Yesterday I was pleased to take part in a Royal Society of Edinburgh session on the challenges facing those who live in rural and remote parts of Scotland as they relate to health and social care delivery. As part of the ‘Islands, past, present and future’ event series it was an attempt to spotlight the stories of Scotland’s Island communities, looking back, taking stock, and imagining the future.

The remote and rural parts of Scotland, not least our island communities, face many of the same challenges which social care provision is experiencing in other parts of Scotland but are doing so with an intensity and immediacy which may not be wholly evident elsewhere. But they also I believe have the capacity and ability to mirror and illustrate for the rest of us some of the pragmatic solutions and potentials for change which we all need to reflect upon and consider into our future.

So what are the challenges and issues?

Geography

Stating the obvious the first and foremost is geography. I am mindful that you define remoteness from where you are – and that it is a very subjective concept. This geographical remoteness impacts on the experience of people who might want to access services but also on organisations who might be willing to provide these. There are fewer services and supports available, reducing the importance of choice and personal control, and also making access to some services challenging because of the sheer distance. I think in particular of the huge number of care homes which have closed in my own island community of Skye where about 20 years ago there were well over a dozen and now only a handful.

A key additional factor both in terms of physically getting to care services and also as it impacts on the ability of staff is the issue of transport or perhaps more the lack of robust co-ordinated public transport together with the cost of self-transport in terms of fuel etc.

Workforce

A related major challenge facing providers is the availability of a skilled workforce. Even without mentioning the ‘B’ word and the hugely damaging impacts of Brexit on rural social care workforce recruitment, it was still immensely difficult for rural and remote provision to attract an available workforce. This is for a huge number of reasons, isolation, lack of support, availability of social housing, cost of living and so on. As hospitality and retail have become more attractive especially during what increasingly feels like a ‘whole year tourist season’ then it has become really hard to sustain workforce levels in social care. So what provdiers end up doing is using agency staff. The exorbitant cost of this emergency provision soon becomes unsustainable.

Since 2022 and the introduction of the Social Care Workers Visa there has been a not insignificant increase in inward attraction to both island and rural communities, but the death knell to such positivity has been sounded by the Tory Government’s restriction on dependents of workers here on a visa.

There are other factors which are evident in island and rural communities. One clearly is demographic – I am not the first nor will I be the last to fear what one newspaper called the new ‘Highland Clearances’ – with an increasing trend of younger people leaving island communities and more townships and communities losing the essentials of infrastructure and community. Added to that is the fact that proportionately the population is older and that this increases demand at a very time when that demand cannot, or it is very difficult to meet. Our islands attract many older individuals who choose the locations in which to retire, and this has and is putting tremendous strain on services when inevitably the ageing process leads to an increased demand.

Increasingly elsewhere when faced with increasing demand, workforce shortage and fiscal challenges both commissioners and providers of social care have turned to technological and digital interventions. Before going much further I would want to declare that I strongly believe such solutions have a place but only alongside humanistic presence and care delivery not as a replacement for and crudely as some sort of cost-saving strategy. But whether it is the increasing use of Ai, of in-house smart devices to monitor acuity and so much more, or simply data and record management, never mind the potential of robotics there are obvious challenges including digital connectivity, technological infrastructure robustness and access, digital poverty and so much more which are potentially faced by island and rural communities.

And of course, the elephant in this island room is economic limitation, lack of investment and the raw reality of rural and island poverty which affects everything not least the availability of social housing – though I was delighted to read this week that the island of Rassay off Skye has after over a decade finally got some more social houses!

Personally, I believe that if our island communities are not just going to maintain themselves in some sort of Celtic aspic then they need focussed and urgent national investment – an Islands Fund! We need social care providers for instance to have a fiscal weighting that enables them to be sustainable in the delivery of services given increased workforce, housing, infrastructure, commodity and related costs.

So the challenges are not insignificant but I also think the potential is equally capable of addressing and overcoming these. Addressing the challenge of social care in island communities requires a multifaceted approach, including improved funding, targeted recruitment and training initiatives, infrastructure development, and the integration of innovative care models. But it can be done and is being done.

Take workforce as an example. NHS Highland is currently funding my own organisation in appointing someone to a post as a Sector Career & Attraction Lead for Care Homes in North Highland. It is a new post yet the post holder Laura Dobinson who comes with a rare blend of sector knowledge but also recruitment and HR skills is working to develop new and innovative approaches to recruit working with local communities to achieve real people into real roles. This is the first post of its kind in Scotland and is already bearing fruit. I hope we will see more of focussed and targeted approaches like this one rather than relying on some of our more traditional methods.

Key to enhancing recruitment has to be a whole system approach – there is no point in having a work ready carer if she or he cannot find a house to come into the island and live in.

But as well as workforce we must look at innovative ways of working. At the heart of this is what already happens in our island communities and that is a degree of integrated and collaborative, whole system working that is the envy of others and is I think the only way forward. Islanders cannot afford the luxury and fantasy of silo working. People who require care and support don’t care a toss about the uniform you wear, the organisational badge you work under, what they want is immediate, professional care and support and a level of continuity, consistency and quality which is the heart of all person-led care and support.

But perhaps we also need to build on the communitarian and co-operative strengths of our island communities, not in a romantic sense but in practical realistic ways.

Communities whether rural, remote or urban, will increasingly have to look after one another more – and as a community is nothing more or less than a collection of individuals – that means we all have and increasingly will have an individual responsibility to ‘be our sister’s keeper’ and look out for one another, care and support one another. Put simply if we do not then no one else will not least given the global ageing, health and care dynamic we will increasingly face.

There are insights and lessons of how we can achieve this all over the world – and if nothing else at least in my experience of having seafarers in the family islanders are the best folks for having an openness to learning from others.

So whether it is the truly integrated and community based approach with care hubs bringing together healthcare, social services, and community support under one roof and so offering a holistic approach to care and improving coordination between services as has been successfully operated for some time in Tasmania, Australia, or the model in New Zealand where the government offers scholarships and incentives for healthcare and social care professionals to work in remote and island communities, and financially fosters a locally trained and dedicated workforce.

There are global insights to learn from. And one I have got to know is a new community-based approach to working developed by Dr Emi Kiyota who I have been privileged to know and work with.  Emi is an environmental gerontologist. She has taught and published across the world but most of her work is in East Asia, especially Singapore, Japan and the Philippines. She established an organisation called Ibasho and developed a model for delivering care and support led by older people themselves in rural and island communities.

‘Ibasho means “a place where you can feel like yourself” in Japanese.

As Emi says: ‘At Ibasho we believe this is what every person should have as they age – a place to live in safety, comfort and dignity, where he or she is valued as a person full of history and experience.’

‘Ibasho recognizes that people fear two things as we age — social isolation and losing respect from others in society. Our goal is to create a shared future in which aging is not something to fear, but to enjoy, as a respected and valued member of communities across the globe.’

She often uses a quote she found at an elementary school in Bhutan said:

“The time to be happy is now, the place to be happy is here, the way to be happy is to make other people happy.”

I believe a lot of what Dr Kiyoto is doing resonates with the Scottish Gaelic concept of dùthchas. It’s a complex phrase that is often used in many contexts but for me it’s one of the many words that suggest ‘belonging’ – that sense of being at one and at home amongst a community or in a particular location.

When my mother developed dementia the most important thing for her health and wellbeing was staying in place, amongst people and spaces she knew, and listening to the language and tongue of her youth.

We can and we must develop models of community-based support which nurture such belonging. It is less about resource than about aspiration. It needs to be less about systems and regulations, than relationships and priority.

As Emi said once:

“Elders living in grass huts in Africa with children at their feet are often happier than people in assisted living homes with a chandelier over their heads.”

Donald Macaskill

Photo by Asa Rodger on Unsplash