The vanguard and the people it serves
With an emphasis on transforming care from cradle to grave, the West Cheshire drives for change.
Local people will be encouraged to take more control of their own health and wellbeing and children and young people will be equipped with the tools they need to live happy and healthy lives.
The partners include:
- Primary Care Cheshire (a federation of all 35 West Cheshire practices)
- NHS West Cheshire Clinical Commissioning Group (local community services)
- Cheshire and Wirral NHS Partnership Foundation Trust
- Countess of Chester NHS Foundation Trust
- Cheshire West and Chester Local Authority
- partners from the third sector; and local patient, voluntary and community groups including Healthwatch Cheshire West
The partners serve a population of around 260,000.
What is changing?
This vanguard is showing how the national programme’s support for organisations to empower patients and to better integrate the buying and delivery of services can make a difference to patients while also easing pressure on NHS services.
There will be easier access to more joined-up services in the community through new health and social care teams, wellbeing coordinators and direct access to physiotherapy for patients.
By working together with clinicians to design self-care plans, where appropriate, individuals, their families and carers will be given the tools and confidence to understand and manage their health condition themselves as far as possible.
GPs and community teams will act as the first port of call for accessing coordinated support for children and young people. Adults with long-term conditions will be identified and supported to minimise the impact of their conditions on their daily lives, again with care models designed together with clinicians.
Vulnerable older people who are most at risk of poor health and wellbeing will be identified by GPs. They will then work with that person’s nominated care coordinator (who works with health and social care teams to help people obtain care, understand their options and make care decisions) to develop care plans and ensure care is provided by teams with members from the specialties needed.
- Patients work with clinicians to manage their own health better
- Wellbeing coordinators help people manage the wider issues that may affect their health, such as loneliness or financial worries
- Clinicians from various teams work together to deliver more co-ordinated, effective and efficient care.
Contact West Cheshire Way
1. Helping patients address the social issues affecting their health
The new role of the Age UK Cheshire wellbeing coordinator was introduced after feedback from GPs showed they were often asked by patients about issues where there was no appropriate medical solution but where social issues were impacting on their patient’s health.
A team of 10 wellbeing coordinators now receives referrals from GPs, healthcare teams, physiotherapists and district nurses and, during the pilot stage of the project from January 2015 to March 2016, the team received more than 1,400 referrals.
In one case, a patient was referred by their GP as family issues were impacting on their mental health. The patient felt depressed and socially isolated. The wellbeing coordinator referred the patient to a befriending organisation and addressed their transport issues. The patient joined a choir and also felt empowered to take part in a project study about mental health and access to services.
The support has made a real difference to the patient, who said: “Life is good; I’m a totally different person now.
“The service has made me aware of all the things that were going on around me otherwise I wouldn’t have known about them and it’s made a big difference to me. I thought the answer was more medication but actually it wasn’t.”
By supporting people to manage the wider issues that affect their health in more appropriate ways, this new service will help reduce the pressure on GP practices.
2. Sharing experiences helps individuals learn from each other
A self-care management programme that empowers patients to manage their own health conditions is being funded for two years as part of the new care models programme.
During 2015/16, 145 patients completed a six-week course run by volunteers who have a long-term condition themselves and have received training to become self-management coaches.
Patricia Parker, Commissioning Manager, said: “Previously patients were disempowered and isolated by the effects of their condition but this new service, with its peer support element (people who have lived through similar experiences), is really helping improve their quality of life. For each group of up to 18 participants, around two go on to become training volunteers.”
Course participant Chris, 67, who has a bi-polar condition, said: “There were 12 of us with different conditions and we learned a lot from each other.
“The aim was to try to identify ways to improve our condition and each person identified a goal and was set a target for the following week, a bit like Weightwatchers.”
Chris, who has returned to running since undertaking the course, added: “The course has given me a sense of control. I would definitely recommend it to others.”
He has also now received the training to become a self-care coach.
Empowering patients to better manage their health conditions will reduce unnecessary hospital admissions and the demand for GP appointments.