The lay of the land

08 February 2019

Community practitioners working in remote and rural areas face a rather different set of challenges from those in town. Journalist Radhika Holmström investigates country CP life. 

Rural iStock

Recruiting and retaining health visitors is hard enough across the UK, but the problem is even more acute in the rural areas of the UK. The announcement that Scotland’s health visitors have been agreed a new job description and pay scale, making them eligible for Band 7 funding, has been widely welcomed. Given Scotland’s thinly spread population outside the big cities, it should particularly assist in recruiting skilled practitioners to work in rural areas. In fact, across the UK, health visitors, community nursery nurses and school nurses are working in remote and/or rural communities. What are the specific challenges and rewards encountered, and what lessons for other CPs?

The rural perspective

NHS workforce planning lacks a ‘rural component’, says the study Rural workforce issues in health and care from the University of Birmingham and Rose Regeneration (2018). A report from the Local Government Association (LGA) and Public Health England (PHE) the previous year also indicated that ‘national models of service delivery tend to be based on urban/semi-urban settings and are less likely to consider or test delivery in sparse rural areas’ (LGA and PHE, 2017).

‘You have to be quite creative and inventive in using a policy designed for inner-city Glasgow and creating an equal service in areas where people can be very hard to access,’ says Queen’s Nurse Clare Stiles, team leader for child health in Shetland. ‘But,’ adds fellow Queen’s Nurse Keri Rutter, school nurse for NHS Shetland, ‘just because you’re in a small school on one of the smallest islands doesn’t mean you don’t have the same needs as a child in an inner-city school. We have exactly the same social problems happening in Shetland as anywhere in Scotland but not as high figures, so that we don’t necessarily have the specialist services locally.’

Getting from A to B

‘Transport issues are massive,’ says Professor Philip Wilson, director of the Centre for Rural Health at the University of Aberdeen. The most acute examples are of course on remote islands, which may require a whole day’s journey involving ferries, long waits and an eye on both timetables and the weather forecast – but others are in quite unexpected areas. ‘Some of the practitioners in my area have huge rural areas to cover,’ says Jane Beach, lead professional officer at Unite.

Ginny Taylor, head of children and family services at Southern Health NHS Foundation Trust, adds: ‘Hampshire includes the New Forest, which is a national park with a speed limit of 20 to 30 miles across the whole of it. From a staffing point of view, teams have to add additional timing to their journeys, and from April to September the area is also full of traffic because it’s so popular with tourists.

‘The reality of being able to schedule a caseload of people a day is completely unrealistic’

‘I think the ways of working are fundamentally different, because the reality of being able to schedule a caseload of people a day is completely unrealistic,’ says Dr Rachel Rahman, director of the Centre for Excellence in Rural Health Research at the University of Aberystwyth. ‘It’s much more about how to schedule travel most effectively.’ Rachel’s team, for example, is based in the child health department of the local community hospital, with regular drop-in services at local schools and other travel scheduled when needed. ‘We have to be practical about where the children are and where the biggest need is.’ At the same time, public transport is often very poor, so clients cannot access clinics or other groups easily.

Travel poses other potential problems too, Jane adds. ‘Within the commissioning process, it’s determined how many visits and contacts a person should have per day, which can put people under tremendous pressure. It’s also costing them, because there is a cut-off for mileage payments.’

‘Obviously, lone working is an issue too,’ says Dave Munday, lead professional officer at Unite. ‘People need appropriate systems for knowing where staff are if they’re not back in time, how they can raise the alarm and so on.’

Rural practice also requires dealing with people who live in small communities. For CPs, that also means they may do at least some of their work in the village where they live; they are personally as well as professionally involved with clients and parents.

Again, there’s a positive aspect to this, as most practitioners agree. ‘In general, rural communities tend to be more tolerant and accepting and forgiving,’ Philip explains. ‘People get to know you very well, and the other side of the coin is that people are more likely to accept you; you’re in a somewhat less hostile environment than you could be in an urban centre.’

But the lack of privacy has implications for the clients too, points out former school nurse Angharad Jones, who is currently seconded to Rural Health and Care Wales: ‘If you’re a young person, you want to access a particular service and you’ve drummed up the courage to go to a clinic, there’s always the chance you may know someone there, and that can put people off.’

Making a go of it

Inevitably, the crisis in staffing and recruitment has its own particular twists in rural areas. People have to think about finding jobs for their partners, and about schooling for their children, in areas where there often isn’t much choice over either.

‘Sometimes people apply for jobs after a great holiday in the area and find that the reality is very different,’ says Susan Russel, lead nurse for health visiting at Highland Council.

Clare Stiles adds: ‘If going to the opera is important, you’re not going to manage that on a regular basis. You’re not going to a premium supermarket for ready meals. There are days when the freight boat doesn’t get in, and there’s very little of the fresh vegetables you’re after.’ And indeed people who have to travel long distances have to be prepared to stay over if the return journey is impossible.

Country Living for CP's

Rural challenges

  • Professional isolation

  • Transport problems

  • Access to signal and/or wi-fi

  • Personal isolation

Rural rewards

  • Close-knit communities

  • Professional autonomy

  • Easier working with multiple agencies

  • Personal fulfilment

Adapting at work

One approach is to organise staff into local teams or ‘hubs’, as for instance happens in Northumberland, and with the North Somerset Community Partnership’s team of health visitors. ‘The locality teams flex their provision according to the needs of their communities,’ explains Karen Herne, senior public health manager at Northumberland County Council.

Another approach, which practitioners repeatedly flag up, is flexibility and a degree of more ‘generalist’ working. ‘Services may be delivered by one person rather than a team,’ says Angharad. ‘That puts a lot of emphasis on that practitioner, because they have a lot of responsibility and autonomy, which can of course be quite rewarding in terms of professional practice.’

Rachel adds: ‘Efficiency in the urban setting means delegation; in the rural, it’s more joined-up and saves someone else who may be in a completely different role.’

In addition, Susan explains: ‘You have to be resourceful about travelling and think about joint services and travel sharing: for example if you need to visit a family on an island – which can be a whole day visit – nurses have to think about what other contacts they can make while they are there, especially where they have dual roles such as health visitor/school nurse, in order to make the most out of a trip.’

There are other ways of thinking flexibly too, Ginny points out. ‘For the school immunisation programmes, we’ve devised a scheme of hiring vans which fit three members of staff and all the paperwork and equipment; they can unload at the school and they have a much better experience for everyone. They can travel together, take everything in one go, and they’re not lifting and carrying things.’

‘It’s about having that ability to take an overview but also to step in and support colleagues,’ says Clare Cable, chief executive of the Queen’s Nursing Institute Scotland. ‘It’s about being able to look at the breadth of need of children and families and bring a whole range of skills to that, and being able to call on additional support when you need it. Remote and rural practice in particular requires that, and it’s what the practitioners are so good at.’

Remote working

Another area where rural practitioners have their own expertise is in remote working – always allowing, of course, for the technology to work (getting a connection can be very difficult in some areas).

‘In many ways these practitioners are leading the way in terms of how we supervise staff and get expert advice and/or joint consultations with practitioners,’ says Clare Cable.

‘We’ve used videoconferencing for years to keep us up to date, and we recently introduced a secure system where people can ask for an appointment and have a face-to-face appointment with a school nurse – pupils can do that directly – or OT [occupational therapist] and physiotherapist,’ Clare Stiles explains. Health visitors are also exploring using videoconferencing when home visits are difficult.

It helps professionally too. Good supervision is even more important for practitioners who may have no immediate peers, and digital technology is augmenting face-to-face supervision sessions and the professional forums which bring scattered professionals together.

The positives

It is easy to focus disproportionately on the downsides of rural working. Yet there are also huge upsides.

‘We are a small team, and we can pick up the phone and talk to each other personally. We know the schools, the police and the social workers; we’re all small teams and multi-agency working is much easier,’ says Clare Stiles.

‘And we’re not just working here, we’re living here as well. On my way to work every day I might see killer whales, otters or wild Shetland ponies. It’s very beautiful. There’s very little crime. When I first came here with my husband we loved it, but we said we’d be here for two years… and 25 years later we are still here.’ 


Image credit | iStock



Local Government Association, Public Health England. (2017) Health and wellbeing in rural areas. See: 
https://www.local.gov.uk/sites/default/files/documents/1.39_Health%20in%20rural%20areas_WEB.pdf (accessed 22 January 2019).
University of Birmingham, Rose Regeneration. (2018) Rural workforce issues in health and care. See: https://www.ncrhc.org/assets/downloads/20181012_Rural_Workforce_Issues_in_Health_and_Care-min.pdf(accessed 22 January 2019).

Subscription Content

Click To Return To Homepage

Only current Unite/CPHVA members or Community Practitioner subscribers can access the Community Practitioner journals archive. Please provide your name and membership/subscriber number below to verify access:

Membership number

If you are not already a member of CPHVA and wish to join please click here to JOIN TODAY

Membership of Unite gives you:

  • legal and industrial support on all workplace issues 
  • professional guidance on clinical and professional issues 
  • online information, training and support 
  • advice and support for all health professionals and health support workers
  • access to our membership communities 
  • CPHVA contribution rate is the Unite contribution rate plus £1.25 per month 

Join here https://www.unitetheunion.org/join-unite/

If you are not a member of Unite/CPHVA but would like to purchase an annual print or digital access subscription, please click here