Targeting prevention

'Keep Well' (previously called Prevention 2010)

One of the three strands of the NHS Lothian strategic framework for reducing health inequalities is the targeting of additional help to geographical areas that experience higher levels of deprivation. Keep Well is one example of this approach. Keep Well is an initiative designed to identify people in areas of deprivation at increased risk of cardiovascular disease, reduce barriers to care and treatment, and reduce ill-health. In particular, it aims to enhance capacity to identify people aged 45-64 with risk factors for cardiovascular disease and provide preventive services to them.

Edinburgh City is one of the pilot areas for the first wave of Keep Well. 16 Edinburgh general practices will participate, serving about 25,000 people in the target age group of 45-64. They are the practices that serve the most deprived populations and are situated in 4 geographical clusters (see Box 1).

This clustering will allow the practices to develop links with each other and with local community projects in the areas. The project aims to encourage a holistic approach to assessment and build links between general practices and local community projects.

Specially employed senior nursing staff will help practices establish systems to reach people and to carry out clinical assessments called Keep Well health checks. These nurses will work with partners such as community pharmacists, community mental health teams, voluntary sector partners and others in each cluster area to identify people. Each cluster will also have an outreach worker to provide ongoing support for people who require follow up but find it hard to engage with health and other services. The outreach workers will develop relationships with voluntary sector organisations in each cluster and help practices refer people to their services appropriately.

The Keep Well health checks will include assessment of each person's risk of cardiovascular disease. They will also recognise other social issues that may prevent people engaging with interventions to reduce health risks. Practices will provide (or refer to) services including drug treatment of hypertension or high cholesterol, smoking cessation, weight management, support to address alcohol problems and other services that aim to meet the health and social needs identified.

Underpinning local work on this initiative there is significant national support. This support includes changes to clinical IT systems in general practices to facilitate assessment. A communications strategy is being developed, that will involve design of leaflets, letters and other resources to publicise Keep Well. Training is being provided for health professionals in health behaviour change. The initiative has been informed by evidence gathered in a literature review from Health Scotland, and will be evaluated so that the elements that work can be adopted across Scotland.

So... is this the right approach to reduce health inequalities in Lothian? It can certainly play an important part. There are precedents for this kind of working. For example, in Sheffield a targeted programme was set up to identify people who already had cardiovascular disease and offer them interventions. This resulted in more rapid decline in mortality from cardiovascular disease in the most deprived areas. The evidence base for the clinical interventions to reduce cardiovascular risk is strong; so it is reasonable to expect that implementing these in the population that experiences the greatest health risks should improve their health. It is argued that clinical interventions are most likely to show an impact in the short term, compared with interventions that address the underlying determinants of inequalities and ill health.

But this is not the only approach to addressing health inequalities and should not detract from other work already in place in Lothian. The project focuses solely on cardiovascular risk, when there are other health needs, particularly mental health needs, that are also high in deprived communities.

The reasons for inequalities in health are very complex and no one initiative can address them all. Although clinical care may give quick results, to achieve longstanding reduction in inequalities in health it is also important to address determinants that underpin these inequalities, such as poor life circumstances. The focus on individual risk may result in victim blaming unless publicity about the initiative, and the assessments themselves, recognise the wider problems that prevent many people from 'keeping well'. Finally the funding is only available for 2 years.

There is already some funding for anticipatory care available to all Scottish general practices. This project will provide support to the practices serving the most deprived populations to enable them to try different approaches and make a head start on this way of working.