Empowering people and communities

Helping people to help themselves

Empowering people and communities to take a more active role in their own health and wellbeing is central to the changes that the new care models programme is making to the way services are delivered across our health and care system.

Whether it is helping people to manage their own long-term conditions, or working in partnership with communities to promote healthy living and wellbeing, the programme has been working with the 50 vanguards to ensure it is central within the design, implementation and spread of new care models. This work has been underpinned by the NHS Five Year Forward View and six principles that define good person-centred, community-focused health and care.  This is also built on the evidence base of the initiative Realising the Value.

Through this, the vanguards are already making great progress:

  • As part of Symphony Integrated Healthcare (South Somerset) (@SymphonyProj) health coaches work alongside GPs and practice teams to support people through a coaching style. This enables people to set their goals in terms of ‘what matters to them’ and how they might improve their health and wellbeing. There are more than 50 health coaches based within the GP practices and Symphony will soon be rolling out a fourth wave of coaches to other practices.
  • At Better Care Together (Morecambe Bay Health Community) vanguard (@BCTMorecambeBay), an initiative called ‘Let’s Get Moving’ is aimed at getting schoolchildren to undertake exercise regularly. Better Care Together has also been putting support for self-care into action with a community-led series of weekly groups, ‘Hope and cope’, which bring together local people with long-term conditions, such as diabetes, depression and coronary heart disease – where the aim is to encourage them to support one another.

Building on this, in late January 2017 we launched an intensive package of support to help local health and care services to make the changes they are putting in place faster.

In 2016, vanguards within the new care models programme were invited to apply for this support – and the successful 15 have now been confirmed. They will receive assistance to work together as part of a dedicated learning network to implement the following key actions, which, if delivered together and in a systematic way, could have a real impact in terms of empowering people and communities in their own health and wellbeing:

Working in partnership with communities to build public health and wellbeing

  • Mapping community activities and resources, such as walking clubs – and connecting them at a locality level
  • Growing these resources, creating solutions to improve public health and wellbeing, such as healthy eating, physical activity and social connectedness – in response to local need
  • Building a network of community health and wellbeing champions to reach people most in need of support.

Supporting self-care for people living with long-term conditions

  • Putting in place the patient activation measure – to identify people with long-term conditions who need more support to manage their health and wellbeing
  • Delivering systematic and tailored self-care support; this includes a single point of access, care and support planning, self-management education and/or health coaching, and access to community resources – such as peer support – and group-based activities, through social prescribing. This will start with people in the following groups and then will aim to extend to all people with long-term conditions, who might benefit:
    • Diabetes
    • Chronic obstructive pulmonary disease (COPD) or heart disease
    • People with multiple (three or more) conditions
  • Producing a way of identifying and supporting carers
  • Considering the interrelationship with integrated personal commissioning and personal health budgets.

All 50 vanguards will also have access to masterclasses to support delivery of these key actions.

The 15 vanguards are based within integrated primary and acute care systems (PACS) – new models of care that join up GP, hospital, community and mental health services – and multi-specialty community providers (MCPs) – which are moving specialist care out of hospitals into the community.

The 15 vanguards are:



The network will meet on a quarterly basis to share experiences and learning. It will also support spread across the wider health and care system through the co-production of materials to facilitate implementation of best practice.