Scotland's Population Health Framework: Island Communities Impact Assessment

4. Information relating to island communities

Taking into account of regional variations including amongst our island communities will be vital in the success of the Population Health Framework going forward to ensure that it addresses the specific circumstances and lifestyles across the country.

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.^[2] 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. Access to amenities and services also 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]

Similarly, access to grocery stores ranges from island with several shops, including national chains, to those with only a single community-run store or none at all. With educational provision differing as well with some young people able to complete their education locally whilst others required to travel daily or live away from home to access secondary schooling.

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. ^[4]

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 are more likely to express worry about paying for essentials such as heating and hot water compared to the wider population. ^[5]

In addition, consideration has also been given to rural areas more broadly, recognising that many of the challenges faced by rural island communities are shared with those in remote and rural parts of the mainland.

Rural Scotland accounts for approximately 17% of the country’s total population, with 6% living in remote rural areas and 11% in accessible rural locations – a proportion that has remained consistent since 2011. These areas have a distinct demographic profile, characterised by a lower proportion of people aged 16 to 44 and a higher proportion of those aged 45 and over.^[6] This trend is especially notable among people aged 65 and above in remote rural areas, suggesting a pattern of individuals choosing to reside in rural settings after retirement.

Health outcomes also vary between rural and urban areas. Life expectancy in rural Scotland is 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. ^[7]

Access to key services, however, remains a significant challenge in rural communities. The proportion of people able to reach essential amenities such as shopping centres or GP services within a 15 minute journey by public transport is considerably lower in rural areas. Only 22% of people in accessible rural areas live within such proximity to a shopping centre, rising slightly to 29% in remote rural areas. For healthcare access, less than half of rural residents live within a 15 minute drive by public transport to a GP compared to 92% of the rest of the country. ^[8]

Despite these service challenges, access to natural environments remains relatively strong. Over 90% of residents across all of the Scottish island groups agreed that they had access to blue or green spaces within a 5 minute walk from their home, compared to only 56% of adults across Scotland.^[9] With the 2023 Scottish Household Survey indicating that Those in remote rural areas or accessible rural areas (73% and 71%, respectively) were more likely to describe their neighbourhood as a ‘very good’ place to live, compared to 48% in large urban areas and 52% in other urban areas.^[10]

In terms of employment, the working age employment rate is generally higher in rural and islands with 78% of this group economically active compared to 74% in mainly rural areas and larger cities.^[11] In addition, self-employment is more common in rural Scotland is more common. With almost a quarter of people in remote rural areas (24%) compared with the rest of the country and 16% in accessible rural areas compared with only 9% of the country as a whole.^[12] However, economic inequality can still persist.^[13] Fewer pupils in rural areas are registered for Free School Meals compared to those in urban areas. Moreover, 5% of rural residents are living in relative poverty, while 11% are in severe poverty, highlighting the hidden nature of inequalities within our rural communities. ^[14]

Mental health outcomes, particularly suicide mortality rates, also present cause for concern in some 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.^[15]

As we continue to take forward the actions outlined within the Framework, we shall ensure that appropriate assessment is carried out to achieve the best outcomes for all our communities. This will include the conduct of Island Communities Impact Assessments at a policy level when applicable to ensure delivery can adapt to specific need.

Consultation and engagement

To date, extensive engagement has taken place to support the development of the PHF. Throughout the first part of 2024, local and national government officials, analysts, academics and public health system leaders participated in evidence sessions and policy workshops to help develop thinking for the PHF. With over 75 engagement sessions taking place in second half of 2024 with a wide set of stakeholders across the public, private and voluntary sectors.

Stakeholders overwhelming agreed with the PHF’s wider focus on primary prevention and early intervention through a whole system approach, with a call for clear definitions for each term. Respondents varied in how they thought the PHF should be taken forward and what areas should be prioritised, with some calling for a small number of key priority areas and others asking for action across a wide spectrum of topic areas. Despite these differences, many placed an emphasis on the need for the appropriate implementation of a ‘health in all policies’ approach through greater local and national leadership and for all actions taken forward to be developed through the use of evidence.