Who to visit? Distance decision making among providers


Rural services cost more to provide than urban ones. This is a well known factor in the design and delivery of services. However, these costs are determined by rurality funding calculations which tend to leave the more sparsely populated locations inadequately funded. In short this means that providers are running at a loss when they decide to meet the needs of those in the most rural areas.This is because the resources such as travel costs in fuel, damage to cars on tracks and staff time all become too difficult for commissioned providers, such as home care services, to justify. There may be only one provider who because of limited staff resource cannot support the extra travel time required to fulfill the needs of one home in a more remote area compared to their overall demands. People living with dementia in the more sparse areas are vulnerable in that their needs can often only be determined by face to face conversations and so home visits become increasingly important as the condition progresses.

This is of little comfort to the statutory services striving to fulfill the agreements for daily support. It is of even less comfort to the person who qualifies for these visits yet despite an often lengthy assessment process is denied this option. The consequences may lead to home care providers unable to resource several visits a day to a person with dementia who may wish to remain in their own home. Formal services are then left with the stark reality of trying to avoid residential care by regular monitoring of the person without adequate support. This is understandably stressful for all concerned.

Occasionally I hear professionals who justify this inequity on somewhat dubious grounds along the lines of, “well they chose to live in the middle of no where so why should I spend all the extra time on home visits when I can see four others in the same time?” It’s an interesting logic and based on behaviours which we all recognise. Academics have named this the distance decay behaviour. But it is simply the balancing the losses in physical distance required, time and effort against the gains of doing so. For each journey consideration there will be differing balances but crudely the nearer and easier a journey is with the potential for achieving the goal then the more likely this is to happen. The decision to travel on a hot bus to the seaside is outweighed by the enjoyment of eating ice cream on the seafront. More seriously, for professionals, decisions about how far to go are influenced by many factors, not least the pressures to meet performance targets. Basically many professionals are measured by the total number of face to face contacts they make. There is a tipping point at which the demands of the distance out weigh the benefits of undertaking the journey. This is something we all do; we weigh up if the effort is worth the possible gains.

Rural dwellers have such decision making down to a fine art; clustering of activities into one trip are planned to maximise the time and costs of the journey. GP visits, shopping and meeting up in a cafe are all planned on the same day. Professionals will plan home visits as much as possible within the same location and times to maximise efficiency. The difficulty is that this logical way of organising our time, journeys and goals so often fail miserably to meet the needs of those with dementia. Dementia knows no such formula and tends to favour the moment. Even if the now seems a repeat of the previous hours to others. Dementia has no regard for the challenges so many professionals face day to day as they manage ever expanding caseloads. This isn’t about a lack of compassion or blaming people for the places they were born in among providers but one of trying to pull together the contradictory demands of performance models devised in the absence of any knowledge of rural working. In short, most frameworks have failed to rural proof dementia care, and so pressures are placed at all levels to fit a dubious collapsing framework.

At Government level, new strategies have to be supported which sanction the increasing demands and costs of rural care services. Local managers could consider pragmatic approaches to supporting the front line staff who are paying the extra costs of rural working. Ultimately though the costs are paid by the families affected by dementia who find they have no option but to leave their homes and face the inevitability of moving away from the locations they know and love. If the person moves into residential care then this will incur increasing costs for the families and statutory services. People who wish to approach end of life in the places they know well are denied this choice in rural areas. This can hardly be equitable.







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