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 .