Background and Policy Information

Background and policy information

Within Delivering for Health, the Scottish Executive’s response to the Kerr Report, it was confirmed that a key national priority would be to strengthen and enhance primary care services in deprived areas to reduce health inequalities. To support delivery of this, the Keep Well programme (previously known as Prevention 2010) was announced with the intention of piloting an anticipatory care model within geographic communities of greatest need.

Quick links on this page:
Delivering for Health – reducing inequalities
Evidence overview
Pilot projects
Supporting the pilot projects
Health Scotland's Role
– Logic modelling
– Developing the evidence base
– National Evaluation
– Quality assurance
– Programme management
– Capacity building
– Communications strategy
– Practical support for delivery
– Learning for rollout
Relevant Scottish policy and legislation

Delivering for Health – reducing inequalities

The Scottish Executive's aim of reducing health inequalities is to be achieved by:

Targeting health improvement action and resources at the most disadvantaged areas.
Building capacity in primary care to deliver proactive, preventative care.
Providing early interventions to prevent escalation of health care needs.

Keep Well will assist in the delivery of the Scottish Executive's health inequalities targets, and is part of the overall implementation of Delivering for Health.

Evidence overviews

Evidence suggests that the best short-term gains in health inequalities are likely to come from NHS action. Keep Well will see up to £25 million invested between 2006 and 2009 to strengthen primary care services in the most deprived areas of Scotland. Additional staff will identify those at particular risk of preventable, serious ill health and offer health checks, screening and advice.

The focus will be on cardiovascular disease and its main risk factors, especially blood pressure, cholesterol, smoking and diabetes. Treatments and referral to community and other NHS services will be offered, with regular monitoring and proactive follow-up. Resources will be targeted where they are needed most – that is in areas where the risk of ill health is high.

Using the Scottish Index of Multiple Deprivation, five Community Health Partnerships in Greater Glasgow (North and East), Lothian, Tayside and North Lanarkshire, have been identified to pilot this new approach in wave 1 (2006/08). In wave 2 (2007/09) Community Health Partnerships have been identified as Fife, Aberdeen City, Ayrshire (North & East), Glasgow (South West), Inverclyde and West Dunbartonshire.

Keep Well Engagement and Concordance: Evidence Overview – A resource for pilots
This paper by Elizabeth Bream, Specialist Registrar in Public Health at NHS Lothian, provided an overview of current evidence relating to two main areas that the projects need to consider:

What evidence is there about how to contact and offer assessment/preventative care to hard to reach populations (in primary care)?
What evidence is there about how to ensure compliance/concordance with interventions (in primary care)?

The paper is available to download from the Scottish Executive's Keep Well web pages (external link).

Keep Well Interventions: Overview of Guidelines and Evidence - A resource for pilots

The purpose of this resource is to provide pilots with an easily accessible overview of:

- current 'guidelines' on action that can be taken by professionals and members of communities in pursuing the vision and focus of Keep Well

- evidence on the effectiveness of relevant interventions where this helpfully supplements and complements the guidelines identified.

This is an interim document and is currently in the process of being revised following the launch of the new SIGN Guideline on risk estimation and the prevention of cardiovascular disease in February 2007. The resource is being reviewed and amended as necessary and a revised version should be available by July 2007.

Keep Well Interventions: Overview of Guidelines and Evidence A resource for pilots

Pilot projects

Initial activity will be through two phases of pilot projects prior to general application of the principles of anticipatory care for those 'at risk' wherever they live.

The first wave (2006) will involve five Community Health Partnerships (CHPs) in local authority areas with highest numbers of people in most deprived 15% of population (using the Scottish Index of Multiple Deprivation).

The second wave (2007) will involve a further seven CHPs with high levels of deprivation.

Key features of these programmes will be:

Extra resources for primary care in deprived areas, primarily for additional staff to identify, contact and offer health checks and risk assessment to those who may be at risk.
Offering effective treatments and referral to community and other NHS services for those found to be at risk, with regular monitoring and follow-up.
Clear targets for outputs and outcomes from the pilots.
Nationally commissioned evaluation, and development of risk stratification and assessment tools.

The target population is 45-64 year olds at risk of serious ill-health.

Interventions will be centred on:

Tackling intermediate clinical risk factors – identifying, treating and controlling high cholesterol and high blood pressure, and promoting the effective application of tailored cardiovascular disease (CVD) secondary prevention packages among people who already have CVD and/or diabetes.
Tackling lifestyle risk factors, through smoking cessation services, Counterweight (addressing diet and physical activity) and brief interventions on alcohol.

Supporting the Programme Areas

The pilots will be supported at senior level by NHS Board and CHP partners, to be developed with, and led by, local GP practices, and to involve community pharmacists other key health professionals, local government and the voluntary sector.

A specification was drawn up to provide the basis for development wave 1 of Boards' outline plans.

The specification is available to download via the Scottish Executive's Keep Well pages (external link).

This specification is currently being amended to then provide a basis for wave 2 proposals to be developed. This will be available in April 2007.

Health Scotland's Role
Working collaboratively with NHS Boards, Community Health Partnerships (CHP), pilots and others, Health Scotland (HS) will play the following parts in the provision of national level support. These cover all stages from the planning and design of the pilots through to their delivery, evaluation and ensuring that the learning from the pilots informs the intended rollout of anticipatory care across Scotland.

Programme Management
It is clear from the Keep Well specification that, while there will be some defined scope for local context and expertise to influence the specific details of each project, there is expected to be a significant degree of commonality of abjectives and delivery across pilots, with strong links to national policy and strategy.

There will thus be a need for an overall programme management resource for Keep Well.

This will be provided by HS, and will:

Link with the pilot projects, Have a Heart Paisley (HaHP), SEHD, ISD and the MPHN.
Support the pilots through the planning, implementation and evaluation stages, and coordinate the support available to the pilots from HS, lSD, the MPHN, HaHP, the external quality assurance group (see under 'Quality assurance') and others.
Help ensure an appropriate degree of consistency of management across pilots.
Enable effective performance management.
Facilitate sharing of information and learning across the pilots and more widely in NHSScotland.

The delivery infrastructure for Keep Well is documented here Keep Well delivery Infrastructure

Logic modelling
An important early input by HS, in collaboration with the Managed Public Health Network (MPHN) and Information and Statistics Division (ISD), was to develop a logic model to guide planning, monitoring and evaluation of the Keep Well programme.

This covers local service delivery by GP practices and infrastructure support from CHPs, NHS Boards and national agencies. Ultimately, this process will help ensure success by testing out the overall 'logic' of the programme and thinking through the linkages between resource inputs, activities (national, local) and expected outcomes (short-, medium- and long-term).

The logic model provides a basis for assessing the plausibility (in terms of evidence), do ability (in terms of capacity to deliver) and testability (in terms of evaluability) of the programme, and for making any necessary adjustments.

For more information on our work to develop logic models for Keep Well, please consult our page on Logic Models.

Developing the evidence base
HS, jointly with the MPHN, will provide rapid overviews of existing evidence and guidance relating to effective interventions and effective engagement with target groups. This will feed into the logic modelling and inform the design and delivery of the pilot phases.

HS also have a lead role in translating evidence – both from evaluation of the pilots and from elsewhere – into practical guidance for the nationwide rollout of anticipatory care.

An early step in this will be to identify and prioritise, in collaboration with NHS Boards, CHPs, pilots and the MPHN, needs for more in-depth evidence reviewing and for the development of infrastructures for, and approaches to, evidence-related dissemination and learning.

National evaluation
In collaboration with lSD, HS has commissioned a national level evaluation of the Keep Well pilots. This has been an early prority so that the appointed team can contribute an evaluation perspective to the development of plans and help to develop a monitoring and evaluation framework.

The national evaluation will run from March 2007 until March 2010 and is split into two phases. Phase 1 (2007/09) will focus on tracking national and pilot theories of change, and tracking the impact of Keep Well on "anticipatory care" in the target population using secondary data analysis. Phase 2 (2009/10) will focus on the assessment of merit and worth of Keep Well, however, the exact design will be informed by findings from phase 1.

An Evaluation Advisory Group is established and chaired by HS to oversee the evaluation, identify and solve problems, and ensure quality and progress.

The Keep Well National Evaluation research and design specification is documented here
Evaluation Specification

Quality assurance
HS will set up an external group that can provide relevant expertise and technical assistance at key stages.

The group's role will include:

Reviewing the draft plans for the pilots developed by NHS Boards/CHPs, to maximise their evidence-fit, feasibility and potential to achieve the desired health outcomes.
Reviewing the evidence-based guidance provided by HS and the MPHN.
Reviewing and advising on evaluation plans.

Capacity building
Delivering for Health calls for an innovative culture that promotes redesign whilst remaining focused on the delivery of better care for patients. Key to achieving such a culture is building the capacity of NHS staff to develop understanding and skills related to the planning, implementation and evaluation of health improvement activity.

Capacity building support will be made available to the pilot CHPs. Links with the HaHP work on competencies for health coaches will be important. More generally, the Public Health Workforce Development Group is the primary vehicle for collaboration between the key national players in workforce development for health improvement: SEHD, NHS Education Scotland (NES), the Convention of Scottish Local Authorities (COSLA), Health Protection Scotland, the Community Health Exchange (CHEX) and Voluntary Health Scotland (VHS).

Focused on the practitioner and wider workforce, that work will support all HS's learning and workforce development activity for capacity building in CHPs and Community Planning Partnerships.

The main output for 2006/07 will be to implement the workforce development action plan agreed in March 2006. It will be essential to ensure that capacity building for the Keep Well pilots is given specific priority within the overall work.

Communications strategy
Health Scotland has developed a marketing and communications strategy to support the delivery of Keep Well.

The strategy reflects the need to engage effectively both with local GPs and other health professionals and with the target population, with the aim of securing the support and participation of all concerned and promoting concordance as regards interventions, referrals and follow-ups. A communications toolkit has now been developed to assist CHPs in engagement with the local target population. Work is planned in 2007/08 to develop a new Keep Well website and a regular e-bulletin.

Practical support for delivery
Information about, and access to, a wide range of existing practical health improvement resources will be made available to the pilots in order to support delivery of the pilot projects.

These resources will cover the range of relevant priority topics and will include:

National campaigns, helplines, websites and printed materials.
Local training, guidelines, referral pathway support and printed materials.
Practice networks.
Links to other health improvement partners and initiatives, including HaHP.

This work should have the added benefit of helping HS to enhance its ability, more generally, to deploy resources such that they reach and help disadvantaged and at-risk populations.

Learning for rollout
As referred to under 'Evidence base', HS will have key parts to play in disseminating lessons, and promoting learning, from the Keep Well pilots, and in developing practical guidance for the rollout of anticipatory care across Scotland.

Relevant Scottish policy and legislation

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