Health and social care - service renewal framework: island communities impact assessment

Island Communities Impact Assessment

Step One – Develop a clear understanding of your objectives:

Rural and island areas face distinct and persistent challenges in accessing health and social care, often shaped by unique patterns of health inequalities. These inequalities are rooted in systemic issues that effect the overall resilience and wellbeing of rural communities – including island communities.

Service Renewal Framework (SRF)

The Service Renewal Framework (SRF) is a key reform initiative outlined by the First Minister during a keynote speech on public service reform in January 2025. The SRF has been developed collaboratively, taking a refreshed cross-government and cross-sectoral approach to health and social care.

It is a document which sets out the framework within which system leaders and staff, along with the wider population, will plan future health and social care services. It focuses on building on areas of good practice and shifting towards new models of care, driven by the needs of the population and the people that use the services. It emphasizes prevention and early intervention, and promotes more equitable access to primary community healthcare with the aim of supporting people to manage their own health and wellbeing.

Vision and Objectives

Our vision for health and social care in Scotland is “A Scotland where people live longer, healthier, and fulfilling lives.” The Framework provides a high-level blueprint for change and aims to ensure the sustainability, efficiency, quality, and accessibility of health and social care services through a comprehensive framework that combines the immediate focus of the Operational Improvement Plan (OIP) with the long-term objectives of the Population Health Framework (PHF).

To deliver on our vision, the SRF outlines five priorities for change, including a set of specific, realistic actions in the first five years where detailed planning has already been completed. Further change will be shaped by ongoing engagement with delivery partners and evolving population needs. This framework encourages leaders to plan future services while building on existing successes.

Design and Delivery Principles

The SRF emphasizes the following design and delivery principles, which we anticipate applying across Scotland, including in island communities:

1. Prevention – Prioritize preventive measures over reactive sickness responses.

2. Population – Focus on population needs instead of structural boundaries.

3. Community – Implement community-based models rather than hospital-centric approaches.

4. People – Centre care around individuals rather than the ‘system’ or ‘service.’

5. Digital – Adopt modern, integrated digital solutions over outdated methods.

Major Areas of Change

The framework outlines four major areas of transformation:

• Person-led health and wellbeing
• Enhanced capacity in primary care and community healthcare
• Shift towards community-based care settings
• Redesign of the hospital model of care

Implementation and Leadership Support

While the SRF sets out essential values, principles, and desired changes for Scotland’s health and social care system, the delivery landscape is complex, and the Scottish Government's direct levers are limited. Consequently, the Government will support accountable and collective leadership through the Chairs and Chief Executives of the NHS Boards. Collaboration with Integration Authorities and other local partners is crucial to achieve the best outcomes for all individuals in Scotland, and take account of specific local needs and conditions, including in the islands.

Step Two - Gather your data and identify your stakeholders:

Health and wellbeing amongst island communities can be understood through a variety of sources that offer insights into population health, access to services and inequalities. These include:

• Health Board Data
• Scottish Public Health Observatory
• SIMD
• NRS Stats and island specific demographic and economic data
• Scottish Islands Survey as well as
• Direct engagement with local partners and stakeholders.

Population levels across Scotland’s inhabited islands vary greatly – from a few as seven people to over 21,000 – with a median population of just 192.^[1] These population dynamics can significantly affect the human capacity of island communities, influencing everything from delivery of services to the availability of volunteers in key roles. Life expectancy across rural Scotland is also generally higher than the national average. For females, it stands at around 83 years – just two years more than for females in the rest of Scotland. For males, the gap is slightly larger, with life expectancy reaching approximately 79.5 years in rural areas, around three years higher than the national figure. ^[2]

Access to healthcare in island communities varies widely; while some islands have on-island GP practices and hospitals offering additional medical services, others are required to travel off-island to receive treatment.^[3] In rural areas more generally, less than half of residents live within a 15 minute drive by public transport to a GP compared to 92% of the rest of the country. ^[4]

According to the 2023 Scottish Islands Survey, one third of islanders report living with a mental or physical health condition. While the overall prevalence of such conditions appears lower on the islands compared with the national average, the burden may be disproportionately high among those in the lowest income brackets – almost half of whom report a mental or physical health issue. ^[5] More generally, mental health outcomes, particularly suicide mortality rates, present cause for concern in a number of rural areas. From 2019 to 2023, the suicide mortality rate was above the Scottish average in the health board areas of Highland and Tayside. At a more local level, significantly higher rates were recorded in Dundee City, Highland and East Ayrshire. Elevated rates were also observed in the Western Isles and Orkney however due to small population sizes, it is more difficult to determine whether these differences are statistically significant.^[6]

The recent cost-of-living crisis has been an area of major concern for island communities, with island households less likely to report managing well financially and more likely to express worry about paying for essentials such as heating and hot water compared to the wider population. ^[7]

Whilst island communities face unique challenges as set out above, the development of the SRF is designed to benefit the population as a whole. The expectation though is that, during the delivery and implementation phases, individual actions will be tailored to address the needs of particular communities and population groups.

Empowering our communities to have greater control over how health and social care services are delivered is central to this approach. To support this, we are developing clearly defined core services and delivery models to ensure equitable access for people living in remote, rural, and island areas. This work is being progressed through the Remote, Rural and Islands Task and Finish Group, as outlined in the May 2024 Cabinet paper. A key principle is that service planning must reflect local population needs while ensuring consistency in access and patient outcomes across Scotland

Linked to our outcomes based approach, we will utilise data to right-size where and how we deliver health and social care services, enabling a shift to greater provision in the community. In taking this approach, we will consider impact on health inequalities, appropriate models of care and the specific needs of remote, rural and island communities. Within the first year of implementation, we will develop collaborative plans that set out prioritised service changes at sub-national and local level, as well as national – allowing the needs of specific communities to be addressed. We will also set out a new approach to supporting delivery of digital change so that by year 4 the Digital Front Door service will be fully rolled out.

The opportunity presented by development of the new National Islands Plan provides a key opportunity to help deliver the vision and objectives of the framework.

Step Three – Consultations:

As a result of tight development timelines, consultation on the emerging direction of the SRF has been limited to key partners, rather than a wider public consultation. In creating the SRF, we have had regard to island communities under s7 of the Islands (Scotland) Act 2018. The evidence base for the SRF and our plans are informed by extensive prior public consultation on health and social care.

Our intention is to further to open up discussion about how we deliver the vision as we move to implementation.

Step Four – Assessment:

You must now determine whether in your opinion your policy, strategy or service is likely to have an effect on an island community which is significantly different from its effect on other communities (including other island communities).

If your answer is NO to the above question, a full ICIA will NOT be required and you can proceed to Step Six.

If the answer is YES, an ICIA must be prepared and you should proceed to Step Five.

• To form your opinion, the following questions should be considered.
• Does the evidence show different circumstances or different expectations or needs, or different experiences or outcomes (such as different levels of satisfaction, or different rates of participation)?
• Are these different effects likely?
• Are these effects significantly different?
• Could the effect amount to a disadvantage for an island community compared to the mainland or between island groups?

At this stage, no unique impacts for island communities has been identified due to the high strategic level of the framework – with the key design principles and major areas of change designed to benefit island communities as much as (and potentially more than) other communities.

To ensure that any policy level impacts are fully understood and mitigations are in place where applicable, appropriate impact assessments will be carried out where relevant on each individual action of the Framework. This will include, where necessary, full ICIAs.

Step Five – Not included

Step Six – Making adjustments to your work:

• Should delivery mechanisms/mitigations vary in different communities?
• Do you need to consult with island communities in respect of mechanisms or mitigations?
• Have island circumstances been factored into the evaluation process?
• Have any island-specific indicators/targets been identified that require monitoring?
• How will outcomes be measured on the islands?
• How has the policy, strategy or service affected island communities?
• How will lessons learned in this ICIA inform future policy making and service delivery?

We expect that the delivery of the SRF within communities will be done in such a way that respects Sections 7, 10 and 12 of the Islands (Scotland) Act 2018. However, to ensure that any policy level impacts are fully understood and mitigations are in place where applicable – ICIAs should be undertaken where relevant by partners which will be involved in executing actions.