NHS FIFE KEEP WELL THE JOURNEY SO FAR Keep Well Margaret Bell, Keep Well Manager

Countdown TIME UP 40

Countdown 100 x = x 40 = – 240 – 1 = 9759

NHS Fife Timeline  Wave 2 of National Pilot Programme 2007  First Health Checks June 2008  Phase 1 – Mixed Model of Delivery from June December 2009  Phase 2 – Central Team delivery from January 2010-to date  Pharmacy Programme 2010-to date

Cohort  Age 40 – 64 living in SIMD 20% most deprived areas  Other Vulnerable populations  Scottish Index of Multiple Deprivation  Original cohort 17,272  Extension to age group, cohort today 25,836

NHS Fife Delivery Model  Central team of Keep Well staff employed by NHS Fife oversee, identify, engage and deliver health checks to the identified cohort and vulnerable populations.  Work from one centralised base  Peripatetic model of delivery in community venues  Service operates 8am-8pm over 7 days  Partnership with local GPs and a range of partner agencies

KW Identify and Read Code cohort KW contact identified individuals KW carry out health checks General Practice accepts clinical referrals from KW team Data entry of clinical health check After training KW staff or GP staff Accept electronic data Allow extraction of electronic clinical data GP or KW install KW data entry screens KW store extracted data KW report on data GP Partnership

Keep Well DB SCI-DC Gateway GP System Keep Well Information System (KWIS) KW Health Check ‘Out and About’ form CHI Periodic spreadsheet ISD and Local reporting SIMD Periodic spreadsheet Patient Invite letters Patient Telephone Invite Patient Telephone consultation Clinic Lists Patient Clinic Appointment KW Health Check EXISTING KEEPWELL INFORMATION PATHWAY

Keep Well DB SCI-DC Gateway GP System Keep Well Information System (KWIS) KW Health Check ‘Out and About’ form CHI Periodic spreadsheet ISD and Local reporting SIMD Periodic spreadsheet Patient Invite letters Patient Telephone Invite Patient Telephone consultation Clinic Lists Patient Clinic Appointment KW Health Check EXISTING KEEPWELL INFORMATION PATHWAY MAINSTREAM KEEPWELL INFORMATION PATHWAY CHI24 Nightly Update Electronic Data Capture on laptop

Cohort Reached Since June 2008 :  Keep Well has attempted to contact 22,631 patients  Via 47,498 contacts  29% (n=13,579) successful reach  22% (n=10,556) appointed  21% (n=9,759) attended (includes 444 patients without tracking data)

Successful Contacts

Clinical Measurements Mean Assign score = 16 % Assign score 20 or greater = 28% Mean Cholesterol measurement = 5.2 mmol/l % Cholesterol over 5 mmol/l = 54% Mean BMI = 29 % BMI in obese categories 37% Mean systolic blood pressure (BP) = 135 mm/hg % systolic BP greater than 140 mm/hg = 33%

Clinical Outcomes Referral to services (excl. General Practice) = 14%

Clinical Outcomes  12% of (n=770/6438) patients added to one or more disease registers post health check

Lipid Regulating Drugs

Evaluation Overview

Summary  Full evaluation report is available  A 12 month follow up evaluation is currently underway. Report will be available December 2011 Contact: Clare Robinson Department of Psychology Stratheden Hospital Cupar Fife KY15 5RR Tel :

Countdown IRANTRPSEPHPARTNERSHIP

Contact Details Margaret Bell Keep Well Manager Lynebank Hospital Dunfermline Fife KY11 4UW Tel: