A new approach to long term conditions in the west of Newcastle Tara Case Chief Executive

Ways to Wellness – an introduction Provides help to people with long-term health conditions who live in the west of Newcastle upon Tyne Non-medical ‘link workers’ help them to have better quality of lives and, as a result, to reduce the cost of their care to the NHS

The Ways to Wellness Link Worker role— supporting patients to achieve their goals

The Ways to Wellness Model

Ways to Wellness Referrals 158 referrals in April 2016 against target of 143 Year 1 Successful New Referrals 1126 = 103% of target Service to Date Successful New Referrals: 1,285 = 104% of target

Referrals by GP Practice

What worked well in development: Engaging commissioners & GP practice staff Evidence is critical – of both unmet need and improved benefit over current provision CCG clinical chair part of WtW steering group and later CCG Delivery Project Lead became a regular guest at board meetings until delivery well established Involvement of key people of influence in decision-making GP Practice Staff Evidence – focus on patient need and benefit but particularly frame in terms of GP practice focus, resources and approach Ask to be on agenda for regular meetings (from before and into delivery): Individual GP Practice team meetings Joint Practice Manager meetings Practice Nurse meetings Practice Patient Participation Groups CCG-hosted GP Time-out sessions Identify and look to engage influence of “champions” for your service approach Ask for input and feedback - “Critical Friends” meeting across sectors and including GP practice staff

What working well in delivery: Engaging GP practices & referral generation Work with early adopters to establish what’s working well Build processes and systems and share across practices GP IT system – enabled ‘pop-up’ reminders and flag of who is eligible If possible, establish a presence in GP practices office space, drop-in sessions, waiting room presence, attendance at team meetings, banners in front of building Continue to build awareness of service with both staff and patients Feedback patient testimonials/quotes and case studies League tables of performance against other practices Continued requests to attend meetings (as in development phase) Emphasise long-term benefit of shifting practice and referring habits Share success stories – outcome measures, referrals levels, accolades, etc.

Challenges & Opportunities Information Governance – sharing of patient-identifiable data Commissioner and commissioning support (NECS) have key roles to play – engagement and clear communication critical Asking practice staff for input during development but not being able to incorporate into service design Cultural differences between community and voluntary sector and primary care, NHS, public sector Politics and historical relationships Shortage of staff and time in primary care, NHS, commissioning; change-weary and overwhelmed staff Ability to generate referrals not within control of service providers Social model of care can mean different things to different people – threaten role boundaries, be associated with reduced NHS, etc.

Patient Quotes “I do believe that knowing the Ways to Wellness team is like winning a lottery ticket in life.” “I feel like finally there is a light at the end of the tunnel and I want to say thank you for calling me and listening, I really appreciate it.” “This service has resolved a lot of issues that worried me.” “I feel really proud of myself that I’m getting out and about more.” “I now have a totally different outlook.” “It has helped to focus my mind and gave me belief that things can change.” “I felt my Link Worker was on the same wavelength as me and I could trust her to help me.” “I feel better already talking to you. It helps motivate me.”

Questions or Comments. Website: http://waystowellness. org Questions or Comments? Website: http://waystowellness.org.uk Email: tara.case@waystowellness.org.uk