NHS Lothian CHD Managed Clinical Network

1
NHS Lothian CHD Managed Clinical Network

• Introduction to Keep Well and the story so far
• June 2008

2
Origins and purpose

• Policy Background Kerr Report gt Delivering for
  Health gt Prevention 2010 gt Keep Well
• Based on Dr. Tudor Hart model (in Wales) which
  was based on BP screening
• Focusing assessment on those with potentially
  biggest gains age, social deprivation
• Wave one (2006-8) gt NHS Lothian, Greater Glasgow
  and Clyde, Tayside and Lanarkshire.
• Wave two (2007-9) gt NHS Fife, Grampian, Ayrshire
  and Arran and Greater Glasgow and Clyde.

3
Keep Well in Lothian

• Project aim strengthening and enhancing primary
  care services to deliver anticipatory care and
  reduce inequalities in deprived communities.
• Project focus cardiovascular disease and its
  key risk factors.
• Target population 45 64 year olds (circa
  24,000).

4
Keep Well in Lothian

• Lothian approach GP Practice based model with
  strong outreach element.
• Key components
• engaging eligible patients
• provision of 40min assessment gt risk calculation
• appropriate clinical management
• sign-posting and referral to community services
• one-to-one support to empower change.

5
Participating Practices

• 14 GP practices within Edinburgh (those in most
  deprived communities - measured by average SIMD
  for registered pop)
• 4 geographical clusters
• South East (eg Craigmillar
  Gracemount) South West (eg Sighthill Wester
  Hailes)
• North East (eg Leith Restalrig)
• North West (eg Muirhouse, Crewe)

6
Activity to Date (data to 30 May 08)
7
How do we engage people?

• Practice model of letter invitations
• Phone invites
• In the community
• Opportunistic
• Core team in practices using combination
• Out of hours clinics
• Other.

8
The Keep Well assessment

• Focused on cardiovascular risk
• Core Measurables Blood Pressure, Full lipid
  profile, Random or fasting glucose
• Lifestyle issues
• Social issues
• What is their take on health and health issues?

9
Cardiovascular Risk

• Many assessment tools, they are a guide only
• Some have significantly under or over-estimated
  risk relative to population in past
• JBS 2 (2005) adopted in current NHS Lothian
  guidelines, ??may change to ASSIGN
• Currently based on age, sex, systolic BP,
  smoking status, total cholesterol and HDL
• Many independent risk factors not taken into
  account using current framework

10
Independent risk factors

• Family history of premature CVD
• Social deprivation
• Personal factors stress, social isolation
• Renal disease
• Ethnicity
• Impaired glucose tolerance
• Obesity, especially abdominal
• Raised triglycerides

11
What are we uncovering?

• IT challenges delaying concrete clinical data
  analysis, HOWEVER being currently addressed
• Manual extraction of data by IT Dept indicates
  over a smaller number of practices that those at
  CVD primary prevention (gt 20) threshold range
  between 10 and 18, those at intermediate
  (10-20 risk) range between 30 and 38
• New diagnoses of Diabetes range between 1 and 8
  of all seen
• New diagnoses of hypertension average around 5
  of all seen
• Anecdotally those at the obese criteria (BMI gt
  30) around 30 of all seen
• Multiple complex needs gt wider determinants of
  health gt barriers to health specific behaviour
  change
• Questions over definitions of hard to reach.
  Many regular attenders have significant
  previously unmet needs.

12
What are we doing about it?

• Those with clinical need proactively managed
  in-house via NHSL guidelines. Case management
  element enough capacity to fully implement?
• Signposting to services and training of practice
  staff
• 11 support via our Outreach Workers
• Counterweight!
• Provision of support services ringfenced money
  (for 08/09 circa 70K) to establish these with
  the voluntary sector purely for Keep Well
  attendees (e.g. alcohol support, activity
  groups, food and nutrition support)
• Involvement of statutory services (e.g. smoking
  cessation, Edinburgh Leisure)

13
11 support via Outreach Workers

• Those motivated to make lifestyle changes or to
  address ambivalence
• Those with complex multiple needs
• Signposting (literacy, benefits/money, social
  advice, mental well-being)
• Vast majority to address stress/anxiety (wide
  spectrum)
• What does this mean for ongoing health
  improvement?

14
Next steps

• Initial extension of funding focus engagement
  activities on hardest to reach or other?
• Alternative means of delivery?
• Final phase revisit those with highest risk?
• Sustainability

15
Any questions?