Rural Services Network – Written Evidence (LOL0038)
In preparing this response we have consulted with our membership across rural England.
The Rural Services Network is a Special Interest Group of the Local Government Association. We are a membership organisation and work on behalf of our members as the national champion for rural services.
We support our member organisations through the sharing of best practice and rural expertise, and advocate on their behalf to ensure that the rural voice is raised up the agenda with parliamentarians and decision makers.
The Rural Services Network has different levels of membership and currently represents:
- 121 Principal Local Authorities (County, District and Unitary Councils) serving rural areas
- 215 Organisations across England as part of the Rural Services Partnership
- Over 140 Rural Market Towns and Larger Parishes
In addition, many Parish and Town Councils have community membership of the RSN, due to their Principal Council being in Sparse or Rural Assembly membership.
Digital Health Services in rural areas can be described as falling into a number of categories:
- Aids and adaptations capable of remote monitoring which enable people to live independently at home
- Online consultation and referral which remove the need for people to visit their GP
- E-enabled record keeping and patient management systems which provide enhanced access to information to speed up service delivery and focus
- Apps and access to websites which provide information to enable people to undertake more effective self - management of their health through the provision of information and more direct support in relation to for example programmes of exercise or diet
Providers of a number of these services also feel constrained by regulators who are often perceived as slow and bureaucratic in providing authority to roll some applications and devices out.
In considering digital medicine it is important not to forget the ongoing potency of simple process
linked to “basic” technology such as the telephone.
Digital Access Challenges
Notwithstanding the availability of these facilities several issues constrain access in rural areas:
- Poor access to broadband and mobile signal
- A lack of knowledge or capacity to use and interact with IT
- For some the lack of sufficient income to afford the necessary hard and software and internet connections
- The cost of using internet and mobile services
The decision of the Spending Review 2020 to only allocate government monies to the tune of £1.2bn over the period 2021/22 to 2024/25 [despite the reference to £5bn in the Spending Review and the National Infrastructure Strategy] means that in rural areas the Digital Access Challenges will remain for most of the remainder of the decade. It follows from this that any benefits from digitalisation – be they health and welfare, economic or social will not be felt in rural areas for many more years to come. Rural areas will be falling behind not ‘levelled up’.
As a point of general principle, digital needs to complement what is already there not replace it. The danger is that the technology is used to replace the face – to - face contact and service rather than enhance it. Technology should not replace face to face, it should just be another choice for people to engage with services. Digital is good but not perfect and does not suit many people. It should be considered as part of a solution, rarely ever the whole solution. However, it does offer a new way of doing things for many people and should be supported to maximise its potential in rural communities.
'Digital medicine' can increase independence, but it is by no means a given. Skills can be developed and support can be in in place, but confidence and/or willingness to use technology are very separate issues. Not having face to face or phone contact i.e. talking to another person is a major problem for significant numbers of people. For them, if technology becomes the driver of change rather than a facilitator of it, they will get left behind.
Digital health services come with a number of challenges including:
- A tendency in some quarters to see “clever” technology as a solution to a problem, perceiving the availability of these services as an end in themselves rather than as a means to support a broader objective i.e., improved physical and mental health
- Ethical considerations, particularly in terms of monitoring devices, about personal confidentiality and dignity
- Vulnerability in terms of the scope for electronic information to be accessed by third parties
- Where machine learning or AI is a component of applications the danger of stereotyping and disempowering end users
The significant returns in terms of savings and improved health outcomes which can accrue to the NHS and Social Care authorities through enabling people to remain independent for longer making the digital medicine area one of great potential profit for businesses.
E-medicine applications provider opportunities for people like carers to work more effectively remotely – having a “clinician” in their pocket and introduce opportunities to make the rural health and care workforce more flexible and efficient. In some cases, such as personal care this can help people become self-employed rather than relying on more traditional models of employment.
Covid-19 has accelerated the use of digital medicine. It has enabled consultations for vulnerable groups to be undertaken remotely. It has enhanced the use of e-media generally which has increased the capacity of individuals to engage with e-medicine. It has reduced the level of regulation around information governance which has led in the short term to a more effective process of record management and electronic information sharing.
The benefits of digitisation we refer to in this submission have, of course, only been felt in areas where there is sufficient broadband capacity to support them.
- Digital medicine increases the independence and improves the quality of life of people in rural settings.
- Digital medicine enables people to get better access to services and in a number of situations to live independently in their homes for longer.
- Digital medicine would increase the quality of life of people living in rural areas if they had better mobile and broadband connectivity.
- People should not be denied access to the benefits of digital medicine because they don’t have the means to pay for IT equipment, a broadband connection or a mobile phone.
- People should be provided with the training and support they need to understand how to access online services and interact with home - based devices to enable digital medicine to be accessed as effectively as possible.
- The loss of personal choice and risk around governance associated with digital medicine could, for some, outweigh the technical benefits it offers to people in rural settings.
- More should be done to provide digital medicine in rural areas.
- More thought should be given to making the case for and realising the economic benefits of digital medicine in rural areas.
- Digital medicine is crucial for improving health access in rural areas but there are many barriers to access (skills, infrastructure, financial resources) which must be addressed. Our members point out that rural communities also desire increased pre-clinical mental health support, and we believe digital medicine should form part of a much broader digital approach to supporting rural wellbeing.
- Analysis of mental health prevalence data shows that, overall, rates of poor mental health are slightly lower in rural than in urban areas. However, there is a difference between sparsely and non-sparsely populated rural areas. Rates of poor mental health are notably higher in sparsely populated areas. The link between deprivation/poverty and mental health are well recorded. The national data on deprivation/poverty (including the Index of Multiple Deprivation) does not properly capture rural deprivation/poverty. Mapped data also shows that rates of poor mental health are typically higher in rural areas which are in coastal locations. Academic research indicates, too, that there can be a tendency for poor mental health to be hidden in rural areas due to a culture of stoicism found in rural communities, the visibility and stigma attached to admitting such issues in smaller communities and difficulties accessing (often urban based) mental health services.
- A lack of trust in digital technologies, especially amongst older people, also contributes to digital exclusion. We would stress that rural areas are severely underrepresented in the mental health research base, and there is a strong need for increased research and data collection to better identify poor mental health prevalence in rural areas.
- A major survey of Mental Health Trusts concluded that access to mental health services is consistently more restricted in rural areas than it is in urban areas. Even where its accessibility is better, patchy provision can disrupt a patient’s ability to access different elements of a healthcare pathway. That same survey showed that, relatively speaking, rural areas have fewer mental health professional per head of population and that patients received less contact with mental health professionals. This held true across a range of services examined, including mental health teams, early intervention, assertive outreach, crisis resolution, community rehabilitation, day care and psychotherapy.
RSN member Plymouth University has commented “People living with dementia and their families in rural communities are less likely to have access to Health and Social Care Services due to lack of transport and broadband connectivity. These two key issues during the pandemic further exacerbated the isolation, loneliness, stigma and despair experienced by people living with dementia and their families in a rural location, which has had a negative effect on their health and wellbeing. We know that 24% of older people living in rural communities are carers. Projections indicate that the number of older people in need of care will grow faster than the number of their children who might help provide it (SORS). In many rural areas, the percentage of older people can be as high as 56% of the total population for that area. The number of people aged 65+ is set to rise by over 40% in the next 17 years to over 16 million (ONS). It is widely known that farming is an isolated live style and has become more so as fewer people living in the countryside work on the land. Due to this isolation, there is a reliance on the availability of super-fast broadband. Examples of reliance on mobile phones and broadband to support people living with dementia and their families during the pandemic were captured through the Alzheimer’s Society’s welfare calls and other rural community organisations and charities regular telephone contacts. The most challenging statistic for rural communities is a third of people with living with dementia live on their own in their community. The lack of appropriate community services and super-fast broadband in rural communities makes life increasingly difficult for people living with dementia and those who care for them.”
1. Digital technology undoubtedly helps most rural residents to stay in contact with relatives and friends. It (as well as non-digital solutions) can play an important role in addressing the isolation and loneliness to be found within rural communities. Physical isolation can be an added dimension in rural areas for those living in small or outlying settlements. This may be compounded by a lack of transport options (especially for those without access to a car) and a lack of local facilities where people might typically meet and interact. Many villages have lost their shop or pub. Village halls (of which there are around 10,000) frequently play a key role as somewhere that activities take place e.g., social groups, health workouts, arts classes. Indeed, some village halls are becoming digital hubs which offer public access wi-fi connections.
2. Video and/or telephone calls are a real potential benefit to people who struggle with the idea of connecting to professional support, especially if it involves leaving the security of their home. This also applies to people who are content with face to face but are limited by transport. Again, technology should not replace face to face, it should just be another choice for people to engage with services.
3. Many rural areas benefit from digital inclusion initiatives or projects that seek to provide the digitally excluded with basic online skills and the confidence to use them. Such projects typical aim to help clients use online applications for social interaction, as well as for accessing services and information. Some of these projects depend on volunteer Digital Champions to deliver the skills training. (There are, of course, a variety of other initiatives which seek to address rural isolation and loneliness, but do so using non- digital solutions e.g., good neighbour schemes, lunch clubs, befriending schemes, men in sheds projects.) All of these approaches are tried-and-tested and would merit from support to enable their wider roll out.
4. Three groups of rural residents are more likely to be digitally excluded than others. The first group are those older residents who have not had the opportunity to acquire digital skills, though this is a group which is diminishing in size. Nonetheless, it should be noted that rural areas have a significantly older age profile than urban areas. Digital skills initiatives should be well suited to this group, at least for those wishing to acquire such skills. The second group are residents on a low income who would find it hard to afford IT equipment and connection charges. This group may need additional help, for example the provision of public access to digital hubs or projects which recycle IT equipment. The third group is young people who continue to be the most isolated / lonely members of our communities generally (The Co-Op Foundation research) - and this is amplified further in rural areas where there are less things for Young People to do, and where there are transport issues and digital connectivity continues to be an issue.
5. An additional consideration in rural areas is those households that live in locations where usable connectivity to digital networks (either fixed broadband or mobile) is still problematic. As noted elsewhere in this response, rural connectivity has improved, but it is still an issue for a sizeable minority of rural households and so a constraint on using digital solutions to address social isolation and loneliness.
6. Particularly in the rural context, consideration needs to be given to a host of related issues. But what happens when people find their laptop/tablet/router etc. is not working properly at home. Who can support them then? Digital disadvantage is a huge issue, and by no means does this relate to older people only e.g., we HAVE to be online to get (and communicate with) Universal Credit, to easily switch energy suppliers to get a better deal, to get the online only special offers from many companies etc. Local authorities have automated phone lines: how many people give up at the first hurdle when they cannot get to speak to someone. Blue Badge applications have to be made online in many cases. What about people (of all ages) who have lost their job and don't' have an up-to-date CV? Many jobs now are online applications only.
Quality of working life
- Prior to Covid-19 levels of home working were already higher in rural than in urban parts of the country. In part, this reflects higher levels of self-employment in rural areas. It is likely the pandemic has accelerated the long-term trend towards more home working and that this will be just as true in rural areas. Indeed, there is much speculation that, as a result of the pandemic, more urban professionals will choose to move residence to rural areas This may in turn lead to better take up of connections etc. making them more commercially viable. That said, urban professionals are only likely to move to areas with good broadband and mobile connectivity.
- There may be a notable difference in home working prospects for those working in rural- based employment and those living in rural areas but employed elsewhere. This, reflecting the sectoral mix of rural-based jobs. Rural areas have a below average share of jobs in the professional, financial and communications sectors, whilst having an above average share of jobs in the agriculture, manufacturing and construction sectors. By contrast, those who commute from rural homes to urban workplaces seem (on average) more likely to be in jobs where home working is possible. This could include people who home work for half the week and stay over near to city-based jobs for half the week. An implication is that, for employees at least, rural home working seems more likely among those in higher skilled and better remunerated jobs.
- Problems accessing fast and reliable digital connectivity have been a long-standing issue for many rural communities and businesses. Although the geographic reach of superfast broadband and 4G mobile networks has improved considerably over recent years, the pandemic has highlighted continuing concerns, not least for those now expected to work from home. Issues are likely to be most common for those living or working in the smallest rural settlements or in the most peripheral areas. These locations will be uncommercial, in terms of network upgrades, and will have relied to a significant extent on government subsidy or intervention to spur previous network investment.
- Growing online use and applications which require more bandwidth mean that rural areas now need full fibre connectivity or equivalent. Government has previously stated its ambition to ensure full-fibre or gigabit connectivity is universally available by 2025. To that end it indicated £5 billion of public investment would be available to ensure such networks reach the 20% of premises where provision will be uncommercial. The stated objective is to ensure that roll out in rural areas happens in parallel with that in commercial urban areas. This full level of public investment needs to be allocated in the 2021 Spending Review and the government and the industry must work together to resolve whatever capacity or regulatory issues there are. Otherwise, rural areas will fall badly behind, with totally avoidable adverse consequences for rural growth and employment.
- In a survey for Rural England CIC over half of rural-based businesses identified digital constraints above and beyond network connectivity, many of which concerned digital skills. Businesses identified issues accessing digital training, recruiting staff with digital skills and having existing staff without adequate digital skills. It was the comparatively larger rural businesses (rather than micro-businesses) that most often cited recruiting staff with digital skills as a constraint. The survey report noted a need for employers and training providers to collaborate locally to address these needs. This could happen through Skills Advisory Panels. It also recommended that training courses and tools to boost digital skills were made shorter in duration and available online, to suit more rural-based businesses and their employees.
- The survey report referred to above modelled the productivity gain if digital constraints were removed for businesses that are based in rural locations across the UK. It estimated that at least £12 billion per annum of additional productivity (Gross Value Added) would thereby be released. This would be a sizeable contribution to the wider UK economy.
- The longer-term impacts for rural areas of a growth in home working are likely to prove mixed. That more currently urban employees may choose to live in rural locations in future has been mentioned above. This could inflate rural housing markets further, with affordability consequences for existing communities. Home working could mean less traffic (with ‘environmental benefits’) on rural roads, especially on prime commuter routes. However, in the short term the main impact has been less patronage of public transport, which could undermine financially marginal rural bus routes. Intelligence during the earlier stages of the pandemic indicated that village shops were benefitting from home working. However, it is less clear whether the same can be said for shops in rural town high streets. Some of their trade is likely to come from those who commute to offices or employment sites in those small towns.
9 December 2020