The first cottage hospital has closed despite Labour's pledge to retain them. Patrick Butler reports

The doors shut on nearly a century of care at Horncastle War Memorial Hospital, Lincolnshire, last week, just months after the government pledged in its New NHS white paper to support community hospitals.

It is the first cottage hospital to close under the present government. And while it may not have the symbolic power of a Bart's, it crystallises a growing feeling that rural areas are losing in the share-out of healthcare resources.

'The NHS in rural areas will cease to exist at this rate. Everything is being sacrificed on the altar of biggest is best.

We are being disenfranchised, ' says Trevor Butterworth, chair of Horncastle Hospital League of Friends.

The closure has embittered the local community. From the heart of rural Lincolnshire rises a groundswell of the kind of anti-metropolitan resentment that fuelled the recent countryside march.

'All this talk about providing a better service for the people of Lincolnshire. . .

The consultation was a cosmetic exercise. It was a case of 'We have written the minutes now let's have the meeting', ' says Mr Butterworth.

'We have been to see (health minister) Alan Milburn. He wrung his hands and said he was concerned, but then said he could do nothing. It's no good, we are up against the bean counters and the men in grey suits.'

This disillusionment is not confined to tiny Horncastle. The Community Hospitals Association estimates that around 20 NHS cottage hospitals - around 5 per cent of the total - are under threat of closure.

Labour's electoral success in some rural areas may have been based on the assumption that cottage hospitals would be saved. Other community units - including Horncastle - have come under threat since Labour took power.

This despite a pledge from Labour that community hospitals, often saved from the health authority axe by GP fundholders, will not be marginalised because primary care trusts will be able to run them.

'Too often in the past community hospitals have been sidelined. Their potential contribution to managing the pressures of rising emergency admissions has been ignored, ' says the white paper.

It continues: 'Patients will be able to use local community hospitals to the full rather than having to travel to more distant acute hospitals. This will be particularly significant in rural areas.'

But primary care trusts will not appear until 1999, by which time many community units may have shut. For this reason, says CHA chairperson Helen Tucker, there should be a moratorium on closures. 'There are lots of GPs who are calling for a delay. They are saying: 'We are the ones who may be purchasing in the future and we may want to use this hospital', ' says Ms Tucker.

The arguments deployed by the Horncastle campaigners are familiar, ranging from the sentimental ('built by public subscription to honour the war dead') to the persuasive (poor public transport means access to general hospitals 20 miles away is difficult, particularly for elderly people).

Lincolnshire HA's counter arguments are also familiar: replacing hospital services with care at home is more efficient and clinically effective; most inpatients already go to general hospitals; access is not critically difficult.

The key factors, though, are the twin banes of rural services: cash and clinical quality. On paper, Lincolnshire does not have enough of either. The HA has a financial deficit of up to£6m; at the same time many of its hospital departments do not meet royal colleges' standards.

Richard Banyard, project director of Lincolnshire HA's service review, says there are 10 hospitals (including three DGHs) in Lincolnshire, supporting a population of 500,000.

This apparent over-provision has to be weighed against the size and sparsity of the county and the access needs of the population.

The royal colleges complicate the equation. In obstetrics, for example, two out of the three departments from which the HA purchases do not have the required number of cases. The same figures apply to paediatrics.

Of eight casualty departments, only one meets the 'critical mass' standard of 35,000 annual admissions. The cost of providing community nurses, or of maintaining buildings, is also higher than in urban areas, factors Mr Banyard argues are not reflected in the resources allocated to the HA.

'We have been pushing the claims of sparsity and rurality for quite a long time. It is the case that the extra money we need to continue the number of buildings we have got is not met by central revenue funding.'

But Peter Smith, professor of economics at York University, who helped construct the government's NHS resource allocation formula, is sceptical that the countryside - aside from perhaps island areas - is a special case.

'We could not find any evidence that rural areas had special healthcare needs that would not be accounted for by the usual indicators such as poverty and deprivation, ' says Professor Smith.

Mr Milburn has made it clear that there will be no grand blueprint for rural areas. 'It is a question of horses for courses. . . there are differences between rural and urban areas, but not all rural areas are the same, ' he says.

'We must take into account whether any change in local health services will improve care for patients - that is the bottom line. . . there is no exception for community hospitals.'

10 issues for rural healthcare

Variety: It is not possible to develop a uniform solution for rural problems as communities and their needs vary widely.

Access: The decline of public transport makes car ownership crucial since it may not otherwise be possible to get to hospital or even the local GP surgery.

Efficiency: Pressure to deliver efficiency savings penalises rural areas as low population densities lead to high costs per case, and to further centralisation.

Deprivation: Rural deprivation is less obvious as aggregated information on populations hides small pockets of intense poverty.

Knowledge: There is little research on rural health issues, but some studies suggest the further people live from hospitals the less they use them.

Older people: Transport problems are especially acute for older people, and are exacerbated when there are many older people in a rural community.

Technology: New technology may help by making information and expertise readily available, and by reducing the isolation of carers and service users.

Costs: Healthcare providers in rural areas face higher costs, particularly when income is calculated on the basis of the number of patients seen or treated.

Service models: Skill requirements may differ for rural areas, where a higher level of generalist skills and more mobile services may be appropriate.

Mental health: There are rural dimensions to mental health, alcohol and drug problems which may not be reflected in models based on urban experiences.