Written evidence submitted by Nuffield trust (MH0035)

Nuffield Trust Submission to the Environment, Food and Rural Affairs Select Committee: rural mental health

The Nuffield Trust is an independent health think tank. We aim to improve the quality of health care in the UK by providing evidence-based research and policy analysis and informing and generating debate. In this brief submission, which we hope is helpful to the Committee, we outline the particular problems facing mental health and related NHS services in rural areas of England.

  1. Issues to address

Alongside the particular issues raised by this inquiry, we know there is evidence that mental health problems are associated with living in a rural area.[1] Children living in isolated areas may also experience particular challenges due to the limitations in providing mental health care in rural areas, and the impact of the wider social determinants of health such as education, housing and poverty.[2] Covid-19 is also likely to have had a significant impact on mental health.[3]

Others will be better placed to explain the epidemiology and experiences of mental health in rural areas in greater depth. This short submission draws on our specific expertise in NHS systems, national policy, and finances to explain the particular difficulties in providing sustainable services, and how these might be addressed.

  1. Difficulties facing care in rural areas

The NHS is defined and perceived as a national service, but in reality we know that certain areas of England face disproportionate problems in delivering care to the standards people expect.[4] Certain operational issues tend to be focused in rural areas, and understanding these is vital for ensuring that people living further from cities and large towns are able to access the support they need.

Staffing, funding and infrastructure may all be impacted. The NHS is facing significant staff shortages.[5] Rural areas experience particular limitations on their impact on ability to recruit, with smaller, more spread out populations, fewer younger people and greater competition for the locum or agency staff relied on to deal with shortfalls.[6] Services – including specialist ones can be spread across a large area, making practical access for both patients and staff more difficult, particularly if public transport is limited.

The impact of Covid-19 has also not been felt equally across the country, with the challenges rural areas face being further exacerbated by the pandemic. This includes bearing the brunt of staff shortages, ambulance response times and waiting times for elective care. The level of referral for talking therapies – via the Improving Access to Psychological Therapies (IAPT) programme – in rural areas dipped especially sharply during the first wave of the pandemic falling by 52% in rural Clinical Commissioning Group areas compared to 44% in other areas.[7]

Some of these challenges could be addressed through greater use of technology and remote care, and during the pandemic we have seen an increase in the use of technology to respond to the pressures caused by Covid-19. Technology can offer the potential to increase access to services within mental health through for example greater use of virtual consultations or communication.[8]

However, people in rural areas are also more likely to be digitally excluded, with access to the internet and broadband being particularly challenging in rural areas.[9] These issues can also affect how the NHS delivers care, with organisations in rural and remote areas facing particular barriers to ensuring technology works for their populations, despite the opportunities it can bring.[10]

  1. Costs and financing

Rural and remote areas can face unavoidably higher costs in providing healthcare. Our previous review[11] found that this can be driven by several factors:

If insufficient adjustment or compensation is made for such unavoidable costs, the affected health services may not be able to provide their populations with the same access to, and quality of, care that others do.

Funding for mental health services has been provided as part of wider allocations for core services, of which mental health accounts for around 13%, for primary care such as general practice and pharmacists, and for specialised services commissioned nationally. These allocations are given out according to formulae which estimate the population’s need for care and the cost of delivering it in a local area.

However, to date, some of the key adjustments have the effect of moving significant sums from rural to urban areas. These include the ‘pace of change’ adjustment, which slows down or delays changes in funding with the aim of avoiding disruption for areas which the formula says need relatively less. This has the effect of providing, for example, West London with 15% more funding than its fair share in 2019-20.

Specialised services – within which mental health is one of the largest service areas – have an additional historical spending element to their allocations which had the effect of moving around £700 million within target allocations to predominantly urban areas in 2018-19.

Allocations have, over time, been changed to account for some additional rural costs – in particular for ambulance services and a small number of remote Trusts with major A&E facilities. But these do not benefit mental health services. In fact, a previous review suggested applying the travel time adjustment for ambulance trusts to community and mental health trusts[12]. We recommended in 2019 that further work is needed to explore associations between rurality and performance and financial pressures, including for non-acute providers.


[1] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/824717/Health_Inequalities_in_Ageing_in_Rural_and_Coastal_Areas-Messages_and_summary.pdf

[2] https://www.centreformentalhealth.org.uk/sites/default/files/2020-06/CentreforMentalHealth_CovidInequalities_0.pdf

[3] https://www.health.org.uk/publications/reports/unequal-pandemic-fairer-recovery

[4] https://www.nuffieldtrust.org.uk/news-item/what-might-levelling-up-mean-for-the-nhs

[5] https://digital.nhs.uk/data-and-information/publications/statistical/nhs-vacancies-survey

[6] https://www.eastmidlandsdeanery.nhs.uk/sites/default/files/rural_workforce_issues_in_health_and_care.pdf

[7] https://www.nuffieldtrust.org.uk/research/rural-remote-and-at-risk

[8] https://www.nhsx.nhs.uk/key-tools-and-info/digital-playbooks/mental-health-digital-playbook/

[9] https://www.tinderfoundation.org/sites/default/files/research-publications/doingdigitalinclusion_rurallinks.pdf

[10] https://www.nuffieldtrust.org.uk/news-item/friday-faqs-james-hadlow-and-mike-bedford

[11] Nuffield Trust (2019) Rural health care: A rapid review of the impact of rurality on the costs of delivering health care. Available at: https://www.nuffieldtrust.org.uk/files/2019-01/rural-health-care-report-web3.pdf

[12] Frontier Economics (2017) Review of the market forces factor, A report prepared for NHS Improvement and NHS England https://improvement.nhs.uk/ documents/3353/MFF_review_SupportingDocs.pdf