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Recommendations for service planners and providers
The "PRaCTiCe" mnemonic developed by SDHI provides an extremely useful framework in which to consider the findings from the other pilot studies. Taken together, the Tayside Health Board pilots and the pilots conducted by Greater Glasgow Health Board and the former Argyll and Clyde Health Board not only support many of the characteristics identified by the SDHI evaluation, but also allow this framework to be further developed and refined.
The outcome of this further development and refinement is a set of eight recommendations which can be used when developing services designed to improve access by those in the most deprived areas who have unmet needs.
1. Shape and adapt services to fit users - the services provided should be shaped by the communities and populations that are to receive the service. This point is highlighted by the observation made by one of the unmet needs project managers, Heather Sloan, who stated "People are not hard to engage; rather it is the process of engagement which is not suited to the target population".
For example, the coronary heart disease patient journey project in Paisley utilised a range of creative methods to engage potential clients such as attendance at local social activities, slots on community radio and attendance at bookmakers and public houses . These methods were all part of a unique targeted community approach which was developed following the failure of the "Have a Heart Paisley" initiative to engage with the most deprived sections of the population in Paisley.
2. Deliver services at appropriate times - Issues of childcare, finances and often chaotic lifestyles mean that the timing of service delivery needs to be flexible.
The "Health Inequalities in the Homeless" unmet needs pilot in Tayside sought to provide an outreach primary care service to homeless people living in hostels. In its efforts to adopt a preventative approach, timing of the service delivery was crucial in order to engage with clients, especially given their often chaotic lifestyles. Therefore, by providing a range of contact options such as drop-in clinics, one-to-one contracts and informal attendance at hostels, the service was able to be flexible in the timing of its services.
In Greater Glasgow, the "Stress Centres" unmet needs pilot operated with a 'refer or self-refer' contact option, thereby increasing the flexibility of its service delivery times for clients. In addition, by locating the centres in the local community, this increased their accessibility and allowed clients to visit more regularly than might have been the case had they been located more centrally.
3. Deliver services in the community - services should be prepared to be mobile to reach their intended recipients. This may mean moving out of the buildings and places where they are traditionally delivered.
In Tayside, the methodology used by the "Uptake of Cardiology Services" unmet needs pilot had two key features, both concerned with the delivery of services in the community. Firstly, the specialist cardiology clinic was delivered in a community venue or the clinical mobile unit. Secondly, opportunistic cardiology assessment was used whereby the identification of potential patients was made through attendance at local events such as gala day, bingo halls and mosques.
In Greater Glasgow, the West of Scotland breast screening service implemented a variety of interventions that evidence suggested might be of benefit in increasing attendance. For example, they utilised a personally directed intervention method, using letters to personally invite clients to participate. In addition, they used community seminars to engage with clients and tailored their other information material to suit clients, for example by producing a DVD aimed at ethnic minority populations.
4. Integrate with other services - service delivery should be integrated as should access to services at the point of delivery.
In Greater Glasgow, the "Primary Care Mental Health Teams" unmet needs pilot project utilised a 'stepped' or 'matched' care model which, in practice, meant that a range of interventions were offered to clients such as advice, information, group and individual therapies. Through the use of both standard GP referral and self-referral, the service was able to match the needs of clients to an appropriate and timely intervention.
In Argyll and Clyde, the "Health Advocacy" unmet needs pilot, in seeking to utilise the services of an advocate worker to facilitate access to appropriate health services for people with learning disabilities, relied on the availability of the appropriate health services at the time of contact to measure improvements in service use.
5. Provide patient pathway support - services should provide consistent support along the whole patient pathway.
In Tayside, the "Breastfeeding" unmet needs pilot, by seeking to provide women on low incomes with additional information and support to improve breastfeeding initiation and duration, sought to deliver outcomes that evidence showed were valued by clients. In this case, an infant feeding survey carried out in 2000 found that while most women stopped breastfeeding in the first six weeks, 90% of those who stopped in the first week wished that they had continued for longer. Results from the pilot showed a 9% increase in intervention areas and the service received high ratings of satisfaction by those who used it, further supporting the suggestion that the outcomes were valued by clients.
6. Use a personal approach - services should support and facilitate links and relationships between specific workers and specific service users so that their needs are met in a way that is personal, respectful and non-judgemental.
For example, the "Health of Homelessness People" unmet need pilot in Argyll and Clyde identified that the crucial factor in the success of the pilot were the relationships that nurses built with colleagues in other services and clients that were potentially vulnerable. These relationships allowed the development of trust with clients, greatly facilitated the timeous access to services and enabled nurses to work co-operatively with officers from other services.
In Argyll and Clyde, the "Improving Looked After and Accommodated Children's ( LAAC) Access to Services" pilot sought to establish a specialised nursing service for LAAC in residential care. The importance of seeing the same individual over time was highlighted by results of a service analysis questionnaire that showed that the opportunities to build up relationships between the nurses and young people was seen as a real strength of the intervention. In addition, the suggestions to improve the service drop-in opportunities and increase the amount of group-work and interactive learning again highlight the importance of aspects of continuity in successful service provision.
7. Be persistent - in order to overcome the significant barriers to engagement with services, those services should have an incrementally stepped approach to engagement, doing whatever is necessary to overcome barriers such as illiteracy and poor organisational skills. It is therefore important that to support staff with models of practice/ training around how to engage recipients.
In Tayside, the "Improved Access to COPD Services" unmet needs pilot involved the use of personal contact methods to engage with potential clients. In the case of the pilot, project nurses wrote letters, telephoned and visited patients in deprived areas to attempt to increase access to Chronic Obstructive Pulmonary Disease ( COPD) services. The success of this proximity approach was evidenced by the increase in COPD clinic attendance following contact.
Similarly, another Tayside project, the "Outreach Service for Gypsy Travellers" unmet needs pilot found that initially, a lack of trust by potential service users proved a significant barrier to identifying needs and accessing services. This had led to a lack of continuity of care experienced by this population in accessing healthcare. However, as a result of the persistent approach of the project manager in attempting to build relationships, the project encouraged use of the patient held record of personal health, which acts as a transportable medical record and can be used when contacting healthcare services across Scotland. In this way, a degree of continuity of care was developed to allow health professionals access to healthcare information about the individual and identify gaps in provision.
8. Provide services that users value - services should adopt intervention models and approaches that involve working with service recipients to identify goals.
The importance of this is evidenced by the "Oral Health Promotion for Vulnerable Children" project in Greater Glasgow. This delivered clear benefits with its aim of improving the oral health practice of children in this group. By undertaking a variety of activities, from providing additional services to nurseries, to increasing support to parents and carers of 0-3 year olds through a range of local initiatives such as weaning fairs and cooking classes and by establishing clear links with primary schools through the enhanced provision of fruit in schools, the service was able to not only deliver dental benefits for those who participated, but deliver a range of health benefits that were valued by those who participated.
In Argyll and Clyde, one of the key factors cited as reason for the lack of referrals to the "Lomond Volunteer Transport" unmet needs pilot was reported to be the result of a failure to deliver an outcome that was valued by clients. In the case of the project, which sought to provide a volunteer run transportation service to a local podiatry clinic, the clinic in question was already well served by a good public transport system. In addition, the stigma associated with receiving volunteer transport as opposed to being able to utilise personal transport and wariness of accepting transport from unknown volunteers were also thought to contribute to a lack of service uptake and again points to a lack of value attached to the service by clients.
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