Social Science & Medicine 57 (2003) 673–686

Dr. John has gone: assessing health professionals’ contributionto remote rural community sustainability in the UK

Jane Farmera,*, William Lauderb, Helen Richardsc, Siobhan Sharkeyd

aDepartment of Management, University of Aberdeen, Edward Wright Building, Dunbar Street, Aberdeen AB24 3QY, UKbFaculty of Arts Health & Sciences, School of Nursing & Health Studies, Central Queensland University, Rockhampton,

Queensland 4702, Australiac Highlands & Islands Health Research Institute, University of Aberdeen, The Green House, Beechwood Business Park North,

Inverness IV2 3ED, UKd Department of Nursing and Midwifery, University of Stirling, Highland Campus, Old Perth Road, Inverness IV2 3FG, UK

Abstract

Due mainly to increasing difficulties in recruiting and retaining health professionals to work in remote and peripheral

areas of Scotland, there is discussion of the need to implement new models of primary health care provision. However,

innovative service models may imply a reduction in the number of health professionals who live and work in remote

communities. Currently decisions about remodelling service provision are being taken by National Health Service

stakeholders, apparently with little consideration of the wider social and economic impacts of change. This paper aims

to argue that health professionals contribute to the fabric of rural life in a number of ways and that decisions about

health service redesign need to take this into account. As well as fulfilling a wide health and social care role for patients,

the authors seek to show that health professionals are important to the social sustainability of rural communities as, due

to their unique position, they are often at the heart of networks within and between communities. The wider economic

contribution of health services in remote communities is important, but often underplayed. The authors propose that

theories of capital, principally the concept of social capital, could help in investigating the wider contribution of health

professionals to their local communities. Ultimately, it is proposed that health services, as embodied in nurses, doctors

and others, could be highly important to the ongoing livelihood and social infrastructure of fragile remote communities.

Since this area is poorly understood, there is a need for prospective primary research and evaluation of service redesign

initiatives.

r 2003 Elsevier Science Ltd. All rights reserved.

Keywords: Rural healthcare; Service redesign; Professional roles; Community sustainability; Social capital; Scotland, UK

y the task of achieving sustainability—economic,

environmental and social—is a complex one, de-

manding direct attention to retaining and weaving in

the strands that make up the fabric of social lifey

(Reed, 1999)

Introduction

Rural areas are suddenly on the UK policy agenda

(Department of Environment, Transport & the Regions,

2000). The agricultural industry has been in decline for

years and tourism is a fragile replacement. Many rural

areas have been experiencing the curious joint effects of

out-migration of young people and in-migration of older

retired people which has led to an ageing population

(Philips, 1999). Accessible rural areas have been

colonised by commuters and the decline of local

services—the village shop, post office, bank—are

ARTICLE IN PRESS

*Corresponding author. Tel.: +44-1224-273237; fax: +44-

1224-273843.

E-mail address: j.farmer@abdn.ac.uk (J. Farmer).

0277-9536/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved.

PII: S 0 2 7 7 - 9 5 3 6 ( 0 2 ) 0 0 4 1 0 - 0

hastened. In 2001, the effects of UK rural decline also

hit urbanites as, for some considerable time, the

countryside (their idyllic green and leafy heritage park

(Pahl, 1970)) closed to public access due to foot and

mouth disease.

In Scotland, the effects of these economic and

demographic changes have prompted policymakers to

make:

y a commitment to economic, social and environ-

mental development of y rural communities—even

the most remote (Scottish Executive Rural Affairs

Department, 2000).

A parallel interest in remote and rural health care has

emerged, with policymakers’ attention tracing back to a

key Scottish health services review in 1998 (The Scottish

Office Department of Health, 1998). This confirmed the

views of academics that there was a dearth of remote

and rural health care research in the UK (Higgs, 1999).

Remote and rural health care research is now develop-

ing, particularly in relation to health service concerns

about a crisis in recruitment and retention of health

professionals to more remote places (Cox, 1997; Remote

and Rural Areas Resources Initiative (RARARI) Solu-

tions Group, 2002).1

Due mainly to the manpower crisis, though partly to

the availability of new technologies and desire to

rationalise costs, new models of providing primary

health care services are being considered, some targeted

specifically at remote rural areas. These include: branch

surgeries; mobile clinics; peripatetic teams working from

a central hub; family health nurses (Proctor, 2000) and

nurse practitioners (who would take on some of the roles

of general practitioners (GPs)); enhancing the role of

paramedics; training local people for a first responder

role; NHS24 telephone advice line; telemedicine and

telehealth; and health ‘booths’ providing information

and an advice link to external health professionals

(Scottish National Rural Partnership, 2000; Deaville,

2001; RARARI, 2002).

These ‘solutions’ will sometimes mean radical change

in the provision of primary health care services to

remote or peripheral communities. They may imply

some loss of locally resident health professionals.

Further, given the interconnected nature of life in such

places, the ripples of decisions about service redesign

may have wider and unpredictable effects on social

stability. Evidence points to the importance of secure

infrastructure in resilient communities (Reimer, 2000).

Health care provision is often included among a list of

services noted as being fundamental to community life

(Cloke, Milbourne, & Thomas, 1994; Hope, Anderson,

& Sawyer, 2000), although there is still a lack of evidence

regarding what people in different areas consider to be

an ‘acceptable level’ of local service provision. Acces-

sible health services are certainly seen as crucial by many

local people as highlighted by recent action of commu-

nities in the Scottish Highlands mobilised by loss of GP

and consultant surgeon services (see, for example:

Helmsdale & District GP Action Group, 2001). Rural

areas have traditionally been seen as bastions of

‘holistic’, patient-oriented continuing care and studies

have shown the adverse effects on utilisation of services

(Haynes & Bentham, 1982; Jones et al., 1998), screening

uptake (Bentham, Hinton, Haynes, Lovett, & Bestwick,

1995), health outcomes (Launoy, Coutour, Gignoux,

Pottier, & Dugleux, 1992; Jones & Bentham, 1995, 1997;

Jones, Bentham, & Horwell, 1999; Campbell et al., 2000)

and rural patients’ health and quality of life (Baird,

Donnelly, Miscampbell, & Wemyss, 2000) of having to

travel some distance to access health services. However,

perhaps rural patients also sense that more than

accessible health services would be lost to their commu-

nity should some of the new models of service provision

be implemented. The presence of many professionals

(clergy, police, teachers, local government) living and

working in remote communities has already been eroded

(Boyle & Halfacree, 1998). The further potential loss of

health professionals, leads one to ask—can service

infrastructure continue to decline without heavy costs

to community wellbeing?

Of course, change is not necessarily wrong. Commu-

nities and service provision should not be in stasis, but

there are important issues at stake. Evidence to inform

decision-making about rural health service redesign is

essential. This paper highlights the need to know more

about the contribution of health professionals to the

sustainability of remote rural communities. We propose

that health services, embodied in GPs, nurses and allied

health staff, are part of the important underpinning for

community and not simply because of their direct

(curative, preventive and palliative care) contributions

to patient health. Due to their role and status in rural

communities, health professionals are often deeply

embedded in the social networks that make up the

‘fabric’ of rural life. The existence of dense social

networks is said to build social capital, a concept

currently popular among policymakers and social

scientists in helping to explain communities’ ability to

adapt to change (Putnam, 1993a). We briefly consider

how theories of capital might provide a useful frame-

work for examining the contribution of health

professional to remote communities. This paper brings

together evidence from existing literature and seeks to

ARTICLE IN PRESS

1The crisis has arisen for different and complex reasons,

including: general lack of medical and nursing staff, increased

specialisation of clinical workforce, feminisation of medical

model of working, comparison with perceived urban ‘9 to 5’,

poor mobility for career moves out of remote/rural work.

J. Farmer et al. / Social Science & Medicine 57 (2003) 673–686674

make a case for research on the wider role of

health professionals in remote communities. There is

little evaluation of the social impacts of different

models of health service provision. We argue there is a

need to generate knowledge before personnel are lost or

replaced by alternatives and before change is wrought

that might affect the viability of some remote commu-

nities.

Remote and peripheral communities

The diversity and fluidity of rural areas is widely

accepted (Halfacree, 1993). While a multitude of

definitions and typologies of rurality exist (Hoggart,

Buller, & Black, 1995), it is probably impossible to

identify a definition that encompasses the many facets

relevant to primary care across the UK (Farmer,

Iversen, & Baird, 2001) and, indeed, researchers have

been advised to use a definition that best suits their area

of enquiry (Rousseau, 1995). Therefore, this paper does

not tie itself to a quantitative or factorial characterisa-

tion, but instead broadly characterises the types of

remote or peripheral locations envisaged.

Research on migration in several countries has shown

that accessible and attractive rural areas have actually

experienced a renaissance in population growth in recent

years (Boyle & Halfacree, 1998). This has been variously

attributed to greater car ownership, willingness to travel

over longer distances to work and failure to develop

attractive inner city living environments (Hugo &

Smailes, 1985; University of Aberdeen & University of

Cardiff, 2001). Many rural areas adjacent to towns and

cities have thus experienced ‘rurbanisation’ effects

(European Society for Rural Sociology, 2001) which

have changed the nature of communities. Change tends

to be characterised by mutually reinforcing effects;

chiefly, travel over longer distances to access products

and services and decline in local amenities (Joseph &

Chalmers, 1995). Service decline impacts most on

indigenous, poorer and elderly people as it is experi-

enced as a loss (White, Guy, & Higgs, 1997). The result,

reported by long-standing rural residents, is deteriorat-

ing community cohesion and identity.

While sharing these wider rural problems of local

service decline, the types of areas envisaged in this paper

are yet more challenged as they are characterised by

relatively greater inaccessibility to urban centres and

sparser infrastructure. These are the more remote areas

of Scotland, including the Highlands and Islands,

Argyll, Dumfriesshire and Galloway which contain

areas of high peripherality, lack transport and commu-

nications infrastructure and do not readily attract

medical or nursing staff. They generally have few

economic opportunities and are highly dependent on

service industry employment. These are areas:

y at the edge of a communication systemyaway

from the core or controlling centre of the economyy

(Goodall, 1987).

A study considering health care for UK island

communities noted that remote islands, in particular,

experience a ‘penalty’ in service provision (Gould &

Moon, 2000). This occurs through multiple effects:

having to provide a certain standard of service to meet

statutory and professional requirements although popu-

lation numbers may be low; the need to cater for

fluctuating population of temporary residents; high

proportions of elderly patients; costs of transporting

goods; and the need to pay incentives to recruit and

retain health professionals.

The Scottish Highlands and Islands area extends over

39; 050 km2 and is described as one of the last unspoilt

areas of Europe, a fifth of the land being classed as

National Scenic Area and almost all of it as Less-

Favoured Area for agriculture (Highlands & Islands

Enterprise, 2001).

The area is one of most sparsely populated in the

European Union (EU), with a population density of 9.5

people per square kilometre compared with Scottish

average of 65.5 and EU average of 116 people per square

kilometre in 1998. This places the region on a par with

northern parts of Finland and Sweden. Thirty per cent

of the population live on more than 90 inhabited islands

including those forming the Orkney and Shetlands

Islands to the north and the Inner and Outer Hebrides

(Western Isles) to the west (Highlands & Islands

Enterprise, 2001).

While more accessible areas within the Highlands are

flourishing, the population of island and remote areas is

declining and ageing. The population of the Western

Isles has fallen by five per cent since 1991 (Highlands &

Islands Enterprise, 2001).

Average gross weekly earnings for males and females

in 1999 were lower in the Highlands and Islands

compared with a Scottish average (male: d377:40

(Highlands and Islands) d406:00 (Scotland); female:

d276:50 (Highlands and Islands) d297:70 (Scotland)).

Highest employment is within service sector jobs (as

shown in Fig. 1). Employment in public administration,

education and health accounted for 39% of jobs on the

Western Isles in 1997. Women occupied 74.9% of these

jobs, many working part-time. There are high rates of

long-term unemployment in island and remote areas,

particularly among older age groups. The cost of living

is higher than in more accessible parts of Scotland, with

average prices for a range of goods being 9.8% higher,

in winter 2000/01, than in the North-East Scotland city

of Aberdeen. At that time, the price of petrol on the

island of Islay, Argyll was 18.4% higher than in

Aberdeen (Highlands & Islands Enterprise, 2001).

ARTICLE IN PRESSJ. Farmer et al. / Social Science & Medicine 57 (2003) 673–686 675

Recent research in rural Scotland has shown

that residents think activities for teenagers, facilities

for sport and leisure and local service decline need to be

addressed (Hope et al., 2000). The need for differing

policy for remote areas is highlighted by Highlands and

Islands Council’s desire for major investment in

roads development in contrast to national transport

policy where emphasis is on boosting public transport

use (University of Aberdeen & University of Cardiff,

2001).

The role(s) of health professionals

Given the situation in remote and peripheral Scot-

land, it is not surprising that studies of work in these

areas show primary health care professionals dealing

with patients presenting diverse health and social

problems (Iversen, Farmer, & Hannaford, 2000). In

other areas, these might be dealt with by a range of

services and professionals. A district nurse in a study of

Argyll, Scotland provided a flavour of her multi-faceted

work:

There is a complete lack of services around here. I

end up doing everythingyrurality causes problems. I

have to drop off medicine to people because there’s

no pharmacy. I have to arrange carers. We just have

to cobble everything togethery (Farmer et al., 2002)

Cox and Mungall (1998) outline the wide-ranging tasks

for UK rural health professionals and there is evidence

confirming a similar picture for primary health care in

remote areas in North America (Larson & Hart, 2000)

and Australia (Wilks, Barnes, Paul, Wood, & Jones,

1997).

In remote areas of Scotland, nurses have combined

roles including elements of community nursing, health

visiting and midwifery. Findings about district nursing

activity in remote areas of Scotland reveal different

types of patient contact for district nurses (Lauder,

Reynolds, Reilly, & Angus, 2001; Farmer et al., 2002).

These might include intensive activities focused on

particular sick or elderly people, often involving several

ARTICLE IN PRESS

0 5 10 15 20 25 30 35 40

Agriculture & Fishing

Energy & water

Manufacturing

Construction

Distribution, hotels & restaurants

Transport & Communication

Banking, finance & insurance

Public administration & education

Other services

Scotland

Western Isles only

Highlands & Islands

Fig. 1. Employment by sector: a comparison of Western Isles, Highlands & Islands and Scotland in 1997. Figures supplied by

Highlands and Islands Enterprise (2002).

J. Farmer et al. / Social Science & Medicine 57 (2003) 673–686676

visits each day to provide health and social care and

support to patients and relatives. One Hebridean nurse

reflected her emphasis on keeping sick or elderly people

‘on the island’:

I’m a great believer in keeping patients in their own

homes here because if you send them away from here

you’re taking them away from what they’re used to.

(Farmer et al., 2002)

While there is increasing evidence of the multiple facets

of nursing in remote areas, coupled with findings about

gaps in social (Harrop, 2000) and voluntary care

provision (Craig & Manthorpe, 2000; Milligan, 2000),

there is still a lack of explicit acknowledgement by senior

health service management that social and wider ‘caring’

responsibilities are a valid part of the nurse’s job. This

implies that a range of ‘social care’ tasks currently

undertaken, may be undervalued (Audit Commission,

1992; Lauder et al., 2001). Because the wider role is

difficult to record and undertaken implicitly, nurses may

be left in a vulnerable position when their workload and

productivity are audited.

General practice, regardless of where it is conducted,

should take into account patients’ social and cultural

contexts. In remote rural areas, where there may be no

choice of GP, and poorer access to secondary care,

social services and other support networks, the holistic

nature of primary care is particularly important. In

urban settings, continuity of care, a core value of UK

general practice, is being eroded (Guthrie & Wyke,

2000). This relates to organisational changes, such as the

move towards larger practices and the establishment of

out-of-hours co-operatives. In remote rural areas, which

often have small practices and little scope for sharing

on-call, continuity remains (Cox, 1997). These organisa-

tional differences mean that rural general practitioners

are likely to be more intensively involved with the health

and social needs of their patients compared with their

urban counterparts.

In addition to a responsive role in health and social

care, it has been suggested that health professionals in

remote areas can use their rich knowledge of community

and patients proactively to protect and sustain health. A

Scottish study found that rural district nurses became

aware of a wide range of family and individual health

problems at an early stage and from sources other than

formal channels (Lauder et al., 2001). The researchers

identified the concept of ‘community embeddedness’ as a

central feature of the work of district nurses in rural

areas. Embeddedness refers to nurses’ degree of integra-

tion with place and people in the community in which

they practice. The research concluded:

The theme of community embeddedness suggests that

rural nurses have a unique position within their

community. This enables them to gain early insights

into evolving human problems in the context of

family systems and the dysfunctional person’s posi-

tion within that community. This community-family

perspective has both a practical and a symbolic

elementy[rural nurses]y are seen as central to a

healthy and vigorous sense of community, in a very

similar way to the local primary school. (Lauder

et al., 2001)

As this last point suggests, the presence of health

professionals may bring yet another category of benefits

to communities. Indeed, we are proposing that health

professionals may have a key role within the social

structure of fragile remote and peripheral places. This

role emerges from their situation and status in the

community which legitimates them to be richly inte-

grated in formal and informal social, as well as

organisational, networks.

There is some evidence supporting this proposition,

although none emerging from direct empirical study of

health professionals’ contribution to social aspects of

community. Cutchin (Cutchin et al., 1994; Cutchin,

1997a,b) studied the relationship between physician

retention and ‘place integration’ in rural America.

Intriguingly, he found that rural doctors who made a

commitment to staying in a location, actively sought out

roles in community associations and networks. Over

time, rural doctors’ integration in the local social fabric,

made quitting their job a less likely or attractive option.

As the researcher concluded:

yby interacting through time with the emergent and

ongoing problems posed by place, physicians become

woven into the fabric of place. (Cutchin, 1997b)

Those who were not integrated tended to leave rural

places. The overall theme emerging from Cutchin’s

studies was that, if communities desired to retain doctors

and nurses, they should make efforts to include them in

local activities. These findings infer that health profes-

sionals who stay in rural areas over a number of years

are likely to be well integrated socially.

Further evidence of health professionals’ roles in

social structure is provided by Scottish research. An

investigation of life in the Highlands and Islands

described local district nurses and teachers acting as

‘mediators’ for their communities in negotiations with

external bureaucrats (Shucksmith, Chapman, & Clark,

1996). These ‘boundary spanners’ (Anderson, 2000) were

seen to be legitimised by the community to make such

‘vertical linkages’, while also enjoying ‘horizontal

linkages’ through wide social contact with local people

(O’Brien, Raedeke, & Hassinger, 1998). A study in rural

Grampian, Scotland revealed that GPs were sometimes

called upon to help in organising local events and

arbitrate in disputes among neighbours; findings that

ARTICLE IN PRESSJ. Farmer et al. / Social Science & Medicine 57 (2003) 673–686 677

infer a role in community ‘leadership’ (Iversen et al.,

2000).

While this evidence exists, we do not wish to suggest

that health professionals hold a unique position regard-

ing social integration and community leadership. In-

deed, other service professionals, ‘entrepreneurial

incomers’ (Anderson, 2000) and others may be similarly

placed. However, it seems their position as respected

cosmopolitan members of the local community must

locate health professionals as key points of (apparently)

‘neutral’ advice and participation.

Empirical evidence about primary health care in

remote areas of Scotland is only beginning to emerge,

but data so far suggest the importance of carefully

examining existing models of service provision before

changes are considered (Farmer et al., 2002). Current

provision may already represent efficient and effective

models of supplying seamless health and social care for

communities, simultaneously bridging gaps in access,

and sparing demand on secondary care and centralised

social services. Also, and of perhaps key importance to

the ongoing life of fragile remote communities, they may

be providing a crucial contribution to social infrastruc-

ture. It is interesting to note that in countries such as

Australia where the problems of recruitment and

retention of rural health professionals have been

recognised for many years, there is still a policy of

employing doctors and nurses locally, where possible

(National Rural Health Policy Forum, 1999). Attention

to the value of rural health professionals is evident at a

number of levels including the establishment of several

Australian university departments of rural health, a

rural medical school, a range of incentives to rural

working and support for health professionals’ families.

It seems the presence of rural nurses and GPs is

perceived as being intrinsically valuable as a sign of

confident and sustainable rural communities (Bryant &

Strasser, 1999). On a political level this is a sign of the

value of the Australian rural vote.

To summarise, this initial consideration of health

professionals’ roles suggests there is evidence of social

contributions to community that extend beyond desig-

nated health service responsibilities. In considering

health service redesign, it is important to appreciate

and understand the full value of health professionals to

community sustainability.

Life for health professionals working in remote areas

Studies of health professionals who continue to live

and work in remote rural areas indicate that they and

their families appreciate aspects such as ‘clean air’,

beautiful scenery and a secure environment for bringing

up children. Professional aspects such as variety of work

and the chance to practise continuing holistic care are

also reported to be important (Hamilton, Gillies, Ross,

& Sullivan, 1997).

However, professional life in remote areas can be less

than idyllic. A common view expressed is ‘it’s like living

in a goldfish bowl’. It can be difficult to attain family

privacy and appropriate employment for health profes-

sionals’ spouses (Hays, 1999). More than this, isolated

populations can tend to engender feelings that the local

doctor or nurse is ‘owned’ by the community (Rosenthal

& Campbell-Heider, 2001). As Scottish researchers

found:

Many district nurses took the view that locals

regarded them as their own property and not

someone doing a job for 37.75 hours a week. (Lauder

et al., 2001)

In turn, health professionals may feel they are ‘obliged’

to help out at all times:

District nurses embedded in the community reported

feeling a commitment towards their community,

which went beyond their professional remit. (Lauder

et al., 2001)

Far from being a source of job satisfaction, health

professionals’ status can act as a barrier to ‘normal’ life

as it is perhaps difficult to integrate as an ‘ordinary

person’.

Since there are undoubted pressures inherent in

working as a health professional in remote and

peripheral areas, it is perhaps worth asking why some

health professionals do actually stay? Do some profes-

sionals obtain more benefit from life in these commu-

nities than others? While Cutchin’s work, previously

discussed, reveals how health professionals become

‘entangled’ in community networks, it is also likely to

be true that some are more inclined to life and work in

rural communities due to a variety of personal and

professional traits and preferences.

Accomplishing community

In seeking to understand health professionals’ pro-

posed social contribution, it is first necessary to review

some findings about what is meant by ‘community’ and

how people accomplish it (Scott, Park, & Cocklin, 2000).

Shortall (1994) defines community in terms of people

‘‘y living in the same geographical area and frequently

feeling a sense of ‘community spirit’ ’’. It has been

suggested, when considering health policy, that the term

‘locale’ is most useful as it describes the ‘space used as a

setting for routinised interaction’ (Moon, 1990). Having

examined many definitions of ‘community’, Hillery

(1955) defined a typology based on:

ARTICLE IN PRESSJ. Farmer et al. / Social Science & Medicine 57 (2003) 673–686678

* Geographical location: a human settlement with a

fixed and bounded territory.* Social system: the inter-relationships between and

among people living in the same area.* Sense of identity: community resides in a group of

people who share a particular set of values.

In this paper we are interested in health professional’s

contribution to each of these aspects of community.

Although the myth of the rural idyll has been firmly

dispelled (Cloke & Thrift, 1994), rural communities are

still often portrayed as the last strongholds of ‘tradi-

tional society’, characterised by ecological friendliness,

self-sufficiency, spirituality of life and exchange based on

trust and kinship (Pawar, 2001). Exemplified by strong

family or neighbourhood ties, as in Tonnies’ (1887)

notion of ‘gemeinschaft’, they are held to be imbued with

qualities of solidarity and reciprocity, where something

of high value is obtainable: ‘‘y a sense of belonging to a

face-to-face group’’ (Crichton, 1964). In Sack’s (1997)

terms they are communities where life is ‘thick’, enriched

by closely bound networks interacting in relative

isolation (Rousseau, 1995).

Discussions of rural community see their identity

emerging from a combination of historical, relationship

and spatial elements (Jones, 1995). ‘Institutions’ (includ-

ing public services and the churches) have effects on

shaping identity and sense of place, laying down

‘‘sediments’’ of action that serve to shape the norms of

life (Philo & Parr, 2000). Cloke and Jones (2001) discuss

the ‘‘taskscapes’’ that meld together jobs, people and

place like the elements of a landscape. These elements

combine to build the social structures with which local

people identify to give them a sense of belonging to a

place. Place and people are actively involved in this

process of identity building (Entrikin, 1999) which has

significant emotional effects (Cloke & Jones, 2001).

Indeed, Casey (1993) highlights the power of place to:

ydirect and stabilize us, to memorialize and identify

us, to tell us who and what we are in terms of where

we arey .

Findings from ethnographic studies of rural locations

are salutary in warning that beneath the apparent

interconnectedness of ‘communities of place’, there lies

a diversity of ‘communities of interest’ (Bell & Newby,

1971). Philo (1992) has highlighted the importance of

considering the often-excluded ‘‘others’’ of rural com-

munities (that is, non-middle-class, white, male perspec-

tives (Murdoch & Pratt, 1997)). A study of the

Mangakahia valley in New Zealand revealed three key

social groupings (affluent incomers, traditional farming

families and poorer Maoris returning from cities), each

with a different perspective on societal change (Scott

et al., 2000). In the Orkney islands of Scotland, Forsythe

(1980) revealed a number of communities of interest

affected differently by migration effects: former out-

migrant returners, service professionals, ‘urban refugees’

and ‘natives’. Research in rural Grampian, Scotland

revealed health professionals’ perceptions of a number

of different patient groups, with differing service needs

and demands: commuters, women at home with

children, older people, families with socio-economic

difficulties, incomers and rural people who had been

born and brought up in the area (Iversen et al., 2000).

The Cattell (2001) description of ‘membership groups’ in

London communities highlights that such groups can

appear distinct, but are generally inter-linked through

patterns of membership.

These ideas about community suggest factors that

could be important in examining health professionals’

contribution to social structure. They raise questions of:

whether health services as ‘institutions’ might represent

part of a geographical focus for ‘community of place’?;

whether health professionals are a vital part of the

network of social interactions that bind together

disparate ‘communities of interest’?; or whether the

presence of health professionals is important in main-

taining community identity and values? The local

presence of health professionals might have varying

importance and relevance for different ‘communities of

interest’.

According to a study by Shucksmith et al. (1996),

there are three essentials of community: school, church,

and a medical practice. (At the time of that study, only

56% of the Scottish Highland population had access to

a GP within five miles). Later research revealed that the

‘‘core services’’ for a community were thought to be:

shop, primary school, GP and community hall (Hope

et al., 2000). These statements about essential or core

elements require serious consideration. Are they really

saying that, without these institutions, community is

threatened?; or is a spatial concept of ‘community of

place’ focused on central infrastructure being implied? If

so, it is important to develop understanding of how key

services affect the social and cultural fabric such that

they bind together communities, enhancing quality of

life and nurturing a sense of identity. If, in the future,

fewer services are provided in situ, lost through societal

change, service redesign or inability to recruit staff,

might make a community lose its sustainability or begin

to disintegrate?

This is clearly a bleak scenario whose existence can

currently only be sustained through amalgamating hints

of evidence. A New Zealand study revealed that the

combined problems of ageing population and service

depletion make life ‘tough’ for older people who choose

to remain living in rural communities (Joseph &

Chalmers, 1995). Younger people tended to move out

to areas where services were accessible. Bryant and

Strasser (1999) suggest that people need to feel ‘secure’

that they will be able to access the necessary level of

ARTICLE IN PRESSJ. Farmer et al. / Social Science & Medicine 57 (2003) 673–686 679

health care, should a serious situation arise. People will

not move to, or remain in, a community where they

cannot receive health care in an emergency. It is perhaps

mostly from these feelings of insecurity that anger about

local health services decline arise, even although some

studies (for example of rural hospital closures in Canada

(Liu, Hader, Brossart, White, & Lewis, 2001)) have

shown little impact on actual health. Clearly, there is a

need for further information about how deteriorating

access to local primary health care services might affect

longer-term community viability.

Discussion has so far focused on ‘communities of

place’. There are, as noted earlier, other constructions of

community. Massey (1994), for example, argues that

place is not static or authentic, but resides in social

interaction. Thus, predicting the decline of remote

communities through service depletion is both unrealis-

tically romantic, regarding place; and an over-reaction,

regarding community decline. Massey (1994) describes

community as residing where social interactions knit

together. These ‘hubs’ may, indeed should, change over

time. Further, due to the existence of different ‘commu-

nities of interest’, everyone has a different sense of place

and community.

Following this line of argument, there would be little

point in worrying about the effects of service decline on

existing remote communities because societal change

and adaptation are inevitable. Alternative constructions

of community and identity will emerge around places

and social systems. There are other societal forces, such

as access to information and communications technol-

ogies, which are reconstructing the concept of commu-

nity. Counter-migration back into remote and rural

areas by entrepreneurial incomers and those seeking

improved quality of life are engendering economic and

social revival in some places (Anderson, 2000). Given

the distances over which affluent people will commute or

consume, it could be that a sense of community will be

formed over wider geographical areas. Within such

scenarios, although traditional community infrastruc-

ture changes and new patterns of health service

provision emerge, the concept of community is still

sustainable.

Community sustainability

Within a considerable literature on sustainability,

Bryden (1994) highlights the need for rural communities

to have:

ythe capacity to regenerate socially and economic-

allyythe capacity to reproduceyand evolve eco-

nomically, socially, culturally and ecologically.

Sustainability is a concept notoriously difficult to

define, but Bryden’s description seems to encapsulate the

notion envisaged in this paper. That is, we are interested

in health professionals’ contribution to a community’s

capacity to evolve and be a vibrant place to live, in the

face of societal change.

Traditionally, discussion of community sustainability

has emphasised the economic dimension, and it is only

fairly recently that environmental, social and cultural

aspects have become recognised as important (Rivlin,

1993). The Brundtland Commission on Environment

and Development has urged work on measures of

sustainability that emphasise the relationship between

economic, environmental and social conditions (World

Commission on Environment and Development, 1987).

As yet, though, the relationship between factors and

how they work to engender community sustainability is

still poorly understood (Reed, 1999).

There is a developing discussion about the importance

of social aspects in sustainability (Smailes, 1995). Social

sustainability is said to depend on elements of ‘‘liveli-

hood, social participation, justice, equity’’ (Scott et al.,

2000) and sense of place (Stedman, 1999). Research

involving Canadian forestry communities (Nadeau,

Shindler, & Kakoyannis, 1999) has identified a set of

concepts that are important in enriching understanding

of social sustainability, as follows:

* Community stability: is proposed as a measure of the

prosperity, adaptability and cohesiveness of people in

an area and their positive reaction to change (Society

of American Foresters, 1989).* Community capacity: is the characterisation of a

community’s ability to face changing economic,

social and political circumstances.* Community wellbeing: focuses on the degree of match

between local community resources and the social,

cultural and psychological needs of people living

locally.* Community resiliency: is concerned with the capacity

of people and institutions to adapt to change over a

long period of time.

These concepts are all underpinned by notions that

infrastructural and social resources are required for

communities to adapt successfully to change. We argue

that local primary health care provision simultaneously

contributes service infrastructure and ‘social capital’

(discussed later). The concepts listed above present a

useful framework for analysing these inputs and

considering the mechanisms by which they help com-

munities to function and cope with change

Health professionals and community sustainability

We need to begin to understand the role of

health professionals in sustaining remote and rural

ARTICLE IN PRESSJ. Farmer et al. / Social Science & Medicine 57 (2003) 673–686680

communities, particularly in light of what has already

been lost to social structure through increasing centra-

lisation. Research has revealed the significance of

services that have already declined: the social role of

resident clergy (Francis & Lankshear, 1992); the

problems (real or perceived) with rural crime due to

lack of police presence (Morris, 2001); the role of post

offices, banks and village shops as ‘social hubs’ (The

Countryside Agency, 2001): rural schools’ relevance in

helping in-migrant parents to integrate and as a meeting

place for parents from all social groups (Joint Unit for

Research on the Urban Environment and the Depart-

ment of Educational Enquiry, 1981; Witten, McCrea-

nor, Kearns, & Ramasubramanian, 2001).

The current focus on access to health services in

remote areas has revealed a surprising lack of under-

standing of the value of health services to communities.

Some studies have noted the physical importance of the

GP surgery as a meeting place (Farmer & Kennedy,

2001), but there has been little research into the nature

of health professionals’ contribution to wider social

wellbeing. The significance of health professionals to

specific ‘communities of interest’ within localities is also

poorly understood, for example, the importance of visits

from the district nurse for the social inclusion of people

with mobility problems.

The economic contribution of health service employ-

ment to remote communities has also been underplayed.

Roberts (2002) described the increasingly important part

played by the state funding of public sector activity in

remote communities as the traditional economic base

(fishing and textiles in the case of the Western Isles)

declines. The key contribution of the public sector in

local people’s employment has already been shown (see

Fig. 1). Around 17,000 jobs are directly provided by the

health care sector in the Scottish Highlands and Islands

compared with around 8,000 in education and 12,000 in

local government.2 A recent US study highlighted that

15–20% of local employment was generated by direct

health care posts and jobs created in servicing the health

care community (Doeksen & Schott, 2002). A glance at

the local directory on the Hebridean island of Tiree

demonstrates little industrial activity and surprisingly

little tourism-related development. Yet the island sup-

ports a population of around 750 people, many of whom

obtain full or part-time employment from services such

as transport, education and health care. It could be that

service sector employment is making a key contribution

to some younger families’ decisions to remain living and

working in the community. With such a complex inter-

dependent network of jobs and people, decline in the

health service sector would have impacts on both direct

health service employment and on associated posts.

Further, both US and Scottish studies have highlighted

the important economic effect of local public service

infrastructure in attracting tourists and retirees to locate

in rural areas (Roberts, 2002; Doeksen & Schott, 2002).

These are important groups in terms of their propensity

to consume within local communities.

We argue that assessing the social and economic

contribution of health professionals to community

sustainability is worthwhile and timely. Examination

of different types of remote communities (i.e. those that

have traditionally had poor health service infrastructure,

those that have recently lost services and those where

service provision is still vigorous) could assist in

detecting the contribution of health professionals. This

strategy could prove useful in developing knowledge of

who fulfils the proposed extended social role of health

professionals, as well as their professional role, when

they are gone. Such studies could reveal whether

communities with and without accessible working health

professionals exhibit different patterns of social inter-

connections. And, if infrastructural changes occur in

communities, whether, and at what pace, society adapts.

Health professionals and capital

A growing body of work by sociologists, political

scientists and others could provide a potential theore-

tical framework for understanding and analysing the

resources necessary for community sustainability. This

envisages the generation and spending of ‘capital’

(resources) within a number of key areas, including:

material, cultural, symbolic and social. Consideration of

health professionals’ role in relation to capital could be

important in understanding their contribution to com-

munity. The possible relevance of theories of capital is

discussed briefly here.

Social capital

The concept of social capital is currently prevalent in

policy and academic circles (Baron, Field, & Schuller,

2000; Cote & Healy, 2001; Atterton, 2001) and it is

therefore particularly relevant in examining issues

pertinent to public services design. It is additionally

apposite in the examination of remote communities

which are thought to be more ‘traditional’ and therefore

might be assumed to have greater potential to generate

social capital. Like sustainability, social capital is an ill-

defined concept. Although it is generally agreed that

high levels of formal and informal social interaction

benefit society, it is unclear whether this amounts to

‘social capital’. A lack of empirical evidence means that

mechanisms, indicators and tools for measurement of

social capital, are poorly developed (Baron et al., 2000).

ARTICLE IN PRESS

2Figures supplied by Highlands and Islands Enterprise

(2002).

J. Farmer et al. / Social Science & Medicine 57 (2003) 673–686 681

Social capital is said to form out of repeated social

interaction between individuals and groups which

develops trust, reciprocity and norms of behaviour

(Coleman, 1994). The amount of capital built depends

on the quality and quantity of interactions (Falk &

Kilpatrick, 2000). A recent study of social capital within

a rural community described resources as emerging

through exchange of ‘knowledge resources’ and ‘identity

resources’; that is, frequent allusions to shared knowl-

edge, history and vision for the future served to enhance

and embed social relations (Falk & Kilpatrick, 2000).

Since it is proposed that health professionals in remote

communities have a high level of interaction within their

local community (horizontal linkages) and externally

(vertical linkages), they are likely to be important

contributors to building social capital.

There is some debate as to whether social capital can

only reside with groups (Lochner, Kawachi, & Kennedy,

1999), having developed out of interaction; or whether

individuals can hold ‘slices’ of social capital that are

dependent on their place and status in social groups

(Bourdieu, 1986). Adherence depends on different

interpretations of the concept of social capital (Siisiai-

nen, 2000). Use of the word ‘capital’ would imply that

the idea of social capital is premised on rational

economic ‘exchange theory’. Bourdieu’s (1986) inter-

pretation certainly holds that no accumulation of capital

is disinterested and thus social capital would be built as

a source of personal power. However, in viewing social

capital as a by-product of social activities, other

interpretations imply that it could have developed out

of altruistic actions (Putnam, 1993b).

A disturbing element of social capital is its potential

use to maintain status in the social hierarchy (Hawe &

Shiell, 2000). Shucksmith (2000) notes the discord

inherent within the concept of social capital which:

ycan be a source of cohesion, but also of conflict as

those who are excluded from the group in which the

capital resides will not benefity .

He provides an illustrative example from his own work,

which found that European Union LEADER pro-

gramme funds tended to be granted to those well-

networked local ‘notables’ who already dominated rural

development rather than to less experienced applicants.

Massey (1991) confirms this notion of ‘power geometry’,

conspicuous in rural areas. It might be argued that

health professionals, simply through their position in the

social hierarchy, exclude others from meaningful social

roles; although again, there is no evidence on this issue.

Social capital is argued by some to be a key element in

community viability and whether or not it develops to

become a coherent and enduring concept, there is wide

support for the relevance of strong social infrastructure

to community wellbeing. Evidence indicates that health

professionals are well placed to contribute to social

infrastructure and, therefore, the relevance of social

capital to an underlying theory for health care provision

in remote communities should be considered. It is

important also to reflect on those who stand to gain

and lose from health professionals’ role in producing

social capital when assessing the effects of their loss to

communities. Again, it might be that different ‘commu-

nities of interest’ might be affected in varying ways.

Symbolic and cultural capital

Since we are hypothesising that health professionals

play a role in community sustainability and that they are

important contributors to social capital, it is now

pertinent to ask—to what extent does this role reside

with the job or with the individual? One school of

thought argues that it is charismatic individuals who

energise community or group achievement (Wilkinson,

1991). A study of the Scottish Highlands and Islands

noted that:

y in the scattered communities, the doctors were

revered for their commitment to the community and

their accessibilityypersonal involvement with the

community, integrity and conscientious visiting

habitsy[They were]yviewed as key local personal-

ities. (Shucksmith et al., 1996)

Only two of the features present in that statement,

‘visiting’ and ‘accessibility’, might be construed as

related to doctors’ health care role. Indeed the emphasis

is on their value as individual personalities.

Contrary to this position, theories of capital would see

power residing in the cultural and symbolic resources

inherent in the professional role (Bhaskar, 1979).

Bourdieu’s writing on social theory implies that health

professionals are seen as respected ‘leaders’ by their

communities both because of the cultural capital they

hold (derived from educational and professional quali-

fications) and their symbolic capital or power (Swartz,

1997). Symbolic capital is that which is accrued through

exercising their professional status. Health professionals

and their patients might be viewed as being involved in a

cyclical process of developing this capital. Put simply,

because it is perceived by the community as important to

have a local doctor, the person in that role can gain

symbolic power within the community. Bourdieu’s

philosophy suggests that such arrangements would be

typical within traditional societies, where:

yindividuals and groups draw on a variety of

cultural, social and symbolic resources in order to

maintain and enhance the social order (Swartz,

1997).

ARTICLE IN PRESSJ. Farmer et al. / Social Science & Medicine 57 (2003) 673–686682

While the relevance of this theory within the context of

contemporary (i.e. non-traditional) Western societies

might be considered doubtful, there is some evidence

from research in remote rural Scotland suggesting its

validity. The Ennew (1980) ethnographic study of life on

a Hebridean island and previously mentioned work by

Shucksmith et al. (1996) noted that service professionals

such as doctors, nurses and teachers were ‘expected’ to

undertake tasks such as negotiating with those external

to the community. Forsythe’s (1980) study of an Orkney

island showed that cosmopolitan incomers tended to

become community leaders and were ‘expected’ to provide

employment, while the attitudinal norms of indigenous

people forced them to be more reticent and passive.

This choice between charismatic personality or symbolic

role being most important in ascribing health profes-

sionals’ identity in the community implies a dichotomy.

Inevitably, the situation is probably more complex than

this. Indeed, it seems likely that aspects of personality and

role are inter-twined. It may even be that only certain types

of personality respond to the social responsibilities

attendant with working in remote communities.

Conclusions

This paper has attempted to develop the argument

that health professionals, working and residing locally,

make a valuable contribution to the social structure of

remote communities, in addition to health care, social

care and economic contributions. It seeks to stimulate

consideration of the extent to which primary health care

services are necessary to the infrastructure required to

sustain communities into the future. It suggests that

consideration of theories of capital, and particularly the

concept of social capital, might be pertinent in under-

standing the extended role of health professionals in

remote places. At the same time, it acknowledges that

society thrives on change and communities might form

around different models. New ‘communities of place’

and ‘communities of interest’ might have different

patterns of leadership and perspectives on social activity

and identity. New models of health care provision, with

fewer local health professionals, might actually empower

those traditionally excluded from participation in social

infrastructure by prevailing hegemonies.

At root, we are urging for greater understanding of

the roles of health care professionals in remote commu-

nities before new models of primary health care

provision are introduced which might have unforeseen

effects on social and economic structure. Currently, it

seems, decisions about service redesign are being

considered solely by health service stakeholders. Yet

health service decisions regarding fragile communities

may affect their sustainability and are relevant to all in

society. A holistic approach to service redesign needs to

be taken, informed by evidence about the potential

impacts of change. At the very least, any new health care

models implemented should be evaluated by assessing

social and economic, as well as health care, effects.

Moreover, decisions about health service remodelling

should ideally be seen as part of a wider debate about

the future sustainability of remote communities. As a

society, do we value these communities? Do we want to

keep them? Are they important to our cultural and

historical heritage? What do they contribute to the

future we envisage for our country? If they are valued,

we need to invest in supporting them. This is a debate

relevant to all in society, rural and urban dwellers alike.

Government policies may need to reorient so that they

are not simply addressing economic issues such as

compensation for agricultural decline and small business

start-ups. (Only so many pottery shops are needed in the

Hebrides!) A substantial proportion of current full and

part-time employment in remote communities is based

around service and utility jobs. If society decided it

wanted to invest in retaining remote communities, then

steps to maintain service infrastructure could be taken.

Careful reflection on policies and their outcomes in

countries with a record of considering the rural agenda

(for example, Canada, Sweden, Norway and Australia)

would be instructive in highlighting the relationship

between government support for services and rural

community vibrancy. This paper does not seek to

romanticise the role of health professionals in rural areas

nor does it advocate an anti-change ‘museum strategy’ to

service provision. It merely proposes that we need to

explore health professionals’ roles in remote rural areas so

evidence can be generated to inform strategic investment

decisions about future health care provision.

Acknowledgements

The authors would like to thank: Dr Craig Veitch,

Associate Professor of Rural Health, James Cook

University, Townsville, Australia; Dr Gordon Baird,

general practitioner, Sandhead, Dumfries & Galloway;

Dr Andrea Nightingale, Research Fellow, University of

Aberdeen Arkleton Centre for Rural Development

Research; and Mrs Lisa Iversen, Chief Scientist Office

Health Services Research Fellow, University of Aberd-

een Department of General Practice & Primary Care

and anonymous reviewers of this paper for their time in

considering earlier versions and for their helpful

comments and suggestions.

References

Anderson, A. R. (2000). Paradox in the periphery: An

entrepreneurial reconstruction? Entrepreneurship & Regional

Development, 12, 91–109.

ARTICLE IN PRESSJ. Farmer et al. / Social Science & Medicine 57 (2003) 673–686 683

Atterton, J. (2001). The role of civil society and the business

community in rural restructuring. Edinburgh: Scottish

Executive Central Research Unit.

Audit Commission (1992). Caring systems: Effective implemen-

tation of ward nursing management systems. London: Her

Majesty’s Stationery Office.

Baird, A. G., Donnelly, C. M., Miscampbell, N. T., & Wemyss,

H. D. (2000). Centralisation of cancer services in rural areas

has disadvantages. British Medical Journal, 320(7236),

717.

Baron, S., Field, J., & Schuller, T. (Eds.). (2000). Social

capital—critical perspectives. Oxford: Oxford University

Press.

Bell, C., & Newby, H. (1971). Community studies. London:

Allen & Unwin.

Bentham, G., Hinton, J., Haynes, R., Lovett, A., & Bestwick,

C. (1995). Factors affecting non-response to cervical

cytology screening in Norfolk, England. Social Science &

Medicine, 40(1), 131–135.

Bhaskar, R. (1979). The possibility of naturalism. Brighton:

Harvester.

Bourdieu, P. (1986). The forms of capital. In J. E. Richardson

(Ed.), Handbook of theory of research for the sociology of

education (pp. 241–258). London: Greenwood Press.

Boyle, P., & Halfacree, K. (1998). Migration into rural areas:

Theories and issues. Chichester: Wiley.

Bryant, L., & Strasser, R. (1999). The delivery of sustainable

rural and remote health services (Regional Australia Summit

papers 27–29 October 1999). Canberra: Regional Australia

Summit Unit [wwwdbtrs.gov.au/regional/summit]. Accessed

10/12/01.

Bryden, J. (1994). Some preliminary perspectives on sustainable

rural communities. In J. Bryden (Ed.), Towards sustainable

rural communities: The Guelph seminar series (pp. 40–50).

Guelph: Canada: School of Rural Planning & Development.

Campbell, N. C., Elliott, A. M., Sharp, L., Ritchie, L. D.,

Cassidy, J., & Little, J. (2000). Rural factors and survival

from cancer: Analysis of Scottish cancer registrations.

British Journal of Cancer, 82(11), 1863–1866.

Casey, E. (1993). Getting back into place: Toward a renewed

understanding of the place-world. Bloomington: Indiana

University Press.

Cattell, V. (2001). Poor people, poor places, and poor health:

The mediating role of social networks and social capital.

Social Science & Medicine, 52(10), 1501–1516.

Cloke, P., Milbourne, P., & Thomas, C. (1994). Lifestyles in

rural England. A research report to the Department of the

Environment and the Economic and Social Research

Council and the Rural Development Commission.

Cloke, P., & Thrift, N. (1994). Refiguring the rural. In P. Cloke,

M. Doel, D. Matless, M. Phillips, & N. Thrift (Eds.) Writing

the rural: Five cultural geographies (pp. 1–5). London: Paul

Chapman.

Cloke, P., & Jones, O. (2001). Dwelling, place and landscape:

An orchard in Somerset. Environment & Planning A, 33,

649–666.

Coleman, J. S. (1994). Foundations of social theory. Cambridge,

MA: The Belknap Press of Harvard University Press.

Cote, S., & Healy, T. (2001). The well-being of nations. The role

of human and social capital. Paris: Organisation for

Economic Co-operation & Development.

Cox, J. (1997). Rural general practice: A personal view of

current issues. Health Bulletin, 55(5), 309–315.

Cox, J., & Mungall, I. (Eds.). (1998). Rural healthcare. Oxford:

Radcliffe Medical Press.

Craig, G., & Manthorpe, J. (2000). Fresh fields: Rural social

care: Research, policy and practice agendas. York: Joseph

Rowntree Foundation.

Crichton, R. (1964). Commuters’ village; a study of community

and commuting in a Berkshire village. Dawlish: David &

Charles.

Cutchin, M. P. (1997a). Community and self: Concepts for

rural physician integration and retention. Social Science &

Medicine, 44(11), 1661–1674.

Cutchin, M. P. (1997b). Physician retention in rural commu-

nities: The perspective of experiential place integration.

Health & Place, 3(1), 25–41.

Cutchin, M. P., Norton, J. C., Quan, M. M., Bolt, D., Hughes,

S., & Lindeman, B. (1994). To stay or not to stay: Issues in

rural primary care physician retention in Eastern Kentucky.

The Journal of Rural Health, 10(4), 273–278.

Deaville, J. A. (2001). The nature of rural general practice in the

UK: Preliminary research. Newtown, Wales: Institute of

Rural Health.

Department of Environment, Transport & the Regions (2000).

Our countryside: The future: A fair deal for rural England.

Cm 4909. London: The Stationery Office.

Doeksen, G. A., & Schott, V. (2002). The economic importance

of the health care sector on a rural economy. Paper

presented at the Fifth Wonca World Conference on Rural

Health, Melbourne, Australia, April 30–May 3, 2002.

Ennew, J. (1980). The Western Isles today. Cambridge: Cam-

bridge University Press.

Entrikin, J. N. (1999). Political community, identity and

cosmopolitan place. International Sociology, 14(3), 269–282.

European Society for Rural Sociology (2001). The term is used

in the call for papers for the XIXth Congress of the

European Society for Rural Sociology. ‘‘Society, Nature,

Technology: The Contribution of Rural Sociology’’. Dijon,

France 3–7th September 2001 [http://cc.joensuu.fi/~alma/

esrs/arc/19calpa.htm] Accessed on 24th October 2001.

Falk, I., & Kilpatrick, S. (2000). What is social capital? A study

of interaction in a rural community. Sociologica Ruralis,

40(1), 87–110.

Farmer, J., Iversen, L., & Baird, G. (2001). Rural deprivation:

Reflecting reality. British Journal of General Practice, 51,

486–491.

Farmer, J., & Kennedy, L. (2001). Citizen’s Advice Bureau

outreach services evaluation. Aberdeen: University of

Aberdeen.

Farmer, J., West, C., Whyte, B., Black, F., Mulvenna, G.,

Morton, D. (2002). Rural–urban morbidity recording project:

Interim evaluation report of the early stages. Aberdeen:

University of Aberdeen.

Forsythe, D. E. (1980). Urban incomers and rural change. The

impact of migrants from the city on life in an Orkney

community. Sociologica Ruralis, 20, 287–307.

Francis, L. J., & Lankshear, D. W. (1992). The rural rectory:

The impact of a resident priest on local church life. Journal

of Rural Studies, 8(1), 97–103.

Goodall, B. (1987). The dictionary of human geography.

London: Penguin.

ARTICLE IN PRESSJ. Farmer et al. / Social Science & Medicine 57 (2003) 673–686684

Gould, M. I., & Moon, G. (2000). Problems of providing health

care in British island communities. Social Science &

Medicine, 50, 1081–1090.

Guthrie, B., & Wyke, S. (2000). Does continuity in general

practice really matter? British Medical Journal, 321(7263),

734–736.

Halfacree, K. H. (1993). Locality and social representation—

space, discourse and alternative definitions of the rural.

Journal of Rural Studies, 9, 23–27.

Hamilton, I. J., Gillies, J., Ross, S., & Sullivan, F. (1997).

Attitudes of general practitioners who practice in remote

communities. Health Bulletin, 55(2), 103–108.

Harrop, A. (Ed.). (2000). Changing views of rural Britain: Why

services matter. London: New Policy Institute.

Hawe, P., & Shiell, A. (2000). Social capital and health

promotion: A review. Social Science & Medicine, 51,

871–885.

Haynes, R. M., & Bentham, C. G. (1982). The effects of

accessibility on general practitioner consultations, out-

patient attendances and in-patient admissions in Norfolk,

England. Social Science & Medicine, 16(5), 561–569.

Hays, R. B. (1999). Common international themes in rural

medicine. Australian Journal of Rural Health, 7(3),

191–194.

Helmsdale & District GP Action Group (2001). Helmsdale &

District GP Action Group. Our Position in Brief.

[www.helmsdale.org/News/news.html]. Accessed 18/12/01.

Higgs, G. (1999). Investigating trends in rural health outcomes:

A research agenda. Geoforum, 30(3), 203–221.

Highlands & Islands Enterprise. (2001). Highlands & Islands

Enterprise Economic Information. [http://www.hie.co.uk/

welcome.asp.locID-hieecoint.htm]. Accessed 10/12/01.

Hillery, G. A. (1955). Definitions of community: Areas of

agreement. Rural Sociology, 20(2), 111–123.

Hoggart, K., Buller, H., & Black, R. (1995). Rural Europe:

Identity and change. London: Arnold.

Hope, S., Anderson, S., & Sawyer, B. (2000). The quality of

services in rural Scotland. Edinburgh: Scottish Executive

Central Research Unit.

Hugo, G., & Smailes, P. (1985). Urban–rural migration in

Australia: A process view of the turnaround. Journal of

Rural Studies, 1, 11–30.

Iversen, L., Farmer, J., & Hannaford, P. (2000). Perceptions of

work and workload pressures in rural and urban general

practice: A pilot study. Final report. Aberdeen: University of

Aberdeen Department of General Practice & primary Care.

Joint Unit for Research on the Urban Environment and the

Department of Educational Enquiry (1981). The social

effects of rural primary school reorganization in England: A

study on behalf of the Department of the Environment and the

Department of Education and Science. Final report.

Birmingham: University of Aston.

Jones, O. (1995). Lay discourses of the rural: Developments and

implications for rural studies. Journal of Rural Studies, 11,

35–49.

Jones, A. P., & Bentham, G. (1995). Emergency medical service

accessibility and outcome from road traffic accidents. Public

Health, 109, 169–177.

Jones, A. P., & Bentham, G. (1997). Health service accessibility

and deaths from asthma in 401 local authority districts in

England and Wales 1988–1992. Thorax, 52(3), 218–222.

Jones, A. P., Bentham, G., Harrison, B. D. W., Jarvis, D.,

Badminton, R. M., & Wareham, N. J. (1998). Accessibility

and health service utilization for asthma in Norfolk,

England. Journal of Public Health Medicine, 20(3),

312–317.

Jones, A. P., Bentham, G., & Horwell, C. (1999). Health service

accessibility and deaths from asthma. International Journal

of Epidemiology, 28(1), 101–105.

Joseph, A. E., & Chalmers, A. I. (1995). Growing old in place:

A view from rural New Zealand. Health & Place, 1(2),

79–90.

Larson, E. H., & Hart, L. G. (2000). The rural physician. In J.

P. Geyman, T. E. Norris, & L. G. Hart (Eds.), Textbook of

rural medicine. New York: McGraw-Hill.

Lauder, W., Reynolds, W., Reilly, A., & Angus, N. (2001). The

role of district nurses in caring for people with mental health

problems in rural settings. Journal of Clinical Nursing,

Special Edition: Primary Care, 10(3), 337–344.

Launoy, G., Coutour, X., Gignoux, M., Pottier, D., & Dugleux,

G. (1992). Influence of rural environment on diagnosis,

treatment and prognosis of rectal cancer. Journal of

Epidemiology and Community Health, 46, 365–367.

Liu, L., Hader, J., Brossart, B., White, R., & Lewis, S. (2001).

Impact of rural hospital closures in Saskatchewan, Canada.

Social Science & Medicine, 52, 1793–1804.

Lochner, K., Kawachi, I., & Kennedy, B. P. (1999). Social

capital: A guide to its measurement. Health & Place, 5(4),

259–270.

Massey, D. (1991). A global sense of place. Marxism Today,

June (pp. 24–29).

Massey, D. (1994). Space, place and gender. Oxford: Polity

Press.

Milligan, C. (2000). ‘Breaking out of the asylum’: Develop-

ments in the geography of mental ill-health—the influence

of the informal sector. Health & Place, 6(3), 189–200.

Moon, G. (1990). Conceptions of space and community in

British health policy. Social Science & Medicine, 30(1),

165–171.

Morris, S. (2001). Rural policing is no better, say villagers. The

Guardian Wed Oct 31, 2001. [wysiwyg://162/http://

www.guardian.co.uk/martin/article/0,2763,583837,00.html].

Accessed on 18/12/01.

Murdoch, J., & Pratt, A. C. (1997). From the power of

topography to the topography of power: A discourse on

strange ruralities. In P. Cloke, & J. Little (Eds.), Contested

countryside cultures: Otherness, marginalisation and rurality

(pp. 51–69). London: Routledge.

Nadeau, S., Shindler, B., & Kakoyannis, C. (1999). Forest

communities: New frameworks for assessing sustainability.

The Forestry Chronicle, 75(5), 747–754.

National Rural Health Policy Forum (1999). Health horizons:

1999–2003: A framework for improving the health of rural,

regional and remote Australians. Adelaide: NRHPF.

O’Brien, D. J., Raedeke, A., & Hassinger, E. W. (1998). The

social networks of leaders in more or less viable commu-

nities six years later: A research note. Rural Sociology, 63(1),

109–127.

Pahl, R. (1970). Patterns of urban life. London: Longman.

Pawar, M. (2001). Resurrection of traditional communities in

postmodern societies. Accessed Dec 10th, 2001 [http://

www.csu.edu.au].

ARTICLE IN PRESSJ. Farmer et al. / Social Science & Medicine 57 (2003) 673–686 685

Philips, M. (1999). Migration and social change. In The Rural

Group of Labour MPs, Rural audit: A health check on rural

Britain (pp. 26–29). Cheltenham: The Rural Group of

Labour MPs.

Philo, C. (1992). Neglected rural geographies: A review. Journal

of Rural Studies, 8, 193–207.

Philo, C., & Parr, H. (2000). Institutional geographies:

Introductory remarks. Geoforum, 31(4), 513–521.

Proctor, M. (2000). The future of community nursing. In

Scottish Council for Postgraduate Medical and Dental

Education, Seeking solutions: Education and training for

remote and rural health professionals. Report of a multi-

disciplinary conference 30–31 March 2000.

Putnam, R. (1993a). Making democracy work: Civic traditions in

modern Italy. Princeton: Princeton University Press.

Putnam, R. D. (1993b). The prosperous community. The

American Prospect, 4(13), 35–42.

Reed, M. G. (1999). ‘‘Jobs Talk’’: Retreating from the social

sustainability of forestry communities. The Forestry Chroni-

cle, 75(5), 755–763.

Reimer, B. (2000). Leading and lagging sites in rural Canada.

Conference paper presented at ‘European Rural policy at the

crossroads’. Aberdeen: University of Aberdeen Arkleton

Centre for Rural Development.

Remote and Rural Areas Resources Initiative (RARARI)

Recruitment and Retention Working Group. (2002)

[www.rararibids.org.uk/rarari/index.asp?TopicID ¼ 107].

Accessed 29th Jan 2002.

Remote and Rural Areas Resources Initiative (RARARI)

Solutions Group. (2002). Solutions for the provision of

health care in the remote and rural areas of Scotland in the

21st century. Fort William, Scotland: RARARI.

Rivlin, A. M. (1993). Values, institutions and sustainable

forestry. In G. H. Aplet, N. Johnson, J. T. Olson, & V. A.

Sample (Eds.), Defining sustainable forestry (pp. 255–259).

Washington, DC: Island Press.

Roberts, D. (2002). The changing economic base of rural areas:

A SAM-based analysis of the Western Isles. A report for

Western Isles Enterprise. Aberdeen: University of Aberd-

een.

Rosenthal, T. C., & Campbell-Heider, N. (2001). The rural

health care team. In J. P. Geyman, T. E. Norris, & L. G.

Hart (Eds.), Textbook of rural medicine (pp. 41–55). New

York: McGraw-Hill.

Rousseau, N. (1995). What is rurality? In J. Cox (Ed.), Rural

general practice in the UK (pp. 1–4). Occasional paper 71.

London: Royal College of General Practitioners.

Sack, R. (1997). Homo geographicus. Baltimore, MD: John

Hopkins University Press.

Scott, K., Park, J., & Cocklin, C. (2000). From ‘sustainable

rural communities’ to ‘social sustainability’: Giving voice to

diversity in Mangakahia Valley, New Zealand. Journal of

Rural Studies, 16(4), 433–446.

Scottish Executive Rural Affairs Department. (2000). Rural

Scotland: A new approach. Edinburgh: Scottish Executive.

Scottish National Rural Partnership. (2000). Services in rural

Scotland. Edinburgh: Scottish Executive.

Shortall, S. (1994). The Irish rural development paradigm: An

exploratory analysis. Economic & Social Review, 25,

233–260.

Shucksmith, M. (2000). Endogenous development, social

capital and social inclusion: Perspectives from LEADER

in the UK. Sociologica Ruralis, 40(2), 208–218.

Shucksmith, M., Chapman, P., & Clark, G. M. (1996). Rural

Scotland today: The best of both worlds?. Avebury: Alder-

shot.

Siisiainen, M. (2000). Two concepts of social capital: Bourdieu

vs. Putnam. Paper presented at International Society for

Third-Sector Research (ISTR) Fourth International Confer-

ence ‘‘The Third Sector: For what and for whom?’’ Trinity

College, Dublin, July 5–8 2000.

Smailes, P. J. (1995). The enigma of social sustainability in rural

Australia. Australian Geographer, 26(2), 140–150.

Society of American Foresters. (1989). Report of the Society of

American Foresters (SAF) National Task Force on Commu-

nity Stability. SAF Resource Policy Series. Bethesda, MD:

SAF.

Stedman, R. C. (1999). Sense of place as an indicator of

community sustainability. The Forestry Chronicle, 75(5),

765–770.

Swartz, D. (1997). Culture and power: The sociology of Pierre

Bourdieu. Chicago: University of Chicago Press.

The Countryside Agency (2001). Rural services in 2000.

London: The Countryside Agency.

The Scottish Office Department of Health. (1998). Acute

services review report. Edinburgh: The Stationery Office.

Tonnies, F. (1887). Community and society: Gemeinschaft and

gesellschaft. (C. P. Loomis Trans. and Ed.). New York:

Harper and Row, 1957, Preprint.

University of Aberdeen & University of Cardiff. (2001).

Transport policies for rural Scotland: The assessment of

policies in relation to rural development and sustainability

objectives. Edinburgh: Scottish Executive Central Research

Unit.

White, S. D., Guy, C. M., & Higgs, G. (1997). Changes in

service provision in rural areas: Part 2: Changes in post

office provision in Mid Wales: A GIS-based evaluation.

Journal of Rural Studies, 13(4), 451–465.

Wilkinson, K. P. (1991). The community in rural America. New

York: Greenwood Press.

Wilks, J., Barnes, J., Paul, K., Wood, M., & Jones, D. (1997).

Managing patient records and documenting service delivery:

The results of a ‘best practice’ remote area nursing program.

Australian Journal of Rural Health, 5(3), 153–157.

Witten, K., McCreanor, T., Kearns, R., & Ramasubramanian,

L. (2001). The impacts of a school closure on neighbour-

hood social cohesion: Narratives from Invercargill, New

Zealand. Health & Place, 7, 307–317.

World Commission on Environment and Development. (1987).

A common future. Oxford: Oxford University Press.

ARTICLE IN PRESSJ. Farmer et al. / Social Science & Medicine 57 (2003) 673–686686