Rural Communities: Health

HL Deb 15 April 1993 vol 544 cc1224-40

6.14 p.m.

Lord Shackleton rose to ask Her Majesty's Government what steps they are taking to meet the impact on people's health of their policies towards rural communities.

The noble Lord said: I ask an Unstarred Question. That is something I did not have the opportunity to do when I was occupying the position of Leader.

The purpose of the Unstarred Question is to raise issues upon which we have not concentrated specifically; namely, the social and health needs of rural communities. Many of the points which I make are explicit in the White Paper The Health of the Nation. The Health of the Nation supports healthy cities, healthy schools and healthy workplaces, but does not make provision for supporting healthy rural communities. For that we have to look at the report on rural health by Jeremy Fennell of ACRE.

Some rural areas are not in designated Rural Development Commission areas. I am not an expert on this matter and should like to know what is the qualification for being a rural development area. What are the criteria for recognition and applying for those areas which are not currently covered by the Rural Development Commission? Rural development areas may receive community grants. Again, I should like to know how they are arrived at.

My speech is based mainly upon the work of Dr. Derek Browne, my local GP, who has shown tremendous energy in developing caring community facilities not just in his area but throughout the country. His work is well known to many people. In particular, it focuses on the Brockenhurst area.

Brockenhurst is a rural community in the heart of the New Forest with a population of 3,500, with 25 per cent. over the age of 65 years. The local general practitioner, with his practice team of four doctors, two practice nurses, two health visitors and a district nurse, has developed networks of care involving the village hall, church, education centres, hotels and the environment. Local clubs, societies and care groups are supported by the primary care team. Those organisations provide support for the social, physical and psychological needs of the community.

Much can be achieved by the initiative of just one doctor. However, rural areas have social, economic and health needs, many of which are unmet and unknown to statutory authorities because the communities tend to be more caring and self-sufficient. Their needs still require coherent policies for action and support by the statutory and voluntary agencies.

Rural areas are thought to be wealthy and self-sufficient, but they are usually scattered communities with poor transport and communication networks, with increasing numbers of dependent elderly people, with psychogeriatric problems, degenerative disorders such as Alzheimers, schizophrenia and manic depression. There are children with special needs. Unemployment is increasing in all social groups and families are having to move as financial constraints and commitments cannot be met. Health and social needs are increasing, but as the authorities are often not aware of the needs, the rural community does not receive the needed resources.

The community care provisions came into effect on 1st April 1993 with the intention that local authorities should provide the care but with the proviso that they should be given sufficient funds to discharge the responsibility. Social security spending has escalated from £10 million in 1979 to £2,400 million in 1992–93 in respect of residential and nursing home care. It will be expensive to meet the demands of community care for rural communities. Such help must be achieved by properly organised voluntary action.

Rural cottage hospitals face closure in the new round, even though unit costs are less than in general hospitals. There is a most valuable hospital at Lymington but there is uncertainty as to its future. Problems also arise over discharge. For example, recently it was announced suddenly in Lymington that as many as possible of the patients would have to go home for Easter. That caused considerable alarm, especially as some had no adequate facilities at home. In the event, it did not happen quite like that. It was done much more humanely and sensitively. Discharge procedures after planned hospital admissions back into the rural areas can be made beforehand, but many admissions are emergencies and there is fear of bed blocking and difficulties in assessing responsibility to either health or social care. The philosophy is to allow choice and advocacy for the user but that will be governed by the resources available.

A valuable component both in the medical and caring field is the local pharmacy and here I wish to ask the Minister whether the Government will revise the proposals which so far have aroused great anxiety among pharmacists. In Brockenhurst we have a very able pharmacist and an excellent service is provided; indeed, many people see her as a substitute for the doctor. But there are some pharmacies which are too small to qualify for the supplement dependent on the number of prescriptions prepared. At Sway, for instance, which is part of the Brockenhurst practice, there is a very good pharmacist who will just about survive, but there are others in the neighbourhood who simply will not and their withdrawal on financial grounds will be a tremendous loss to the community.

Another problem is the availability of ambulances. I know of cases where doctors have waited sometimes for hours not feeling able to leave a patient because there was not sufficient clarity as to priorities. Difficulties will arise about demand and nobody knows now how the pay factor will operate.

GPs in single handed practices have their own particular problems which should be addressed. They tend to have smaller lists and although rural GPs do receive additional remuneration, this has no bearing on those allowances which are dependent on list size. Their isolation also makes it difficult for them to find time to attend postgraduate courses, and this could be made easier if they received direct reimbursement of locum allowances.

A valuable solution, and indeed a contribution to networking local facilities, would be via the appointment of a local community co-ordinator who could help network local facilities, resources and people supporting the primary care team. Wessex Regional Health Authority, under its chairman, Sir Robin Buchanan, supports those concepts. Is the difficulty over providing such a co-ordinator for Brockenhurst the fact that Wessex Regional Health Authority has had some heavy financial losses? Sir Robin Buchanan has stood up very strongly in what must have been a period of considerable stress.

Economic, social and health needs can be supported in rural communities. The primary care team, including the general practitioner will organise that but it would need help. It would be useful if a co-ordinator could be appointed.

Social support for health involves interaction between individuals, groups and communities where they receive mental, emotional, informational material and operational support. This helps reduce factors which cause social strain and social disparities.

Community support with transport, people and social needs can be met. Local resources such as village halls, churches, schools and hotels can be used by the community for the community to help build healthy alliances between individuals and the community in which they live. Supportive community environments which enhance the physical, social and psychological dimensions, provide conducive conditions for people to pursue healthy lifestyles. However, they need the opportunity to practise what they are advised to do.

Advocacy for national policies supporting rural communities is an important step to strengthen interagency collaboration, including the voluntary and statutory organisations. These ideas were discussed in Sweden at the Sundswall international conference on Action on Public Health and Supportive Environments in 1991. There is a real need that the facilities which are available are known so that inadequacies are noted successfully. And there will always be a need for continuous monitoring of the activities such as described in the ACRE report by Jeremy Fennell.

Earlier this afternoon I heard of yet another development, this time in Southampton. The local education officer, Mike Clarke, has initiated schemes to bring health-related services into schools, thus ensuring that children receive the medical services which they need rather than the children having to go to the service at some distance. A similar scheme is already in place in Lymington. There are other schemes which call for special attributes in those seeking to carry out such work.

There is a great deal of opportunity to develop health care in rural areas but there must be additional work and additional funds so that that can be carried out properly. Meanwhile, we must look at the problem of the chemists, the ambulance services and so forth to ensure that the problems are met and that there is a continuous concern to watch how the systems work. It is all too easy to assume that they cannot work perfectly. Others can show that they do work well but that an effort is called for.

6.26 p.m.

Lord Colwyn

My Lords, it will come as no surprise to your Lordships that I intend to use this opportunity of a debate on rural health policies to comment on the availability of dental services in rural areas. I thank the noble Lord, Lord Shackleton, for initiating the debate and I congratulate him on an excellent speech, which clearly highlighted the problems of rural areas. However, I am a little disappointed by the shortage of speakers in the debate. I had hoped to slip my name into a long list of rural experts and raise a couple of dental questions which would be answered together with all the other questions at the end of the debate. However, I shall "do my thing" for dentistry.

In the Minister's reply to the dental debate on 10th June last year at col. 1354 of Hansard, she restated the Government's commitment to the NHS dental service and stressed the importance of the forthcoming fundamental review, which she said would assist the Government in their task of building a better NHS dental service for the future. As far as I am aware the Government intend to publicise their response to the review in mid-June. Although the debate may not be the ideal time for an answer I shall be interested to know why the Government have recently compressed a consultative period to mid-May, putting the profession under severe pressure to assimilate and to discuss the report within such a short period of time.

Before the current NHS dispute there was apparently no crisis of availability of NHS dental services to patients living in rural areas. It would of course be true to say that it would not have been unusual for patients to have to travel 10 or 15 miles to the nearest dentist because of simple commercial demand and supply factors. The need to travel that distance would be routine for patients living in those areas because they would expect a journey of that length in respect of most other services that they would need and would presumably combine a trip to the dentist with other purposes.

In rural communities, where the population may be widely scattered, few villages would be able to sustain a full-time practice, although many seem to have been served on a part-time basis—perhaps between one and three days per week—by smaller branches of larger practices based some distance away. I did that myself when I worked in Gloucestershire but found that even in the 1970s the system of dental remuneration did not encourage principals to set up practices in different areas and work in them on a part-time basis.

It would seem natural to assume that in most rural areas dentists would have been more reluctant to accept patients for treatment on a domiciliary basis. In fact, there appears to be no evidence to support that; indeed, even the reverse may be the case. The dispute which arose last year over NHS fees, and on which Sir Kenneth Bloomfield has now reported, has had effects at three levels.

First, existing patients have, by and large, suffered no problems in obtaining services, unless their dentist has actively de-registered them; that being the exception rather than the rule. Secondly, the majority of practices have refused to accept any new NHS patients, or in some cases, those NHS patients who are liable to charges. Patients not already registered, or new patients coming to a rural area, then face a particular problem, because if they cannot become registered with the nearest practice they may have to undertake a 25 to 30 mile journey to the next nearest dentist who is prepared to take them on. Thirdly, patients needing domiciliary treatment in such an area would certainly find it extremely difficult to persuade a dentist to make a round trip of perhaps 60 miles, on several occasions, to make, for example, a set of NHS dentures, requiring three or four visits on a domiciliary basis.

Rural practices tend to have been less ready to combine together in protest action than the dentists in the city centres and larger towns, perhaps because they are so much more dependent upon local goodwill. On the other hand, a small town or a large village with only one dentist is acutely vulnerable to the possibility of that dentist withdrawing from the NHS. Precisely that has happened in Llandovery in Dyfed, where the only NHS dentist withdrew from the NHS, leaving many patients facing a 25 to 30 mile journey. On the other hand, when several dentists in a small rural area all go private, it leaves the door open for a new practice to open up and take over many of the patients. That happened in Tenby. The FHSA was faced one minute with no local dentist to serve 10,000 patients, and the next, with a new practice on its doorstep, keen to sign up as many patients as possible.

Among the FHSA/health board areas where the availability of services has led the department to seek funding for salaried dentists, there is a large number of FHSAs with a rural component. The socioeconomic status of the area seems to be a factor. The likelihood of the household having a car—making a trip of even 20 miles or more manageable—and the availability of local bus or train services is important. For example, mid-Dorset is very rural, but has reported little or no problems of availability, while North Cornwall is equally rural but has suffered far greater problems due to a heavier reliance upon a local bus service which leaves a lot to be desired.

I am informed by the British Dental Association that problems in Gwynneth FHSA and Highlands and Grampian Health Board have been brought specifically to their notice and other inquiries have shown that round trips of 50 miles or more might be necessary within Devon, Cumbria, Clwyd, Dyfed, Gloucestershire, Powys and Cornwall FHSAs. I am also informed by a dental colleague who carried out some research for me that Lincolnshire should be added to that list, but staff at the FHSAs in Lincolnshire, Gwynneth and Gloucestershire are saying that they have been given instructions not to discuss the local situation with anybody, nor to give out any figures and I am unable to make any further assessment.

In conclusion, there are clearly some local problems, but I am not convinced that they are very much worse than in more urban areas. In rural areas the problem is obviously one of distance, whereas in urban areas it is more likely to be one of actually finding a dentist to accept you at all.

I apologise for speaking solely on dentistry. I shall look forward to hearing from the real experts on the Front Bench and from my noble friend the Minister.

6.33 p.m.

Lord Beaumont of Whitley

My Lords, I too thank the noble Lord, Lord Shackleton, for asking this Question. Indeed, I also thank the noble Lord, Lord Colwyn, for his contribution because the consideration of a particular case, such as dentistry, illuminates the problems arising from the general issue.

I speak for a political party which, during much of the time I have been a member—although not now, I am delighted to say—had almost all its representation in rural areas. Therefore, we have had the time and the opportunity to put together and represent the desires of individuals living in the countryside. I am particularly interested in the point made by the noble Lord, Lord Colwyn, about the distances which have to be travelled. I believe that he under-estimated rather than over-estimated the distances involved.

The problems of access to health facilities in rural areas are familiar. A widely scattered population, many with limited mobility, make access to facilities difficult and render large units financially unviable. Also, many rural communities have a larger than average proportion of elderly people. Current government policies, including the introduction of the internal market within the health service, and the increase in the capitation element in GPs' contracts, have led to a significant worsening of services for people living in thinly populated areas, hitting in particular those who have difficulty travelling to obtain their services.

The provision of services on a single district general hospital site is inappropriate and inconvenient for rural users, especially out-patients. The social benefits of provision on multiple sites must be balanced against the need to make use of staff and skills in the most resourceful way. Very often it can be said that the marriage of the two—using social benefits and staff and skills—produces the best answer. I am not an admirer of the use of large units for the provision of health care. I believe that it will be found in this regard, as in so many others, that we shall move away from gigantism and towards "small is beautiful".

We should certainly, where appropriate, introduce mobile out-patient clinics which could take place in village halls and community centres. Rural ambulance services and hospital travel schemes are essential to many people living in villages and those must be properly funded. I shall say a few words in conclusion about the length of time for which money will be necessary. At present, we certainly ask for proper funding of those services. In Cornwall, an air-ambulance scheme has been pioneered. It is possible that in remote areas, something along those lines should be copied.

There should be more peripatetic primary and community health services, from chiropody to family planning. The setting up of primary health care, including GPs, practice nurses, health visitors, social workers, district nurses and midwives and dentists, would be of major importance in rural areas. Even some hospital care can be provided in the local community. Suitable patients can be discharged from hospitals and looked after by community nurses in their own homes.

We believe that there should be special financial arrangements to enable rural pharmacies to survive in areas of scattered population. The noble Lord, Lord Shackleton, mentioned that. The aim is to ensure that the local population has access to a reasonable amount of medication and also that community nurses are able to prescribe medication knowing that it can be made.

It is essential that the body responsible for administering the health care in an area should be representative of that area. Mechanisms need to be in place to ensure rural representation on relevant health associations and boards. Funding formulae for services must reflect the additional costs of providing a decent services in the rural areas.

Having said that, there is now the additional community care which will be needed for those who come out of institutions needing to be looked after. The countryside is almost ideal, not just because it is a reasonably healthy place in which to live but because there is a tradition of community care in villages and rural areas which can he tapped. If it is to be tapped it must be supported. It needs subsidy and support. In particular carers need support. There is an absolute need for machinery to be on tap so that carers can be given the support they need if they are to do their job properly and if they are not to be totally exhausted looking after people suffering from Alzheimer's disease or complete disablement of various kinds.

The real answers to the problem lie in a return to the countryside; in other words, a re-population of the countryside. I have said that in your Lordships' House on more than one occasion. There is a chance that it may happen. If it does and if we develop the kind of industry, services and jobs which, for example, do not depend on electronics, people will actually be able to live in the countryside and work. We can then start re-populating the countryside and will be able to keep the post offices, the village hall and schools that we have and provide the kind of medical care which is absolutely necessary. I sincerely hope that that will happen. I think that governments of this country must ensure that it does happen.

When it does happen, the financial burden foreseen at present will become much less because the communities themselves will be able to support what is going on. In the meantime, it must be the business of the Government to ensure that the rural areas do not suffer merely because a little more money is needed to keep operations going. The people of the country must not be the sufferers. The Question that has been asked this evening is a very important one. I look forward to hearing the Government's reply.

6.42 p.m.

Lord Carter

My Lords, the House will be grateful to my noble friend Lord Shackleton for giving us the chance to debate a particular aspect of rural life which certainly needs examining. I think we can all agree that this is an area which needs intervention by government and local authority—that is, both action and intervention. It is certainly not a problem which can be left to the market. We know that approximately 10 million people live in the rural areas and that is about one-fifth of the population. In fact, the population of rural areas is increasing. A recent survey showed that 13 million people now living in towns and cities would like to live in the country and that 4 million people expect to move to a more rural area within the next five years.

But alongside that evident love of the countryside and rural living, there is the uncomfortable fact that 25 per cent. or more of rural households are living on or near the margins of poverty. I know that the Government find it hard to make any connection between health and poverty; but everyone knows that it exists. There are problems of transport, housing and unemployment and they all have an impact on the health of people who are living in rural areas. That can be both directly as regards their state of health and indirectly through such matters as poor transport facilities which make it harder for people to visit their GP or to get to their community, district, or regional hospital.

A particular district health authority that I know well claims to be over-provided with community hospitals. It is trying to reduce those facilities and to centralise much more of the services on the district hospital. But that is taking place in a city with notorious traffic problems, on a site where it is sometimes literally impossible to park a car and where, if a parking place can be found, the hospital car park is now charging for the service and clamping those who forget to pay. Of course, that is not the problem for 25 per cent. of rural families in Wiltshire that do not own a car; they just have the problem of a very inadequate public transport system.

ACRE (Action with Communities in Rural England) has produced an excellent publication entitled Health Care in Rural England which describes the problems extremely well and which sets out proposals for action. That report was mentioned by my noble friend in his opening speech. It draws attention to the complexity of organisation in analysing and delivering health care in rural areas; for example, the regional and district health authorities, the family health service authorities, the GP fund holders, the non-GP fund holders and now the local authorities with their new responsibilities for community care all overlay and intermingle to a rather confusing degree where rural health care is concerned.

But, overall, there is one economic fact which must be faced: services are expensive to provide in rural areas. We know that the populations are scattered, the economic use of resources is difficult and effectiveness is harder to achieve by conventional non-rural yardsticks. Within that difficult framework efficiency, however defined, often demands that the consumer has to come to the service rather than vice versa, that the extra costs of service provision may be externalised by the provider to the customer—for example, he or she will have to pay more either directly or indirectly than the urban consumer—that fragile rural services are often withdrawn first when budgets are stretched (that is certainly what is happening in the area where I live) and that services are often enhanced by the use of voluntary organisations to help secure their delivery.

My noble friend Lord Shackleton gave an excellent example of what can be achieved at local level by an imaginative GP, a Dr. Browne, and good coordination of services. I have to say that such co-ordination is rarely present at the various levels of bureaucracy where there is hardly a rural dimension at all in planning, developing and monitoring good practice. The situation is unlikely to improve with yet another reform of local government structures on the way, a third wave of NHS trusts, another round of GP fund holders and all the problems of implementing community care reforms. Those reforms present a problem in rural areas. I know that the Minister is aware of that fact.

Another excellent report also by ACRE entitled Who Cares deals with community care policies in rural areas. It conducted a questionnaire in the Autumn of 1991 asking a number of rural community councils and social services departments to look forward to the situation as they saw it in April 1992. Overall, 27 county areas are covered and there was a good rate of response. I shall quote just two of the conclusions that were drawn from the answers. The first concluded that some counties are covered by more than one health authority and that some health authorities embrace a higher proportion of rural areas than others; but no respondents noted any specific differences in approach to rural areas in their planning. Secondly, it was noted that two-thirds of the rural community councils say that their county is not planning a specific rural care strategy.

With the exception of the rural practice payments within the GP contract and the arrangements for small pharmacists in rural areas, can the Minister say what other rural dimension exists in health planning? I have already given the example of one district health authority that has a deliberate policy of reducing community hospital facilities and centralising much more of the services. If such a decision is being planned, just how much of the cost-benefit analysis is conducted to measure the effect of such considerations as the lack of public transport, more travel for patients and their relatives, the greater load that is likely to be placed on informal carers and all the other problems that surround what seems to be a straightforward bureaucratic decision which is taken entirely on cost grounds?

Can the Minister say how much research has been carried out, or is contemplated, on the whole matrix of rural health problems? For example, such matters as the lack of public transport and, where it exists, its high cost. I have already referred to the fact that 25 per cent. of families in Wiltshire do not own a car. I am sure that that is a percentage which is repeated in many other areas. There is also the difficulty of running surgeries from village halls.

There are other difficulties over prescription and collection services. There are problems with establishing self-help initiatives in rural areas. Some health authority policies are insensitive to the needs of rural areas. Cuts are being made in ambulances and in the hospital car service. There is poor provision of ante-natal care and of maternity services in rural areas. Above all, there is a lack of recognition of the wider social care role of the rural GP. How much work is being done in the department on the whole matrix of rural health problems?

As I said in the debate on 3rd March: The problem of child care can be severely worsened by rural isolation, as can the situation of the army of informal carers looking after the elderly, the infirm or people with disabilities. The pressure to close community hospitals is intense in some rural areas, certainly my own".—[Official Report, 3/3/93; col. 670.] The problem of rural pharmacies has been mentioned. That problem, together with the problem of a lack of child care and of informal care and the closure of community hospitals, are all examples of the many problems in rural areas that may be small in terms of absolute numbers but the impact of which on a local community can be very severe. The other vital players besides GPs in the rural health scene are, of course, nurses. I am sure there is no need for me to expand on the vital role that community nurses play. They work in rural communities, assessing needs, and providing care and support for those at home or in residential or nursing homes. Community nurses are particularly well qualified to assess the need for help through their regular visits. It follows that under-provision of community nurses in rural areas will be reflected immediately in the standard of care of people who are living at home or who are in residential care. That will place an immediate extra burden on the friends and relatives of those people.

The new funding arrangements for community care may result in a greater incentive to place people in residential rather than nursing homes to save costs. That will immediately place an extra burden on community nurses. There is great concern at the moment about the failure to co-ordinate health and social services at local level. That is particularly the case in rural areas. The January edition of the BMA News Review gives truly alarming figures. Those figures were given in January, only three months ' before the implementation of the community care reforms. The review shows that more than 90 per cent. of the GPs surveyed were not aware of a formal hospital discharge policy and more than 80 per cent. had not been informed of the proposed arrangements between the various community care agencies. It is clear there will be a grave problem in rural areas.

In conclusion I wish to compare and contrast this situation with the excellent GP initiative in Hampshire which was described by my noble friend Lord Shackleton. I am sure the Minister will tell us that that is just the kind of initiative the Government support. The idea of a local community co-ordinator is an excellent one, but who pays? If the Department of Health could find the money to support such appointments, that would be money well spent. It could eventually lead to a reduction in overall costs by keeping people in rural areas, especially elderly people, fitter for longer. That would reduce the need for residential, nursing and hospital care. I repeat my thanks to the noble Lord, Lord Shackleton, for giving us the opportunity to debate this important subject which affects some 10 million people. Like other speakers in the debate I, too, await with interest the Minister's reply.

6.53 p.m.

Baroness Cumberlege

My Lords, this debate should be set in the context of the successful one generated by the noble Lord, Lord Carter, on 3rd March, in which he set out so clearly the social and economic needs of rural areas. I do not wish to add to the overall picture which he so well described then and again in his opening remarks tonight but to start by expressing my gratitude to the noble Lord, Lord Shackleton, for concentrating our minds today on the issue of rural health. No one is better qualified to do so since the noble Lord has not only lived in a Hampshire village for many years but served as Herbert Morrison's Parliamentary Private Secretary. He will have observed at close hand the complexity of the issues surrounding the setting up of the NHS, and watched, I suspect with interest, its evolution both countrywide but perhaps more particularly in the countryside.

I wish to add a personal note. I am also a country person and when the noble Lord was PPS to Herbert Morrison I was six years old and sometimes accompanied my father, a GP, around the villages he served, and later the village I served as a parish, district and county councillor. One quickly learnt that it was futile to treat rural areas as an entity. Two of the neighbouring parishes that I represented appeared to be not only different, but constantly at war with each other. These seemingly irreconcilable differences only made sense to me when it was explained that one supported the Royalists and the other the Roundheads a mere 300 years ago.

The effects of history cannot be eradicated. The intimacies of village life are complex. Traditions are important and they need to be understood, respected and taken into account when services are delivered by any government body, whether national or local. It is this philosophy which has inspired the Government to devolve the delivery of health care to as low a level as possible. Local people seek local solutions. They work with the grain of the community; they understand its dynamics; they identify its strengths, and they achieve results because instinctively they know what works where, and what does not.

Primary care in these situations assumes an even more important role. In the depths of rural areas the GP, nurse, health visitor and midwife are the NHS. The primary health care team has to be comprehensive, providing not only advice and treatment but rehabilitation, minor surgery, maternity, preventive and supportive services. For rural people a visit to hospital is not simply an inconvenience but for some a dreaded and even an alien experience—a last resort. Nurses, midwives and health visitors working in remote areas have enormous opportunities to push forward the boundaries of their professional practice. They can teach front-line carers many of the functions routinely performed by nurses, and they can take in some of the diagnostic, therapeutic and health promotion responsibilities normally associated with GPs. GPs on the other hand, working within the new reformed NHS are encouraged to perform minor surgery and other treatments normally associated with hospital care.

In many areas we have witnessed the success of GP fundholding schemes but in rural practices because of their size there may be difficulties in meeting the requirements of the scheme. To ensure the benefits of fundholding are spread as widely as possible, the Government are piloting a number of schemes. Under these schemes an agency adopts the day-to-day management of the fund leaving health professionals to concentrate on the clinical aspects of fundholding. This makes it easier for small practices to come together and for rural communities to benefit from the added advantages of fundholding.

The noble Lord, Lord Shackleton, highlighted the crucial role played by community pharmacists. Before 1983 there were no formal restrictions on NHS dispensing; any qualified pharmacist or doctor could dispense. It is a measure of the complexity and importance of the issues that it took the two professions eight years to agree on how the joint regulatory committee would operate. Under present arrangements before either a pharmacist or doctor starts dispensing, the family health services authority checks to see whether this would have any detrimental effect on existing services. Also there is a scheme under which small pharmacists who are some distance from the next pharmacy can claim financial support. I can assure the noble Lord, Lord Shackleton, that as part of the current negotiation on pharmacist fees, the department is committed to strengthening the essential small pharmacy scheme. Despite the scheme, however, I know that in rural communities access to a pharmacy is not always easy. When there are difficulties dispensing doctors provide a convenient and tailored service delivered close to the people who need it. There are additional rural practice payments allowed within the GP's contract in recognition of the extra expenses incurred through call-out and travelling times.

I am delighted that my noble friend Lord Colwyn decided to raise the subject of dentistry. I believe that for some time there has been an uneven distribution in that service across the country. My noble friend highlighted the current and, in his view, exacerbating problem. The Government are monitoring the situation along with local FHSAs which are able to assist patients in obtaining NHS dental treatment. As always, some patients may need to travel to their dentist. Patients who are unable to travel can obtain treatment from the community dental service. The FHSA may also appoint salaried dentists to ensure adequate provision of services. The White Paper Promoting Better Health published in 1987 recognised concern over the location of NHS dentists. A location incentive scheme was agreed between the British Dental Association and the Department of Health, providing financial assistance with the cost of setting up or expanding dental practices in areas where there is a shortage of general dental practitioners.

My noble friend Lord Colwyn also asked what was the current position and what progress had been made on the recommendations of the Bloomfield Report. My honourable friend the Minister has clarified the position regarding progress on the report. He has indicated that he wishes to make determined but realistic progress on consultation and expects to have heard the views of all interested parties by the end of May. He will then be in a position to consider all the points that have been made when making a decision on the way forward.

A key feature of Working For Patients has been to change the focus of health authority work from the management of services to the purchasing of services. I believe that that will meet the anxieties and answer the questions raised by the noble Lord, Lord Carter, this evening.

Purchasing requires health authorities in both rural and urban areas to change their habits and for the first time to act as the champions of the people, identifying their needs and setting contracts to meet those needs. That greater responsibility has been reinforced by the Patient's Charter with its emphasis on local service standards and people's rights under the NHS. We believe that decisions which involve local people, where they are encouraged and given the opportunity to influence contracts, will result in more appropriate services which are better targeted and sensitive to the needs of users and therefore more effective.

Health authorities are having to justify in public the decisions they reach. That includes the location where care and treatment is given and, in particular, whether or not for instance a cottage hospital might fit in with their overall proposals.

Accessibility, local geographical factors and transport links are key factors which those responsible for purchasing health services need to take into account. They need also to consider how best to secure high quality and value for money. Those are often very difficult judgments to make and we are all aware of how much concern there is when a much-loved local service is deemed to be no longer viable.

I should like to say a word about community hospitals. I generally share the views of the noble Lord, Lord Beaumont of Whitley. I think that small is very often more beautiful, especially when it comes to rural hospitals. In my experience, decisions to close community hospitals are seldom made due to the poor quality of the service which they provide. The arguments are usually financially based. Of course, those charged with spending public money must be satisfied that it is well spent.

I believe that with the new funding arrangements under the reformed NHS we may see that the financial aspects of community hospitals change. Again in my experience, where a community hospital is paired up with a much larger district general hospital, the overhead costs of the district general hospital are often carried by the community hospital. That is an unfair burden. Under the new arrangements where there are community units which include a community hospital, I suspect that their value will alter, and their financial viability will also change.

The noble Lord, Lord Beaumont of Whitley, may perhaps gain a crumb of comfort from the latest OPCS figures that I have seen which show that the population of rural areas is increasing. That fact was supported by the noble Lord, Lord Carter.

In order to achieve sensitive and effective purchasing, the local community must be involved and alliances built. We recognise that improvements in people's health cannot be delivered by the NHS alone. It needs the collaboration of everyone. Healthy alliances identify and harness the strengths in the community, bringing the many and varied contributions together for the benefit of everyone. NHS managers are being encouraged to form alliances with parish councils, community health councils, other local authorities, employers, voluntary bodies such as the local branches of the Women's Institute, WRVS, and professional associations such as the National Farmers Union, charities, playgroups, industry, retailers, religious bodies, schools and local media.

Those healthy alliances build on and enhance existing services. They are an integral part of the implementation programme for The Health of the Nation. Handbooks covering each of the five key areas—coronary heart disease and strokes, cancers, mental illness, HIV/AIDS and sexual health, and accidents—mention the importance of seeking ways and means of engaging the wider community into accepting and meeting the agreed targets.

The new proposals for community care, which were also mentioned by the noble Lord, Lord Shackleton, and the noble Lord, Lord Carter, and which were fully implemented on 1st April, should improve services as individuals will have their needs assessed on a personal basis. Perhaps I may also reassure the noble Lord, Lord Beaumont of Whitley, that carers' views have to be taken into account.

Alliances are based on the important principles of commitment, trust, working to common objectives, willingness to share, communication skills, acceptance of responsibility and good personal and working relationships. The noble Lord, Lord Shackleton, raised the example of Brockenhurst. I too have been impressed by the vision, the work, energy and enthusiasm of Dr. Derek Browne and his team, and I look forward to visiting them in June. The success of their work is based on having accurately identified the needs of their local community and having a clear vision as to how those needs should be met.

There are other examples of vibrant alliances, such as the Oasis project at Hailsham in East Sussex. There local GPs, in partnership with the Wealden District Council, prescribe a fitness programme at the local leisure centre rather than embark on a drug regime. That has benefited patients by improvements in their health, and better use is made of the facilities at the leisure centre. I have long believed that there are more imaginative prescriptions for depression and stress than Valium. And that scheme proves that.

Another example is the Meres Day Centre based in Ellesmere in the midst of the Shropshire lakelands. It occupies the ground floor of the former cottage hospital. That facility is owned by the people of Ellesmere and surrounding villages by means of a charitable trust. It provides short term intensive support during a crisis, help to recuperate after an illness or stay in hospital and longer term support for people who are unable to care for themselves as well as for providing relief for those who care for them.

Before concluding, I should like to pick up the point raised by the noble Lord, Lord Shackleton, at the beginning of his speech about the role of the Rural Development Commission. My noble friend Lord Strathclyde in his speech responding to the debate on 3rd March, referred to how the commission was the Government's main agency for diversifying rural enterprise. It is sponsored by the Department of the Environment and therefore outside my immediate area of responsibility. However, I understand that the priority areas are being brought up to date with the benefit of information arising from the 1991 national census. It is hoped that new areas will be announced this summer for implementation next year.

The noble Lord, Lord Carter, asked what research is being undertaken into rural problems. At this moment I am not aware of any national initiative; but health service purchasers are carrying out a great deal of local research into the needs of their local populations. Clearly, without that information they would be unable to do a useful and worthwhile job.

In conclusion, support for rural health, particularly through good practice schemes, has been provided for a number of years and will continue. But what is of particular importance to rural communities is the greater sensitivity, improved information and more responsive pattern of services which have been introduced through the NHS reforms. The approach to greater community involvement through healthy alliances helps to ensure that the right balance between promotion, prevention and treatment is achieved, and allows services to be designed specifically to meet the needs of local populations, particularly those in rural areas.

I very much welcome the contributions made by noble Lords tonight, for I believe that in trying to provide such a diversity of solutions to such a multiplicity of personal problems it would be arrogant indeed if the Government pretended to have every answer.