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



Research commissioned by NHS Health Scotland explored motivators and barriers to engagement with the Keep Well programme. The report Strategies for Reaching the Target Population describes five broad approaches that can be tailored to specific target populations to enhance reach and engagement.

Practice-based approaches:

Mostly centred around letters and telephone calls. However, opportunistic contacts are key. Such as:

  • Reception staff identify eligible patients when they arrive at the practice and offer linkages to other supports/services.
  • Reception staff offer patients calling to arrange specific types of appointment (ie smear or BP check) an extended appointment to access further support at the same time.
  • Introduce flags/prompts on patient records to facilitate ad hoc engagement.
  • Each eligible patient is provided with an appropriate information leaflet by a health care professional when they visit the practice.

Local authority/private sector partnership approaches:

Located within the local authority or private sector, and working in partnership with the NHS. For example NHS Lanarkshire partnered with a private provider (ReferToUs), and NorthLine (North Lanarkshire Council call centre).

Community-based approaches:

Reach and engagement may be facilitated by an external community-based organisation. This may also be pivotal in the provision of services following onward referral, e.g. health coaching provided by the Dundee Healthy Living Initiative.

Outreach approaches:

Reach and engagement are facilitated through outreach workers, usually employed by the NHS. Outreach workers may support a person through their care pathway to help support adherence. Flexibility is important. Home visits, out of hours availability and high visibility in the local community have proven effective in engaging patients. For example, in Edinburgh outreach workers work alongside nurse case managers.

Wider NHS approaches:

Reach and engagement are facilitated by other groups within the wider NHS community, e.g. NHS 24 in Edinburgh; community pharmacists.

NHS Health Scotland maintains a practitioner intervention resource and a record of reported activity which provide assistance on methods of engagement and involvement.