging or not widely available.
The 'rural agenda' includes a multiplicity of perspectives, although discussion is comparatively underdeveloped in respect of social care. Two main themes were found: first, the association of rural areas with significant levels of deprivation and social exclusion; second, the need to tailor social care services to the specific geography of an area. At national level there has been long-standing discussion of the most appropriate allocation of central government funds between rural and urban areas. These arguments for a 'sparsity factor' or 'rural premium' are reflected in the key problems encountered in rural social care, which centre around access, levels of service provision, isolation, higher costs and lack of choice or quality provision. Centralised service provision and models of working based on urban developments contribute to feelings that rural social care is neglected.
Respecting rural issues
In a largely urban country such as the UK, defining rural areas can be complicated and contentious. There is a variety of competing means of defining and mapping indicators of rural deprivation. In this research a simple classification system was used to categorise all British local authorities which had been subject to local government reorganisation between 1995-98.
Postal questionnaire data from these authorities were analysed to identify particular issues for rural areas.
Some findings showed similarities across rural and urban settings. For example, a small but equal percentage (17 per cent) of both urban and rural authorities had moved to further internal departmental reorganisation - particularly joining together housing and social services. The impact of this approach needs assessment. However, there were also differences: for example, between rural and urban use of the independent or private sectors of care. Rural authorities had traditionally spent less on services and direct provision. Thus while both new rural and urban authorities faced financial constraints, rural authorities appear to have been put under particular pressure at and shortly after the time of reorganisation. Reorganisation often entailed additional administrative costs and few economies of scale. This led to increases in charges to users and reviews of contracts with providers of social care. The costs associated with reorganisation could not be absorbed within already stretched budgets.
To update this data, telephone interviews were conducted with a sample of those local authorities defined as rural for the purposes of this study. This survey of 20 rural authorities provided information about the changing and complex set of inter-agency relationships. Most social services authorities were significantly smaller in size than they had been prior to reorganisation yet had to relate to larger Health Authorities and Trusts (as well as emerging Primary Care Groups). Telephone interviews with representatives of NHS organisations and voluntary sector groups confirmed this imbalance. Nonetheless, it is clear that there is an increasing range of interesting developments in rural health care and that these need to be better connected to social care issues. From the interviews, for example, both health and the voluntary sector were found to be experimenting with mobile services but these initiatives did not always appear integrated with local authority initiatives (or even known about in some instances).
The interviews confirmed an issue widely understood by those working in rural areas but infrequently referred to in policy discussions about rural social care, that is the differences between rural areas. A series of case studies was used to illustrate this point. One focused on an island - with its sense of identity and key geographical characteristics. Another explored a large rural authority with pockets of both affluence and deprivation and incorporating towns ranging from seaside and retirement centres to urban industrialised areas with economic problems. In contrast, social care in another rural authority was greatly influenced by the proximity of towns and reasonable communication networks. In some rural areas, good practice in collaboration and community initiatives appears to have been occurring quietly. A final case study explored a small, scattered authority where transport difficulties affect services, staff and those users wanting a choice of support. It is clear that policy and service development needs to incorporate a rural dimension which reflects other influential factors such as service traditions, the pattern of local economic activity and the characteristics of ordinary life and support.
Social care services in rural areas often appear to follow policy lines developed in more urban areas. One priority for research could be the collection of examples of good practice and innovation to establish evidence about what works and why. The researchers found numerous examples of initiatives but less reflection on their key lessons. Little work appears to have been done to evaluate training in this area or to establish what training and development models are used among practitioners or volunteers working in rural areas.
Despite general agreement that service users and carers are important guides to the effectiveness of services there is equally little evidence about their own priorities, their ways of coping and their resourcefulness. It is no longer enough simply to identify 'transport difficulties', for example, as the main issue in rural areas: a more sophisticated and imaginative analysis of problems and solutions is required.
Funding and financing
The allocation of funds to rural areas is also part of a wider European debate. This will affect social care supported by local authorities and associated agencies. This research shows that the mixed economy of social care at local level remains highly variable between and within rural areas. New moves to give fair access to care will need to incorporate a specific rural dimension. There is much evidence at local level of the use of funding mechanisms to develop social care initiatives. There is also anecdotal evidence on how local economies, dependent on low wages and the changing holiday trade, encourage or subdue specific care initiatives. Patterns of seasonal work may place year-round support in jeopardy. Useful work could be developed to explore the inter-relationships between social care and other local social and economic development and the opportunities for developing local care provision which goes with the grain of rural economies.
This research found that issues in rural social care are evoking interest, not before time perhaps, in research, policy and practitioner debates. At local level there is a variety of service developments. New initiatives may well have been tried elsewhere but lessons have not been widely disseminated. The researchers conclude that involving service users and local community organisations should be central to the construction of a rural agenda for social care.
About the study
The study comprised four components: a review of recent literature and current activity in respect of rural-based social care; a reanalysis of data gathered in a study of the reorganisation of UK local government 1995-98; a telephone survey of rural authorities; and the collection of a series of examples of initiatives in social care emerging from rural areas. The work was carried out in 1999 and sets out, for a range of interested parties, a programme of work needed in research, policy development and practice.