It has suited government to cope with the complexity of organising health and social care by subdividing topics or themes and creating distinct governance process, standards, accountabilities for each of these themes. This makes sense in an urban environment where this approach contributes to efficiencies of scale - each team has its own master and rules to follow. However in a rural context, such specialisation is a barrier to effective care and organisation of services. There is not the scale to justify such distinct teams. Instead, small numbers of people have to cooperate in the interests of patients. This means to adapt and to improvise. Distinct governance process get in the way of such cooperation and rounded service provision. Local staff end up having a multitude of masters and the governance hurdles take up more and more time of already stretched staff. These effects are compounded by more and more centralisation eg proposed NCS. Investigate the idea of increased local autonomy and flexibility for rural practitioners. Maybe even contemplate a distinct rural governance infrastructure that aims to reduce specialisation and increase cooperation at a local level by enabling communities as owners not recipients of services and seeing the patient as a complete human being at the centre, rather than seeing patients as distinct diseases or conditions. The Alaskans and Canadians have taken this approach with considerable success. They call it Nuka.


The concept of a distinct rural governance process is good. This should be linked to teams of multi-discipline health specialists based in rural hubs, with either mobile resources such as screening units or appropriate technology allowing the local health specialist to guide and interpret remote consultations for patients.

Co-production and co-design with people of lived experience is vital.

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