Bishop of Exeter speaks on healthcare in rural areas

The Bishop of Exeter spoke in a debate on healthcare in rural areas on 23rd February 2023, emphasising the need to address challenges in staff retention in the NHS and the care service:

The Lord Bishop of Exeter: 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.


Extracts from the speeches that followed:

Lord Alan of Hallam (LD): 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.


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.

Baroness Merron (Lab): 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.

Lord Evans of Rainow (Con): 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.

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