Integrated care in action – self-care and prevention

Case study summary

Understanding how integrated care systems are supporting people to stay well.


For many health conditions, people are already taking control themselves supplemented with expert advice and peer support in the community and online. Around 80% of all care in the UK is self-care and many people feel comfortable managing everyday minor ailments themselves. However, there are still 57 million GP consultations a year for minor ailments, while one in seven emergency admissions are preventable.

Empowering people with the confidence and information to look after themselves when they can, and visit the GP when they need to, gives people greater control of their own health and encourages healthy behaviours that help prevent ill health in the long term. In many cases, people can take care of their minor illnesses, reducing the number of consultations and enabling healthcare professionals to focus on caring for higher risk patients, such as those with co-morbidities, the very young and elderly, managing long-term conditions and providing new services.

Often just simple changes aimed at meeting the needs of local communities can be very effective at encouraging increased self-care. These include giving patients the information they need to care for themselves and to make healthy lifestyle choices, signposting people to the right local services and outreach work to provide health advice in non-traditional settings such as pubs, libraries and job centres.

Tackling loneliness and isolation

People with low mood and long-term health conditions are benefiting from a unique partnership aimed at improving patient wellbeing and reducing pressure on doctors.

The social prescribing pilot scheme means that GPs are now able to refer people to Haverhill LifeLink, which helps with low level mental health issues such as loneliness and anxiety, or those with social isolation wanting to improve their life skills or long-term health conditions. Once referred, people meet with a LifeLink coordinator who spends some time getting to know them and helping them connect with people and activities in their area.

Around one in five visits to the GP are made for social needs such as isolation, debt management, low mood and anxiety. The programme is reducing pressure on GPs and the NHS by reducing repeat GP appointments, wider NHS appointments and prescription costs and increasing employment opportunities.

Working with the community to help people with diabetes

Community champions are helping to make a difference across Slough by increasing awareness, prevention and self-management of diabetes. The champions, who are all from ethnic minority backgrounds, have been recruited as part of a community project, commissioned by East Berkshire CCG and run by Diabetes UK.

Slough has the highest prevalence of diabetes in the South East, with 8.9% of people living with a diagnosis. Slough also has a high proportion of people from South Asian, African and Caribbean communities – who are two to four times more likely to develop Type 2 diabetes than White Europeans.

The champions bridge the gap between local communities and healthcare settings and their role is to help to educate and raise awareness of diabetes by organising local events, and delivering presentations and talks. They can explain what Type 2 diabetes is, who is at risk, signs and symptoms, myths and misconceptions, complications, and the NHS services that are available to people locally, including the NHS Diabetes Prevention Programme. They also inspire others to help reduce their risk of diabetes, or to manage their diabetes better.

Health and wellbeing coaches supporting people in Wealden

A health and wellbeing coach based at a GP surgery in Herstmonceux in Wealden is improving the quality of life for some of their older patients.

The GPs were used to seeing a high number of older people with multiple long-term health conditions, many who were from rural, isolated areas and had needs that could be better met by services in the local community.

The district council worked with local partners to develop the scheme in which doctors refer people directly to the health coach who can ‘prescribe’ a range of activities such as fitness classes, coffee mornings, walking groups and even choirs. This method of social prescribing has been proven to aid recovery from stroke or cancer, prevent obesity, tackle social isolation and manage mental health conditions.

Almost 200 patients have benefitted from expert coaching and many have improved mental health, increased physical activity, lost weight or reduced their medication requirements. Twenty-nine patients who regularly visited their GP in the six months before receiving coaching reduced these visits by 61% in the six months after. The scheme is now being expanded to neighbouring GP practices, supported by the local CCG.

CATCH app is helping parents better understand their children’s health needs

A free app developed by the local council and CCGs in Cheshire is helping parents and carers to self-care for children. The CATCH app (Common Approach to Children’s Health) gives parents the confidence to know when medical treatment is required or when self-care would be a better option.

The number of children aged 0–4 being taken to A&E in the area was well above the national average and many of the children were being sent home with basic advice and information only.

CATCH provides health advice, localised information about healthcare services and support groups in Cheshire East, notifications about key health dates such as childhood immunisations and an interactive map of Cheshire East healthcare services, such as GP surgeries, dentists and pharmacies.

In a survey of Cheshire East app users, 47% said they had chosen self-care instead of attending A&E since downloading the app, while 35% said it had helped them feel more confident in self-caring for their child and in knowing where to find the best treatment. Over winter 2016/17, the number of children aged 0-5 who had been discharged from A&E with basic information and advice only had reduced by 22% since the previous year.

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