1. Remoteness and Use of Health Services Professor David Godden www.abdn.ac.uk/crh

2. Characteristics of Rural Health Services - Primary care Accessibility ~ increased consultations Wide skill-mix required by individual clinicians Constraints of geography and travel Seasonal fluctuations Contribution to local “social capital” Variable engagement with technology

3. Characteristics of Rural Health Services - Secondary care Generalism Limited junior staff support Onerous consultant on-call commitments Volume/quality issues Recruitment difficulties Strong engagement with communities

4. Clinical Peripherality Gill Swan, Kim Walker, S. Selvaraj, David Godden

5. Study Objectives To characterise remote and rural primary care To develop a relevant method of expressing rurality

6. © Hugh Noble www.tartanhen.co.uk 3 LHCCs in West Highland c7000 square miles 53 practices + 6 branch surgeries Study Setting

7. Settlement size classification of study area with urban comparison SHOS Levels Level 2 Urban Level 3 Accessible Level 4-7Level 8 Very Remote Study Area 5% 17%73% Inverness84%16%--

8. Generation of practice profiles

9. Characteristics of remote rural practices Distant from secondary care Distant from NHS boards Low population density Small list sizes Wide spectrum of activity

10. Population density/practice area by LHCC Persons Per Hectare Inverness WR SS&L Lochaber A & B 40 30 20 10 0 -

11. Travel time from practices to nearest acute hospital by LHCC InvernessLochaber 400 300 200 100 0 - A & B WR SS&L Minutes

12. Travel time from practices to Health Board by LHCC 400 300 200 100 0 - Inverness WR SS&L Lochaber A & B Minutes

13. Creation of Clinical Peripherality Index

14. Clinical Peripherality by LHCC WR S.S & L A & B Lochaber Inverness

15. Does Clinical Peripherality correlate with activity?

16. Spectrum of Roles - Components Minor surgery, pharmacy, hospital cover Patients across water, temporary residents score, branch practice, shared practice, out of hours Helicopter escort, GP registrar, undergrad teaching, postgraduate teaching, occupational health, police surgeon, airport duties, rescue team duties, sports team duties Practice nurse, practice HCA, administrator, counsellor, health visitor, district/family health nurse, midwife, CPN, chiropodist, dentist

17. Correlation of clinical peripherality with spectrum of roles R = 0.685

18. Conclusions (1) Rural LHCCs are characterised by low population density and prolonged travel times to acute hospitals and educational facilities A “Clinical Peripherality” factor has been derived from these indicators

19. Conclusions (2) Clinical Peripherality correlates with the spectrum of roles adopted by rural practitioners This has implications for service development, education and training policy

20. What is the Scottish Picture?

21. CP Indices for Scottish Practice Communities

23. Greater Glasgow Fife Lothian Lanarkshire Ayrshire & Arran Forth Valley Borders Tayside Shetland Dumfries & Galloway Grampian Western Isles Highland Orkney Argyll & Clyde Clinical Peripherality scores by NHS Board area

26. Discussion Points Importance of “Insularity” in determining CP score Critical importance of acute receiving hospital and board location Distributed nature of CP among NHS Boards