A fifth of the population of England and a third of the population of Scotland live in rural areas. Wales and Northern Ireland lie somewhere between. In rural areas socio-economic deprivation is masked because indices of deprivation have been designed primarily for use in urban settings. The remoteness or absence of specialist services leads to a health access inequality that crosses social groupings, which are particularly vulnerable to these factors.
Rural primary care teams must be more flexible and develop a wider range of individual skills than urban counterparts. Living within a small community has advantages and disadvantages.
Patients often choose community management, and achieving a good result, particularly in terminal care, is profoundly satisfying and invokes respect and appreciation from individuals, families and community.
Involvement with medical emergencies can improve outcomes. For example, thrombolysis of myocardial infarction was reported in a GP community hospital before being available in many district general hospitals and rural GPs led the use of thrombolysis in a pre-hospital setting.
Challenges for the future include rapid access to increasingly centralised services. The ability to develop a wide range of skills generates professional satisfaction.
Practising medicine in a rural area creates a mixture of responsibilities and privileges that is rapidly disappearing in mainstream general practice. Being part of a community creates difficulty with confidentiality (both patient confidentiality and the privacy of the doctor and his or her family). The need to treat friends and sometimes even family creates pressures within the consultation.
Access to care and clinical outcomes
Mortality for road traffic accidents, asthma and cancer is higher in rural areas. Cancer is diagnosed at a later stage, appearing to be best correlated with distance from a GP surgery and intervention rates for coronary artery disease are lower. Rural patients are admitted to hospital less frequently than urban patients. Screening interventions for mammography and diabetic retinopathy reduce over distance.
Health services are configured differently from urban areas. Where outcomes are heavily dependent on the time it takes to access care (e.g. thrombolysis, major trauma), optimal outcomes are unachievable and optimal care depends on on-site or GP community hospital treatment.
The expense of providing local ambulances, needed to access highly specialised services such as angioplasty or trauma care, means that even these basic services are below the standards expected in urban areas.
There may be outreach services may be based locally but can be peripatetic, and the latter are often less responsive to needs, when seeing a single rural patient can take several hours. There is an inevitable temptation for urban based outreach staff to see greater numbers first.
Most deprivation scales are designed for high homogeneous population density without the marked heterogeneity that characterises rural communities. Little attention is paid to the effects of poverty in rural areas. For example, car ownership is used as a marker for deprivation but in a rural and remote setting, personal transport may be essential (even for those on low wages).
For those disadvantaged, either in health or wealth or both, primary care needs to deliver care locally. In order to achieve this, the GP must take on a greater advocacy role and coordinate the link between health and social care more effectively using innovative solutions. While doing so it must also protect currently effective mechanisms that reduce these inequalities eg local surgeries, community hospitals, dispensing, pre-hospital care. Policymakers may ignore rural issues when formulating strategy.
- A patient with end-stage terminal ovarian carcinoma has developed distressing ascites. Discussion with palliative care and with the gynaecologist confirms the need for drainage as symptomatic treatment. The patient states that she wishes to die at home, having had only brief respite since her last fluid removal. She refuses admission to hospital 75 miles away. The specialist firmly recommends further paracentesis. What is your next move?
- An 18-year-old attends stating he has a heroin problem. His mother is a secretary with the local substance abuse team. That unit is 10 miles away, the next nearest 40 miles. He cannot afford regular 80 mile round trips, nor could he conceal travelling from his mother. He would rather not access treatment at all if it meant his mother would find out. What can you do to help resolve his dilemma?
- A 64-year-old man requires to attend hospital weekly for specialist management of a chronic leg ulcer. He is otherwise fit. The round trip is 60 miles and ambulance services are adamant he does not fulfil their criteria. Public transport is, he states, unaffordable. What options can you suggest to him?
RCGP. Rural GPs forum.http://www.rcgp.org.uk/rcgp-near-you/faculties/rural-forum.aspx
Dr A. Gordon Baird has practised as a rural GP and was a founder member and later chair of the RCGP Rural Practice Standing Group.
This is an extract from the book Working with Vulnerable Groups, edited by Paramjit Gill, Nat Wright and Iain Brew published by the RCGP.