Skip to content

Q logo

Meet the team


  • Ian Gray
  • health coach (tbc)
  • social prescriber (tbc)
  • Steve Williams
  • Sacha Lewis
  • Tyne Williams

What is the challenge your project is going to address and how does it connect to your chosen theme?

Investment and evolution:A five year framework for GP contract  reform to implement the NHS long-term plan (2019) includes  new ways of working in primary care networks ..Year one incorporates  social prescribers.

The Health Foundation publication ‘Helping People Help Themselves ‘ (2011) demonstrates  there is a clear distinction between behaviour change and information provision.

The Richmond Group of Charities  publication ‘Social prescribing: options for outcome measurement. A summary’ provides a valuable overview.

Two major challenges are

1 how we integrate social prescribes in areas which are already  have health coaching

2 how we measure outcomes.

The project will  use heuristics, overseen by an additional team member , using unique patient data to help the primary care team provide the best pathway for the patient and most efficient use of our resources. It will also  use  outcome measurements to help evolve the service , hence building improvement capability across boundaries.

What does your project aim to achieve?

The objective of the project is to develop a set of heuristics that can be used by any member of the primary care team.

The heuristics will be developed using unique patient information drawn from

1 tools for measuring self identified outcomes

2 tools for measuring improved well-being

3 tools for measuring increased activation

4 Electronic frailty index score

5 ePACT2 data

A team member will b ensure that when a patient is considered for health coaching or social prescribing, that relevant scores  are available and up-to-date.

We will develop heuristics which will help signpost the patient. A good example is the Gold COPD decision aid.

The patient will connect with the most appropriate team member relevant to their particular situation who will  understand when best to integrate additional team members. The social prescriber may not always be the first step for optimum efficiency but once deemed  ready they will be most likely to engage with practical and emotional support from the community.

How will the project be delivered?

A small working group  formed  of

The  lead GP partner, a project manager from Help and Care Dorset (provider organisation ) , an existing  health coach, a manager from the primary care network (PCN),  the  PCN senior clinical  pharmacist ,and the  social prescriber .

The group will meet  on two separate occasions with protected time. The first meeting will be to look at the parameters that we have access to for our individual patients and to decide which are the most useful to help stratify and prioritise patients needing health coaching and social prescribing.

The second meeting will develop heuristics to help guide the primary healthcare team on how to optimally signpost their patient .

The outcome of these two meetings will then be presented at an in-house  education meeting in each of the four practices making up the primary care network. Feedback will be used from the four meetings to finalise and publish  heuristics to add to a computer  template to  adopt and implement.

What and how is your project going to share learning throughout?

This project will allow in-house multidisciplinary learning and discussion about new ways of working with health coaches and social prescribers. This alone has significant educational value and will facilitate team working with a greater understanding of each other’s roles. Standardisation of data entry and codes will be emphasised.Patients will be better served because staff will understand the best opportunities for each individual.

This project is eminently adoptable for one hour’ lunch and learn ‘ / in-house education  meetings held throughout Wessex at individual general practices. Evaluation of the  meetings will be obtained.

Adoption and monitoring of the use of patient scores and relevant codes facilitates future audit purposes as and when required .

Information from this project will help inform  the short life working group that has been established for the  NHS National Overprescribing Review. Our  senior clinical pharmacist is a member and this was one of the  triggers .

How you can contribute

  • Feedback from members in the community working in primary care will be very helpful in understanding how health coaches, social prescribes and clinical pharmacists are deployed in the first year of the new GP contract . It is envisaged lots of different models will evolve and our work with Q community feedback and updates will help shape the evolution of this new way of working in primary care .
  • In addition , the Health Foundation has produced some very useful working documents related to this subject and some selected communications with past authors would be very helpful.

Plan timeline

31 Oct 2019 2 x small group planning meetings completed
31 Dec 2019 in house MDT meetings completed at the 4 practices in PCN
31 Jan 2020 computer template completed for adoption in 4 practices
1 Jul 2020 6 month review and audit
31 Oct 2020 PCN meeting to decide how review adoption and future plan


  1. Hello Lawrence, I really like the sound of what you're planning.  Would this be similar in some ways to the framework is used in the PAM to assess broad levels of self-efficacy and therefore the kinds of interventions/support that is most likely to be helpful?

    Best wishes


    1. Guest

      lawrence brad 1 year, 8 months ago

      Thank you.

      We have been using health coaches who have been recording PAM scores .  I have been concerned that we are introducing social prescribers who also have PAM scores on their job description too . So , by using  some co production including frailty , activation and wellbeing scores we ought to be able to stratify and prioritise how we best enable our patients to improve self care and self mangement  . My instinct is that once we have understood health behaviours then we can information signpost better, but not the other way around .Lawrence .

Leave a comment

If you have a Q account please log in before posting your comment.

Read our comments policy before posting your comment.

* required fields

This will not be publicly visible

Please note that you won't be able to edit or delete comments once posted.