1. Address Lewis D Ritchie

2. 2 Duke Lane, Fraserburgh Lewis D Ritchie

5. Keep well – reflecting back…. and moving on Lewis D Ritchie

6. Aims of talk To take us on a journey, tinged by my personal experience 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

7. Theme 1 Reflecting back…..

12. 673 patients: nurse-led clinics for one year 19 general practices (69% RR) Original Randomised controlled trial 1995/96 (Campbell, Ritchie et al) randomisation 1343 patients with CHD (71% RR) 670 patients: usual care

13. 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

14. 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

15. Key messages “Nurses save lives” “Delay costs lives” “Evidence-based use of resources”

16. Theme 2 Taking stock...where are we now?

17. Q: What does this represent?

20. But……. The tyranny of inequalities

23. 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

24. ?Keep Well -Evaluation

26. Keep Well Impact Evaluation 2006-12 Three components: Local variability study Outcomes analysis Synthesis of national and local evaluations

27. 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

28. Findings Pragmatic assessment has not demonstrated appreciable impact on intended outcomes. There are lessons for primary care-based prevention programmes addressing health inequalities.

29. 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

30. 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

31. Theme 3 Moving forward – where do we go from here?

33. Direction of travel from Keep Well?

34. 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

35. NHSG Vision 2020 Performance w orkforce E health Scottish Government Policy Resources Integration

36. Clinical Services Patients Social Services Before Keep Well Health Promotion Services

37. Performance monitoring Network of Services Changing Behaviour Addressing ‘causes of the causes ’ Intervention – holistic health check Training Evidence Fitting it together for deprived patients Engaging patients and communities Targeting patients Keep Well systems and beyond Id entifying Spend Local Enhanced Service Integration/standard within partners’ services

38. “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

39. 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)

40. ‘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)

41. Aims to deliver the highest quality healthcare services to the people of Scotland

43. 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

45. 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

46. 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

47. 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

48. 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

49. Moving forward Enabled professionals – education/training Empowered patients – supported self care Maximise best use of information technology/eHealth

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

52. Effective leadership is key …requiring courage and resolve….

54. Effective teamwork essential….