Skye and Lochalsh

Seasonal population and its impact on primary and unscheduled care services

Paper 3 of a population needs assessment for Skye and Lochalsh

Health Intelligence Team

Directorate of Public Health

NHS Highland

June 2019

NHS Highland Public Health Directorate, Health Intelligence Team June 2019 2

The Health Intelligence Team are part of the Directorate of Public Health of NHS Highland and provide an expert resource of demographic and population health evidence.

Health Intelligence Team

Directorate of Public Health

NHS Highland

Larch House

Stoneyfield Business Park

Inverness

IV2 7PA

Telephone: 01463 704939

Fax: 01463 235189

Email: High-UHB.HealthIntelligence@nhs.net

NHS Highland Public Health Directorate, Health Intelligence Team June 2019 3

Table of contents

Table of contents ................................................................................................................... 3

Skye and Lochalsh Population Needs Assessment ............................................................... 3

Background ........................................................................................................................... 3

Tourism ................................................................................................................................. 4

Overnight stay visitor number estimates ................................................................................ 8

GP practice Temporary Resident registrations ...................................................................... 9

Unscheduled care seasonal patterns ....................................................................................13

Summary ..............................................................................................................................15

References ...........................................................................................................................16

Skye and Lochalsh Population Needs Assessment

In this report we consider the seasonal population visiting Skye and Lochalsh and the associated impact on health service activity. This is the third report in a series that will contribute to a population needs assessment in relation to adult health and social care services for the area. Reference is also made to the area of South West Ross that includes Lochcarron.

In the first report1 we looked at the demography and population dynamics of the area using available population estimates and projections. The second report2 reviewed the social context of the population health of the area through the lens of deprivation. A subsequent series of reports are planned that will look at mortality, morbidity and the implications for health and social care services.

Further details of future reports are available in the Project Initiation Document (PID).

The timescale for the epidemiological and comparative part of the needs assessment is from April to June 2019.

Background

The Skye Lochalsh and South West Ross (SLSWR) community reports a growing seasonal rise in the population of the area, driven by tourism. The estimated resident population of SLSWR in 2017 is 14,608 with 10,462 living on Skye1.

Information on the levels and characteristics of tourism activity is available from a range of information sources at national and local level. However, this picture is partial with measures of local tourist impact being dependent on estimates most usually from the number staying in accommodation and day visitors. Visit Scotland, Visit Britain and The Highland Council provide estimates of visitor numbers based on surveys. Department for Transport publish traffic statistics for count points across the UK: site number 80594 covers the Skye bridge3.

The best sources of information on the pattern of tourism in local areas are provided by detailed visitor studies. The Glasgow Caledonian University Moffat Centre4 has been commissioned to carry out an assessment of the impact of tourism on Skye and the results are expected to be available in early 2020.

The effects of tourism activity on health care services will vary depending on the relative scale of visitor activity set against the levels of activity normally generated by local residents.

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We can evidence that the tourist impact varies substantially by season of the year with particular pressures in the summer months.

Visitors to the area access health services via NHS 24, Scottish Ambulance Service, Pharmacies, local GP Practices and Out of Hours services at Portree and Broadford hospitals. Health care in Scotland for holidaymakers from overseas is explained in the NHS inform leaflet5 and Portree Medical Centre have prepared a guide to accessing appropriate health care services6.

In this report we look at how this may impact on health services for the local population where data are available; GP practices record temporary patient registrations and Out of Hours services data include patient postcodes. Non-resident use of secondary care services on Skye will be considered in work planned for the needs assessment on hospital activity (Project Initiation Document, Work-stream 3, Section 8.37).

Tourism

Visit Scotland reports that during 2017, the Highlands welcomed 534,000 international visitors, totalling almost 2 million bed nights, 17 percent of total international tourism in Scotland for 2017. In the same year, 2 million domestic visitors spent 8.6 million bed nights in the Highlands and Islands, 19 percent of total domestic tourism in Scotland. Over 14 million domestic day visitors went to the Highlands, 10 percent of the total day trips in Scotland in 20178.

Figure 1: Visit Scotland, highest performing regional visitor attractions, 2017

Source: Visit Scotland Insight Department, Visitors to Highland and Islands8

https://www.visitscotland.org/binaries/content/assets/dot-org/pdf/research-papers-2/highlands-and-islands-

regional-factsheet-2017-v2.pdf

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The popularity of Skye for tourism has been accelerated by TV shows, adverts, music videos and social media9.

The Isle of Skye is the most Instagrammed road trip attraction in Europe, according to recent social media analysis by Europcar10, with almost 21,000 posts; the Eiffel Tower has 12,463 posts.

The Scotsman11 reports that Skye has become a popular destination for cruise ships between May and September. The Guardian9 writes that more than 30 cruise ships were scheduled to moor in Portree bay in the summer of 2017, each for less than a day and some with 2,200 passengers on board.

Precise, up to date visitor data for Skye which distinguishes overnight stays and daytrips are difficult to obtain with most published survey results being at a national or regional level. It is widely reported that Skye attracts more than 500,000 visitors a year11,12.The Highland Council’s Principal Tourism Officer presented a paper on the challenges of tourism to the Isle of Skye and Raasay Committee in September 201813,14:

“As we all know, tourism has been doing well and the estimated 2017 figures for Skye are 660k visitors, spending 1.6m overnight stays…This is reflected by the increase in tourism Highland-wide with Highland visitor attraction numbers up 10.5% to the end of June 2018”

This is more than the 167,000 overnight visitors and 800,000 bed nights reported by Visit Scotland and Visit Britain as detailed in Table 1 and Table 2 below. However, Table 1 only includes international visits estimated as going to Portree town based on survey data. Visit Scotland do not list other towns on Skye; where international visitors advised other towns or were unable to give the name of a town but were able to give the county name, these are grouped by Highland instead; this grouping was estimated at 126,000 overnight international visitors for all Highland in 2017.

The Skye Bridge was opened in 1995 and is the only road access onto Skye (although there are car ferries from Mallaig to Armadale and from Uig to Lochmaddy and Tarbert). Toll collection for crossing the bridge ceased in December 200415. The Press and Journal reported a drop in traffic over the Skye Bridge in 201816. Department of Transport publish traffic statistics based on counts and estimates3. The data for the Skye Bridge count site are illustrated in Figure 2 below, showing a 4 percent reduction between count years 2015 to 2017. No manual count is recorded between 2004 and 2015, possibly accounting for the step change as estimates for the intervening years are based on 2004 data. However, it should be noted that the manual counts on which these data are based were carried out in either September or October, therefore will not reflect a seasonal increase in traffic.

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Figure 2: Annual average daily flow (both directions) of traffic at site number 80594 (Kyleakin roundabout to Stoney Road, Kyle of Lochalsh) from 2000 to 2018. Count years are indicated, all other years are estimates.

Data source: Department of Transport, Road traffic statistics3

Transport Scotland operate an automated counter adjacent to the Department for Transport site referred to in Figure 2 above. The counter was not in operation for some months; this is represented by estimated data shown in dark grey on the graph below. There is a clear seasonal pattern with a 33 percent increase (additional 1,400 vehicles per day (both directions)) from April and May 2014 counts to the same months 5 years later in 2019. A request for data by vehicle type is with Transport Scotland.

Figure 3: Monthly average daily traffic (both directions) from automated counter at Skye Bridge

Data source: Transport Scotland, by email from Senior Traffic Technologist, 13 June 201917

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Channel 4 News informed that AirBnB had over 500 rental listings on Skye in 201718. They and The Scotsman11 report that this equates to one in eight properties on the island being let via AirBnB. IsleofSkye.com19 (Skye’s largest marketing website20) lists the following accommodation in June 2019:

4 campsites (~ 120 hard-standing hook-ups pitches and ~ over 300 tent pitches)

5 hostels

~150 B&Bs

~30 Hotels

~300 self-catering properties

In February 2019 it was reported11,12 that SkyeConnect20, the island’s official destination-management organisation, commissioned researchers from Glasgow Caledonian University Moffat Centre4 to carry out a major new study to assess the impact of tourism on Skye. The results are expected to be available in early 2020.

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Overnight stay visitor number estimates

The International Passenger Survey (IPS) is a continuous survey carried out by the Office for National Statistics (ONS). It covers all major air, sea and tunnel ports, providing detailed information on the numbers and types of visits made by people travelling to and from the UK. Anonymous face-to-face interviews are undertaken with a random sample of passengers as they enter or leave the UK. Approximately 95 per cent of passengers entering and leaving the UK have a chance of being sampled on the survey.

IPS data for towns and cities typically measures staying visits (where visitors stay overnight) and not day trips. Table 1 shows estimates of numbers of visits by non-UK residents where they have stayed overnight in Portree. Over 90 percent of international visits to Portree are for holidays and about 90 percent take place between April and September (52 percent are between July and September)21. Visit Britain also reports the top international markets to Skye are USA, France, Italy and Germany. Average length of stay for an international visitor to Scotland between April and September 2018 was 7 nights; data are not available for Skye22.

Table 1: Estimates of annual International Inbound staying visits to Portree

Visits 2010 2011 2012 2013 2014 2015 2016 2017

Portree, Highland 29,000 40,000 38,000 52,000 58,000 52,000 65,000 49,000

Source: International Passenger Survey, Office for National Statistics via https://www.visitbritain.org/town-data

Visit Scotland Insights team provide estimates of Great British resident overnight visits to the Isle of Skye based on the Great Britain Tourism Survey23. There was an estimated 42 percent increase in GB overnight stays from 2013-15 to 2015-17 (Table 2) but minimal change over the same periods for international visitors (Table 1). As with international visitors, over 90 percent of stays are for holidays or visiting family and friends (Table 2). The mean length of stay by GB residents is 4 nights24.

Table 2: Estimates of GB Resident Overnight Visits to the Isle of Skye

Three year annual average Total trips Holiday /leisure / visiting family & friends

2013-15 83,000 78,000 (94%)

2015-17 118,000 108,000 (92%)

Source: Great Britain Tourism Survey / Visit Scotland Insights

The above survey data suggests an estimated additional overnight population on Skye over summer of around 4,000 to 5,000 peoplea. The resident population of Skye in 2017 is estimated at 10,4621.

a Based on 90 percent of visits taking place between April and September with international visitors staying on average 7 nights and domestic 4 nights.

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GP practice Temporary Resident registrations

The Scottish Government25 and NHS National Services Scotland (Practitioner Services)26 advise that people can only register with a GP practice if staying in an area for more than 3 months. People may however still be treated, but as a temporary resident.

The new GMS contract 201827 advises that GP practices are currently paid to treat Temporary Residents based on their annual average claimed prior to 1 April 2003. This Temporary Patient Adjustment leaves practices exposed to the risk of their number of Temporary Residents fluctuating while the resources to treat them remain constant. Under the new contract, practices will be required to report on numbers of Temporary Residents in 2018/19 to allow the Temporary Patient Adjustment to be reformed and uplifted on the basis that funding will follow activity as soon as practicable and by 2020/2127.

GP practice Temporary Residents fall into two categories: registrations for under 16 days and registrations between 16 days and 3 months. In SLSWR the under 16 day registrations are mainly tourists, from both UK and overseas. A practitioner on Glenelg suggests those registering for 16 days to 3 months include members of Gypsy/Traveller communities and longer term visitors28. Members of seasonal workforces are anecdotally reported as usually being young with an acute episode of illness or injury.

The data presented below are the numbers of individuals temporarily registering. The count of consultations and resulting clinical and non-medical staff administration time generated by temporary residents are not currently readily available. However an SLSWR GP suggested (email correspondence) the majority of temporary residents will only be seen once.

Some of the issues associated with visitors accessing GP services with the potential to impact on time available for the resident population are:

Tourist demographics – older age groups presenting with multiple co-morbidities and

time consuming issues

No access to medical and medication history. Prescription requests for medication left

at home or run out result in visitors accessing GP services19. This is more problematic

if the patient is from a country with a differing approved formulary

Communication - language barriers and poor mobile phone signals resulting in

difficulties during both triage and consultations

Tourists moving around Skye and accessing more than one GP practice.

Expectation – visitors may want immediate appointments to minimise interruption of

tour schedules

Practice staff morale – no additional resources provided to deliver services to visitors

– the burden is relatively larger on small practices (Figure 4) and at a time when staff

are seeking to take annual leave themselves

Temporary registration data does not capture activity where tourists access GP

practice resources (e.g. with reception and/or dispensing staff) where no GP

appointment is necessary and therefore no registration took place. By way of

anecdote, a GP on Skye informally reports one or two additional visitors being dealt

with over and above every temporary registration. There is currently no formal

mechanism to record staff time spent on these interactions.

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Figure 4: Annual ratios of total temporary to permanent patient registrations at GP practices in SLSWR

Data source: GP practice data extracts provided by Practice Managers in May 2019

The following graphs show the counts of temporary residents per quarter for the GP practices in SLSWR which are over and above permanent registrations. A seasonal pattern is illustrated, in particular for under-16 day registrations, with peaks between April to June and July to September. This is similar to the traffic activity shown in Figure 3.

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Figure 5: Numbers of under-16 day temporary patient registrations at GP practices in SLSWR

Data source: GP practice data extracts provided by Practice Managers in May 2019

Note: Portree Medical Centre had a change in classification policy in 2016/17 to improve allocation to either ‘16 day to 3 month’ or ‘under 16 day’ temporary

registrations.

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Figure 6: Numbers of 16 day to 3 month temporary patient registrations at GP practices in SLSWR

Data source: GP practice data extracts provided by Practice Managers in May 2019

* Portree Medical Centre had a change in classification policy in 2016/17 to improve allocation to either ‘16 day to 3 month’ or ‘under 16 day’ temporary

registrations.

* *

*

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Unscheduled care seasonal patterns

The following analysis refers to all unscheduled care, within normal working hours and Out of Hours, seen on Skye.

There are two Urgent Care Centres on Skye, at Dr Mackinnon Memorial Hospital in Broadford and at Portree Hospital. Out of Hours Primary Care Services are located at both sites. The ADASTRA patient management system is used to manage and record all urgent care activity in Accident and Emergency (Broadford), Minor Injuries Unit (Portree) and Out of Hours settings. The term ‘unscheduled care’ is used to summarise the activity. Over 90 percent of contacts at Broadford and Portree were appointments in the 5 years to December 201729.

A limitation of the way that the ADASTRA system is used at Broadford and Portree is that it is not possible to distinguish care provided as Out of Hours from that which occurred in Accident & Emergency or the Minor Injuries Unit. This is due to the clinical integration between these services – they are delivered by the same teams.

The seasonal pattern is primarily driven by service contacts with patients who live out with the SLSWR area (Figures 7-9 below).

In total in 2017 twenty percent of contacts were with ‘out of area’ patients at the two sites. Contact with ‘out of area’ patients varies by month. In January 2017 fifty three contacts (9%) were with ‘out of area’ patients. This figure peaked in July and August when the services dealt with 250 patients with out of area postcodes in consecutive months (30% of the contacts)29.

Figure 7: Unscheduled care activity at Portree and Broadford (combined), Jan 2013 to Dec 2017

Source: NHS Highland, 2018. Urgent care on Skye: a summary from routine patient management data. p.6. Available on request from Project Lead, Out of Hours and Acting Primary Care Manager North & West (GMS)

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Figure 8: Unscheduled care activity at Broadford from January 2013 to December 2017

Source: NHS Highland, 2018. Urgent care on Skye: a summary from routine patient management data. p.6. Available on request from Project Lead, Out of Hours and Acting Primary Care Manager North & West (GMS)

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Figure 9: Unscheduled care activity at Portree from January 2013 to December 2017

Source: NHS Highland, 2018. Urgent care on Skye: a summary from routine patient management data. p.7. Available on request from Project Lead, Out of Hours and Acting Primary Care Manager North & West (GMS)

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Summary

The popularity of the SLSWR area as a tourist destination is testified in the media coverage. In this paper we have identified seasonal use of health care services in General Practice and unscheduled care:

2018/19 temporary to permanent registration ratios range from 0.09 to 0.25 amongst

SLSWR practices

A third of urgent care activity at hospitals on Skye in the summer of 2017 was for non-

residents

No additional resource is currently provided to GP practices to deliver consultations to temporary residents over and above the 2003 levels. The new GP contract in Scotland states that funding will follow activity as soon as practicable and by 2020/2127.

Similar seasonal patterns of additional service use of primary care services by non-residents are likely to happen in other popular tourist areas within NHS Highland.

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References

1. NHS Highland Health Intelligence Team. Paper 1 of a population needs assessment for Skye and Lochalsh. 2019.

2. NHS Highland Health Intelligence Team. Paper 2 of a population needs assessment for Skye and Lochalsh. 2019.

3. Department for Transport. Road traffic statistics - Manual count points, site number: 80594. 2019. Available from: https://roadtraffic.dft.gov.uk/manualcountpoints/80594 [Accessed June 2019].

4. Glasgow Caledonian University. Moffat Centre for travel & tourism business development. 2019. Available from: https://www.moffatcentre.com/ [Accessed June 2019].

5. NHS inform. Health care in Scotland for holidaymakers from overseas - version 5. 2018. Available from: https://www.nhsinform.scot/media/1124/health-care-for-holidaymakers-from-overseas-v5-2016.pdf [Accessed June 2019].

6. Portree Medical Centre. Information for visitors to Skye. 2018. Available from: http://www.portreemedical.scot.nhs.uk/website/S55573/files/Information%20for%20visitors%20to%20Skye.pdf [Accessed June 2019].

7. NHS Highland. Skye, Lochalsh and South West Ross Needs Assessment - Project Initiation Document. Report number: V3, 2019.

8. Insight Department. Visitors to Highland & Islands. Visit Scotland. 2018. Available from: https://www.visitscotland.org/binaries/content/assets/dot-org/pdf/research-papers-2/highlands-and-islands-regional-factsheet-2017-v2.pdf [Accessed June 2019].

9. Carrell S. Skye islanders call for help with overcrowding after tourism surge. The Guardian. 9 August 2017. Available from: https://www.theguardian.com/uk-news/2017/aug/09/skye-islanders-call-for-help-with-overcrowding-after-tourism-surge [Accessed June 2019].

10. Europcar. Europe's most popular road trips. 2019. Available from: https://www.europcar.co.uk/roadtrip/EUROPE.html [Accessed June 2019].

11. Cameron L. Impact of tourism in the Isle of Skye to be assessed by academics. The Scotsman. 22 Feb 2019. Available from: https://www.scotsman.com/business/companies/media-leisure/impact-of-tourism-on-the-isle-of-skye-to-be-assesed-by-academics-1-4877447 [Accessed June 2019].

12. Glen L. Skye tourism operators to conduct year-long survey. The Press and Journal. 22 Feb 2019. Available from: https://www.pressandjournal.co.uk/fp/news/islands/1682962/skye-tourism-operators-to-conduct-year-long-survey/ [Accessed June 2019].

13. The Highland Council. Spotlight on Skye tourism challenges. 2018. Available from: https://www.highland.gov.uk/news/article/11285/spotlight_on_skye_tourism_challenges [Accessed June 2019].

NHS Highland Public Health Directorate, Health Intelligence Team June 2019 17

14. The Highland Council. Minutes of Meeting of the Isle of Skye and Raasay Committee - Monday 3 September 2018. Available from: https://www.highland.gov.uk/meetings/meeting/4015/isle_of_skye_and_raasay_committee/attachment/74209 [Accessed June 2019].

15. BBC News. Tolls abolished for Skye Bridge. 2004. Available from: http://news.bbc.co.uk/1/hi/scotland/4112085.stm [Accessed June 2019].

16. Ross C. Traffic over the Skye Bridge drops amid reports the island has become overcrowded. The Press and Journal. 13 Feb 2019. Available from: https://www.pressandjournal.co.uk/fp/news/islands/inner-hebrides/1675720/traffic-over-the-skye-bridge-drops-amid-reports-the-island-has-become-overcrowded/ [Accessed June 2019].

17. Transport Scotland. Email correspondence from Senior Traffic Technologist. 13 Jun 2019.

18. Channel 4 News. How Airbnb rentals are affecting Isle of Skye. 2018. Available from: https://www.youtube.com/watch?v=Y5pM3kXNj3o [Accessed June 2019].

19. IsleofSkye.com. IsleofSkye.com: the ultimate guide to the Isle of Skye in the Highland of Scotland. 2019. Available from: https://www.isleofskye.com/ [Accessed June 2019].

20. SkyeConnect. The Isle of Skye Tourism Management Organisation. 2019. Available from: https://www.skye-connect.com/ [Accessed June 2019].

21. Visit Britain. Inbound town data - International Passenger Survey, Office for National Statistics. 2019. Available from: https://www.visitbritain.org/town-data [Accessed May 2019].

22. Visit Britain. Inbound nation, region & county data. 2019. Available from: https://www.visitbritain.org/nation-region-county-data [Accessed May 2019].

23. Visit Scotland. Scottish Tourism Statistics & Research - Research and Insights. 2019. Available from: https://www.visitscotland.org/research-insights [Accessed May 2019].

24. Visit Scotland. Insights Research team email correspondence. May 2019.

25. Scottish Government. mygov.scot - Health, social care and wellbeing - Register with a doctor. 2017. Available from: https://www.mygov.scot/register-with-doctor/ [Accessed May 2019].

26. NHS National Services Scotland (Practitioner Services). NHS Inform - Registering with a GP Practice. 2018. Available from: https://www.nhsinform.scot/care-support-and-rights/nhs-services/doctors/registering-with-a-gp-practice [Accessed May 2019].

27. Scottish Government. GMS contract: 2018 - 8. The Role of the Practice. 2017. Available from: https://www.gov.scot/publications/gms-contract-scotland/pages/10/ [Accessed May 2019].

28. General Practitioner Glenelg. Email correspondence. May 2018.

29. Project manager Out of Hours North and West Highland. Urgent care on Skye: a summary from routine patient management data (available on request). NHS Highland. 2018.