By: Caroline O’Neill, Head of Community Support and Partnerships, Community First Yorkshire; and Julie Lawrence, Former Project Manager, South Hambleton and Ryedale Primary Care Network
Improving rural access to healthcare in North Yorkshire
A partnership of voluntary, community and health organisations set out to improve access to healthcare and wellbeing services for three rural communities in North Yorkshire by exploring specific solutions tailored to the needs of local communities.
North Yorkshire is predominantly (85%) a rural area and is the largest rural county in England. For residents, this means access challenges that are particularly felt in later life – such as reaching GP and hospital appointments. Public transport is sparse, taxis are expensive, and local community transport mainly consists of volunteer drivers using their own cars and with precarious funding, making it difficult for people to travel to hospital appointments and access the healthcare they need:
‘It’s not just the case of a missed appointment or two: for older people, missing appointments can have life-altering consequences, like acute health problems or the need for social care. This goes beyond individuals, and places strain on the health system. When patients miss appointments, it can present operational challenges, like lower uptake of screenings and appointment backlogs.’
The North Yorkshire Clinical Commissioning Group (CCG) reported 29,508 ‘no-show’ appointments in 2019 at an estimated cost of £885,240 in lost consultation time, which is significantly higher than in other areas. Similarly, cancelled appointments at short notice create a significant cost for community transport providers: ‘Distance equals delay in accessing health and care services’.
Rural residents face higher costs and greater difficulty accessing specialist and emergency services, and the distances cause delays in access to healthcare – increasing the health inequalities faced by rural communities.[2] James Cook Hospital lies outside the county, in Middlesbrough, and is the largest in the area with a 24-hour A&E department and specialist services, which communities need to access regularly: ‘For many residents and patients, the journey time can be as long as two days for a round trip, when the national average is 60 minutes’.
We were very aware of the scale and the range of complexities and challenges from both sides, and we felt compelled to bring partners together across the health and voluntary sectors to strengthen the ties between us, and work together to improve access to healthcare and wellbeing services for residents.
Who was involved?
We are a cross-sector group with Community First Yorkshire, Hambleton Community Action (HCA), Nidderdale Plus Community Hub, Next Steps, Pickering Medical Practice, North Yorkshire Council, Healthwatch North Yorkshire, Humber and North Yorkshire Health and Care Partnership, and the MoorsBus, working together to develop workable models to improve access to healthcare appointments and wellbeing services.
In February 2022, we reached out and brought together cross-sector stakeholders, including voluntary and community groups, community transport, ambulance services, service users, GP practices, Primary Care Networks (PCNs), hospitals, leads in the Integrated Care Partnership (ICP) and Board (which were all still being formed at the time) and service users to understand what is essential for patients and people in the community when they think about transport for health and care, including safety, cost, accessibility, comfort, navigation and communication about available transport options.
We selected three neighbourhoods with known access difficulties that were also home to organisations keen to be involved and interested in looking at a range of solutions: Hambleton and Richmondshire, Nidderdale, and North Ryedale. The emphasis of this work is on people with existing inequalities and challenges accessing health and social care interventions or activities, lack of advocates in the community and/or lack of a support system, all of which were affecting their access to healthcare.
What did we do?
Our workshops brought together people from the community and staff across the health and voluntary sectors to scope out how to access healthcare. We aimed to design models that would improve the situation. To be effective, each needed to be designed in a way that would work at a practical level.
The first workshop in February 2022 was a virtual meeting with more than 60 attendees. Later workshops took place in familiar local venues, such as village halls, to ensure residents from the local areas could attend. These workshops usually had about 20 attendees, including three to four service users.
Our workshops were structured but informal. Throughout our conversations, one regular activity, ‘Wouldn’t it be brilliant if …’, enabled people to imagine solutions without parameters. For example: ‘Wouldn’t it be brilliant … if rurality was recognised as a health inequality and every policy or plan had to be rural-proofed for our communities’.
Later activities were more action-oriented, exploring barriers to change – such as a lack of clarity about who to phone for community transport. People were very realistic about what was possible, and not all of the ideas required money: it was more about changes to how we all work together, talk to one another and support people.
Examples of barriers to accessing healthcare
Not everyone meets the threshold for the ambulance service to pick them up. Those who do might be charged £40–80 and some use ambulances several times a week. People were unsure how to arrange other forms of community transport. Where people knew how to access transport, appointments provoked high anxiety levels due to the complexity of making these arrangements.
In Hambleton and Richmondshire, we focused on transport integration through expanding the existing Hambleton & Richmondshire Rural Transport & Access Partnership[3] (RTAP). We revisited volunteer involvement; communication and coordination for transport users by working with GP surgeries and others, for example trying to group non-urgent appointments and bringing integrated services to communities.
In Nidderdale, we integrated community patient management, by developing a closer working relationship with Harrogate Hospital and the Volunteer Manager at the hospital, for better transfers of patient care from community transport drivers and for appointment grouping, exploring how community transport can benefit services and the people using them.
In North Ryedale, we took services into communities, exploring volunteer-led digital access and digital consultations at local hubs, by expanding the conversations and wider engagement in the existing Community One Stop Hub.
Overall, ‘the culture was one of openness and making sure everyone had an equal voice. It was very professional but still informal’. We didn’t start with preconceived ideas – it was very much driven by local conversations, with each community focusing on areas they were interested in and building on their existing connections and work. After all, it was local people and local groups who would be making things happen. We’ve seen this energy and ambition create a difference:
‘What gave me most pleasure is the way everyone wanted to work together. Detailed practical actions and longer-term possibilities were being shared and shaped by everyone who has a part to play in the health system. We’ve seen lots of energy and ambition to create a difference.’
What’s happened since our workshops?
In North Ryedale, the Community One Stop Hub – a VCSE-led centre by Next Steps and Carers Plus – where local groups come together to discuss issues, has extended its services to low-level health checks. During and since the project, more PCNs have become involved, along with GP practices planning quarterly outreach clinics, and taking blood tests and blood-pressure readings at the village hall:
‘For us at the PCN [South Hambleton and Ryedale], we’re seeing a definite shift in the way the NHS is working. The collaboration we saw in this project – alongside new roles such as social prescribers and wellbeing coaches – is making primary care more connected with our communities.’
‘For us at Next Steps, our key learning has been around how to target this to work, i.e., bringing in the right people and managing the logistics of doing this work well. It is also about how two VCSE organisations are working well together, playing to their strengths and having funding in place to support the work. It really shows the importance of communication and the results from the intent of working well together.’
Getting started: Building relationships and effective engagement with PCNs
- Know their agenda: PCN contracts highlight their role in reviewing their population health management data for health inequalities. PCNs have plans in place to co-design and implement interventions to tackle those inequalities. Any work that aligns with that task is their agenda and they’ve been keen to work with organisations/models trying to improve health for their population groups.
- Understand the budget available: Given the current situation with budgets, the key is to ‘work cleverer and smarter and better together, rather than work with/ wait for new resources for new services’. It is important to establish better ways of working together.
- PCNs are keen for collaboration: Knowing their role in primary care and needing to work with various population groups through Healthwatch and other VCSE organisations, PCNs are keen to work in partnership and to support existing services ‘rather than set-up new shiny services’.
- Have a clear action plan: Having ready plans for funding from the ICB can help, i.e. have data/tested models and have action plans that tackle inequalities ready for discussion.
Some Frequently Asked Questions (FAQs):
- How can we know who the key players are in our area? Speak to someone who manages PCNs and ask who in the PCNs are the right people to speak to. It might not be the Practice Manager or Clinical Director, but someone who has a more strategic role.
- How can we develop ways to share knowledge between PCNs and us? Develop relationships with key contacts who have strategic roles, so that knowledge, feedback and insight between VCSEs and PCNs can be shared.
- What do we do when the person we have built a connection and relationship with leaves the organisation or their role? ‘Rebuild the connection with the new person!’ – if there is a handover period, meet the two people together (the one who is leaving and the one taking over their role).
In Nidderdale, we have developed better links with the hospital to make transport run more smoothly. For example, ensuring that someone is available to take the person to their appointment and, if they do, that there is somewhere to park. Nidderdale Plus is delivering a pilot around the provision of adult social care with a community element, focusing on stronger community links to support and recruit local carers. It explores how to embed a transport element within this to enable people to access the care and support they need easily. Alongside this, we have a Digital Champions Project with regular outreach sessions, called Coffee, Click and Connect, based in village halls where people turn up and get help to go online, to improve their digital skills to use devices they have been given, and to build their confidence to access online appointments from their homes.
In Hambleton and Richmondshire, we are looking at extending the rural community transport model, alongside working with PCNs to explore the clustering of appointments led by HCA. HCA has also started exploring ways to bring services to communities via monthly hubs (with six place leads and six thematic providers) to improve people’s access to health and wellbeing services. HCA is also doing a research piece engaging with social prescribers, mental health practitioners and others to explore their transport priorities, and also try and understand PCNs’ transport priorities.
What did we achieve through working in partnership?
Overall, the work in North Yorkshire has raised the profile and importance of working together to have alternative ways of easing access to health appointments, including the need for closer engagement with transport providers, particularly community transport.
It has showcased the breadth of VCSE sector activity (and its role in health and wellbeing in communities) to various partners on the steering group and in workshop sessions.
Three models developed: As each of the three areas chose its approach, different models are now emerging. These add value because they produce three learning areas that can be tested and applied elsewhere, with potential for growth.
Better access to health and care services for patients: We have been able to inform the right patients about the right services in larger numbers, rather than one-to-one, and ensure that services are designed to suit patient needs. One unintended benefit has been reduced isolation when people travel to appointments or services together:
‘A lot of people using community transport are fairly isolated, so an unintended consequence is that it is focused on bringing people together and supporting one and other, especially when they are in quite a vulnerable situation.’
Power of word of mouth: Not just between partners but also between people where the work is happening in the areas that have been supported. For example, other areas are already adapting the approaches for their own needs. At one event held in Hambleton and Richmondshire, local authority representatives from nearby Craven District attended and have since set up a similar group there.
Motivated colleagues continue to make changes and work in collaboration with partners: The project has forged a more joined-up partnership approach, building new relationships between PCNs and local organisations and a better understanding of each other’s priorities. Over 100 colleagues, patients, and system leads have been involved in this work and it has influenced peers and the whole system to work together:
‘It is not easy doing this alone, and this programme has helped recognise the potential and encouraged people to keep trying and not give up, which is really powerful. There was a real enthusiasm from all involved to move towards the “wouldn’t it be brilliant if” ideas.’
Next steps: The NHS is considering providing longer-term funding for community transport, recognising that this may help ease hospital pressures. The steering group will continue to meet. Now that new connections have been made, the plan is to continue to work together. In a period of system evolution and change, the connected approach is fundamental and provides a basis for collective responses to the peaks in demand for NHS services. It means the core people central to this initiative will continue collaborating, irrespective of who they work for.