Health & Place 16 (2010) 275–283

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Hea lth & Place

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Terri torial tension s: Misal igned mana gement and community perspecti ves on
health services for older people in remote rur al areas
a, n b
Jane Farmer , Lorna Philip , Gerry King c, John Farring ton b, Marsaili MacLeod d

a
Centre for Ru ral Health, UHI Millennium Institute, Centre for Health Science, Old Perth Road, Inverness, IV2 3JH, UK
b
Geogr aphy and Environment, Uni versity of Aberde en, Elphinstone Road, Aberdeen, AB24 3UF, UK
c
Centre for Ru ral Health, Uni versity of Aberdeen, Centre for Health Science, Old Perth Road, Inverness, IV2 3JH, UK
d
Land

Economy and Envi ronment Resea rch Group, Scottish Agricultu ral College, Kings Buildings, West Mains Road, Edinburgh, EH9 3JG, UK

a r t i c l e i nf o a b s tr a c t

This
Article histor
Recei ved 27 y:
January 2009 paper presents findings from a qua litative study investi gating ol der peo ple’s he alth service pr ovision in
Recei ved in rev ised form remo te rural Scotland. Com paring stakehol ders’ persp ecti ves, contested issu es we re exposed where
8 October 2009
commun ity memb ers, serv ice man agers and policym akers disagreed. Con side ring thes e, led to the proposal
Acce pted 14 October 2009
that fu ndame ntal tensions exist be tween commun ity and management/pol icy stak ehold ers’ persp ecti ves
and these underlie service change conflict s. While high lighting issues for older people’s service design,
findings suggest that impac ts of the current pla nning process require to be understood, and aspec ts ne ed to be
changed, before the voice of older people can inform local service polic y.
Keywords:
& 2009 Else vier Ltd. All rig hts reser ved.

Older peoples services

Ru ral health care
Reconfiguration Service

1. Intro duction 06 Europea n Union Norther n Peripher y (EU NP) Programm e project, Our
Life as Elde rly (OLE),2 explo red views of olde r resident s about
In Sc otland , remote and rural communit y-based healt h care n
Corresponding autho r. Tel.: + 44 1463 255895; fax: + 44 1463 255802.
servic es have bee n rega rde d as a basti on of qualit y servic e provision. E-mail address: jane.farmer@uhi.ac.uk (J. Farmer).
There has been a high rati o of healt h professi onals in relatio n to 1
The NHS Scotland Information and Statistics Division (ISD) states that
populatio n size ,1 wit h conse quen t relative eas e of acces s to numbers of practices in the most rural NHS Boards st ayed similar 1998–2 005
appointment s (Scottis h Execut ive, 2005a) and high public satisfac- (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].
tio n (Farme r et al., 2005). Simu ltaneous ly, special ised aspect s of care can 2
Our Life as Elder ly (OLE) was a European Northern Periphery Progra mme
be difficul t to access ; for example , menta l healt h service s (Philo et al., project, incorporating aspects of resea rch and policy design focussing on older people
2003). Internati onal ly, rural servic e ‘modernisation ’ is urged by a neo- in northern reg ions of Finland, Sweden, Nor way, the Faroe Islands and the Scottish
libe ral politica l respons e to con textual challen ges. Policy- maker s Highlands.
reassu re that service s will remai n local ly acc essibl e and high qualit y
(Scottish Execut ive, 2005b), but question s remain abo ut how changin g
serv ices will affec t communities.
This pape r present s finding s from a study of older people in
remote part s of the Sc ottish Highlands . Conduc ted as par t of a 2005–
healt h ser vice provisio n to infor m futu re polic y direction. The re is publi c desi re for connec ted persona lise d serv ices aligne d to rural socia l
littl e evidenc e abou t olde r Sc ottish rural com munity member s’ cond itions.
views in a con text of rising proportio ns of olde r peopl e and service
chan ge. Our previou s work in rural communities highli ghted disc ord
bet ween communitie s and servic e mana gers (Farme r et al., 2007); we 2. Bac kground
were interested in stakeholders ’ views and reaso ns for
similaritie s and diffe rence s bet ween perspect ives. An expl oratory 2.1. Rurality and service change
app roach was adop ted becaus e the same overall topi c was being
investiga ted across the internationa l region s of OLE and we wan ted to Hu go (2005) describes how ‘rural’ and ‘re mote’, terms used
avoid complicatin g interview question s for internation al par tici- pant s conjoint ly, actually have distinct implications. Rurality comprises a set
by introducin g specifi c nat iona l issues . Here, we present con testin g of social living conditions and remo teness is about inaccessibilit y.
views of communit y member s and planner s on key issues raise d abou t Henceforth, we use the term ‘rural’, but as shorthand to
ser vice provis ion for olde r peopl e in remote rural Scotland . We use encompass both featu res of rural social organisation
thes e as evidenc e for suggestin g that there are fundamenta l
tension s in squaring manageria l concern s with efficienc y with the

1353-829 2/$ - see front mat ter & 2009 Elsevier Ltd. All rights reser ved.
doi: 10.1016/j.healthplace.2 009 .10. 010
 276 J. Farmer et al. / Health & Place 16 (2010) 275–283

and inaccessibility to service centre s. The Scottish Government ‘the same’ quality of services as urban citizens, though they may be
defines rurality in terms of population sparsity and distance from accessed through new types of providers and techno logy (NHS
service cent res. The communities included here are designa ted Scotland Remo te and Ru ral Steering Group, 2008). Local people
‘very remote rural’ (Sco ttish Executi ve, 2004): areas with settle- tend to reject this chan ge (Farmer et al., 2007), fearing a locally
ments of less than 3000 people and a dr ive time of over 60 min to a adap ted model provided by ‘locals’ will be replaced by peripa tetic
settlement of 10,000 or mo re, they are defined as rural in OECD teams of specialists and impersonal tele- services. Citizens
(2006) population sparsity terms and because their economic associa te reco nfigura tion with threa tened community sustain-
act ivity cent res on agricultu re and services. They lack inf rastruc- abilit y, perhaps justifiably as resea rch from other countries has
ture and their ter rain is mountain, hill and moo rland. For health highligh ted the bu rden, for rural communities, of dealing with
care, the study communities experience typical ‘rural’ challen ges of neo-libe ral rural service models (Skinner and Rosenberg, 2006;
small, widely dispersed clien tele, limit ed human resour ces, physical, Hanlon et al., 2007).
technical and economic barriers to provi sion (Br yant and Joseph,
2001).
Inte rnational ly, rural health services are being reco nfigured 2.2. Service require ments of older rural people
(British Medical Association, 2005; Humph reys, 2008), rep resent- ing
operatio nal responses to fundamental socio-political force s. Service High pro portions of older people livi ng in rural areas
mana gers must match polic y, cont ext and a budget to provide aggr avat es service pr ovision challen ges. Older people tend to
safe, accessible and sustainable services. Technicalisation of public experience compl ex long- term conditions demanding ong oing, and
service work is one issue underpinning chan ge in rural service inter mittent ly acute, support to ensu re stability (Elkan et al.,
models. This is manifes ted in professional role specialisa- tion; for 2001). The re is no general ly acce pted definition of an ‘older
example, the NHS gradi ng sys tem rigidly delineates practice person’. In the UK, using the sta te pension age—current ly 60 for
boundaries (De pt. of Health, 2004). Gene ralism is a poor career women and 65 for men, 3 is a pragmatic solution. OLE
choice, with specialism linked posit ively to patient safety because included those aged 55 and over, incorporati ng a ‘pre-r etirement’
prac titioners are mo re experienced. Supp lying specialist services in perspect ive, acti ve and independent and frailer ind ividuals
rural areas is prohi biti ve as large numbers of staff would be (Scot tish Executi ve, 2007). By 2025, Scotland is projected to
requir ed (to comply with legal working time direct ives) and staff see have 30% of its population aged over 60, compa red with 27.4% for the
insufficient patient numbers to maintain specialist skills. To UK, a figu re compa rable with Germa ny, Spain and Italy
counte ract negati vity about rural employ ment, working conditions (Raeside and Khan, 2008). For the Highland Council area where this
and pay have been add ressed for some groups; for example, the study was located, mid-2 006 population estima tes showed
2004 UK gene ral prac titioner (GP) contr act was part ly introd uced
25.3% of the population was of pensionable age (GRO-Sco tland,
to stimulate recrui tment, rele asing GPs from out of hours wo rking
2007, p. 54). This is projected to incr ease by 51.3% by 2031,
requir ements and incr easing remune ration (Cha rlton, 2005).
compa red with a Scot tish incr ease of 31.2% (GRO-Scotl and, 2008).
Manag erialism is the application of mana gement techni ques to
National and regi onal demog raphic statistics obscure smaller
service provision and per vades con tempo rary service deli very trends
scale patte rns influencing local service deli very. One Highland
(Cla rke et al., 2000). Industrial quality mana gement techni ques
area, Ross and Croma rty, is projec ted to see a 149.4% incr ease in
have influenced UK public service mana gement since the 1980s.
its over 75 population bet ween 2006 and 20 31 (Highland
Target setting, bureauc ratized gover nance and perfo r- mance
Council, 2008).
fram ewo rks were de veloped under the 1990s New Labour
In the UK, pre or immedia te post- retire ment mig ration is
administ ration, depleting health professio nals’ auton omy (Ex-
common, with relo cation to rural Scotland percei ved as offering
worthy et al., 2003; McDonald and Harrison, 2004). Conte mpor-
quality of life benefits (Richar ds and Farme r, 2003). UK rural
aneousl y, evidence-based medicine (EBM) affected clinical practice,
demog raphic ageing is predominantly attributable to the out-
prescribi ng technical algori thms for care underpinned by findings
mig ration of younger people, ageing of ‘local’ residents and the in-
from large clinical trials. Al gorithmic care and volume targe ts have
mig ration of middle-a ged and reti red people who then age in situ
become para digmatic, superseding con textual pa- tient-focused
(Commission for Rural Communities, 2004). Older in-mig rants
care, placing ‘‘mat ters of efficiency abo ve those of equity and
may give scant thought to future care needs (Richards and Farme r,
entitlement’’ (Hanlon and Rosenberg, 1998 , p. 559). This mass
2003 ), while their relo cation can crea te considera ble pressure for
market approach fails to incorpora te differing priorities that steer
service providers because small differ ences in population needs
citizen’s healthcare choices, including access to transport or
impact considera bly on staffing levels requir ed. Rural health and
proximity to relat ives (Fotaki, 2005).
social care workers have inconsis tent wo rkloads: they may be
UK public service provision foll ows neo-libe ralism, a political
requir ed, for example, to provide intensi ve palliat ive care for a period,
agen da prescribi ng withd rawal of the sta te and encou rage ment of
follo wed by a time of light workload. This challenges service
ind ividual and community responsibilit y. Sco ttish government policy
mana gers in designing sustainable jobs.
sta tes that the Na tional Health Service (NHS) is a ‘mutual
In Sc otland, rural areas have the highest proportions of older
association’ owned by diverse stakeholders (Sc ottish Government,
people, 4 but little is known about how being older may be
2007). Rural health policy see ks ‘re silient’ communities (NHS
differ ent in rural or urban areas. The wlis (2001) found that older
Sco tland Remo te and Rural Steeri ng Group, 2008), suggesti ng
rural people apprecia te continuity of place and inte rdependence.
citizens should participa te, for example, in self-care and commu-
Older people are the larg est group in income poverty in rural
nity first responder schemes.
Worl dwide, similar approach es to rural healthca re reconfig ura-
tion; have often resul ted in centra lisation (Fraser et al., 2005; 3
Be tween 2010 and 2020 the st ate pe nsi on age for women wi ll
Mungall, 2005 ), outre ach rather than in-situ services and citizen
involvement. Resistance to reco nfigu ration is also international ly increa se to 65. The Sta te Pe nsion age for both men and women will increa se from 65 to
68 between
manifes ted, resulting in conflict bet ween rural citizens and
2024 and 2046. /ht tp: //th epe nsionse rvi ce. gov.uk/s tate- pens ion/ home. aspS
service managers (ABC News, 2007, 2008; Thomson et al., 2008). 4
In Scotland, for the years 2001–2 005, over a quarter of the population in
Typical ly, policymakers tell rural residents that they will rece ive pred ominantly rem ote rural local authority areas (Dumfries and Gall oway,
Western Isles, South Ayrshire, Argyll and Bute and the Scotti sh Borders) we re
ag ed 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 over
60 (GRO-Scotla nd, 2007).
 Fig. 1. European North ern Periphery Prog ramme Regions (Interreg IIIB), left, and location of the study region and study areas, right.

Britain (Philip and Gilbert, 2007). Access to public transport isConcern, 2006). The current rural policy pa radigm supports territo rial
problematical (Wenge r, 2001) and over 75s are less like ly to own their planning, that is a place-based focus for dete rmining service provision,
own cars than youn ger adults, resulting in difficulty reac hing advice, economic planning and development (OECD,
information and key services (Philip et al., 2003). Movi ng to support ed2008). This reflec ts the interconnec tedness of rural life and reco gnises
accommodation often requir es removal from rural communities (Philip the uni queness of di verse rural con texts (Pezzini,
et al., 2003), making it difficult to retain social connections. 2001; Kitson et al., 2004). The re is deba te about how terri torial
Con versel y, older rural residents are mo re secu re from crime, planning could happen, with questions raised about the exte nt to which
compa red with their urban counte rparts (Scottish Executi ve, 2000a). local people want to participa te in community governance (Shortall,
Impacts of ageing on service provi sion are often portr ayed2008). Gi ven the pre valence of older people in rural communities,
apoca lyptical ly. Inte rnational ly, public expenditu re is two to three times the lack of resea rch intere st in the role of older people in rural
higher for the aged than for the yo ung (Gee, 2002). Older people, terri torial planning is surprising.
especial ly the very old, are more like ly than other age gro ups to
require a compl ex pat tern of inputs from a ran ge of services. A high
proportion of older people repea tedly readmitted to hospital sug gests3. Methodology
insufficient community support (NHS Scot- land, 2002). Policy promo tes
older people livi ng independent ly at home and urg es joined-up working3.1. The case study communities
bet ween the caring agenc ies (Scottish Executi ve, 2000b).
Simultaneous ly, the delineations bet ween health and social care tasks Part of an EU NP Pro ject, this study was located in the Highland
are quite strict ly defined, making joint working compl ex for workersCouncil area. With an expanse of 39,050 km 2 and a population of
and those cared-fo r. Apoca lyptic demog raphy has been challen ged,373,000, it is one of the most sparse ly popula ted EU regi ons
with sug gestions made that older people are undemanding and(Highlands and Islands Enterp rise, 2008).
resilient. Although older people in Scotland may appear burdensome Two communities were selected as case studies with the potential
on the state, rece iving if eligible, free home nursing care, personal care orto highlight views rela ted to inaccessibility to service cent res and
help 5 as well as free health care, it has been no ted that it is a small staffing challen ges (see Fig. 1). These met prag matic cri teria in that,
proportion of older people that are intensi ve users of expensi vefirst ly, they were remote rural sites and, second ly, project partners –
specialised services (Wilson et al., 2005 ). Evans et al. (2001) have notedHighland Community Care Forum (HCCF) – had workers located in the
that new technologies and pharmaceutic als account for much of rising villa ges who could assist us with identifying study participants
service provision costs. With impr oved health the and participating in data collection. Case study Site 1, a community of
‘‘young–old’’ are acti ve participants in societ y, taking on caring roles appr oxima tely 400 people, is on the north coast. Case study Site 2 is on
and volunt eering (Philip et al., 2003 ). the north- west coast and has appr oxima tely 900 inhabitants.
Their settlement structure is one of dispersed cott ages and coastal
2.3. Planning rural services for older people strip housing, often linked to ‘crofts ’.6 In 2005, Site 1 had 29.9% of the
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
It is fre quent ly said that older people should have a grea ter
gene ral practice providing 24/7 cover. Both are within
‘voice’ in service planning as their experiences and priorities can be
70 miles of a Rural District General Hospital and have day care
misunders tood (Joseph Rowantree Fo undation, 2004; Age
facilities. Site 2 has nursing home facilities.

5
Personal care is intimate
requires the skills of a trained
around the house and shopping.
6
Crofting is a sys tem of landholding uni que to the Highlands and
care, including wa shing and toileting. Nursing care
health profe ssional. Domestic help includes cho res Islands of Scotland. /http://ww w.crof terscommission.org.uk/What-is-Cr ofting.as pS It
in- vo lves a small agricultu ral land holding (commonly around 5 ha), normally held in
tena ncy and perhaps with associated buildings.
 278 J. Farmer et al. / Health & Place 16 (2010) 275–283

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Fig. 2. Summary matrix of stakeholder vie ws.
3.2. Data collection methods service mana gers and policymakers were then compa red against themes
raised by older people. Relationships bet ween older peoples’ and
OLE involved five participant EU NP regi ons investigating older other stakeholders’ responses were then explo red. A summary ‘matrix’
people’s vie ws about health services. Each participant region, other(see Fig. 2), encapsulating resp onses of stakeholder gro ups, was
than ours in the Scottish Highlands, included local gover nment circ ulated to participants for verification.
representati ves. Our uni versity -led Sc ottish team was challen ged by
EU partners to invol ve service mana gers and policymakers so that
3.3. Findings
findings could influence polic y. We did this by engaging managers and
policymakers in discussing findings from inter views with older people.
The inter view guide for older people asked about health services,
With ethical commit tee app roval, an explo ratory qualitat ive research
but responses ran ged across topics including formal social care,
design was ado pted. Inte rview data were gathe red from older people,
informal helping, housing, transport and meals provi sion, appa rently
focusing on opinions about health services. These data we re used to
indicating percei ved interco nnection of ma ny aspects of community
deri ve themes about services that were then discussed with service
life and wellbeing. Here, we report the most consiste nt emer gent
providers, service mana gers and policymakers. This app roach allo wed
issues about services from inte r- views with older people and juxtapose
stakeholders to respond to older people’s view points in a non-
these with the reac tions of health and social ca re pr oviders, managers
conf rontational situation. Differing perspecti ves on service provision
and politicians to highlight where there were differing perspecti ves.
were revealed which, in turn, allo wed us to consider unde rlying
Issues are gro uped into three bro ad themes: where older people should
tensi ons.
live; the way that services should be pr ovided; and who should care
Firstl y, semi-structu red face- to-face intervi ews were held with
and help.
12 men and 11 wome n: age ran ge 55–87 (median 64, mean 67), even ly
split bet ween the two study communities. Partic ipants were
recr uited with the assistance of the HCCF. To include differ ent3.4. Where should older people live?
vie ws, our sample included varying socio-economic bac kgro und, lengths
of time lived locally and levels of community involvement. Partic ipants Reflectin g othe r studies , olde r peopl e emphas ised the importance of
were app roached by researc hers once initial consent was obtained byliving independent ly in their own home s if possibl e (Cloutie r- Fishe r
HCCF wo rkers. Intervi ews lasted for about 1 h and we re conduc ted inand Joseph , 2000; Harrefor s et al., 2009). Healt h profession als confirm ed
people’s homes. A topic guide covered experiences of local health that olde r local resident s and mo re recen t incomer s were fie rcely
services, individu al’s wants rega rding key attributes of future services, independen t and largely undemandin g of services . If needs necessita ted
the role of technology and the role of family and the community inmoving, mos t intervi ewees emphasis ed the importance of staying in thei r
supporting older people. commun ity. Som e raise d the impo rtanc e of the view from their wind ow
Issues raised by participants we re consiste nt within and bet weenand being near friend s (alive and dead). Reflecting on how older people
case study site s. The most frequently repea ted themes emer gent fromneedin g ext ende d care have to leave thei r communit y and go to live at
the intervi ews with older people we re used to form a topic guide forconside rable distance , in a variety of diffe rent residentia l facilitie s,
a second phase of inter viewing; this time, with health and social careintervi ewees sai d tha t onc e older residen ts leave, other s accep t they
practitioners. In these, participants were asked questions in thewill not return . Removal was describe d as depressing for the older
format: ‘The older people we spoke with thought X, what do you think perso n an d for thei r friend s and relat ives who becom e sep arated by
about that?’. Inte rvie ws lasted bet ween 40–60 min. Practiti oners weredistanc e. It was suggested that importan t socia l, cultu ral and historica l
identified by contacting gene ral practices and requesting that a GP, aasset s were lost to commun ities whe n a long- term local residen t ha d to
nurse, a home care worker and a healthca re assistant be nomina ted.leave to live in a care home.
The residential care home mana ger at Site 2 was also intervi ewed. This
made a total of nine phase 2 (service practitioner) intervi ewees: two ‘ ‘y where somebody got to that stage when they had to go into care.
GPs, two community nurses, two home care workers, two home care They went to Invergo rdon or some where like that y The day they
assistants and one residential care home manage r. A further iteration of went in there was the last day they would see their villa ge that they
intervi ewing (phase 3) involved a similar process with service mana gers loved’’ (Male aged 60)
and politicians. These comprised the Heads and Deputy Heads of Inte rvie wees wanted small local residential care facilities so that,
Departments providing health and social care services for older people even when very infirm, older people could remain in their communit y.
in Highland (four inter viewees), three local authority councillors andHealth professionals recognised the significance for older people of
three local Members of the Scottish Parliament (MSPs) (re presenting staying locall y, but noted times when the level of care required meant
Sco ttish Nationalist Party (SNP), Gr een Party and Labour Party) with athis was impossible (e.g. for those needing dementia nursing care ).
stated intere st in older people’s services. All persons who we re Service managers noted that older people’s desi re to live
approach ed consented to be intervie wed. independent ly aligned with policy prom oting ‘act ive ageing’ and self-
Inte rvie ws were reco rded and transcri bed ver batim. Data anal ysisreliant livi ng (Scottish Execut ive, 2007). Mana gers interpre ted
follo wed ‘frame work anal ysis’ (Ritchie and Spence r, expr essions of a desi re for independence to mean that older people
1994 ), adap ted to accommoda te our iterative approach. The tran scrip tsagre ed with their policy of focusing on home care and disin vesting
from inter views with older people were read inde- pendent ly byin rural residential care; ho weve r, community members still
three researche rs and a thematic coding schedule was developed based wan ted local residential care for those who could no long er cope at
upon issues rai sed consis tently by respon- dents (for example chan ge tohome. Mana gers noted that supporting frail people at home was
‘meals-on-wheel s’ service and high satisfaction with GPs). Data werecomplica ted by poor pri vate housing conditions in the rem oter
coded, using NUnDIST soft ware for mana gement. Data we re scrutinised
Highlands, 7 but aspi red to develop
for similar and divergent perspect ives, but there was strong
con verge nce of themes amongst the transcri pts. Inte rview data from
service pr oviders, 7
Research by Scotti sh Homes, Communities Scotland and the Commission for Ru ral
Communities has identified a high pro portion of pri vate housing below tole rable
standard in rem ote rural areas.
 280 J. Farmer et al. / Health & Place 16 (2010) 275–283

housing with integral social and e-monito ring support. Service Health and social care professionals said the new meal
mana gers and councillors thought that mo re of those current ly inprovi sion model neglect ed elements of social support and day- to-
residential care could be livi ng at home, sug gesting older people wereday sur veillance. Service managers had a differ ent vi ew and were
sometimes placed in residential care to meet their distant relat ives’support ed by most of the local councillors, one of whom said:
desi res to know they were ‘secure ’, rather than from need. In 2001,
the number of people, per 1000 population, aged 65 and over in ‘‘I think there are two things there. The need for a meal and the need
residential care in Scotland was 17, while in Highland Council area it to meet people. The two are not the same y If a care plan is saying
was 23 (Scottish Execut ive, 2001). that Mrs. MacK ay needs a meal, she needs a meal seven days a
Considering small local care facilities, two MSPs (SNP and week—not once a week when it can come from the school kitchen
Labour) and all councillors and service mana gers sta ted that these were or something like that y If all she needs is social contact, then you
unsustainab ly expens ive at per person costs aro und four times need to build that into the care plan y’ ’ Councillor 1
more expensi ve than in larg er facilities (in 2006, the avera ge
gross weekly cost of a local authority care home place in Highland Service managers thought service users unde restima ted the
council area was £612, compa red with an avera ge of challen ge of providing meals acro ss the Highlands. Chan ge was
£512 for Scotland) (Sco ttish Go vernment, 2004). Due to sporad ic client requir ed because the old scheme did not meet health and safety
thro ughput, care facilities we re said to ope rate below capacity andrequir ements: del iveri ng consiste ntly hot meals in a rural area at
staff recr uitment was difficult. Suppor ted housing was promoted aslunchtime was difficult. Some people got their meals ear ly and
the most feasible option. Service managers sta ted that their goal, inreheated them; others rece ived meals in the afte rnoon when they had
allocating resour ces, was achieving the most gain for the most people: got cold and reh eated them. Some of the food prepared was of poor
nutritional quality (‘pink custa rd’ and ‘like school meals’) and it was
‘‘The problem is that residential care, especial ly in remote and rural
difficult to recruit volunt eers in some areas meaning that regional
areas where the numbers of beds are low, it is extr emely expens ive
coverage was inconsis tent. Local councillors thought a good meals-
y We have closed y resi dential beds because they were costing
on-wheels service was ideal, but overly challenging to provide.
almost £2000 a week per person y If we are given the mon ey
Technology is increasi ngly propos ed as part of the solution to home
we will not be spending it on two or three beds in a remo te
care for older people. Inte rvie wees acce pted that technol- ogy would
are ay’ ’ Councillor 2
incr easing ly featu re in futu re care, but they fea red impersonal,
‘‘You have got to decide on—do you disad vanta ge that very small technical, solutions being implemen ted as the whole, rather than part
gro up of people who may have to travel a bit further so that youof, the service.
can continue to maintain the people in that community so
they don’t have to mo vey that is the very difficult decision that ‘‘I think it (tec hnology) has its place as long as we do not lose the
councillors have to make y’’ Councillor 1 actual face-to-face contact as well. It is not a replace ment y
certain ly it is not an alter nati ve to the real thing’’ (Female aged 60)
At the time of the stud y, Highland Council’s policy was to focus on
home care iro nicall y, with a political leadership reorientation in 2007 Inte racting with health and care wo rkers was regarded as social ly
older people’s care policy has chan ged and Highland Council is nowand emoti onally beneficial. Inte rvie wees st ressed the value, in
developing some rural residential care facilities. isola ted settings, of maintaining personal and social connections. Ma ny
houses were second homes and, in winte r, the re might be few people
3.5. How should services be provided? livi ng close by to talk to or to ‘keep an eye’ on neighbours.
Service mana gers and politicians thought that techno logy would
‘Meals-on-whee ls’ provision (the del ivery of meals to people whoincr easing ly support livi ng in rural area s. Health professionals agre ed
find it difficult to prepare a meal at home) was raised frequent ly bythat techno logy was part of future health- care, but rei tera ted the
older inter viewees as an example of what they did not want to, butsocial and sur veillance aspects of personal interactio n, as well as
fea red would, happen to services in the futu re. In the rural Highlands, the therape utic aspects. A visit to an older person’s home has
food used to be cooked locally and del ivered by volu nteer s. In 2004 aadded value that could be overlooked if replaci ng the appa rent
Highland Council policy decision was taken (also by other Sc ottishhealth or care inter vention with a phone call or a moni toring device.
local authorities) to replace the Health pro fessionals, in particula r, have legitimised access to pri vate
‘meals-on-wheel s’ service with frozen meals, produced and del iveredhomes that few others enjo y.
monthly or fortnight ly by staff of a pri vate compa ny. Meal provision
mo ved from being a visiting volu ntary service to one consisting of
providing a freeze r, a micr owave oven and a fortnight ly del ivery of a3.6. Who should provide care and help?
frozen meal suppl y.
Inte rvie wees liked food being cooked and del ivered by volunt eers, Changes have occur red recently in the provision and term inol- ogy
locall y. They sug gested that the meals are, in a sense, incidenta l—it isof care in the UK. Home carers now conduct ‘personal care’ tasks such
what they and the service aro und them repres ent that is critical. Thisas washing and toileting, with domestic care rs designa ted to assist
is, having someone local visit reg ular ly with whom ‘news’ and chatwith household tasks. Older intervi ewees expr essed unease at home
can be exchan ged, a connection providing social contact to those care rs carrying out intima te aspects of care. They thought that
whose mobility is restrict ed. Intervi ewees thought that the way meals ‘nursing assistants’ should undertake these tas ks. Seve ral sugges ted
are now provi ded was impersonal and symbolic of society’s lack ofthat one generic wo rker, combining social and health care, but ‘‘from a
value of older people. nursing backg roun d’’, was a sensible, multi-functional, solution. There
was frust ration with
‘‘y a few times I did meals on wheels myself. When you went
rou nd to some of the old people’s 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
isola ted’’ (Male aged 72)
the cur rent di vision of labour:
‘‘yyou seem to have differ ent care rs for differ ent jobs y the
carer just does certain things and she is not allo wed to do
anything else. Sometimes you don’t need them to do a lot and
other times you need them to do things that you cann ot do
yourself. The re seems to be a rule that they are only doing one
thin gy’’ (Male aged 60)
Health and social care professionals repor ted that they we re
working to reduce multiple pro fessional and carer visits. Most of the
service mana gers and politicians thought that those with nursing
skills should not conduct the tas ks of home (social) care rs;
ra the r, they should be depl oyed on specific nursing profession tasks.
Some expr essed the dilemma about an efficient model of care:
‘‘yI have heard of nurses in remote commu nities going in and
giving pe ople ba ths because there is no -one to do it. Is that the
most efficient use of a trained nu rses’ time? In some respects you
can argue, yes, because while you are doing that, you are doing an
assessmenty but if that pe rson actually does not have any nursing
ne eds other than a bath, then is it ap propriate? If that pe rson is
having that nurse spending an hour at their ho use doing
everything that they need, then who is carrying out the nursing
needs of the pe rson down the road?’ ’ Service Manager 4
In spite of provisions of their cont ract, GPs in the two study
communities had opted to continue 24/7 cover. Older people
app reciated this and they and local health professionals wanted
24/7 cover to continue. GPs and nurses discussed how wo rking
collabo rati vely with colleagues from other agenc ies was key to
providing services that looked joined-up to their recipie nts. They
sta ted that, although services often did not integra te well at the
mana gement level, they could ‘make things work locally ’.
Politicians and service mana gers app recia ted the benefits of GP out-
of-hours cover, but said local people would have to become mo re
self- reliant. They sug gested that GP cover was unsustainab le and that
continuous care will disappear as older health profes- sionals retire.
It was ackn owle dged that services are often worked out ‘on the
groun d’ because of confusion bet ween differ ent mana gers and,
despite a pe rception of collabo rative relati onships at stra tegic level
mana gement, co-ope ration disinte grated when budge ts were
involved.
4. Discussion
We set out to explo re issues for rural older people that would
inform future policymaking around service provision. In doing so, we
revealed service areas that we re con tested bet ween rural
communities and mana gers and policymakers. Looking across
these, we identified some recurri ng tensions that appeared to
unde rlie disag reements. We prese nt these here and sug gest that
these may be fundamental to understanding the gap bet ween
cur rent methods of planning and managing to actual ly implement new
service provision models. If older people’s voices are to be
meaningful ly incorpo rated into planning and developi ng new rural
services, these require to be ackn owle dged as legitima te and
add ressed.
4.1. Tensions in management appr oach: divided vs. connected
The re is a tension bet ween the way that community members
inte ract with services and the ways that services are planned and
mana ged. Community members’ discussions crissc rossed be- twe en
health services, social care, transport, meals and housing,
showing an inte rconnec ted understandi ng of these topics. They
app recia ted the ‘added value’ aspects of services: visits by health and
care profes sionals we re 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 ten dencies of
technicalisation and mana gerialism are revealed, with mana gers
struggling 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’. Gi ven
difficulties, including recr uiting specialists and maintaining their
skills, di vided service provi sion appears in- app ropria 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 pr oviders 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 con text
(Granovette r, 1985 ), manoeuvring around Eur opean 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 sug gestions of Malpas
(2003) who argues there has been a mo ve in service provi sion
planning from a place/con text focus to an abst ract,
‘spatial’, efficiency orientation.
4.3. Tensions in resou rce 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 pr ovide the most satisfaction for the most
people. Community members, con versel y, were focused on how local
people could stay in their communities and did not sug gest issues of
how resources might be shared acro ss the regi on. While councillors
expr essed 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 Inver ness (the Highland ‘capital’,
population 45, 000), for example, be able to mo ve to resi dential care
within their communit y, yet someone from North -west Suthe rland
(3–4 h dri ve from Inver ness) be unable to do so? Both places are
on the Sc ottish mainland and sha re the same local authority and
NHS Boa rd. Hanlon et al. (2007) highlight the ‘particular tyr anny of
numbers’ associa ted with service cent ralisation that disad vantages
rural communities. Con tempo rary policy loose ly add resses equit y,
sug gesting equiva- lent outcome should be expected, rather than
equivalent service experience (NHS Scotland Remo te and Rural
Steering Group,
2008). It is som ewhat 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.
 282 J. Farmer et al. / Health & Place 16 (2010) 275–283

4.4. Tensions in knowledg e: management experts vs. community mana gers and community members, by all owing an are na for
experts information exchan ge, discussion and building relati onships bet ween
stakeholders and for identifying local priorities. Pilots of differ ent
A further tension lay in communities’ ‘we want what we have’ ways that rural community members, and in particular the
perspect ive and service manager s’ reconfigu ration preferenc es. In arr ay of rural older people’s voice s, could be incorpo rated in local
this stud y, locals liked what they had kn own because they service planning and governance (including bud get-holding), would
pe rcei ved it to wo rk for them. Simultaneous ly, as in the case of be an inte resting next ste p. Incorpo rating rural community voices
meals on wheels, mana gers and councillors illust rated why should contribu te to creati ve solutions as local people respond to
traditional solutions no long er worked due to regula tion or their own challen ges with con textuall y- achie vable solutions. Taking
legislation impe rati ves, such as failing to meet health and safety more ambitious ste ps in local governance would show the degree to
standa rds. Mana gers also showed that they access compa rati ve which ‘mutuality’ in service planning and pr ovision is real isable,
information (for example, the costs of provision of differ ent types of its effects and whether
care) when considering option s. Thus, the re is incongruence ‘bet ter’ services emerge from formal local governance.
bet ween the type of knowle dge steering citizens’ decision-making
and the type that service mana gers and politicians use. Incompat-
ibility bet ween lay con textual kn owle dge and ‘expert facts’ has Ackno wled gements
been highlighted as a source of disco rd in service provider public
enga gement (Hea ly, 2008). The authors would like to ackn owled ge the community
What does our ana lysis sug gest for engaging older people’s members, service providers, mana gers, councillors and politicians
voice in rural service policymaking? Ad voca tes for terri torial who were intervi ewed and gave feedba ck. We thank the EU
planning might view community members’ bricola ge tactics in Northern Periphery Prog ramme for funding the Our Life as Elder ly
constructing services locally to fit their needs as evidence for (OLE) project. Alison Sandison drew the maps in Fig. 1.
instituting place-based governance. Had local (sub-local govern-
ment unit) gover nance been in place, communities could have
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