What works well with Keep Well? Initial providers’ perspectives on anticipatory care.

1. What works well with Keep Well? Initial providers’ perspectives on anticipatory care. Faculty of Public Health Scottish Conference Aviemore 10 & 11 November 2011 Anne Ludbrook, Flora Douglas, Linda Leighton-Beck, Dorothy Ross-Archer The author accepts full responsibility for this talk

2. Background Keep Well – national programme to increase rate of health improvement in deprived areas Health check includes clinical aspects (e.g. cardiac risk assessment), health behaviours and social interventions NHS Grampian 2nd wave – local evaluation in Aberdeen CHP using qualitative and quantitative methods The author accepts full responsibility for this talk

3. Local context • Most practices had relatively small numbers of patients in deprived postcode areas • more manageable but less visible impact for staff • Some deprived postcode areas tended to have mixed demographics • SIMD problematic in City (and some rural areas) • some ‘wrong’ patients attending for health checks

4. Evaluation methods • Planned structured interviews with up to 10 general practices at baseline, 6 months and 12 months • 3 interviews only achieved with 4 practices (early adopters) and over an extended timescale; 6 other practices and 4 other provider venues interviewed at least once • Analysis of routine statistics : cases diagnosed, referrals etc

5. Expected benefits • At baseline respondents identified benefits to patients and the practice as motivators for being involved in Keep Well • Disease prevention / early diagnosis • Less patients with chronic disease long term • Benefits to staff from KW training • Contribution to practice budget

6. Realised benefits • Reported benefits fell into similar categories • GP respondents identified case finding in small numbers of patients; hypertensives, diabetics • Nurses less certain about benefits but noted some success with weight management / healthy eating • Benefits of staff training transferrable to other activities • Patient benefits limited by numbers taking up health check and perhaps not reaching those at most need

7. “I would say at least 50% … have some sort of problem. The most common problem is really them having raised cholesterols …. if their risk is sort of a low risk, and the vast majority of them are low risk, then they get an information sheet and a letter…” Case 1 “I think there’s been a steady trickle of things like new hypertensives or new diabetics ….. I’m sure just reflects the actual overall number of checks … If we did more checks I’m sure we might uncover more morbidity.” Case 4

8. Evolving delivery • Practices interviewed across the whole process had made some small changes • Appointment length, split appointments, new referral routes • Other delivery models developed to overcome problems such as accommodation or staffing • Delivery at other health (NHS Grampian G-Med out-of-hours, The Healthy Hoose, Community Pharmacy) and community (Aberdeen Sports Village) settings

9. “I think the only thing that we possibly have done is we've increased the number of Keep Well appointments …. we do it in half an hour” Case 3 “there’s a lot more things now that you can refer to, the health coach as well” Case 4 “I think the only change is we've got a new alcohol counsellor” Case 8

10. Barriers and facilitators I • ‘Early adopters’ identified few barriers • Concerns expressed regarding take-up, reaching the target group, limited appointment slots • Facilitators were • ‘champions’ within the practice, existing preventative initiatives, NHSG support (KW Programme staffand finance)

11. Barriers and facilitators II • ‘Late adopters’ expressed a similar range of views and attitudes about KW but faced additional challenges of staffing or accommodation • Addressed by KW Programme staff providing support from data screening to developing a ‘mixed economy’ allowing practices to circumvent their own accommodation or staffing difficulties (e.g. alternative venues; Community Bank Nurses)

12. “The down side of it is the practical issues of (a) trying to reach the group themselves and find the time to do it in amongst all that we’re having to do for people who’ve actually got illness” Case 11 “the support element of the programme is excellent…. having XX and YY there, and your queries are answered promptly, they come and they support the nurses …addressing their concerns in a timely fashion” Case 4

13. Conclusions The main barriers and facilitators for implementation were practice specific The main driver for evolving the delivery of the health check was overcoming these barriers There was a lack of shared information to allow providers to fully assess benefits Any expressed reservations about the KW programme did not impact on the number of health checks delivered The author accepts full responsibility for this talk

14. Acknowledgements • We would like to thank the anonymous participants involved in delivering Keep Well for giving up their time for interview. • We would also like to thank the members of the NHSG KW Evaluation Steering Group for their advice and insights, particularly the late Dr Stuart Watson.