Stroke improvement plan: island communities impact assessment

Island communities impact assessment for the stroke improvement plan.

Stroke Improvement Plan (2023) - Island Communities Impact Assessment

1. Stage 1: Framing

1.1 Results of framing exercise

A number of areas where we should make specific efforts to address inequalities facing people living in island communities throughout the implementation of our plan were identified.

Issues around healthcare provision include centralisation of services & workforce shortages.[1] The same study recognised the potential for community participation to shape and design rural primary care services. Work by the Royal College of GPs identified a number of challenges their members faced including: connectivity, transport, fragility of support services, workload (including the 24 hour commitment), professional development, education and training, professional and social isolation.[2] Older people in particular accessing the out-of-hours GP surgery is highlighted as an issue in an Irish study.[3]

The Scottish Government’s National Island Plan Survey in 2021[4] found that there were striking differences in reported levels of access to health, social care and wellbeing services between the island groups. Almost all residents of Orkney Mainland and Shetland Mainland reported they could easily access a hospital, a dentist and a pharmacy. However, substantially fewer residents of Orkney Outer Isles and Shetland Outer Isles reported this. The Scottish Government is committed to work with NHS Boards, Local Authorities and Health and Social Care Partnerships to ensure that there is fair, accessible health and social care for those on islands.[5]

The Scottish Government also continues to build on the work of Shaping the Future Together: Remote and Rural General Practice Working Group report to establish a formal proposal for a National Centre for Remote, Rural and island Healthcare in Scotland that is inclusive of the needs, opportunities and models of excellence from the whole remote and rural health and care workforce.[6]

The Scottish Burden of Disease Study.[7] indicate that cause-specific forecasts for the five leading grouped causes in 2019 are the same as those forecast to be the leading causes in 2043. And that absolute increases in annual disease burdens are forecast to be largest for cardiovascular diseases, cancers, and neurological diseases. These three disease groups account for 68% of the total increase in forecasted disease burden.

The Stroke Improvement Plan is intended to complement broader workstreams to support island communities access to health care services.

The Stroke Improvement Plan has an overall vision to ‘support delivery of the best possible stroke care in Scotland’. Therefore, while we do not envision that the plan will impact negatively on any individual or group, we recognise that as the priorities within the plan are implemented, we need to continue to engage with the lived experience of stroke to ensure that these voices are captured as a core part of this process to reflect those of island communities. This will support us to ensure that progressive stroke pathways, and new models of care take into account the needs and challenges of those communities and avoids an increase in any inequities.

1.2 Extent/Level of ICIA required

We have carried out an ICIA process and identified a number of areas that we will consider in the implementation of the Stroke Improvement Plan.

2. Stage 2: Data and evidence gathering, involvement and consultation

Include here the results of your evidence gathering including framing exercise), including qualitative and quantitative data and the source of that information, whether national statistics, surveys or consultations with relevant equality groups.

Island Communities

Island Communities

Evidence gathered and Strength/quality of evidence

Rural Scotland accounts for 17% of the total population in Scotland (6% in remote rural and 11% in accessible rural) and has consistently done so since 2011. A higher proportion of residents of rural Scotland, compared to the rest of Scotland, rate their neighbourhood as a ‘very good’ place to live. Life expectancy in rural areas is higher compared to the rest of Scotland and in 2019, the lowest rate of emergency admission was in remote rural areas.[8] There were 93 inhabited islands in Scotland at the time of the 2011 Census. Their total population was 103,700, 2 per cent of the population of Scotland.[9]

Stroke incidence is strongly related to age. In Scotland, the age and sex adjusted rate for the under 75s in 2021/22 was 128 per 100,000 population but for the over 75 age group, it was 1,415 per 100,000 population.[10] The Rural Scotland – Key Facts report 2021 highlights that rural areas have a lower proportion of the population in the age range 16 to 44 but a higher proportion of people aged 45 and over. This was reported as particularly true for the age range of 65 and over in remote rural areas - indicating that those of retirement age are more likely to live in rural areas.[11]

Factors influencing unequal access to care can be:

  • Geographical and demographic: Reflecting a less dense population and large area, more people in rural areas are outwith a reasonable drive time to key services such as GPs compared to the rest of Scotland and fewer people are satisfied with the quality of the public transport services delivered. Fewer than half of rural Scots are within a 15 min travel time by public transport to a GP practice and less than half find hospital outpatient departments convenient by geographic area.[12]
  • Availability of / access to eHealth: The proportion of households with home internet access is very similar across all areas of Scotland. A lower proportion of Scots in remote areas connect to the internet via superfast broadband: 29% vs 53% in the rest of Scotland and are more dependent on DSL broadband: 66% vs 40%.[13]

I. A study had found that eHealth had the potential to overcome some traditional challenges of providing rural healthcare[14] while Scotland’s Technology Enabled Care programme found that remote Blood Pressure monitoring had contributed to the achievement of a number of outcomes and recognized there were more citizens who could benefit.[15] NHS Ayrshire and Arran reported on a small scale pilot by testing Near Me for patients referred for swallowing assessment.[16] The Scottish Government is committed to support the extension of NHS Near Me/Attend Anywhere, and other digital health initiatives, to reduce unnecessary travel and enable more care to be delivered on Islands.[17]

II. Scottish Government’s National Island Plan Survey in 2021[18] also found the majority of respondents could access the internet from home. However, speed and reliability of internet connections were an issue for many. Mobile signals varied, with particularly poor reports from Orkney Outer Isles. Islanders were generally confident in using the internet for most tasks, but slightly less so in attending online health and social care appointments.

III. Strategic Objective 6 in the National Island Plan is to improve digital connectivity. Work to progress a step change in the quality of digital connectivity is also reported in the 2021 National Island Plan Annual Report.[19]

  • Data: The Scottish Government’s National Islands Plan annual report 2021 highlights a commitment to address any equality, health and wellbeing related data gaps that exist in respect of, for example, women and girls, pregnancy and maternity, gender reassignment and sexual orientation.[20]
  • Economic:

i. The main issues in rural areas include higher costs of living: access to services, lack of affordable housing and higher fuel costs.[21]

ii. Noting the link between deprivation and poorer health outcomes, the proportion of households experiencing low-income poverty living in rural areas of Scotland is approximately 13%.[22]. Rural deprivation can be more dispersed in rural areas compared to urban areas.[23] Western Isles, Shetland and Orkney had no areas among the 20% most deprived in Scotland, while levels of deprivation had increased in Highland, albeit by no more than 2%.[24]

iii. Effects of austerity: a study by Cardiff University found that austerity had compounded problems of rural poverty.[25]

iv. Analysis by the Scottish Government of the areas most vulnerable to Brexit (published in September 2019), showed that many of the communities most vulnerable to Brexit are on the islands. Reasons cited were depopulation, poor balance of working age versus older age communities, poorer access to services, and high proportions of the island workforce being employed in Brexit sensitive industries.[26] The National Island Plan report 2021 points to support the Scottish Government is giving to the work of the group of Wellbeing Economy Governments (WEGo) to work with islanders to contribute, where the Scottish Government can, to the creation of a fairer, healthier, happier nation for all of Scotland.[27]

  • Social / Cultural: A culture of independence and self-reliance in rural areas may discourage individuals from accessing income support or other benefits.[28] The National Islands Plan annual report 2021 highlights a commitment to ensure that health, social care and wellbeing services are available through the medium of Gaelic to support Gaelic speaking island communities.[29]
  • Impact of COVID-19: A study of rural England found a number of issues including a more detrimental effect on waiting times, care activity having fallen particularly dramatically, and an exacerbation of workforce issues.[30] A global survey of the impact of COVID on islands, including Scottish Islands found the potential for digital connectivity limited as large parts of an increasingly elderly population may not use technology such as smartphones.[31] A report by the James Hutton Institute and Scotland’s Rural College also identify an aging population and digital connectivity as factors that make rural and island communities vulnerable to the effects of COVID as well as reliance on limited employment sectors and being located far from centralised services.[32] Informed by learning of how island communities have responded and adapted to COVID-19, the Islands Programme is investing £30 million of Infrastructure Investment Plan capital funding over five years supporting a range of areas, including tourism, infrastructure, innovation, energy transition and skills. In 2020/21, the £1.3 million Healthy Islands Fund (HIF) focused on building local capacity to increase wellbeing, foster connections and promote healthy and resilient islanders and communities.[33]
Data gaps identified and action taken

We have identified that there is a gap in our understanding of how people living in rural and island communities access care for stroke.

We do however, have access to a wider range of evidence around barriers to access of health care in general and we suspect that many of these challenges will be reflected within access to stroke care.

To address gaps in our understanding, we have sought feedback on our plan through sharing with the National Stroke Voices group to reflect input from those with lived experience of stroke.

Building on the recommendations in the Progressive Stroke Pathway (2022), The Stroke Improvement Plan makes a number of commitments on priority areas across the whole stroke patient pathway workforce, including a focus on collaborative implementation to support improvements in the delivery of stroke care across Scotland.

To ensure that the implementation of these actions takes account of, and addresses, the challenges faced by people living in island communities we will embed the voices of people living in the islands within a national patient engagement structure which will underpin and drive the actions identified within the plan.

3. Stage 3: Assessing the impacts and identifying opportunities to promote equality

Having considered the data and evidence you have gathered, this section requires you to consider the potential impacts – negative and positive – that your policy might have on each of the protected characteristics. It is important to remember the duty is also a positive one – that we must explore whether the policy offers the opportunity to promote equality and/or foster good relations.

Do you think that the policy impacts on people who live in an Island community ?

Eliminating unlawful discrimination, harassment and victimisation: None

Reasons for your decision:

The refreshed plan does not directly address unlawful discrimination.

Advancing equality of opportunity: Positive

Reasons for your decision:

The plan underlines our commitment to support the Scottish Stroke Improvement Programme and effective use of data. Improvements in this area will enable us to identify and address unwarranted variation, including those based on geography, across Scotland in the delivery of stroke care.

Promoting good relations among and between different groups: None

Reasons for your decision:

The Stroke Improvement Plan does not specifically seek to promote good relations between different groups.

4. Stage 4: Decision making and monitoring

4.1 Identifying and establishing any required mitigating action

If, following the impact analysis, you think you have identified any unlawful discrimination – direct or indirect - you must consider and set out what action will be undertaken to mitigate the negative impact. You will need to consult your legal team in SGLD at this point if you have not already done so.

Have positive or negative impacts been identified for island communities?

Yes we have identified that the Stroke Improvement Plan creates opportunities for positive impacts for people living in island communities.

Is the policy directly or indirectly discriminatory under the Islands Act 2018?


If the policy is indirectly discriminatory, how is it justified under the relevant legislation?


If not justified, what mitigating action will be undertaken?


4.2 Describing how Island Impact analysis has shaped the policy making process

The vision of the Stroke Improvement Plan is to ‘support delivery of the best possible stroke care in Scotland’. Through this, we do not envision that the plan will have a negative impact on any individual or group. We recognise however, it is vital that in the implementation of the plan’s priorities and commitments, we continue to engage in a robust lived experience process epitomised by National Stroke Voices. Through the Island Impact analysis, we understand the importance of ensuring that the lived experience voices of people living in island communities are reflected through the implementation process to ensure we develop models of care reflective of the challenges highlighted.

The Stroke Improvement Plan is designed to be aligned with the work already underway in the Heart Disease Action Plan and to complement the commitments of the National Plan for Scotland's Islands to improve and promote health and wellbeing:

  • Work with NHS Boards, Local Authorities and Health and Social Care Partnerships to ensure that there is fair, accessible health and social care for those on islands.
  • identify and promote good practice, especially as regards the improvement of services in islands and other remote areas.
  • Work with our partners to consider a range of options to ensure that adequate mental health care is available, whilst taking into consideration the uniqueness of our island communities.
  • Address any equality, health and wellbeing related data gaps that exist.

These commitments are reflected in our plan, in particular in Priority 6: Collaborative implementation, Priority 5: Emotional and psychological wellbeing and through the Scottish Government support for the Scottish Stroke Improvement Programme (SSIP), and Scottish Stroke Care Audit.

Regarding Workforce, in March 2022, the Scottish Government published the Health and Social Care: national workforce strategy, setting out a vision for the health and social care workforce to support recovery, growth and transformation of our workforce. The strategy set out numerous actions to help bolster the health and social care workforce. The Stroke Improvement Plan recognises workforce as a key element in its vision and reflects the ambitions in the Health and Social Care Workforce plans around equity and sustainability of health and care services.

The Stroke Improvement Plan includes a priority to prevent as many strokes as possible, by working to improve the detection and management of the main underlying risk factors for stroke; high cholesterol, high blood pressure and atrial fibrillation. Work is already underway via the Scottish Heart Disease Action Plan, to improve the detection, diagnosis and management of these risk factors for heart disease and stroke. We will align closely with the work already underway, and assess where additional input may be required to target primary prevention towards stroke, particularly where innovative technology can be engaged.

We will continue to engage with colleagues and people living in island communities to progress delivery of the priorities in the Stroke Improvement Plan to ensure that the steps we take support the objectives of the National Plan for Scotland's Islands.

4.3 Monitoring and Review

The National Advisory Committee for Stroke will be responsible for overseeing the implementation of the Stroke Improvement Plan and reporting annually on its progress.

5. Stage 5 - Authorisation of EQIA

Please confirm that:

  • This Equality Impact Assessment has informed the development of this policy: Yes
  • Opportunities to promote equality in respect of island communities have been considered, i.e.
    • Eliminating unlawful discrimination, harassment, victimisation;
    • Removing or minimising any barriers and/or disadvantages;
    • Taking steps which assist with promoting equality and meeting people’s different needs;
    • Encouraging participation (e.g. in public life)
    • Fostering good relations, tackling prejudice and promoting understanding.
  • If the Marriage and Civil Partnership protected characteristic applies to this policy, the Equality Impact Assessment has also assessed against the duty to eliminate unlawful discrimination, harassment and victimisation in respect of this protected characteristic:

    Not applicable


I am satisfied with the equality impact assessment that has been undertaken for the Stroke Improvement Plan and give my authorisation for the results of this assessment to be published on the Scottish Government’s website.


Position: Deputy Director

Authorisation date: 8 June 2023



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