Graham Biggs and Kate Garner.

The Chair: The second session this afternoon is essentially about how rural services and rural communities experience, provide and are challenged by the challenges in adult social care. We have with us Graham Biggs, chief executive of the Rural Services Network, and Kate Garner, who is the service manager at Shropshire Council. Thank you for your time. We have members of the committee who know a great deal about rural areas, as you probably know from your own homework, and I will ask one of those members, Baroness Jolly, to kick off the questioning.

Q129 Baroness Jolly: What are the key challenges to delivering adult social care services, both for individuals with care needs and for unpaid carers, in a rural setting? To what extent are these particular challenges acknowledged in the way policymakers currently design adult social care? Could you give specific examples of failures to rural-proof policy in adult social care?

Graham Biggs: Thank you for the opportunity and the invitation to talk specifically about the rural aspects of social care.

A starting point for me on this whole subject is that we are not suggesting that the nature of needs of rural residents for support from social care is any different to the nature of those needs in the rest of the population. We contend that it is the consequences of the rurality of the areas in which they live that create the substantial differences, the challenges in meeting those care needs, including—I am sorry, but I will return to this several times during what I have to say—the additional costs of providing the same level of care support in rural areas.

It is not just issues relating directly to social care that impact in rural areas. The whole issue of care and the needs of the individual are also affected by serious impacts from things like older and more difficult housing stock, which is harder to heat and to insulate; lack of affordable homes; lack of downsizing properties in local communities; poor digital connectivity; lack of public transport. Those impact not only on the well-being of those needing care, and of course on their families, but on some of the staff recruitment and retention issues.

Moving away from the generality to the specifics of your question: the key challenges. We have already submitted to your secretariat a document that was submitted by the All-Party Parliamentary Group on Rural Services in a discussion with the Care Minister. I would certainly direct your attention to that. The key challenges are demographics. That is not just the older age of the population in rural areas, although the rural population is older and at the older range of what you would describe as older. The age is very much older in rural areas compared to urban. But, of course, the overall demographics means that there is a smaller stock of workers to support those in need of social care.

There is the sparsity of population and therefore the time and costs involved with delivering personal social care over large distances. Integral to that are lack of economies of scale, and weaker competitive markets where the case may be.

There are significant issues in respect of workforce recruitment and retention, and not just because of the smaller working-age population to draw from. By and large, we are talking minimum wage-type jobs, and there are many other minimum wage-type jobs in rural areas, particularly in the summer in coastal and tourist areas. Those are jobs without the responsibility and stresses of working in the care sector. Of course, the huge spike in vehicle transport costs is having a huge impact at the moment.

I referred earlier to affordable housing. The lack of affordable housing on local wages in our rural areas means that our younger people who might be the workforce in the care sector simply cannot afford to live in those areas, and equally cannot afford to move to a larger county town and then drive back in, at their own expense, before they get on to their patch. So there are huge issues in relation to workforce.

Of course, the older population tends to give rise to more complex and expensive care needs, and another challenge is care homes. The proportion of residential care homes in rural areas is significantly higher than in metropolitan areas, which often, as reported to us, encourages service user inflow into county areas.

In terms of the current reforms to adult social care, the self-funder is an issue. The balance of adult self-funding in care is higher in rural areas, so those rural areas are much more sensitive to the proposed reforms to the funding system. I will not keep banging on about it, but I have already mentioned the issue of resources and resource distribution. Those are significant challenges. To give just one flavour of that, per head of population rural areas get 15% less specific social care grant from central government to local government than their urban counterparts.

You have asked whether the rural challenges are acknowledged by central policymakers. This has a much shorter answer: no. We see a one-size-fits-all approach, and although it is arguable that the policymakers also exist at the individual local authority level, I would argue that the reductions and lack of fair funding for rural authorities impedes quite critically some of the ability to respond, too. Those issues will be very well-known and may be acknowledged at local authority level, but the ability to respond to them is another issue altogether.

You asked about rural proofing. We have to start by reflecting what we mean by rural proofing. It is not what I mean, and it is not what you mean. Let me just quote from Defra’s annual rural-proofing report published in 2021, the first ever annual rural-proofing report: “The process of rural proofing involves examining government policies closely from a rural perspective throughout their development and adjusting them as needed to ensure that their intended outcomes can be realised in rural areas”.

The report then poses some questions that may inform that process, such as, “How might outcomes differ between rural and urban areas?”, and, “How might the situation vary between different types of rural area?” That last one is important, because we use the word “rural”— I do myself—as though all rural areas were the same. They are clearly not. A rural area that is in relatively close proximity and that may surround a larger more urban area will have very different needs and opportunities to a rural area that is peripheral, economically and socially, and distanced from other centres. The Defra rural-proofing guidance suggests that, “Rural proofing is not a single, prescribed process—different approaches may be taken depending on the policy and department in question”.

In answer to your question about whether I can identify any areas where rural proofing has not been carried out, my answer is: find me one where it has, because in all honesty I cannot find it. I will be very happy if any of my own members or anybody else can say, “Here is a policy in respect of social care—be it adult social care, children’s social care, working-age population or older-age population—that absolutely has been changed because of rural proofing”. I cannot find it. Certainly when we look at that resource distribution formula, it is absolutely not the case.

Let me give you one more very recent example. As part of the new social care levy, a fund of £150 million of additional funding has been made available “to drive greater adoption of technology and achieve widespread digitisation”. That is absolutely right, but absolutely useless ifyou do not have broadband or decent mobile phone connectivity. Will any of that £150 million be left available for when areas that are currently not served become served, perhaps by 2028, perhaps not? I doubt it. Where is the rural proofing in that?

You asked about the impacts on carers. I mentioned some of those, but one of the features of the elderly population is some people, who are significantly aged themselves, providing care for their loved ones—for their partners, their wives, their husbands, or whatever—and they will feel isolated and lonely in the rural context in which they live.

The Chair: Thank you. It is important for us to hear this very comprehensive account, which we have not had a chance to hear before.

Q130 Lord Polak: Gosh. What has been coming into my mind listening to you, Mr Biggs, is that this is a postcode lottery. We hear a lot about postcode lotteries in where you might live and how things work, and it does sound as though, if you live in rural areas, you will be seriously disadvantaged in the area of adult social care, which we are looking at.

We have been told quite clearly about the benefits of having a local place-based approach. It seems almost impossible to understand how the advantage of this local and place-based approach can work in a rural setting because of the things you have already described—finance, staffing and so forth. What will it take—I urge you not to just say money—for this model to be successful and to overcome the challenge specifically in rural areas?

Graham Biggs: Yes, absolutely. I just remind you that government policy is that nobody should be disadvantaged by virtue of where they live.

Lord Polak: Listen, I am from Liverpool, so I understand that. Do not worry.

Graham Biggs: Indeed. The issues in a rural context are perhaps twofold, and we need to think through seriously what we are trying to achieve in social care in that rural setting, and to recognise the differences in different places between people’s expectations and what they like to receive, and then try to match delivery approaches to that. We very much support the approach based on prevention and keeping people as independent as possible. We need to see how that can best be supported within the challenges of a rural area.

I do not know whether you have heard during your inquiry from Community Catalysts. They have developed some models that we are very supportive of. I say “we”; the Rural Services Network is the secretariat to the All-Party Parliamentary Group on Rural Services, which held an inquiry a number of years ago—in 2018, I think—into what we saw as the rural aspects of social care. It took evidence from Community Catalysts and was enthused by their approach, which in a sense is twofold. They have developed tiny enterprises; it is a micro-enterprise model. So they charge for what they do and are commercial in that respect, but they are led by local people and provide support for local people.

We already know of 500-plus people in Somerset providing support under that model, offering services that range from personal care through to shopping. The providers have a range of different structures: some are community-interest companies, some are sole traders. Community Catalysts acts effectively as a network of data providers to support them and to make sure that people are doing things well, legally and sustainably. Their focus is on quality and learning and, of course, they have to work with the local authorities.

That drops the concept of local down to what local means in a rural area, which is very local except for the extensive geography in which you categorise the word “local”. We heard from Community Catalysts, and some of their workers, that what develops is a range of people—it may be only half a dozen in a particular village—providing that support, but they can match that with their own family requirements, their own childcare or whatever. If one of them falls ill on a particular day, they arrange for somebody else in the village to do it, so the person who gives the care is known locally to the carer and a rapport develops between the carer and the person whose needs are being supported. That, we think, is an excellent way forward. Of course, there is a need to make sure that they are safe and properly trained and all those things, and that is a task for the local authorities in commissioning such an approach.

The other example from Community Catalysts was what they call local area co-ordination, which apparently is based on a model from Western Australia. It is based on mixed funding, but the people are employed by the local authorities and are based in the communities, and they work with anyone who can help to deliver that mission of co-ordinated local care. The work is mainly preventive rather than direct support.

The issue we are addressing is that it is about doing things that matter and supporting the kind of life that people want in those local communities and in the context of those local communities. It is a different, and wider, set of models from commissioning somebody to go in and meet explicit care need, such as helping someone to get out of bed or back into the bed—whatever those care needs are. Certainly the case of rural Somerset is extremely interesting. Over the last five years the approach has been to support 500 enterprises supporting 2,000 people and delivering 20,000 hours of care a week. I do not believe there has been any adverse outcome from that. It all seems to be very positive.

It is trying to build on a natural community perception in rural areas about people wanting to help their neighbours, but doing so in perhaps a more structured way for social care. Of course, the great advantages to the local micro-provider are that you cut down on travelling time and travelling costs, and you support so many agendas in this and have people earning an income in their local area, who will almost certainly spend that in their local area. It is potentially a serious win-win.

Lord Polak: The Community Catalysts sound very interesting, and hopefully we will hear from them. I was going to make the plea to the Chair that the committee visits Western Australia to see it.

Graham Biggs: Via Somerset, if you do not mind.

The Chair: I will take that away, as we say. Thank you, Mr Biggs. What you are telling us is wonderful and fascinating.

Q131 Lord Bradley: Following on from your answer on place-based commissioning and services, what is the potential of existing and future integrated care systems (ICSs), as the consequence of the Health and Care Act, when it comes to designing and delivering adult social care in rural environments? What particular conditions do you think need to be in place for integrated care systems to work successfully in rural areas?

Graham Biggs: When the ICSs start to develop their plans, strategies, service commission, and all those sorts of things, the starting point needs to be genuinely to rural proof the needs of those rural communities.

My concern about the ICSs generally is that the areas they cover are so big, and if you simply look at the statistics for the area as a whole, rural needs get lost. There is a rural proofing for health toolkit in place that was developed by the National Centre for Rural Health and Care—I should declare my interest as a director of that body—and the Rural England Community Interest Company; I declare another interest as its company secretary. Those two bodies, which have specialist knowledge of rural health and rural circumstances, have developed a rural proofing for health toolkit precisely for this purpose. It does not tell you the answer, but it tells you the questions to ask. It directs you to the sort of data that you need to get underneath to come to those answers.

That is what I would suggest as a short answer to your question. This almost needs each service being commissioned to be looked at. That would necessarily bring together a review of National Health Service services and social care services, which need to work together. We can already see statistics on bed blocking—is it still called that? Bed blocking is certainly much higher in rural areas at the moment. That must be a failure of the system that one would hope the ICSs would be able to resolve in some way.

Lord Bradley: Time is short, but we will follow up on your suggestions on that.

The Chair: I will depart from the script slightly. Baroness Shephard, you did not have a question, but I know how interested you are in the rural affairs. Do you want to add anything at this point? Sorry to spring this on you, but I did not want you to miss out on the opportunity.

Baroness Shephard of Northwold: That is very kind of you. It has been extremely encouraging to have positive messages. Obviously every rural area is different, as Graham Biggs has pointed out. I would have thought that Shropshire, with its great empty spaces, probably has more difficulties than some counties in East Anglia, but it has been encouraging to hear how different areas are able to find different solutions. I am grateful. I will not ask a question, but I am enjoying the answers.

Q132 The Chair: I will take Baroness Goudie’s question to Kate Garner, because Baroness Goudie has had to leave us. The fact that you are last in the quartet means nothing other than somebody has to be. I will ask you a brief question, set up very nicely by Baroness Shephard.

The design of traditional social care services in a rural area of Shropshire does not seem to work. From what you know of Shropshire, how do they overcome those challenges? What can anyone learn from that?

Kate Garner: I suppose that delivering centralised services in somewhere like Shropshire, a rural county, does not work because it is expensive and very heavy on time getting to anywhere, and trying to get to know 152-plus parishes, 18 market towns, numerous small towns, villages, hamlets and clusters is extremely challenging. One of the points I was thinking about with Shropshire is that we do not have that many big empty spaces. That is one of our challenges. Shropshire, apart from the Shropshire Hills area of outstanding natural beauty, is covered in settlements, which leads to a lot of travelling for people, lots of road, lots of infrastructure challenges. One way to get around that is to adopt a locality approach. You can have a hub in each of our 18 market towns, but it will still be a significant journey for some people to get to one of those market towns. It does not solve all the difficulties.

Shropshire took another approach a number of years ago. We saw the Care Act 2014 as an opportunity to do something different, and we became quite radical in our strengths-based and community-led support approach. We created a body of social care practitioners and voluntary sector co-ordinators that sat slightly outside the council. That was called People2People. They had permission to do things differently and to focus on community asset and community resource.

It was interesting hearing the first session and to see from someone else’s perspective, because my world is all about prevention, community assets and social capital, and to think about that in relation to social care law in legislation. That is what Shropshire is very good at. Historically we have had strong social capital and a strong voluntary and community sector, and through investment and adopting this strengths-based and community-led support approach it has until now been quite an effective way of supporting people to find good things to do within their communities, and to find the people who live in those communities, that enable them to stay well emotionally, physically and mentally, and to stay at home.

Sadly, that model is now challenged through societal changes, demographic changes and the issues that we have at the moment to do with the cost of living. I am wondering about the last seven or eight years of our model and what we need to do now. It looks like we are coming to a new era.

The Chair: You made the very important point that you have social capital, by which I presume you mean the voluntary and social connectivity that binds people and creates a sense of mutual responsibility, mutual aid and so on. Is that the thing that is being challenged? Do you think that is particular to rural areas in some way, or a particular characteristic? Is that what is being challenged by the cost of housing and the particular sorts of issues with living in rural areas that we heard about from Graham?

Kate Garner: Some of it is nationwide and some of it will be to do with rural areas. If we think of people who retired earlier, perhaps 10, 15, 20 years ago——some were fortunate enough to be able to retire early and to have lots to give. It was their time to give back to communities, and Shropshire has been an inward investor. We have managed to pull people in who have chosen to live in Shropshire because it is a very lovely place, and people have had great quality of life here and have contributed to their communities.

Those people are now getting older. I do not want to make generalisations, but these days the people who are a bit younger perhaps have more caring responsibilities, because people my age—50-odd—have elderly parents and can also have children and grandchildren. So there may be four generations of people, and there will be a couple of generations sandwiched in the middle looking both ways for caring, and there is less time for community things because of that. Our local voluntary and community sector leads are telling us that some people who felt that they had the resources to volunteer are now having to work.

There is something about a rural area where there has perhaps been a slightly older sector of people who historically have been very active. I think it was Graham who said that we have elderly people looking after elderly people. That is absolutely it. When I was growing up in Shropshire, that is what I saw all the time—my mum with four ladies in her car going off to WIs and doing lovely things together. That is still happening, but I wonder if that time has passed.

The Chair: It is raising very large questions about demographic and economic impacts, which we must be aware of.

Q133 Baroness Fraser of Craigmaddie: We have spent a lot of time in this session looking at the implementation of the Care Act and whether it can be implemented. We have heard from many local authorities that have looked at the principles of wellness, choice, control, co-production and prevention that were established in the Care Act. I was interested to hear about you in Shropshire taking a radical approach and giving people permission to do things differently. What does the example of Shropshire demonstrate about the feasibility of implementing these care services? Can we meet the principles of the Care Act in a rural setting?

Kate Garner: If you have a model of adult social care, which most local authorities will have now, it is strengths-based, community-led support, which is fundamentally based on there being a strong voluntary community sector. You have to have something to make that model work.

Thinking about it from that point of view and about Shropshire, and thinking about our provider markets, when I was looking at the principles I thought that perhaps it does depend on you as an individual and what your life has been like, because if you are having that strengths-based conversation with somebody and their family is still living around them and they have that strong network because they are still living in the village that they have lived for 40 or 50 years, the chances are that you will have good choices. That well-being principle can be enacted because there will be a conversation about your life and how you can reach out and perhaps ask other people to support you, and think of different ways to do the things that you want to do.

However, if perhaps you moved to Shropshire 10 years ago and your spouse perhaps passed away quite quickly, and you are living in a larger house in a rural area, those principles could be quite hard to enact with our model. Rural areas can be very lonely places to live. They are also very lonely if you feel that you are a bit different to everyone else. Communities of interest can be very hard to bring together in rural areas, because often there are not enough people. A geographical community and a community of interest put together in a face-to-face way can be hard. There would be a role there for digital communities of interest, but if you are living somewhere where you do not have good broadband or a good mobile phone signal, that is not always such a good solution either.

When we think about wellness, choice, co-production and so on, a lot of those are to do with adult social care practice and should not be affected by rurality. I was interested in something Belinda said about creating support plans that have nothing in them. If you were not interested in or felt attracted to what was going on around you in your community geographically, you could get stuck because of rurality and there only being 323 people living in five square miles around you. It would be incumbent on a social care practitioner to get imaginative and to think about how those principles are enacted.

Q134 Baroness Eaton: My last question is in three parts. First, what lessons can be learned from the experiences of delivering social care in Shropshire? To what extent could these lessons be applied to other rural local authorities? Finally, how can these lessons be disseminated to the rest of the country?

Kate Garner: I am aware that I have not talked much about the care market. Graham talked a lot about some of the challenges that we are experiencing at the moment, so please do not think that those issues with social care providers, residential homes and care homes are not in my mind when thinking about what we need to learn from our experience of delivering.

When I was looking at this question I thought about the integration and multidisciplinary teams of health, care and the voluntary sector working in a locality way. We had a shot at that in Shropshire, and we are very keen on doing something like that again. There were challenges and it would be very good if lessons could be learned about some of the functional challenges that prevent multidisciplinary teams from being able to work together effectively, which are to do with things like IT systems, information sharing, processes and structures. They are often based on good will and relationships, and people working together. It would be great if the integrated care partnerships could focus on that sort of thing.

Having an excellent first point of contact in your customer services can make a difference. Again, I listened to the first witnesses talking about signposting, and how that can get people into circular routes of people going round and how you land somebody well somewhere that you signposted them to. Our first point of contact in Shropshire is a good model, with good people who go the extra mile to make sure that if they have suggested that somebody get in touch with an organisation, they call back and make sure that that has happened, and if it has not happened, they start again.

I would like to see adult social care and social prescribing more closely aligned. We are lucky in Shropshire in that we have a strong social prescribing model delivered by our public health team. It is easy for us to align our community-based adult social care conversations with a broader perhaps more preventive health kind of conversation.

Try to believe that older people are more capable of using digital technology than perhaps we think. We write off older people, saying that they will never be able to tackle that iPad or whatever, but older people can. Like everyone else, they want a mix of doing some things digitally and some things face to face.

I would definitely encourage digital means of communications in particular. Loneliness is a huge issue nationwide, and it can be particularly lonely living in a rural area where perhaps you do not see anybody going past your door because of where you live. So digital means of connecting with people can be great.

All these things could be applied to other local authorities. Lots of local authorities will already being doing something that looks a bit like this. Perhaps some things are slightly different, some things are better, some things have not quite landed for them. I was thinking about how these lessons can be disseminated, and there are lots of different ways that I am aware of. The Rural Services Network is certainly one of them. Shropshire has a key role in that network. For us, West Midlands ADASS—the Association of Directors of Adult Social Services—is a great way. There is the LGA (Local Government Association). There is the NDTi—the National Development Team for Inclusion—which we are members of and which is a fantastic way of sharing information. There is also something very good called the FutureNHS platform, which you can sign up to as a practitioner because that is all online. It is a great way to have those virtual conversations and webinars. There is a lot. We are good at that.

Baroness Eaton: That was most interesting. It was also very encouraging hearing about the dissemination at the end, and that these good things are not just in isolation but can be disseminated much more widely. Thank you for those very interesting answers.

The Chair: That is a good note on which to end, because I could not agree with you more. It has been a great pleasure to hear two perspectives this afternoon from Graham Biggs and Kate Garner, and to realise what expertise there is out there in the rural community and how proactive and passionate you both are about getting the best for the rural communities. Kate mentioned the sandwich generation, the growth of care needs and the demand on care services, and these will be hugely stressful in rural areas, for all the reasons that Graham gave. It is incumbent upon us as a committee to make sure that we get that message across, along with very pragmatic solutions, diagnosis and prescription. You helped us this afternoon to get both those aspects.