PCIMG
13 April 2011
Dr Linda Leighton-Beck (Programme Director)
Dorothy Ross-Archer (Programme Manager)

• What is Keep Well?
• Current position in NHSG?
• What is in the guidance ?
• What action do we need to take?
– Strategic
– Operational
– Immediate
– Short – Medium term

• Scottish Government flagship programme to increase the rate of health improvement in deprived areas (SIMD 2006).
• Eligible? 45 to 64 year olds in most deprived areas in
Aberdeen City.
• Health check (30-40 minutes) to identify: intermediate clinical risk factors lifestyle risk factors other issues that may impact on health
• Support as required.
• Local Enhanced Service
• HEAT target = number of completed health checks

Initiation/set up for practice
Monitoring ( national & local)
Engagement
Assessment (Health check)
Treatment
Preventive interventions (from menu/directory largely supported from out with the practice)
New disease (identification, treatment, disease register)
Data Screening
Job sizing
Load KW template
Phase patient recruitment
Enter data
National & local extraction
Engage in local evaluation
Invite patients
Secure appointments.
Follow up non-respondents
Deliver health checks
Cardiovascular risk ASSIGN
Lifestyle related risk
Social issues impacting
Medical management of risk factors.
Non-clinical management of:
Cholesterol
Smoking
Obesity
Management of symptoms eg chest pain
Non-health eg Cash in Your Pocket Partnership
Hypertension
Diabetes
CHD (angina)

• Sept 2007NHSG proposal signed off
• Dec-March 2008 – Early adopter practices data screened
• Aug 2008 – NHSG Local Enhanced Service agreed
• Aug 2008 – Local evaluation procured
• Sept 2008 - First local health checks in KW in 4 practices in City
• 2008-09 - HEAT target introduced
•
2008
– *Health Psychology - NES
(1)
• Dec 2009 – *Community Pharmacy (CP) proposal signed off
• Nov 2010- First local health checks in CP
• 2010 - *Health Psychology - NES (2)
• March 2011 HEAT target met
• April 2011 20 Practices and 6 Pharmacies delivering in Grampian .
• April 2011 – SG Guidance on Mainstreaming KW
• May 2011 – Local Evaluation signed off and disseminated
• June 2011- Proposal to be submitted to Scottish Government
• Sept 2011- Initial Feedback from SG
• April 2012 – KW extended
* Successful bids for additional monies to support targeted primary prevention

Current providers of Keep Well & Well North
GP practices
• Keep Well in Aberdeen City: 17
• Keep Well/ GRANITE in Aberdeenshire: 1 GP Practice
• Well North in Moray : 2 GP practices
Community Pharmacies
• Aberdeen City : 2
• Fraserburgh :3
• Moray: 1
Other venues/models
• G-Meds OOH Nursing
• Healthy Hoose
• Aberdeen Sports Village
• Saturday practice sessions-bank nursing

• Menu of interventions offering referral and signposting e.g.
• Cash In Your Pocket Partnership
• Healthwise Aberdeen (health & literacy)
• Credit Union’s – e.g. St Machar, Torry, Grampian
• Smoking Advice Service
• Healthy Helpings
• Healthpoint
• Wellbeing Circuit Session Classes – Aberdeen Sports
Village
• Health Behaviour Change Training
• Health Coach Pilot(s)

Keep Well Steering Group
• Clinical Lead
• Public Health Leads - City/Shire/Moray
• Nursing Services Manager
• Head of ICT Services
• Finance Manager
• Consultant in Pharmaceutical Public Health
• Development Pharmacist
• Information Analyst
• Professional Head of Dietetics
• Coronary Heart Disease & Stroke Managed Clinical Network Manager
• Patient representative
• Programme Manager
• Programme Director (Chair)

National
Keep Well
Board
Scottish Government
Performance Management
& Monitoring
Grampian X system
Performance Review
Sub Groups
Keep Well
Steering Group
City CHP Committee
AHIG
Moray CHSCP
Community Pharmacy
X Grampian
Well North Steering Group

• Mainstreaming health check in routine practice
• Lowering eligible age to 40
• Repeating health check every 5 years
• Extending programme to all in 15% most deprived areas; some local flexibility to reach deprived/high risk populations out with those areas
• Targeting vulnerable groups

• 2012-13 – circa 500 k*
• Nationally Agreed Framework for LES
*
Indicative, and subject 10 NHSG 10% top slice of allocation and current % efficiency savings

Guidance on mainstreaming: overview
• Full guidance available at: www.hi-netgrampian.org/keepwell .
Eligible Populations
• Individuals between 40 and 64 at high risk of CVD (with additional steps to identify eligible carers ) and
• Living in the most deprived communities (Identified through
Scottish Index of Multiple Deprivation, 2009 )
• Specific Vulnerable Populations (definitions to be supplied) to include:
– South Asian ethnic subgroups;
– Black and Afro-Caribbean ethnic subgroups;
– Offenders;
– Gypsy Travellers;
– Homeless individuals;
– Individuals affected by substance misuse.

• Identifying core target population
• Identifying, targeting & engaging specific vulnerable populations
• Models of delivery
• Onward Referral Procedures
• Resource Plan
• Data Collection
• Implementation
• Risks

Planning from the pilot
…..
• The Keep Well pilot in Aberdeen City.
• Early adopter practice in Aberdeenshire
• Well North pilot in Moray.
• KW Community Pharmacy pilot in 3 CHPs.
• KW November Workshop Report.
• Local evaluation of Keep Well.
• National evaluation of Keep Well
• KW Steering Group key issues and actions.

• GP sub updated and advised of extension target population (April)
• KW briefing note to all GP practices and identified community pharmacies to support engagement in process. (April)
• NHSG issues flagged by Keep Well Steering Group and others and progressed (April-June)
– Data screening
– Scenario planning
– IMT systems
– Health Intelligence
– Resource
– Systematic, integrated model(s) of inequalities-targeted primary prevention
–
Local dialogue on options
– City Cluster Clinical Leads
 Aberdeenshire
 Moray
• Agreement on local models (May)
• Proposal discussed with PCIMG (June)
• Submission of NHSG proposal (June)
• Contacts: linda.leighton-beck@nhs,net ; dorothy.ross-archer@nhs.net