Meet the team
This member's profile is private - please log in to view all the information.
- 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.
|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|