All patients in the NHS are entitled to high-quality care. This should not depend on the geographical accident of where they happen to live.' So said health secretary Frank Dobson in his foreword to the government's quality mission statement, A First Class Service.
But last week he was presented with some stark facts by people who 'happen' to live in the countryside. Around 83 per cent of them have no resident GP, 91 per cent no dental surgery and only one per cent have easy access to a community hospital.1
The message for Mr Dobson, who was guest speaker at a forum on rural health, was that country people are at a distinct disadvantage when it comes to accessing healthcare.
The event was staged at the Royal College of Physicians in London by the Institute of Rural Health, and Rural Voice, an alliance of national organisations representing country communities.
Mr Dobson began with assurances that the health of rural communities had always been one of his 'obsessions'. And he pointed out that it was at his insistence that the rural areas of Northumberland and north Cumbria were included in the first round of health action zones.
He continued with a spirited defence of the community hospital, which he said had a rosy future, thanks to developments such as telemedicine. He criticised those who are still wedded to the idea of larger and larger units, singling out the Royal College of Obstetricians, who he accused of engaging in a 'search and destroy mission' against smaller maternity units.
Mr Dobson said he wanted to save as many small hospitals as possible, explaining that was why he reprieved four units in Cornwall. 'I am not promising every small hospital will be kept open, but short-term considerations now should not lead to us having to rebuild these units in a few years' time when the new technology really gets going. That would be quite absurd.'
He stressed that joint working by health and social services was nowhere more important than in rural areas, and he hoped pooled budgets would help make this a reality. In some places it would mean the NHS providing services which in other areas might be provided by social services, and vice versa. 'I don't give a stuff about who provides it, as long as someone provides it,' he declared.
During question time Mr Dobson was asked whether he agreed that rural areas did not always get their fair share of resources because of their 'leafy, green and wealthy' image.
He denied that the government concentrated resources on urban areas. He said there was 'a statistical problem' and that many decisions about resource allocation were based on averages. 'Take the county of Northamptonshire. Mr Heseltine's house wipes out 43 slum cottages.'
Asked whether the Department of Health had any plans to develop a research programme on rural health issues, Mr Dobson took a swipe at the 'pointy- headed academics' he has castigated in the past. 'My approach is there have been too many research programmes... Some were badly done and others were stuck in filing cabinets. I'm cutting back on all that.'
He said he believed what was needed were practical policies and he would rather give 'a couple of bob' to a rural GP to do something than employ six researchers. 'My view is most of what we need to know about health problems of rural areas we know already.'
But this view was challenged by other speakers. Leicestershire community health council chief officer Philip Sturman said: 'There is not a lot of research on best ways of doing things in rural areas. We don't have the evidence.'
IRH director and mid-Wales GP John Wynn-Jones called for more subtle indicators which accurately reflected the needs of rural areas. He said the normal measures of poor health, such as prevalence of disease and mortality rates, appeared to make rural areas look healthy while concealing pockets of ill health.
Other themes to emerge included the huge impact primary care groups are likely to have on rural health, with who sits on their boards a key issue.
Cumbria GP Jim Cox said he feared that PCGs would be dominated by urban people because those living in peripheral areas would not be able to give up the time to travel long distances to meetings.
Dorset Community trust chair Professor Mike Schofield said it was important to dispel the myth that the countryside was all cream teas and thatched cottages. Bournemouth has four of the 50 poorest wards in the country yet the authority was 'actively discouraged' from putting in a bid to be a HAZ.
The issue of resources cropped up several times, with calls for the government to take into account the increased cost of delivering healthcare in rural areas.
But the day ended on an upbeat note, with Dr Wynn-Jones declaring: 'We have been banging our head against a brick wall which looks like it's going to give way at last. Rural health is finally on the agenda.'
1 Rural Development Commission. Survey of Rural Services. 1997.