Strategic intelligence monitor on personal health systems, phase 3 (SIMPHS3) : SPARRA (United Kingdom), case study report.
Date: 2015-07-16
Institutions: Institute for Prospective Technological Studies
Subjects: United Kingdom, care for the elderly, case study, data collection, elderly person, health care, health care system, health policy, medical institution, new technology, organisation of health care, public health, research report

Strategic Intelligence Monitor on 
Personal Health Systems Phase 3 
(SIMPHS3) 

SPARRA (United Kingdom) 
Case Study Report 

Authors:  
Francisco Lupiañez-Villanueva 
Alexandra Theben 

Editors: 
Fabienne Abadie  
Cristiano Codagnone 

2 0 1 5  

Report EUR 27268 EN 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
European Commission 
Joint Research Centre 
Institute for Prospective Technological Studies  

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EUR 27268 EN 

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Abstract 
SPARRA/ACP is an integrated care management approach based on two main components: the predictive model “Scottish 
Patient  at  Risk  of  Readmission  and  Admission”  (SPARRA)  which  aims  to  measure  the  risk  of  hospital  admission  of  a 
targeted  patient  and  an  Anticipatory  Care  Planning  (ACP)  approach  which  designs,  implements  and  monitors  the  most 
suitable intervention according to the degree of hospital admission risk of the targeted patient. Together they form the 
SPARRA/ACP  Patient-Centric  Integrated  Care  approach  that  is  being  implemented  in  several  communities  in  Scotland, 
promoted by the Scottish Government and NHS Scotland as part of its strategy of national health care system renewal. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Preface 

The Strategic Intelligence Monitor on Personal Health Systems (SIMPHS) research started in 
2009 with the analysis of the market for Remote Patient Monitoring and Treatment (RMT) 
within Personal Health Systems (PHS). This approach was complemented in a second phase 
(SIMPHS2)  with  the  analysis  of  the  demand  side,  focusing  on  needs,  demands  and 
experiences  made  with  PHS  by  healthcare  producing  units  (e.g.  hospitals,  primary  care 
centres), healthcare professionals, healthcare authorities and patients amongst others.  

Building  on  the  lessons  learnt  from  SIMPHS2  as  well  as  on  the  European  Innovation 
Partnership  on  Active  and  Healthy  Ageing  initiative,  SIMPHS3  aims  to  explore  the  factors 
that  lead  to  successful deployment  of  integrated  care  and  independent  living,  and  define 
best operational practices and guidelines for further deployment in Europe. This case study 
report is one of a series of case studies developed to achieve these objectives. 

The outcomes of SIMPHS2 are presented in a series of public reports discussing the role of 
governance, innovation and impact assessment in enabling integrated care deployment. In 
addition,  through  the  qualitative  analysis  of  27  Telehealth,  Telecare  and  Integrated  Care 
projects  implemented  across  20  regions  in  eight  European  countries  investigated  in 
SIMPHS2,  eight  facilitators  have  been  identified,  based  on  Suter’s  ten  key  principles  for 
successful health systems integration.  

The eight main facilitators identified among these as necessary for successful deployment 
and adoption of telehealth, telecare and integrated care in European regions are:  

Interoperable information systems 

  Reorganisation of services 
  Patient focus 
  Governance mechanisms 
 
  Policy commitment, 
  Engaged professionals 
  National investments and funding programmes, and  
 

Incentives and financing.  

These  eight  facilitators  have  guided  the  analysis  of  the  cases  studied  in  SIMPHS3  and  a 
graphical  representation  with  arrows  whose  length  represents  the  relative  importance  of 
each facilitator is presented in each case study. 

In  addition  to  the  above  facilitators  analysed  in  each  case  report,  a  specific  section  is 
dedicated  to  the  analysis  of  care  integration.  It  should  be  noted  that  the  definition  of 
vertical  and  horizontal  integration  used  in  this  research  is  taken  from  the  scientific 
literature  in  the  field  of  integrated  care1 and  differs  from  the  one  mentioned  in  the 
European  Innovation  Partnership  on  Active  and  Healthy  Ageing  Strategic  Implementation 
Plan2. We define horizontal integration as the situation where similar organisations/units at 
the same level join together (e.g. two hospitals) and vertical integration as the combination 
of different organizations/units at different level (e.g. hospital, primary care and social care).  

1   Kodner, D. (2009). All together now A conceptual Exploration of Integrated Care.  
2   http://ec.europa.eu/research/innovation-union/pdf/active-healthy-ageing/steering-group/operational_plan.pdf (page 27) 

1 

 
                                                      
TABLE OF CONTENTS 

CASE OUTLOOK .................................................................................................................................................. 3 

1  BACKGROUND ............................................................................................................................................. 5 
SCOTTISH SOCIAL AND HEALTH CARE SERVICES ............................................................................................................ 5 
SCOTLAND (UK) ................................................................................................................................................................... 6 
THE SPARRA/ACP .............................................................................................................................................................. 7 

1.1 
1.2 
1.3 

2 

INTEGRATED CARE ANALYSIS ............................................................................................................. 10 
DIMENSIONS OF INTEGRATION ....................................................................................................................................... 10 
IMPACT ................................................................................................................................................................................. 12 
BARRIERS AND DRIVERS ................................................................................................................................................... 13 
ORGANISATION, HEALTH PROFESSIONAL AND PATIENTS .......................................................................................... 14 
INFORMATION AND COMMUNICATION TECHNOLOGIES ............................................................................................. 15 
GOVERNANCE ...................................................................................................................................................................... 17 
ORGANISATIONAL PROCESSES ........................................................................................................................................ 19 
REIMBURSEMENT MODEL AND ECONOMIC FLOW ....................................................................................................... 21 

2.1 
2.2 
2.3 
2.4 
2.5 
2.6 
2.7 
2.8 

3  TRANSFERABILITY .................................................................................................................................. 22 

4  CONCLUSIONS ......................................................................................................................................... 23 

REFERENCES .................................................................................................................................................... 26 
DOCUMENTATION ................................................................................................................................................................................ 26 
SCIENTIFIC PUBLICATIONS ................................................................................................................................................................. 27 

LIST OF TABLES 

Table 1:  

Scotland (UK) health care system and demographic characteristics ........................................... 6 

Table 2:  

Initiatives supported by SPARRA ........................................................................................................................ 9 

LIST OF FIGURES 

Figure 1:   Scottish National Health System characterisation .................................................................................. 6 

Figure 2:   Scottish NHS anticipatory care planning and medication pathway ............................................... 8 

Figure 3:   Anticipatory Care Continuum of Risk with SPARRA ................................................................................. 9 

Figure 4:   Scottish population covered with SPARRA tool (source: NHS-NSS, 2011) .............................. 10 

Figure 5:   Anticipatory care continuum of risk with SPARRA ................................................................................ 16 

Figure 6:  

Integration of SPARRA, ACP and KIS ............................................................................................................. 17 

Figure 7:  

Local Governance of SPARRA/ACP initiative ............................................................................................. 19 

Figure 8:   SPARRA/ACP approach .......................................................................................................................................... 20 

Figure 9:   A system of local care: the chronic care model ..................................................................................... 21 

Figure 10:   SPARRA/ACP Integrated Care Facilitators .................................................................................................. 25 

2 

 
 
 
 
 
Case outlook 

SPARRA/ACP is an integrated care management approach based on two main components: 
the  predictive  model  “Scottish  Patient  at  Risk  of  Readmission  and  Admission”  (SPARRA) 
which  aims  to  measure  the  risk  of  hospital  admission  of  a  targeted  patient  and  an 
Anticipatory  Care  Planning  (ACP)  approach  which  designs,  implements  and  monitors  the 
most  suitable  intervention  according  to  the  degree  of  hospital  admission  risk  of  the 
targeted patient. 

Together they form the SPARRA/ACP Patient-Centric Integrated Care approach that is being 
implemented in several communities in Scotland. This approach is promoted by the Scottish 
Government  and  NHS  Scotland  as  part  of  its  strategy  of  National  health  care  system 
renewal. 

The  SPARRA/ACP  case  started  about  8  years  ago  on  the  initiative  of  the  Scottish 
Government. In 2006, the government launched a shift from a healthcare system oriented 
towards  hospital-based  treatment  to  a  system  founded  on  preventive,  anticipatory 
approaches  to  the  management  of  long-term  conditions.  This  case  focuses  on  preventive 
care  management, and in  particular, on  chronic disease management to avoid the  risk of 
unplanned  hospital  admission.  To  achieve  its  objectives,  SPARRA/ACP  enables  vertical 
integration within the  Communities  of Health Partnerships (CHPs), and should  lead to  full 
integration in  the short to medium-term, given that new legislation will enter into force in 
2015,  aimed  at  integrating  health  and  social  care  units  as  a  consequence  of  a  recent 
health care spending review.  

Key drivers of the SPARRA/ACP case comprise:  
  organisational  stability  with  no  major  structural  changes  in  the  NHS  for  a  period  of 
about 10 years or in the local government for almost 17 years, together with political 
consensus among the parties committed to health and social care issues;  

  combined  responsibility  for  planning  and  delivery  of  acute,  primary  and  community 

services within the CHPs;  

  a strong performance management culture within the NHS.  

Barriers to the diffusion of SPARRA/ACP case, that could also hinder the transferability of 
the initiative comprise:  
 
  slow adoption by citizens; interoperability issues;  
 

lack of availability of citizens’ data for continuous update of predictive modelling;  

lack  of  integration  amongst  funding streams, budgets  and  accounting  systems  across 
organisations/departments/units;  

 

inconsistency  of  quality  of  care  for  people,  and  the  support  provided  to  carers, 
particularly for elderly people, across Scotland. 

3 

 
4 

 
 
1  Background 

1.1  Scottish social and health care services 

The  health  services  in  Scotland  are  available  to  all  inhabitants  and  are  financed  through 
general  taxation,  which  means  that  services  are  largely  free  at  the  point  of  delivery.  The 
responsibility  for  health  and  health-related  services  lies  with  the  Cabinet  Secretary  for 
Health  and  Wellbeing.  The  Scottish  Parliament,  however,  plays  a  huge  role  in  scrutinising 
the  health  system  via  its  Minister  (Minister  for  Public  Health  and  Minister  for 
Commonwealth Games and Sport), as well as through a parliamentary Health Committee, 
Audit  Scotland  and  Health  Care  Improvement  Scotland.  The  Scottish  government  is  also 
committed  to  the  outcomes-based  approach  as  set  out  in  2007  in  the  National 
Performance Framework's (NPF) 10 year vision which was reviewed in 2011. As well as the 
National  Health  System,  there  is  a  private  not-for-profit  health  care  sector,  which  is 
independent and financed through private contributions.  

The Scottish Government distributes the budget between the NHS (Director-General Health 
and  Social  Care  and  Chief  Executive  of  NHS  Scotland)  and  other  social  services,  such  as 
education and sport. Once the budget is split, the Cabinet Secretary, advised by the Scottish 
Government Directorates for Health and Social Care, decides how to allocate the funds to 
health  and  social  care  and  monitors  their  use.  The  Scottish  Government  Directorates  for 
Health  and  Social  Care  retain  responsibility  for  health  and  social  care  policy.  They  also 
manage the NHS and monitor social care services as provided by local authorities, and by 
private and third sectors. These Directorates are led by a Director General who is also Chief 
Executive  of  the  NHS,  and  is  supported  by  professional  advisers.  The  role  of  the 
Directorates includes the definition of objectives and policies for health protection, setting 
of  targets,  providing  a  statutory  and  financial  framework  for  the  NHS,  and  intervening  in 
the event of any problems or deficiencies that may arise at local level. Most of the health 
budget is distributed among 14 geographically-based NHS Boards that are in charge of the 
planning and delivery of services to meet the healthcare needs of each region's population. 
The NHS boards retain significant powers over local care provision and the setting of local 
priorities.   

The  Boards  provide  strategic  leadership  and  manage  the  performance  of  the  entire  local 
NHS system. Responsibility for service delivery, however, is delegated within each Board to 
operating divisions for acute services and to specific committees (CHPS) for community and 
primary care services. Through the CHPs, the Boards contract independent professionals in 
primary  care,  such  as  GPs,  dentists  or  community  pharmacists,  who  are  reimbursed  in 
accordance with the services provided by them on behalf of the NHS.  

In  addition,  there  are  nine  national  bodies  in  charge  of  services  provided  to  the  entire 
country,  which  are  in  turn  supported  by  the  regional  Boards.  These  focus  on  delivering 
services best provided by  a single entity, e.g. ambulance transport, information, education 
and training, and quality improvement.  

However, there is no purchaser-provider split. Most of the primary care providers function 
as independent contractors and are reimbursed according to their specific contracts for the 
services  provided.  The  NHS  boards  employ  the  staff  working  in  hospitals  and  in  the 
community directly on a salary basis.  

5 

 
 
Figure 1: Scottish National Health System characterisation 

1.2  Scotland (UK) 

Source: Steel & Cylus (2012) 

Scotland  is  78,387  km2 and  has  a  population  of  5.2  million  inhabitants,  with  a  density of 
about 67 inhabitants per km2. It is located in the North of the United Kingdom. Scotland has 
an annual GDP of more than €166 billion, with an annual per capita GDP of €31,569. The 
average age of the Scottish population is about 44 years old, and 17% of individuals are 
over  64.    Current  projections  suggest  that  the  population  of  Scotland  will  rise  to  5.78 
million by 2037, and that the population will age significantly, with the number of people 
aged  65  and  over  increasing  by  59%,  from  0.93  million  to  1.47  million.  The  key 
characteristics of the health care system in Scotland are summarised in Table 1: 

Table 1: Scotland (UK) health care system and demographic characteristics 

Geographical coverage, km2 
Inhabitants per km2 
Number of inhabitants 
Life expectancy at birth, years 
Regional GDP (2012), billion € 
Regional GDP per inhabitant (2012) €/inhabitants 
General Practitioners /1.000 inhabitants (2010) 
Specialists /1.000 inhabitants (2010) 
Regional  Budget  for  Health  services  management  (2013), 
billion € 
Health care professionals / 100.000 inhabitants 
Regional health care budget, € per inhabitants (2013) 
Hospital beds (2012) 
Hospital beds/1.000 inhabitants (2012) 

78,387 
67 
5,254,800 
80.09 males – 85.1 females 
€166 billion  
31,590 € 
0.79 
1.94 
€10 billion  

294 
€1,903  
24,800 
4.7 

6 

 
1.3  The SPARRA/ACP  

Scottish  Patients  at  Risk  of  Readmission  and  Admission  (SPARRA)  and  Anticipatory  Care 
Planning  (ACP)  are  the  two  main  components  of  the  Scottish  integrated  care  case  study. 
SPARRA  is  a  predictive  model  which  measures  the  risk  of  hospital  admission  of  targeted 
patients, and ACP is an intervention which aims to design, implement and monitor the most 
suitable care plan in accordance with the degree of hospital admission risk of the targeted 
patients, their needs and their family contexts. 

The  SPARRA/ACP  initiative  has  been  implemented  in  several  Scottish  communities, 
promoted by the Scottish Government and the Scottish NHS. The latter has encouraged the 
approach as part of its strategy for the national health care system renewal. The objective 
of  the  SPARRA/ACP  approach  is  to  develop  and  integrate  care  services, enabling  the  shift 
from a healthcare system based on acute care (hospital-centric), to a system founded on 
preventive care and an anticipatory approach to the management of long-term and chronic 
conditions.  

The Information Systems Division (ISD) of the  NHS National Services Scotland (NHS-NSS) 
has been developing SPARRA since 2006. The initial model was largely based on the PARR 
model  developed  by  the  Kings  Fund  and  used  in  England  and  Wales.  In  its  initial 
implementation  phase,  the  SPARRA  (SPARRA  Version  1  –  “Classic”)  was  restricted  to 
patients aged 65+. In 2008, the SPARRA  algorithm was  extended  to cover all age groups 
(SPARRA  Version  2  –  “All  Ages”)  in  order  to  meet  the  commitment  made  by  the  Scottish 
Government in the “Better Health, Better Care Act” (Scottish Government, 2007). The initial 
SPARRA  algorithm  used  national  in-patient  admission  data  and  calculated  risk  scores  for 
patients in Scotland who had had an emergency admission in the preceding three years. In 
2009,  the  Scottish  Government  committed  the  ISD  to  expanding  the  scope  of  SPARRA 
(Version 3) to use other data than recent hospital admissions3.  

SPARRA  has  been  essential  to  the  implementation  of  integrated  care  experiences,  and  of 
the related Anticipatory Care Planning (ACP). Figure 2 describes their logical management 
processes and shows that SPARRA enables the use of statistical analysis of patient data to 
supplement  clinical  judgement  It  is  used  as  the  entry  level  for  the  design  and 
implementation  of  a  more  personalised  ACP,  the  main  objective  of  which  is  to  avoid 
unscheduled hospital admissions (NHS Highland, 2011). 

3  

I.e. prescribing data is also used. A SPARRA score is calculated for people aged 16+ whether or not they have had a 
previous Emergency Admission. Then in 2012 SPARRA was developed further with algorithms for 3 adult sub-cohorts 
(YED, LTC, FE).  

7 

 
 
 
 
 
 
 
 
 
                                                      
Figure 2: Scottish NHS anticipatory care planning and medication pathway 

Source: YEHC, 2013 

Other elements of the SPARRA/ACP approach comprise: 

  Review of the patients’ actual therapies and pharmacological treatments. 
  Assessment of individuals' healthcare and also social and psychological needs. 
  Co-design  of  personalised  care  plans  that  can  include  new  therapies  and 

pharmacological treatments. 

  Register  of  clinical  and  other  relevant  information  in  the  Key  Information  System 
(KIS), managed by the NHS, which permits the sharing of patient data (provided the 
patient has given consent) with health care professionals during the implementation 
of the patients’ care plans, based on the ACP. 

  Monitor and review the ACP on a regular basis in line with patients’ characteristics 

and the degree of severity of the disease. 

However, the SPARRA tool, as anticipated, is not only used for supporting clinical decisions 
in the definition of a more personalised ACP. In its recent configuration, the tool can also be 
used to categorise the population more precisely (Figure 3), according to each individual's 
"risk of hospital admission”. 

8 

  Section 2 7 Figure 2.1: NHS Scotland Anticipatory Care Planning / Polypharmacy Review Pathway        Use risk tool to identify patients for ACP/Polypharmacy view Effective interventions may include:  Self-management;  Homecare;  Reablement;  Falls prevention/exercise;  Telehealth, telecare;  Housing adaptations and equipment;  Other health care interventions such as audiology, continence, dietician and podiatry;  Medicines management. Internal and external team meetings to share, review and learn. Invite person to ACP/Polypharmacy review Share eKIS with those delivering planned response Assess individuals needs, co-design plan and record in eKIS  Arrange, implement and monitor interventions, and review  
 
 
 
Figure 3: Anticipatory Care Continuum of Risk with SPARRA 

Source: NHS, 2014 

Following  the  SPARRA  approach  depicted  in  the  above  figure,  the  population  can  be 
segmented  into  several  categories  according  to  the  degree  of  “hospital  admission  risk” 
(“SPARRA  SCORE”).  The  “SPARRA  SCORE”  allows  the  division  of  the  population  into  three 
categories, with two of them requiring an ACP approach, while the population segment with 
the lowest “SPARRA SCORE” can be subject to preventive lifestyle advice only. In this way, 
an  individual  can  have  a  more  personalised  preventive  lifestyle  intervention,  and  health 
care  professionals  are  better  supported 
in  their  decisions  about  therapies  and 
pharmacological treatment. Scottish health care authorities have used SPARRA as support 
tool for the following initiatives.  

Area 
Highland Community 
East & Midlothian 
Community 
Lanarkshire Community 

Ayrshire & Arran CHPs 
Moray Community,  

Aberdeenshire CHP,. 
East & Midlothian CHP,  
NHS Fife,  
NHS Lanarkshire,  
Inverclyde CHP,  
Glasgow City CHP,. 
NHS Lothian  

Table 2: Initiatives supported by SPARRA 

Initiative 
Anticipatory care patient alerts (ACPAs) for all care home residents  
Patients are identified as being suitable for case/care management 

Referral  system  between  social  and  health  care  targeting  people 
identified as at high risk 
Case management approach to provide health care services. 
Telecare  and  Telehealth  service  provisioning  for  people  at  risk  of 
readmission 
Anticipatory Care Plans between primary care and community care 
Home care management approach  
Case management to support older people in their own homes. 
Nursing home care management approach. 
Nursing home care and community care for people under the age of 18 
Community based anticipatory care 
Polypharmacy analysis 

Source: Authors' elaboration 

9 

 
 
2  Integrated care analysis 

2.1  Dimensions of integration 

Since  January  2012,  a  new  SPARRA  tool  has  been  available.  This  tool  allows  the 
identification of patients at risk who have not experienced a recent emergency admission 
(e.g.  16+  years  old).  Since  August  2013,  the  risk  scores  are  calculated  by  the  ISD  on  a 
monthly basis, and made accessible to NHS Boards, Community Health Partnerships and GP 
practices.  Figure  4  illustrates  the  population  coverage  of  the  most  recent  version  of  the 
SPARRA tool (Version 3). This new version of the SPARRA tool can potentially derive scores 
for  approximately  3.5  million  patients,  which  corresponds  to  67%  of  the  population.  The 
diagram  (left  side  of  the  figure)  further  illustrates  that  the  expanded  cohort  includes  a 
much larger proportion of individuals experiencing an emergency hospital admission. 

Figure 4: Scottish population covered with SPARRA tool (source: NHS-NSS, 2011) 

Source: NHS-NSS, 2011 

The SPARRA/ACP approach described in Figure 2 could be applied to the entire population of 
Scotland in a more personalised way. However, the SPARRA/ACP approach is only applied at 
the  moment  to  vulnerable  subgroups  of  patients  and  patients  with  complex  illnesses.  In 
particular,  the  target  pathologies  considered  are  chronic  diseases,  cognitive  impairment, 
frailty and related comorbidities. Patients with any of these pathologies are likely to have a 
higher  risk  of  emergency  admissions.  Preventive  care  management  and  chronic  disease 
management  interventions  in  these  cases  can  reduce  the  number  of  unplanned  hospital 
admissions. 

Looking  at  the  implementation  examples  of  the  SPARRA/ACP  approach  described  above, 
better  home care management and  chronic  care management in  primary and community 

10 

 
care settings constitute the main focus. For both home care and chronic care management, 
the SPARRA/ACP approach foresees strong integration across primary and secondary care, 
in order to reduce the risk of unplanned hospital admission or re-admission. In most of the 
cases where the SPARRA/ACP approach has been implemented,  a quite advanced  level  of 
integration between health and social care within the local Communities of Health Practices 
(CHPs) was a prerequisite. 

The  implementation  of  the  SPARRA/ACP  approach  supports  service  integration.  It  enables 
the  organisation  of  fully  personalised  care  pathways  for  each  individual  at  risk  of 
emergency  admission,  from  the  initial  identification  of  the  admission  risk  to  the 
implementation of the care pathway. To this end, a joint intervention of GP, specialists and 
nurses is required, to enable them to cooperate in both the design and the implementation 
of the personalised care pathways. This foresees a high degree of professional integration, 
and strong coordination between  different organisations. This holds true, even though the 
degree  of  organisational  integration  can  vary  from  case  to  case  according  to  the 
coordination capability of the local CHPs and the level of commitment of the local authority.  

In  general  terms,  organisational  integration  among  the  care  actors  applying  the 
SPARRA/ACP  approach  has  still  been  only  partially  achieved.  However  the  new  regulation4 
that  was  planned  to  come  into  force  in  March-April  2015  at  the  time  of  writing,  should 
contribute  to  accelerating  the  process  of  integration  by  merging  health  and  social  care 
organisations  in  single  entities.  Despite  the  fact  that  the  scope  of  this  law  targets  the 
reduction of health and social care expenses, it  could  also  prove beneficial  for scaling-up 
fully-integrated care.  

The  SPARRA/ACP  approach  has  achieved  some  vertical  integration  within  Communities  of 
Health  Practices,  regarding  health  and  social  care  actors  involved  in  the  care  pathway 
processes. According to the experts consulted, vertical integration could be further improved 
in  the  short  to  medium  term  when  the  new  legislation  enters  into  force5.  The  new 
legislation should facilitate integration between health and social care and  the sharing of 
common objectives and budget. 

On  the  other  hand,  the  degree  of  horizontal  integration  supported  by  the  SPARRA/ACP 
approach  implemented  in  different  locations  is  debatable.  The  opinions  expressed  by  the 
experts interviewed reflected disagreement: the people in charge of SPARRA from JIT and 
ISD  agreed  that  the  horizontal  integration  through  the  SPARRA/ACP  approach  was 
widespread  in  the  current  care  practices,  whereas  the  experience  in  Aberdeenshire  was 
reported to have been different.  

There  is  no  further  evidence  of  full  integration  across  the  health  and  social  care  actors, 
despite  the  fact  that,  according  to  the  respondents,  it  is  the  ultimate  goal  of  the 
SPARRA/ACP approach in the long-term perspective. 

4  

i.e.  “Joint  Working  (Scotland)  –  Act 2014  which  “is  seen  as  a  framework  to  support  improvement  in  the  quality  and 
consistency in the delivery of health and social care services in Scotland  – to be achieved through formal integration 
of services for adults….”. In particular the Regulation and Orders section of the Act sets out: “those functions of a Local 
Authority that must be  delegated in support  of the integration  of health and social care services.  This is set out in 
pages 28-39 of Set One – including reference to the sections of the various underpinning social work legislation.  The 
services set out in this section relate to people over the age of 18….”. 

5   The Joint Working (Scotland) – Act 2014. 

11 

                                                      
2.2 

Impact 

In the last 5-8 years, the SPARRA/ACP approach has been widely monitored at both national 
and  local  level.  The  objective  was  to  provide  evidence  of  cost  reduction  in  health  care 
management  by  reducing  unplanned  hospital  admissions,  unnecessary  visits  and 
pharmacological  treatments.  However,  as  underlined  in  a  report  on  the  status  of 
implementation of the SPARRA/ACP (YECH, 2013), the measured impacts were not based on 
counterfactual  evidence6 of  the  benefits  achieved.  Bearing  in  mind  this  limitation,  YEHC 
(2013) measured the following impacts7 across the whole of Scotland:  

  20%  reduction  in  emergency  admissions,  with  sensitivity  analyses  using  25%  and 

15%. 

  10% reduction in length of stay with sensitivity analyses using 5% and 15%. 
  £16  million  (€21  million)8 total  cost  savings  in  general  medicine  in  terms  of  the 

total cost in 2013/2014. 

  £90 (€120) saved per persons in polypharmacy reviews. 

Lastly,  some  of  the  most  interesting  evidence  of  the  impacts  of  the  implementation  of 
SPARRA/ACP was measured by the local communities: 

  Aberdeenshire  CHP.  Since  anticipatory  care  planning  was  put  in  place  in  2010, 
Aberdeenshire has reduced secondary care bed utilisation associated with the frail 
elderly by 10% across the early implementation practices. It has actively shifted the 
balance of care, and has made it possible to cut the equivalent of 30 beds for acute 
admissions.  This  equates  to  £298  x  30  x  365  (£3.2  million)  shifted  to  community 
activities.  

  East  &  Midlothian  CHP.  Results  of  a  2010/11  patient  evaluation  questionnaire 
showed that the service was highly valued by patients and significant improvements 
were  made  to  aspects  of  self-management.  The  use  of  SPARRA  data  was  very 
useful in flagging patients not otherwise known and in engaging GPs in anticipatory 
care planning. Further success includes a  reduction in  the number of bed  days per 
patient from 23 to 7 (according to the service's own informal evaluation).  

  Highland Community. Outcomes of this approach in 2011 were;  

(1)  29%  reduction  in  emergency  and  47%  reduction  in  occupied  bed  days  for 
patients who had an ACP in place;  
(2) Patients with a SPARRA score of ≥ 50% but no ACP in place showed an increase 
in both emergency visits (+59%) and occupied bed days (+63%).  
A  new  evaluation undertaken in  2012 with 1,556 individuals  split into two groups, 
one assisted with ACP (ACP cohort) and a control group, belonging to the top 1% of 
the population with the highest hospital admission risk  has produced the following 
results:  
(1) Before ACP implementation - emergency admissions and bed days increased by 
51% and 49% respectively;  

6  

It  is  important  to  notice,  as  YEHC  (2013)  said:  “….these  examples  of  potential  benefits  are  only  evidence-base 
available to inform the potential reduction in admission and bed-days following adoption of the ACPs. Quality of the 
studies is weak, limited by the absence of a matched control”. 

7   YEHC (2013) tried to overcome the lack of counterfactual evidences through a cross-cases analysis of the evidences 

measured during the SPARRA/APC experiences. 

8   As YEHC (2013) explained this savings are purely hypothetical and are valid only if structural changes in the hospital 

system are introduced and the beds are removed from the system. 

12 

 
                                                      
(2)  After  ACP  implementation,  emergency  admissions  and  bed  days  decreased  by 
38% and 49%; decrease of 52% hospital days for the ACP cohort compared to the 
non-ACP (before and after the implementation compared to the same timeline with 
the non-ACP) with a net saving of £190 per patient for the ACP cohort (Baker et al., 
2012).  However,  it  has  to  be  noted  that  emergency  admissions  in  the  Highlands 
increased in the observed period, so the effective re-organisation of the health care 
service was not fully implemented. 

2.3  Barriers and drivers 

Drivers  for  the  SPARRA/ACP  approach  depend  on  the  characteristics  of  the  local  context 
where the service is implemented. However, the experts interviewed agreed that in the local 
communities  where  both  the  local  authority  and  the  health  care  actors  are  strongly 
committed,  an  integrated  care  initiative  is  more  likely  to  be  successfully  implemented.  It 
was also recognised  that the most successful cases of  SPARRA/ACP  implementation  were 
those  with  well-established  CHPs,  capable  of  combining  primary  and  community  services 
with  a  shared  responsibility  for  planning  and  delivery  personalised  care  pathways. 
Ultimately, a strong performance evaluation culture constitutes an important driver for the 
success of the initiative. This has become evident in all the cases of local implementation 
of  the  SPARRA/ACP  approach,  where  the  integrated  care  processes  that  have  been 
implemented are periodically monitored and revised on the basis of the results achieved. 

Barriers  to  the  use  of  the  SPARRA/ACP  approach  in  integrated  care  services  comprise  the 
following: 

 

Inequalities in terms of leadership between NHS and health care providers (primary 
and secondary care, social and health care). 

  Strong  institutional  and  sector-related  responsibilities  expressed  through  vertically 
and  organisationally  discrete  power  structures9,  which  are  linked  to  cultural, 
educational, and professional differences among physicians, nurses and social care 
workers. 

  Lack  of  integration  among  funding  streams,  budgets  and  accounting  systems  and 

 

among health and social care providers.  
Inconsistency in the quality of care for people, and  the support provided to carers, 
particularly for older people, across the country. 

According to the experts consulted, one of the most important barriers is related to the lack 
of  continuous  update  of  patient  data,  which  would  allow  a  more  frequent  and  precise 
calibration of the SPARRA tool. This is due to a lack of integration of SPARRA with Electronic 
Health Records (EHR). A way to overcome this barrier is the attempt of the JIT to promote 
the  Key  Information  System  (KIS),  which  according  to  the  Scottish  NHS  should  support  a 
shared management of electronic  health records across different health care actors, and, 
at the same time, offer the opportunity for the ISD to receive more updated information on 
patients which can be used to calibrate the SPARRA model. 

Another  important  barrier  that  potentially  hinders  the  diffusion  of  the  SPARRA/ACP 
approach is the lack of integration between health and social care. This is evident in several 
barriers listed above, such as the inequalities  in  the leadership  between different tiers of 
health  and  social care,  the  power structures  at  different  layers  of  health  and  social  care, 
which  often  have  divergent  managerial  and  strategic  objectives,  the  lack  of  integration 

9  

It might be overcome by the new regulation fostering the integration of health and social care. 

13 

                                                      
among funding streams, budget and accounting systems across the entire health and social 
care  value  chain.  Together,  they  constitute  the  strongest  barriers  that  would  have  to  be 
overcome  in  order  to  achieve  the  full  potential  of  the  approach.  However,  most 
interviewees agreed that the new regulation coming into force in March/April 2015 will help 
to  achieve  full  integration  of  health  care  and  social  services  with  a  common  power 
structure, shared budget and accounting system. 

Lastly,  the  inequalities  of  the  cost  of  the  service  provisioning  and  the  different  pricing 
policies applied by the local communities to patients and their families constitutes another 
significant  barrier,  preventing  equal  access  and  same  quality  of  service  that  could  be 
provided with the SPARRA/ACP approach across the country. 

2.4  Organisation, health professional and patients  

In  all  the  examples  analysed,  the  implementation  of  the  SPARRA/ACP  approach  involved 
several types of actors, such as: 

  GPs in single surgeries or in associated practices that together with the district and 

practice Nurses constitute the Community Health Practices (CHP). 

  Social Care units that, according to the new legislation, should be better integrated 

with health care units. 
  Community hospitals. 
  Private hospitals and rehabilitation clinics.  
  Groups of practices, private organisations, NGOs, etc., delivering home care services. 
  Non-professional carers, physiotherapists, psychologists etc. 

The implementation of the SPARRA/ACP approach requires close collaboration between all 
health  and  social  care  actors.  In  particular,  the  GPs  are  the  main  gateway  to  the  care 
planning process and, thanks to the SPARRA tool, they can assess the risk of admission of 
their  patients.  In  the  Lothian  Community,  for  example,  the  GPs  use  SPARRA  to  make  an 
initial screening of  COPD patients. They then  define personalised care pathways,  together 
with the local hospital unit in charge of COPD patients and the nurses, in accordance with 
the ACP protocols.  

The local implementation of the SPARRA/ACP initiative also requires an integrated approach 
among health and social care actors in delivering and monitoring the care pathways. This 
requires that each of these actors follows the care pathway as specified for each patient, 
and  they  all  provide  the  required  services  in  an  integrated  manner.  The  introduction  of  a 
more  structured  approach  supported  by  the  SPARRA  tool  and  the  ACP  methodology  has 
produced  a  significant  reorganisation  of  the  service  provided  to  chronic  patients  by  local 
health and social care actors. The new approach has required stronger cooperation between 
primary care, local hospitals, district or practices nurses, and social care representatives in 
terms of identification of patients’ needs and the design, management and monitoring of 
care  pathways.  This  approach  has  then  been  implemented  at  local  level  in  the  different 
communities.  

For example, in NHS  Lanarkshire10 patients’ data are downloaded from  the SPARRA tool 
online and stored in the local Management Information system of Lanarkshire CHP (MiLAN) 
on  a  monthly  basis.  The  information  specialist  of  CHP  sends  patient  listings  to  district 
nurses’ organisations. Nurses print the report and go through all records to identify which 

10   SPARRA/ACP started in 2007 and it is still on-going. 

14 

                                                      
patients are known already and which are not. They also identify which patients' risk scores 
have  increased  or  decreased  and  they  monitor  patient  records  in  GPs'  administration 
systems.  Based  on  this,  decisions  on  district  nurse  or  practice  nurse  visits  (depending  on 
familiarity with patient) are made. The extent of health and social care service provision for 
each patient has to be discussed with social care actors at local planning group meetings. 
Furthermore, information from  medication plans and prescriptions has started to be  used 
to identify patients that may require medication review. 

In  Aberdeenshire  CHP11 data  from  SPARRA  is  currently  used  by  almost  80%  of  GP 
practices (28 out of 36 GP practices), and it covers 1.8% of the local population aged 65+. 
From an organisational point of view, the process has four phases: 

  The  Preparation  Phase  where  the  practice  team  (GP/Practice  Nurse),  supported  by 
the Health and Community Care Team (HCCT) of the CHP, identifies those patients 
who will benefit most from an Anticipatory Care Plan by reviewing monthly multiple 
admission data for people aged 65+, combined with local knowledge and data from 
SPARRA, available monthly from IDS. The range of local options available to support 
each patient is considered before they are added to the ACP register.  

  Planning  and  Review  Phase  where  the  HCCT  identifies  the  most  appropriate 
member  of  the  team  to  act  as  care  manager.  The  care  managers  meet  with  the 
patient and where possible, their relatives and/or carers, to develop a plan at one of 
four levels: self-care (focusing on what patients can do for themselves); initiating or 
informal 
increasing  community  care 
arrangements;  care  within  a  community  facility  (hospital  or  care/nursing  home); 
admission to an acute hospital.  

(social  or  medical) 

to  supplement 

 

Implementation  Phase  where  finalised  plans,  once  agreed  with  the  patients,  are 
faxed or e-mailed to the out-of-hours (OOH) service and added to the Single Shared 
Assessment tool and the Patients' Notes. 

  Maintenance  Phase  where  patients’  care  pathways  are  monitored  and  collected 
data  is  reviewed  by  the  practice  team  during  the  periodic  HCCT  meetings.  Thus, 
corrective actions can be undertaken if necessary.  

This  approach  facilitates  effective  cooperation  between  tiers  of  service  provisioning. 
Following the personalised care pathways, every task is well detailed and specified in terms 
of  role  and  responsibilities.  The  joint  design  of  the  care  pathway,  that  requires 
multidisciplinary collaboration amongst the health and social care actors, allows an initial 
agreement to be reached among all the organisations involved in the service provisioning, 
and  also  in  the  monitoring  of  the  care  pathway  implementation.  Furthermore,  the 
continuum  of  care  is  guaranteed  based  on  personalised  care  pathways,  including  case 
management  and  patients’  access  to  multiple  points  of  contact  for  detecting  and  solving 
problems that might arise during the evolution of the disease.  

2.5 

Information and Communication Technologies 

At  the  moment,  the  ICT  infrastructure  supporting  SPARRA/ACP  case  is  rather  limited. 
According to the  experts  interviewed, there  are still  interoperability issues  among existing 
software  applications  currently  used  by  the  health  and  social  care  actors.  The  limited 
investment  in  ICT  infrastructures  certainly  affects  the  release  of  the  full  potential  of  the 
SPARRA/ACP  approach.  Currently  the  main  software  that  underpins  the  SPARRA/ACP 

11   SPARRA/ACP service proof of concept began in October 2008, moving to early implementation in January 2010 

15 

                                                      
comprises  two  modules:  an  online  business  objective  software  and  the  Key  Information 
Summary. 

The  SPARRA  tool based on the  on-line business objective  software that  was  developed  in 
2006 is continuously updated by ISD to improve both its predictive capability in measuring 
the  risk  of  unplanned  hospital  admissions  and  its  usability  by  the  local  CHPs.  This 
application  has  been  designed  to  enable  a  variety  of  health  care  users  to  stratify  and 
analyse their population.  

The  Key  Information  Summary  (KIS)  tool  was  developed  in  2012  by  the  NHS  to  support 
CHPs and local health and social care actors in sharing Anticipatory Care Plans’ information. 
As described in the figure below, the KIS tool is shared securely with all the local health and 
social care actors to develop better ACP and ISD, so as to calibrate the SPARRA predictive 
model.  Currently, the level  of adoption of the  KIS  system is quite  low, with no more  than 
65,000 individuals registered, which represents only about 1.5% of the Scottish population. 
Low adoption is also registered at GP level, where until April 2013, only 3,000 KIS records 
were shared among 86 practices. 

Figure 5: Anticipatory care continuum of risk with SPARRA 

Source: NHS, 2014 

The  rationale  behind  the  two  tools  and  their  contribution  to  the  whole  SPARRA/ACP 
integrated care management process is described in the following figure: 

16 

 
 
 
 
Figure 6: Integration of SPARRA, ACP and KIS 

Source: McCall, 2013 

The  SPARRA  tool  is  the  entry  level  of  the  integrated  care  process  and  it  allows  both  the 
definition of a personalised Anticipatory Care  Plan and the review  of  the  medication plan 
prescribed  to  any  given  patient.  The  information  generated  by  both  the  ACP  and  the 
medication  plan  is  registered  in  the  KIS  (Key  Information  Summary)  and  provided  to  the 
local  health  and  social  care  team  in  order  for  them  to  implement  the  care  pathway  of  a 
given patient.  

On  the  basis  of  the  experiences  described  above,  the  ICT  infrastructure  supporting  the 
implementation of the SPARRA/ACP approach does not seem to be very well developed yet. 
Moreover,  the  main  aim  of  the  two  tools  seem  more  aligned  with  the  need  to  create  a 
national  patients  information  management  system  to  support  the  ISD  in  improving  its 
predictive  models,  rather  than  establishing  an  interoperable  information  system  fully 
integrated  with  other  eHealth  tools  (e.g.  EHR  used  in  the  GPs  practices  or  in  the  local 
hospital). 

2.6  Governance 

The SPARRA/ACP approach has two layers of governance: the national and the local. 

The  national  governance  aims  to  stimulate  and  diffuse  the  initiative  in  all  the  local 
communities  of  Scotland.  The  key  actors  of  the  national  governance  are  the  Scottish 
Government  as  the  promoter  and  the  founder  of  both  the  SPARRA  Emergency  Admission 
risk model and the KIS tool development, and the NHS-NSS, that has developed both tools 
thanks  to  the  change  funds  provided  by  the  Government.  The  latter  structured  the 
SPARRA/ACP  approach  promoting  local  health  actors  to  reorganise  the  health  and  social 
care services for their population. 

To  this  end,  NHS-NSS  has  established  the  Scottish  Information  Service  Division  (ISD 
Scotland) commonly known as the “SPARRA Team”. This organisational unit of the NHS-NSS 
aims to continuously continuous improve the predictive capability of the SPARRA model. It 

17 

 
works  in  close  collaboration  with  the  NHS  Boards,  hospitals,  general  practitioners, 
Community Health Partnerships (CHPs), local authorities, voluntary organisations, and many 
other care and service providers to build and maintain the national database of patients.  

The  ISD  also  supports  the  local  health  care  organisations  in  the  development  of  local 
SPARRA  tools  to  achieve  better  risk  stratification  of  the  population  and  thus  a  more 
personalised  implementation  of  the  SPARRA/ACP  approach.  At  the  same  time,  the  ISD 
provides the local communities with updated statistics of the emergency admission risks of 
the Scottish population, based on the review of patient data that are available at national 
level, on a monthly basis. 

The second operational part of the national governance of the SPARRA/ACP initiative is the 
Joint  Improvement  Team  (JIT).  It  is  a  partnership  between  the  Scottish  Government,  NHS 
Scotland,  the  Convention  of  Scottish  Local  Authorities  (COSLA),  and  the  Independent  and 
Housing Sector. It provides a range of practical improvement support structures, including 
knowledge exchange, developmental innovation, improvement capacity and direct practical 
support  to  local  health,  housing  and  social  care  partnerships  across  Scotland  in  order  to 
implement the SPARRA/ACP approach. 

The  close  collaboration  of  the  Scottish  Government  and  NHS-NSS  has  created  the 
conditions and the necessary operational and practical instruments to promote SPARRA/ACP 
adoption by  local initiatives. Therefore, the national governance of the  initiative  is mainly 
focused  on  providing  the  necessary  instruments  (SPARRA  tool;  ACP;  KIS  tool)  and  the 
operational support through ISD and JIT to the local communities, rather than forcing the 
local  health  and  social  care  organisations  and  the  local  government  to  reorganise  the 
health  and  social  care  services  for  their  population.    From  this  perspective,  every  local 
community  can  freely  choose  to  apply  the  proposed  SPARRA/ACP  approach  and  to  set  up 
the initiative in  a way corresponding to the needs of its population, the characteristics of 
the health and social care actors and the specificity of the local context. 

In  general  terms,  the 
local  governance  that  steers  the  SPARRA/ACP  approach 
implementation is described in Figure 7. Local government with its health and social care 
departments,  and  the  local  NHS  organisation  are  the  two  main  players.  The  two 
organisations  have  different  roles  and  responsibilities  in  terms  of  commitment  to  and 
promotion of the SPARRA/ACP approach in their local contexts. In particular, the local NHS is 
responsible  for  the  local  health  care  organisations  (GPs  practices,  district  and  practice 
nurses,  local  hospitals, professional  carers),  while  the  local  government  is  responsible  for 
the social care workers and for all the social services provided to the citizens.  

18 

 
 
Figure 7: Local Governance of SPARRA/ACP initiative  

Source: Authors' elaboration 

In quite a significant number of local Scottish communities, the close collaboration between 
the local NHS and the local Government enabled the establishment of Community Health 
Partnership (CHPs). According to the experiences of the SPARRA/ACP approach and provided 
that they are well established, the CHPs are in charge of the management of the initiative 
and of the coordination among the different health and social care actors. However, in spite 
of  close  collaboration  between  local  NHS  and  local  government  in  overseeing  the 
implementation of the SPARRA/ACP approach, and even though this may be done through 
CHPs, effective coordination between health and social care service management is often 
is  because  they  have  separate  managerial  structures,  and  distinct 
lacking.  This 
administrative and budgeting processes. According to the experts consulted, this weakness 
in steering the initiative may prevent the full achievement of the expected benefits. Lastly, 
the ISD and JIT act as facilitators in the establishment, implementation and evaluation of 
the approach in the local governance of the SPARRA/ACP initiative. 

2.7  Organisational processes 

The  SPARRA/ACP  initiative  is  an  integrated  care  management  process  that  starts  with 
categorising the population according to their risks of unplanned hospitalisation. It supports 
both  the  design  and  implementation  of  a  personalised  care  pathway  to  avoid  the 
occurrence of this risk. The generic implementation process of the SPARRA/ACP approach is 
organised in the following six steps: 

19 

 
 
 
 
Figure 8: SPARRA/ACP approach 

Source: NHS-NSS, 2014 

According  to  the  experts  consulted,  there  are  several  ways  of  implementing  the 
organisational process underpinning the SPARRA/ACP approach. 

The  complexity  of  the  approach  and  the  need  to  involve  different  organisations  in  a 
continuum of care service processes require strong coordination. In most cases, this can be 
provided  by  the  respective  CHPs.  These  are  the  most  successful  cases  because  they  are 
able to clearly define a manager who takes responsibility for the coordination of the care 
processes and guarantees the integration of the services provided by the health and social 
care actors involved. The respective care manager assigned by the CHP mainly serves as a 
facilitator of the process, as he or she has no direct responsibility for the health and social 
care  team  established  by  the  organisation  in  charge  of  service  delivery.  However,  in  the 
medium-term,  the  new  regulation  that  is  underway  could  increase  the  power  of  the  CHP 
manager and, most probably, could also increase the effectiveness of the care process. 

GPs  and  district/practice  nurses  are  the  gateways  to  the  organisational  process  and  in 
charge  of  categorising  their  patients  using  the  SPARRA  tool.  In  most  of  the  examples 
analysed,  the  online  versions  of  the  SPARRA  tool  provided  by  ISD  to  categorise  their 
patients  are  being  used.  In  this  case,  however,  the  risk  stratification  is  based  on  average 
statistics  of  the  population.  This  may  affect  the  results  when  risk  stratification  is 
implemented at local level. Therefore, in some instances (e.g. Aberdeenshire CHP), the CHP 
in charge of the coordination of the local SPARRA/ACP implementation preferred to provide 
the  GPs  and  nurses  with  a  risk  stratification  tool  based  on  the  SPARRA  model  calibrated 
with local patient data. 

The definition of the care pathway requires joint coordination of several health and social 
care specialists that support GPs and district/practice nurses to identify patients’ and their 
families’ needs, review polypharmacy and design the personalised care plan. In this process, 
the strong involvement of the CHP manager to facilitate the organisation of the meetings 

20 

 
 
among the health and social care actors and the design of the patient’s care pathways with 
shared goals, clear task assignments and timing is very important.  

In the implementation stage, the role of the CHP manager is less important, and the care 
team of different experts, allocated by the organisations in charge of service delivery, work 
on  the  basis  of  the  already-established  care  pathway.  During  the  delivery  process  all  the 
care team members are responsible for assessing the changing health of the patients, their 
needs  and  the  needs  of  their  families,  and  the  patients’  degree  of  responsiveness  to  the 
implementation of the care pathway. In case of problems, the CHP manager facilitates the 
revision of the patient’s care plan. 

Monitoring activities are the responsibility of the care team, while the review of the results 
and  the  periodic  revision  of  the  patient’s  care  plan  are  the  responsibility  of  the  CHP 
manager. 

The  following  figure  sketches  the  Chronic  Care  Model  which  supports  the  organisational 
process described. 

Figure 9: A system of local care: the chronic care model 

Source: JIT (2009) 

2.8  Reimbursement model and economic flow 

The reimbursement models of GPs and the other health care providers in Scotland are still 
based  on  a  bundled  payment  plus  coordination  fee  for  the  implementation  of  specific 
activities such as the one foreseen for SPARRA/ACP.  

As  yet,  no  innovative  reimbursement  model  has  been  applied  and  no  outcome-oriented 
incentives are foreseen for the care managers and health care professionals involved in the 
delivery process.  

21 

  10Figure 1. A System of Local Care: The Chronic Care Model  Community Health Partnerships working withlocal authorities and other local partnersSelf-care  supported By e.g.  ICT, expert patient initiativesand NHS 24NHS Boards working collaboratively with other health providers and with socialcare to develop integrated careConsistent, national application of tested approaches deliveredlocallyAn agreed framework for deliveringcare in local settings that reducesavoidable hospital admission, andfacilitates local diagnosis, treatment and rehabilitationICT to support:a) Risk stratification and planningb) Care delivery and co-ordinationc) Monitoring, review, QIInvolvedHaving established the efficacy of the Nairn Case Finder as a screening tool for emergency hospital admissions, it is important to investigate whether it can be used efficiently to improve the management of patients with complex needs.  The Nairn ACT’s primary objective is to manage the care of the Fortune 500, who have complex needs and co-morbidities, in order to prevent emergency hospital admissions and reduce bed utilisation.  Currently, with less than 3% of the list receiving a more managed approach to their care, Nairn is on target for a 15% reduction in occupied bed days as identified by the Better Health, Better Care: Action Plan (Scottish Government 2007). The clinical and financial effectiveness of the Nairn Anticipatory Care Project is currently undergoing quantitative analysis.  It was important that a qualitative evaluation of the project also be carried out.  This report is the result of a qualitative evaluation of the Nairn Anticipatory Care Project to assess the current care provided for the target group and make recommendations for its future.  
 
The SAPRRA/ACP approach does not affect the cost of the services provided to the patients. 
These  remain  unchanged  and  are  based  on  current  practices,  whereby  the  cost  of  the 
service depends on the  typology of the disease and the socio-economic characteristics of 
the patient and his or her family.  

Lastly,  the  Scottish  Government  and  the  Scottish  General  Practitioners  Committee  of  the 
British  Medical  Association  reached  an  agreement  over  changes  to  the  General  Medical 
Services contract for 2013/14, based on the results of the SPARRA/ACP implementation. In 
this  new  service  contract,  anticipatory  care  planning  and  medication  review  indicators 
replace  quality  and  productivity  indicators  of  the  emergency  admission  and  emergency 
pathways.  In  the  short  to  medium-term,  these  new  performance  indicators  should  affect 
the reimbursement cost levels of the local hospital emergency units and promote a faster 
take-up of the approach in other local communities in Scotland. 

3  Transferability 

The SPARRA/ACP model is currently being applied to different local contexts in Scotland. It 
includes  the  SPARRA  Tool  and  the  direct  support  offered  to  the  local  communities  by  the 
ISD  and  JIT.  However,  the  most  difficult  part  of  the  approach  is  the  setting  up  of  the 
organisational  process  underpinning  the  SPARRA/ACP  service  delivery.  The  degree  of 
fragmentation of health and social care provisioning at the local level could slow down the 
implementation  of  SPARRA/ACP  and  hinder  the  effective  deployment  of  the  services.  The 
most  favourable  local  contexts  where  the  SPARRA/ACP  case  could  more  easily  be 
transferred are therefore those where a well-established CHPs exists, which could function 
as a catalyst of the initiative. 

Efforts to transfer this model to other Scottish local contexts can, however, be regarded as 
limited, despite the fact that the SPARRA tool is provided by ISD online and free of charge. 
In addition, the JIT has already set up all the required material and coaching mechanisms 
that would facilitate the transfer of the approach to the local health and social actors. 

Due  to  the  specificity  of  the  approach  and  the  need  for  the  calibration  of  a  risk 
stratification  tool  that  supports  the  identification  of  target  patients,  all  the  experts 
consulted  agreed  that  there  is  a  low  degree  of  transferability  to  other  EU  countries.  The 
difficulties  of  applying  the  services  in  other  countries  becomes  apparent  in  the  example 
provided by England, where the definition of a risk stratification tool was abandoned by the 
English  Government,  after  several  attempts  to  achieve  a  shared  consensus  within  the 
health  care  community.  Thus,  SPARRA/ACP  requires  strong  commitment  from  the  local 
authorities  in  charge  of  the  health  and  social  care  processes,  and  a  very  significant 
organisational effort to coordinate all the local health and social care actors in the delivery 
service process. 

22 

 
 
 
4  Conclusions 

The SPARRA/ACP case in Scotland is a patient-centred integrated care management process 
that  could  be  applied  to  the  entire  Scottish  population,  despite  its  currently  limited 
application  to  vulnerable  subgroups  of  patients  and  patients  with  complex  illnesses  in 
several local CHPs. SPARRA/ACP has been developed over the last 8 years and is based on a 
combination  of  a  predictive  model  of  risk  of  hospital  admission  and  a  structured 
Anticipatory Care Planning process.  

The starting point of SPARRA/ACP was a change of policy in 2006: this required a shift from 
a  healthcare  system  focused  on  hospital-based  treatment  to  one  based  on  a  preventive, 
anticipatory  approach  to  the  management  of  long-term  conditions.  To  achieve  this,  the 
main  focus  of  the  SPARRA/ACP  approach  rests  on  preventive  care  management  and  in 
particular, chronic disease management to avoid risks of re-/hospitalisation.  

The full scaling-up of the project has prompted the development of several integrated care 
initiatives  across Scotland in  recent years. An example  is the Highland Community, where 
anticipatory care patient alerts (ACPAs) have been implemented for all care home residents 
and the top 1% of population at greatest risk of unscheduled admission, using SPARRA risk 
prediction data. Another example is the Lanarkshire community, where the local health and 
social care partnership has implemented proactive integrated care management across six 
localities  for  people  identified  as  high  risk  by  SPARRA.  In  Ayrshire  &  Arran,  CHPs  operate 
three different models for case management built on SPARRA, real time hospital data and 
an  enhanced  service  for  intensive  Co-ordinated  Case  Management;  and  in  several  other 
local contexts.  

GPs and nurses, who play a pivotal role in service implementation, are the gateways to the 
SPARRA/ACP approach.   

The Scottish Government has been a promoter and a founder of the SPARRA/ACP case.  It 
has been fully committed, together with the Scottish NHS’ national and local organisations 
to supporting and diffusing the approach across Scottish communities.   

The ICT infrastructure supporting the SPARRA/ACP case is currently rather limited, and there 
are still interoperability issues with existing software applications used by different health 
and social care actors. The limited investment in ICT infrastructures has certainly delayed 
realisation  of  the  full  potential  of  the  SPARRA/ACP  approach  to  integrated  care 
management.  

To  partially  overcome  the  interoperability  problems,  the  NHS-NSS  started  to  test  the 
adoption of the KIS (the Electronic Key Information Summary) to be used among the health 
practices to share patient health histories, in 2012. By April 2013, over 3,000 KIS records 
were  shared  by  86  practices  in  the  CHPs  of  Ayrshire  and  Arran  CHPs,  and  during  March 
2013  alone,  these  summaries  were accessed about  9,000 times  by  NHS24,  Out  of  Hours 
and the CHPs of Ayrshire and Arran.  

Since  the  initial  implementation  of  SPARRA/ACP  in  the  Scottish  communities,  it  has  been 
considered extremely important to provide evidence-based results of the impacts produced 
by the local SPARRA/ACP initiatives. Despite the fact that most of the evidence is not based 
on  a  counterfactual  evaluation  approach,  a  recent  review  of  the  measured  impacts 
undertaken by YEHC (2013) has provided the following adjusted evidence: 

  20%  reduction  in  emergency  admissions,  with  sensitivity  analyses  using  25%  and 

15%. 

23 

  10% reduction in length of stay with sensitivity analyses using 5% and 15%. 
  £16 million (€21 million) total cost savings in general medicine in terms of the total 

cost in 2013/2014. 

  £90 (€120) saved per person in medication reviews. 

However,  health  care  actors  agreed  that  in  order  to  realise  the  full  potential  of  the 
SPARRA/ACP approach, the following barriers need to be tackled: 

 

Inequalities in terms of leadership between NHS and health care providers (primary 
and secondary care, social and health care). 

  Strong  institutional  and  sector-related  responsibilities  expressed  through  vertically 
and  organisationally  discrete  power  structures12,  which  are  linked  to  cultural, 
educational, and professional differences among physicians, nurses and social care 
workers 

  Lack  of  integration  among  funding  streams,  budgets  and  accounting  systems 

among health and social care providers.  

 

Inconsistency in the quality  of care for people, and the support provided to carers, 
particularly for older people, across the country. 

Figure 10 displays the main facilitators of the SPARR/ACP approach. Based on the analysis 
of  the  case  study,  governance  mechanisms  constitute  the  most  important  drivers  for  the 
success of the initiative and should be very well established at both national and local level. 
Strong  national  governance  is  needed  to  support  the  development  of  a  risk  stratification 
model and tool, and also a common approach to the ACP process implementation. Strong 
local  governance  in  turn  is  needed  to  create  the  prerequisite  for  the  effective 
implementation  of  the  approach,  which  requires  wide  collaboration  among  all  the  local 
health and social care actors.  

Policy  commitment,  patient  focus  and  engagement  of  professionals  follow  as  facilitators 
after  strong  governance  mechanisms.  In  particular,  the  engagement  of  professionals 
constitutes  a  very  important  driver  for  the  success  of  the  initiative.  To  this  end,  a  strong 
coordination  effort  has  to  be  considered,  as  well  as  continuous  monitoring  and  periodic 
evaluation of the performance parameters of the proposed approach.  

National investment and funding programmes are mainly important for the development of 
the tools underpinning the initiative (e.g. SPARRA tool and KIS tool), while the setting up of 
the  services  and  their  implementation  do  not  require  specific  funding.  Interoperable 
information systems, incentives and financing do not appear to be important drivers of the 
initiative, but a lack of one of these could hinder the realisation of its full potential. Another 
important element that has to be considered in the implementation of the initiative is that 
potential  benefits  are  significant  both  in  terms  of  cost  savings  and  quality  of  services. 
These  benefits  could,  however,  remain  purely  hypothetical  if  no  effective  national 
governance mechanism is put in place to use the results for effective reorganisation of the 
health care system. 

12   It might be overcome by the new regulation fostering the integration of health and social care. 

24 

 
 
                                                      
Figure 10: SPARRA/ACP Integrated Care Facilitators 

25 

 
 
 
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27 

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28 

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European Commission 
EUR 27268 EN – Joint Research Centre – Institute for Prospective Technological Studies 

Title: Strategic Intelligence Monitor on Personal Health Systems Phase 3 (SIMPHS3). SPARRA (United Kingdom) Case Study 
Report 

Authors: Francisco Lupiañez-Villanueva, Alexandra Theben 

Luxembourg: Publications Office of the European Union 
2015 – 28 pp. – 21.0 x 29.7 cm 

EUR – Scientific and Technical Research series – ISSN 1831-9424 (online) 
ISBN 978-92-79-48396-7 (PDF) 
doi:10.2791/26519 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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doi:10.2791/26519 
ISBN 978-92-79-48396-7