We have a new website go to gov.scot

Long Term Conditions Collaborative: Making the Connections - Food For Thought



Health inequality remains one of our biggest challenges in Scotland. The Scottish Index of Multiple Deprivation ( SIMD) identifies small area concentrations of multiple deprivation across Scotland. These areas, datazones, are ranked in order of most deprived (Datazone area 1) to least deprived (Datazone area 6505). The result is a comprehensive picture of relative area deprivation across Scotland.

Equally Well: Report of the Ministerial Taskforce on Health Inequalities states that the healthy life expectancy in the most deprived 15% of datazones in Scotland is 57 years for men and 59 years for women. Poorer mental health is also associated with increased deprivation and health inequality. A combination of economic, personal, social and environmental factors influence health and contribute to the fact that people living in the more deprived communities are likely to have the most complex health and social needs. They are also more likely to be high users of health and social care services at a younger age.

The Keep Well programme targets 45-64 year olds in datazone areas which fall into the 15% most deprived in the country. Through systematic targeted approaches to case finding, people who have long term conditions not yet identified on GP disease registers, or other related systems, can be identified and more effectively managed. This may include secondary prevention, pharmaceutical care, lifestyle advice and signposting to local supports for self management. At the same time those who do not yet have a long term condition but are at risk of developing one can benefit from primary prevention activity, lifestyle advice and supports for health behaviour change.

Health Coaching

Health Coaching is a way of engaging with people from communities which have identified health inequalities. Coaches discuss health behaviours, health improvement, assist people to decide whether they are ready to change or not, engage people in setting appropriate goals, support self management and promote active participation in planning and implementing behaviour change. This approach is complemented by a variety of services to tackle life circumstances and the wider determinants of health. These include money and employability advice; bereavement counselling and welfare rights/benefits advice. Community-led health initiatives are organised and led by local people who provide a range of services and social supports (e.g. stress management and volunteering), often in areas with identified health inequalities. See pages 16-27 for more information on these services.

Risk Prediction

The Scottish Patients At Risk of Readmission and Admission ( SPARRA) tool identifies people who have entered a cycle of repeat admissions to hospital in the previous three years and predicts the probability of future hospitalisation. For detailed information on SPARRA, please see the LTCC guidance note ' SPARRA Made Easy'. SPARRA is only one way of identifying people who may need proactive anticipatory approaches. Practice registers hold disease specific and prescribing information and can be used to identify people for targeted efforts to optimise primary and secondary prevention. This could be enhanced further by using markers of health inequality to identify people for targeted interventions.

Food For Thought:

  • How do you address health inequalities in your day to day practice?
  • How do you quantify and show the outcome from this work?