New Models of Care – The Blackdown Support Group

Case study summary

The Blackdown Support Group, a charitable organisation working in partnership with the Blackdown Practice, made a significant contribution to support isolated and vulnerable people in need of social help. Around 100 volunteers provided service as and when the patient needs it, even outside conventional working hours.


The rural nature of the practice and changes to the traditional model of family support where grandparents, parents and children are less likely to live within the same community means that patients accessing surgery services can be socially isolated and vulnerable. This impacts on the health and wellbeing of patients but capacity to deal with what may be considered social issues as well as navigate the social care system is limited and is outside the traditional GP contract model.

The population of the Blackdown Hills is dispersed over a large, geographical, rural area. There are isolated dwellings and farms, hamlets and small villages. Due to poor transport links and lack of availability of services associated with larger, more urban areas, the population of the Blackdown Hills has needed to become self-sufficient in many aspects of daily living.


The Blackdown Support Group (BSG), a charitable organisation working in partnership with the Blackdown Practice made a significant contribution to support these isolated and vulnerable people. Around 100 volunteers were coordinated by a very small team of part-time admin staff working each morning to operate the booking service. Services provided by the volunteers are as and when the patient needs it, even if these are outside  conventional working hours.

BSG arranged the following:

  • Escorted transport to health – including escorted transport to hospital, doctor, dentist, physio and podiatry appointments, improving access to health services, reducing DNAs and supporting positive health outcomes and efficiency in the healthcare system.
  • Volunteer visits (otherwise known as befriending) – visiting people, often socially isolated, in their home to maintain independence, potentially reducing the need for health and social care services.
  • Carer support – sitting with the cared for person to enable the carer to attend (for example) health appointments again, improving access to health services as well as providing vital support to fellow  volunteers, i.e. carers.
  • Mentoring – to help patients through periods of stress and reintegrate back into their community without the need for more formal intervention, highlighting where further help may be required.
  • Foot care – a self-funding service to improve the foot care of those unable to manage it themselves (excludes patients with diabetes and those on anti-coagulants).
  • Advocacy – assisting people to ensure they are receiving the correct benefits to maintain independence.
  • Short-term wheelchair loan.
  • Disabled access vehicle – available for use by individuals and families in the community with specific needs.
  • Lunch and tea clubs – providing opportunity of social contact in a relaxed and friendly manner for hard to reach patient groups in a very rural community.
  • Supported shopping.
  • Additional paid contracts(for example) for the community health and social care team.


One area where the coordinator of the BSG has provided particular support to the practice was to the community matron function within the practice and, if funding for the clinical service is continued, it is intended that the social care element provided by the BSG will become more integrated into the project. The ability for the BSG co-ordinator to navigate the social care system rather than the senior nurse is a more cost-efficient use of resources and benefits the patient.

More recently, the BSG and practice have been able to work with a new charitable organisation, the Blackdown Healthy Living Centre, to which both the practice and BSG can refer patients to for different services and support groups e.g. memory café, exercise classes. This organisation provides much needed support for patients and their loved ones and/or promotes self-care/health and wellbeing. The three organisations continue to develop services collaboratively as a campus health and wellbeing hub.

There are many more ad hoc services provided, or arranged, by the BSG that are best described as one friend or family member helping another. For example,   a vulnerable adult telephoned the surgery as she had locked herself out of her house, a handyman was found within minutes by the BSG to help at no cost. A vulnerable adult required a visit to A&E due to an eye injury but had no transport. The surgery staff telephoned a BSG volunteer out of hours and the patient was taken to hospital. The volunteer waited until she had been seen and brought her home.

The staff and volunteers of the BSG are  kind people, problem solvers and helpers.

The BSG is co-located with the practice and although the BSG have their own telephone line, the practice has an extension of their telephone system so that calls can be transferred to the BSG office. The BSG also has an NHS email. All these elements mean that the BSG staff are considered part of the practice team,  referrals can easily be made and there can be direct liaison between BSG staff, practice staff and clinicians.

The benefits are numerous – better access to, and more cost effective use of healthcare services, targeted signposting to social care services, and supporting patients to get the social care and benefits they need, supporting patients in their own home to maintain independence, and supporting the practice to highlight where intervention may be required and avoid an admission to hospital.

One benefit that has been quantified is the escorted transport to health appointments. From workload statistics and information from the Devon Car Forum, every £1 invested on this scheme could save up to £17 in the health service. In one month the BSG volunteers completed 250 transport jobs for health appointments, of which 60% were for hospital appointments. This equates to an investment in the service of £303 and savings of up to £3,132 (this is assuming a 25% DNA rate) in avoiding wasted appointments for CCG commissioned services.

Providing you have the right people coordinating such a service and a community spirit, the services provided could be replicated across the NHS with minimal investment.

Tips for adoption

Recruit the right person as a coordinator and then integrate ways of working as much as possible.

Often there is a lack of cover by care agencies in rural areas due to the distances that need to be travelled by care staff and the rate of pay/lack of reimbursed travel time. It is intended that a flexible working model can be developed with the care home, so when home care is needed trained staff can come out of the home and provide care in patients’ homes in the community. Involvement with the BSG would be required in terms of expertise and knowledge.

For further information please contact:

Barbara Starkiss
Hemyock Surgery
Station Road
EX15 3SF

Telephone: 01823 681036