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

2. 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

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

4. The Ways to Wellness Model

5. 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

6. Referrals by GP Practice

7. 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

8. 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.

9. 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.

10. 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.”

11. Questions or Comments. Website: http://waystowellness. org
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