Opinion: Why the Safe System must work harder for rural communities

In this opinion piece, Professor Tim Nutbeam outlines the important role bystanders can play in building a Safe System that works for rural communities.

Tim is a consultant in Emergency Medicine and Prehospital Emergency Medicine based at Plymouth Hospitals NHS Trust and the Devon Air Ambulance. Tim is Professor of Emergency Medicine and Post-Collision Care at the University of Plymouth. Tim has worked on extrication and post-collision research for the last decade and is the lead for the EXIT project and director at IMPACT. IMPACT the Centre for Post-Collision Research Innovation and Translation is supported by The Road Safety Trust and Vision Zero South West.

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If you are injured on a rural road, your odds of survival are lower.

This isn’t because rural crashes are always initially more severe—but because every aspect of the Road Injury chain of Survival is negatively affected by rurality…. This is the Rural Paradox: those most likely to benefit from timely, high-quality trauma care are also the least likely to receive it.

The Rural Paradox isn’t confined to post-crash care, but its impact is especially pronounced in this final and often most critical opportunity to save a life. In this article, we explore how the Rural Paradox manifests across all five pillars of the Safe System—and why strengthening post-collision response in rural areas is key to closing the gap.

The Rural Paradox in the Safe System
The Safe System framework provides a comprehensive approach to road safety, built on the idea that no death or serious injury is acceptable. It aims to anticipate human error and reduce the impact of crashes when they do occur. But its delivery is not geographically neutral.

Across all five pillars, the Rural Paradox quietly undermines equity:

Safe Roads: Rural roads are often narrow, poorly lit, and in a poor state of repair. Visibility is reduced by hedgerows and winding terrain. There are fewer footpaths and cycle lanes. Roadside hazards like ditches and unforgiving trees can increase crash severity.

Maintenance standards and investment often lag behind urban areas. And while urban environments benefit from speed-calming infrastructure and pedestrian crossings, rural routes are commonly unsegregated and shared.

Safe Vehicles: Modern vehicles offer mostly excellent protection—but rural drivers may be less likely to own newer models. Older vehicles are more common in lower-income rural households and small farming operations. This means fewer safety features such as autonomous braking or automatic crash notification. Vehicles often used in farming such as tractors or quads pose additional risks.

Safe Speeds: Default speed limits on rural roads are often high yet these roads also carry high risk. Inappropriate speed is not just about exceeding limits—it’s about speed that’s unsafe for the conditions. Rural drivers are more likely to encounter slow-moving agricultural vehicles, animals, and adverse weather without warning.

Safe speed interventions are harder to enforce in rural areas due to fewer fixed cameras and patrols, and lower perceived risk.

Safe Road Users: Rural communities face unique challenges. Elderly drivers often continue driving longer out of necessity, and young drivers may begin earlier due to lack of alternatives. Both groups are statistically at higher risk of being involved in serious crashes.

Social and health inequalities also shape risk-taking behaviours. Alcohol use, seatbelt non-use, and driver fatigue are compounded by longer journeys and social isolation.

Post-Collision Response: The final safety net is frequently patchy, delayed, or absent.

Each of these weak points increases both the likelihood of serious crashes and the difficulty of responding to them effectively. It is in post-collision response, however, that the Rural Paradox most starkly translates into avoidable harm.

The Rural Paradox in Post-Collision Response
Post-collision care is the final chance to save a life or reduce harm. In rural areas, every link in the Road Injury Chain of Survival is weakened by geography, resources, and access.

1. Early Recognition and Call for Help

Prompt recognition is essential, yet rural crashes are often discovered late due to poor mobile signal, older vehicles without crash alert systems, and absent bystanders. Even when calls are made, describing the location can be difficult. Digital tools like eCall and What3Words help but are underused or unreliable in areas with limited coverage.

2. Early Rescue

Rural rescue services may rely on volunteers, limited equipment, and infrequent exposure to complex extrication. Entrapment is more dangerous without rapid, skilled intervention. Although self-extrication is often safe, rural responders need training and protocols tailored to local realities.

3. Early Initial Care

First responders may face long travel times, leaving untrained lay bystanders as the only immediate help. Yet few rural communities have access to the kit or training needed to treat road injury.

4. Early Transport

Distance to definitive care is a major rural disadvantage. Helicopter support is vital but limited by weather, daylight, and availability. Transport decisions are complex: should a patient be stabilised locally or go straight to a trauma centre? In rural settings, these judgments are made with less support and greater risk.

5. Early Hospital Care and Rehabilitation

Rural hospitals often lack trauma teams and key resources. Even after initial care, patients face long journeys for rehabilitation—delaying recovery and worsening outcomes. Follow-up care is harder to access, particularly for older or less mobile patients.

Addressing these gaps requires rural-focused systems, training, and resources—recognising that delayed care is not just inconvenient, but life-threatening.

Bridging the Gap: What Needs to Change
To build a Safe System that works for rural communities, we need to recognise that many of the current solutions are urban-centric—designed for dense populations, short travel times, and specialist infrastructure. In contrast, rural safety relies more heavily on local people, local knowledge, and local resilience.

Of all the opportunities for improvement, one of the most promising—and most overlooked—is the role of bystanders.

Bystander-enabled care: an untapped rural asset
When a crash occurs in a rural area, the first person on scene is rarely a professional responder. It might be a farmer, a dog walker, a passing driver, or a local resident alerted by the sound of impact. These early bystanders are often the only help available during the critical first minutes—and yet they are usually untrained, unequipped, and unsupported.

This presents both a vulnerability and an opportunity.

Bystander-enabled care—such as calling for help, making the scene safe, providing reassurance, stopping bleeding, or guiding rescuers to the location—has the potential to save lives and reduce suffering. In urban areas, professional help may arrive before this is needed.

Despite this, the evidence base for what works in bystander care is limited, particularly for trauma and road injury. Unlike cardiac arrest, where the chain of survival has long included public training in CPR and defibrillator use, trauma care has not yet translated this model to the public.

The IMPACT team, supported by funding from The Road Safety Trust, is currently addressing this gap. We are working to develop an evidence-based framework for bystander intervention in road injury, exploring what actions are safe, effective, and feasible—especially in rural settings. This includes:

• Understanding in which patients we can make a difference and what that difference is
• Identifying the psychological and physical barriers to helping;
• Understanding what enables bystanders to act effectively;
• Evaluating tools and training models that empower early intervention;
• Exploring how simple messages and resources can be embedded in vehicles, public spaces, and apps.

This work recognises that rural communities (in fact all communities!) not just an at risk group, but as an underused resource in improving post-collision outcomes.

Other essential areas for change
While bystander support is vital, it must sit within a system that is coherent, integrated, and ready to respond. To address the Rural Paradox in full, we must also act on the following:

• Local empowerment: Rural responders—fire crews, paramedics, community first responders—must be supported with context-specific training, including self-extrication techniques, trauma triage, and prehospital decision-making tailored to rural constraints.
• Smart technology: We need reliable, low-connectivity crash alert and location tools that work in rural areas, along with accessible public guidance on how to use them.
• Integrated pathways: Strong hub-and-spoke trauma systems are needed to link rural care to specialist services. This requires interoperable communication, shared decision-making, and logistics support that works across distances and sectors.
• Policy and funding reform: Rural trauma readiness carries different costs—and different benefits. Funding models and policy priorities must reflect the greater per-patient investment required to ensure equitable care, including sustainable staffing, equipment, and outreach services.
• Data and visibility: Rural trauma patients are often under-represented in datasets and policy discussions. Standardised, rural-inclusive data collection—incorporating bystander actions, scene times, and outcomes—is essential for designing and evaluating improvements.

Conclusion
Post-collision care must evolve— as a tailored, community-supported model that values its greatest assets: time, local knowledge, and people.

By recognising bystanders as the first link in the road injury chain of survival, and equipping them accordingly, we can convert moments of isolation into moments of action. The evidence is growing—and so is the opportunity.

If you would like to know more about our work, please contact me at timnutbeam@nhs.net.

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