A special recipe is required for rural health and social care

Rural health economies are challenged by an older population, hidden health inequalities and a shortfall against target funding levels. Photograph: Alamy

It has been said that healthcare policy is like a primeval soup where the ingredients of problems, policies and politics are thrown together, liberally stirred by various players and interest groups, and served up to the NHS and patients to digest. Occasionally, so the theory goes, the juxtaposition of these often incongruous ingredients, can create unintended and unforeseen consequences.

The recent report by Sir Bruce Keogh into the mortality rates of NHS hospitals highlighted one of the current issues served up from this soup – namely the mediocrity of some hospitals in delivering high standards of care. Tellingly, a significant number were smaller size, district general hospitals (DGHs) hampered, as Keogh's report comments, by their geographic isolation and inability to attract professional staff.

For rural communities the primeval soup is a particularly tricky dish for the palate. As the NHS Confederation reported in 2011, rural health economies are challenged by a disproportionately older population, pockets of severe yet often hidden health inequalities and a shortfall against target funding levels in about 80% of what were rural primary care trusts (PCTs). The issues of geographic isolation and difficulty in recruiting clinical staff, highlighted by Keogh, compound the issue.

In this soup are found some urban focused policies such as choice and competition, enshrined in the foundation trust model, and now a requirement for all hospitals. When Monitor undertook a simulation of these new rules last year, the rural scenario only functioned when collaboration, and not competition, existed. This reflects the reality that rural communities often face journeys of up to 30 miles to reach any hospital, let alone have the luxury of choice. Tellingly, it was assumed that all trusts would meet the authorisation requirements for FT status – a presumption now unlikely given the lessons from the Francis report and the size of rural DGHs.

More recently, into this competition arena the totems of collaboration and integration have been introduced. These are watchwords of resilient rural communities who have recognised that collaborating across boundaries is a means not only of sharing assets – whether structural or services, seeking to address the needs identified in Keogh's report, but more importantly puts patient outcomes as the key driver. Such collaborations, seen in places such as Cumbria, Herefordshire and Torbay, have demonstrated innovative thinking yet been put under severe pressure by the economic squeeze and fragmentation caused by recent policy changes.

A third key ingredient has been the compelling centrifugal force of clinical evidence that complex specialised healthcare is best delivered in centres of excellence. While most patients accept the argument in principle, in reality the downscaling or closure of speciality provision or A&E evokes strong political and popular revolt. Commentators have seized on the Tesco business model as a solution, creating out-of-town super hospitals while a form of NHS-extra provides local services. While opponents fear the loss of the service model, there is something of merit in the need to look differently at how services are provided in rural areas, but using integration as the start point.

As this potent mixture simmers, the chefs have begun to squabble over the right recipe for healthcare. The customer – the patient – waits benignly but increasingly nervously for whatever is served up from the kitchen. The quality of the services, the outcomes for patients, the sustainability of the system is left to simmer – possibly to spoil, or maybe to boil over with catastrophic consequences for rural people.

In rural areas, where the NHS is often the main employer, it is not just health but the economic health and wellbeing of whole areas at stake. Competition, collaboration, integration – what is the answer? One thing is for certain, a special is needed on the menu if we are to serve up palatable health and social care for rural communities.

Jo Newton has been a chair within the NHS for 10 years. She will be speaking at the Rural Health Network Conference – Challenging Times One Year On on the 18 October 2013 in Exeter.

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