Scottish Government

3. What will HaHP do to achieve its intended outcomes?

The intended outcomes will either generate new knowledge, or take existing knowledge and develop it further in its application.

Intended outcomes

Dimension A

A1 A Central Data Repository ( CDR) that enables implementation of a targeted primary prevention system through primary care.

A2 A primary prevention intervention for Paisley residents aged 45-60 years that effectively reduces the targeted population's risk of cardiovascular disease.

Dimension B

B1 A CDR that enables implementation of a targeted secondary prevention system through primary care.

B2 Improvement of the cardiovascular health of Paisley residents who already have identified coronary heart disease and who are currently maintained in primary care.

B3 Delivery of effective 'phase III' cardiac rehabilitation (comprising structured exercise and other risk factor modification) in a community setting for appropriate patients. At the same time a safe and effective cardiac rehabilitation service is designed for the highest risk patients ( i.e. the most ill CHD patients) who are referred to the cardiac rehabilitation programme at the Royal Alexandra Hospital, Paisley.

Dimension C

C1 Maximum participation of target population in both A and B interventions using a social marketing approach and innovative community planning workforce development.

C2 Influence on wider policy and practice through dissemination of learning/lessons from HaHP.

Central Data Repository ( CDR)

The IT based Central Data Repository ( CDR), successfully developed in Phase 1 will play an important role in Phase 2. Drawing on population data, services can be directed to those most in need and the CDR will work as a powerful public health tool in helping to address health inequalities relating to life circumstances. The current policy context in Scotland promotes greater responsiveness to patient needs and it is proposed that an equity audit be carried out in Paisley with a view to improving access and services to vulnerable populations and to promote patient involvement. The CDR will enable multi-practice audits to examine equity between population groups as well as between practices. Annex 2 provides further information on the functioning of the CDR.

Dimension A

Evidence

• Recent research suggests that CHD registers in primary care settings can impact positively on patient care and outcomes. In these settings, evidence exists that CHD registers have supported evidence-based practice and favourable health outcomes. However, while some of the potential benefits of CHD registers have been identified, further work is required to determine how the HaHPCDR can support changes in risk factor management and clinical decision-making.
• The 2004 Department of Health (DoH) public health White Paper, Choosing Health: Making Healthy Choices Easier, states that:
• evidence supports a health trainer role in helping people to change and maintain healthier lifestyles
• the 'self-care' or 'expert patient' approach has been successful with people who are ill and that this approach should be expanded into the prevention field enabling people to take greater control of their own health
• further inequalities in health can be prevented through identifying people who may be at risk of developing chronic diseases or supporting people with existing chronic conditions. This sort of approach has been shown to be effective in work with people in their 50s - an age at which people often begin to experience illnesses that can develop into chronic disease and is a time when people's motivation to improve their own health increases.
• Much of what the DoH proposes fits with the HaHP Phase 2 approach for Dimensions A and B. HaHP proposed a health coach approach prior to the launch of the White Paper and subsequently used the DoH's description of the health trainer to develop further its own health coach concept.

Intervention

• The Central Data Repository will be used to support the delivery of a targeted primary prevention intervention through primary care. The CDR extracts all relevant data from the GPASS systems.

A primary prevention intervention will be designed and implemented for people aged 45-60, with the intention of reducing that population's risk of cardiovascular disease. For deprived communities staff from an NHS Argyll and Clyde unmet need pilot project, funded by the Scottish Executive, will work with staff from HaHP to increase uptake through the use of community development approaches. Individual participants will have their cardiovascular risk score calculated. Those found to be at increased risk will be offered a service that helps reduce their risk through a model of health coaching. Those whose scores do not indicate increased risk will be given advice to help them maintain their current low level of risk. People whose individual scores do not suggest increased risk but who live in area with Depcats 6 or 7 will be offered a positive mental health promotion intervention. This component will be developed subject to the recommendations of a systematic review of positive psychology literature that will be completed by the Glasgow Centre for Population Health early in 2006.

In the first six months of Phase 2 a mapping exercise and needs assessment will be carried out that will enable identification of current services and opportunities in Paisley in relation to CHD risk factors and identify the service needs of the target population (45-60 year olds). This will subsequently inform the decision process around the development of interventions and services required to strengthen the overall preventive effort in Phase2.

Health coaching will engage those at risk in the target population, help maintain them on their planned lifestyle changes and plan with the individual how they will adhere to this on a long-term basis including sign-posting to other relevant services, as identified by the mapping process. This will include sign-posting to local alcohol services should that be found to be required. Questions around alcohol consumption will be asked as part of the enquiry relating to diet with health coaches having a basic level of knowledge and understanding about alcohol and its impact on health.

A lay mentoring approach will also be used within communities to aid healthy lifestyle promotion in relation to tobacco, physical activity and healthy eating, helping to overcome some of the barriers that this target group faces through empowerment and support. Evaluation of this approach will add to the evidence base in this largely untested area.

Health coaching roles and staff numbers will be clarified by October 2005. A competency framework for health coaching along with innovative workforce development will be developed with NHS Education Scotland, NHS Health Scotland and others. The workforce is likely to be drawn from HaHP development staff, Unmet Need staff, lay mentors, NHS and local authority staff. This training approach will inform any additional recruitment requirements of the health coaching role/function.

In year 1 a computer based Health Behaviour Change Network ( HBCN) will be developed that will capture details of all the available services in a web based tool that can be used by the Health Coaches to signpost individuals to suitable services. HaHP will work with the Big Lottery Fund development of the CHD and Stroke MCNs on the Web project that is seeking synergies with related health care projects.

Dimension B

Evidence

• The weight of evidence indicates that exercise-only cardiac rehabilitation reduces all cause mortality by 27%, cardiac death by 31% and a combined end-point mortality, non-fatal myocardial infarction and revascularisation by 19%.

• Evidence is being sought as to whether it is possible to create a systematic and integrated programme to improve cardiovascular health for those with existing heart disease.
• It has been found that effective and safe phase III cardiac rehabilitation can be delivered in a community setting. It is recommended for safe practice that cardiac rehabilitation services for the highest risk patients ( i.e. the most ill CHD patients) should be delivered in a hospital setting.

Intervention

• An intervention will be designed and implemented that aims to improve the cardiovascular health of patients who only attend primary care and already have been identified with coronary heart disease. This will engage the patients in comprehensive secondary prevention and rehabilitation through the most appropriate and desired setting using the health coaching model. This rehabilitation will also include support from trained lay mentors to encourage adherence and give added social support.

• The cardiac rehabilitation service will be redesigned to deliver menu-based phase III cardiac rehabilitation in a community setting and provide a safe and effective cardiac rehabilitation service for the highest risk patients ( i.e. the most ill CHD patients) in a hospital setting. Successful delivery of this intervention requires ongoing partnership working with the Local Authority and other stakeholders to develop a broad range of sustainable exercise opportunities.

Dimension C

Evidence

• It has been shown that the provision of information and 'persuasive messages' (as in social marketing) can increase individuals' knowledge of health risks and appropriate action.

Intervention

• Dimension C will

• Help to deliver A and B through social marketing approaches incorporating co-branding of HaHP and the national Healthy Living campaign.
• Facilitate learning and development for the target population and those providing interventions based on lessons from Phase 1 and expanding to include positive mental health and wellbeing.

As Phase 2 of HaHP will concentrate on building the capacity of both the target group identified and that of partners who can help facilitate heart health change, there will be considerable emphasis on education and learning within these distinct areas. The project will work closely with Renfrewshire Council on their developing 'Community Learning and Development Strategy' and in integrating HaHP learning with the local Community Learning Plans. Workforce development activity will be aimed at those working within the direct and wider HaHP field to deliver Phase 2 of the project. The purpose of this area is to build the capacity of community planning partners in relation to heart health promoting needs.

A training needs assessment will take place at the start of Phase 2 and solutions generated to support the capacity of these professionals according to need and setting. This could include topics such as CHD awareness and risk factors for non health related staff, or motivational interviewing for those performing a health coaching role.

• Influence policy and practice through dissemination of learning from Phase 1, the Transition Phase and Phase 2 as it progresses.

The following organisations have been identified as potential agents for enabling capacity building in respect of Dimension C:

a) Social Marketing:

• Local press and media
• Liaison with National Healthy Living Campaign
• ASH Scotland
• Scottish Executive - Press Health Team
• NHS Health Scotland
• Scottish Community Diet Project
• National Physical Activity Co-ordinator

b) Education/Learning:

• Community Learning & Development within Renfrewshire Council
• Integrated Community Schools within Renfrewshire Council
• NHS Argyll and Clyde Learning and Development
• Paisley University and Reid Kerr College
• Local education centres ( e.g. adult learning centres, RCVS)
• NHS Health Scotland
• NHS Education Scotland
• Centre for Confidence and Wellbeing

c) Dissemination

• NHS Health Scotland - Heart Health Learning Network
• All local contacts listed above in a) and b)
• National organisations ( e.g.BHF, COSLA, CHSA, Diabetes UK, Heart of Mersey, Braveheart)

Annex 3 gives further details on the planned activity for Dimensions A, B and C.