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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: [email protected] (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:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]://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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