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Health & Place 16 (2010) 275283
Contents lists available at ScienceDirect
Hea lth & Place
journal homepage:ww w.else v ier.co m /l o c at e /he a lthpl a c e
rri torial tension s: Misal igned mana gement and community perspecti ves on
alth services for older people in remote rur al areas
e Farmera,n
,Lorna Philip b,Gerry Kingc, John Farring ton b,Marsaili MacLeod
d
re for Rural Health, UHI Millennium Institute, Centre for Health Science, Old Perth Road, Inverness, IV2 3JH, UK
gr aphy and Environment, Uni versity of Aberde en, Elphinstone Road, Aberdeen, AB24 3UF, UK
re for Rural Health, Uni versity of Aberdeen, Centre for Health Science, Old Perth Road, Inverness, IV2 3JH, UKd
Land
my and Environment Resea rch Group, Scottish Agricultu ral College, Kings Buildings, West Mains Road, Edinburgh, EH9 3JG, UK
t i c l e i n f o
histor y:ved 27 January 2009ved in revised form
ober 2009
pted 14 October 2009
ords:
peoples services
health care
figuration Service
a b s t ra c t
This
paper presents findings from a qualitative study investi gating older peoples health service provision inremo te rural Scotland. Com paring stakehol ders persp ectives, contested issues we re exposed where
commun ity memb ers, serv ice man agers and policym akers disagreed. Con sidering thes e, led to the proposal
that fundame ntal tensions exist between commun ity and management/pol icy stak ehold ers persp ectives
and these underlie service change conflict s. While high lighting issues for older peoples service design,
findings suggest that impac ts of the current pla nning process require to be understood, and aspec ts need to be
changed, before the voice of older people can inform local service polic y.
& 2009 ElsevierLtd. All rights reser ved.
ntro duction
n Scotland, remote and rural communit y-based healt h care
ces have been rega rded as a basti on of qualit y servic e provision.
e has been a high ratio of healt h professi onals in relatio n to
latio n size ,1
wit h conse quen t relative ease of acces s to
intment s (Scottish Execut ive, 2005a) and high public satisfac-
(Farme ret al., 2005). Simultaneous ly,special ised aspect s ofcare can
ifficul t to access ; for example , menta l health service s (Philo et al.,
3). Internati onally, rural servic e modernisation is urged by a neo-
al politica l respons e to con textual challenges. Policy- makers
u re that service s will remai n local ly accessibl e and high quality
ttish Execut ive,2005b), but questions remain abo ut how changin g
ces will affec t communities.
his pape r present s findings from a study of older people in
ote part s ofthe Scottish Highlands . Conduc ted as par t of a 2005
06 Europea nUnion Norther n Peripher y (EU NP) Programm e project, Our
Life as Elde rly (OLE),2
explored views of older resident s about
nCorresponding autho r.Tel.: +44 1463 255895; fax: +44 1463 255802.
E-mail address: jane.farmer@uhi.ac.uk (J. Farmer).1
The NHS Scotland Information and Statistics Division (ISD) states that
numbers of practices in the most rural NHS Boards stayed similar 19982 005
(Highland 1998: 74 and 2005: 69 pract ices; Orkn ey Islands 1998: 15 pract ices,
2005: 14; Shetland Islands 1998: 10 practices, 2005: 10) [personal communica- tion].2
Our Life as Elder ly (OLE) was a European Northern Periphery Progra mme
project, incorporating aspects of resea rch and policy design focussing on older people
in northern reg ions of Finland, Sweden, Nor way, the Faroe Islands and the Scottish
Highlands.
http://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacehttp://www.elsevier.com/locate/healthplacemailto:jane.farmer@uhi.ac.ukmailto:jane.farmer@uhi.ac.ukmailto:jane.farmer@uhi.ac.ukmailto:jane.farmer@uhi.ac.ukmailto:jane.farmer@uhi.ac.ukhttp://www.elsevier.com/locate/healthplace -
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service provisio n to infor m futu re polic y direction. There is
evidenc e abou t olde r Scottish rural community members
in a con text of rising proportions of olde r peopl e and service
e. Our previous work in rural communities highli ghted discord
en communitie s and servic e mana gers (Farme r et al., 2007); we
interested in stakeholders views and reaso ns for
itie s and diffe rence s bet ween perspect ives. An exploratory
ach was adop ted becaus e the same overall topi c was being
iga ted across the internationa l region s of OLE and we wanted to
complicatin g interview question s for internation al partici- pants
troducin g specifi c nationa l issues . Here, we present con testin g
ofcommunit y member s and planner s on key issues raised abou te provis ion for older peopl e in remote rural Scotland. We use
as evidenc e for suggestin g that there are fundamenta l
n s in squaring manageria l concern s with efficienc y with the
publi c desire for connec ted persona lised services aligne d to rural socia l
cond itions.
2. Background
2.1. Rurality and service change
Hugo (2005) describes how rural and remote, terms used
conjoint ly,actually have distinct implications. Rurality comprises a set
of social living conditions and remo teness is about inaccessibilit y.
Henceforth, we use the term rural, but as shorthand toencompass both featu res ofrural social organisation
829 2/$ - see front mat ter & 2009 Elsevier Ltd. All rights reser ved.
0.1016/j.healthplace.2 009.10.010
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276 J. Farmer et al. / Health & Place 16 (2010) 275283
inaccessibility to service centre s. The Scottish Government
es rurality in terms of population sparsity and distance from
ce cent res. The communities included here are designa ted
remote rural (Sco ttish Executi ve, 2004): areas with settle-
s of less than 3000 people and a drive time of over 60 min to a
ment of 10,000 or more, they are defined as rural in OECD
6) population sparsity terms and because their economic
vity cent res on agricultu re and services. They lack infrastruc-and their terrain is mountain, hill and moo rland. For health
the study communities experience typical rural challen ges of
l, widely dispersed clien tele, limit ed human resources, physical,
nical and economic barriers to provision (Bryant and Joseph,
1).
nte rnational ly, rural health services are being reco nfigured
ish Medical Association, 2005; Humph reys, 2008), represent- ing
atio nal responses to fundamental socio-political force s. Service
a gers must match polic y, cont ext and a budget to provide
accessible and sustainable services. Technicalisation of public
ce work is one issue underpinning chan ge in rural service
els. This is manifes ted in professional role specialisa- tion; for
mple, the NHS gradi ng sys tem rigidly delineates practice
daries (Dept. of Health, 2004). Gene ralism is a poor career
ce, with specialism linked posit ively to patient safety becausetitioners are more experienced. Supp lying specialist services in
areas is prohi bitive as large numbers of staff would be
ir ed (to comply with legal working time direct ives) and staff see
fficient patient numbers to maintain specialist skills. To
te ract negati vity about rural employ ment, working conditions
pay have been add ressed for some groups; for example, the
4 UK gene ral prac titioner (GP) contr act was part ly introd uced
imulate recrui tment, releasing GPs from out of hours working
irements and incr easing remune ration (Charlton, 2005).
Manag erialism is the application of mana gement techni ques to
ce provision and pervades con tempo rary service delivery trends
rke et al., 2000). Industrial quality mana gement techniques
influenced UK public service mana gement since the 1980s.
et setting, bureauc ratized governance and perfo r- mance
eworks were developed under the 1990s New Labournist ration, depleting health professio nals auton omy (Ex-
thy et al., 2003; McDonald and Harrison, 2004). Conte mpor-
usl y, evidence-based medicine (EBM) affected clinical practice,
cribi ng technical algori thms for care underpinned by findings
large clinical trials. Algorithmic care and volume targe ts have
me para digmatic, superseding con textual pa- tient-focused
placing mat ters of efficiency above those of equity and
ement (Hanlon and Rosenberg, 1998 , p. 559). This mass
et approach fails to incorpora te differing priorities that steer
ens healthcare choices, including access to transport or
imity to relat ives (Fotaki, 2005).
UK public service provision follows neo-libe ralism, a political
da prescribi ng withd rawal of the state and encou rage ment of
vidual and community responsibilit y. Scottish government policy
s that the National Health Service (NHS) is a mutualciation owned by diverse stakeholders (Scottish Government,
7). Rural health policy seeks resilient communities (NHS
land Remo te and Rural Steeri ng Group, 2008), suggesti ng
ens should participa te, for example, in self-care and commu-
first responder schemes.
Worldwide, similar approach es to rural healthca re reconfig ura-
have often resul ted in centra lisation (Fraser et al., 2005;
gall, 2005), outre ach rather than in-situ services and citizen
lvement. Resistance to reco nfiguration is also international ly
fes ted, resulting in conflict bet ween rural citizens and
ce managers (ABC News, 2007, 2008; Thomson et al., 2008).
cal ly, policymakers tell rural residents that they will rece ive
the same quality of services as urban citizens, though they may be
accessed through new types of providers and techno logy (NHS
Scotland Remo te and Rural Steering Group, 2008). Local people
tend to reject this chan ge (Farmer et al., 2007), fearing a locally
adap ted model provided by locals will be replaced by peripa tetic
teams of specialists and impersonal tele- services. Citizens
associa te reco nfigura tion with threa tened community sustain-
abilit y, perhaps justifiably as resea rch from other countries hashighligh ted the burden, for rural communities, of dealing with
neo-libe ral rural service models (Skinner and Rosenberg, 2006;
Hanlon et al., 2007).
2.2. Service requirements of older rural people
High proportions of older people livi ng in rural areas
aggr avates service provision challen ges. Older people tend to
experience compl ex long- term conditions demanding ongoing, and
inter mittent ly acute, support to ensu re stability (Elkan et al.,
2001). There is no general ly acce pted definition of an older
person. In the UK, using the state pension agecurrent ly 60 for
women and 65 for men,3
is a pragmatic solution. OLE
included those aged 55 and over, incorporati ng a pre-retirement
perspect ive, acti ve and independent and frailer ind ividuals
(Scot tish Executi ve, 2007). By 2025, Scotland is projected to
have 30% of its population aged over 60, compa red with 27.4% for the
UK, a figure compa rable with Germa ny, Spain and Italy
(Raeside and Khan, 2008). For the Highland Council area where this
study was located, mid-2 006 population estima tes showed
25.3% of the population was of pensionable age (GRO-Scotland,
2007, p. 54). This is projected to incr ease by 51.3% by 2031,
compa red with a Scot tish incr ease of 31.2% (GRO-Scotl and, 2008).
National and regi onal demog raphic statistics obscure smaller
scale patte rns influencing local service deli very. One Highland
area, Ross and Croma rty, is projec ted to see a 149.4% increase in
its over 75 population between 2006 and 2031 (Highland
Council, 2008).
In the UK, pre or immedia te post- retire ment mig ration is
common, with relocation to rural Scotland percei ved as offering
quality of life benefits (Richar ds and Farme r, 2003). UK rural
demog raphic ageing is predominantly attributable to the out-
mig ration of younger people, ageing of local residents and the in-
mig ration of middle-a ged and reti red people who then age in situ
(Commission for Rural Communities, 2004). Older in-mig rants
may give scant thought to future care needs (Richards and Farme r,
2003), while their relocation can crea te considera ble pressure for
service providers because small differ ences in population needs
impact considera bly on staffing levels required. Rural health and
social care workers have inconsis tent workloads: they may be
required, for example, to provide intensi ve palliat ive care for a period,
follo wed by a time of light workload. This challenges service
mana gers in designing sustainable jobs.
In Scotland, rural areas have the highest proportions of older
people,4
but little is known about how being older may be
differ ent in rural or urban areas. The wlis (2001) found that older
rural people apprecia te continuity of place and inte rdependence.
Older people are the larg est group in income poverty in rural
3Between 2010 and 2020 the state pension age for women wi ll
increase to 65. The StatePension age for both men and women will increase from 65 to
68 between
2024 and 2046. /ht tp: //th epensionservice.gov.uk/state-pens ion/ home.aspS4
In Scotland, for the years 20012 005, over a quarter of the population in
pred ominantly remote rural local authority areas (Dumfries and Gall oway,
Western Isles, South Ayrshire, Argyll and Bute and the Scotti sh Borders) we re
aged 60 or over but under a fifth of the population in the high ly urbanised local
authorities (including West Lothian, North Lanarkshire and Edinburgh) we re over60 (GRO-Scotla nd, 2007).
http://thepensionservice.gov.uk/state-pension/home.aspShttp://thepensionservice.gov.uk/state-pension/home.aspShttp://thepensionservice.gov.uk/state-pension/home.aspShttp://thepensionservice.gov.uk/state-pension/home.aspShttp://thepensionservice.gov.uk/state-pension/home.aspShttp://thepensionservice.gov.uk/state-pension/home.aspShttp://thepensionservice.gov.uk/state-pension/home.aspShttp://thepensionservice.gov.uk/state-pension/home.aspShttp://thepensionservice.gov.uk/state-pension/home.aspShttp://thepensionservice.gov.uk/state-pension/home.aspShttp://thepensionservice.gov.uk/state-pension/home.aspShttp://thepensionservice.gov.uk/state-pension/home.aspShttp://thepensionservice.gov.uk/state-pension/home.aspShttp://thepensionservice.gov.uk/state-pension/home.aspShttp://thepensionservice.gov.uk/state-pension/home.aspShttp://thepensionservice.gov.uk/state-pension/home.aspShttp://thepensionservice.gov.uk/state-pension/home.aspShttp://thepensionservice.gov.uk/state-pension/home.aspShttp://thepensionservice.gov.uk/state-pension/home.aspS -
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Fig. 1. European North ern Periphery Prog ramme Regions (Interreg IIIB), left, and location of the study region and study areas, right.
in (Philip and Gilbert, 2007). Access to public transport is
lematical (Wenge r, 2001) and over75s are less likely to own their
cars than youn ger adults, resulting in difficulty reac hing advice,
mation and key services (Philip et al., 2003). Movi ng to support ed
mmodation often requires removal from rural communities (Philip
al., 2003), making it difficult to retain social connections.
versel y, older rural residents are more secu re from crime,
pa red with their urban counte rparts (Scottish Executi ve, 2000a).
mpacts of ageing on service provision are often portr ayed
a lyptical ly. Inte rnational ly,public expenditu re is two to three times
er for the aged than for the young (Gee, 2002). Older people,
cial ly the very old, are more like ly than other age groups to
ire a compl ex pat tern of inputs from a range of services. A high
ortion of older people repea tedly readmitted to hospital sug gests
fficient community support (NHS Scot- land, 2002). Policy promo tes
people living independent ly at home and urges joined-up working
ween the caring agenc ies (Scottish Executi ve, 2000b).
ultaneous ly, the delineations bet ween health and social care tasks
quite strict ly defined, making joint working compl ex for workers
those cared-fo r. Apoca lyptic demog raphy has been challen ged,
suggestions made that older people are undemanding and
ient. Although older people in Scotland may appear burdensome
he state, rece iving ifeligible, free home nursing care, personal care or5
as well as free health care, it has been noted that it is a small
ortion of older people that are intensi ve users of expensi ve
alised services (Wilson et al., 2005). Evans et al. (2001) have noted
new technologies and pharmaceutic als account for much of risingce provision costs. With impr oved health the
ungold are acti ve participants in societ y, taking on caring roles
volunt eering (Philip et al., 2003 ).
Planning rural services for older people
is frequent ly said that older people should have a grea ter
e in service planning as their experiences and priorities can be
nders tood (Joseph Rowantree Foundation, 2004; Age
Concern, 2006). The current rural policy paradigm supports territorial
planning, that is a place-based focus for dete rmining service provision,
economic planning and development (OECD,
2008). This reflec ts the interconnec tedness of rural life and reco gnises
the uniqueness of diverse rural con texts (Pezzini,
2001; Kitson et al., 2004). There is deba te about how terri torial
planning could happen, with questions raised about the exte nt to which
local people want to participa te in community governance (Shortall,
2008). Given the prevalence of older people in rural communities,
the lack of resea rch interest in the role of older people in rural
terri torial planning is surprising.
3. Methodology
3.1. The case study communities
Part of an EU NP Project, this study was located in the Highland
Council area. With an expanse of 39,050 km2
and a population of
373,000, it is one of the most sparse ly popula ted EU regions
(Highlands and Islands Enterp rise, 2008 ).
Two communities were selected as case studies with the potential
to highlight views rela ted to inaccessibility to service cent res and
staffing challen ges (see Fig. 1). These met prag matic cri teria in that,
first ly, they were remote rural sites and, second ly, project partners
Highland Community Care Forum (HCCF) had workers located in the
villa ges who could assist us with identifying study participantsand participating in data collection. Case study Site 1, a community of
appr oxima tely 400 people, is on the north coast. Case study Site 2 is on
the north- west coast and has appr oxima tely 900 inhabitants.
Their settlement structure is one of dispersed cott ages and coastal
strip housing, often linked to crofts .6
In 2005, Site 1 had 29.9% ofthe
population aged over 65 and Site 2 had 24%, compa red with Highland
and UK proportions of 16.7% and 16%. Both sites have a community
general practice providing 24/7 cover. Both are within
70 miles of a Rural District General Hospital and have day care
facilities. Site 2 has nursing home facilities.
Personal care is intimate care, including wa shing and toileting. Nursing care
es the skills of a trained health profe ssional. Domestic help includes cho resd the house and shopping.
6Crofting is a sys tem of landholding uni que to the Highlands and
Islands of Scotland. /http://ww w.crof terscommission.org.uk/What-is-Cr ofting.as pS It
in- volves a small agricultu ral land holding (commonly around 5 ha), normally held in
tena ncy and perhaps with associated buildings.
http://www.crofterscommission.org.uk/What-is-Crofting.aspShttp://www.crofterscommission.org.uk/What-is-Crofting.aspShttp://www.crofterscommission.org.uk/What-is-Crofting.aspShttp://www.crofterscommission.org.uk/What-is-Crofting.aspShttp://www.crofterscommission.org.uk/What-is-Crofting.aspShttp://www.crofterscommission.org.uk/What-is-Crofting.aspShttp://www.crofterscommission.org.uk/What-is-Crofting.aspS -
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278 J. Farmer et al. / Health & Place 16 (2010) 275283
Fig. 2. Summary matrix of stakeholder views.
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Data collection methods
LE involved five participant EU NP regi ons investigating older
les views about health services. Each participant region, other
ours in the Scottish Highlands, included local gover nment
esentati ves. Our university -led Scottish team was challen ged by
partners to involve service mana gers and policymakers so that
ngs could influence polic y. We did this by engaging managers andymakers in discussing findings from inter views with older people.
h ethical commit tee approval, an explo ratory qualitat ive research
gn was adopted. Inte rview data were gathe red from older people,
ing on opinions about health services. These data were used to
ve themes about services that were then discussed with service
iders, service mana gers and policymakers. This app roach allowed
holders to respond to older peoples viewpoints in a non-
rontational situation. Differing perspecti ves on service provision
revealed which, in turn, allowed us to consider unde rlying
ons.
irstl y, semi-structu red face- to-face intervi ews were held with
men and 11 wome n: age range 5587 (median 64, mean 67), even ly
between the two study communities. Partic ipants were
uited with the assistance of the HCCF. To include differ ent
ws, our sample included varying socio-economic background, lengthsme lived locally and levels of community involvement. Partic ipants
app roached by researc hers once initial consent was obtained by
F workers. Intervi ews lasted for about 1 h and were conduc ted in
les homes. A topic guide covered experiences of local health
ces, individu als wants rega rding key attributes of future services,
role of technology and the role of family and the community in
orting older people.
ssues raised by participants were consiste nt within and between
study site s. The most frequently repea ted themes emer gent from
intervi ews with older people we re used to form a topic guide for
cond phase of inter viewing; this time, with health and social care
itioners. In these, participants were asked questions in the
at: The older people we spoke with thought X, what do you think
t that?. Inte rviews lasted bet ween 4060 min. Practiti oners were
ified by contacting gene ral practices and requesting that a GP, ae, a home care worker and a healthca re assistant be nomina ted.
residential care home mana ger at Site 2 was also intervi ewed. This
e a total of nine phase 2 (service practitioner) interviewees: two
two community nurses, two home care workers, two home care
tants and one residential care home manage r. A further iteration of
vi ewing (phase 3) involved a similar process with service mana gers
politicians. These comprised the Heads and Deputy Heads of
artments providing health and social care services for older people
Highland (four inter viewees), three local authority councillors and
local Members of the Scottish Parliament (MSPs) (representing
tish Nationalist Party (SNP), Green Party and Labour Party) with a
d interest in older peoples services. All persons who were
oach ed consented to be intervie wed.
nte rviews were reco rded and transcri bed verbatim. Data analysis
wed frame work anal ysis (Ritchie and Spence r,
), adap ted to accommoda te our iterative approach. The transcrip ts
m inter views with older people were read inde- pendent ly by
researche rs and a thematic coding schedule was developed based
issues raised consis tently by respon- dents (for example chan ge to
ls-on-wheel s service and high satisfaction with GPs). Data were
d, using NUnDIST soft ware for mana gement. Data were scrutinised
similar and divergent perspect ives, but there was strong
verge nce of themes amongst the transcri pts. Interview data from
ce providers,
service mana gers and policymakers were then compa red against themes
raised by older people. Relationships bet ween older peoples and
other stakeholders responses were then explo red. A summary matrix
(see Fig. 2), encapsulating resp onses of stakeholder groups, was
circulated to participants for verification.
3.3. Findings
The inter view guide for older people asked about health services,
but responses ranged across topics including formal social care,
informal helping, housing, transport and meals provi sion, appa rently
indicating perceived interconnection ofmany aspects of community
life and wellbeing. Here, we report the most consiste nt emer gent
issues about services from inte r- views with older people and juxtapose
these with the reac tions ofhealth and social care providers, managers
and politicians to highlight where there were differing perspecti ves.
Issues are grouped into three broad themes: where older people should
live; the way that services should be provided; and who should care
and help.
3.4. Where should older people live?
Reflectin g other studies , olde r peopl e emphas ised the importance of
living independent ly in their own home s if possible (Cloutier- Fishe r
and Joseph ,2000; Harrefor s et al., 2009). Healt h profession als confirm ed
that olde r local residents and more recen t incomer s were fiercely
independen t and largely undemandin g of services . If needs necessita ted
moving,mos t intervi ewees emphasis ed the importance of staying in thei r
commun ity. Som e raise d the impo rtanc e of the view from their window
and being near friend s (alive and dead). Reflecting on how older people
needin g extende d care have to leave thei r communit y and go to live at
considerable distance , in a variety of different residentia l facilitie s,
interviewees sai d tha t onc e older residen ts leave, others accep t they
will not return . Removal was described as depressing for the older
perso n and for thei r friend s and relat ives who becom e separated by
distanc e. It was suggested that importan t social, cultu ral and historica l
asset s were lost to commun ities when a long- term local residen t had toleave to live in a care home.
ywhere somebody got to that stage when they had to go into care.
They went to Invergo rdon or some where like that y The day they
went in there was the last day they would see their villa ge that they
loved (Male aged 60)
Inte rviewees wanted small local residential care facilities so that,
even when very infirm, older people could remain in their communit y.
Health professionals recognised the significance for older people of
staying locall y, but noted times when the level ofcare required meant
this was impossible (e.g. for those needing dementia nursing care).
Service managers noted that older peoples desi re to live
independent ly aligned with policy promoting act ive ageing and self-
reliant living (Scottish Execut ive, 2007). Mana gers interpre tedexpr essions of a desi re for independence to mean that older people
agre ed with their policy of focusing on home care and disin vesting
in rural residential care; however, community members still
wanted local residential care for those who could no long er cope at
home. Mana gers noted that supporting frail people at home was
complica ted by poor private housing conditions in the remoter
Highlands,7
but aspi red to develop
7Research by Scotti sh Homes, Communities Scotland and the Commission for Rural
Communities has identified a high proportion of private housing below tole rable
standard in remote rural areas.
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280 J. Farmer et al. / Health & Place 16 (2010) 275283
ing with integral social and e-monito ring support. Service
a gers and councillors thought that more of those current ly in
dential care could be livi ng at home, sug gesting older people were
times placed in residential care to meet their distant relat ives
res to know they were secure , rather than from need. In 2001,
number of people, per 1000 population, aged 65 and over in
ential care in Scotland was 17, while in Highland Council area it
23 (Scottish Executive, 2001).Considering small local care facilities, two MSPs (SNP and
our) and all councillors and service mana gers stated that these were
stainab ly expens ive at per person costs aro und four times
expensi ve than in larger facilities (in 2006, the average
weekly cost of a local authority care home place in Highland
cil area was 612, compa red with an average of
2 for Scotland) (Sco ttish Government, 2004). Due to sporad ic client
ughput, care facilities were said to ope rate below capacity and
recruitment was difficult. Suppor ted housing was promoted as
most feasible option. Service managers stated that their goal, in
ating resources, was achieving the most gain for the most people:
The problem is that residential care, especial ly in remote and rural
reas where the numbers of beds are low, it is extremely expens ive
y We have closed y resi dential beds because they were costing
lmost 2000 a week per person y If we are given the mon ey
we will not be spending it on two or three beds in a remo te
reay Councillor 2
You have got to decide ondo you disad vanta ge that very small
roup of people who may have to travel a bit further so that you
an continue to maintain the people in that community so
hey dont have to movey that is the very difficult decision that
ouncillors have to makey Councillor 1
At the time of the stud y, Highland Councils policy was to focus on
e care ironicall y, with a political leadership reorientation in 2007
peoples care policy has chan ged and Highland Council is now
eloping some rural residential care facilities.
How should services be provided?
Meals-on-whee ls provision (the del ivery of meals to people who
it difficult to prepare a meal at home) was raised frequent ly by
inter viewees as an example of what they did not want to, but
ed would, happen to services in the futu re. In the rural Highlands,
used to be cooked locally and del ivered by volu nteer s. In 2004 a
land Council policy decision was taken (also by other Scottish
authorities) to replace the
ls-on-wheel s service with frozen meals, produced and delivered
thly or fortnight ly by staff of a pri vate compa ny. Meal provision
ed from being a visiting volu ntary service to one consisting of
iding a freeze r, a micr owave oven and a fortnight ly delivery of a
n meal suppl y.
nte rviewees liked food being cooked and del ivered by volunt eers,l y. They sug gested that the meals are, in a sense, incidenta lit is
they and the service around them repres ent that is critical. This
aving someone local visit reg ularly with whom news and chat
be exchanged, a connection providing social contact to those
e mobility is restrict ed. Intervi ewees thought that the way meals
now provided was impersonal and symbolic of societys lack of
e of older people.
y a few times I did meals on wheels myself. When you went
ou nd to some of the old peoples houses you had a job getting away
y You would have a dozen meals still to del iver and they were
wanting to sit and have a wee blether because they were quite
sola ted (Male aged 72)
Health and social care professionals said the new meal
provision model neglect ed elements of social support and day- to-
day surveillance. Service managers had a differ ent view and were
support ed by most of the local councillors, one of whom said:
I think there are two things there. The need for a meal and the need
to meet people. The two are not the samey If a care plan is saying
that Mrs. MacKay needs a meal, she needs a meal seven days aweeknot once a week when it can come from the school kitchen
or something like thaty If all she needs is social contact, then you
need to build that into the care plany Councillor 1
Service managers thought service users unde restima ted the
challen ge of providing meals across the Highlands. Chan ge was
requir ed because the old scheme did not meet health and safety
requirements: del iveri ng consiste ntly hot meals in a rural area at
lunchtime was difficult. Some people got their meals ear ly and
reheated them; others rece ived meals in the afte rnoon when they had
got cold and reheated them. Some of the food prepared was of poor
nutritional quality (pink custa rd and like school meals) and it was
difficult to recruit volunt eers in some areas meaning that regional
coverage was inconsis tent. Local councillors thought a good meals-
on-wheels service was ideal, but overly challenging to provide.Technology is increasi ngly propos ed as part of the solution to home
care for older people. Inte rviewees acce pted that technol- ogy would
incr easing ly featu re in futu re care, but they feared impersonal,
technical, solutions being implemen ted as the whole, rather than part
of, the service.
I think it (tec hnology) has its place as long as we do not lose the
actual face-to-face contact as well. It is not a replace ment y
certain ly it is not an alter native to the real thing (Female aged 60)
Inte racting with health and care workers was regarded as social ly
and emoti onally beneficial. Inte rvie wees stressed the value, in
isola ted settings, ofmaintaining personal and social connections. Ma ny
houses were second homes and, in winte r, there might be few people
living close by to talk to or to keep an eye on neighbours.
Service mana gers and politicians thought that techno logy would
incr easing ly support livi ng in rural area s. Health professionals agre ed
that techno logy was part of future health- care, but rei tera ted the
social and sur veillance aspects of personal interactio n, as well as
the therape utic aspects. A visit to an older persons home has
added value that could be overlooked if replaci ng the appa rent
health or care inter vention with a phone call or a moni toring device.
Health pro fessionals, in particula r, have legitimised access to pri vate
homes that few others enjoy.
3.6. Who should provide care and help?
Changes have occur red recently in the provision and term inol- ogyof care in the UK. Home carers now conduct personal care tasks such
as washing and toileting, with domestic care rs designa ted to assist
with household tasks. Older interviewees expressed unease at home
care rs carrying out intima te aspects of care. They thought that
nursing assistants should undertake these tasks. Seve ral sugges ted
that one generic worker,combining social and health care, but from a
nursing backg round , was a sensible, multi-functional, solution. There
was frust ration with
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current division of labour:
yyou seem to have differ ent care rs for differ ent jobs y the
arer just does certain things and she is not allowed to do
nything else. Sometimes you dont need them to do a lot and
ther times you need them to do things that you cann ot do
ourself. The re seems to be a rule that they are only doing one
hin gy (Male aged 60)
Health and social care professionals repor ted that they were
king to reduce multiple professional and carer visits. Most of the
ce mana gers and politicians thought that those with nursing
should not conduct the tasks of home (social) care rs;
er, they should be depl oyed on specific nursing profession tasks.
e expr essed the dilemma about an efficient model of care:
yI have heard of nurses in remote communities going in and
iving people baths because there is no-one to do it. Is that the
most efficient use of a trained nurses time? In some respects you
an argue, yes, because while you are doing that, you are doing an
ssessmentybut ifthat person actually does not have any nursing
eeds other than a bath, then is it appropriate? If that person is
aving that nurse spending an hour at their house doing
verything that they need, then who is carrying out the nursingeeds ofthe person down the road? Service Manager 4
n spite of provisions of their cont ract, GPs in the two study
munities had opted to continue 24/7 cover. Older people
eciated this and they and local health professionals wanted
cover to continue. GPs and nurses discussed how working
bo ratively with colleagues from other agenc ies was key to
iding services that looked joined-up to their recipie nts. They
d that, although services often did not integra te well at the
a gement level, they could make things work locally .
oliticians and service mana gers apprecia ted the benefits ofGP out-
ours cover, but said local people would have to become more
reliant. They sug gested that GP cover was unsustainab le and that
nuous care will disappear as older health profes- sionals retire.
as ackn owle dged that services are often worked out on then d because of confusion bet ween differ ent mana gers and,
ite a perception of collabo rative relati onships at stra tegic level
a gement, co-ope ration disinte grated when budge ts were
lved.
Discussion
We set out to explo re issues for rural older people that would
m future policymaking around service provision. In doing so, we
aled service areas that were contested bet ween rural
munities and mana gers and policymakers. Looking across
, we identified some recurri ng tensions that appeared to
rlie disag reements. We prese nt these here and suggest that
may be fundamental to understanding the gap bet ween
ent methods ofplanning and managing to actual ly implement new
ce provision models. If older peoples voices are to be
ningful ly incorpo rated into planning and developi ng new rural
ces, these require to be acknowledged as legitima te and
essed.
Tensions in management appr oach: divided vs. connected
here is a tension between the way that community members
ract with services and the ways that services are planned and
a ged. Community members discussions crissc rossed be- twe en
h services, social care, transport, meals and housing,
showing an interconnec ted understandi ng of these topics. They
app recia ted the added value aspects of services: visits by health and
care profes sionals were noted as having a social inte raction
dimension, for example. In contr ast, policymakers and mana gers saw
needs as silo-ed technical inputs; for example, a councillor said
meals are about nutrition and social interaction is a differ ent input.
The challen ges caused by the divisionist tendencies of
technicalisation and mana gerialism are revealed, with mana gersstruggling to provide delinea ted specialist functions (nursing, nutrition,
social care, social interaction inputs) in a cont ext where citizens see
interconnec tion, where services have previous ly been provided
connec tedly and where local health and social care professionals say
they still ende avour to join-up services on the gro und. Given
difficulties, including recr uiting specialists and maintaining their
skills, divided service provision appears in- appropria te for our
study communities. Combining service inputs could cut costs and
provide sustainable portfolio jobs in rural area s.
4.2. Tensions in solution size: regio nal vs. local
Community members and local service providers described how
provision on the gro und occur red thro ugh combining differ ent local
service providers and neighbours. Thus, organisa- tion of provi sion is
neg otiated and embedded within the local social context
(Granovette r, 1985 ), manoeuvring around European and national
structure s. Some aspects are so monolithic that they cann ot be
adap ted for local pre fere nces (e.g. the new model for meal
provi sion), but other national agre ements are adap table, notably
24/7 cover by GPs. The situation exemplifies suggestions of Malpas
(2003) who argues there has been a move in service provision
planning from a place/con text focus to an abst ract,
spatial, efficiency orientation.
4.3. Tensions in resource allocation philosop hy: utilitarianism vs.
communit y-cent red
In this stud y, service managers and policymakers displ ayed a
utilitarian philosop hy of resour ce allocation, stating that resou rces
should be alloca ted to provide the most satisfaction for the most
people. Community members, conversel y, were focused on how local
people could stay in their communities and did not suggest issues of
how resources might be shared across the regi on. While councillors
expressed concern over the unsustainable cost of small local
facilities, they neglec ted ine quitable access to residential care
facilities across the vast Highland regi on. The question might be
asked: why should an older person in Inverness (the Highland capital,
population 45, 000), for example, be able to move to resi dential care
within their communit y, yet someone from North -west Suthe rland
(34 h drive from Inver ness) be unable to do so? Both places are
on the Scottish mainland and share the same local authority andNHS Board. Hanlon et al. (2007) highlight the particular tyranny of
numbers associa ted with service cent ralisation that disad vantages
rural communities. Con tempo rary policy loose ly addresses equity,
suggesting equiva- lent outcome should be expected, rather than
equivalent service experience (NHS Scotland Remo te and Rural
Steering Group,
2008). It is somewhat ambiguous what this actually means, but
presumab ly that citizens in differ ent places may obtain their
services through differ ent providers or via a differ ent patient
journ ey, but they should emerge equally well; for example, in a
remote area it might be bet ter to airl ift an inju red person rather than
send an ambulance.
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282 J. Farmer et al. / Health & Place 16 (2010) 275283
Tensions in knowledg e: management experts vs. community
rts
A further tension lay in communities we want what we have
pect ive and service manager s reconfigu ration preferenc es. In
stud y, locals liked what they had known because they
ei ved it to work for them. Simultaneous ly, as in the case of
s on wheels, mana gers and councillors illust rated whytional solutions no long er worked due to regula tion or
lation impe ratives, such as failing to meet health and safety
da rds. Mana gers also showed that they access compa rative
mation (for example, the costs of provision of differ ent types of
when considering option s. Thus, the re is incongruence
ween the type of knowledge steering citizens decision-making
the type that service mana gers and politicians use. Incompat-
y between lay con textual knowledge and expert facts has
highlighted as a source of disco rd in service provider public
gement (Hea ly, 2008).
What does our ana lysis suggest for engaging older peoples
e in rural service policymaking? Advocates for terri torial
ning might view community members bricola ge tactics in
ructing services locally to fit their needs as evidence for
uting place-based governance. Had local (sub-local govern-unit) gover nance been in place, communities could have
ned their own local solutions to service deli very challen ges.
tions to providing a meals service might have result ed in
rse solutions such as developing a social enterprise or
lishing a lunch club. On the other hand, we found
rnalistic attitudes to service provision among older people and
service providers (expressed in, for example, desi re for
on-call GPs and personal care from nurses), suggesting work
ld be required to persuade people about more participat ive
els of governance and service delivery.
egardi ng our study methods, inter views with older people
ided rich data on wants for services in settings where service
very systems are pushed to their limits. Using this data to
views of other stakeholders was beneficial as it: (a) focused
tioning on the real issues as seen by older people; and (b)ed to inform and enga ge stakeholders in discussing older
les views as well as eliciting their views. The findings, based on
(in ma ny ways, relat ively homo geneous) locations with
ssible residential care and a 24/7 local gene ral practice may not
y all of rural Scotland. Other communities, with differ ent service
ssibilit y, may have divergent opinions. While lacking urban
pa rator site s, we sug gest that aspects of our findings are
nctly rural/ remo te and would not be manifest in urban/
ssible settings. In cities, providing service specialisation is
ent because populations are large and co-loca ted. Service
are more like ly to be able to access tran sport alternat ives to
h service options. They are less likely to know their providers or
used to neg otiating provision with them. Far from service
nat ives, rural resi dents may be mo re tenacio us in holding on to
existing services, seeing chan ge as threa tening the very
lity of their communitys futu re.
Conclusion
n this paper we sug gest tensi ons that result from a misfit
ween the way communities live and the ideology and methods
ng manage ment and polic y-making. If the voices of local
le are to truly be incorpo rated in service design, then the first
is to ack nowledge that rural citizens have a distinct and
ma te perspect ive that aligns with their desi re for quality of
in sustainable communities. Place-based policy might help
uce app ropriate services and fewer dispu tes bet ween
mana gers and community members, by allowing an arena for
information exchan ge, discussion and building relati onships bet ween
stakeholders and for identifying local priorities. Pilots of differ ent
ways that rural community members, and in particular the
array of rural older peoples voice s, could be incorpo rated in local
service planning and governance (including budget-holding), would
be an inte resting next step. Incorpo rating rural community voices
should contribu te to creati ve solutions as local people respond totheir own challen ges with con textuall y- achie vable solutions. Taking
more ambitious steps in local governance would show the degree to
which mutuality in service planning and provision is realisable,
its effects and whether
bet ter services emerge from formal local governance.
Ackno wledgements
The authors would like to acknowled ge the community
members, service providers, mana gers, councillors and politicians
who were intervi ewed and gave feedba ck. We thank the EU
Northern Periphery Prog ramme for funding the Our Life as Elder ly
(OLE) project. Alison Sandison drew the maps in Fig. 1.
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