Address

Lewis D Ritchie

2 Duke Lane, Fraserburgh

Lewis D Ritchie

Keep well – reflecting back….and moving on

Lewis D Ritchie

Aims of talk

To take us on a journey, tinged by my personalexperience and views - (public health warning!)

Three themes:

• To reflect back – where we have been

• To take stock - on where we are

• To look forward – on where we want to be

Theme 1

Reflecting back…..

673 patients:nurse-led clinics for one year

19 general practices (69% RR)

Original Randomised controlled trial 1995/96 (Campbell, Ritchie et al)

Original Randomised controlled trial 1995/96 (Campbell, Ritchie et al)

randomisation

1343 patients with CHD (71% RR)

670 patients:usual care

Key findings

• At one year – significant reductions in all risk factors between groups (except smoking) and hospital admissions

• At four years – significant reduction in total mortality (15%); highly cost-effective

• At ten years – reduction in total mortality maintained but no longer significant

Survival (years)

80

90

4321

100

control

clinic

0

Nurse-led 2ndy prevention clinics in GP (BMJ 2003)

Nurse led systematic care

Usual care group

Key messages

• “Nurses save lives”

• “Delay costs lives”

• “Evidence-based use of resources”

Theme 2

Taking stock...where are we now?

Q: What does this represent?

But……. The tyranny of inequalities

0

20

40

60

80

100

120

140

160

180

200

10 9 8 7 6 5 4 3 2 1

Least Deprived

Most Deprived

Sta

nd

ard

ised

Mo

rtal

ity

Rat

io

SIMD Deprivation Decile

Coronary Heart Disease Standardised Mortality Ratios by age group and SIMD decile*; Scotland 2007-2011

*(1=most deprived; 10=least deprived)

All Ages Ages under 65 Ages 65 and over

Key Messages:

37% of deaths in Scotland still due to CVD

INTERHEART Study suggests that up to 80% of

CHD deaths in Scotland remain potentially preventable

?Keep Well -Evaluation

Keep Well Impact Evaluation 2006-12

Three components:

• Local variability study

• Outcomes analysis

• Synthesis of national and local evaluations

Keep Well Impact Evaluation 2006-12

Main lessons:

• The underlying theory for Keep Well may be flawed

• Variations in implementation

• Barriers to an effective assessment of impact

Findings

• Pragmatic assessment has not demonstrated appreciable impact on intended outcomes.

• There are lessons for primary care-based prevention programmes addressing health inequalities.

Selected recommendations 6/11

Programme/intervention to:

1 Align with the principles for effective policies to reduce inequalities

2 Include a developmental phase before implementation

3 Balance risks and benefits

Selected recommendations 6/11

4 Manage variability effectively

5 Agree evaluation framework from inception

6 Evaluate outcomes with comparison group and follow up, if continuing Keep Well

Theme 3

Moving forward – where do we go from here?

Direction of travel from Keep Well?

Key issues

•Integration•Interventions at scale•Need for focus on post 2015 – now

•Attribution of spend on health inequalities•Attribution of cause and effect i

NHSG Vision 2020

Performance

workforce E health

Scottish Government Policy

Resources

Integration

ClinicalServices

PatientsSocial Services

Before Keep Well

Health Promotion Services

Performance monitoring

Network of

Services

Changing Behaviour

Addressing‘causes of the

causes’

Intervention – holistichealth check

TrainingEvidence

Fitting it together for

deprived patients

Engaging patients and communities

Targeting patients

Keep Well systems and beyond

Identifying Spend

Local EnhancedService

Integration/standard within partners’

services

“The dogmas of the quiet past are inadequate to the stormy present. The occasion is piled high with difficulty. As our case is new we must think anew and act anew…..”

Abraham Lincoln

Transforming our healthcare system

Priorities include:

• More systematic and proactive management of chronic disease

• Empower patients

• Take a population based approach to commissioning

• More integrated models of care (and prevention)

‘Doing the right thing’ & ‘Making the right things happen’

• ‘Much of what we describe has been known for some time, yet it is not applied in practice..........

Why?........ Because while it is relatively straightforward to impart knowledge about what to change, it is much harder to create the culture and enthusiasm required to deliver change, particularly when working across organisational boundaries.’

King’s Fund (2013)

Aims to deliver the highest quality healthcare services to the people of

Scotland

Keep Well ‘fit’ with Vision 2020 priorities

• Patient-centred care• Safe Care• Primary Care• Integrated Care • Care for multiple and chronic illnesses• Health Inequalities• Prevention• Workforce• Innovation• Efficiency and Productivity

Delivering on 2020

Suggest we need to:

• Take a more strategic approach to KW - as part of an overall approach to inequalities, as well as health inequalities - at every level

• Ensure economies and efficiencies of scale

• Agree a system of monitoring and management

• Take a more strategic approach to modelling delivery

Delivering on 2020

And....

• Support further change pilots as part of modernisation - in pilot practices and non-pilot practices

• Stimulate co-production at practice and locality levels

• Streamline current delivery

• Create greater synergies to support patients and practices

Guiding Principles

• All things will not be possible – prioritisation necessary against fiscal constraints

• Striking a balance that is desirable, affordable and achievable

• Need for targeted approach to those in highest need – equity and fairness – striking back at health inequalities

Moving forward

• Continuing to evolve public health policy population interventions - Keep Well, AAA Screening etc

• Looking again at educational interventions and starting early

• Improved screening programmes – using new evidence and experience – based models

Moving forward

• Enabled professionals – education/training

• Empowered patients – supported self care

• Maximise best use of information technology/eHealth

“Public Health (CHD) is everyone’s business”

Effective leadership is key

…requiring courage and resolve….

Effective teamwork essential….