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Healthcare in Rural Areas

Volume 827: debated on Thursday 23 February 2023

Question for Short Debate

Asked by

My Lords, I am delighted and grateful to have secured this debate this afternoon and I look forward to contributions from other noble Lords across the Committee, especially my noble friend Lord Evans in summing up. I draw attention to my entry in the register, my work with the Dispensing Doctors’ Association based at Kirkbymoorside in North Yorkshire, and to the fact that I am a proud daughter and sister of dispensing doctors. I also sit on the Rural Affairs Group of the Church of England General Synod.

I pay tribute to all those who deliver health and social care in rural areas: doctors, nurses, carers, pharmacies, paramedics, and community hospitals—where they still exist, such as St Monica’s in Easingwold and Malton Community Hospital. I thank all those in the NHS for their help with my recent injury, from the accident and emergency department through to orthopaedics. I am hugely grateful for the care provided.

One-fifth of the population live in remote, rural and coastal communities. This amounts to 9 million people, more than the population of Greater London, yet at present there is a stark disparity in the care and services available. Undoubtedly, the cost and challenges of delivering healthcare in a rural area are markedly greater than those in urban areas, and I question the extent to which this is reflected in current policy decision-making. For example, is the policy tool of rural-proofing used by the department and NHS England? There was a very useful report on this by a committee of this House chaired by the noble Lord, Lord Cameron of Dillington, in 2016. I have not yet seen any evidence that those recommendations have been acted on.

Similarly, last year the All-Party Group on Rural Health and Social Care published a report that has a wealth of recommendations on how to improve the provision of services to patients. It has to be asked: why have the Government failed to act on any of its recommendations?

In the past, rurality and sparsity of population used to be reflected as criteria in health spending, but that is no longer the case. Many remote, rural and coastal GP practices are permitted to dispense medicines to their patients for the simple reason that there is no community pharmacy within a reasonable distance. The department’s cost of service inquiry from 2010 demonstrates that the income from dispensing cross-subsidises the general practitioner service.

Dispensing practices are under the same cost pressures as their community pharmacy colleagues, buying their medicines in the same marketplace. Despite this, the recent changes to the system of drug reimbursement in pharmacies have not been reflected in the dispensing doctor contract. A recent example was the spike in chickenpox cases, where penicillin was to be issued to all children, but my understanding is that rural practices were not properly reimbursed for the cost. I hope that my noble friend Lord Evans will take this opportunity to revisit that.

In addition, there are barriers such as poor connectivity for both broadband and mobile signals. How widely is it known that electronic prescription services cannot be delivered in rural areas by dispensing doctors for this very reason? Similarly, remote consultations to patients and other telehealth innovations are unable to be delivered. I was disappointed that in the exchange at Oral Questions earlier today my noble friend Lord Markham seemed unaware of this problem in remote rural areas. The problem is seen not just in health. When we have the influx of population in all the beauty spots represented by the Members of the Committee today, tourists often rely on mobile signals if their car breaks down or if they are involved in an accident. This needs to be addressed as a matter of urgency. I applaud the investment that the Government have made and the work of local authorities such as North Yorkshire County Council and others, but it is the last 3%, 4% or 5% of deeply rural, remote and isolated areas where we have not yet got full connectivity either for mobile phones or broadband.

I am grateful to Alzheimer’s UK for alerting me to the clear irregularities of dementia diagnosis in rural areas, with the consequential effect on the care and support that families can access. I therefore urge my noble friend to level the rates of dementia diagnosis across rural areas, allowing those living there faster and more equal access to the essential care and support that they and their families desperately need.

I want to raise the role of NHS England in this regard, which is clearly undermining the role of GPs and demoralising practitioners and therefore patients. The level of micromanagement is breathtaking. It has removed all the regular interface that GPs would normally have with patients in rural areas—and, I accept, in other areas as well. You can no longer access minor injuries treatment; you can no longer have your ears dewaxed; you can no longer have a routine check-up in the way a GP used to give before, giving the GP the opportunity to question patients about their general health and mental welfare.

NHS England has been asked to focus on a one-size-fits-all solution, oblivious to the fact that what may work in an urban area is totally inappropriate and cannot necessarily be delivered in a rural one, across a highly isolated, sparsely populated, deeply rural area with, in addition, many elderly patients with a number of comorbidities. This level of micromanaging is inappropriate and must cease, and clinicians must be allowed to decide on treatment.

At its inception in 1948, the NHS was set up to be universally available to everyone, free at the point of delivery and based on clinical need and not the ability to pay. My father was one of the very first practitioners, commencing his practice in 1948.

Equality of access was reflected in the more recent NHS constitution. As I referred to earlier, the APPG report on rural health called for levelling up between rural and urban areas and removing impediments in rural areas such as lack of workforce capacity and poorer access through inadequate transport, leading to the inequalities of outcomes for patients which it identified.

I regret that, at the moment, the Government seem blind to the challenges of delivering healthcare in rural as opposed to urban areas. I hope that the contract about to be negotiated will provide an opportunity to revisit this issue and ensure both that there is a better balance between primary and secondary care spending and that rural areas are identified as a priority. I urge my noble friend the Minister to use his good offices, through today’s debate, to address the issues before us; to ensure delivery of universal healthcare across the country, delivering in rural as well as urban areas; and to reduce the health inequalities for those of us who live in rural areas. I beg to move.

My Lords, I thank the noble Baroness, Lady McIntosh, for obtaining this debate. She is a powerful champion for these issues; we are grateful that she continues to raise them. I also add my thanks to and appreciation of all those who work on the front line in our rural areas. They often have to drive huge distances, sometimes along quite difficult roads; it is not always easy and is certainly not always as wonderful as our memories of remote rural areas from our holidays. I declare my interest as president of the Rural Coalition.

Although many people in this country dream of retreating to the rural idyll that is deeply embedded in the English psyche, they do not always realise that, if their dream comes true, they may face many challenges in living in rural areas: poor access to banks and cash; patchy broadband; sporadic mobile signal; virtually non-existent public transport; and little childcare. Then, of course, there is the topic we are exploring today: the stresses on the healthcare system, which is primarily and unsurprisingly designed for an urban context. Rurality faces a unique challenge in the delivery of healthcare, demanding that the Government adopt a clear strategy for improvement. I welcome His Majesty’s Government’s promise to rural-proof our healthcare system; my hope is that that promise will be able to deliver what is needed.

Rural areas are home to significantly older populations than those in towns and cities, with a quarter of England’s rural population aged over 65—and that figure is due to rise. An older population exacerbates the difficulties of delivering healthcare in rural areas because those people are much more likely to require higher levels of intervention and support. Although many rural areas have a strong sense of community—it is often much stronger than in urban areas—there is nevertheless the challenge of isolation. More than 1 million older people in England suffer from persistent, chronic loneliness as they are cut off from wider society. As a consequence, rural areas face a significantly higher rate of hospital admissions for alcohol-related harm and self-harm. Put simply, mental health issues are exacerbated in rural areas.

Fortunately, in many rural areas, such as some of the villages and communities in Bedfordshire and Hertfordshire that I serve in my diocese, there are all sorts of active churches and charities working on the ground. They visit the lonely and offer support and practical help. However, they are not in a position to offer the professional care that is required. We therefore need the Government to develop and fund a comprehensive, universal rural healthcare strategy that is fit for the future. The Rural Services Network has found that rural residents receive 14% per head less in social care support overall. I therefore ask the Minister what assessment he has made of the gap in social care funding between our urban and our rural areas. Will His Majesty’s Government take any steps to close it?

It is not just social care that suffers from lower levels of funding. The Rural Services Network also noted that the NHS receives less funding per resident in rural areas despite the unique challenges that they face. With an older population, higher levels of mental health problems, issues with connectivity and poor access to services, it is clear that those areas need more support, not less. As His Majesty’s Government rightly noted in their report on rural-proofing England, we need to pursue innovative solutions to those challenges. Just throwing money at them is not enough to tackle the structural issues that we face; we need to bring all the parties together to work out how we can address them.

Improving rural infrastructure will help people to get the help they need. Going to the doctor or the pharmacy should not be a difficult task, but currently many people rely on expensive transport or on taxis, and it is not easy.

Finally, it is important that we work to recruit and retain a workforce of healthcare professionals in those areas. Those who work on the front line know that this is not easy. Life in the city has its benefits: higher wages, greater access to services and a faster pace of life. It would be helpful if programmes to help people return to work were as flexible as possible and part-time jobs were available. What are the Government doing to attract carers to work in rural areas and, indeed, ensure that they want to stay there?

I look forward to hearing from the Minister the plans His Majesty’s Government have to support this vital part of our healthcare system.

My Lords, I thank the noble Baroness, Lady McIntosh of Pickering, for securing this debate and for overcoming her injury to make it in today. I put this issue of rural healthcare out to Green councillors around England. What I got back could be described only as a flood of concern.

We have heard an overview from the first two speakers. I will narrow down largely to one county, Shropshire, which is one of the most rural counties in England, with a population of 323,000, around a quarter of whom live in Shrewsbury. The rest are widely dispersed across small market towns and rural areas. As the right reverend Prelate noted, 23% of the population are over the age of 65, compared with the English average of 18.5%.

Public transport is often simply non-existent. The NHS’s own figures state that 45,000 people live 30 minutes or more away from a GP practice by public transport. It is clear that access has got dramatically worse in recent years.

Rural healthcare is often seen as inefficient. In Shropshire, it is centralised at either the Royal Shrewsbury Hospital or Telford’s Princess Royal Hospital. This is undoubtedly cheaper for the NHS, but the cost is transferred to individuals, who might simply not be able to bear that cost or might encounter barriers they simply cannot overcome. Cost, age, disability and a lack of transport lead to people either seeking healthcare later, which greatly increases costs to the NHS in the long run, or simply deciding to go without, with significant social, personal and economic impacts.

In many cases, services have simply disappeared. Cardiology outpatient appointments, including diagnostic tests, used to be available in Shrewsbury, but recently there were centralised to Telford. That is an hour’s drive from Ludlow or Bishop’s Castle. By public transport, you need two trains, a bus and a hearty wish of good luck.

Another issue is midwife-led maternity units. There used to be a network of five of those. Closure was first mooted in spring 2016, with cost explicitly cited as the issue. There was then a period of short-term closures, often at extremely short notice—as little as two hours—so women would find out on the day they were giving birth that their expected plan for birth simply could not be followed through. It is not that there has been no reaction to this; there were very strong protests against these closures in Ludlow, Bridgnorth and Oswestry. Although the MLUs remain open as a base for antenatal and postnatal care, there is no out-of-hours service, so if a patient finds themselves with unexpected bleeding or reduced foetal movement at night, they very often have no chance to get care. You might say, “Take a taxi”, but in many rural areas there simply is no taxi available to take. So that is the reality in Shropshire.

I have just one more point to make in that area about community hospitals. We see repeated attacks on the whole concept of community hospitals, and we have seen cutbacks and further cutbacks, but there needs to be a vision for such hospitals—that is, a strategy of how they can best be used for local people and the local healthcare system, taking medium acuity patients to relieve some of the enormous pressures that the acute hospitals are experiencing and, of course, making sure that people can visit patients and that patients can remain in and be part of their communities. It is suggested that Shropshire could become a centre for training and education for rural healthcare, perhaps teaming up with Keele University to offer better services to meet local needs.

I just want to branch out briefly into a couple of other areas. We are focused on healthcare but, of course, health and social care are closely interrelated elements. I heard from a councillor in north Somerset about the huge issue in very rural areas of simply finding a carer who is available to provide care in a small village. If someone needs that care and there is one person available, it means that the patient has absolutely no choice at all in terms of the carer they receive; if it is not working out very well, there is simply no other option available.

Finally, another terribly important issue is that of the shortage of dental care. I should declare my position as a vice-president of the Local Government Association because I will refer to recent LGA analysis that shows that rural and deprived communities particular suffer from a lack of dental provision. In comparing data from January 2022 for the bottom 20 areas, a year on, we can see that only one of them had seen improvements; all the others are going backwards. Meanwhile, the areas with the best access to dental care are seeing more and more dentists opening up and offering NHS services. So we are seeing a huge displacement of services to areas where there is relatively little need, but we are not seeing services coming into the areas where they are needed. Of course, what that means is that people either forgo dental treatment or resort to DIY dentistry. That is hideous in terms of pain but also in terms of the final cost of treatment that will need to be provided by the NHS. Indeed, if the Government will not listen to any other arguments, we can again come back to the issue of economic costs. We are looking for workers but those workers are all too often too ill to be available for work.

My Lords, the Minister was nobbut a lad when I last lived in a city but I do not buy this idea that there is some kind of clash for resource between urban and rural and that rural areas somehow get the worst of it. Having been a parliamentary representative and therefore also having an obligation to live in London, I know that access to services in London is significantly worse than I have ever seen in any rural area.

I think that the issue is different. I have specific questions relating to dispensing pharmacies. I recall the 2008 consultation by the then Government, when I personally put in more than 50% of the national responses and turned over the Government to allow the system, which was crudely a subsidy of local GP services—in particular, therefore, of smaller ones in more rural areas—to maintain the dispensing. That subsidy was critical to the maintenance of the GP practice; that was my argument to the Minister of the day. It was not particularly about convenience, although there are marginal arguments there; it was about the maintenance of GP practices. Have the Government any intention of watering that down or moving away from it in any way, or does that remain guaranteed as a principle that they will actually enshrine further rather than cut away from?

My second point for the Minister is the one that I find the most unfathomable. Let me take the example of stroke care. I live in an area that is generally described as a former coal-mining area; it is not one of the wealthiest areas. Statistics can be used in many ways but, in many of the rural areas that I once represented and where I live, there is no longevity of life. Where is the use of technology?

Let us take Iceland as an example—one that I have cited repeatedly over the years to local health services in the north Midlands and South Yorkshire. Iceland has the best outcomes for stroke care in the world, by quite a degree. I do not know how many noble Lords have had the opportunity to visit Iceland but, if they have not been, they can envisage that it is incredibly rural: it takes a day to get the whole way round it. There is one main hospital, in Reykjavik. What happens when someone has a stroke? You are not going to get, in a golden hour, from any rural part of Iceland into the capital city and the hospital—it is not possible—so they use online consultation. The specialist in Reykjavik, who is available 24 hours a day and is doubtless at home, is there on the computer. This has been the system for the past 20 years. They diagnose on whether to thrombolyse and a skilled, but not particularly highly skilled, nurse of some kind then does the thrombolysis, if that is determined as the outcome. More people live; indeed, all people who have a stroke have a better outcome.

If that can be done in such a rural situation, with one hospital, why are we not doing the same in so many different areas? Let us take me as an example. I may not be a typical patient but I am not that atypical of the people the NHS is a bit worried about and advises, “Make sure you’re looking after yourself. Make sure there’s early diagnosis, otherwise you might be up for a bad time and you’re going to cost us a lot”. I am more than happy to have a face-to-face discussion. I would prefer to be able to speak to a specialist in Sheffield or London—or, frankly, in Tokyo or New York—if that is what is determined rather than having to book to see a generalist GP who can then only refer me on and try to get me to a specialist, about whom the GP may or may not have specialist knowledge about whether they are any good. That is not a coherent system.

We are not using technology in the health service. It is obvious to me that rural communities could be the biggest beneficiaries. I accept that there are issues with broadband in some areas but, frankly, even recent Governments have managed to move us on somewhat in relation to that. It would be a game-changer. If I needed to speak to my local GP, I would be happy to do it face to face, but I suspect that this would be more efficient for them. I am not saying that it should be a system for everybody, that everyone would be comfortable or want to do it or that, in every scenario, I or the medical practitioner would feel that it was appropriate, but does the Minister think that we could do far more in resource to move this forward in the next year or two?

My Lords, I begin by thanking the noble Baroness, Lady McIntosh, for securing this important debate. We all acknowledge that the NHS is operating under enormous pressure at the present time. Perhaps inevitably, publicity focuses on our inner cities but, as we have been hearing this afternoon, rural communities are also pinch points. My own county of Devon has the second-oldest population in the country. We should not underestimate the challenge, both logistical and financial, of delivering healthcare to an ageing population, particularly in coastal communities and remote rural areas.

In his 2021 report on coastal communities and their patchy provision of medical services, the Chief Medical Officer for England observed that some

“of the most beautiful … and historically important places”,

including in the south-west region,

“have some of the worst health outcomes in England, with low life expectancy and high rates of many major diseases”.

As we heard in the Chamber this morning, patients experience difficulty in accessing physiotherapy following strokes and operations. This is exacerbated in rural areas by poor and non-existent public transport. In parts of the south-west, we are finding it difficult to recruit GPs and I encourage His Majesty’s Government to think outside the box and consider adopting a salaried approach to recruitment, rather than a partner approach.

Age UK estimates that each day a medically fit patient occupies an NHS bed costs three times as much as if they were to be cared for in a nursing home. Given the age demographic of shire counties, you do not have to be a brilliant mathematician to realise that the NHS and care services are under huge pressure in rural areas. Our ageing population, with increasing levels of frailty and multimorbidity, is generating increased demand for social care at a time when capacity in the sector is shrinking, not expanding. We need to face the fact that successive Governments of all complexions have failed to grapple with the social care problem. Social care is the responsibility of local authorities but over the last 10 years it has been subject to severe cuts, so what is to be done?

One reason is that it is hard to recruit carers following a patient’s discharge from hospital because of zero-hour contracts that do not allow for transport time between sites. Devon is a massive county and it may take an hour, without pay, for a carer to travel between visits. As a result, admissions to care homes may be the only viable option, although it is the least attractive. This leads me to say two things: first, there has got to be a better deal for unpaid carers. Secondly, there is an urgent need to transform what is a low-paid, low-status workforce in the care sector into a viable and noble career.

Last month saw the publication of the report by the commission of my most reverend friends the Archbishops of Canterbury and York on social care. Entitled Care and Support Reimagined, the report identifies a pressing need for a new national care covenant that would set out the respective rights and responsibilities of national and local government, communities, families and citizens. “Covenant” has strong biblical overtones, and the commission chose it in preference to “contract” because the health of a nation is dependent on the underlying principles and values that shape a society.

The report also points to a malaise at the heart of the NHS that needs to be addressed. The greatest resource the NHS has is its staff: people matter. The unpalatable fact is that good, capable and experienced staff are leaving the NHS in droves. It takes years to train doctors and nurses, and even longer for a qualified medic to accumulate the experience that is the prerequisite of good healthcare. Older and experienced staff are burnt out and retiring early. The loss of their expertise is a national tragedy that could have been avoided. Many are exhausted by the obligation to record unnecessary data and navigate a health system that has become byzantine in its complexity. They find themselves servicing the system rather than the patient. If we are to secure a more effective delivery of healthcare in our rural areas, we need to address these challenges and, above all, give energy to raising the morale of our hard-pressed NHS and social care staff.

My Lords, we too are grateful to the noble Baroness for creating this opportunity. All health and social care services are under strain, but there are particular challenges in rural areas and it is worth some time to focus on those. I will touch on four important topics: staffing, structure, transport and digital.

On staffing, there are issues with shortages everywhere but an especial challenge with trying to attract qualified staff into rural areas. The right reverend Prelate the Bishop of Exeter referred to the idea of salaried GPs, which is one way to attract people in; it would be interesting to hear the Minister’s views on that. Another approach that I understand can work quite well is to train staff in situ—in other words, to train up people already living in those rural areas, rather than seeking to bring people in from outside.

The Times tells us that the Government are going all out on trying to come up with what are effectively apprenticeship schemes for nurses and doctors to take people already in the profession to the next level. Is that something that the Minister thinks could be particularly important for rural areas, where we have staff with some skills but can train them up to be fully qualified nurses and doctors? Of course, that would require us not to insist that they move out of those rural areas for the training; we should be willing to deliver it where they already are. Additional training is a long-term fix, and I hope the Minister will also be able to offer some shorter-term government initiatives to make sure that we can create attractive options for qualified nursing and NHS staff, in particular doctors, to move into rural areas.

On structure, I know that the Government’s response to everything is integrated care boards, and I expect we will hear that again today. It is interesting that many of the integrated care boards combine rural and urban areas. The noble Lord, Lord Mann, pointed out that there are challenges in both, and we should not necessarily see it as one against the other. I can certainly see that integrated care boards could work in both directions. It could be that by combining those areas you get a particular focus on the rural areas and much better integration of centres that tend to be in the more populated urban areas with need in the rural areas. Equally, it could work the other way; an integrated care board could look at impact on population and think, “We’ll put all the resources into the most densely populated area”. In that context, I wonder whether the Government are carrying out monitoring and research for these integrated care boards, which are a new creature, to understand the impact they are having on rural areas and whether they achieve some positive benefit in bringing together people across a community.

The third area is transport, mentioned by the right reverend Prelate the Bishop of St Albans and the noble Baroness, Lady Bennett, who said that taxis are not always there for patients. Certainly, if you have a medical emergency at the time of the school run, in most rural communities you will find that the taxi or the two taxis in your town or village are already fully booked. There are real issues for patients, but I will focus on the issues for staff and the calculation of travel times for them. As I understand it, health and care staff in the most sparsely populated areas can spend 10 times as many hours on travel as those in the most urban areas. That means that you cannot look after the same number of people with the same number of staff, because the ratio of travel hours versus treatment hours is very different.

The right reverend Prelate the Bishop of Exeter raised the issue of care staff on zero-hours contracts, and that is very relevant. I would be interested to hear what the Minister thinks of the proposal we have put forward that there should be a higher minimum wage for care staff, above the current national minimum wage. Care staff need something more to attract them into the profession. That also means looking at their contracts and making sure that travel time in rural areas is not something they have to absorb but something they are reimbursed for.

Another part of the solution to travel time is to look at where services are delivered, with more local clinics and more diagnostic centres. A lot could be done around bringing services to people rather than necessarily making people go to the services, but that has limits. It is certainly a solution when somebody needs to be on site—when they are producing blood samples or need scanning equipment that can be only in a fixed setting—but, as the noble Lord, Lord Mann, reminded us helpfully with that illustration from Iceland, other services can be delivered entirely remotely.

That brings me to my final point, where I want to touch on digital. There are a couple of issues here. First, Iceland’s system works because it has fully digitised its electronic health records. In the United Kingdom, we still have a real patchwork. To be able to deliver proper, effective digital services, we need a fully electronic national health record. However, we are some way off. I hope that the Minister can talk a little about our ambitions in that direction.

Secondly, on connectivity, again, it is about looking at specific locations. We should not generalise. We should look at specific locations and be prepared to invest where a location is missing the connectivity it needs.

Finally, I turn to digital health skills. Again, one of the differentiators for Iceland, a country I also love, is that it has invested in such skills; I learned this from a friend who is a Pirate Party MP, which says something about Iceland’s approach to digital. People understand how to use these technologies and interpret the results. Again, I hope that the Minister will have something to say about digital health skills. I emphasise the “health” part of that; digital is important but there is something specific about teaching people to use applications to do remote consultations.

My Lords, I start by congratulating the noble Baroness, Lady McIntosh, on giving us this opportunity to debate what I believe is a very important matter: equality of access to healthcare. I listened closely to the noble Lord, Lord Mann, as I always do, but for me this is not about rural versus urban. It is about saying that no one thing fits everybody. The health service is not one size fits all.

There are a lot of givens in respect of rural, remote and coastal areas; we heard them outlined today. The Nuffield Trust, which produced an important report after the pandemic, has said that the problems in healthcare were made worse by the pandemic but that it also threw up some new problems. We heard about a number of them today. Like other noble Lords, the right reverend Prelate the Bishop of Exeter talked about workforce challenges, including difficulties with recruitment and retention, higher overall staff costs and the larger distances that people need to travel. There is a high amount of unproductive healthcare time as staff must travel. That is not going to change, because the nature of the areas is based on the distance between them. This matter must be addressed, but the way we address it is not a given. There are challenges relating to the size of areas, such as difficulties in realising economies of scale and access to certain resources—such as telecommunications, training and consultancy—being more expensive or difficult.

It is worth saying that, for all those givens, it was shown just before Christmas that people in certain rural areas are waiting almost three times longer for emergency ambulances than those in urban areas. I make that point in the context of the number of debates we have had in the Chamber about the inadequacy of response times in respect of ambulances across the country. Yet we have a particular issue in rural areas, with an ageing and older population. For example, the longest wait for an ambulance was registered in Cornwall at just over an hour and 41 minutes, whereas—this is the important point—two years previously the equivalent figure was 32 minutes. That begs the question as to why it has gotten so much worse, especially in rural areas; the Minister may be able to assist us on that.

The noble Lord, Lord Mann, expanded on the point that I made earlier today in my Oral Question about access to GP appointments. I want to emphasise that choice is so important. Here is an opportunity in rural areas because one cannot necessarily just wander down the street or get a bus to a GP practice. The Government are going to have to be much more creative. In so doing, they can embrace this and provide choice for people on how they wish to have their consultation.

I want to say one word about the Answer given to me earlier today; perhaps the Minister here can assist. The Minister in the Chamber made an assumption about people being able to use smartphones. I accept that many of us can, but there is a whole swathe of the population for whom this is just not going to happen, which adds to their distress and discomfort. Perhaps the Minister here could assist in this regard.

I want to refer to the matter of dispensing doctors. I am grateful to the Dispensing Doctors’ Association for its briefing, because it threw up a lot of whys for me. I want to put those whys to the Minister. Dispensing doctors are NHS GPs who can dispense medicines in designated rural areas where a community pharmacy is not economically viable. This seems a good thing to me. They account for some 15% of all prescriptions dispensed. We know that pharmacies now provide more clinical services to their patients, such as hospital discharge planning and medicine use reviews. Again, that is a good thing, but such services are not available for rural patients who use dispensing practices. Why not? Can this be addressed?

Similarly, the electronic prescription service is not available for dispensing patients. This builds on the point made by the noble Lord, Lord Allan, about the whole system, to which the right reverend Prelate the Bishop of St Albans also referred. The EPS is not designed with dispensing practices in scope. Can the Minister confirm that, as the NHS moves towards ever more integrated IT solutions, it will be possible for a hospital consultant to send a prescription to a patient who receives their medication from a dispensing practice, which is not currently the case?

It has been said that rural residents are paying more, receiving fewer services and earning less on average than those in urban areas, and that this is inequitable. That is indeed the case. I hope that the Minister can help us today.

I thank the Committee, noble Lords and noble Baronesses for their contributions to this debate. I know that this topic raises great interest across your Lordships’ House. I also congratulate my noble friend Lady McIntosh of Pickering on bringing forward this debate and on her work not just in this House but over many years as the Member of Parliament for the wonderful constituency of Thirsk and Malton.

I recognise many of the challenges of delivering healthcare in rural areas, including the distinct health and care needs of rural populations and the challenges of access, distance and ensuring a sufficient workforce to enable safe and sustainable services. As a resident of a rural area myself—Rainow—I am no stranger to the challenge of people having to travel further to access healthcare, or their difficulties in relying on rural transport networks to reach the care that they need. However, I assure my noble friend that this Government are, and will remain, committed to improving the health service in rural areas, as we are committed to improving it across England.

First, I can give my noble friend an assurance that we are in full agreement that the NHS needs to be flexible enough to respond to the particular needs of the various rural areas in England. That is why we passed the Health and Care Act 2022, which embeds the principle of joint working right at the heart of the system, promoting integration and allowing local areas the flexibility to design services that are right for them.

Integrated care boards and integrated care partnerships give local areas forums through which to design innovative care models, bring together health and social care and prioritise their resources to ensure they best align with the needs of their area. We are also enabling the NHS to establish place-based structures covering smaller areas than the ICS—for example, covering a local authority footprint or, in some cases, even smaller subdivisions for those larger county areas.

By establishing these models for the NHS to follow we have set the framework, but we have left it to individual areas to tailor the specific details. That is the right approach because, as established in this debate, local areas know better than Ministers in Whitehall how best to organise themselves to design and deliver the best possible care for patients. While we can guide and hold accountable, it is right that we also protect that local flexibility.

I share noble Lords’ passion on internet connectivity. We recognise that some rural areas may have greater challenges accessing the internet than others. I assure the Committee that the Government are taking action to improve broadband and mobile phone connectivity in rural and hard-to-reach parts of the UK. More than 73% of premises in the UK can now access gigabit-capable broadband, which is a huge leap forward from January 2019, when coverage was just 6%. This will only get better.

To help drive this rollout further, we are awarding a series of contracts to suppliers to deliver gigabit-capable connectivity in areas to which the market will not go without subsidy. We have already awarded six contracts and, in total, have made almost £1 billion of funding available through our live contracts and procurements, covering up to 681,000 premises—two-thirds of a million homes. This can be a solution for those hard-to-reach communities on a case-by-case basis. However, we recognise that connectivity remains limited in some areas at this time. As such, digital approaches to health and care should always be only one part of a multipronged offering reinforced with the right support, including face-to-face meetings and visits for those who struggle to access digital services.

The Government recognise the important work done by dispensing practices. This is reflected in the five-year GP contract framework we agreed with the British Medical Association in 2019, underpinned by a record-level addition of £4.5 billion for primary and community care by 2023-24, as part of the NHS long-term plan. This money will help ensure that dispensing practices can continue to provide patients and communities with the prescriptions that they need and to which they are entitled.

I would like to address the important topic of dementia, which my noble friend specifically raised. I assure your Lordships that the Government and the NHS are committed to tackling dementia head-on. On 24 January this year, the Government announced that they will publish a major conditions strategy covering six conditions including dementia. An interim report on the major conditions strategy will be published in the summer. Only in December, the recovery of the dementia diagnosis rate to the national ambition of 66% was included in the NHS priorities and operational planning guidance. This reinforces the importance of dementia as a key priority for the NHS and provides a clear direction to those with responsibility for planning healthcare to make sure that they deliver timely diagnosis.

What is more, work is under way to investigate underlying variation in dementia diagnosis rates. This includes the assessment of underlying population characteristics such as rurality, ethnicity and age. The aim of this work is to provide the context for variation and, in doing so, enable targeted support at local levels to improve diagnosis. This is important work and that discovery must be undertaken to learn how we can make things better for patients in rural areas.

I turn briefly to resources, which many Members have mentioned today. As noble Lords will know, it is vital that we allocate resources in a fair way. NHS England is responsible for funding allocations to integrated care boards. This process is independent of government, and NHS England takes advice on the underlying formula from the independent Advisory Committee on Resource Allocation. That formula takes into account various factors including population, age and deprivation.

In 2019-20, the Advisory Committee on Resource Allocation introduced a new element to the formula to better reflect needs in some rural, coastal and remote areas that, on average, tend to have older populations. NHS England is now using this formula and making allocations accordingly. However, we recognise that some systems are significantly above or below the target of where their allocations should be, so NHS England has a programme in place to manage convergence over several years.

I will now answer some of the specific questions that noble Lords asked. The right reverend Prelate the Bishop of Exeter mentioned social care. The Government have read the archbishops’ report with great interest. We have already committed to publishing a plan for adult social care by spring 2023, which will build on progress so far. We will consider the report as part of that work. The noble Baroness, Lady Bennett, and the right reverend Prelate the Bishop of St Albans also mentioned social care. The Government are putting £2.8 billion next year into additional funding. In spring 2023, the Government will publish a plan for adult social care system reform.

The noble Baroness, Lady Bennett, also mentioned dental care in Shropshire. I am sorry that I am not quite familiar with dental care there—in Cheshire, perhaps, but not Shropshire. The Government put £50 million into funding for NHS dentistry in 2021-22. We acknowledge that some areas are experiencing recruitment issues, and we are actively considering what measures can incentivise dentists to work in more rural areas. We know that we can go further, however, and our priority is to improve access to rural dentistry.

In response to the noble Lord, Lord Mann, I have not been to Iceland, but I hope to one day. He made a very powerful point. We have increased significantly—by 50%—the money going into virtual ward beds. By the end of this year, 100,000 people will be able to have consultations through the virtual ward system. It is a way forward but, as he said, we need digital connectivity for that to be effective.

In response to the noble Lord, Lord Allan, electronic patient records are close to my heart. Our digital health and social care plan sets out a commitment to ensure that all trusts have electronic patient records. NHSE will produce a digital work plan by the autumn. I will take a keen interest in that, as I am sure he will too. The noble Lord also mentioned the correct apprenticeships for key priority areas. The Government are working on that so that it mirrors the local population apprenticeships as a good way for young people to get into the health service.

In response to the noble Baroness, Lady Merron, iPhones are popular with all ages, but I take the point that this is not for everyone. I went to a 102 year-old’s birthday lunch; he took a photograph on an iPhone and texted it to me. There is hope for us all but she made a good point: digital technology is not for everybody.

Before I close, I pay tribute to the NHS and social care services across England for their work. They deliver excellent care now and did so throughout the pandemic. The country is rightly proud of them. We absolutely recognise the importance of ensuring that the challenges faced by rural areas are given due diligence and consideration. These areas face a different range of challenges from those of the NHS in more urban or suburban areas and it is right that we give the systems the flexibility to respond to them.

I hope that I have given my noble friend some reassurance that the current system works. I also hope that she has a speedy recovery from her damaged leg.

Sitting suspended.