The purpose of outreach within Keep Well
Across the four locations outreach was developed in response to the limitations of earlier attempts within the Keep Well programme to reach and engage the target population. These attempts were, largely, relatively traditional, with an initial focus on sending letters with fixed or open appointment times to targeted individuals. Practices found this method useful in engaging part of their population but not all of it. This is consistent with the findings of a review of the access literature [4] which found that appointment systems requiring people to attend a particular place at a specified time are likely to incur high levels of non-engagement amongst the most deprived. In Keep Well telephone approaches were also used to encourage attendance amongst those who had not responded to letters and patients were 'opportunistically' invited as they attended the surgery for another reason; outreach became a common feature across the programme as significant parts of the target population remained unengaged [34].
Despite the common driver of improving on these approaches, the original purpose of outreach varied between pilots. In two areas (A & B) the initial purpose was to increase the number of individuals attending for an initial health check; in the remaining two areas (C & D) outreach initially focused on the longer term engagement of individuals in health improvement interventions. Figure 1 - 'The Purposes of Outreach as part of the overall Keep Well approach' illustrates how these two purposes fit with the logic of the wider Keep Well programme with its short-term goals of health service engagement and longer term health improvement and inequality reduction. However, these initially distinct approaches blurred over time as pilots learned from each other and changed their ways of working accordingly [36]. By the time that the case-study was conducted, all pilots described their work as having these two aims.
Aims expressed in this way, however, reveal little about tacit hypotheses relating to who are perceived to be hard to engage in preventive services and why; nor about the mechanisms by which outreach interventions might be anticipated to meet their goals; nor, indeed, what the goals of practitioners might be.
The nature of outreach interventions in Keep Well
Six broad categories of intervention by those with an outreach remit were identified across the four wave 1 pilots. Figure 2 - 'Emerging Outreach Approaches' illustrates the alignement of these intervention types with the two primary purposes of outreach described above. Thus, in order to increase levels of attendance at the health check three main approaches were utilised: (1) 'doorstepping' people's homes to invite their participation or to provide health checks in situ; (2) providing support to remove psychological barriers to attendance (for example, motivational interviewing or solution-focused therapy); and (3) inviting participation of individuals encountered in community venues. To increase levels of engagement in health improvement three approaches were also taken: (1) the use of psychological approaches to facilitate lifestyle changes; (2) support to attend referrals to services within and outside the primary care practice; and (3) signposting and referral to other services (including those aimed at tackling social and structural determinants of poor health, such as welfare advice).
In describing their roles within these activities participants provided evidence, both implicitly and explicitly, of their theories about why engagement with primary prevention services was a problem for particular sub-groups of the population and mechanisms for generating positive outcomes. In the next section we explore these hypotheses and, where relevant, assess their fit with the concept of candidacy.
Seven 'problems' and their outreach 'solutions'
As outlined above, across the two purposes of outreach within Keep Well different types of outreach work were operating to solve seven non-engagement problems derived from the interview data; this mirrors the multi-faceted nature of outreach discussed earlier [13]. Figure 3 - Implicit theories of outreach within Keep Well summarises the pathways identified from problem through mechanisms to aim of intervention. Each of these is now described in turn.
Problem 1: target population do not receive their Keep Well Health Check invitation
Across the wave 1 pilots Keep Well experienced difficulties in reaching a group of patients within their target population because their contact details were incorrect. In this scenario, the message about an individual's candidacy for preventive services literally did not reach them. The limitations of existing practice registers were exacerbated in areas that were undergoing housing regeneration. In these circumstances outreach workers were therefore found to be working in the capacity of a healthcare postal worker, where health check invitations were personally delivered and practice registers updated to remove non-existent addresses and identify those who had moved on. As a result, there was a view that, over time, outreach work may provide a more realistic picture of those in 'hard-to-reach' categories by eliminating 'ghost' patients. Without this approach, the target population still to be reached and engaged would have been inflated. This problem is illustrated as follows:
"[t]here's certain barriers that we face with some of the information that we get from practices and it could be that people have moved away so you're going to empty buildings and stuff like that, or they haven't updated the practice that they have moved on to, so that kind of thing. They're hard to reach in terms of that, but in terms of going out and visiting them, they're not hard to reach."(A13)
Except where patients deliberately avoid their general practice (or avoid providing their practice with up-to-date contact details), this 'problem' could be tackled by more proactive practice efforts to update their patient registers and does not require intervention by skilled health professionals.
Problem 2: literacy or health literacy barriers preventing engagement with health checks
Given the demographics of the areas within which Keep Well was located, there was an expectation that part of the target population would have difficulties with literacy, e.g. reading letters of invitation. If telephone contact had also not succeeded then this problem could be overcome by visits from outreach workers to individuals in their homes. In addition, outreach workers reported instances where individuals were functionally literate but had not attended for a health check either because they believed that they had already had a health check (e.g. by virtue of attendance at a previous unrelated screening appointment), or because they did not understand the purpose of the health check or its place within the health system. One worker, for example, said:
"I think people need... rather than a letter going to their door and... even though we would put one of the blue Keep Well leaflets in to explain it, but it's not going into the detail that we can go into when we're at the door talking to them; it's a far better way of engaging with people rather than just sending a letter because if they've got any questions then they can just ask us right there and then we can tell them, so it is far better, definitely." (B21)
In these circumstances outreach workers can be argued to bridge gaps in understanding about preventive services and so contribute to solving the problem of health literacy, as described by Nutbeam [37].
Problem 3: work/caring commitments prevent engagement with the health check and/or subsequent health improvement interventions
Early in its implementation Keep Well had identified that one driver of non-attendance at health check appointments was the timing of appointments. In particular, feedback from patients had raised awareness of the problems experienced by the working population in attending appointments during the working day - a problem more prevalent for those in low-waged employment with little flexibility to take time out of their working day without losing income. To tackle this, some practices had made efforts to offer more flexible out-of-hours appointment times. Outreach workers were faced with a parallel access problem for those who had significant caring responsibilities and were able to offer practical assistance by providing health checks within the home. In this respect outreach workers were acting as facilitators of access to health checks. One worker, for example described the following case:
"I've been on the doorstep with a person who was a carer and [they] actually said they couldn't take forty minutes out of their day to come to the health centre, to get a bus, to do it, and to get a carer, to get someone else in to care for her son... So then we had the opportunity to say 'well, have you got forty minutes just now... because we could come in now'. That was done there and then and we identified issues when we were doing the assessment... it was like a complete sort of package of care... you weren't leaving it cold at the doorstep, you were following it through" (C2).
Problem 4: preventive health not given priority
The existing literature on inequities in access to preventive services supports the view that those living in deprived circumstances are less likely to prioritise health maintenance than those living in more affluent areas [4], borne out by the current study but it is important to note that, once outreach staff made contact with individuals, they found only a minority of individuals who expressly stated that they did not want to know whether or not they were at risk of illness. One worker said, for example "[we] do get some people that say 'no, I'm not interested, I don't want to know if I'm ill. You'll get that an odd time." (A13). Thus, the experience of outreach staff in the Wave 1 pilots was that candidacy for preventive services or for cardiovascular disease was rarely rejected outright by individuals.
On the other hand, it was often reported that patients found it difficult to find time to prioritise preventive health care. This is supported by the work of Goddard and Smith [38] who found that barriers of time that would be surmounted during a health crisis hindered the prioritisation of preventive health. For example:
"I think a lot of people that I speak to will say to me, 'If I'm sick then I'll go to the doctors.' They're busy, they've got busy lives; sometimes they've got chaotic lives and this is just another thing to do that they don't have time to do." (A15)
Outreach workers viewed pressure of time as another barrier preventing those with caring responsibilities from initial engagement in Keep Well. By visiting the homes of those with caring roles outreach staff were able to prompt individuals to consider their eligibility for Keep Well. In this way outreach was viewed as a means of highlighting candidacy for a group of individuals who have to deal with the ill-health of their parents, children and spouses on a daily basis. This translational role was deemed necessary because, as one worker said, "if you're caring for somebody... you can't think about yourself." (C5) and chimes with the long-established literature on how caring for others can be a risk factor in relation to one's one health [39, 40].
Problem 5: psychosocial barriers prevent engagement with the health check and/or subsequent health improvement interventions
For another group of patients outreach had to move beyond the role of convincing individuals of their eligibility for Keep Well, and of the benefits of primary prevention for long-term health, into tackling psychosocial problems preventing engagement. Such problems were seen as barriers to engagement with initial health checks and/or the health improvement interventions to which Keep Well referred patients following the identification of clinical risk. One outreach manager explained that:
"Our outreach workers are very skilled too at going out and signposting patients to other agencies, where the patient might not be ready to come into Keep Well initially for a health check, but need other services in there at that particular time." (B18)
Pilot areas differed in the extent to which the provision of different forms of psychological interventions (including motivational interviewing) was considered to be part of the outreach worker's role. In two pilot locations such interventions were provided in the home by the outreach worker, while in the remaining two the role of the outreach worker was to identify problems and signpost/refer to other services.
Problem 6: structural barriers prevent prioritisation of health check and/or engagement with subsequent health improvement programmes
Two types of structural problem were highlighted by outreach staff. First, there was the need to fill an existing deficit in partnership working between primary care and other services of relevance to health improvement. For example, one manager stated that "[the] [role] of an outreach worker in [C] was to help to bridge between GP practice and all the other services; with NHS, Council, voluntary sector that are out there" (C1). The second type of structural problem arose when a focus on health improvement goals was impeded by material disadvantage. Outreach workers reported spending considerable time attempting to address issues such as poor housing, unemployment and debt, predominantly through signposting, referral and the mobilisation of good community networks. The lengthy quotation below illustrates the perception that Keep Well was originally focused on a narrow behaviour change model but that a broader understanding of structural determinants helped to contextualise non-engagement. This offers the perspective that taking control of one's candidacy is problematic and/or irrelevant when the rest of one's life is shaped by poverty and/or negative psychosocial factors and is consistent with outreach research in the field of homelessness [41].
"I think the thinking was quite medical initially. Even although I heartily agree with health behaviour inputs, it's absolutely vital that we'll do that, I still think... the role of all these other [structural] barriers was strongly underestimated because basically, I mean, what is point in giving up smoking if... the rest of your life is so absolutely infuriatingly problematic. You know, there are all these other barriers so, you know, if we can help people to rid these other barriers of debt.... I mean for most people the chief priority is not eating five pieces of fruit a day but if you get rid of loads of other things and you motivate people, and you, you know, people feel that they have some control and power over their health... the five pieces of fruit a day becomes logical and understandable and reasonable, and 'I'll try and do that' and it becomes pleasurable because it's part of a future if... because I think again hopelessness is something that, you know, if people are optimistic they're planning ahead, they're future focused and they've got hope. But if they're not they're... if they're living in the moment with a whole bunch of issues that are weighing down on them they're not future focused. They are... they probably lack hope."(C5)
Outreach workers have a limited capacity to 'solve' this underlying reason for non-engagement in primary prevention, beyond sign-posting and referral and operating as a source of intelligence to GP practices. Operating within people's homes was, however, perceived to have provided insights into living conditions that put their non-attendance at a health check into perspective. One worker said, for example:
" That was a real eye opener... you go to the home and they haven't got a cooker or haven't got any furniture, it's just floorboards... maybe a microwave, you know." (C4)
Problem 7: The hidden and multi-faceted nature of outreach 'problems'
The final 'problem' of non-engagement that was identified was the hidden nature of the reasons for not attending a Keep Well health check. In other words, prior to making contact with the target individuals it was not possible for outreach workers to second guess the nature of the problem that they would be required to solve. The contingent nature of their role is illustrated by one outreach worker as follows:
"Our daily job is that we're given lists from GP practices to go out and find people that's like, hard to reach in terms of maybe their chaotic lifestyles; it could be that they're working all the time and they can't get into practices, they're carers to housebound people, that kind of thing.... you come up against a number of issues when you're out in the fields; you find a lot of people, it might be that they specifically don't want to come in. There could be areas that they've got phobias of needles and they don't want to come to the doctors. They could be a carer, for like, a person in their family, and they're unable to get of the house; there's people that have got agoraphobia and panic attacks and they just don't get out at all, but they certainly would like to take part in the health checks so it's kind of trying to kind of work a way to get all these people into the practice." (A13)
Problems were not only hidden behind doors but, not surprisingly, many individuals experienced multiple psychosocial and structural problems. This is captured by the following description:
"[There] was a couple that I went to and the husband has lost his job and he's been in the building trade and was made redundant about six months ago and he was quite down and you know, at home, so he's down already but he's a home so he's eating all the time and he's put on weight which is making him feel worse about himself, do you know, so there's always other issues in there but I suppose the success comes from maybe being able to help people deal with what's going on in their lives that are... you know, ultimately it affects their cardiovascular risk score because, you know, the lack of activity, the poor diet, the weight gain." (D9)
Once again, this points to multiple entry points to accepting candidacy for health improvement programmes, in general, and anticipatory care, in particular. These various entry points may also be more salient to individuals at different times and the outreach worker's role becomes one of assessing readiness for action or change. The following quotation from an outreach worker demonstrates the ways in which routes to health improvement are negotiated by patient and professional.
"He [the patient] was drinking and I can't remember what actually led into it, alcohol wasn't what he wanted to change; he wanted to stop smoking. So although I thought he should be stopping drinking, he thought smoking was the thing he felt was affecting his health more. So I almost feel that if you can tackle one, you can always get to the next one, does that make sense?... I mean I've seen that quite a lot of people, you tackle their weight but they stop smoking six months later. They start to think about stopping smoking." (D10)
This also highlights a type of intervention that is long-term in nature rather than delivered in a single-dose on the door-step. In addition, engagement was emphasised as a process rather than an event:
"Just because they're engaged in a health check doesn't mean to say they're going to maintain their engagement. If they've been difficult to engage with in the first place, okay it can be seen as an achievement to get them in, but if there's points of referral there or other areas that could be more helpful for that person, it's common sense to kind of follow through on that." (B22)
This quotation emphasises that it is unhelpful for programmes such as Keep Well to consider engagement as a single point of contact as opposed to an ongoing negotiation between users and services. This helps to explain why the initial dichotomy of outreach purpose as outlined in Figures 1 and 2 broke down in practice and led to a broader understanding of mechanisms by which engagement might be encouraged (Figure 3).