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Abstract Background The configuration of rural health services is influenced by geography. Rural health practitioners provide a broader range of services to smaller populations scattered over wider areas or more difficult terrain than their urban counterparts. This has implications for training and quality assurance of outcomes. This exploratory study describes the development of a "clinical peripherality" indicator that has potential application to remote and rural general practice communities for planning and research purposes. Methods Profiles of general practice communities in Scotland were created from a variety of public data sources. Four candidate variables were chosen that described demographic and geographic characteristics of each practice: population density, number of patients on the practice list, travel time to nearest specialist led hospital and travel time to Health Board administrative headquarters. A clinical peripherality index, based on these variables, was derived using factor analysis. Relationships between the clinical peripherality index and services offered by the practices and the staff profile of the practices were explored in a series of univariate analyses. Results Factor analysis on the four candidate variables yielded a robust one-factor solution explaining 75% variance with factor loadings ranging from 0.83 to 0.89. Rural and remote areas had higher median values and a greater scatter of clinical peripherality indices among their practices than an urban comparison area. The range of services offered and the profile of staffing of practices was associated with the peripherality index. Conclusion Clinical peripherality is determined by the nature of the practice and its location relative to secondary care and administrative and educational facilities. It has features of both gravity model-based and travel time/accessibility indicators and has the potential to be applied to training of staff for rural and remote locations and to other aspects of health policy and planning. It may assist planners in conceptualising the effects on general practices of centralising specialist clinical services or administrative and educational facilities.

Abstract Background The relationship between geographical location, private costs, health provider costs and uptake of health screening is unclear. This paper examines these relationships in a screening programme for abdominal aortic aneurysm in the Highlands and Western Isles of Scotland, a rural and remote area of over 10,000 square miles. Methods Men aged 65–74 (n = 9323) were invited to attend screening at 51 locations in 50 settlements. Effects of geography, deprivation and age on uptake were examined. Among 8,355 attendees, 8,292 completed a questionnaire detailing mode of travel and costs incurred, time travelled, whether accompanied, whether dependants were cared for, and what they would have been doing if not attending screening, thus allowing private costs to be calculated. Health provider (NHS) costs were also determined. Data were analysed by deprivation categories, using the Scottish Indices of Deprivation (2003), and by settlement type ranging from urban to very remote rural. Results Uptake of screening was high in all settlement types (mean 89.6%, range 87.4 – 92.6%). Non-attendees were more deprived in terms of income, employment, education and health but there was no significant difference between non-attendees and attendees in terms of geographical access to services. Age was similar in both groups. The highest private costs (median £7.29 per man) and NHS screening costs (£18.27 per man invited) were observed in very remote rural areas. Corresponding values for all subjects were: private cost £4.34 and NHS cost £15.72 per man invited. Conclusion Uptake of screening for abdominal aortic aneurysm in this remote and rural setting was high in comparison with previous studies, and this applied across all settlement types. Geographical location did not affect uptake, most likely due to the outreach approach adopted. Private and NHS costs were highest in very remote settings but still compared favourably with other published studies.

Discusses some of the specific challenges to the provision of remote and rural health care in Great Britain. Public engagement processes; Redesign experiments related to screening for aortic aneurysm and consultant-supported care in an island hospital; Issues concerning the use of telemedicine and telephone triage in remote communities.

Objective: To determine whether there is a relation between aortic diameter and morbidity and mortality in men screened for abdominal aortic aneurysm., Design: Prospective cohort study., Setting: Highland and Western Isles (a large, sparsely populated area of Scotland)., Participants: 8146 men aged 65-74., Main Outcome Measures: Morbidity and mortality in relation to presence of abdominal aortic aneurysm and three categories of aortic diameter (≤ 24 mm, 25-29 mm, and ≥ 30 mm)., Results: When screened, 414 men (5.1%) had an aneurysm (diameter ≥ 30 mm), 669 (8.2%) an aortic diameter of 25-29 mm, and 7063 (86.7%) an aortic diameter of ≤ 24 mm. The cohort was followed up for a median of 7.4 (interquartile range 6.9-8.2) years. Mortality was significantly associated with aortic diameter: 512 (7.2%) men in the ≤ 24 mm group died compared with 69 (10.3%) in the 25-29 mm group and 73 (17.6%) in the ≥ 30 mm group. The mortality risk in men with an aneurysm or with an aorta measuring 25-29 mm was significantly higher than in men with an aorta of ≤ 24 mm. The increased mortality risk in the 25-29 mm group was reduced when taking confounders such as smoking and known heart disease into account. After adjustment, compared with men with an aortic diameter of ≤ 24 mm, the risk of hospital admission for cardiovascular disease and chronic obstructive pulmonary disease was significantly higher in men with aneurysm and those with aortas measuring 25-29 mm. Men with an aneurysm also had an increased risk of hospital admission for cerebrovascular disease, atherosclerosis, peripheral arterial disease, and respiratory disease. In men with aortas measuring 25-29 mm, the risk of hospital admission with abdominal aortic aneurysm was significantly higher than in men with an aorta of ≤ 24 mm (adjusted hazard ratio 6.7, 99% confidence interval 3.4 to 13.2) and this increased risk became apparent two years after screening., Conclusions: Men with abdominal aortic aneurysm and those with aortic diameters measuring 25-29 mm have an increased risk of mortality and subsequent hospital admissions compared with men with an aorta diameter of ≤ 24 mm. Consideration should be given to control of risk factors and to rescreening men with aortas measuring 25-29 mm at index scanning.

Between 21 and 23 September 2005, over 200 delegates from eight countries gathered in Tromsö, within the Arctic Circle, to discuss challenges and solutions to rural health issues. This conference was a sequel to a previous event entitled 'Making it Work', held in Scotland in 2003, in which it was identified that service delivery in remote and rural areas needed to be innovative to ensure equity. A major aim of this event was to move the debate forward to describe specific examples of practice that could be adopted in participating countries. The delegates included clinicians, managers and administrators, senior policymakers and educationalists, elected local and national politicians, patients and their representatives. In order to focus debate, the organisers provided an outline of a virtual remote community ('Hope'), including some geographic and demographic information, together with four case studies of individual health problems faced by residents of the community. During the introductory session, a short film was shown featuring the 'residents' of this community, introducing delegates to the specific problems they faced. Throughout the conference, delegates were asked to reflect back to how any recommendations made might apply to the citizens of Hope. The clinical scenarios presented included: (1) a 37 year old pregnant woman in labour during adverse weather conditions; (2) a 17 year old island resident with acute psychosis who attempts suicide; (3) an 80 year old woman living alone who suffers a stroke; and (4) a family of four with a complex range of chronic health issues including smoking, alcoholism, diabetes, teenage pregnancy, asthma and depression on a background of deprivation and unemployment. Parallel discussions and workshops focussed on a number of key themes linked to the examples highlighted in the 'Hope' scenario. These included: maternity services; mental health; chronic disease management; health improvement and illness prevention; supporting healthy rural communities; and education for rural health staff. This approach to targeting discussion is valuable in rural health conferences where the participants may be from diverse backgrounds and the issues discussed are multi-faceted.