LOCAL EVALUATION OF KEEP WELL
IN
ABERDEEN CITY COMMUNITY HEALTH PARTNERSHIP
Professor Anne Ludbrook and Dr Flora Douglas
FINAL REPORT
Contents
Executive Summary / 1
1 Introduction / 4
2 Methods / 8
3 Results: How are additional Keep Well resources deployed? / 11
4 Results: What are the available options for sustaining the Keep Well programme beyond the pilot period? / 20
5 Results: What are the anticipated costs and effects associated with service redesign options? / 26
6 Discussion and conclusions / 31
Appendix 1 Evolution of the research design / 34
Appendix 2 Interview schedules / 39
Appendix 3 Background on practice funding and delivery options / 46
Appendix 4 Management and support cost breakdown / 50
Acknowledgements: The authors would like to thank all those who contributed to this research; in particular, staff in the practices and other venues who gave their time to be interviewed, staff of NHSG who provided quantitative data and members of the Evaluation Steering Group who advised on the development of the research and commented on earlier drafts of this report. Sheetal Sharma assisted with the analysis of the interviews. The authors remain responsible for the contents.
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Executive Summary
Introduction
Keep Well is a national programme initiated by the Scottish Government in 2006 with the objective of increasing the rate of health improvement in deprived communities. NHS Grampian (NHSG) was a second wave board; this report covers the local evaluation of Keep Well. The key questions addressed are:
· How are additional KW resources deployed?
· What are the available options for sustaining the KW programme beyond the pilot period?
· What are the anticipated costs and effects associated with the service redesign options?
Methods
The research involved case studies of Keep Well practices in Aberdeen using both qualitative and quantitative methods. Key informants were interviewed in each practice. Semi-structured interviews were audio-recorded and fully transcribed for analysis. Quantitative data on practice activity and Keep Well costs have been supplied by NHS Grampian.
Findings:
Keep Well Activity and Use of Resources
· At December 2010 16 practices had implemented Keep Well covering 89% of the eligible population. More than half had been invited for a health check.
· The rate of detecting new cases of hypertension and diabetes was estimated to be 4%. A much larger proportion of patients had risk factors for disease.
· The level of early disease and risk factor detection was difficult to assess from routine data.
· Ability to maintain a full complement of nurse staffing and space for Keep Well services were important facilitators of health check provision in general practices and in their absence alternative delivery models were adopted.
· The costs of delivering health checks were relatively low (£100.12 per check delivered including central support) and some significant benefits were identified.
Options for Sustaining the Keep Well Programme
· Practices were still involved in the delivery of health checks and had given little attention to the longer term future of Keep Well or other anticipatory care.
· Options for making Keep Well more sustainable were discussed including shorter appointments, opportunistic delivery, group sessions and changing the skill mix of the delivery team.
· There was no plan for routine follow up of all patients, only those with identified disease or risk factors, although some patients had asked about this. Other target groups for anticipatory care were suggested, particularly younger age groups.
Anticipated Costs and Effects of Service Redesign
· Assessing the anticipated costs and effects of service redesign or alternative delivery models is difficult as interview respondents had no experience of changing their approach to Keep Well and there was a lack of quantitative data to assess whether there would be differences in performance in terms of either delivery and up take of the service or the outcomes for patients.
· There were perceived advantages and disadvantages to alternative models for delivering Keep Well health checks. Maximising the reach and uptake of anticipatory care may benefit from a ‘mixed economy’ of provision.
Discussion and conclusions
The Keep Well programme has been delivered at a relatively low cost by NHSG, compared with other areas, and has provided significant benefits. The basic cost of the health check could be reduced by changes to the content or delivery but with uncertain effects on the benefits and there was no consensus about potential changes to the health check.
Staffing and space were the main barriers to the delivery of Keep Well health checks within the general practice setting. These barriers were being overcome by utilising other staff and premises. There were no obvious cost advantages in any one particular model for delivering Keep Well as contract payments were the same. The findings are more supportive of the need for flexible approaches to delivery but more formal evaluation is required to compare the effectiveness of different models in terms of engaging with the greatest proportion of eligible patients.
There are insufficient data at this stage to evaluate fully the costs and benefits of Keep Well and further evaluation of anticipatory care is required. Better information systems could support the evaluation of national programmes such as Keep Well, if they can include the requisite data for assessing the programme performance and are easy to interrogate routinely.
1 Introduction
Background to Keep Well
Keep Well is a national programme initiated by the Scottish Government in 2006 with the objective of increasing the rate of health improvement in deprived communities by enhancing primary care services to deliver anticipatory care to those aged 45-64; identifying and targeting those at particular risk of preventable serious ill-health (including those with undetected chronic disease); offering appropriate interventions and services to them; and providing monitoring and follow-up. Keep Well was part of a wider national strategy to tackle health inequalities. The Keep Well health check includes clinical measurements (such as blood pressure, cholesterol, blood sugar), assessment of mental health, lifestyle issues (smoking, alcohol consumption, diet, exercise) and social issues (such as literacy, finances). The appointment was expected to take 45 minutes.
The scope and expectations of the Keep Well programme, both nationally and locally, evolved over the period of its implementation; for example, additional referral opportunities were developed for diet and physical activity. The Keep Well anticipatory care programme combines both early disease detection and opportunities to prevent disease through addressing lifestyle risk factors and social determinants of health. Since the national launch of Keep Well, there have been other anticipatory care initiatives and since 2009/10 a HEAT target has been set for the delivery cardiovascular health checks, to which the Keep Well programme contributes.
NHS Grampian (NHSG) was a second wave board. The KW programme was piloted in Aberdeen City, in line with overall deprivation as measured by SIMD (2006). Health checks began in 2008. GP practices were central to NHSG’s core model; that is, the delivery of health checks as part of practice activity. Variation in the delivery model was introduced over time and designed to support practice capacity, e.g. lack of staff or space within practices, or to provide health checks closer to patients’ homes; and in the case of one venue to create greater synergies around a proactive model of health. In addition to GP practices, other venues included other health facilities, a sports facility and community pharmacies. The KW process is described more fully below. NHSG also supported the development and integration of existing and additional referral services.
Local delivery models for Keep Well
Core delivery model: provision of Keep Well is embedded in general practice, with appointment slots provided within the workload of the nurses in the practice. In some cases, a single nurse in the practice may take responsibility for delivering the health checks. In other practices the checks were allocated across the nursing team.
Satellite delivery in other health settings: Keep Well appointments are organised by the general practice but take place in other health settings using other staff e.g. Community Bank Nurses, Community Pharmacists. This overcomes problems related to staffing and space within the general practice and may be more convenient as patients are matched to settings closer to their home.
Satellite delivery in other settings: as above but the venue used is, for example, a sports facility and the Keep Well checks are delivered by a Community Bank Nurse, who in addition is a health advisor from healthpoint (NHS Grampian’s health information service, already trained in health improvement and health advice), or by other Community Bank nurses.
Community pharmacy setting: a pilot service has been developed in which groups of Keep Well eligible patients are identified by the general practice for allocation to community pharmacy delivery. These patients are then ‘engaged’ by the pharmacy team to organise appointments for health checks.
In all cases where the health check is delivered outside the general practice, the information collected is transmitted securely back to the general practice to form part of the patient record and the patient is referred to the GP Practice for any health issues which may require further clinical action. Other referrals may be made by the provider of the health check; for example, to a weight management programme (Healthy Helpings) or for benefits advice (Cash in your Pocket).
Local evaluation of Keep Well
Scottish Government commissioned a national evaluation of the Keep Well programme. Local evaluations of Keep Well were intended to complement and add value to the national evaluation, as well as addressing local issues. This local evaluation has service redesign as the main focus, and includes a health economic component. The scope of the planned evaluation has necessarily adapted to reflect a slower than scheduled delivery of the Keep Well health checks, the extended timescale for the Keep Well programme and limited information about patient outcomes. It is a fairly common feature that the planned implementation of new programmes proves to be ambitious in the face of the demands of maintaining the delivery of mainstream activities. The process by which the research design evolved during the implementation of Keep Well is described in Appendix 1. This report concentrates on a reduced number of research questions and does not cover all aspects of the evolving programme or the process gains that have been achieved. Service redesign remains central to the local evaluation, however, and the key questions addressed are:
· How are additional KW resources deployed?
· What are the available options for sustaining the KW programme beyond the pilot period?
· What are the anticipated costs and effects associated with the service redesign options?
The research methods are described in the next section (2) and results for these research questions are provided in sections 3 – 5, with discussion and conclusions in section 6.
2 Methods
The research involved case studies based on Keep Well practices in Aberdeen using both qualitative and quantitative methods. Ten general practices participated in the interviews and gave permission to access aggregated activity data. Interviews were also held with representatives from each of the other delivery models. Practices were recruited for interview as they signed up to Keep Well and commenced the process of delivering health checks. The interviews were designed to elicit information about: resource use, staffing, activities not covered by routine data sources, and referral patterns; to support the analysis of costs and effects of Keep Well delivery options; and contextual material to identify features of good practice and potential barriers to change within practices.
Key informants were interviewed in each practice. It was anticipated that the key informants would include the practice manager, a GP and another staff member delivering the Keep Well programme. However, an important feature of this research is that it should reflect and be responsive to practice variations. Therefore, the identification of the most appropriate key informants was determined in collaboration with the practice team. Staff were either interviewed individually or in groups, to suit the preferences of the individual practices and the availability of staff.
Semi-structured interviews were audio-recorded and fully transcribed for analysis. At all times the confidentiality of data and the anonymity of respondents was maintained. All data reported here have been anonymised by allocating a case number to each interviewee or group of interviewees. It was planned to interview up to 10 practices on three occasions: at the start of the delivery process; at 6 months; and near the end of the delivery of health checks. In the event, practices were delayed in the start up of the programme and during the delivery phase (see appendix 1). As the programme evolved, other delivery modes were developed and these were added to the interviewing process. Table 1 provides a summary of the interviews conducted and the interview schedules for the three planned phases are provided in appendix 2.
Table 1 Summary data on interviews conducted
First interview / Second interview / Third interviewGeneral practices / 10 practices / 7 practices / 4 practices
29 participants / 19 participants / 10 participants
Other venues / 4 venues
5 participants
Within the general practices, 19% of participants were doctors, 43% were nurses and 38% were practice managers or administrative staff. Practice involvement in the evaluation formed part of the service agreement with NHS Grampian; nevertheless, it proved challenging to arrange interviews with all staff categories and the process of engagement was sensitive to the priority of service needs. There were no outright refusals to be interviewed but interviewees were to some extent self-selected.
Quantitative data on practice activity and Keep Well costs have been supplied by NHS Grampian. Practice activity is taken from routine returns of Keep Well data and from additional extraction of practice data undertaken by NHS Grampian staff. Keep Well costs come from the service agreement with practices and an analysis of time inputs by NHS Grampian staff to support the Keep Well programme.
The remainder of the report sets out the main results of the local evaluation. The activity, costs and outcomes of the local Keep Well service are discussed in section 3. This study was not designed to examine cost-effectiveness as this is covered by the remit of the National Evaluation but some data are given to provide context. Section 4 considers the redesign options and the potential advantages and disadvantages of different approaches are reported in section 5. The final section (6) contains discussion of the findings.