Just because you provide a service doesn't mean that people will use it, says Dee Howkins. As a part-time farmer, as well as a nurse practitioner, she knows that farmers are notoriously reluctant to use health services. So to counter this, she and her NHS colleagues have gone mobile.
One reason for farmers not visiting the doctor is the practical problem of a 24-hour job. If surgery hours clash with milking - and if they don't, chances are they clash with something else - then attending surgery is a non-option. Moreover, many farmers do not really believe there is any point in going: in fact, many say they would rather talk to the vet.
All this adds up to a general belief that "everything gets better with time". Inevitably, though, some things do the opposite. Mental health problems - particularly stress and depression - have long been recognised as a significant rural issue. And there are a number of physical conditions to which farmers are particularly susceptible.
The Rural and Farmers Health Project was originally set up in Cumbria and north Lancashire three years ago, initially as a two-year research project looking into why farmers were not using mainstream services. From the start, it operated from a Transit van travelling round markets and other venues where farmers meet. Having identified a real need for a mobile approach, it evolved into a service run by the Morecambe Bay primary care trust.
At first, many people were too embarrassed, literally, to get on board and it took staff some six months to establish themselves. "A lot of the time it was just a matter of talking to people," says Howkins.
This direct approach worked for Peter Lumb, who has lived and farmed in Gressingham, eight miles north of Lancaster, since 1958. "When it was first explained to me, I was very sceptical about it," he admits. "I could not see how farmers were going to confide in the practitioner nurse and subject themselves to a medical."
He started to change his mind after coming across the van at Lancaster auction mart. "I was very impressed with the way it was kitted out," he says. "It was a bit like an ambulance, with a bench on either side. The doors were closed and it was very private inside; you can see out, but you can't see in. Dee had all the equipment for testing blood pressure and so on - and if she found a serious problem she was on her mobile phone to make an appointment straightaway."
Eventually, Lumb ended up having a check-up. He recalls: "Some time later, we were standing and chatting at Lancaster auction mart and I said: 'You might as well give me a once-over.'" He is now a firm convert - as are others. "There were a lot of sceptics, but they've changed their minds," he says. "The attitude now is very much for it, and for it continuing."
Staff on board the van see anyone who comes to them, and then act as a link between patients and their GPs. The overall client group has been very much what was expected: most of the farmers using the service have been men, aged 40-60, who are registered with a GP but have never visited the surgery. The main ailments have been related to mental health, heart or prostate problems, and muscular or bone injuries.
The van staff understand not just the medical details of conditions such as orf or listeriosis - a virus caught from sheep or goats - but practical ways to avoid or treat them. They are particularly struck by the number of patients who have been referred on to other services but still want to come back to the van because they know and trust it. As Lumb says: "When you get a man who can confide a highly personal problem, you've won."
The service, funded until July, has now been broadened beyond its original remit of farmers to cover other rural people. Along the way, it has had to cope with the unexpected and devastating challenge of the foot and mouth crisis. The effects of the epidemic included depression, financial worries and acute isolation. Farmers who had their stock culled were at least able to get out of their farms, but others felt trapped.
With the immobilisation of foot and mouth, the clinic changed some of its original function to become more of a telephone helpline, putting callers in touch with benevolent funds. After being grounded for 10 months, however, the van started to get out and about again earlier this year. Numbers are still down: before the crisis, staff were registering some 12 new patients a week, whereas now it is more like six a month. But the clinic is visiting some patients directly at home, particularly older farmers who may have seen very few people over the past months.
A lot of the problems that van staff are now treating are conditions that have been left to get worse, as farmers concentrated on the immediate crisis, at the expense of their health. There has not been a surge of explicit new mental health problems, but, as Howkins says, "as you get talking, and you talk about farming and stock, things like overdraft or money or family problems will emerge".
Restocking of farms may bring its own crises (as it did in 1967, after the previous epidemic, when there was a wave of suicides) and even getting back to the pattern of farming work may be difficult for people whose body clocks shifted away from the traditional early start.
Howkins, however, thinks that "in a way, people are looking very hopeful". She says: "They've come through a very bad time, and they do have this stoical attitude. I know two farmers who are restocking - in their 70s, after going through foot and mouth both times. They'll farm till they drop."