Diverse ‘rurals’: comparing mainland and island-dwelling older adults’ perceptions of formal care

Introduction: Care in rural and remote areas is often characterised as problematic, yet this framing can obscure important differences between rural places and the factors driving these. Few studies compare perceptions of formal care recipients between different rural locations. This paper contrasts older adults’ views of a range of care services – including primary, secondary, and social care – across island and mainland rural sites.

Methods: The study draws on 14 months of ethnographic fieldwork conducted in two locations, ‘Insh’, a remote island located off the west coast of Scotland, and the ‘Willow Valley’, an area encompassing three villages in the northern English county of Cumbria. Data were collected through participant observation in community settings and semi-structured interviews. A total of 36 participants were interviewed, comprising 33 older adults aged 66–92 years and 3 family members involved in care. Participants were recruited via community groups and snowball sampling. Interviews were conducted in participants’ homes, transcribed verbatim, and analysed using reflexive thematic analysis.

Results: The findings demonstrate clear contrasts in perceptions of care between the two sites. On Insh, participants generally reported positive experiences, particularly in relation to on-island care. Access to healthcare professionals, especially general practitioners, was described as timely and straightforward. Perceptions were linked by participants to a local ‘diseconomy of scale’, which supported the maintenance of services despite the island’s small population, but also to the broader social geography of the island. Repeated encounters in everyday spaces and the circulation of information through gossip networks meant that residents came to know, and be known by, those involved in delivering their care. These dynamics generated not only practical benefits such as continuity of care but also a broader sense of security and trust. Although participants also identified specific challenges, including difficulties with emergency transport, the need to travel for secondary care, and limitations in aspects of social care provision, overall evaluations of care were favourable.

In contrast, participants in the Willow Valley described more negative and uncertain experiences, particularly in relation to lesser accessibility and continuity of primary care. Difficulties in securing appointments, reliance on telephone triage, and a loss of continuity with clinicians were reported. While concerns were shared with Insh regarding travel to secondary care and the availability of social care, more spatially dispersed social relations meant that care providers were less embedded within local community life. This resulted in more fragmented and uncertain perceptions of care.

Conclusion: Perceptions of formal health and social care can vary significantly across rural areas, challenging ‘deficit’ framings. There is a need for place-sensitive approaches to policy that recognise differences both between and within island and mainland rural settings.

Keywords: deficit perspective, England, ethnography, island care, older adult care, rural care, Scotland.