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Mental Health Concern

Ways to Wellness (social prescribing)

What is Ways to Wellness?

Ways to Wellness is a service for people in the west of Newcastle whose daily lives are affected by certain long-term health conditions (COPD, asthma, diabetes, epilepsy, heart disease and osteoporosis). GPs and their primary care teams use social prescribing to refer patients to the service. Ways to Wellness adds to and complements the medical support that people receive, to help them feel more confident to manage their long-term conditions and make positive lifestyle choices.

In addition to Mental Health Concern, there are three other providers of Ways to Wellness, each working with a cluster of GPs to link service users to the service: Changing Lives, First Contact Clinical, and HealthWORKS Newcastle.

Each service user is given a Link Worker, who helps them to identify and work to overcome their current barriers to managing their long-term conditions. The Link Workers work with participants to produce an agreed action plan, which may include one or more of the following:

  • getting involved in local groups and activities
  • developing positive relationships
  • accessing specialist services and support
  • healthy eating and cooking
  • getting more active
  • getting support around benefits and welfare rights

Social prescribing

Social prescribing is not new to the west of Newcastle upon Tyne (or elsewhere); this project is the culmination of many years of effort to test ways of making it work.

Ways to Wellness is a pioneering, not-for-profit organisation using social impact bond investment; one of the first in the world to use this innovative approach to funding in health. The Ways to Wellness service is also exceptional in its scale, long-term nature and degree of integration with the work of general practices. The project will be financed for seven years and will offer social prescribing for up to 5,000 patients at any one time in the west of Newcastle.

Primary care team staff will make referrals to the Ways to Wellness service, which will provide a link worker to support and motivate the individual. Each practice will have a dedicated team of named link workers.

The expected outcomes from patients will include:

  • improvements in patient self-management
  • improvements in patient’s health compared with predictions
  • reduction in hospital usage
  • reduced visits to GPs
  • reduced reliance on prescription drugs for some conditions (such as those for depression)

Why is it needed?

Over 15 million people in England suffer from LTCs. They experience poorer health outcomes and reduced quality of life as a result. They are proportionately higher users of health services (GP appointments, prescription drugs, outpatient services and in-patient hospital bed days).

55% of GP appointments are with patients with one or more LTCs, 70% of national NHS spend is related to LTCs and this is projected to rise in the future.

Evidence from community health interventions, both locally and nationally, has shown that a contributory factor to health and wellbeing is being linked into a local community and reduced social isolation.

The target group

Ways to Wellness is aimed at people with LTCs who live in the west of Newcastle and who are served by one of the 18 general practices supported by the Newcastle upon Tyne West CCG.

The target group has been identified to ensure that we work with patients for whom we know there is most likelihood that this type of intervention will work, based on locally and nationally available evidence. The target group has been agreed with the CCG as follows.

Patients who are aged 40-74 and are on the relevant QOF Disease Register for any of the following long-term conditions:

  • COPD and Asthma
  • Diabetes Type 1 or 2
  • Coronary Heart Disease
  • Heart Failure
  • Epilepsy
  • Osteoporosis

GPs are asked to prioritise those people who:

  • have poor understanding of their condition
  • are socially isolated
  • have poor adherence to prescription
  • LTC has identified above with depression/anxiety
  • have poor health but scope to improve with lifestyle change (not end-stage illness)
  • are a frequent attender at GP or hospital
  • have poor English literacy
  • are obese and/or inactive

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