This Report Provides Colleagues, Who Have a Role Or an Interest in Keep Well, with a Summary

Key findings 2012 – 2013

Purpose

This report provides colleagues, who have a role or an interest in Keep Well, with a summary of key information on programme performance and learning in the first year of extension across Grampian. We hope this will support further development and refinement of the programme and inform the broader work to address health inequalities.

A set of facts on Keep Well 2012-13 is provided at Annex A: covering reach and attendance; demographics; clinical data; and lifestyle data. A more detailed analysis of data is available at http://www.hi-netgrampian.org/hinet/6595.4.814.html

Background

Health Inequalities is a key priority for NHS Grampian, and the Keep Well programme is an essential component.

Keep Well is designed to offer anticipatory care to those who are at increased risk of cardio-vascular disease. This is achieved by targeting the core group of 40-64 year olds, including carers, living in the most disadvantaged areas and vulnerable groups, e.g. homeless, substance misusers aged 35-64 years.

Over 6000 cardiovascular health checks have been delivered since the inception of the programme (2008) and a network of services and pathways for signposting and referral has been developed. This infrastructure is designed to support practices in embedding inequalities sensitive practice in primary care.

In extending the programme across Grampian, our main focus in 2012-13 was to embed systems and processes within each of the Community Health Partnerships (CHPs). In doing this, we built on the experience of the programme nationally, in Aberdeen City, in Moray (Well North) and in the Community Pharmacy setting (Aberdeenshire and Moray).

Outcomes in 2012-13

Exceeded NHSG’s annual target of 1500 health checks. 1633 checks were delivered (109%).

Reached patients in the most disadvantaged communities. 86% of patients who had a health check were in the most deprived communities, SIMD quintiles 1 and 2.

Increased access to a health check for patients in less urban areas.

Increased the number of deliverers and settings to 33 GP practices and 5 Community Pharmacies.

Established new delivery pathways for individuals affected by substance misuse and for Gypsy Travellers.

Supported a person-centred approach by facilitating access to a range of health and non health services through referral and signposting opportunities.

Provided identified practices with access to health coaching to enable patients to increase their own capacity to change behaviour.

Facilitated increased partnership working to address health inequalities within NHS Grampian and between NHSG and 3rd sector partners.

Challenges

There have been challenges in delivering this complex programme. The limitations of information systems nationally and locally continue to impede seamless data extraction and the tracking of referrals.

Developing and implementing new delivery pathways for vulnerable groups generated an intensity of activity not always reflected in uptake.

These challenges are not unique to Grampian and we continue to seek more optimal approaches.

Conclusion

The Keep Well Programme has provided NHS Grampian with a range of opportunities to develop and optimise support for those at high risk of preventable serious ill-health. We must capitalise on the gains we have made in drawing a range of services round practices, pharmacies and other deliverers. We continue to learn from the responses of patients and practitioners in order to improve our approaches to addressing inequalities.

In 2013-14, to ensure sustainability as part of routine service delivery, we will continue to support integration of the programme within local structures and the progressive mainstreaming of information systems and data analysis within Health Intelligence.

Annex A

Keep Well 2012-13

Analysis of Keep Well practice data

Purpose

This annex summarises evidence on programme reach and attendance; demographics; clinical data; and lifestyle. The data is from the Keep Well Live2 Business Objects Universe, which is populated by data extracted from Keep Well practices, using the SCI-DC platform. A full analysis is available at http://www.hi-netgrampian.org/hinet/6595.4.814.html

Reach and attendance

Of 4358 patients invited for a Keep Well health check showed:

Overall. Of those patients who were invited, 30% attended a health check (uptake).

Age. Of those invited, 6% were under 40; 48% were 40<50; 45% were 50-64. Uptake was highest among 50-64s (34%).

Gender. Of those invited, 54% were male; 46% were female. Uptake among females was only slightly higher (31% females; 29% males).

SIMD 2009 Quintile. Targeting has been effective. Of those invited, 48% were from the most deprived quintile 1, and 40% from quintile 2.

Carers. Have a higher than average uptake (71%). (83 carers were invited for a health check, and 59 attended). Numbers invited may be under-reported in this data set because the information on carers invited (but who did not attend) may not have been recorded in GP practice systems.

Homeless. 59% of those invited, attended. Uptake was high across all age groups. The majority of health checks for homeless persons are delivered in the homeless practice in Aberdeen City

Ethnic Groups. ‘Black Afro-Caribbean’ and ‘South Asian’ are vulnerable groups being targeted in the first year of extension of the Keep Well programme. For each of these groups, uptake was higher than the programme average of 30%: 33% for Black Afro-Caribbeans, and 43% for South Asians.

Invitation Method. Of those who were invited verbally or by phone, the uptake was 64%. Telephone appears to be the most effective method. However, 71% of patients received an invitation by ‘letter only’. This appears to be the least effective method, with an uptake of 22%.

Health checks – demographic data

Of 1360 who attended a health check showed:

Age. The majority of health checks (52%) were delivered to patients aged 50+.

Gender. Health checks were fairly evenly split between males (51%) and females (49%).

SIMD 2009 Quintiles. 86% of health checks were delivered to patients from the most deprived quintiles (44% to Quintile 1; 42% to Quintile 2), indicating that our targeting has been effective.

Employment. The majority of patients receiving a health check were in employment (60%), with 9% unemployed and 9% unfit for work.

Health checks – clinical data

Blood Pressure

Of 1360 health checks, 1151 (85%) had a valid record of blood pressure.

Of the 1151 who had a valid record of blood pressure showed:

Overall. 8% had BP of over 140/90.

Age. Older age groups had a higher percentage of patients with high blood pressure (140/90 or higher); 9% for 50-64s; 1% for <40s.

Gender. 9% of males and 7% of females had high blood pressure (140/90 or higher).

SIMD 2009 Quintile. No specific trend or gradient is evident. Quintile 3 appears to have a higher percentage of patients with high blood pressure (140/90 or higher). However, this is based on a small number of patients in that quintile group.

CHP. Percentage of patients with high blood pressure recorded (140/90 or higher) in Moray (20%) appears much greater than the average of 8%. However, this was based on only 44 Moray patients.

Total Cholesterol

Of 1360 health checks, 1186 (87%) had a valid record of total cholesterol.

Of the 1186 who had a valid record of total cholesterol showed:

Overall. 51% had cholesterol >5.

Age. 31% of under 40s had cholesterol >5 compared to 54% of 50-64s.

Gender. Percentage of males and females with high cholesterol (>5) was not significantly different.

SIMD 2009 Quintile. The percentages with high cholesterol (>5) were fairly similar across the quintiles.

CHP. Aberdeen City (50%) had a lower percentage of patients with high cholesterol (>5) when compared to the other two CHPs. This difference is unlikely to be statistically significant.

ASSIGN CVD Risk Score

A key component of the Keep Well health check is the ASSIGN CVD risk score.

Of 1360 health checks, 762 (56%) had an ASSIGN score recorded.

Of the 762 with a valid ASSIGN score recorded :

Overall. 11% had a high ASSIGN risk score (>= 20%).

Age. CVD risk >= 20% increases with age. 4% of 40<50 year olds had a high CVD risk, compared to 18% among the 50-64s.

Gender. Males (13%) were slightly more likely than females (9%) to have a high CVD risk.

SIMD 2009 Quintiles. 8% of Quintile 1 patients had a high risk score, compared to 11% overall. However, numbers per quintile were low, The differences between quintiles are unliklely to be statistically significant.

CHP. High ASSIGN risk scores were more common among health checks in Aberdeenshire (20%) and Moray (14%), compared to Aberdeen City. However, this finding may have been influenced by the low numbers of health checks with a risk score in Aberdeenshire and particularly Moray, and also because the eligibility criteria used in Shire and Moray specifically targets smokers.

Chronic Disease

Data from National Indicator 4 (Number who have had at least one new chronic disease problem identified within 3 months of their most recent health check, expressed as a percentage of total health check) shows:

1% diagnosed with Diabetes.

1.1% diagnosed with Hypertension.

0% diagnosed with Coronary Heart Disease.

Health checks – lifestyle data

Smoking

Of 1360 health checks, 1187 (87%) had a current smoking status.

Of the 1187 records with a current smoking status:

Overall. 36% were current smokers.

Age. Patients <40 (22%) were the least likely to be smokers (compared to 39% 40<50s and 35% 50-64s).

Gender. Males (40%) were more likely to be smokers than females (32%).

SIMD 2009 quintile and CHP. Smoking data per quintile and CHP is not reported here because it is directly influenced by the eligibility criteria, a combination of quintile and smoking status we agreed in our non-urban areas - Aberdeenshire and Moray, .

Body Mass Index (BMI)

Of 1360 health checks, 1219 (90%) had a current BMI.

Of the 1219 records with a current BMI :

Overall. 65% had a BMI of 25 or more.

Age. Percentage of patients with a BMI of 25+ increased with age. (59% <40s; 67% 50-64s)

Gender. Percentage of patients with a BMI of 25+ was similar for males and females.

SIMD 2009 quintile. Unlikely to be a significant difference in the percentage with BMI 25+ across the quintiles. (Low numbers of patients in the less deprived quintiles).

CHP. Percentage of patients with a BMI of 25+ was similar across the three CHPs.

Exercise

Of 1360 health checks, 1229 (90%) had a current exercise/activity status.

Current guidance for adequate physical activity levels is ‘at least 30 minutes of moderate activity on at least 5 days a week’. One in ten patients stated that they achieved this level of activity. It is possible that this Read code has been under-reported or overlooked. Therefore, in the findings below, the Read codes for ‘Enjoys moderate exercise’, ‘Enjoys heavy exercise’ and/or ‘at least 30 minutes of moderate activity on at least 5 days a week’ are grouped into the statement ‘meets current guidance’.

Of the 1229 records with a current exercise/activity status :

Overall. 30% met current guidance for physical activity.

Age. Activity levels were highest in the youngest age group. (38% <40s; 29% 50-64s).

Gender. Males (37%) were more likely to meet current guidance than females (23%).

SIMD 2009 quintiles. Activity levels across the quintiles were broadly similar.

CHP. No significant difference across the CHPS in the percentage of patients achieving sufficient levels of activity.

Referrals

Data from National Indicator 5 (Number of patients who have been referred from Keep Well health check providers to internal and external services expressed as a proportion of first and review health checks) shows:

5% referred to services (principally weight management, smoking cessation and wellbeing/health coaching).

Note: We recognise not all patients are ‘ready to be referred’. We also have a number of services where patients can self refer. Some of these patients may decide - at a later point - to self refer. Colleagues not traditionally used to referring patients formally have acknowledged they do not always remember to record non-clinical referrals. We also recognise the challenges in tracking referrals and are working with services to explore options to link referral information.

Dr Linda Leighton-Beck

Head of Social Inclusion

November 2013

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