The Scottish Government

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

% of people aged 45-60 in Paisley with risk data populated within CDR, broken down by deprivation status.

% of missing data for each variable.

User satisfaction.

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

% of population who meet the standard for CV risk score at exit from intervention.

% of population who experience a reduction in their CV risk score between entry to and exit from intervention.

% of population who meet the standard for CV risk factors at exit from intervention:

• Blood pressure status
• Total serum cholesterol
• Smoking status
• Physical activity (compliance with recommendation for active living or regular exercise)
• Weight
• BMI
• Waist circumference
• Alcohol intake
• Psychological wellbeing

% of population who experience positive change in CV risk factor between entry to and exit from intervention:

• Measures as defined above for standards and including cigarettes per day

% of population eligible to be on certain medication receiving appropriate pharmacological therapy at exit from intervention (may be measured within Unmet Need pilot):

• % eligible on antiplatelet
• % eligible on betablocker
• % eligible on ACE inhibitor
• % eligible on statin

% of population are started on appropriate medication between entry to and exit from intervention:

• Medications as defined above (may be measured within Unmet Need pilot).

% of eligible population who gain access to intervention, broken down by gender, disability, age, diagnosis, setting and deprivation status:

• % of those at high risk who are invited to health coaching service

• % attended health coaching service
• % referred to HaHP and non- HaHP funded micro-interventions
• % attended micro-interventions
• % adhered to micro-interventions
• % referred/prescribed to maintenance services/activities

Number and % of people attending community development activities from Depcat 6 & 7.

Number, range and adequacy of available services.

Number of appropriate services with an agreed Service Level Agreement.

% of priority gaps filled, as identified by mapping exercise.

% split of investment in new services by HaHP/partners.

Satisfaction with Health Behaviour Change Network amongst Health Coaches.

Satisfaction with available services amongst Health Coaches and users.

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

% of people in Paisley who are identified by CDR as having CHD compared with LHCC records, broken down by deprivation status.

% of missing data for each variable.

User satisfaction.

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

% of population who meet the standard for CV risk factors at exit from intervention:

• Blood pressure status (<140/90mmHg, 130/80mmHg in diabetics)
• Total serum cholesterol (<5mmol/L)
• Smoking status (non/ex smoker)
• Physical activity (compliance with recommendation for active living or regular exercise)
• Weight
• BMI (18.5-24.9)
• Waist circumference
• Alcohol intake (²21 men, ²14 women)
• Psychological wellbeing ( HADS anxiety and depression scores <11, absence of self-reported stress, mean wellbeing score for population)
• Shuttle walking test performance: number of shuttles, peak heart rate, rating of perceived exertion

% of population who experience positive change in each CV risk factor between entry to and exit from intervention:

• Measures as defined above for standards and including cigarettes smoked per day

% of population eligible to be on certain medication receiving appropriate pharmacological therapy at exit from intervention:

• % eligible on antiplatelet
• % eligible on betablocker
• % eligible on ACE inhibitor
• % eligible on statin

% of population who are started on the appropriate medication between entry to and exit from intervention:

• Medications as defined above

% of eligible population who gain access to intervention, broken down by gender, disability, age, diagnosis and deprivation status:

• % referred to health coaching service
• % attended health coaching service
• % referred to non-exercise based services
• % referred for exercise tolerance testing
• % undertaking exercise screening
• % referred to phase III or IV physical activity opportunities
• % attended phase III or IV
• % adhered to phase III or IV
• % referred/prescribed to maintenance physical activity

Number, range and adequacy of exercise-based CR services across multiple settings: hospital, community, home, local authority. Including number of additional venues available for exercise, and volume of exercise sessions on offer out with the hospital.

Number of instructors qualified to deliver phase IV CR exercise.

Number of non-hospital locations at which the CR menu can be accessed.

Number of non-hospital locations where any part of the menu is delivered, broken down by setting (community, LA).

Satisfaction with available services amongst health professionals and users.

B3 Delivery of effective phase III cardiac rehabilitation (comprising structured exercise and 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.

% of population who meet the standard for CV risk factors at exit from intervention:

• Blood pressure status (<140/90mmHg, 130/80mmHg in diabetics)
• Total serum cholesterol (<5mmol/L)
• Smoking status (non/ex smoker)
• Physical activity (compliance with recommendation for active living or regular exercise)
• Weight
• BMI (18.5-24.9)
• Waist circumference
• Alcohol intake (²21 men, ²14 women)
• Psychological wellbeing ( HADS anxiety and depression scores <11, absence of self-reported stress, mean wellbeing score for population)
• Shuttle walking test performance: number of shuttles, peak heart rate, rating of perceived exertion

% of population who experience positive change in each CV risk factor between entry to and exit from intervention:

• Measures as defined above for standards and including cigarettes smoked per day

% of population eligible to be on certain medication receiving appropriate pharmacological therapy at exit from intervention:

• % eligible on antiplatelet
• % eligible on betablocker
• % eligible on ACE inhibitor
• % eligible on statin

% of population who are started on the appropriate medication between entry to and exit from intervention:

• Medications as defined above

Comparison of death and hospital readmission rates amongst different user groups (attenders/non-attenders/adherers/non-adherers etc).

% of eligible population who gain access to intervention, broken down by gender, age, diagnosis and deprivation status:

• % referred to CR
• % referred to part of menu
• % referred to phase III
• % uptake of phase III
• % adherence to phase III
• % referred/prescribed to phase IV

Output and satisfaction measures as for B2.

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

% of 45-60 year olds who are aware of their risk level of CHD.

% of eligible population who gain access to intervention, broken down by gender, age, diagnosis and deprivation status:

• % of those at high risk who are invited to health coaching service

• % attended health coaching service
• % referred to HaHP and non- HaHP funded micro-interventions
• % attended micro-interventions
• % adhered to micro-interventions
• % referred/prescribed to maintenance services/activities

Number and % of people attending community development activities from Depcat 6 & 7.

% of priority gaps filled, as identified by mapping exercise.

Satisfaction with available services amongst Health Coaches and users.

Number of individuals who attend capacity building activities.

Number of targeted group events undertaken e.g. per quarter / year.

Number of training events offered to partner organisations.

% of budget going on capacity building activities

% sample of target group who are aware of the services available.

Number of media items in public domain

Column inches printed and prominence.

C2 Wider policy and practice is influenced by the dissemination of learning/lessons from HaHP.

HaHP is involved in the Community Health Partnership and is involved in the Joint Health Improvement Plan of the Health and Social Care, Community Planning Partnership.

Number of key lessons adopted into policies and services of partner agencies.

Number of key lessons adopted into national policy.

Number of publications (of all kinds)/ presentations disseminated.

HHLNHaHP subsection website hits.