More than health: The added value of health services in remote Scotland and Australia

Health & Place 16 (2010) 1136–1144

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Health & Place journal homepage: www.elsevier.com/locate/healthplace

More than health: The added value of health services in remote Scotland and Australia M. Prior a,n, J. Farmer b, D.J. Godden a, J. Taylor c a

Centre for Rural Health, University of Aberdeen, Centre for Health Science, Old Perth Road, Inverness IV2 3JH, UK Centre for Rural Health, UHI Millennium Institute, Centre for Health Science, Old Perth Road, Inverness IV2 3JH, UK c Spencer Gulf Rural Health School, University of South Australia/University of Adelaide, Whyalla, South Australia b

a r t i c l e in f o

a b s t r a c t

Article history: Received 14 March 2010 Received in revised form 7 June 2010 Accepted 16 July 2010

Health services are suggested to contribute to remote communities in the ways that extend beyond healthcare delivery. This international multiple case-study research provides qualitative evidence of the social, economic and human contributions (the ‘added-value’) that may be lost should remote communities lose in-situ health provision. We present a typology of added-value contributions that differentiates institutional aspects (residing in buildings, or embodied in the specific status, capabilities and skills of health professionals) and individual aspects (attributable to health professionals’ unique personalities and choices). This typology has relevance for communities, policymakers and managers when considering the impacts of potential service changes. & 2010 Elsevier Ltd. All rights reserved.

Keywords: Health professional roles Health policy Rural health Social capital Human capital

1. Introduction Reconfiguration of rural healthcare delivery is influenced by changes in population structure, increasing clinical specialisation, neo-liberal political desires to enhance the consumer’s role in service delivery, the availability of technologies and a desire for efficiency (Alston, 2007; Rural Access Action Team, 2005). In addition to their formal role of delivering healthcare, rural health services are suggested to fulfil a number of less explicit community roles (e.g. social and economic roles) that contribute added-value (Rennie, 2003; Farmer et al., 2003). Currently, there is little empirical evidence to substantiate these suggestions (Cutchin, 1997; Doeksen and Schott, 2003; Farmer et al., 2003; Kearns and Joseph, 1997; Shucksmith et al., 1996). Rural health service reconfiguration may therefore have a much wider impact on communities than is currently considered in policy debates. Vehement community opposition to strategies such as replacement of a resident local health professional with specialist peripatetic teams may, in part, be in response to an innate awareness by communities of these ‘hidden’ roles (Farmer et al., 2003). Whilst there is an emerging literature and research concentration on this topic broadly, the different dimensions of added-value have not previously been fully explored in any one sector. In addition, some aspects of added-value contribution discussed in the literature are intangible and poorly defined. The aim of the study presented in

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1353-8292/$ - see front matter & 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.healthplace.2010.07.005

this paper was to explore the nature of added-value contributions in the rural health sector. This paper delineates the added-value contributions of rural health services and attributes these to social, economic and human dimensions. It provides qualitative evidence about what may be lost to communities should they lose in-situ health provision. Uniquely, we present a typology of added-value contributions that differentiates individual (person-dependent) and institutional aspects. This has relevance for communities, policymakers and managers and adds another dimension to debates on potential service change. This multiple case study research was conducted, during 2006–2007, in the Highland region of Scotland and in remote rural regions of South Australia; areas with differing health service systems, but which both have fragile sustainability and services. The aim of the cross-national design was to increase the transferability of findings, not to conduct a cross-national comparison. We used semi-structured interviews, observational field notes and demographic information to gather data in eight case study communities.

2. Background 2.1. Definitions of rurality, remoteness and ‘community’ Taxonomies of rurality differ internationally, but most are based on population density, demographic structure and land use (Ryan-Nicolls, 2004; Shucksmith, Philip, 2000; Australian Institute of Health and Welfare, 2004; Scottish Government, 2008).

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Remoteness can be considered as distinct from rurality, because of more limited accessibility to goods, services and opportunities for social interaction; (Woods, 2006). The Scottish Government 8-fold Urban Rural (SGUR) Classification defines settlements of 3000 or fewer people to be rural. It classifies areas as remote based on drive-times from settlements of 10,000 or more people (Scottish Government, 2008). It was this classification that was used to identify comparably remote settlements both in Scotland and Australia.1 However, we acknowledge that the SGUR classification does not categorise communities with regard to their infrastructure and level of service delivery. In the UK ‘remote health’ is a contested term, often used interchangeably with e-health provision. For this reason, whilst technically ‘remote,’ the health services within our remote study communities are hereafter referred to as rural health services. The concept of ‘community’ is also contested and problematic to define. In our study, we chose to use the concept of ‘communities of place,’ using Hillery’s (1955) definition as areas having a shared geographical location, social system and sense of identity. The communities became the case study sites and the sites were delineated by health service ‘boundaries,’ i.e. the GP practice territory, as we were interested in the associations between in-situ health services, and the people and area they serve. 2.2. Added-value contributions and healthcare This is the first study to delineate the different dimensions of added-value within a single sector. Studies that have previously raised the issue of rural health services’ added-value are widely dispersed across disciplines and tend to be of two types. In the first type, research focussing on service provision has concluded that there are extended or additional roles for rural health professionals or health service premises. However, these studies fail to ‘tease out’ who, or what aspect of health services, is contributing the added-value. In the second type, a single domain of added-value has been investigated (e.g. economic contributions). Health professionals may be social lynchpins; active in networks or social entrepreneurial roles (Farmer et al., 2003; Farmer and Kilpatrick, 2009). For example, West et al. (2004) studied workload of urban and rural Scottish primary care staff and concluded that the limits of rural jobs were blurred as health professionals were generalists and undertook social care roles in the absence of specialised health and social care staff. Shucksmith et al. (1996) described rural health professionals acting as ‘mediators’ for their communities in negotiations with external bureaucrats, while US and Scottish rural doctors have been found to assume community leadership roles, due to personal qualities and in response to community expectations (Cutchin, 1997; Iversen et al., 2002). Health service premises also provide added-value in rural communities. Kearns and Joseph (1997) observed patients in Hokianga, New Zealand, arriving up to 40 min before their appointment and lingering up to 20 min afterwards, using the meeting place for social interaction. Ravasi and Rindova (2004) describe local services as a source of social identity used by communities to denote their status compared with other places. Protests at closure of GP and maternity services in rural Scotland suggest there are important issues of community identity and ‘wellbeing’ at stake (Farmer et al., 2007). Kearns and Joseph (1997) describe the availability of healthcare in remote 1 Using the Australian ARIA classification (Australian Institute of Health and Welfare, 2004) each of the four Australian communities was classified as Remote.

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communities enhancing community vitality and residents’ ‘sense of place’, which imbues health services with a ‘symbolic’ value. Health services may attract new residents. An US survey showed that access to local health services is one of the four ‘must have’ categories for retirement locations (Doeksen, Schott, 2003). Eilrich et al. (2004) report that local access to healthcare is among the most significant quality-of-life variables considered in business location decisions. The presence of maternity services in a rural community has been suggested to retain and attract young residents (Farmer et al., 2007). Several studies of economic contributions of rural health services have taken place in North America (Doeksen and Schott, 2003; Kleinholz and Doeksen, 1991; Eilrich et al., 2004). Doeksen and Schott (2003) estimated that almost one in five local jobs in Atoka County, Oklahoma, was directly or indirectly related to the presence of the health sector. They suggested that change in the size or structure of the health sector in a community would affect an economic viability. However, other studies have shown minimal effects following hospital closure (Probst et al., 1999; Stensland et al., 2002). For instance, Pearson and Tajalli (2003) used pre- and post-hospital closure data for 24 USA communities and 24 controls and found no evidence of short- or long-term harm to community economies. Holmes et al. (2006) differentiated between the impact of closure of one hospital in a community and closure of the only hospital. Losing the sole hospital in a county resulted in decreased income and employment.

2.3. Added-value in other sectors Health services are not unique in contributing added-value. Our research drew on evidence of the added-value contributions of other rural institutions such as schools, banks, general stores, post offices and village halls. Many of these studies describe the importance of such institutions and services as social arenas for communication, interaction, or foci for community capacitybuilding efforts or creation of social capital (Australia Post, 2008; Civil Renewal Unit, 2006; Forsythe et al., 1983; Hope et al., 2004; Hope et al., 2000; Scott et al., 2000; Witten, 2001). In addition, rural schools have been reported to attract in-migration, aid retention of young people and increase property prices and land values (Hope et al., 2004; Ministry of Agriculture and Fisheries, 1994; Skene, 1990). In economic terms, research by Roberts (2003) looked at the relative importance of different institutions in the Western Isles of Scotland. The study showed that the public sector accounted for 28% of all the employment (2% higher than in Scotland as a whole); further, many of these were professional or skilled jobs with relatively higher salaries. The numbers of public sector professionals in rural areas have decreased in the last twenty years, with concomitant reduction in skills and educational assets available to communities (Boyle et al., 1998). The cross-sector literature enabled knowledge and evidence gaps in the health service literature to be identified (e.g. capacity building role).

2.4. Study context The Highland region covers one third of Scotland’s land mass, but contains only 4% of the population (209,000), making it one of the most sparsely populated areas in the European Union (9.5 people per km2) (Highland Council, 2006). In addition, challenging winter weather conditions accentuate remoteness. The population of South Australia is around 1.5 million, with population density of around 1.5 people per km2. Most (1.17 million)

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live in and around Adelaide. Areas remote from the capital city are generally dry with unpredictable rainfall. The financial and organisational structures of Scottish and Australian healthcare systems differ. In Scotland, the National Health Service (NHS) provides publically funded (from taxation) primary and secondary healthcare that is free at the point of delivery. Scottish GPs are paid, by the NHS, to provide services as independent contractors (Auditor General for Scotland, 2008), whilst community nurses are directly employed (salaried) by the NHS. In Australia, secondary care is centrally funded. General Practice is organised as a for-profit business with GPs working on a fee-for-service basis. Community nursing is provided by private, not-for-profit companies (Commonwealth Department of Health & Aged Care, 2000). The Australian GP payment system has implications for remote communities as it is often not economically viable for GPs to practice in areas with low population numbers. This has added to problems with recruitment and retention of remote GPs (Duckett, 2000; Humphries et al., 2005). In Australia, the most common healthcare model for small remote communities is co-location of a publically funded community hospital and a separate GP Practice, with GPs receiving additional remuneration for providing hospital medical cover.

3. Methods The research design drew on evidence of added-value contributions by health professionals, health services and other rural sectors from the literature, exploring and verifying these to derive a typology of contributions. A cross-national multiple-case study design was appropriate for the exploration of the complex, contextual and poorly understood phenomena of added-value contributions (Yin, 2003b). Ethical approval was granted from The Highland Research Ethics Committee and the University of South Australia Human Research Ethics Committee. 3.1. Case selection Nineteen Highland and South Australian communities met the case study selection criteria of in-situ health services, size (population less than, 3000) and remoteness (more than 60 min drive time to a population of 10,000 or more). From these, eight comparably remote communities with diverse geography and economic history were selected and pseudonyms assigned (Table 1). Populations ranged 300–1100, with mean ages of 36–45 years. Only Pintan has an average individual income higher than the State/National average. All eight communities had GP practices. In addition, the four Australian communities had community hospitals. 3.2. Data collection Prior to visiting communities, senior health professionals (GP or Director of Nursing) in each were approached for information and interview. Community ‘voices’ were represented by key informants (Arthur and Nazroo, 2003): community council members (non-governmental, elected residents), business leaders and head teachers, considered likely to know prominent community workers and issues. Key informants were identified via community websites and key services (e.g. local shop) and were purposively sampled based on an assessment of the relevance of individual’s roles and/or knowledge. Information sheets were provided and written consent obtained for interviews. MP visited each community for up to five days and gathered data via face-to-face, semi-structured interviews and observational

field notes. Background information on the size of health service organisations and data on their role in the local economy or social life was collected, from the internet and health service contacts, prior to community visits. Up to nine participants were interviewed in each community (total 58 interviews (23 health professionals, 35 key informants)). Topic guides ensured that relevant issues were covered systematically, but allowed flexibility to pursue detail that was salient to individual participants (Lewis, 2003). Interviews lasted 20–90 min (with most around 45 min), were audio-recorded and transcribed verbatim. Health professionals were asked about their: roles in the community; networks; links to external organisations; current community issues and perceived role of health services. Key informants were asked about community issues and leadership, involvement and influence of health professionals and the role of health services. Interviews were semi-structured and inductive and categories of added-value identified from the cross-sector literature provided a guide for discussion topics. Observational ‘field’ data collection included noting aspects of individuals’ and community behaviour and context; for example, interaction between residents in the GP practice car park (Eisenhardt, 2002). Data were initially analysed and compared within-case to establish a ‘description’ of each community. Cross-case analysis and comparison followed (Eisenhardt, 2002; Yin, 2003a). MP analysed all data. JF analysed a sample of transcripts for reliability. Findings were consistent. Nvivo software was used for data management. During analysis, a distinction became apparent between added-value contributions that were institutional (i.e. related to the presence of in-situ health services) and those dependent on the personal characteristics of individual health professionals. This fundamental distinction is explored in the findings. Coded data from the eight case-level displays were ‘stacked’ in a ‘meta-matrix’ (Miles and Huberman, 1994) to aid condensing, refinement and ordering of data with respect to the added-value contribution of (a) health service institutions and (b) individual health professionals. 3.3. Methodological strengths and limitations The choice of eight case study sites, as well as the number of interviews within each community, was sufficient to produce data to meet the aim of this exploratory study (Yin, 2003b). Responses within case study sites tended to be consistent and similarities between the eight case studies allow us to assess that the findings are transferable to other remote settings (Maxwell, 2002; Yin, 2003b). Data collection by a single researcher (MP) was both a strength and a limitation of the study. On the one hand the consistency of data gathering was ensured, but the demands of adapting to different cultural settings, in which to conduct interviews was challenging. Possible interviewer bias was controlled by the use of topic guides ensuring that key issues from the research aims and questions were consistently covered.

4. Findings A distinction emerged between the added-value contributions of health services as institutions and the role of health professionals as individuals, with unique personalities, qualities and choices (person-dependent). This is an important distinction as it ‘unpicks’ those contributions that were previously attributed to health professionals, in the literature, into those that are interchangeable between individuals in a role, and thus resistant to changes in personnel and those that are not.

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Table 1 Case study site characteristics. Community

Population

Distance to settlement with population of Z 10,000 (mile)

Mean age (years)

Average annual income

Main employment sectors

12.3%—Education 11.7%—Hotels/catering 10.5%—Manufacturing/construction 17%—Fishing/fish farming 12.2%—Health/social work 11.9%—Hotels/catering 13.4%—Real estate/renting/business 12%—Transport/storage/communication 10.1%—Health/social work 15.8%—Hotels/catering 13%—Wholesale/retail/motor vehicle repair 12.5%—Health/social work 14.7%—Wholesale/retail/motor vehicle repair 12.4%—Health/social work 9.9%—Real estate/renting/business 14.4%—Wholesale/retail/motor vehicle repair 13.2%—Manufacturing 12.4%—Health/social work 26.9%—Agriculture, forestry/fishing 13.3%—Retail trade 8.5%—Health/community services 22.7%—Agriculture/forestry/fishing 14%—Retail trade 9.8%—Health/community services 26.9%—Agriculture/forestry/fishing 13.3%—Retail trade 8.5%—Health/community services 11.9%—Retail trade 11.6%—Mining 10.4%—Health/community services 14.7%—Manufacturing 14.6%—Retail 11.4%—Health/community services

Adair

353

100

41

£18,626

Beagan

920

65

45

£22,204

Moreton

319

105

41

£20,430

Gairden

650

90

39

£18,626

208,914

N/A

40

Not available

Scotland

5,062,011

N/A

39

£22,426

Caltowie

700

70

40

Au$29,030 (£11,800)

1100

105

43

Au$ 31,590 (£12,890)

Elandra

300

105

36

Au$28,790 (£11,750)

Pintan

650

125

37

Au$38,450 (£15,700)

1,527,150

N/A

38

Au$35245 (£14,390)

Highland Region

Doonburr

South Australia

Au$2.45:£1 (based on currency conversion rates from November 2006). (Australian Bureau of Statistics, 2004; Australian Bureau of Statistics, 2007, Australian Institute of Health & Welfare, 2003; Highland Council, 2006; Scottish Executive, 2006)

An institution could reside in a building, or could be embodied in the ‘institution’ of having health professionals (with specific status, capabilities and skills) resident in the local community. Institutional added-value is resistant to changes in personnel. In contrast, person-dependent added-value is impermanent and is lost when individual health professionals leave a community. A complication of distinguishing added-value contributions is that many of the activities of healthcare workers are interconnected, with more or less of a relationship with their direct healthcare role. Similarly, social, economic and human contributions are inter-connected. In attempting to provide clarity, the following portrayal of findings has necessarily, at times, had to isolate, simplify and categorise factors and relationships. 4.1. Added-value contributions of institutions 4.1.1. Economic contributions Health service institutions make direct economic contributions in all eight communities by providing employment. Crossnational differences in the magnitude of this contribution result from the differing nature of national healthcare systems. In the Australian communities, healthcare employed between 4.6% and 8% of the population, making it the largest single employer at three of the four communities (Australian Bureau of Statistics, 2004). In Scotland, the GP practices employed between two and nine people, although social/elderly care facilities in Beagan and Gairden increased the number of healthcare related jobs.

The eight sites had varying industrial bases (Table 1), but traditionally male employment sectors (e.g. agriculture and fishing) predominated. In both countries, health service employees were mainly female and part-time. In 2006, South Australia was experiencing a severe drought and crop yields were poor. Participants mentioned the importance of stable, ‘drought resistant’ health jobs for supplementing family incomes during ‘difficult times’. In Scotland, ‘crofters’2 traditionally have second jobs. Stable, part-time health service jobs are described as playing a part in maintaining crofting lifestyles. Use of local goods and services by health service institutions made indirect economic contributions to communities, but this contribution was not quantified in this exploratory study. Tourism is economically important to all eight communities. Health professionals in both countries reported that tourists presented a significant number of cases, and they and ‘key informants’ suggested that the location of health services in their community provided economic advantage, contributing to attracting tourists, especially elderly visitors or those with health problems, to their community. More indirectly, but related in citizens’ perceptions, was the role that local health services played in community reassurance and security, attracting and retaining residents with health

2 Crofting is a form of subsistence farming unique to the Scottish Highlands and Islands.

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services that were accessible should the need arise. This was attractive to incomers considering relocation:

they have a bit of a chat and especially the elderly that do not get to see a lot of people.’’ (health professional Pintan).

‘‘It (GP surgery) does offer a great deal of reassurance, it is the sort of thing when people are moving hereythere was a couple in to see me actually on Monday, because they were thinking of moving here and they were just like ‘wow, you have got this health centre here’’. (key informant 03 Adair).

‘‘I actually feel guilty sometimes because we have booked appointments in the morning and you go in and you see people engrossed in conversation and you feel, oh, sorry for interrupting you. I mean for instance last week there were people from a more rural area and they do not live far from each other, but they were all elderly people and they had not seen each other I think this year. And yet they came here for various reasons and that was the first time they had seen each other. And I deliberately said ‘I will go and do something and come back’ because I did not wantyto break that up, because it is a social thing.’’ (health professional 02 Gairden).

Similarly, the presence of GPs was important in enabling the retention of residents, until death, within their own community: ‘‘Basically they are (GPs) the very core of the social fabric. The locals have, it is an almost mystical belief in obviously being born, but living and dying herey people do not want to go from this parish elsewhere and die there’’. (key informant 01 Gairden). Although this added-value contribution relates to the core function of health services in providing healthcare, interviewees were keen to express the security and reassurance function and its economic significance in ensuring the viability of communities. Health services were universally viewed as a sign to residents and the outside world alike, that ‘all is well’: ‘‘The greatest way for the community to have a future, I think, is to ensure it has a hospitaly We know that the greatest growth is occurring in coastal areas, but the growth in the coastal areas that are relatively close to a hospital—they have got the greater chance of actually having a long term financial future as a community because people can go there with the knowledge that they can go to a doctor within a 15 min drive or they can have a doctor respond to an emergency at their home within 10 or 15 min.’’ (key informant 07 Doonburr). Having a local GP supporting the viability of other healthrelated services, including community hospitals in Australia, and elderly and social care facilities in both countries. In Australia, community hospitals were reliant on the presence of doctors to function in their present form. South Australia has experienced serious GP recruitment and retention issues in the last 20 years, and GPs are viewed as having ‘keystone’ status, with citizens conveying the impression that their community must have ‘a GP at all costs’: ‘‘I know the two doctors do not get on so well, but the community is prepared to accept that and we humour them on things, because we know how necessary they are to be here.’’ (key informant 05 Caltowie). This view was emphasised when key informants in three of the four Australian communities spontaneously expressed negative opinions of individual GPs, but the importance attached to the presence of these GPs in their community was undiminished: ‘‘people think it is better than nobody’’ (key informant 04 Caltowie). GPs in Pintan and in the Scottish communities were perceived to be important, but the continued viability of the whole community was not pinned on the existence of a local GP. 4.1.2. Social contributions Health service institutions fostered social added-value in three ways: by providing a location for social interaction, by helping to retain social assets and by providing a locus for volunteering. In both countries, the GP surgery and/or hospital waiting rooms were described as important arenas for social interaction: ‘‘It is a bit of a social outing as well for a lot of people, which I do not think a lot of people understand. When they come in

The role of health services in retaining residents with complex needs within their community was socially important to individuals and their families, as it enabled maintenance of social networks and ties. Valued community members could remain active in community life: ‘‘The community is sort of kept alive really by older people and people retired, and because I think there are no jobs and that for younger peopleyso at the moment the community is kept going by older people and older people really need the (health) services’’ (key informant 04 Beagan). The Australian community hospitals provided a focus for industrious community fundraising and volunteering. Feelings of pride and community ownership of their health services were described by volunteers and their activities not only raised funds for health service equipment and refurbishments, but also facilitated social interaction among residents. In three of the Scottish communities, similar social outcomes were described in relation to volunteering and fundraising, but were associated with a village hall, a leisure centre and a residential elderly care facility. 4.1.3. Human contributions Health service institutions contributed to the local community knowledge and skills base. All the GPs working in the study communities and the Australian senior nurses (Directors of Nursing, Clinical Nurse Consultants) were incomers, having moved to the locality to take up their positions. Key informants suggested that there was generally resistance to newly arrived incomers ‘muscling in’ on community matters; however GPs, and to a lesser extent nurses, were not viewed in this way. Respect for their professional status and experience resulted in them being regarded as an asset, rather than a threat, if they chose to become involved in community matters. GPs and nurses who moved into remote communities were described by key informants as having capacity to contribute and as improving the ‘knowledge pool’. Administrative staff and healthcare assistants, in both countries, were recruited largely from the local population. To fulfil the demands of health related jobs, local residents (mainly women) acquire new skills and qualifications. Healthcare assistants in Australia and Scotland undertake vocational training. In Australia, community hospitals host enrolled nurse cadetships. These opportunities were important in enabling local residents to undertake nationally recognised tertiary qualifications locally. 4.2. Added-value contributions of individual health professionals (person-dependent) 4.2.1. Economic contributions Individual health professionals made differing economic contributions to their community related to their personal habits of spending and utilisation of local services and amenities.

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Some made a conscious effort to purchase supplies and services locally in support of the local economy. ‘‘I believe very heavily that we shop locally, if we did not, the little general store would stop or it would not hold a certain line of goods, and so people then did not have to goyI would much rather spend (locally), but then again it is easy for me to do that because I am not short of a quidy.’’ (GP1-Caltowie). Others shopped locally only for convenience, and used larger service towns for cheaper prices, product alternatives and to protect their privacy. These participants valued their individual choice over their role in supporting the local economy. The majority of health professionals’ children were educated within their local community up to secondary school age. Secondary schools were present in three of the four Australian communities (Caltowie, Doonburr and Pintan). In the other, Elandra, all secondary school children are weekly boarders at the nearest school 105 mile away. None of the Scottish study communities has in-situ secondary schools and children commute daily to schools up to 40 mile away. With the exception of Pintan, all health professionals with children in this study sent their children to their local school. However, in Pintan the majority of health professionals chose to send their children to boarding schools rather than to a local school. The personal economic choices of health professionals regarding shopping and schooling influenced key informants’ perceptions of individual health professional’s commitment to their community. 4.2.2. Social contributions Most health professionals engaged in informal or formal social activities that were a direct extension of their health service roles; for example, being a member of the local hospital board, a rural representative on a medical committee, fundraising for new equipment, volunteering to provide medical cover for activities and activities to promote health, such as walking clubs or exercise classes. As well as their health aspect, these activities could be understood as contributing to social capital3 development. A second tranche of activities was less directly related to being a health professional, but was related to knowledge of healthcare and associated needs. This was more an informal help provided to community residents and was commonly reported among nurses in both countries. Activities included lift-giving to and from GP surgeries, delivering medicines and accompanying elderly residents on fact-finding visits to elderly care facilities when off duty. One GP in Scotland, a sole practitioner based in a community with no resident nurses also carried out such informal duties, including delivering newspapers and making drinks and meals for patients/community members. Many of these tasks could be described as ‘neighbourly’ behaviours, but we did not gather an evidence about the ‘extended roles’ of other local skilled professionals, so cannot assess the extent to which health workers make unique types of neighbourly contributions. Three GPs (two in Scotland and one in Australia) were leaders of various community organisations; as it was stated, ‘‘Oh, you name it, the GP is in there somewhere’’ (key informant 07 Beagan). These GPs had each been elected to their local community council and were involved in committees for drama groups, leisure centres, local trusts, business development groups and school councils/boards. One was described as driving the funding and building of a local secondary school so that local children did not have to board away during the week. These GPs described their 3 Social capital is defined here as the networks, shared norms, values and understanding that facilitate co-operation within and between groups (Farmer et al., 2003).

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involvement as related to their personality (‘‘campaigning spirit’’) and a desire to use their abilities to benefit the community, in which they had chosen to work. These GP ‘leaders’ were described by key informants as being influential in all aspects of community life (health and non-health related). GPs uninvolved in community life did not influence nonhealth related community matters: ‘‘As far as the wider community is concerned he is not influential because he is not involved, he would not know what happens outside I do not think, the hospital is his whole life.’’ (key informant 04 Caltowie). Of the other (non-GP) health professionals in the study, most were also involved in community activities, as active participants and/or leaders. 4.2.3. Human contributions The health professionals in this study all possessed high levels of human capital4 associated with their educational attainment, specialist knowledge and skills, which were available to the community via their formal healthcare roles. Some health professionals made their individual skills, abilities and knowledge available to their community in other ways through the informal and formal non-medical and social activities described above, whilst others did not. Thus, although the personal stock of human capital residing in individual health professionals may be similar, the availability of this as a community resource is dependent on personal factors and on individuals establishing networks that enable the ‘flow’ of these stocks of human capital.

5. Discussion This study provides a timely exploration of a topical issue. We drew on knowledge dispersed through various disciplinary literatures and across sectors to examine the diverse range of real and perceived roles that rural health services contribute to the vitality of their communities beyond their direct contribution to health. Ultimately, their contribution has been verified, and we have typologised their added-value contributions (see Fig. 1). Importantly, the study and emergent typology distinguish between individual (person-dependent) and institutional contributions. As Fig. 1 depicts, individuals make choices about the extent to which they spend locally, utilise local public amenities (thereby fostering their ongoing viability) and get involved in a range of bonding and bridging social capitalgenerating activities (Stone, 2003), from direct health-role related committee work to informal health-related help to local citizens, to community civic activity. Institutional added-value resides in more or less tangible aspects of healthcare. The study has shown (as summarised in Fig. 1) that, economically, health services contribute to communities directly through salaries; and, indirectly, by supporting jobs in local services and amenities, the potential for co-location of other health service-dependent facilities and confidence of ‘health safety’ that fosters in-migration, tourism and business location. The presence of healthcare is viewed by citizens as an asset that distinguishes this community, relative to others, engendering intangible benefits, such as community sense of identity and confidence about the future. The healthcare presence can be a worker and/or a building; crucial is the relationship to that 4 Human capital is defined here as the abilities, skill and knowledge of individuals and their capacity to contribute to society through production, decision-making, leadership and innovation (Mission Australia, 2006).

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Fig. 1. The added-value contributions of health services to remote communities.

community. Therefore, in-situ assets are valued and peripatetic teams less so, as they are seen as coming from outside. Healthcare institutions provide physical and conceptual ‘spaces’ for social interaction. A GP practice building or car park provides a territorially neutral arena for interaction between residents with differing social status. Healthcare also provides the ‘space’ that fosters volunteering, a social capital-generating activity. While technology and peripatetic health and social care resources help keep older people living in their remote communities, local presence of healthcare might be argued to maximise this potential. Thus in-situ rural healthcare institutions facilitate the retention of people who may be old and frail, but who still contribute socially and culturally to their community. Healthcare provides professional status jobs to remote communities, implying high level knowledge assets. Professional status was observed as a lubricant, allowing health professionals to assume active civic roles in communities, relatively unchallenged. Healthcare also provides opportunities for growing ‘bottom-up’ local community knowledge and skills (e.g. Australian nursing cadetships). In these ways, in-situ healthcare ‘institutions’ provide multiple dimensions of human capital to remote communities. It is against this backdrop that we should consider protests, by remote community citizens, about service reconfigurations. Citizens are reacting to the potential loss of the institutional added-value dimensions of healthcare. Remote communities have experienced serial loss of local institutions (for example, banks), and given the ageing profile and low employment opportunities of most remote communities, threat to sustainability is real. Our suggestion about recognition of the added-value of healthcare institutions is well illustrated by the counter-intuitive thinking of Australian informants who expressed negative opinions of some local GPs, but still wanted them retained. Without these GPs, they could not have a local hospital and the associated jobs, opportunities and status.

As well as identifying a crucial role for GPs, the Australians identified more value-generating roles of their healthcare institutions, compared with the Scots. This was related to the more extensive presence of healthcare, in the form of community hospitals, acting as a locus for nursing cadetships, volunteering and fund-raising. The larger Australian healthcare institutions, employing 23–62 people, made a proportionately greater economic contribution to the community than the Scottish health services, employing 2–26 people. Thus, although similar in nature across the eight cases, the extent of these economic contributions, and their impact on a community, was accentuated by the size and structure of certain healthcare institutions. This differential economic contribution also influenced residents’ perceptions of the importance of health services to the vitality and viability of communities. In government and health service policies of recent years, scant attention has been given to the importance of the extended roles of health professionals in sustaining remote communities. This situation may be changing, with planners being exhorted to consider the wider impacts of health sector reconfiguration on local economies and social diversity (Donnelley, 2008; Government of South Australia, 2008). However, given the current economic crisis with its predictions of cuts in public services, the question is to what extent are local health professionals a ‘luxury’ that can no longer be afforded, even if they are providing addedvalue that sustains communities? If the apocalyptic vision results in further service cuts for remote communities, their future viability may be jeopardised in ways other than the obvious decrease of service provision (Evans et al., 2001). The case study communities in both countries were similarly sized (populations of between 300 and 1100) and comparably remote, but health sector employment was lower in the four Scottish communities, due to the smaller sized healthcare institutions. Notwithstanding the cross-national differences in institutional size, cross-national similarities in the nature of

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added-value contributions emerged (e.g. community reassurance and security, attracting and retaining residents, facilitating social interaction). These cross-national consistencies suggest that our study findings on the economic, social and human contributions of rural health services can be used to build a typology of addedvalue contributions. Moreover within-country and cross-national consistencies support the potential that the derived typology may be transferrable to other remote communities and areas. We did not scrutinise the relative role of healthcare vis a vis other sectors in remote communities; rather we took a ‘first step’ towards this by co-locating a diverse literature, verifying the existence of added-value dimensions and developing a typology. Considering the relative roles of sectors in remote communities is a logical next step for study, and we propose to do this by translating the typology described here into a tool for assessing community assets and attributing these to constituent service and business ‘sectors’.

6. Conclusions This paper has defined the contributions, over and above direct healthcare, provided by individuals and institutions in remote communities. The next step is development of a tool to measure the relative contributions of different sectors to remote communities. This would be of value to communities, policymakers and managers to predict the impacts of proposed service changes. At a time of traumatic reconfiguration for some remote communities, this study allows the agents of change – managers and policymakers – to understand that it is the fear of the loss of the in-situ institution of healthcare, and all the dimensions of added-value that brings—that is paramount when communities protest about service change. Reassurances that services will be delivered by ‘innovative’ new peripatetic team models fail to recognise the added-value contributions of locally resident health workers by focusing purely on the technical delivery of health services. Simultaneously, while community protest may focus on the value of the institution, it is clear from this study that some individual health professionals contribute more to the community than others. However, it was not within the remit of this study to explore the reasons behind this. In our typology, individual contributions may be influenced by personality, but also by characteristics such as cultural background, age and gender. Future work could further explore the component parts of institutional and individual contributions in our typology. In the meantime, given the potential of varying levels of added-value residing with individuals, community members should take opportunities to involve themselves in selection processes, including job design, advertising and recruitment, so that they obtain the best health worker asset for their community, rather than simply replacement ‘institutions’. Though clearly, given recruitment and retention difficulties in obtaining rural health professionals, this might be considered a luxury. Nonetheless, this paper adds evidence that rural health professionals are working, and should be designed, to produce a range of inputs and outcomes for remote rural areas that go beyond technical healthcare. These require explicit recognition by healthcare professions, educators and policymakers.

Acknowledgements The authors would like to acknowledge the community members and health professionals who were interviewed. We thank Highlands and Islands Enterprise, the Universities of

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Aberdeen and South Australia and the Carnegie Trust for Universities for funding this study. David Williams drew Fig. 1.

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