1. What is rural proofing & why is it important?
Introduction to rural-urban definitions
Rural Issues
Questions to consider
Audrey Roy
Rural Communities Policy Unit,
Defra
Hello,
My name is Audrey Roy, I’m head of Rural Services within the Rural Communities Policy Unit at Defra.
I’m pleased to be able to talk to you today about Rural proofing , why it’s important and how this may help you as you and your colleagues play your part in the NHS changes.
I don’t make any claim to be health service expert.
But I do understand the importance of taking rural issues into account in policy and decision making and especially in front line service delivery.
Whenever you have to plan something, commission and deliver a service or spend money you all know a well as I do that you can’t make the right decisions without having all the information available.
Once the decision has been made, the service designed and commissioned, the money committed – it’s very hard to go back and undo something.
We all have, I’m sure some experience of being on the receiving end of a service where something was bolted on later – it just doesn’t work, it doesn’t feel right and can often be more expensive.
So when you’re working with peoples health it’s even more important to get it right first time.
Rural proofing is a simple concept – it’s all about understanding.
Understanding the issues that rural communities face and trying to incorporate these in your decision making.

2. Different geographies and issues How we define rural and urban
Overview
Why define rural areas?
Different geographies and issues
How we define rural and urban
What we can do with it
Before you can Rural proof of course you need to understand some basics and the most basic is the Rural Urban definition.
I’m going to explain :
Why we define rural areas?
The different geographies and issues ?
How we define rural and urban – on the one hand very simple
What we can do with it, or more importantly , what you can do with it.

3. Why define rural areas at all?
There are two dimensions to understanding why we define rural areas.
First.
It’s sensible and logical, (and I assume that many of you won’t disagree with me), to assume that any policy – whether it covers health, transport, housing, employment, or other, won’t be effective unless that policy understands the issues affecting those that it seeks to serve.
Just as a shop keeper needs to know what their customers want.
The second dimension is that ...
When delivering a service, the service provider needs to understand
a) the service it provides and how it impacts upon the customer
b) how the circumstances of the customer impact upon the service and the desired outcomes
it’s like holding up a mirror.
Online access to health appointments only works if customers and patients have internet access and good broadband speed – so you have to retain a backup (telephone, letter).
Ultimately this is about understanding how the service will make life better or worse for the customer/patient.
Rural areas have distinct differences from Urban areas:
Smaller populations and settlement sizes;
Sparse, more scattered populations;
Distance from larger urban settlements is greater to name a few.

4. The Rural USP 86% of England’s land is rural;
20% of the English population live in rural areas;
Equates to nearly 10m people, in settlements with populations
fewer than 10,000 people;
Nearly a quarter of all older people live in rural areas (55+)
Rural areas are ageing at a faster rate than urban areas. The
fastest rate of growth is amongst the oldest old (age 85 +).
In 2009, 15% of all older people in rural areas lived below the
poverty threshold
Around 23% of rural households are in fuel poverty compared to 18% of urban households (2009)
38% of rural households are off the gas grid, compared with 9% of urban households
But first, let me enlighten you about what it means to be living in a rural area and some of the issues faced by rural communities.
86% of England’s land is rural;
20% of the English population live in rural areas;
Equates to nearly 10m people, in settlements with populations fewer than 10,000 people;
Nearly a quarter of all older people live in rural areas (55+)
Rural areas are ageing at a faster rate than urban areas. The fastest rate of growth is amongst the oldest old (85 +);
In 2009, 15% of all older people in rural areas lived below the poverty threshold;
We know there is a link between poverty and health outcomes
Around 23% of rural households are in fuel poverty compared to 18% of urban households (2009)
Fuel Poverty defined as :
Where a household needs to spend more than 10 percent of its income on fuel for adequate heating (usually 21 degrees for the main living area, and 18 degrees for other occupied rooms).
Living in cold homes can damage people’s health and affect their quality of life. The elderly, children, and those with a disability or long-term illness are especially vulnerable.
38% of rural households are off the gas grid, compared with 9% of urban households

5. The Rural USP
Road fuel is around 2 pence per litre more expensive in sparse rural areas than the national average.
Only 50% of households in villages and hamlets have an hourly or better bus service within13 minutes walk (compared with 96% of households in urban areas)
Residents in villages and hamlets spend % more on transport than those in urban areas
Public transport is more limited in rural places. In % of households in the most rural areas had a regular bus service close by, compared to 96% of urban households
What else do we know about rural areas:
Road fuel is around 2 pence per litre more expensive in sparse rural areas than the national average.
Only 50% of households in villages and hamlets have an hourly or better bus service within13 minutes walk (compared with 96% of households in urban areas)
Residents in villages and hamlets spend % more on transport than those in urban areas
Public transport is more limited in rural places.
In % of households in the most rural areas had a regular bus service close by, compared to 96% of urban households

6. The Good the bad and the ugly?
Overall life expectancy in rural areas is higher than in urban areas - for men years, compared to 76.5 years in urban areas, for women 82.4 years compared to 81.0 years respectively
80% of rural residents live within 4km of a GP Surgery, compared with 98% of urban population
57% of rural residents live within 4km of an NHS Dentist, compared with 98% of urban population
around one-sixth of Primary Care Trusts (PCTs) with the worst health and deprivation indicators were located in rural or significantly rural areas.
But what does this mean specifically for Rural Health services?
Good news – life expectancy is higher
But here’s the bad news:
Only 80% of rural residents live within 4km of a GP Surgery, compared with 98% of urban population
This is measured as the crow flies by the way – not taking into account topography and the windy country lane with no pavement or lighting
Only 57% of rural residents live within 4km of an NHS Dentist, compared with 98% of urban population
Again, measured as the crow flies.
Around one-sixth of Primary Care Trusts (PCTs) with the worst health and deprivation indicators were located in rural or significantly rural areas

7. Different definitions?
Depends on geography:
Rural-urban definition
Local authority rural-urban classification
Classification of parliamentary constituencies, police authorities, education authorities etc
So you can see, it’s important to understand the nature of rural areas and the best place to start is with their definition.
Defining rural may appear far from simple as there are several different geographical definitions but they do build on each other :
For example we all know about Parliamentary constituencies and Police Authority boundaries.
However I’m going to focus today on:
Rural Urban definition adopted by the Office for National Statistics (ONS) – the official definition
Local Authority Rural – Urban definition which is based primarily upon the ONS classification, but is also based upon the number of urban people and percentage of rural people living in a local authority – so there’s a little bit more to it.
This is helpful if you want strategic information at say county or district level, but if you need to assess a service need more locally ( and this is best for rural areas because of their sparsity) then the ONS definition is the one to use.

8. Rural-urban definition
Definition = definitive, official, used by Government
Used when information is needed at a detailed spatial level
Can use for postcode level data, but most commonly used when data is available for census geographies (census output areas, lower super output areas etc)
Census output areas were introduced for the 2001 Census of population.
They were built from adjacent postcode areas.
They were designed to have similar population sizes and be as socially homogenous as possible – based on dwelling type and tenure.
Minimum size was 40 households (100 population) but recommended size was 125 households.
All Output Areas (OA) contained either rural postcodes or urban postcodes.
All Output Areas (OA) fit within electoral wards or parishes – if a postcode straddled a parish/ward it would be split into 2 Output Areas.
In reality, with two neighbouring households split across 2 parishes or wards and therefore 2 output areas, the data will probably be the same due to proximity or you might think so.
In an urban areas household make up is unlikely to change much between two neighbouring households .But in a rural area you can get deprivation at a very local level (posh street poor street etc)
There are over 165,000 Output Areas in England.
These are the fundamental building blocks for all data analysis.
Super Output Areas are simply a collection of Output Areas – there are over 34,000 in England.

9. Rural-Urban ONS definition
Rural-urban definition is a statistical tool
Is based on population not land use/sector
Underpinned by density data for a grid of hectare squares for whole of England
Depends on the residential density in each hectare and in the 200m, 400m, 800m and 1600m around it
E.g. a ‘village’ =
At the 800m scale: a density of greater than 0.18 residences per hectare
At the 400m scale : density at least double the density at 800m
At the 200m scale: density at least 1.5 times the density at 400m.
Rural-urban definition is a statistical tool – useful to help analysis of data which can inform policy
Is based on population not land use/sector

10. Rural-urban definition
Use these building blocks to classify each Output Area (OA) by
Settlement type:
Urban (population is 10,000 or more at Census 2001)
Rural town and fringe
Rural village
Rural hamlets and isolated dwellings
Context:
Less sparse
Sparse (very low residential density for 30km around)
The urban threshold or cut off at a population is 10,000 , is a historical measure – it is an international standard
Within the definition of rural there is a further subtlety which is that settlement types can be described as :
Less Sparse
Sparse (very low residential density for 30 km around).

11. Rural - Urban definition hierarchy
England
Urban
Rural
Sparse
Less sparse
Sparse
Less sparse
This diagram illustrates the hierarchy and the relationship between settlement types.
Town/ fringe
Village
Isolated dwellings
Town/ fringe
Village
Isolated dwellings

12. Map of the rural urban definition
This is a map of England showing rural and urban areas as defined by THE OFFICIAL ONS RURAL –URBAN definition – the dark blue areas are urban.
Interestingly enough you can see the areas around North Devon and North Cornwall , Cumbria and Northumberland, Lincolnshire and South Shropshire as defined as Sparse rural.

13. What can we do with this?
Once we’ve identified our population and classified their rurality , we can apply this to policy and service planning.
Let’s take Fuel Poverty as an example.
Using the ONS Rural – Urban classification we can identify not only the level of fuel poverty but also where it is concentrated.
At Defra we worked DECC to specifically target their funding for Domestic Fuel efficiency schemes. For example, we know that using housing data in Durham County Council, the Local Authority identified a large proportion of rural properties that could not be retro-fitted with standard energy efficiency measures such as double glazing or cavity wall insulation. As a result the funding scheme criteria was adjusted to include other mechanisms such as secondary double glazing.

14. Rurality and Health service delivery
Distance Decay
Costs
Accessibility versus Quality
One size does not fit all
Moving on, What are the key issues to understand with rurality and health services delivery?
Distance decay
The distances from home to hospital are one of the major obstacles rural patients face.
Distance decay is ‘where there is a decreasing rate of service use with increasing distance from the source of health care’. Studies have shown that the closer the service the more likely it will be used. Rural and remote populations are therefore affected by distance decay.
Distance decay is a reflection of service utilisation rates which cannot be taken as a direct proxy for health care need.
Distance decay is a real cause for concern since it leads to delayed intervention and treatment and hence poorer health outcomes become more likely.
Costs
For rural patients, particularly those locked into extended courses of treatment, the costs of travel for cancer treatment for example, can be extremely high.
There is a lack of recognition of the true costs of delivering services,(especially health services in rural areas), by existing funding mechanisms, despite considerable research in this area which highlights,(amongst other things) increased costs of transport, lack of opportunities for economies of scale.
A related problem for service providers is that the thin population spread of rural areas mitigates against specialised and out-of-hours services as the costs of provision, for an individual GP for example, are disproportionately high compared to a large urban practice.
Accessibility versus Quality
The primary challenges for rural areas are the greater distances patients have to travel for treatment.
A study in South Devon (Patel et al 2004) calculated that patients would have to travel on average an extra 5,000 miles if their treatment was transferred to a regional hospital in Bristol in order to access specialist care.
Personal costs created for patients can be extremely high, this is generally posed as a ‘trade off’ between ‘accessibility’ on the one hand and ‘quality’ on the other. Rural service deliverers may also struggle to secure staff with the necessary expertise to operate in remote areas due to the sparsity of the talent pool and the remoteness of the area
It’s important to understand that One size does n ot fit all – a solution for one rural areas may not work as well in another.

15. So what are we doing about this?
Rural Proofing for Health Toolkit
The ‘core’ of the Rural Proofing for Health toolkit is an interactive model that is structured into six domains
Self care – the rural patient,
Patient Choice,
Access to services,
A rural workforce,
Rural partnerships – joint working,
Patient safety and audit
Defra has been working with the NHS Confederation, Department of Health, Local Government Association, Norfolk Rural PCT network and the Institute of Rural Health to update the Rural Proofing for Health toolkit.
What is the toolkit?
Back in 2005 Defra and the Department of Health recognised that delivering rural health services is challenging at the best of times, so together, we produced a Rural Proofing for Health Toolkit- designed to highlight rural issues and showcase good practice in health service delivery.
Fast forward seven years ...
Because of the current changes to the NHS we decided to revisit the toolkit and refresh it – working with a number of stakeholders including
more recently, the Dispensing Doctors Association.
We held a series of regional focus groups with existing shadow CCG members and health service practitioners to develop the toolkit which will be launched this Thursday.
The toolkit is a guide to help practitioners identify the specific rural issues which need to be considered when planning and providing for the health needs of residents living in rural areas.
Quite simply it’s a prompt to help you ask the right questions at the right time.
The end result should be t:hat:
rural specific issues are incorporated into policy making at a strategic level, and
into the design and delivery of services by health service providers on the frontline.
What will the toolkit look like?
The refreshed toolkit will be a web-based product that will act as a source of information and a reference guide, primarily for NHS service commissioners and practitioners.
It will contain
Information which highlights rural issues,
links to other sources of information,
practical examples of good practice in decision making for rural health service commissioning and delivery
a series of case studies
More of the case studies which will be added over time.

16. Rural Links The Rural Evidence Project
ONS Rural/Urban Definition
Rural Proofing
Statistical Digest of Rural England 2012
Useful links to consider for further information :
The Rural Evidence Project
The Evidencing Rural Need project provides the summary information needed to effectively represent rural issues in local and regional programme strategy, planning and prioritization. Developed by Action for Communities in Rural England (ACRE), its members in Rural Community Action Network - RCC’s and Oxford Consultants for Social Inclusion, it shows the real socio-economic picture of rural England – its areas of deprivation, the economy and access to services
ONS Rural/Urban Definition
The ONS Rural/Urban Definition – official, definitive Government adopted definition.
It was introduced in 2004 as a joint project between a number of Government Departments and was delivered by the Rural Evidence Research Centre at Birkbeck College (RERC).
Rural Proofing
Rural proofing is a long-standing process which requires policy-makers across Government and elsewhere to ensure that the needs and interests of rural people, communities and businesses are properly considered in the development and implementation of all policies and programmes.
Statistical Digest of Rural England 2012
The Statistical Digest of Rural Statistics is a collection of statistics on a range of social and economic subject areas. The statistics are split by rural and urban areas, allowing for comparisons between the different rural and urban area classifications. The Digest includes high level statistics which present an overall picture for England.

17. Questions? Then an exercise