1. Delivering anticipatory care in primary care: Lessons from a national programme in Scotland. C O’Donnell, M Mackenzie et al Universities of Glasgow & Edinburgh, Scotland.

2. Burden of ill-health. The Scottish Government, 2008. Equally Well.

3. Inequalities – a Scottish problem. Sridharan et al. Soc Sci Med 2007 65: 1942-52.

4. Determinants of inequalities.

5. Tackling inequalities. The Scottish Government, 2008. Equally Well. Least deprived Most deprived

6. Delivering for Health. Julian Tudor Hart, Glyncorrwg, Wales. Proactive case finding, preventive interventions and regular follow-up. Conducted during patient consultations and build on continuity of care and knowledge of patients. Improvement in health outcomes including 28% reduction in CHD mortality rates (over 25 years).

8. Key stakeholder interviews. Interviews conducted annually in three rounds, from late 2007 - 2009. 74 interviews. National, local and general/family practice level. Strategic and operational personnel: Directors & civil servants in Scottish Government. Programme leads. Directors of Public Health. Pilot level managers. Staff involved in service delivery. Staff in participating general practices.

9. Rationale for the programme. Programme design. 45 – 64 year olds. Living in areas of greatest socioeconomic deprivation. Focus on coronary heart disease. Delivered through family practices. Offered a health check. Medical &/or social interventions. Why? Reducing inequalities. Ministerial driver. Involvement of family practices wanted by the Minister. Risk factors for CHD common to other diseases.

10. Divides and choices General practice/primary care vs health improvement. Medical approaches vs wider social approaches. Population-wide approach vs individual targeting. Reactive care vs anticipatory care.

11. General practice vs health improvement Not the original model – “bolted onto general practice”. Implications for long-term sustainability. May widen inequalities if worried well accept more readily. Building on previous health improvement initiatives. Strengthening link between family practice and non-health sectors.

12. Medical vs wider social approaches. Clear tension between medical and social models. Politicians need quick return for effort. Focus on medical interventions more than social interventions. Recognition that programme has to identify and respond to behavioural and social issues in order to be a success.

13. Population approach vs individual targeting. Confusion as to whether it should be population-level or targeted at individuals. Different models: –Offered to all in the practice age band regardless of socioeconomic status. –Offered only to those in practice living in most deprived areas. May attract worried well. May widen inequalities. Have to be able to justify large scale primary prevention approach.

14. Reactive vs anticipatory care. Opportunity to do things differently. “It tends to be a luxury for the NHS because we’re caught up in dealing with the burden of reactive patients that we see coming through the door.” (B008, L33-35) Recognition that patients with complex health & social needs may not be ready for this.

15. What is anticipatory care? No shared understanding or definition of anticipatory care. “I mean I suppose we’re, we’re still struggling with what we truly are meaning by anticipatory care, and it gets bandied about without people necessarily being concise about what we do mean by that” N013 L340-343.

16. Respondents’ definition. Often seen in the context of prevention. But Broader – encompassing primary & secondary prevention. Included treatment. Early detection of disease. Anticipation of future problems - to prevent the “coming tsunami” of disease.

17. Conclusions. Embedding of anticipatory care approaches in family practice raises important challenges. Clearer, shared definitions would help. Medical and social models must be integrated if anticipatory care is to impact on health inequalities. Accept worried well will participate, but address issues of targeting the “hard-to-reach”. Otherwise, potential to widen inequalities. Need for short-term political gain may run counter to the original ethos of anticipatory care.

18. My colleagues. Mhairi Mackenzie, Maggie Reid, Urban Studies, University of Glasgow. Fiona Turner, Yinging Wang, Julia Clark. General Practice & Primary Care, University of Glasgow. Sanjeev Sridharan, University of Toronto. Steve Platt, University of Edinburgh.