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Meet the team: Busyfish


  • Jane Thomas, Head of Stakeholder Engagement and Patient Involvement, Worcestershire Health and Care NHS Trust
  • Gary Morgan, Head of Communications, Worcestershire Health and Care NHS Trust

The challenge and opportunity we are focusing on

A Patient Self-Management programme was offered in Worcestershire for a year from June 2016.  It offered those with long term conditions two half day courses and access to a range of online materials to help them develop the skills, confidence and knowledge needed to better manage their conditions. The course evaluation indicated that those who attended undoubtedly benefitted from the learning – it recorded a 90% return rate for day two and a majority rating of excellent or good for course content.

The local Sustainability and Transformation Plan indicates the central priority of self-care.  However, limited resource capacity to deliver more courses, combined with feedback from Worcestershire people that told us that most people wanted to receive information through a conversation with their health care professional has led us to re-consider our mode of delivery.  Meetings with the patient trainers of the programme similarly indicated the view that the work would be better linked to GP Practices/local nursing teams.

Our idea

In Worcestershire there are 14 local Neighbourhood Teams comprised a range of nurses, therapists and other professionals who work to keep people well at home. The teams provide the essential foundation upon which we are building out of hospital care and improving patient experience, with teams built around GP practices wherever possible. The teams bring together staff from a range of local health and social care providers, who are working together in new and integrated ways.    

Our project is about how we can embed patient self-management into the work of these teams. We would focus on one or two of the most developed teams who are at a state of readiness to embrace this organisational development initiative. Our aim would be to co-produce this work with these teams, their patients and their carers – over the coming few months we want to work together with these colleagues to understand how to bring the materials and peer support into the work of the teams so that the development can then be adopted by other teams.

Our project will address the challenge we face. Firstly, it will bring prevention and self-care knowledge to many more patients and carers, considerably extending our reach. Secondly, the project will enable us to respond to what people told us they wanted because it will look to embed the knowledge in the health care interaction, supported by peer supporters.

The benefits we expect for those directly involved and for the Q community

The benefits of this project for patients is that they would gain access to key information – the skills, confidence and knowledge they need to better manage their long term conditions.  The hope is that this information will enable them to become more active, aware, goal-orientated and adopting of new behaviours where they see themselves as part of their health care team and where they want to maintain a healthier lifestyle.  The benefit for staff is that they would be working to empower patients, carers so making them more effective.  The benefit to the system is that the services become more responsive and sustainable, making best use of local resources.

This project will achieve the following aims:

  • Evaluation of our current PSM programme.
  • Determination of a new PSM programme in conjunction with selected Neighbourhood Teams.
  • Co-production of the final programme with a Focus Group made up from previous programme attendees and representatives of selected GP practices.
  • Training in delivery of new programme.

Details of our current Patient Self Management programme can be found at


How you can contribute

  • Your support for our project. (Please add your support via the link).
  • Comments on our proposal.
  • Feedback if you have a similar scheme.

Further information

CoCreatingHealth_tutorcasestudy (PDF, 18KB)


  1. This is a great idea. Work on self management with patients and their carers with the expectation of meaningful and measurable outcomes should be embedded in the work of all healthcare teams, but most especially those working in the community. It does require a change in focus and style however for the health professionals. Good luck with your funding proposal, you have my support.

  2. Guest

    Simon Wickes 2 years, 10 months ago

    Dear Thomas,

    this is an interesting proposal. You may be interested in a NIHR CLAHRC Wessex project/product entitled GENIE ( GENIE is an online tool, supported by community navigators, aimed at individuals who are isolated/semi-isolated typically with long term conditions.

    GENIE helps those individuals understand their existing social networks and interactions and through a structured questionnaire, provides a location-based preferential list of peer support groups to reduce loneliness, increase social interaction and improve wellbeing.

    GENIE has been proven to reduce dependence and spend in formal health systems.

    I wonder if this approach might complement your project by providing a tool for your Neighbourhood Teams to use?


  3. Hi Tom. I hadn’t read this bid again since you first uploaded it. I can see how the input from the comments have helped shape your bid since then, so that’s great to see, and the whole purpose of this process. The Neighbourhood Teams sound interesting – perhaps you can tell me a bit more about them another time. I think the aim of giving people more control over their own health is an important one, rightly positioning them as experts in themselves. I haven’t come across the concept of making people a part of their own “health care team”, where they are one of the team, not in so many words, anyway, but it’s another interesting way of looking at it. I’m a little unclear about how peer support comes in here – are you hoping to signpost to existing peer support offerings, or are you hoping to create new peer support offerings? 

    1. Hawys, Thanks for your comments. I have added a bit about our Neighbourhood Teams right at the start of the comments in response to a comment made by Rosie. I'll include some further detail in the idea section. In our previous PSM programme we established a facebook peer support group where clients were able to support each other through the activities of the programme. Clients found this to be very useful. We are planning to have a peer support feature along the same lines as the previous one but we will co-design what that feature actually looks like as the project gets going. We have learnt a lot more about peer support through the Q peer support activities and publications so we feel we can design a more suitable peer support model when other elements of the project programme get established. Additionally we have been looking at what existing schemes are available on the www and will certainly signpost to the ones that we think will be useful. Last week I attended a short training session on mental health. We were given a list of 14 apps and 14 websites that young people could access associated with mental health. I do like to 'keep it simple' so our final offering will have been well thought out. Regards Tom

  4. Brendan, Thanks for your support. Regards Tom

  5. Good idea Tom great to see this based in the community.Are third sector involved and how are you linking with their  self management resources such as asthma uk etc ?

    1. Elizabeth, Thank you for your comments. We do not have any third sector representatives on our project team as yet. Social prescribing will be included in our project and links to some resources are included on the Trust's website. I have been looking at and this looks like a very good site to fined organisations like asthma uk. You make a very valid point and we will make sure that we include access to the very valuable third sector resources. Regards Tom

    Hi. Our project team have communicated with two other project teams with a view to some collaborative working if our projects are successful. The two projects are:
    Wound infection Notional Early Warning Score Risk Tool (Wound N-EWS)
    Design, testing and implementation of an early warning scoring tool to recognise escalating signs and symptoms of wound infection to allow more timely, appropriate treatment BEFORE red flags are raised.
    Blended learning approach to condition management
    Integrating technology into condition management programmes to improve outcomes and promote digital inclusion which will include a range of self management group programmes that are delivered via Skype covering a range of conditions.
    With reference to the first of these two projects, our project is also associated with multidisciplinary Neighbourhoods Teams in a rural county. An issue with Patient Self Management (PSM) is the recognition of patients undertaking PSM that there condition is getting worse and that they should see their GP, particularly when recovering from a wound.
    The second of these two projects has experience of Patient Self Management programmes. Their experience in this area could help with our project and proposed development of our PSM course. Using Skype in a rural area seems like a very good idea.
     A great opportunity for synergy across these three project ideas.
     Please add your support to our project if you think it is valuable idea.
     Regards Tom

  7. Hi Tom, the link will take you to the website where the PIC clinics and some of the background is discussed. Hopefully this will provide some of the background you might need.

    it includes a paper we published outlining some of the difficulties we encountered as well as Vicky Goodwin's work with rheumatology which won a national improvement award. There is also reference to the PIC toolkit we drew up for other centres to use.

    Kind Regards



    1. Thanks Paul. I've followed your link and found some very interesting information regarding PICs. We will certainly investigate further. Regards Tom.

  8. Great bid!  Definite opportunity for collaboration!

  9. Thanks Tom, that would be really helpful - will keep in touch and follow how you're getting on.  Kind regards, Nicola

  10. Hi Tom, you are right, with similar Neighbouhood models I'm sure our projects would benefit from collaboration around communication and sharing ideas, also around the challenges faced in a community setting.  Self care is something we also want to embed so that people feel empowered to contribute to their care.  Kind regards, Nicola

    1. Thanks Nicola. Maybe our Neighbourhood Teams could also do some trials for your project. I'll follow you project page and comment where I can. Regards Tom

  11. Owen, Thanks for your comments. We will have a look at what you offer in this area and see if we can get some ideas to develop our project. We have not yet considered health coaching but now will. We are certainly looking at some form of staff training. Please consider adding your support to our project. Regards Tom

  12. Hi Thomas, Its really interesting to read about your model. We run self management programmes here in Powys. As well as a generic programme for people with (or at risk of) long term health conditions, we also add on disease or symptom specific modules. We offer these either face to face or via Skype which has been really useful for people who find it hard to travel to appointments. In between we use apps and text support to keep people motivated. Do you use any health coaching in your model? Regards, Owen

    1. Owen, Thanks for your comments. I will follow up on health coaching when we have put our full project team together. Regards Tom

  13. Hi Thomas,

    The development of self-care, self-agency, and the effort to embed these in delivery of primary care are essential. The NHS will never have enough resources to address every community need unless patients are engaged as assets in their own health and well being. Please also have a look at the following link which describes a project I have been instrumental in starting. I am a trustee with the advocacy provider charity in Oxfordshire. We engaged a co-production group at the every beginning of our project. The reason for doing this is that services are best configured around the expressed needs of patients. We discovered that the cost profile of missed GP appointments had some characteristics which we thought an asset based approach could address. Individuals over the age of 50 were the most likely to have poorly managed comorbidities and to miss appointments. Those individuals struggling with chaotic lives explained what would help them and from the triangulation of these factors we worked together with a service design. The result is that now patients can be accompanied to GP appointments by a volunteer lay advocate. Patients have reported that inviting an advocate to assist in the GP appointment has been just as valuable as having the volunteer also remind them about appointments and help with getting to the surgery.

    The key has been the involvement of patients in co-determination as well as co-design, configuration and co-production. We subsequently successfully obtained Big Lottery funding to enable us to scale up and scale out of the original pilot Neighbourhood

    Here is the link you can copy and paste into your browser. Please don’t hesitate to contact me if you want more information.

    Regards, Larry Gardiner

    1. Laurence, Thanks for your comments and support. I've had a look at the website via your link and we will certainly follow up on the buddy-client idea. I was born in Oxford and lived in Risinghurst. At one time I ran Barton Youth Club so have some fond memories of Barton. Regards Tom

  14. Hi Thomas, thanks for outlining your project - an important area. Does this link up with Social Prescribing at all? I don't know much about it myself and I believe this is still only in a few pilot areas rather than widespread, but might be worth looking at to see if there is opportunity to learn from this?

    Many thanks Jo

    1. Jo, Have a read of the report referenced in Tim's comment above. Tom

    2. Jo, Thanks for your comment. We have discussed social prescribing in the team and we are looking at how it can fit into our project. We have a number of updates for our project page and hope to incorporate issues raised. Please keep your eye on our updates. Regards Tom

  15. Hi Thomas, Thanks for submitting your proposal. I would be interested whether your project might consider asking the question how patients who are self managing might be helped to best determine when they need to access additional support in managing their health/condition.

    This question became important to us when considering how best to use patient initiated contact as a way of following up patients in secondary care. The lack of follow up capacity and the fact that patients are often asked to return for review when they least need it made this a very important question. The question is easily answered in some conditions but is more difficult in others when clinical signs of deterioration are subtle or silent.

    I would be happy to discuss this further if our experience (and our need for information on this topic) might help inform an aspect of your bid. Kind regards. Paul


    1. Paul, Do you have any reports/recommendations on this subject. I'd like to investigate further. Regards Tom

    2. Paul, Thanks for your comments. This is an aspect of PSM that is well worth developing. We will certainly come back to you for further discussion on this topic as our project develops. Regards Tom

  16. Hi Thomas

    I cant attach the article that you might find helpful but if you search for centre for mental health and recovery colleges it will come up. Its written by Rachel Perkins.

    Do let me know if you want to know more, we run a recovery learning community with multiple partners in the community in Devon and a Recovery (called Discovery) college within our forensic services so have quite a lot of experience in how to get these sorts of things working effectively

    Good luck with your application


    1. Helen, I've found some reports on recovery colleges by Rachel Perkins and will certainly consider this approach as we further define our project. The technique fits with our 'neighbourhood' delivery style to community support.

  17. Hello Thomas

    I wondered if you were familiar with the concept of the Recovery Colleges in Mental Health? In principle each training session is co produced and co delivered by a professional and a person with lived experience of a disorder. The purpose is to support people to manage their own MH problem. I am very happy to send you more details if you would like.


    Kind regards


    1. Helen, Thanks for your comment. Please do send more details of the Recovery colleges. I'm sure the information will be of value to our project. Regards Tom

  18. Hi Tom,

    You may find our evaluation of eight social prescribing projects in Wessex to be relevant (

    We are interested to be part of any bid, offering patient and staff-reported outcome and experience measures and reports. This is likely to come to about £5K per project (about 17% of the bid value).

    1. Tim, I've read the report referenced above. It is very thorough and provides good examples of social prescribing. Thanks

    2. Tim, Thanks for your offer of support.

  19. Dear Thomas

    Suzanne here from the Health Foundation. I am an Improvement Fellow with an interest in person-centred care. I look forward to seeing some more details on your proposal. The Health Foundation has funded quite a lot of work on embedding self-management support into clinical practice (some of this based in primary care). It might be helpful to take a look at some of this including the evaluation of our Co-Creating Health Programme if you haven't already to help inform your proposal (

    LIke Rosie, I am interested to learn more about the Neighbourhood Teams and how they might support your self-management programme and peer support. I would be also interested to know what if any work is being done to support and train clinicians and other members of the health care team to understand and value self-management support and to equip them with the skills and knowledge to do this effectively. This is something that our work shows is equally important alongside supporting people with long-term conditions to develop the knowledge, skills and confidence to self-manage.

    Hope these comments are helpful and if I can help with any more information or comments on a later proposal, let me know.

    Best wishes


      Suzanne, Thank you very much for your comments. They are certainly helpful. I will answer your questions via our project page update. The points that you have made are issues our project will address and your thoughts on our plans will be appreciated when our project page is updated.

  20. Thanks Rosie. We will address all of your points.

  21. Congratulations on being the first to get your idea up!

    I think I've understood the challenge that you are looking to address; it would be interesting to know more about the Neighbourhood Teams and the current programme. 

    Do you also have an idea of how you hope to develop the Patient Self-Management programme using Q Exchange funding, or are you after other members to help you think of possible solutions?

    As a minor point I would also suggest explaining the acronyms as not everyone will be familiar with them in this context.

    1. Rosie, This is a piece from the Malvern Gazette, Friday, June 1, 2018

      Healthy teams to simplify service
      New community healthcare teams are being set up across Worcestershire with the aim of greatly streamlining the way people are treated.
      Councillors who sit on Worcestershire’s Health and Overview Scrutiny Committee heard about the county’ NHS’s plans for Neighbourhood Teams which are already being set up.
      There will be 14 teams across Worcestershire.
      Seven will be in South Worcestershire - two in Worcester, one each in Malvern, Pershore, Evesham, Droitwich and Ombersley, and Tenbury Wells and Great Witley.
      There will be three teams in Wyre Forest – two based in Kidderminster and in Stourport, and four in Redditch and Bromsgrove, with those towns having two teams each.
      Sue Harris, director of strategy and partnerships at Worcestershire health and car trust said: “Health and social care has normally been organised by type of care.
      “We want to organise care on neighbourhood lines by population. Mental health care has integrated teams, but we’ve never tried that for older people. We are organising on neighbourhood lines to keep people living as independently as possible.”
      The teams will include, at their core, GPs, social workers, nurses, including district nurses and matrons, therapists such as physiotherapists and occupational therapists, health care assistants and administrative staff.
      They will serve communities of a population of 30-50,000 people
      Heather MacDonald from Wyre Forest Clinical Commissioning Group said: “There should be better co-ordinated care for patients and more choice for them to stay at home rather than have t0 travel to a hospital.
      “The aim is to also give staff for time to spend on patient care as there should be less duplication.”
      One of the key outcomes of the integrated teams is that patients don’t have to relate their symptoms or medical history repeatedly to different practitioners from different disciplines or departments.
      Health bosses also hope that it reduces costs for the NHS, reducing emergency admissions to hospital and reduce inpatient stays.
      A case study was cited where a newly formed neighbourhood team worked with a woman in her 50s with severe breathing problems and anxiety.. Before the team got involved in October to December last year, the woman went to A&E at hospital 19 times, was admitted 13 times, made a number of 999 calls and had many contacts with her GP and surgery nurse. After she was helped by the neighbourhood team her visits to A&E were cut to seven and she was admitted three times, but had made no 999 calls.
      Jane Harris said all the county’s teams would be operating by the end of June and added: “It’s an incremental launch rather than a big bang.”

    2. Rosie, Regarding updating/improving our PSM programme, we have contacted the 'Powys Progress Partnership' idea project team with a view to collaborating. They also have a PSM programme that has modules that are not included in our programme. We hope to share ideas with them and also other Q members that have a PSM programme. Some Q funding will be required to update our course materials. Regards Tom

    3. Rosie, I've at last been able to include more detail about our current PMS course. This can be found at I will put a link on our project/idea page. I hope to be able to put more detail about our neighborhood teams by the end of next week. Regards Tom

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