Inequalities Targeted High Risk Primary Prevention

Analysis on the Responses to the Scottish Government Consultation Paper on Mainstreaming of

Keep Well/Well North

FINAL

Table of Contents Executive Summary 3 1. Introduction 5 1.1 The aims of the consultation

1.2 The consultation process

1.3 The analysis of the responses

2. Key themes 9 2.1 Overall policy

2.2 Model of delivery

2.3 Targeting

2.4 Engagement

2.5 Health check

2.6 Follow-on services

2.7 Evidence of effectiveness

2.8 Ehealth and information technology

2.9 Workforce learning and capacity to deliver

2.10 Funding

3. Links to the Quality Strategy 15 4. Next steps 17 5. Appendices 18 A Consultation questions and summary of responses

B List of the invitees

C List of the respondents

2

Executive Summary This is the report of the consultation, ‘Mainstreaming of the Keep Well/ Well North programme’. The consultation was led by the Scottish Government and ran from 10 May to 16 July 2010. Thirty-two responses were received from NHS Boards, professional organisations and others. 1. Nearly all of the respondents welcomed the Scottish Government’s continuing policy focus on inequalities targeted primary prevention of cardiovascular disease (CVD) as a mechanism for addressing health inequalities in Scotland. 2. There was a request to link this work to other government strategies, including the ‘Quality Strategy’ and for it to be agreed by partners in other sectors via community planning partnerships, set in the context of Equally Well. 3. It was thought to be vital that individual level primary prevention health checks are appropriately balanced and integrated seamlessly with: concerted public health action at a whole population level, development of a comprehensive inequalities-sensitive approach across a range of conditions, initiatives for individuals addressing wider life circumstances, and optimised secondary prevention of CVD. 4. Overall the respondents agreed that this programme should, in the majority of cases, be delivered by general practice with the flexibility of using either a dedicated central team or existing community health care teams, particularly when working with hard-to-reach groups. 5. Respondents were positive about the inequalities targeting; however there were concerns about how this targeting could be achieved. Many expressed concern about targeting using the Scottish Index of Multiple Deprivation (SIMD) as many deprived people do not live in the 15% most deprived communities, and as a consequence using this method alone would exclude a significant number of the target population. SIMD was not felt to be an appropriate measure of deprivation in remote and rural populations. 6. It was argued that practices with a high proportion of people in deprived communities should target all their patients – a more selective approach would be appropriate if the proportion were low. 7. A wide range of other populations were reported as being at high risk of early onset of CVD. This included: black and minority ethnic (BME) communities, people with learning disabilities, gypsy travellers, homeless people, people in the criminal justice system, people with multiple lifestyle risk factors, and people with a family history of CVD. The target groups named in the Quality Improvement Scotland (QIS) CVD standards reflect these priority populations. Several respondents suggested the age range should be lower for some of these groups. It was also suggested that services working with these groups could support their engagement.

E 3

8. Some respondents raised concerns about excluding people with a long-term condition from the programme (in particular those with sub-optimum support packages), as they are at high risk and could benefit from the same holistic support. 9. There was a desire to retain local flexibility and practice/clinician discretion regarding identifying target populations, how they are reached, and the best service delivery model. There should be more flexibility to offer opportunistic health checks. 10. Successful approaches to engagement were suggested, including: outreach, telephone invitations, opportunistic engagement, community development approaches, working with other services, involving employers, a mobile bus and word of mouth. A mix of methods was suggested to work best. 11. While some respondents reported that one model does not fit all, there was a lot of recognition that General Practice (GP) support was essential to the success of the programme. This was highlighted in relation to identifying populations to be screened, but also with follow-on referral and if appropriate treatment. 12. Concerns were raised about the use of ASSIGN in rural areas. 13. Although concerns were raised about adding time to the health check, there was support for asking about and signposting to cancer screening. There were several other suggested additions to the check. 14. There was general agreement that competencies identified to deliver anticipatory care are not viewed in isolation, and are recognised within a whole practice approach to deliver inequalities-sensitive patient care to all patients within a practice population. 15. There were several concerns regarding the lack of evidence base around clinical outcomes for the proposals. 16. There were a lot of concerns over the proposed funding allocations; in how these were calculated and whether they were sufficient in that they did not take into account other ‘target groups’ such as black and minority ethnic (BME) populations and also that they were based on an underestimate of follow-up care required. 17. It was suggested that resource investment must be appropriate across primary/ secondary prevention continuum and follow-up, rather than one that invests disproportionately in primary prevention health checks. 18. Funding decisions were seen as a matter of urgency, particularly to allow for continuance of existing staff contracts.

E 4

E 5

19. Respondents supported a nationally agreed robust and reliable information and technology (IT) system to support the future programme. This is needed to support call and recall of patients, as well as clinical management of patients, and should be fully integrated with any existing practice system. 20. Respondents noted that professional buy-in was essential and suggested this could be achieved by: collaboration with professional bodies at national and local levels, a strong evidence base, realistic funding levels, training and linking with follow-on services. These comments will be considered as the programme is developed and implemented. A Primary Prevention Steering Group has been set up, chaired by Dr Harry Burns, to oversee and advise on planning for this whole programme in the period to March 2012. This group will replace the current Keep Well Programme Advisory Board. The group will provide leadership for more detailed work that will be required to support the whole programme. The specific management and advisory structures required for that detailed work will be determined this autumn. The group will meet at the beginning of September 2010. The group will consider the analysis of the responses to the consultation on mainstreaming Keep Well and the National Evaluation findings to date as well as other local learning. The group will also consider proposals for the overall programme management activities.

1. Introduction 1.1. The aims of the consultation 1.1.1. The Scottish Government Consultation on the mainstreaming of the Keep Well/ Well North programme ran from 10 May to 16 July 2010. It was led by Frank Strang, Deputy Director for Primary Care, and Kay Barton, Deputy Director, Health Improvement Strategy Division. The consultation document set out current Scottish Government thinking on plans for the Keep Well and Well North programmes beyond 2010–11; this is when the current funding ends. The Scottish Government has announced its intention to mainstream a programme of inequalities targeted high risk primary prevention from 2012–13. The aim of the consultation was to seek views on a number of issues relating to how this should be achieved. 1.1.2. The Scottish Government invited a number of stakeholders – including all NHS Boards, the British Medical Association, The Royal College of General Practice, and others, to consider a number of questions designed to help shape the future design of any inequalities targeted by the high-risk primary prevention programme across Scotland. 1.2. The consultation process 1.2.1. A paper entitled INEQUALITIES TARGETED HIGH RISK PRIMARY PREVENTION: A consultation paper on the mainstreaming of the Keep Well/Well North programme was written by the Scottish Government and included 15 broad questions (Appendix A) which covered the main areas of the Keep Well/ Well North patient journey, from targeting to onward referral. The paper was sent via email to a range of stakeholders (Appendix B). 1.2.2. It was impossible to gauge how many received the paper as it was disseminated in a way that invited comment from further stakeholders. The end date for responses was initially 30 June 2010; however, an extension was then given until 16 July 2010. The responses were received, collated and analysed by NHS Health Scotland. 1.2.3. A data collection plan was devised which included the following;

Professional coding document (anonymous) Coding document (public Viewing) Feedback received register Questions and answers coding document Questions and answers (1–15)

1.3. The analysis of the responses 1.3.1. There were 32 responses in total. All NHS Boards, including some special boards, responded except Orkney. There were 15 responses from other organisations (see Figure 1). Figure 1

RESPONSES

15

17

other organisations

NHS Health Boards

1.3.2. Not all respondents answered all of the questions within the paper. This may be that some questions were felt not to be applicable (see Figure 2). Figure 2

Number of answers to questions

0

5

10

15

20

25

Qu 1 Qu 2 Qu 3 Qu 4 Qu 5 Qu 6 Qu 7 Qu 8 Qu 9Qu 1

0Qu 1

1Qu 1

2Qu 1

3Qu 1

4Qu 1

5

Other c

ommen

ts

E 7

1.3.3. The analysis of the consultation responses has been complex. This is partly because the questions and sub-questions were open-ended and invited free text, and also because in some cases there were conflicting views. However, it became clear that there were some common themes, which are highlighted under the heading ‘Key themes’. A summary of the responses to each question is shown in Appendix A.

E 8

2. Key themes 2.1. Overall policy 2.1.1. Many respondents identified that the programme should be considered as part of a continuum of primary, secondary and tertiary prevention. They noted the need to engage a wide range of stakeholders at national and local levels, to make links with other agendas such as the Quality Strategy, Long-Term Conditions work, Single Outcome Agreements, and wider health improvement initiatives. The future programme needs to be integrated with other core policy strands and be agreed by partners in other sectors via community planning partnerships, set in the context of Equally Well. It was also felt important that future policy continues to highlight that health and health inequalities cannot be addressed by health care alone. 2.1.2. A clearer definition and the focus of anticipatory care in this context would be helpful, as it was reported that this term is used across the health system with different meanings. 2.1.3. It was thought to be vital that individual level primary prevention health checks are appropriately balanced and integrated seamlessly with: concerted public health action at a whole population level, development of a comprehensive inequalities- sensitive approach across a range of conditions, initiatives for individuals addressing wider life circumstances, and optimised secondary prevention of CVD. 2.1.4. Respondents suggested that resource investment must be appropriate across primary, secondary prevention continuum and follow-up, rather than investing disproportionately in health checks, with their undoubted opportunity costs in terms of other effective CVD prevention interventions. Respondents noted that professional buy- in was essential and suggested this could be achieved by: collaboration with professional bodies at national and local levels, a strong evidence base, funding, training and linking with follow-on services. 2.1.5. There was an identified need for more planning at the outset to integrate with all the relevant policy areas and organisations. 2.1.6. There needs to be scope to be flexible at a local level to meet individual/local needs. 2.1.7. More consideration about the anticipated impact and effectiveness of the proposed programme was suggested. 2.1.8. It was also suggested that in the wider context of other health needs generated by multiple deprivation, reduction of cardiovascular risk cannot be effected without first addressing other issues that are of more immediate personal relevance to the patient. Thus, focusing on CVD risk factors alone in health checks would not represent the best model for engaging many patients in individual level health improvement. 2.2. Model of delivery

E 9

2.2.1. Overall the respondents agreed that this programme should, in the majority of cases, be delivered by general practice with the flexibility of using either a dedicated central team or existing community healthcare teams, particularly with hard-to-reach groups. 2.2.2. There was little support for delivery within pharmacies, although some respondents reported they had yet to evaluate pharmacy involvement in Keep Well. 2.2.3. There is a need for clarification on the definition of ‘primary care’ services, as if the focus is on practice-based services this may exclude other professional groups such as district nurses, health visitors, etc. who should have an important role in providing anticipatory care. 2.2.4. The GP and his or her relationship with patients over time is seen by many as the foundation for opportunistic intervention on risk. 2.2.5. It was suggested that the continuum of risk from primary prevention through to secondary prevention should be considered as one, with the aim across both being to support people to slow the onset and progression of the CVD family of conditions. The focus on CVD-focused health checks was seen as too narrow and missing the opportunity to tackle more important issues driving health inequalities. 2.2.6. It was stated that secondary prevention of CVD is well established and offers superior cost effectiveness relative to primary prevention. Stronger links should be made with Long-Term Conditions management. 2.3. Targeting 2.3.1. Most – but not all – respondents welcomed the intention to continue to target deprived populations for the programme. 2.3.2. Respondents raised concerns about the use of SIMD as the main method of targeting for the programme. Many identified the large proportion of deprived individuals living outside these areas. It was argued that a focused approach to reducing experience of poor health in the most disadvantaged communities can create assumptions regarding healthcare requirements in less visibly deprived areas; experience of poor health derived from socially based inequalities remains an issue within more affluent communities. 2.3.3. Targeting only those in the 15% most deprived datazones would also seriously limit any national or local marketing effort to help health boards deliver activity and would risk further stigmatisation of individuals/communities 2.3.4. SIMD was not felt to be an appropriate measure of deprivation in remote and rural populations and would fail to capture significant numbers of people living in deprivation.

E 10

2.3.5. Several respondents identified other groups that were at high risk: BME communities, people with learning disability, gypsy travellers, homeless people, people in the criminal justice system, people with multiple lifestyle risk factors and people with family history of premature CVD. The target groups named by QIS were mentioned as a priority. 2.3.6. Several respondents suggested the age range should be lower for some of these groups. 2.3.7. It was suggested that other services such as addiction services reach these groups. They could assist with targeting and certain elements of the health check that could eventually be incorporated into existing interventions. 2.3.8. It was suggested that data from local authorities and housing associations may help identify at risk people. It was also suggested that GP information systems could identify some of these groups. 2.3.9. There was support for a practice-level intervention targeting all patients in practices serving predominantly deprived areas particularly in urban areas. A more selective approach was supported in general practices with a small proportion of their population in deprived areas. 2.3.10. Some respondents raised concern about excluding people with long-term conditions from the programme, as they are at high risk and could benefit from the same holistic support. This also reflected the view noted above that primary and secondary prevention should be seen as a continuum rather than separate programmes. 2.3.11. There was a desire by some to retain local flexibility and practice/clinician discretion regarding identifying target populations, how they are reached and the best service delivery model. There should be more flexibility to offer opportunistic health checks. 2.4. Engagement 2.4.1. Successful approaches to engagement were suggested including: outreach, telephone invitations, opportunistic engagement, community development approaches, working with other services, involving employers, a mobile bus and word of mouth. A mix of methods was suggested to work best. 2.4.2. There was support to allow practices to maximise opportunistic contact and address elements of the health check as appropriate, rather than focusing exclusively on a separate uptake of a formal ‘health check’. 2.4.3 Several respondents highlighted in particular the importance of outreach approaches to engagement of hard-to-reach groups, either through local health workers or through outreach workers who can support access to health care and follow-up. 2.5. Health check 2.5.1. While most respondents viewed general practice as the vehicle for delivering health checks, further support will be required to help them provide health checks to the most difficult to reach.

E 11

2.5.2. Some respondents raised concern with the use of ASSIGN for scoring, especially in rural areas, as ASSIGN bases its results on SIMD. 2.5.3. There was general support for inclusion of questions about cancer screening in the health check, although it was also noted that this would increase the time required and have implications for IT developments. There were several other suggestions for additions to the health check including screening for: chronic obstructive pulmonary disease (COPD), kidney disease, atrial fibrillation, domestic abuse, child sexual abuse, alcohol brief intervention, vitamin D deficiency and sensory impairment in people with learning difficulties. 2.5.4. It was suggested that the Keep Well check could be adapted for people with learning disabilities or mental health problems. 2.5.5. Many considered it essential that any referral to services occurs in the context of a person-centred approach, and initiated with mutual agreement between the patient and practitioner, and not solely on the presence of a single ‘behaviour’ or ‘circumstance’ identified during the health check. 2.5.6. It was stated that the ability of practices to fully commit to supporting behaviour change presents significant challenges in areas of deprivation, due to already stretched staff capacity, compounded by high prevalence of ‘risk’ behaviours and multiple and complex needs. 2.6. Follow-on services 2.6.1. Several respondents were concerned about the capacity of services to accept additional referrals as a result of the mainstreaming of Keep Well/Well North. 2.6.2. There were also concerns cited around the financial vulnerability of some of these services particularly given the current financial climate. 2.6.3. Decisions regarding the proportion of funding available for follow-on services were requested to enable health boards to model the impact of mainstreaming. 2.6.4. Respondents felt that follow-on services should not be restricted to those with high levels of risk. 2.6.5. Early lessons from Keep Well highlighted the need to recognise both practitioner and patient perceptions relating to the role of general practice in delivering non-clinical care to otherwise ‘well’ individuals and requires a whole-practice approach to ensure staff ‘buy-in’ to anticipatory care in its broadest sense. 2.7. Evidence of effectiveness 2.7.1. Several respondents felt that it is vital that all of our investment in preventive interventions is based on evidence of effectiveness and best economic value, particularly in the current and future economic context. 2.7.2. There were a few responses that questioned the impact screening for high-risk individuals has, on the risk of coronary heart disease incidence or death and whether

E 12

interventions that benefited entire populations could be more effective in reducing CVD events. 2.7.3. Concern was raised at any decision to move forward to the next stage before the full evaluation of the Keep Well programme to date has been completed and considered. 2.7.4. Some comments were made regarding evidence which suggests cardiovascular risk reduction can be potentially achievable from lifestyle modification that may be equivalent to that of medical therapies. 2.7.5. Several of the respondents had concerns about the absence of outcome data from the Keep Well programme, at either a population or individual level. It was suggested that this position is similar to that which prevailed during the planning stages of Keep Well, when Have a Heart Paisley (HaHP) was entering its final phase and runs the risk of perpetuating poorly evidenced interventions, failing to capitalise on prior (very expensive) demonstration programme investments and, ultimately, achieving less health gain than by fully capturing the available evidence. 2.8. Ehealth and information technology 2.8.1 IT was identified as a critical requirement to support implementation of the programme. It was considered that a nationally agreed robust and reliable IT system should be developed to support the future programme. This is needed to support call and recall of patients and should be fully integrated with any existing practice system. 2.8.2 Real-time data inputting, dedicated information technological (IT) systems and prompt, frequent feedback to practitioners is vital to effective programme performance management and effective delivery. 2.9. Workforce learning and capacity to deliver 2.9.1. It was stated that practices are reluctant to implement Keep Well in the absence of more sustainable funding, as recruiting staff for short-term contracts is fraught with difficulty. 2.9.2. The ability of practices to fully commit to supporting behaviour change presents significant challenge in areas of deprivation, due to already stretched staff capacity compounded by prevalence of ‘risk’ behaviours and multiple and complex need. 2.9.3. There was general agreement that competencies identified to deliver anticipatory care are not viewed in isolation, and are recognised within a whole practice approach to deliver inequalities sensitive to patient care and to all patients within a practice population. 2.9.4. It was suggested that the integration of Well North within general activity may be a model for the rest of the country to follow, and should be maintained. 2.9.5. There were mixed views about whether specific training was needed for this programme. Most thought that training for all staff in broader aspects of wellbeing and health inequalities sensitive practice including motivational interviewing was important. This should also be offered to services offering ongoing support. Competencies and

E 13

‘customer care’ attitudes among non-clinical staff (e.g. reception staff) also need to be addressed. 2.10. Funding 2.10.1 Respondents reported that decisions are required regarding long-term investment as a matter of urgency to enable progression with the implementation planning. 2.10.2 It was stated that without clarity regarding the future delivery model and subsequent demand on general practice in particular, it was impossible to determine with confidence whether the indicative resources outlined would be sufficient. 2.10.3 Greater clarity on the expected role of general practice was requested, along with the expected contractual methods to incentivise this. An appropriate level of funding for work is required, especially to secure support of GPs. This was thought crucial. 2.10.4 It was stated that anticipatory care as described by this consultation, is not an essential service as defined by the general medical service (GMS) contract. As such, without negotiated changes to the contract, this programme cannot be considered ‘normal practice’ for general practice. 2.10.5 The document mentions national work on an enhanced service specification, but it was thought unclear whether this is a model which health boards could adapt as a Local Enhanced Service (LES), or would be a National Enhanced Service (NES) or Directed Enhanced Service (DES). There was a strong suggestion that remuneration via any locally enhanced service would be inappropriate as this is a national programme and therefore funding arrangements should be the subject of discussion between the Scottish GPs Committee of the BMA and the Scottish Government Health Directorates. 2.10.6 It was noted that it would be helpful to have a mechanism that allowed Keep Well activity to be mainstreamed as part of the GMS contract in a way that reflects outcomes rather than process. It was noted that incorporating health checks into the Quality and Outcome Framework (QOF) would be helpful, as would QOF+ and Quality Improvement Scotland (QIS) being consistent with the programme proposed. 2.10.7 It was noted that additional funding would be required to meet the needs of other groups such as BME populations and deprived people in affluent areas but this was not recognised in the consultation paper. There was also no acknowledgement of the likelihood of people falling into multiple categories of risk and how to cost this. 2.10.8 It was also highlighted that decisions regarding the proportion of the £200 per health check that will be available for health boards to invest in follow-up services were needed to enable more detailed planning of service delivery.

E 14

3. Links to the Quality Strategy Person-centred Respondents felt that the programme needed to be part of a continuum of primary, secondary and tertiary care recognising the long-term nature of supporting behaviour change. Many of the people identified through Keep Well will have multiple risk factors and require a person-centred approach involving professionals they know and trust. Placing these people in multiple referral pathways may not be the best approach and can be confusing. It was suggested that involvement of local people from target populations in the planning and delivery of the programme will result in a more person-centred approach. Effective There was a lot of feedback stating the importance of ensuring the future model is based on evidence of effectiveness and value for money and that further evidence may need to be captured. Efficiency Further exploration of the role of outreach engagement across the system should also be recognised as an efficiency opportunity. It was suggested that further integration of Keep Well within general practice and routine care, and offering more flexibility to deliver opportunistic health checks should take place. It was hoped that an economic evaluation will inform decisions about the future delivery. Equitable Although the Keep Well model is targeted at the most deprived populations, there was concern that it still attracts more motivated and advantaged subgroups and does too little to tackle the underlying causes that make CVD common, or to reduce the supply of middle-aged people requiring drug treatment. Concern was also raised that, so far, only 37 of the 100 most deprived general practice populations in Scotland have been involved, which needs to be addressed. The model does not take into account the people who are disadvantaged/deprived but live outside SIMD areas. Timely It was suggested that a more timely response to individual patients’ needs would be gained, with more opportunistic health checks and subsequent referral to services. A key area where anticipatory care can break down is delayed availability of the next step in the process. Referral pathways which involve delay or displacement to a distant setting are less likely to be taken up. The timeliness of the availability of referral services should be a key component of regular audits. Safe CVD prevention/health checks should not supersede patients’ other priority health/ social care needs. It is imperative that health checks are fully integrated within local protocols to ensure an appropriate response to any clinical/non-clinical issues disclosed during the health check. This further enforces the importance of ‘whole practice’ based models. This reinforces the need to promote consistency of approach in all health

E 15

board areas, in the delivery of health checks and subsequent clinical and lifestyle interventions. Training and competencies will support safe delivery of health care.

E 16

4. Next steps The results of this consultation will be considered in the further development of the programme. A Primary Prevention Steering Group has been set up, chaired by Dr Harry Burns, to oversee and advise on planning for this whole programme in the period to March 2012. This group will replace the current Keep Well Programme Advisory Board. The group will provide leadership for more detailed work that will be required to support the whole programme. The specific management and advisory structures required for that detailed work will be determined this autumn. The group will meet at the beginning of September 2010. The group will consider the analysis of the responses to the consultation on mainstreaming Keep Well and the National Evaluation findings to date as well as other local learning. The group will also consider proposals for the overall programme management activities.

E 17

Appendix A: Consultation questions and summary of responses Consultation Question 1 1.1. Are there any additional elements required as part of the above anticipatory care pathway? 1.1.1. Several of the respondents highlighted the need for systematic planning from the outset if inequalities targeted primary prevention was to fulfil its potential which must include integration with wider health improvement initiatives. This would require active engagement of wider community organisations (including healthy living centres, workplaces, employability services, housing associations and the third sector) in the care pathway and integration and support with community planning partners. Some respondents mentioned the need to deal not only with people with high CVD risk scores but also those with isolated single-risk factors. 1.1.2. Improving GP access and referral to wider health improvement agencies was seen as an area that required more support. It was felt that more coordinated knowledge of services and feedback mechanisms would help this. 1.1.3. A number of respondents felt that the consultation placed too much emphasis on primary care delivery, which may exclude those people who do not engage in primary care services. However, equally there was support from most that the programme should be placed within general practice. 1.1.4. There was recognition that people with long-term conditions and those at risk of developing long-term conditions are on a common pathway that views health as multi-dimensional, encompassing physical, psychological, social, emotional and financial well being. This pathway needs interventions in all of these areas to support people to flourish and to live their lives to the full. 1.1.5. Several respondents commented on the synergy across the Long-Term Conditions, Keep Well anticipatory care programme and wider health improvement networks as well as the community, voluntary secondary, health and local authority supports for health improvement and self management. They recognised a need to support all practitioners (GPs, practice nurses, healthcare assistants, allied health professionals, social care practitioners and community care self management), to adopt an enabling and anticipatory approach. A clear definition of anticipatory care was needed. 1.1.6. There was disappointment that the Keep Well health check did not include assessment of the additional health needs of people with a learning disability or mental health problem and uncertainty about ‘national screening policy’ in relation to this population. 1.1.7. Several mentioned the need for robust IT infrastructure to support and underpin the programme. ‘Real-time’ performance monitoring data is better established in some health boards than others and was seen as vital to effective programme performance management and delivery. This included dedicated IMT systems and prompt, frequent feedback to practitioners.

E 18

1.1.8. More research was cited as important in ‘post-screening engagement’ particularly where clinical intervention alone is unlikely to fully address CVD risk. 1.1.9. The importance of GP ‘buy-in’ was a common theme across the responses and adequate funding/contracts, training, linking up better with follow-on services were just some of the ways suggested to support this. 1.1.10. Additional services may need to be added to the pathway when successfully working with the most vulnerable groups, as this can lead to uncovering issues that go way beyond CVD risk. 1.1.11. It was noted that it is important to make clear that health and health inequalities needs a much wider approach than health care alone. 1.2. What national guidance directives or targets would ensure strong local leadership and effective delivery of this programme? 1.2.1. There was a mixed response on the usefulness and format of the current H8 target. Some respondents welcomed the delivery focus of the target while some felt that it should not be based solely on participation rates. 1.2.2. It was suggested that integration of HEAT targets, to avoid duplication of effort with respect to training and activity (e.g. ABI, mental health, smoking cessation) would be preferable. 1.2.3. Some respondents suggested that referral and subsequent management could be included in a target. 1.2.4. A reclassification of CEL 14 was suggested to include all settings and all professional groups, linking the anticipatory care approach within the ‘Health Promoting Heath Service’ concept of ‘every healthcare contact is a health improvement opportunity’. This should include the opportunity to assess and record risk factors for CVD and other diseases. 1.2.5. Genuine partnership and collaboration with participating practices was cited, especially in areas of concentrated deprivation where high-risk case loads have a high prevalence. More explicit ‘connect-up’ through HEAT, QOF, etc. would facilitate strong local leadership and effective delivery as ownership of a common SMART agenda would be so much greater. 1.2.6. There were several comments that ring-fencing of all components of the Keep Well programme including follow-on services would provide greater assurances and leadership. Post-screening engagement was thought to need greater emphasis. It was noted that it was unhelpful to have multiple referral pathways for people with several risk factors or more than one condition. 1.2.7. A few respondents suggested that effective delivery would be better achieved if there were greater local emphasis – creating opportunities for citizens to interact with public services. This trend towards co-production/social innovation has resulted in many examples of system change which are rooted in power of participation in communities.

E 19

1.2.8. Involvement of local authorities and voluntary organisations through community planning and the single outcome agreement was felt to be essential by a number of respondents. 1.2.9. One respondent suggested a national approach to consistency such as the use of ‘standard operating procedures’ as included in The Handbook for Vascular Risk Assessment, Risk Reduction and Risk Management would avoid duplication of effort than if all health boards are producing their own guidance and materials. 1.2.10. Clarity of the timetable for this work beyond April 2012 is needed, in particular to set out the expectations for the timescale within which the additional populations will be included. 1.2.11. One respondent suggested a national ‘menu’ on delivery options for NHS Board areas to choose from would be preferred, delivered through an enhanced service approach, with a focus on anticipatory care, and which complemented the existing ‘GMS contract.’

E 20

1.3. How can Scottish Government best secure professional body support and engagement? 1.3.1. There was a suggestion that strong local leadership is not necessarily ensured by ‘national guidance directives or targets’, but by respecting the nature of decisions that can only be taken locally, and by genuine collaboration, involving not only local support for national initiatives but also national support for local activity. 1.3.2. A strong evidence base including learning from the pilots was seen as essential to gain professional support and engagement. 1.3.3. Professional body support would be improved if the benefits and outcomes of the programme were more explicit, and how they will be measured and assessed stated. 1.3.4. A need for wide engagement with Area Clinical Forums; professional representative bodies, BMA, RCGP, NMC, RCN, FPH, UKPHA, etc. Engagement with CHPs and identification of local champions as early adopters could be helpful. 1.3.5. Ongoing and meaningful dialogue with general practice was seen as essential. One respondent suggested identifying ‘pioneers’ who could develop the approach and disseminate the benefits. 1.3.6. There were a lot of comments on the importance of ensuring that funding was adequate and that it was included in contractual payments. 1.3.7. Raising expectation and demand for access to services without creating capacity will create major concerns for GPs and their teams 1.3.8. Decisions regarding long-term funding were seen as essential to gain further practice ‘buy-in’ and would help to recruit and retain staff 1.3.9. There was a lot of support for Keep Well to be mainstreamed into existing healthcare systems. This would help professional engagement by utilising and improving existing infrastructure, rather than cutting across these with perhaps less cost-effective alternatives, and seen as more sustainable. 1.3.10. It was suggested that the long-term condition executive sponsor or clinical lead should be invited to join the steering group.

E 21

Consultation Question 2 In urban settings, where practices serve mixed populations, should all patients be given the enhanced Keep Well checks, or only those who live in the 15% most deprived SIMD areas? 2.1. Overall most – but not all – respondents strongly supported continuing with a targeted programme. It was noted that universal health checks would be likely to increase health inequalities, and several respondents referred to the need to use resources wisely given the tight funding context. However, several concerns were raised with the use of SIMD for targeting. 2.2. Several respondents commented that SIMD is a population level proxy for multiple deprivation at small area level, but an unreliable predictor of individual level deprivation. 2.3. It was suggested that a SIMD led approach would be a barrier to GP involvement if they were asked to select only some of their patients for the intervention. 2.4. There was support for a practice-level intervention targeting all patients in practices serving predominantly deprived areas, where Keep Well health checks are delivered in tandem with the multifaceted health improvement approaches. More sensitive and specific approaches are possible but only at the cost of increased complexity and resource requirements. 2.5. One suggestion was that the intervention could be offered to all patients within practices, but engagement efforts could target deprived geographical communities. 2.6. It was felt that a selective approach was only justified when the target group comprises a small proportion of the practice population. 2.7. Several respondents highlighted that patients are not always registered with their most local GP and can be dispersed across a number of practices, adding to the complexity. 2.8. It was suggested that practices should be able to offer outside the 15% most deprived areas at their discretion. 2.9. The lower age limit of 40 is still too high for some patients. Practices not only need access to attached workers and health improvement services, but also the flexibility to use these services according to the needs of patients. 2.10. Difficulty with marketing Keep Well was raised when only available to a targeted patient group rather than practice. 2.11. Several respondents pointed out that several population groups such as BME, those with learning disabilities will suffer health inequalities and are at risk of a CVD event but won’t necessarily be targeted by using SIMD data. 2.12. It was noted that SIMD is not an appropriate way to target in rural areas in particular.

E 22

2.13. There were several suggestions that a strengthened community development model and the use of local intelligence, rather than a model-based principally in ‘medical’ premises may support the targeted approach and offer the greater potential to ‘close the gap’. 2.14. There were concerns raised that if we broaden how/who we target we start to risk effectiveness and increase costs at a time when there is huge financial pressure, however equally it was felt important to note that a large number of CVD events occur in individuals not assessed to be at high risk. Therefore, it is important to ensure access to lifestyle change support for those who have been risk assessed and found to be less than a 20% 10-year risk and to those outside the high priority groups described in whom modifiable risk factors are identified.

E 23

Consultation Question 3 How should we specify more fully the groups who are at highest risk, and how practically, should they be targeted systematically? 3.1. One respondent felt that it is more important to devise effective systems for processing large numbers of individuals with heterogeneous needs through the various stages of anticipatory care than it is to micro-manage who gets entry to the system. 3.2. There was a suggestion that GP databases could be used more effectively to identify these groups more fully (through QOF data) and that family history was an important factor. 3.3. Closer working with partners such as the criminal justice system and homeless services was suggested as another method of targeting those at higher risk. 3.4. It was suggested by some that looking beyond clinical risk would help to identify and target some groups, particularly the hardest to reach. 3.5. There were several respondents who felt that it was essential that a national programme is not conducted solely on one factor at the expense of a large percentage of the population who are at increased risk due to other factors. 3.6. There was a suggestion that developing a universal scoring system, e.g. patients with learning difficulties who are obese, smoke and live in deprived areas would score more highly that a patients who may have one risk factor. 3.7. While the reduction in age was welcomed by most respondents, a local experience suggests that particularly for individuals with multiple and complex needs a further reduction in the eligible age range is warranted. This is already being done for certain groups, e.g. prisoners and gypsy travellers. One respondent suggested that people 40-45 were at low risk and it would be more effective to include people aged 65-69 instead. 3.8. Some respondents cited that a dedicated team was working well with these groups, offering alternative locations and times for appointments. 3.9. The high priority groups have been set out in the recent NHS QIS CV disease standards but central guidance to define these groups and providing guidance to the NHS about how best to systematically identify and engage with them would help promote consistent processes and services across the whole country. 3.10. A variety of approaches need to be used including social marketing, which could be used to raise the profile of the issues and the need for CVD risk assessment. The use of different locations at which CVD risk assessment and lifestyle checks are offered (such as workplaces, job centres and retail settings) may increase the proportion of the target population being reached; however this introduces challenges to make sure results of CVD risk assessments are captured in the individual’s clinical records to ensure appropriate follow-up and support.

E 24

3.11. Several respondents mentioned the omission of strategies to address the risk faced by BME populations and deprived individuals in otherwise affluent areas, and also pointed out that the funding allocation to health boards does not take account of this. 3.12. People falling into multiple risk categories and how this should be identified and addressed was also highlighted as an omission. 3.13. Identifying individual practices for delivery of Keep Well is problematic, as it is a blunt tool for engaging people at greatest CVD risk, given the demographic variations within practices, the imprecision of SIMD as a predictor of individual level deprivation, and the inherent limitations of deprivation as a modifiable risk factor for CVD. 3.14. Several respondents suggested elements of the Keep Well checks could be adapted and incorporated within existing interventions with the harder-to-reach groups, e.g. addiction services, carers and individuals with mental health needs. 3.15. There was a lot of support for boards to determine at a local level how best to utilise current staff groups and services. 3.16. One suggestion was to combine case finding of family members with the ‘Keep Well’ approach in deprived communities with supporting evidence to suggest this could identify as many as 84% of high CVD risk individuals by screening 41% of the population. 3.17. It was suggested that a two-tier programme could be developed, with universal checks followed by more detailed follow-up for those at high risk. 3.18. It was felt by some that those already diagnosed with vascular disease did not need to be included in the Keep Well programme. But there were a number of concerns about excluding those with a long-term condition, particularly for diabetes and hypertension. The enhanced services available via Keep Well are equally applicable to this group. It was felt that within LTC management at general practice, holistic assessment should be encouraged, but the reality of this if not funded is challenging. 3.19. It was suggested that the groups identified in the QIS standards have huge implications for numbers in the target group. 3.20. Several people suggested people with learning disabilities or mental health problems should be included. It was suggested that separate learning disability health checks may not be viable. 3.21. More detail was requested on 'systematic opportunistic engagement' as part of the minimum approach and in particular how this relates to expectations of GPs and other contractors. 3.22. One respondent suggested building on existing risk prediction and modelling work led by ISD. 3.23. Some respondents wished to see greater practice/clinician discretion in opportunistically offering health checks to individuals deemed at risk (e.g. overweight/obese, have not visited practice in number of years, defaulted from other screening initiatives/clinics). One proposal suggested that further consideration should

E 25

also be given to incorporating CVD check within general practice ‘new patient’ registration. 3.24. One respondent suggested targeting could be even more accurate within 15% datazones by using information held by GPs, local authorities, housing associations and the Department for Work and Pensions (DWP). This would enable the engagement efforts to concentrate on the most at-risk patients who are unemployed, being treated for depression and on incapacity benefit. 3.25. A pilot scheme in Lanarkshire cited the use of intelligence from the Keep Well Team to create a risk score ranging from 1–14 for patients who had been screened but fell just below the threshold for clinical intervention. All those who had a high-risk score post screening were telephoned to say this was the next phase in the Keep Well process. 50% of those telephoned agreed to a home visit where we conducted a holistic assessment to uncover health behaviour changes they would want support with. 50% of this group requested support to make these changes.

E 26

Consultation Question 4 There is good sense in bringing ‘screenings’ together, to maximise the benefit that can be gained from the effort of having reached the target population. Should any other screenings (or reminders/prompts of screenings) be included? Or would this become counter-productive? 4.1. There was general support for practitioners to raise screening issues within the health check with patients who have not attended/defaulted breast, cervical or bowel screening, contingent on sufficient time being allocated to the health check and ensuring that data collection is not at the expense of person-centred goals/care planning. 4.2. Several of the respondents agreed that additional screening would substantially increase the time of a current Keep Well assessment which would further increase staff capacity issues. 4.3. Arguments were made to include screening for: COPD, kidney disease, atrial fibrillation, domestic abuse, child sexual abuse, alcohol brief intervention and screening for sensory impairment in people with a learning disability. 4.4. The point was made that screening is a substantial undertaking with significant potential for harm, that should only be undertaken when defined criteria are met, including clear evidence of effectiveness and robust systems for delivery and quality assurance. 4.5. It was suggested that by having an opportunistic approach to case-finding, it is not necessary for all elements of screening to take place at the same time. Improved IT tracking arrangements are required to support this approach. 4.6. There were lots of examples from respondents where raising the issues and prompts for further screening; e.g. breast and bowel screening had worked well and should be routine within the health check. 4.7. The point was raised that some Keep Well checks were offered in community venues which would not have suitable equipment to undertake further screening. 4.8. Appointments could become overwhelming with a lot of information to take in and could put some people off attending for a Keep Well check. 4.9. Several respondents, while not supporting routinely offering more screening as part of the Keep Well check, would prefer to decide at an individual level whether to include screening for some people attending. Equally, not all staff would have the skills and knowledge to perform some screening tests. 4.10. It may be more appropriate to do this over more than one contact with an individual, particularly if there are multiple risk factors. 4.11. It was suggested that it is worth considering adapting the KW check including screening for people with learning difficulties and those with severe and enduring mental illness, rather than having a separate check/screening for those individuals.

E 27

4.12. The point was made several times that the risk factors for CVD and cancers are similar and as such there is a strong case for including messages about these cancer screening programmes in the Keep Well interventions, particularly within the health check section to raise awareness and in an attempt to increase uptake and aid earlier diagnosis. There is already in place a Keep Well ‘Read Code’ that has been made available to all NHS Boards in Scotland in order for opportunistic bowel screening promotion to be provided to those who fall within the Bowel Screening eligible age range (50–74) although it is recognised that Keep Well is targeting a slightly different age range (those between the ages of 40–64). Targeting those in the most deprived communities also fits with the cancer screening programmes awareness-raising activities. For example, in bowel cancer screening, we know that those living in the most deprived communities are less likely to participate in screening than those living in the least deprived communities. Men too are known to be less likely than women to participate in bowel cancer screening. 4.13. The point was made that if the services are person-centred then opportunistic efforts should be made to help someone access all screening. 4.14. One respondent proposed screening to identify people at risk of Vitamin D deficiency.

E 28

Consultation Question 5 Is there a minimum core set of competences for staff involved in delivering the required elements of a mainstreamed programme? What are these competences? Are they currently achieved via Keep Well/Well North arrangements? 5.1. There was general agreement that competencies identified to deliver anticipatory care are not viewed in isolation, and are recognised within a whole-practice approach to deliver inequalities sensitive to patient care for all patients within a practice population. Competencies and ‘customer care’ attitudes among non-clinical staff (e.g. reception staff) also need to be addressed. 5.2. Any future national competency framework for anticipatory care should be integrated within NHS Education for Scotland (NES) existing work streams. It was felt that NHS Boards will be best placed to develop action plans to respond to local training needs. 5.3. The deployment of healthcare support workers (HCSWs) within Keep Well is increasing and GPs recognise the skill set offered by this staff group. There was support to develop competencies for this staff group. 5.4. There is currently no existing minimum set of competencies for the staff delivering anticipatory care. However, the ‘National health care support worker role development working group’ has been developing guidance on core competencies for health care support workers, (anticipatory care) to support mainstreaming of anticipatory care approaches. 5.5. The timescales for the mainstreaming of Keep Well is likely to present challenging issues, as the demand for HCSWs may outweigh the supply of adequately trained individuals. 5.6. There was recognition that there is a continuum of competencies for staff undertaking anticipatory care and self management which align well with the person-centred Quality Strategy ambition and include clinical risk assessment and management of people at high risk; health behaviour change methods; an understanding of how the wider social context may affect people’s ability to address risks; and communication and consultation skills to ask these questions appropriately and sensitively. 5.7. There were several respondents that supported the need to build the capability of primary and community care staff to adopt anticipatory care and self management approaches as mainstream practice which will need a greater emphasis on self directed and workplace-based learning. 5.8. Enhancing the skills and confidence of staff to support self-management as well as targeted primary prevention, risk factor screening and modification, was seen as important and that education and development should extend to the wider primary and community team workforce including local authority and third sector partners.

E 29

5.9. The LTC (Long-Term Conditions) Collaborative reported that they are working with both NES and NHS Health Scotland to develop a shared capability framework across the continuum underpinned by an educational support package. This collaborative approach will reduce the training burden within primary care and increase the pace CHPs can build their capability to mainstream these two approaches. 5.10. While some respondents said training in core competencies were essential, others stated that it would be inappropriate and unnecessary for the Scottish Government to dictate competencies for providing health checks. Practices involved in the programme should be responsible for determining the skill mix appropriate to delivering the main elements of the programme. Although the Keep Well health checks cannot be viewed as core GP work, this would be consistent with how practices organise themselves to provide the requirements of their contract. 5.11. Core competencies for Keep Well are: health behaviour change, brief interventions, motivational interviewing, completion of cardiovascular risk assessment and risk management, alcohol and mental health risk assessment, knowledge of local resources and referral pathways. Training should be provided for all new staff members particularly in health inequalities and the social determinants of health. 5.12. Issues were raised around how to ensure competencies for staff employed by independent contractors, for example, particularly if this work is a relatively small part of their role. The time needed to invest in skills development for a relatively small return may not be seen as worthwhile. 5.13. The notion of ‘core competencies’ that can be delivered by a wide range of staff is simplistic and undervalues the range of knowledge and skills needed to deliver anticipatory care. Technical skills in information gathering and data entry require competency training and these are the easiest to generalise. Specialist expertise is highly valued. Much of the work depends on relationships and intuition as well as expertise. It is more important for a local team to have collective skills, than it is for everyone to have the same skills. In general, Keep Well is only feasible in a general practice setting with delegation to non-GP staff, working as part of a closely integrated team and with sufficient resources to allow follow-up. 5.14. All staff involved need good knowledge of where and when they can refer or signpost people towards other sources of support, for example mental health, drug misuse and alcohol problems. 5.15. It was noted that administration staff may also need training.

E 30

Consultation Question 6 6.1. What issues arise for NHS Boards from the change of focus from secondary to primary prevention or in other respects? 6.1.1. There were several respondents who felt that primary and secondary prevention is a continuum and that to be truly person-centred in our approach we should not be separating out primary and secondary prevention. Resources for primary and prevention, particularly non-clinical follow-up should be shared. A more holistic approach integrating these with wider social support was needed. 6.1.2. Some respondents worried that the focus on primary prevention would divert resources to the ‘worried well’. 6.1.3. Secondary prevention of CVD is well established and offers superior cost effectiveness relative to primary prevention and therefore should not be compromised with any changes in delivery. Secondary prevention should incorporate health-related behaviour screening and support with onward referral to provide ongoing support for individuals. 6.1.4. The proposals outlining the mainstreaming of Keep Well were seen by some as a ‘stand alone’ approach, in rolling out a highly specific initiative, rather than learning lessons and driving the change required, enabling both primary care and secondary care activities and health improvement services to respond more effectively to preventing and tackling CVD and addressing inequalities. 6.1.5. Greater focus on effective deployment of inequalities-sensitive practice would allow those individuals with more complex healthcare needs or hidden underlying issues, to be afforded time and space to engage with services, discuss and contextualise health opportunities through a person-centred care pathway. 6.1.6. There was also concern that we were giving population groups conflicting messages regarding accessing health services and which service to access. An earlier study of coronary heart disease patients within NHS Greater Glasgow and Clyde revealed that many patients who defaulted from their CHD annual review cited that they felt ‘well’ and didn’t want to waste their GP’s time as the GP could focus on those who were ill. 6.1.7. It was suggested that when the prevalence of eligible patients in practice reaches a given level, e.g. 50%, then health improvement activities need to be integrated within the practice and not organised outside it. 6.1.8. The main challenges reported related to the volume of people who will be eligible for health checks and the costs involved in offering appropriate therapies to those at high risk. The workload will be highest in areas or socioeconomic deprivation and will require a greater focus on engagement and self-management. 6.1.9. Case finding will generate more work and resource allocation. The Primary Care drug budget will also need to reflect the potential greater prescribing of statins, hypoglycaemics etc. Transfer of work must always involve transfer of funding of that work.

E 31

6.1.10. There is potential for confusion between this programme, existing approaches to anticipatory care (such as the introduction of a case management approach), and interventions for the self-management of long-term conditions. Not only are self-management programmes just another stage in a continuum of prevention, many of the same staff will be involved, using the same competencies and skills. At a community-wide level the same interventions and projects will support both stages of prevention. So joint planning is essential, particularly for training. 6.2. How can NHS Boards be best supported to move to the mainstream model described in this paper? 6.2.1. Having a strong evidence base to support this proposal was seen as key, particularly with increasingly scarce resources and stronger evidence of effectiveness of working with those who already have a disease. 6.2.2. In moving to mainstreaming it is recognised that there still needs to be a cultural shift to prevention/anticipatory care, as well as support for targeted interventions. This may be helpful if this were to become ‘national’ work via QOF/GMS. 6.2.3. There is an increasing focus on communities being central to this and increased linkage at Scottish Government level of policy agenda linked to this is important, particularly when considering the multi-agency working required. 6.2.4. It was suggested a CEL would add weight to any recommendations and may encourage the shift of resources from secondary care to primary care and primary prevention work. 6.2.5. At NHS Board level, HEAT targets are a very powerful tool in ensuring engagement. These can have the same effect on organisational change at health board level as QOF does at primary care level. 6.2.6. Several respondents cited shared learning from pilots and other health boards would help support the mainstreaming process.

E 32

Consultation Question 7 7.1. Is the minimum set of follow-up services correct? 7.1.1. Most respondents felt that theses services were about right, however they wanted flexibility for adaptation to local circumstances and to develop referral pathways accordingly. Other suggestions included: addictions services, occupational health, mental health support, benefits advice, carers support, family services, legal support, adult basic education, debt/money management, self-management services, housing, domestic abuse services, child sexual abuse services, services for offending behaviour and medicines management. 7.1.2. It was reported that case management is required for individuals to prioritise support needed. 7.1.3. It was reported that some issues identified during a health check can be sensitive and require follow-up referral on, for example, disclosure of sexual abuse/gender-based violence. It is therefore important not to be too prescriptive. 7.1.4. One respondent suggested the list was too problem-focused and a more appreciative approach building on assets would be useful. 7.1.5. It was suggested a list of clinical risks needing follow-up should also be provided as well as non-clinical support services. 7.1.6. The location of follow-up services was stated as an issue rather than the list available to ensure they are acceptable, accessible and used. 7.1.7. One respondent argued for reducing the BMI cut-off at which weight management is offered. 7.2. Do NHS Boards and partners believe there is sufficient local capacity across organisations to respond to anticipated levels of newly identified need? If not where are the key gap areas? 7.2.1. Several respondents felt that the ability of practices to fully commit to supporting behaviour change presents significant challenge in areas of deprivation, due to already stretched staff capacity compounded by prevalence of ‘risk’ behaviours and multiple and complex need. 7.2.2. Further emphasis on the role of community pharmacy to support medicines management for patients is required, particularly as significant numbers of asymptomatic patients may be prescribed statins as a direct outcome of their ASSIGN score. Capacity was reported as an issue here. 7.2.3. Risks to other external funding for services delivered outside the NHS, e.g. financial inclusion, employability and literacy were seen as a potential issue. 7.2.4. Many of the follow-on services were reported as already stretched, particularly weight management services, mental health and wellbeing services

E 33

7.2.5. Mitigation of these risks requires urgent agreement of the delivery model to enable health boards to model the impact of mainstreaming on core services. Decisions regarding the proportion of the £200 per health check that will be available for health boards to invest in follow-up services are needed, to enable more detailed planning of service delivery. 7.2.6. It was suggested that the proposed extension would cause a further high demand for clinical investigation/management (e.g. statin prescribing) and that the impact of this has been understated. These can’t be accommodated within existing resources. 7.2.7. Some respondents agreed there is a need to maximise integration with other programmes, e.g. ABIs, smoking cessation, and work with partners (e.g. community pharmacies) to share workload and make most efficient use of resources. One respondent commented on the need for attached workers in general practice to ensure support can be streamlined. 7.2.8. It was considered that there were still specific gaps in remote and rural areas, e.g. poor public transport service (none in some smaller communities), safe pavements (none in some areas), affordable fresh fruit and vegetables and debt counselling advice. 7.2.9. The impact of the current economic climate was seen as a potential issue for staffing across the health system and follow-up services. 7.2.10. It was also noted that general practice teams have limited capacity, given that some of the issues around staff and space and the increasing prevalence of a number of long-term conditions will increase with Keep Well in the short to medium term. 7.2.11. It was reported that patients referred on for lifestyle interventions are not currently actively followed up. Resource should be provided to support additional call and recall activity. 7.2.12. Several respondents reported access to weight management and dietary advice as an issue due to dietetic capacity. 7.2.13. Access to leisure facilities can be severely limited in local communities, both in terms of times of access during the day as well as a lack of availability. This is particularly true in remote and rural areas. 7.2.14. In remote and rural areas, the desire for simple areas to walk which may seem so obvious in a rural landscape is also an issue. Outside the local town area all roads have a prominent lack of pathways alongside. Many patients have commented on this as a reason for not walking (due to traffic risks and the rough nature of the surrounding landscape). This type of issue requires a huge shift in planning rather than a specific health intervention. 7.2.15. Transport links are limited across the island chain and travel costs are becoming more and more prohibitive. This creates a disincentive to travel to local sports and leisure facilities. Such issues require planning around costs and subsidies for travel. 7.2.16. It was suggested that the listed services in the proposal are only available to those who have developed the motivation to change. An ‘intermediate’ (health coach) service would fill this gap, whereby dedicated staff could work with patients to build the

E 34

motivation and confidence required in order to make changes and to prompt access to these support services. 7.2.17. Many of the non-clinical services are likely to come from voluntary sector. There is a need to ensure that these are also mainstreamed and integrated into pathways of care. 7.2.18. One respondent suggested a need for a process for managing the prioritisation of follow-on services, i.e. which service patients attend first as they may have multiple needs and case management of further support was seen as missing. 7.2.19. A further suggestion was that more emphasis could be placed on peer support and self-management.

E 35

Consultation Question 8 8.1. How can outreach and engagement of the most vulnerable groups be best supported? 8.1.1. Most respondents reported that the harder-to-reach were more likely to attend for a health check if contacted via outreach and offered one-to-one support to both attending a health check and follow-on services. Face-to-face engagement was felt essential for this group. However, it was felt that these workers should be part of the wider health system and not just available as part of the Keep Well team. 8.1.2. Telephone engagement was reported as reasonably successful if staff were trained in communication including motivational skills and knowledge of the health check and follow-up services. This could be followed up with text messaging. This could involve GP and community pharmacy if linked to repeat prescriptions. 8.1.3. Opportunistic engagement, probably within a general practice was felt to be the best method for the hardest to reach. 8.1.4. A local community development approach engaging and working with people in their own surroundings was felt to be more successful than a letter or telephone call. 8.1.5. It was hoped by several respondents that the national evaluation of Keep Well and shared local learning would be informing on the best method of engagement with this group. 8.1.6. It was suggested that as there are other programmes trying to engage the same ‘targeting group’, pooling resources and intelligence will target and support the most vulnerable in a more streamline way. 8.1.7. Generally it was felt that effective engagement particularly with vulnerable groups requires a wide range of flexible approaches geared to specific populations. 8.1.8. One suggestion was to use telecommunication providers such as Orange and Vodaphone for text messaging. 8.1.9. It was also emphasised the importance of word of mouth, and the link to communities to support this. It is important to recognise that those in very vulnerable groups often have even more complex issues than the ‘mainstream’ Keep Well, and such will required more time to effectively engage and support them which requires a greater resource. 8.1.10. In the more rural areas, a mobile bus has shown some success with local engagement. 8.1.11. Working in partnership with employers to both signpost and where appropriate provide health checks was suggested by one respondent. 8.2. Would national actions such as marketing or phone engagement be welcome? 8.2.1. A national marketing approach would be welcomed by some respondents whereas others questioned the cost effectiveness of large campaigns particularly as

E 36

they are only available to a small number of the population. Any such campaign would also need to be available in a wide range of languages and be accessible for those with limited literacy levels. It would be important not to stigmatise target groups. 8.2.2. Scottish Government could support by nationally highlighting the benefits of the health check and also through proactive briefings for MSPs, MPs and councillors etc. 8.2.3. National marketing materials were viewed as providing a consistency in information and quality but may need local adaptation. 8.2.4. One NHS Board reported local experience of using NHS 24 phone invitations in the evenings and weekends had been very positive and suggested a national contract should be considered to support mainstreaming. However others did not feel a national telephone service was appropriate. 8.2.5. The proposed national decision to target only those living in the 15% SIMD most deprived datazones was not seen as helpful for national and local marketing campaigns and risks further stigmatisation of individuals and communities.

E 37

Consultation Question 9 Should your NHS Board consider any alternatives to the ‘general practice and central team’ model for delivering the mainstreamed programme? 9.1. Overall the respondents agreed that this programme should, in the majority of cases, be delivered by general practice with the flexibility of using either a dedicated central team or existing community health care teams particularly with hard-to-reach groups. However considerable thought will need to be given to how the service is provided where a practice is not central to the programme including: how to identify patients, data sharing to and from GP practices, patient consent for sharing of information, responsibility for ongoing medical care, and indemnity for those undertaking the checks. Where a mix of approaches is used, the costs will increase considerably and may become prohibitive. 9.2. Concerns were raised around regulations for non-NHS staff and quality standards if an alternative model was used. 9.3. There was support to integrate further with the existing healthcare team activity. 9.4. While some respondents reported that one model does not fit all, there was a lot of recognition that general practice support was essential to the success of the programme. This was highlighted in relation to identifying populations to be assessed but also with follow-on referral and appropriate treatment. 9.5. One respondent suggested the benefit of a community-based approach to health checks and follow-up; a one-stop shop. 9.6. The wider links to a range of agencies, (statutory, voluntary and community), are all crucial to support the overall delivery of the pathway. 9.7. It was felt that there was still a good argument for continuation of a service from a dedicated team unless it is to become embedded in QOF and even then for the harder- to-reach people or those not in touch with healthcare services. 9.8. There was one suggestion of a complementary National programme approach similar to breast screening/bowel screening programmes where a national team would keep and operate central lists and invite participants for checks feeding into local provision. 9.9. There was a suggestion of a role for an intermediate service to enhance delivery of Keep Well through provision of support to work with people on developing motivation and confidence to prompt behaviour change and access to appropriate support services such as health coaches. 9.10. The Long-term Conditions Unit is funding the development of a self-management module of the ‘Voices’ programmes. This trains people with conditions such as heart disease, stroke and diabetes to take part in the work of their local managed clinical networks. The effect of the module will be to create a group of champions who will promote the concept of self management. This sort of peer example could be helpful in this context.

E 38

9.11. There was very little support for community pharmacies to actually carry out the health checks for a variety of reasons but including capacity, challenges of motivational interviewing in such a setting, long-term nature of support required, difficulties in sharing data and lack of evidence. Some areas reported that community pharmacy involvement was still being piloted. 9.12. A need for a multi-agency model across the wider primary care team, and partner organisations was suggested by several respondents.

E 39

Consultation Question 10 Are the requirements set out for engagement and follow-up comprehensive and achievable by April 2012? 10.1. It was noted that the proposed arrangements are for the roll-out of screening, which is only one part of what is now required. 10.2. Overall many – but not all – respondents felt that the timescale was too ambitious and that quite a lot of work is needed to take place at local NHS Board level to ensure that the requirements set out for engagement and follow-up are achievable by 2012. 10.3. Local planning will require expansion to support many more practices to deliver renegotiation of practice contracts, developing mechanisms to engage with those who are eligible but not registered with a participating practice and developing IT solutions for patients who are not seen within a practice environment. Migration of practices from GPASS to new IT systems will also need to be included in the planning process. 10.4. It was noted that not all the requirements listed in paragraph 31 of the consultation paper currently happen in GP practices, particularly in terms of lifestyle interventions. It was also queried as to how feasible it will be to get all relevant staff groups (not currently involved in Keep Well/Well North) across the 14 NHS Board areas trained sufficiently in time for delivering the mainstreamed programmes. 10.5. Identification of deprived populations and target groups, incorporating ASSIGN into GP systems, could be difficult to achieve. 10.6. Past experience has shown significant delays in gaining GP sign-up to the programme which could remain an issue. 10.7. There is an absolute requirement for a robust data collection system in place with agreed codes for reach and clinical indicators. There should be consistent nationally provided data collection screens that interface with all existing GP systems. If these elements are not in place, then performance monitoring data will not be forthcoming. Ideally this system should be provided centrally. 10.8. Securing transfer of information between GP practices and non-NHS sites remains problematic, e.g. with multiple pharmacy organisations. 10.9. One respondent felt that there needed to be a further stage to consider in the implementation and that was the stage of explanation of risk to people (and their families where appropriate) following risk assessment.

E 40

Consultation Question 11 Will the indicative resources be sufficient, with additional support from local NHS Boards, to deliver on the planned targeted health checks, including outreach and follow-up? 11.1. There were a lot of concerns from most of the respondents around the levels of funding proposed in the consultation paper and how funding allocations were made. Most felt this would be insufficient for what was being asked for and felt that a lot more work needed to be carried out once a delivery model was agreed to ensure a robust financial plan. 11.2. Several health boards requested further clarification regarding their own allocation. 11.3. There were several comments that remuneration via any locally enhanced service would be inappropriate as this is a national programme, and therefore funding arrangements should be the subject of discussion between Scottish GPs, Committee of the BMA and the Scottish Government Health Directorates. 11.4. It was noted that any further defined target populations, such as BME populations, must also be reflected in resource allocation. 11.5. It was felt that there should to be some evidence on how much can be saved in the future by primary prevention. 11.6. There was a request for overhead costs such as facilities, e-health support, etc. to be built into allocations. 11.7. There was a suggestion that the current Keep Well resource should be examined to see how it currently meets distribution of need. 11.8. It was suggested that health boards would need to make changes to current infrastructures to support the mainstreaming proposal and that these costs have not been addressed. 11.9. Several respondents felt that the proposed resource levels would result in a cutback to current service provision. 11.10. Concerns were raised over funding and sustainability for the voluntary sector who provide some of the social prescribing interventions. Most of their funding would come from other sources and they are likely to be subjected to reductions, given the current economic climate. 11.11. Concerns were noted on prescribing costs on top of statins such as an increase in demand for anti-hypertensives. 11.12. Respondents felt that the allocation for national support was excessive. 11.13. Any agreed funding needs to accurately reflect the target group not based on population estimates.

E 41

11.14. It was felt that the programme should be fully funded centrally and not have to rely on local health board contributions. 11.15. One respondent questioned why separate funding arrangements were proposed for Well North health boards, as other health boards also have rural areas with similar issues.

E 42

Consultation Question 12 Will the focus on primary prevention pose particular difficulties for delivery in Well North health boards, where staff often have generic roles? 12.1. It was reported that generic roles may well assist in the focus on primary prevention. This is because staff work across a range of duties and age groups and meet a variety of needs so will be aware of a wider range of issues in their locality. This helps to identify and work with those with the greatest needs, as well as identify those who do not attend at all, or who need greater support. Not all of the health boards in the Well North area have staff with generic roles and therefore this question would best be answered at local health board level. 12.2. It was suggested that the integration of Well North within general activity may be a model for the rest of the country to follow, rather than something to be dismantled. 12.3. While volume of activity is an appreciable challenge for those with a generic role, there are also benefits in efficiency, and potentially in effectiveness around primary prevention. In some respects, the core skills required would sit best/most comfortably with those whose role is more generic. 12.4. The outlined programme presents significant areas of concern for Well North in the Western Isles. In particular what the alternative is to the use of SIMD for remote areas and also the alternative to using ASSIGN (a SIMD based tool). Major concerns were raised on the impact this would have on determining funding allocation. 12.5. The complete lack of any of the local population in the official target group coupled with the statistics relating to high levels of obesity, alcohol abuse and premature CVD death in the islands provides stark evidence that the approach suggested will disadvantage this type of population (the exact opposite of the stated aims of the project). 12.6. The workforce generally works across health and social care settings. A competency framework for remote and rural health and social care support worker (rural support worker), allows for development of an accessible programme of education in partnership with colleges and the Scottish Funding Council. It is important that the developments being led by the Remote and Rural Health Care Alliance are linked with the anticipatory care HCSW role development programme. 12.7. The Western Isles has proactively adopted the approach of taking the service to local communities in an attempt to use this as a surrogate measure of tackling deprivation: by providing a service which is more likely to be accessed by the target population as it is not medicalised and it does not require significant transport costs for individuals. 12.8. There may be problems of lack of clinical support / supervision for isolated generic practitioners and telehealth solutions to improve their links with practitioner’s delivery services in other parts of the country.

E 43

Consultation Question 13 Are there additional specific areas of national work which should be included? 13.1. There was agreement that information on the evidence base on all aspects of what is being proposed should be provided nationally including cost effectiveness. It was argued strongly that the evidence base for the programme is lacking, and it had potential for harm by medicalising well people, stigmatising target populations and/or increasing inequalities. 13.2. Engagement with professional bodies and stakeholders on a national level and ensuring links and integration between related policies and programmes was seen as essential. 13.3. Many respondents identified agreement on contractual issues as being critical. 13.4. Many respondents identified robust, fit for purpose IT to support the programme as being critical. They recommended development of a national electronic template to improve consistency of recording of health check data, e.g. use of the Infopath template developed by Ayrshire and Arran and adapted by NHS Grampian. 13.5. Staff in remote and rural areas have found the ability to take part in online or web-based networking opportunities extremely useful, and would be keen for that to continue. National support for training was identified as a need. 13.6. It is worth noting that HEAT targets have little meaning for general practice. 13.7. One respondent suggested work is needed on how the active ingredients of Keep Well can be delivered as part of opportunistic case-finding. Work is also needed to define the generic features of successful attached working in general practice. 13.8. One respondent proposed using NHS24 as part of engagement pathway. 13.9. One respondent said it would be important to ensure that clear patient pathways are developed across Boards for mobile population groups such as gypsy/travellers. 13.10. Further work on prescribing costs and compliance systems would be helpful. 13.11. One respondent suggested a review of clinical judgement and prescribing of statins nationally, working with clinicians would be useful, as would a national review of the effectiveness of using ASSIGN – covering practical aspects, the consistency of use, messages to clients on risk, medium-term impact on risk and its management for example. 13.12. It was noted that many useful resources have been developed locally including service specifications, LES models and staff training programmes. These should be considered when the implementation group begin their work. 13.13. It was suggested that the paper appears to overestimate the extent to which the programme can be managed nationally. More important are the local arrangements, supported by national facilities and coordination.

E 44

Consultation Question 14 Does this timeline identify all the critical activities? What are the key risk areas in terms of timing and activities? 14.1. Overall the respondents felt the timeline is ambitious. 14.2. One respondent suggested that the plan appears based on the model developed so far, mostly in areas where deprivation is less concentrated and that the model for working in areas of concentrated deprivation needs to be different, in which case the timeline would need to fit the necessary steps. 14.3. It was felt by many that there had to be proper preparation and time before implementation began, in particular agreement on funding and competency areas to allow development of staff. The evaluation arrangements and criteria should be established at the outset and before the programme begins. 14.4. It was suggested that lessons from evaluation of Keep Well should be built into future programmes. 14.5. The key risks are ‘bought in’ at organisational and independent practitioner levels. Being given priority locally to implement, at a time when there are so many competing demands on resources. 14.6. In addition the following were identified as critical:

• ASSIGN adoption as the national CVD risk assessment tool • IT infrastructure • Development of enhanced service template or national contract • Competency framework • Premises • Performance management • Engagement of professional groups and other agencies • Development of follow-up interventions

14.7. It was noted that there is no timeline for a national (social) marketing campaign. It is important that there is adequate time to consult with local communities as this was not feasible at the start of Keep Well. 14.8. One respondent stated that the timeline does not include any information on the other health check approaches outline in the covering letter. The findings from this have an impact on how to mainstream Keep Well from 2012, particularly around marketing and capacity in services. 14.9. It was suggested that there may be issues in terms of the amount of funding available locally to both continue to test and deliver current services, and to prepare for the mainstream programme from 2012. Additional training to achieve competencies is one example of this. 14.10. Consideration should be given to aligning Keep Well roll-out with the QIS standards for heart disease, if possible through the QOF.

E 45

14.11. It is critical that the funding allocation for NHS Boards in the intervening year 2011/12 is confirmed in a timely fashion, preferably by September 2010. There is a significant risk that existing staff whose contracts are coming to an end will be lost, just when Keep Well needs to draw in their experience. 14.12. A further comment was that clarity of the timetable for this work beyond April 2012 is needed. While there are details of the work required before this time the final stage is described as ‘Phased implementation begins: rollout to populations not currently covered by Keep Well.’ While we accept that details of local delivery will be the responsibility of each area health board, it would be useful to set out the expectations for the timescale within which the additional populations will be included. 14.13. Ability to deliver on all other requirements will be determined by decisions relating to the delivery model and associated NHS Board recurring resource allocation. Practices are reluctant to continue recruiting staff for short-term contracts. Therefore decisions are required regarding long-term investment as a matter of urgency to enable to progress with implementation planning. 14.14. Greater clarity on the expected role of general practice would be helpful, along with the expected contractual methods to incentivise this and definition of the elements of existing general practice activity most clearly contribute to this e.g. GMS Quality & Outcome Framework (QOF). The document mentions national work on an enhanced service specification, but it is unclear whether this is a model which boards can adapt as a Local Enhanced Service (LES), or will be a National or Directed Enhanced Service.

E 46

Consultation Question 15 Are the 6 dimensions of quality (as defined within the NHS Scotland Quality Strategy) adequately covered in this paper? If not where are the gaps? Person-centred It was suggested that there is a need to fully embed anticipatory care approaches within therapeutic relationships that recognise the long-term nature of supporting behaviour change, and that the proposals focus more on a stand-alone programme of activity. This requires to be addressed more fully in the final delivery plans to acknowledge a system response to addressing person-centred care and addressing inequalities in health. Several respondents suggested that a screening model may not meet the needs of the ‘hard to reach’, many of who are in contact with services, but not for anticipatory care. People with complex needs are likely to need a more personal approach, involving a professional they know and trust. Screening is more impersonal, especially when a large part of the encounter is taken up with data collection. Gaps would include ensuring patient feedback, and staff feedback, from formal evaluations as well as involvement of local people from target populations in the planning and delivery of outreach and engagement to promote a person-centred approach. Effective Several respondents supported the need for further evidence before committing to rolling out the programme. Concerns were raised regarding the lack of evidence on the impact of the risk of coronary heart disease incidence or death. It was suggested that there is no ‘grade A’ evidence of the effectiveness of cardiovascular prevention based on an absolute risk approach, or of screening as a method of delivering anticipatory care. Efficiency It was felt that the economic evaluation of Keep Well should inform decisions about future delivery. It was suggested that greater efficiency would be gained from integrating approaches within routine care and offering more flexibility to deliver opportunistic health checks. Further exploration of the role of outreach engagement across the system should also be recognised as an efficiency opportunity. The major inefficiency is the lack of integration between the start of Keep Well, based on screening and referral and its long-term sustainability requiring continuity and coordination. Screening on its own (including health checks) without effective coordination and follow-up is inefficient. Equitable It was suggested that the Keep Well model differentially attracts more motivated and advantaged subgroups (even within our most deprived communities), does nothing to tackle the underlying causes that make CVD common, or to reduce the supply of middle-aged people requiring drug treatment. The deployment of Keep Well so far, involving only 37 of the 100 most deprived general practice populations in Scotland, has not been equitable. Regular audit is required to show that this omission is being rectified; it does not take into account the people who are disadvantaged/deprived but live outside SIMD areas.

E 47

Timely Several respondents suggested further recognition of flexible approaches to enable practices to offer health checks and support health improvement opportunistically, and subsequently refer to services as appropriate, would enable a more timely response to individual patients’ needs. A key area where anticipatory care can break down has delayed availability of the next step in the process. Referral pathways which involve delay or displacement to a distant setting are less likely to be taken up. The timeliness of the availability of referral services should be a key component of regular audit. Safe It was stated that CVD prevention/health checks should not supersede patients’ other priority health/social care needs, and that it is imperative that health checks are fully integrated within local protocols to ensure appropriate response to any clinical/ non-clinical issues disclosed during the health check. This further enforces the importance of ‘whole practice’ based models. Some respondents felt there was a need to promote consistency of approach in all health board areas in the delivery of health checks and subsequent clinical and lifestyle interventions. Training and competencies will support safe delivery of health care. The move to align HEAT targets with the quality strategy is generally welcomed. It was felt that there is limited evidence in relation to some aspects currently at a local level, and that some would be hard to assess/measure. In relation to wider assessment of quality it was felt that qualitative information is important in addition to more measurable aspects. Overall it was felt that a number of the quality strands raised issues for Keep Well, for example, continuing care requires effective referral and signposting, efficient recall systems and well planned follow-up.

E 48

Appendix B List of consultation invitees Association of Community Health Partnerships British Heart Foundation British Medical Association Community Pharmacy Scotland COSLA/SOLACE/ADSW Directors of Public Health Keep Well Leads NHS Board Chief Executives NHS Board Directors of Nursing NHS Board Medical Directors NHS Board Primary Care Leads In at the Deep End GPs Royal College of Nursing Royal College of General Practitioners

E 49

E 50

Appendix C List of Consultation Respondents British Medical Association Scotland, Committee Executive, Scottish General Practitioners Committee British Heart Foundation Community Renewal Scotland Counterweight, Robert Gordon University, Aberdeen Greater Glasgow & Clyde Diabetes Managed Clinical Network-Clinical Lead Greater Glasgow & Clyde Respiratory/ Chronic Obstructive Pulmonary Disease, Managed Clinical Network, Clinical Lead Glasgow Local Medical Committee, GP Subcommittee Long-Term Conditions / T6 Delivery Network Long-Term Conditions Unit, Scottish Government National Health Care Support Workers, Working Group NHS Ayrshire & Arran NHS Borders NHS Dumfries & Galloway NHS Education Scotland NHS Fife NHS Forth Valley NHS Greater Glasgow & Clyde NHS Greater Glasgow & Clyde (Community Health & Care Partnership North) NHS Grampian NHS Health Scotland NHS Lanarkshire NHS Lothian NHS Mid Highland NHS Shetland NHS Tayside NHS Western Isles NSS National Coordinator Screening Programme RCCP: In at the Deep End GPs Well North