Skye and Lochalsh

Deprivation and rural service need

Paper 2 of a population needs assessment for Skye and Lochalsh

Health Intelligence Team Directorate of Public Health NHS Highland

May 2019

The Health Intelligence Team are part of the Directorate of Public Health of NHS Highland and provide an expert resource of demographic and population health evidence.

Health Intelligence Team Directorate of Public Health NHS Highland Larch House Stoneyfield Business Park Inverness IV2 7PA

Telephone: 01463 704939 Fax: 01463 235189

Email: [email protected]

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 2

Contents

Skye and Lochalsh Population Needs Assessment ...... 4 Background ...... 5 Key points ...... 6 Multiple Deprivation in Skye, Lochalsh and South West Ross ...... 7 Summary ...... 16 References ...... 17 Appendix 1: How the Scottish Index of Multiple Deprivation 2016 is constructed ...... 20 Appendix 2: SIMD 2016 individual scorecards for SLSWR data zones ...... 21

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 3

Skye and Lochalsh Population Needs Assessment

This is the second report in a series that will contribute to a population needs assessment in relation to adult health and social care services for Skye and Lochalsh. Reference is also made to the area of South West Ross that includes Lochcarron.

In the first report1 we looked at the demography and population dynamics of the area using available population estimates and projections. This report reviews the social context of the population health of the area through the lens of deprivation. The health of populations is influenced by a wide range of factors, including the demographic structure, availability of housing and employment, crime and safety, accessibility of services, the physical environment and social networks. Socio-economic factors contribute to health inequalities and there is a strong link between deprivation and poor health. Rural deprivation is often hidden and dispersed.

A subsequent series of reports are planned that will look at, morbidity, mortality and the implications for health and social care services. Specific work is also planned about the seasonal population of the area.

Further details of future reports are available in the Project Initiation Document (PID).

The timescale for the epidemiological and comparative part of the needs assessment is from April to June 2019.

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 4

Background

Where people live affects their health and life chances. The links between socio-economic deprivation and people’s health and well-being outcomes are well evidenced and deprivation impacts on child development, people’s lifestyle choices, healthy life expectancy, including living with an illness or chronic condition, and life expectancy. A consequence of deprivation and poverty is generally an increased demand for health and social care services2.

NHS Health Scotland defines inequalities in health as the unfair and avoidable differences in people’s health across social groups and between different population groups3.

Urban and rural differences in the interaction of the social determinants of health can have a profound influence on population health and the provision of health and social care services. While most of the Scottish land mass is rural, most of the population lives in urban areas. It has been strongly argued that there has been a long-term focus on socio-economic deprivation in urban areas with a lack of systematic integration of rural dimensions of poverty and disadvantage in national policy4.

Related to this, progress on many of the health-related indicators set out in the National Performance Framework5 (for example, on smoking, problem drug misuse and alcohol- related admissions to hospital) are particularly targeted at people living in the most deprived communities nationally. The latest report on Long Term Monitoring of Health Inequalities was published in December 20186.

In 2017 the Scottish parliament passed the Child Poverty (Scotland) Act 20177. This is an Act of the Scottish Parliament to set targets relating to the eradication of child poverty; to make provision about plans and reports relating to the targets; and to establish the Poverty and Inequality Commission and provide for its functions.

In 2018, the Joseph Rowntree Foundation published Poverty in Scotland8, looking at poverty trends for families with children in Scotland. The report highlights gender and disability as barriers to work being intrinsically linked with poverty. Nearly 1 in 4 children live in relative poverty in Scotland after housing costs are considered.

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 5

Key points

The Scottish Government classifies all areas in Skye, Lochalsh and South West Ross (SLSWR) as very remote rural9, including Portree and Broadford.

The Scottish Government’s official tool for identifying small area concentrations of deprivation is the Scottish Index of Multiple Deprivation (SIMD)10. The area identified as that most deprived in SLSWR by SIMD 2016 was Skye North East. This area was ranked as being the 2050th most deprived small area (data zone) across Scotland with the most deprived ranked 1, to the least deprived ranked 6,976.

The SIMD is less accurate in rural areas11. This is in part a reflection that the statistical indicators used in the index do not capture the nature of rural deprivation and that disadvantaged and poor households in rural areas are unlikely to be spatially concentrated12.

Rural areas tend to be less homogenous than urban ones in terms of deprivation with the numbers involved tending to be smaller. Deprived households in rural areas are therefore unlikely to make much statistical impact on an area basis. A consequence is that rural disadvantage is less visible and ‘less easily tractable’.

Data from the income and employment domains of the SIMD is available as counts of individuals and these can potentially be used to identify absolute numbers of people experiencing deprivation and to highlight these elements as components of rural deprivation. In SIMD 2016 9 percent of the population of the SLSWR were identified as being income deprived and 5 percent employment deprived. Table 3 and Table 4 below show the range of proportions across the individual areas of SLSWR. These proportions are significantly lower than in many urban areas in Highland.

Absolute figures highlight that not all deprived people live in deprived areas and that an analysis using the overall score of the SIMD can obscure those experiencing employment and income disadvantage.

Rural poverty, disadvantage and deprivation have been recognised to have particular characteristics. These include: low incomes due to seasonal, short-term employment; fuel poverty due to old housing stock and being off-grid; and in difficulties in accessing services4,12,13.

Potentially useful measures for rural areas such as those capturing social isolation are not systematically collected.

Remote rural area characteristics are particularly associated with challenges in accessing services (Figure 5). The rate of those finding access to hospital out-patient services, dentists, public transport and pharmacy services ‘very or fairly’ convenient decreases as rurality increase12.

The geographic access to services domain of the SIMD evidences wide disparities in access to local services across the SLSWR area. Differing area characteristics are associated with differing economies of scale for service providers that can have important implications for service accessibility and quality. Higher unit costs in very sparse areas or in highly peripheral areas make attempts to promote equity of access considerably more difficult14. The variation in the access domain ranks within the SLSWR area highlights the challenge of providing visiting services such as home care given the distances, times and costs.

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 6

Deprivation works in combinations and the elderly in remote rural areas are vulnerable to low income in combination with problems of isolation and access to services. Younger people can experience the combination of problems relating to housing, transport and employment opportunities, and are more likely to move out of remote rural areas than other age groups4.

Multiple Deprivation in Skye, Lochalsh and South West Ross

The Scottish Index of Multiple Deprivation (SIMD) is the official and widely used composite measure of deprivation for data zones (small areas with a median population of about 760 people) in Scotland10. The most recent version of the SIMD was published in 2016 and is based upon 2011 Census geography.

Multiple deprivation does not just identify areas with ‘poor’ or ‘low income’; it can also mean people live in areas that have relatively fewer resources and opportunities within the seven domains of the index: Income, Employment, Education, Health, Access to Services, Crime and Housing. The SIMD is put together by combining indicator scores from these 7 domains for every small area and ranking (Figure 1 and Appendix 1) these areas from the most to the least deprived, where 1 is the most deprived and 6,976 the least deprived in Scotland (Figure 2).

Figure 1: SIMD domains and their weightings

Data source: Scottish Government – The Scottish Index of Multiple Derivation10

Figure 2: Data zones across Scotland and SIMD domains 2016

Data source: Scottish Government – The Scottish Index of Multiple Derivation10

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 7

These ranks are commonly grouped into quintiles (20% bands) and deciles (10% bands) of deprivation by data zone either within Scotland, Health Board or Council Area. This permits benchmarking within the area of interest in detail with deciles or an overview with quintiles. SLSWR data zone ranks range from 2,050 (Skye North East) to 4,579 (Plockton and Achmore). These fall into national quintiles 2 to 4 (Figure 3 and Map 1Map 2) and Highland Council area quintiles 1 to 4 (Figure 4).

The overall SIMD profiles of the small areas within SLSWR identify no extremes of deprivation (Figure 3 and Appendix 2). The individual domain ranks that indicate population health and material wellbeing scores generally reflect the overall distribution of deprivation in Highland with the majority of areas falling into national quintiles 3 and 4. The exception to this picture is the access domain score that places some areas in SLSWR among the most deprived in Scotland in terms of access to local services (Figure 3). Almost 80 percent of the SLSWR population live in the 20 percent most access deprived areas in Scotland.

Figure 3: SIMD 2016 overall and domain rankings within Scotland: SLSWR data zones in blue and Highland Council data zones in grey

Data source: Information Services Division population weighted SIMD 2016 lookup file for 2011 data zones15

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 8

Map 1: SIMD 2016: small area overall deprivation in SLSWR by national decile

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 9

Figure 3 above illustrates the deprivation rank of SLSWR data zones within Scotland and Highland. We now consider how deprivation in SLSWR compares to the Highland Council area based upon the overall SIMD rank of the 312 data zones in the local authority summarised by within Highland quintiles (Figure 4).

Around 1,300 people in the SLSWR area (Skye North East and Portree West data zones) live in what can be described as the 20 percent most deprived parts of Highland (Table 1).

Figure 4: Proportions of the SLSWR population living in Highland Council SIMD quintiles, 2017

Table 1: Numbers living in Highland Council SIMD quintiles, 2017

SIMD 2016 quintile (population weighted Highland council rankings) Area 1 (most 5 (least Total 2 3 4 deprived) deprived) North Skye 1,313 3,935 1,727 - - 6,975 South Skye - 1,885 1,602 - - 3,487 Skye 1,313 5,820 3,329 - - 10,462 Lochalsh - 635 1,297 749 - 2,681 Skye & Lochalsh 1,313 6,455 4,626 749 - 13,143 South West Ross - - 1,465 - - 1,465 SLSWR 1,313 6,455 6,091 749 - 14,608

Table 2: Proportions of populations living in Highland Council SIMD quintiles, 2017 SIMD 2016 quintile (population weighted Highland council rankings) Area 1 (most 5 (least Total 2 3 4 deprived) deprived) North Skye 19% 56% 25% - - 100% South Skye - 54% 46% - - 100% Skye 13% 56% 32% - - 100% Lochalsh - 24% 48% 28% - 100% Skye & Lochalsh 10% 49% 35% 6% - 100% South West Ross - - 100% - - 100% SLSWR 9% 44% 42% 5% - 100% Data source: Information Services Division population weighted SIMD 2016 lookup file for 2011 data zones15 and National Records of Scotland mid-2017 Small Area Population Estimates (SAPE)16, best fit by data zone to local areas.

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 10

The figure below shows that people living in remote rural areas find key services less convenient. This is particularly notable for hospital outpatients, dentists, public transport and banking services, but less so for general medical services located at a GP surgery.

Figure 5: Percentage of the population finding services very or fairly convenient by Scottish Government Urban Rural classification area type17

Data source: Scottish Household Survey 2016 (Using Scottish Government Urban Rural Classification 2016) The health domain suggests that relative health is generally better in SLSWR than in most areas in Scotland. However, caution should be exercised in drawing any conclusion about population health need from this data. To compare areas the SIMD methodology calculates standardised ratios of health and disability to describe variation from what might be expected of a population of a particular age. The health domain therefore does not report actual levels of poor health and disability. We know that the prevalence of chronic conditions and limiting long-term illnesses increase with age.

As highlighted in our demography paper1, in common with other rural populations, that of SLSWR is generally older and predicted to age. Age places increased demand on health and social care. The Institute for Fiscal Studies estimates that a 65 year old costs double in terms of health spending when compared to a 30 year old, and a 90 year old eight times more18.

Data from the income and employment domains of the SIMD is available as counts of individuals and these can potentially be used to identify absolute numbers of people experiencing deprivation and to highlight these elements as components of rural deprivation (Map 2). SIMD 2016 identified 9 percent of the total population of SLSWR as being income deprived and 8 percent of the working age employment deprived (Table 3 and Table 4).

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 11

Map 2: SIMD 2016: number of people income and employment deprived in SLSWR

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 12

Table 3: Analysis of income deprivation in SLSWR, 2014

Number of people % of people income deprived Area income deprived All data zones Lowest Highest North Skye 719 10% 7% 18% South Skye 278 8% 5% 13% Skye 997 10% Lochalsh 211 8% 5% 13% Skye & Lochalsh 1,208 9% South West Ross 81 6% 5% 6% SLSWR 1,289 9% 5% 18% Highland Council 9% 1% 41% Scotland 12% 0% 73%

Data source: Information Services Division population weighted SIMD 2016 lookup file for 2011 data zones15 Table 4: Analysis of employment deprivation in SLSWR, 2014

% of working age population employment Number of people Area deprived employment deprived All data zones Lowest Highest North Skye 365 9% 3% 15% South Skye 165 8% 4% 10% Skye 530 8% Lochalsh 115 7% 4% 12% Skye & Lochalsh 645 8% South West Ross 45 5% 5% 6% SLSWR 690 8% 2% 9% Highland Council 8% 0% 34% Scotland 11% 0% 53%

Data source: Information Services Division population weighted SIMD 2016 lookup file for 2011 data zones15 Individual data zone counts of the number income and employment deprived are included in the SIMD “score cards” in Appendix 2.

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 13

The SIMD is designed to identify concentrations of deprivation and as a tool it is known to be less sensitive to deprivation in a rural context where populations are more spatially dispersed and socially heterogeneous. Evidence from the literature highlights that people living in rural areas experience deprivation differently from those living in towns and cities4,12,13. Particular issues in rural areas include:  Less accessible key services including health and social care, childcare and high speed digital networks  Higher consumption of fuel for heating and transport  Reduced opportunities to earn adequate income  Higher cost of living impacted by prices to for basic essential supplies  Limited frequency and coverage of public transport These factors can work as a compound with the low incomes of people in remote rural areas being exacerbated by additional costs including more expensive food and fuel, as shown in work on the Minimum Income Standard for Remote Rural Scotland19. Figure 6 and Figure 7 below illustrate how such disadvantages interact. However, while we can describe these relationships it is not always possible from routinely collected national data to create metrics to inform the SIMD12.

Figure 6: Access to services and employment in rural areas identified from the literature

Data source: Scottish Government12

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 14

Figure 7: Housing issues and associated impacts in rural Scotland identified from the literature

Data source: Scottish Government12

The current evidence suggests that people living in remote rural areas face different challenges than those living in urban areas, and therefore, the experiences of deprivation are not the same.

Rural communities are increasingly older and our previous work on the demography of SLSWR1 projected a 150 percent increase in the population over 75 years of age by 2041. Deprivation works in combinations and the elderly in remote rural areas are vulnerable to low income in combination with problems of isolation and access to services. The younger population tends to decline the more remote and rural the settlement type is, with implications for informal care and workforce supply.

The SIMD currently includes no measure of access to secondary care services. However, it would be anticipated that there would be a strong positive correlation with the existing indicators of access to local services for remote rural areas.

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 15

Summary

The Scottish Index of Multiple Deprivation identifies no single area in Skye, Lochalsh and South West Ross as particularly experiencing multiple deprivation. However, exploration of the individual component domains of the index highlights areas with issues of income and employment deprivation that will impact on families and households. The literature suggests that rural deprivation is often hidden and dispersed within areas of apparent affluence with the financial challenges accentuated by a combination of low pay and higher cost of goods and transport.

The health domain of SIMD also indicates that the population of the area is relatively healthy in both the context of Scotland and Highland. However, changing population demographics have resulted in an increasingly elderly population living in the area. This group are more likely to be predisposed to a range of associated health conditions (such as dementia) and long-term chronic conditions that require regular ongoing treatment and services.

The SIMD access domain clearly highlights that availability of services is a major issue in remote rural areas. The focus of the domain measure is access to local services including pharmacies and GP and there are area differences across SLSWR. Limited availability of primary care services can be compounded by distance to specialist services. There are difficulties of supplying specialist health services in rural areas including the availability of staff and the lower numbers of patients with associated challenges to maintain clinical skills. Accessing specialist services such as for cancer care are likely to mean that people who live in rural areas are required to travel long distances regularly. A lack of specialist care can negatively impact on patient health, particularly on those with complex support needs. As healthcare may not be readily accessible certain groups do not report illnesses or present until later stages in disease progression20,21. This can contribute to health inequalities and higher levels of unmet need. Urban deprivation can result in similar delays in help-seeking and stage of disease presentation, for different reasons.

Transport links are therefore vital for rural populations requiring care in other areas. Reciprocally, patient location impacts on healthcare staff and such as social workers, nurses, GPs or home carers who need to travel to provide services within homes and clinics.

Innovative approaches to the provision of remote and rural healthcare are required. Outpatient video appointments are increasingly possible in more rural areas of NHS Highland through the ‘Near Me’22 programme that allow patients to ‘attend anywhere’. However, the increasing employment of technology to deliver remote care raises issues of digital exclusion. Although internet connectivity remains a challenge, the NHS Near Me programme aims to minimise access differences by engaging across population groups and offering the service in appropriately equipped clinic rooms in remote rural areas where people cannot connect from home.

A range of health issues affect the population of SLSWR. These include accessibility, isolation, population dynamics and demographic change and socio-economic challenges. Not all these issues are unique to the area but the future models of care need to consider how these factors interact on population health and wellbeing in one of Scotland’s remote areas.

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 16

References

1. NHS Highland Health Intelligence Team. Paper 1 of a population needs assessment for Skye and Lochalsh. 2019.

2. Wilkinson R, Marmot M. Social determinants of health: the solid facts. 1998; Available from: http://www.who.int/iris/handle/10665/108082 [Accessed May 2019].

3. NHS Health Scotland. Health Inequalities: What are they? How do we reduce them? 2015; Available from: http://www.healthscotland.scot/media/1086/health-inequalities-what-are-they- how-do-we-reduce-them-mar16.pdf [Accessed May 2019].

4. Skerrat S, Atterton J, Brodie E, Carson D, Heggie R, McCracken D, et al. Rural Scotland in Focus 2014. Scotland's Rural College (SRUC). 2014. Available from: https://www.sruc.ac.uk/downloads/download/828/2014_rural_scotland_in_focus_report [Accessed May 2019].

5. Scottish Government. National Performance Framework. 2019; Available from: https://nationalperformance.gov.scot/ [Accessed May 2019].

6. Scottish Government. Long-term monitoring of health inequalities: December 2018 report. 2018; Available from: https://www.gov.scot/publications/long-term-monitoring-health- inequalities-december-2018-report/ [Accessed May 2019].

7. Scotland. Child Poverty (Scotland) Act 2017 (asp 6). Available from: http://www.legislation.gov.uk/asp/2017/6/introduction [Accessed May 2019].

8. Congreve E, McCormick J. Poverty in Scotland 2018. Joseph Rowentree Foundation. 2018. Available from: https://www.jrf.org.uk/report/poverty-scotland-2018 [Accessed May 2019].

9. Scottish Government. Urban Rural Classification. 2018; Available from: https://www2.gov.scot/Topics/Statistics/About/Methodology/UrbanRuralClassification [Accessed May 2019].

10. Scottish Government. The Scottish Index of Multiple Deprivation. 2016; Available from: https://www2.gov.scot/Topics/Statistics/SIMD [Accessed May 2019].

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 17

11. Scottish Government. Income, employment and access deprived rural datazones. 2011; Available from: https://www2.gov.scot/Topics/Statistics/SIMD/deprivedruralpaper [Accessed May 2019].

12. Thomson J. SIMD 2016: Rural Deprivation - Evidence Summary. Scottish Government. 2016. Available from: https://www2.gov.scot/Resource/0051/00514495.pdf [Accessed May 2019].

13. Local Government Association. Health and wellbeing in rural areas. 2017; Available from: https://www.local.gov.uk/sites/default/files/documents/1.39_Health%20in%20rural%20areas_ WEB.pdf [Accessed 2019 May].

14. Palmer B, Appleby J, Spencer J. Rural health care: A rapid review of the impact of rurality on the costs of delivering health care. Report prepared for the National Centre for Rural Health and Care. Nuffield Trust. 2019. Available from: https://www.nuffieldtrust.org.uk/files/2019-01/rural-health-care-report-web3.pdf [Accessed May 2019].

15. Information Services Division. Scottish Index of Multiple Deprivation 2016 - Data Zone 2011 population weighted lookup file. 2016; Available from: https://www.isdscotland.org/Products-and-Services/GPD-Support/Deprivation/SIMD/ [Accessed May 2019].

16. National Records of Scotland. Mid-2017 Small Area Population Estimates for 2011 Data Zones. 2018; Available from: https://www.nrscotland.gov.uk/statistics-and- data/statistics/statistics-by-theme/population/population-estimates/2011-based-special-area- population-estimates/small-area-population-estimates/mid-2017 [Accessed May 2019].

17. Scottish Government. Rural Scotland: key facts 2018. 2018; Available from: https://www.gov.scot/publications/rural-scotland-key-facts-2018/pages/2/ [Accessed May 2019].

18. Luchinskaya D, Simpson P, Stoye G. UK health and social care spending, Chapter 5 in the IFS Green Budget. Institute for Fiscal Studies. 2017. Available from: https://www.ifs.org.uk/uploads/publications/budgets/gb2017/gb2017ch5.pdf [Accessed May 2019].

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 18

19. Hirsch D, Bryan A, Smith N, Ellen J, Padley M. A minimum income standard for remote rural Scotland: A policy update. Highlands and Islands Enterprise. 2016. Available from: http://www.hie.co.uk/regional-information/economic-reports-and-research/archive/a- minimum-income-standard-for-remote-rural-scotland---a-policy-update.html [Accessed May 2019].

20. Campbell NC, Elliott AM, Sharp L, Ritchie LD, Cassidy J, Little J. Rural and urban differences in stage at diagnosis of colorectal and lung cancers. British Journal of Cancer 2001;84(7): 910-914. Available from: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.280.7427&rep=rep1&type=pdf [Accessed May 2019].

21. Asthana S, Gibson A, Moon G, Brigham P. Allocating resources for health and social care: the significance of rurality. Health and Social Care in the Community 2003;11(6): 486- 493. Available from: https://onlinelibrary.wiley.com/doi/epdf/10.1046/j.1365- 2524.2003.00454.x [Accessed May 2019].

22. NHS Highland. NHS Near Me. 2019; Available from: https://www.nhshighland.scot.nhs.uk/NHSNearMe/Pages/Welcome.aspx [Accessed May 2019].

23. Scottish Government. Scottish Index of Multiple Deprivation 2016 - Interactive mapping. 2016; Available from: http://simd.scot/2016/#/simd2016/BTTTFTT/9/-4.0000/55.9000/ [Accessed May 2019].

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 19

Appendix 1: How the Scottish Index of Multiple Deprivation 2016 is constructed

Data source: Scottish Government – The Scottish Index of Multiple Derivation10

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 20

Appendix 2: SIMD 2016 individual scorecards for SLSWR data zones

Glenshiel & Glenelg Balmacara & Dornie Plockton & Achmore Kyle of Lochalsh

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 21

Broadford South Skye East Skye West Sleat

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 22

Skye East & Raasay Skye North East Portree East & Rural Portree West

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 23

Portree North Portree Central North Uig Dunvegan & Waternish

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 24

Duirinish Applecross, Shieldaig & Torridon Lochcarron

Data source: Scottish Index of Multiple deprivation 2016 interactive mapping23

NHS Highland Public Health Directorate, Health Intelligence Team May 2019 25