The debate about the future of England’s hospitals naturally focuses on what is happening in the big cities.

But in rural areas the specific demographic and geographic challenges mean a different set of solutions are being explored which will also have major implications for how many people will experience healthcare.

Most significant is the rejection of the centralisation of specialist services, which is driving so much acute reconfiguration in built-up areas.

This week’s HSJ Local Briefing examines the strategy being adopted in Cornwall. A centralised model would leave some patients facing 70-mile round trips. The county is now exploring an approach which would see some elective services delivered in community settings.

The Cornish model is attracting interest throughout the South West, noticeably from Weston Area Health Trust, which needs a new modus operandi to guarantee future sustainability.

Elsewhere across the region, trusts are increasingly looking to cooperation to avoid the kind of closures and service shifts that would leave many towns and villages poorly served.

Royal Devon and Exeter and Taunton and Somerset foundation trusts have entered the early stages of courtship.

Taunton is already working with Weston on emergency care, with Yeovil District Hospital FT on pathology and with Northern Devon Healthcare Trust on vascular services.

These “networked” service structures are not straightforward to implement, not least because it is not clear how they would work within the current payment by results system.

But most importantly, commissioners will need to be convinced of the appropriateness of the model and Monitor that it does not undermine competition to the detriment of patients.