Ways to Wellness: a collaborative approach to social prescribing for long-term conditions

There is a clear social gradient in whether you get a long-term condition, and your outcomes if you do are often socially and behaviourally determined. Social prescribing of non-medical activities, which address the concerns of the individual rather than their medical condition, seems a fairly obvious way forward. It has been around for a long time but despite numerous pilots and lots of anecdotal evidence of benefit it has never been done systematically and at scale with a defined population.

West Newcastle, with high levels of long-term conditions and social disadvantage, provided an opportunity to do this. There was a history of previous small-scale pilot studies run by HealthWORKS Newcastle, and the GP commissioning consortium prior to becoming a CCG, had been a partner in the production of Thanks for the Petunias: a guide to developing and commissioning non-traditional providers to support the self-management of people with long-term conditions. The CCG was also a Nesta People Powered Health site exploring the delivery of social prescribing. At about the same time in 2012, Voluntary Organisations Network North East (VONNE) was exploring the feasibility of developing and testing a social impact bond (SIB) as a new way of funding the sector.

Nearly three years later in April 2015, Ways to Wellness went live as a charitable foundation with a seven-year contract with Newcastle/Gateshead CCG as the prime contractor, with four sub-contractors employing link workers to deliver social prescribing to patients with specific long-term conditions in 17 practices covering a population of 120,000 in West Newcastle.

Reflecting on the key elements leading to this point, it is possible to identify a number of factors:

  • A strong steering group with good local credibility and connections located in a voluntary sector umbrella body.
  • Success in securing development funding, first from the DH Social Enterprise Investment Fund and secondly from the Big Lottery Commissioning for Better Outcomes Fund, which allowed us to secure the services of a project manager, financial and business management expertise.
  • Early discussion with the CCG to ensure that Ways to Wellness would be the prime contractor with a long-term contract, so that once developed the service would not have to be tendered.
  • Production of a regular newsletter and continuing discussions with key stakeholders including patient groups, the local voluntary sector and local GPs and Practice Managers.
  • Detailed study of the available data on the incidence and cost of long-term conditions, in order to develop an appropriate costed intervention and the metrics to demonstrate improved social and financial outcomes.
  • An open and transparent consultation process for developing a service specification and subsequently for procuring four service providers to employ link workers, and to work with discrete geographical practice clusters.
  • Securing the interest of potential investors and refining the policies, referral criteria and processes so that successful applications could be made for additional grant funding from the Cabinet Office Social Outcomes Fund and the Big Lottery Commissioning for Better Outcomes Fund.
  • Development of a website and a dedicated management information system to provide real time data on key performance indicators.
  • Patience and persistence in retrofitting the service to the NHS Standard Contract and NHS information governance requirements and for negotiating and agreeing a complex set of final contracts.

Nearly one year on, what is working well and what needs further development?

Referrals, at one year are 1,129 which is ahead of an ambitious target figure of 1,094.

All of the practices are referring but there is significant variation between them, and between the ability of the four providers to generate referrals. Generating referrals in a new programme is always challenging but both Ways to Wellness and the link workers are getting better at doing this through a combination of shared learning and using data feedback to generate a degree of competition between both practices and providers.

The Long-Term Conditions Wellbeing Star is proving a useful tool for the link workers in their interaction with clients and as a quality of life repayment measure: initial analysis of second Wellbeing Stars done at six months are showing significant improvement. Lots of data are being generated on goal-setting and the choice of activities that people are making. Broadly, social activities around exercise and healthy eating seem to be the most common but welfare rights, housing issues and help with mental health problems also figure as significant issues. Looking at and discussing all of the data generated with the service providers, it has also become clear that the management information system needs more input from the link workers in order to make it more user-friendly.

More work is also being done on understanding the link worker intervention and on different ways of measuring the impact of this intervention. This has led to a focus on trying to define the key skills and competencies of link workers and exploring the feasibility of developing an accredited training course. Work is also going on to use some of the data that we are generating to try and clarify what might be an appropriate case load and case mix for link workers.

The prime contractor model, with a specially created charitable foundation with two staff managing four not-for-profit providers who employ link workers, seems to be working. It has enabled four local organisations that would not have wanted, or perhaps been able to, take the risk of a large outcomes-based contract to test out the model. It has also meant that the CCG has a single contract with an accountable body that is responsible for contract management of the providers.

Balancing collaboration and competition between providers with regular meetings of the provider link worker managers and the link workers learning community group has also been an interesting challenge.

The next step is to see whether or not we have produced savings in hospital costs when compared with a control group with similar socio-demographic features from a neighbouring area, who are not receiving social prescribing.

Bibliography

NHS (2011) ‘Thanks for the Petunias.’

Ways to Wellness Bulletins. 

‘Ways to Wellness Deep Dive Evaluation report.’

Author

Professor Chris Drinkwater CBE

Professor Chris Drinkwater CBE, is the Chair of Ways to Wellness.