Chapter 5 5.1 Overcoming Barriers to Accessing Healthcare Services the Keep Well Pilot Inequalities in access to NHS services were first described by Dr Julian Tudor Hart in the 1970s. 1 He postulated the inverse care law to describe the situation where the availability of good medical care tends to vary inversely with the need for it in the population served. Keep Well is a national pilot funded by the Scottish Government that aims to address the inverse care law in areas of socio-economic deprivation. The goals are to identify people most at risk of developing heart disease or stroke in deprived areas, and to offer help with quitting smoking and/or losing weight, and medication to lower cholesterol and blood pressure. Keep Well also links people to mainstream services for mental health, employment advice, benefits advice and social work support where appropriate. The Lanarkshire Keep Well service includes some innovative service delivery approaches that aim to address barriers to accessing healthcare in deprived areas. People in the Keep Well target population (aged 45 64 years) that fail to respond to a postal invitation are followed up by telephone or home visits. During a home visit, the outreach workers can have a discussion about health issues and can arrange a Keep Well appointment. Up to January 2011, the Keep Well outreach service in Lanarkshire managed to recruit over 5,000 people to the service at an average cost of just over 60 per person recruited. The people recruited through outreach were statistically more likely to be male, more likely to smoke and more likely to live in an area of socio-economic deprivation; these are all factors that are associated with a higher risk of cardiovascular disease and other health problems. Some in-depth local qualitative research has shown that most of the people recruited to Keep Well through outreach required little by way of persuasion to make and attend an appointment. Rather, they required a little extra effort over and above routine letters and phone calls. The Keep Well service in Lanarkshire has now been mainstreamed within the community nursing as was originally described in the NHS Lanarkshire Long Term Conditions Strategy. The outreach team has been retained as a parallel service to support people to attend the community nursing treatment room service, from where Keep Well health checks are now delivered. 45
Key Points Outreach workers have been employed through Keep Well in Lanarkshire to support people in overcoming barriers to accessing preventive healthcare services. The people recruited to Keep Well appointments through outreach had characteristics that are associated with a higher risk of cardiovascular disease and other health problems. Most people welcomed the intervention of outreach workers and many only needed a little extra support to make and keep their Keep Well appointment. Priorities for Action The ongoing work of the outreach team should be supported to help embed the anticipatory care ethos of Keep Well within the NHS Lanarkshire treatment room service. By its nature, outreach is an individually-targeted approach to engagement. Other community-based approaches to Keep Well engagement should be considered in the future to complement the outreach work, particularly if the target community can be well defined. Further refinements to the Keep Well service model in Lanarkshire should be considered once the findings from the national evaluation emerge over the next few years. References 1 Hart JT. The Inverse Care Law. The Lancet 1971;1(7696):405-12. Dr Brian O Suilleabhain Consultant in Public Health Medicine Email: brian.osuilleabhain@lanarkshire.scot.nhs.uk Telephone: 01698 858218 46 Public Health 2011/12
5.2 Dementia Services in Lanarkshire The Annual Report of the Director of Public Health for Lanarkshire 2010/11 made clear that dementia is a key public health priority. 1 Since last year s report, the multi-agency Lanarkshire Dementia Strategy Implementation Group has continued to co-ordinate the development and improvement of services for people with dementia by implementing Scotland s National Dementia Strategy. 2 Prevalence Alzheimer Scotland estimates that there are over 9,250 people living with dementia in Lanarkshire, and that this will double over the next 25 years. 3 All GP practices in Lanarkshire have a dementia register, with over 4,093 people registered, exceeding the Scottish Government performance target for dementia diagnosis in 2010/11. Progress A mapping exercise has been undertaken across Lanarkshire to benchmark all services against the Standards of Care for Dementia in Scotland, and the resultant action plan will assist comprehensive improvement. 4 Work is ongoing to increase public understanding of dementia and to reduce the associated fear of the diagnosis. A Worried About Your Memory Campaign was launched in Lanarkshire in June 2012, providing first point information and advice in collaboration with the Dementia Helpline. Helping people live well with dementia requires a much wider community approach. Examples of actions include a pilot programme in Motherwell to support the town centre to become a dementia friendly community promoting awareness, access and support, and, in collaboration with Sport Relief and Motherwell Football Club, a football reminiscence programme using sporting heritage to improve the quality of life for people with dementia. Post-diagnostic support for people living with dementia is a priority, with local actions including dementia cafés and a pilot post-diagnostic support programme in the Wishaw locality supported via the North Lanarkshire Dementia Demonstrator Site. The Scottish Government s Change Programme continues to assist the redesign of services and to develop integrated health and social care with a focus on older people, including those with dementia. Around 400 people living with dementia in Lanarkshire are estimated to be under 65 years of age, 3 and the Young Onset Dementia Team has been expanded to become multidisciplinary and includes staff from nursing, occupational therapy, psychology and psychiatry. An extensive programme of workforce development is underway, utilising Promoting Excellence as the competency framework to ensure the Lanarkshire workforce has the skills and knowledge to provide quality care for people with dementia. 5 47
Nine Dementia Champions are supporting a wide range of action to improve the care of people with dementia in acute settings, along with an Acute Liaison Psychiatrist and Nurse Consultant for Dementia. Good progress has been made in Lanarkshire in increasing public awareness to care and treatment and improving primary care, community and acute services. However, there remains much to do. Key Points It is estimated that 9,250 people in Lanarkshire have dementia. The number of people with dementia is expected to double over the next 25 years. Productive and co-ordinated partnerships are essential to the development and delivery of services for people with dementia. Priorities for Action Continue to focus on support for reducing risk while also developing services for people with dementia. Continue work to address stigma and discrimination. Continue to promote understanding of dementia among the population and dementia friendly and capable communities. References 1 Department of Public Health, NHS Lanarkshire. Public Health 2010/11. The Annual Report of the Director of Public Health. Bothwell: Lanarkshire NHS Board, 2011. www.nhslanarkshire.org.uk/ Services/PublicHealth/Directors-Annual-Report-2010-2011/Pages/default.aspx (accessed 16 June 2012). 2 Scottish Government. Scotland s National Dementia Strategy. Edinburgh: Scottish Government, 2010. www.scotland.gov.uk/publications/2010/09/10151751/0 (accessed 16 June 2012). 3 Alzheimer Scotland website statistics: Number of people with dementia in Scotland 2012. www.dementiascotland.org/news/statistics-number-of-people-with-dementia-in-scotland/2012/ (accessed 16 June 2012). 4 Scottish Government. Standards of Care for Dementia in Scotland. Edinburgh: Scottish Government, 2011. www.scotland.gov.uk/publications/2011/05/31085414/0 (accessed 16 June 2012). 5 Scottish Government. Promoting Excellence. Edinburgh: Scottish Government, 2011. www.scotland.gov.uk/publications/2011/05/31085332/0 (accessed 16 June 2012). 48 Public Health 2011/12
Dr John Logan Consultant in Public Health Medicine Email: john.logan@lanarkshire.scot.nhs.uk Telephone: 01698 858241 Kevin O Neill Public Mental Health & Wellbeing Development Manager Email: kevin.oneill@lanarkshire.scot.nhs.uk Telephone: 01698 366750 Dr Jennifer Borthwick Clinical Director Old Age Psychiatry Email: jennifer.borthwick@nhs.net Telephone: 01698 210021 Jim Wright Mental Health & Learning Disabilities Unit General Manager Email: jim.wright@lanarkshire.scot.nhs.uk Telephone: 01698 366690 Acknowledgement: Lanarkshire Dementia Strategy Implementation Group 49
5.3 Salus NHS Lanarkshire s Occupational Health, Safety and Return to Work service (known as Salus) has headquarters in Beckford Street, Hamilton and departments at all three acute hospitals across Lanarkshire. Broadly, occupational health is about the interaction between work and health. Evidence abounds that work is good for physical/mental health and wellbeing. Conversely, unemployment is associated with poorer wellbeing. 1 Occupational health seeks to maximise individuals opportunities to benefit from healthy and rewarding work while not putting themselves or others at risk. 2 The Scottish Government recognises the importance of this and set a standard for NHS staff absenteeism in 2009. Early Access to Support for You (EASY) service A HEAT target was set by the Scottish Government for NHS boards to achieve an annual sickness absence rate of 4% from March 2009. A concerted effort has been made by human resources, occupational health, local and senior management, and staff side representation to achieve this sickness absence rate within NHS Lanarkshire. The EASY service provides early, targeted support to employees and their managers during sickness absence. EASY adopts a holistic approach known as the bio-psycho-social model of health as recommended in the report Working for a healthier tomorrow. 3 Salus is committed to quality management. It has been accredited with ISO 9001:2008 for over ten years and has completed its submission for the recently introduced Safe Effective Quality Occupational Health Service (SEQOHS) accreditation, which it expects to receive soon. The big picture In addition to work for NHS Lanarkshire, Salus provides its services to public, private and third sector organisations. This also includes vocational rehabilitation services to a diverse range of clients including those absent from work, those employed and at risk of absence, and those who are unemployed and seeking work. The multidisciplinary team at Salus has now grown to over 150 staff, with offices in Lanarkshire, Glasgow, Ayrshire and Fleetwood in Lancashire. EASY signposts the employee to appropriate support services, including counselling, physiotherapy, occupational health, human resources and occupational therapy. Figure 5.3.1 shows the percentage of working hours lost to sickness over each of the last five years. This shows that, following the introduction of EASY in 2009, there has been a sustained reduction in sickness absence. 50 Public Health 2011/12
Figure 5.3.1 Sickness absence rates in NHS Lanarkshire before and after the introduction of EASY 7% % of working hours lost to sickness 6% 5% 4% Pre-EASY 2007/08 Post-EASY 2008/09 Post-EASY 2009/10 Post-EASY 2010/11 Post-EASY 2011/12 HEAT standard 3% May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Source: Scottish Workforce Information Standard System (SWISS) Staff influenza vaccination programme 2010/11 saw an uptake of 33% for NHS Lanarkshire staff flu immunisation. While this represents a 3% improvement in uptake on last year, and an 18 23% increase in uptake from previous years, it remains short of the Scottish Government 40% uptake target. Figure 5.3.2 shows vaccination uptake by staff group. When broken down in this way, uptake is noted to be very high in managers while frontline medical/dental and nursing staff have lower uptake rates of 36.4% and 27.8% respectively. Staff flu immunisation, and in particular improving uptake in frontline clinical staff, will continue to be a priority in the coming year. Figure 5.3.2 Uptake of influenza vaccination by staff in NHS Lanarkshire, by staff group, 2011/12 100% Percentage uptake 80% 60% 40% 20% 0% Managers Assoc. health prof. Health science Medical & dental Support services Admin. & clerical Nursing & midwifery Other therapeutic Source: Salus 51
Key Points Salus Occupational Health, Safety and Return to Work service is part of NHS Lanarkshire. EASY has played a significant role in reducing staff sickness absence levels. Overall staff influenza vaccination rates increased to 33% in 2011, but further work is required to boost uptake in specific subgroups such as doctors and nurses. Priorities for Action Continue to assist NHS Lanarkshire in reducing staff sickness absence. Increase staff influenza vaccination uptake, particularly in frontline medical and nursing staff. Achieve SEQOHS accreditation. References 1 Waddell G. and Burton K. Is Work good for your Health and Wellbeing. London: The Stationary Office, 2006. 2 Faculty of Occupational Medicine website. www.fom.ac.uk (accessed 1 May 2012). 3 Black C. Working for a healthier tomorrow. London: The Stationary Office, 2008. Dr Imran Ghafur Clinical Director Occupational Health and Safety Email: imran.ghafur@lanarkshire.scot.nhs.uk Telephone: 01698 206348 52 Public Health 2011/12