Q Exchange

Churchdown Connections

We will empower patients to self-care by training a member of staff in health coaching skills, mapping community assets and facilitate connections between patients and community-based peer support groups.

Read comments 56

Winning idea
2018

Meet the team: #ChurchdownConnections

Also:

Dr Thomas Agobar, GP Partner, Churchdown Surgery
Caitlin Lord, Project Manager, Self-Management, Gloucestershire CCG

“One in four of us is living with a long-term health condition and/or diagnosable mental health problem”. (Nesta, 2016) 40% of GP appointments now involve mental health and 90% of people with mental health problems are supported solely within primary care settings (Mind, 2018). Loneliness and social isolation can be as bad for patients with chronic health conditions, with a GP seeing up to 5 people a day who are lonely (RCGP, 2018).

With an ageing population and increasing numbers of patients with multiple medical problems, the pressures on general practice are growing.

Nesta suggests that a bold new approach is needed in order to meet these challenges; “we need an unconventional new approach in how we design and deliver health and care services that put people in the lead, uses the resources in our communities, and embeds co-production as a core principle.”

With 85% of people visiting their GP every year, GP surgeries are in a great position to engage with their patients, carers and communities to help realise this vision.

The GP Forward View (NHS England, 2016) includes patient wellbeing and self-care at the heart of their proposals, and two of the Releasing Time to Care High-Impact Actions are designed to reduce GP workload (1. Active signposting and 9. Supporting self-care).

Churchdown Surgery in Gloucestershire has recently moved into new, state-of-the-art premises in the middle of their practice area next to the local Community Centre. The practice area is largely suburban with a few outlying villages. The practice cares for many middle-income families, but there are also areas of affluence and social deprivation. The practice list size is 13,851 and growing.

Despite being a popular practice with high patient satisfaction, the staff are tackling an increased workload – from patients struggling with multiple chronic diseases, frailty, loneliness, and mental health problems. It is apparent that many of these patients find it difficult to make lifestyle changes and engage with sources of support.

57.6% have a long-standing health condition (England average 53.5%). 360 patients have pre-diabetes, 754 patients have Type 2 diabetes.
21.4% of the practice population is over the age of 65 (England average 17.3%). In the 2001 census, 495 pensioner households had no access to a car or van, and 674 pensioner householders were living alone. 110 people are coded as having dementia, and 2,854 people registered in the practice are over the age of 65.
20% of the practice population, 2,754, are recorded as BMI > 30.
92% of respondents to the 2017 GP practice survey would recommend Churchdown Surgery to someone new in the area (CCG average 83%, national average 77%).

The practice is keen to move away from the old-fashioned focus of a GP surgery focussing on illness to a practice embedded and connected to the community with a focus on empowering patients to look after their own health, support each other and their community.

Three potential patient groups have been identified as priority areas, along with supporting carers for people in these groups:

Adults living with diabetes or pre-diabetes.
Young and working-age people with mental health conditions.
Older people experiencing loneliness and social isolation.

By mapping the assets in the community and matching them to health needs from practice data, Churchdown Connections will adopt and adapt new models in place in other areas in the country, for example, Compassionate Frome and Health Connections Mendip to create the connections between the health needs of the community and community-based assets.

Models such as the Quadrant model piloted with diabetes care (Hart, 2018) can be used to segment people to ensure that their needs are matched to the appropriate level of intervention.

A member of staff will receive training in health coaching to help patients (and carers) identify peer support groups in the community relevant to their own individual perceived physical, social, or psychological needs. This “Community Connector” would be available for immediate coaching conversations for patients attending the surgery or if recommended by their GP or practice nurse.

Volunteer peer support champions will be recruited to support patients to attend groups for the first time (often a block to the effectiveness of peer support activities as highlighted by the Q labs work). There is evidence that becoming a peer support champion has health benefits such as better knowledge and awareness, increased self-esteem and confidence, and improved well-being. For some individuals, this will be the start of a journey to other opportunities such as education, volunteering roles or paid employment. (Altogether Better).

What is health coaching? “Health coaching is a patient-centred process that entails goal setting determined by the patient, encourages self-discovery in addition to content education, and incorporates mechanisms for developing accountability in health behaviours. The evidence is that there are many benefits associated with health coaching”. (Better Conversations Resource Guide).

A steering group of stakeholders comprising the Community Connector, representatives from the patient participation group, Churchdown community centre, Gloucestershire Community Wellbeing Service and cluster Community Frailty matron would meet regularly and work together to facilitate a streamlined experience for patients, avoid duplication of work, and share resources and learning.

The premises offer new opportunities for promoting patient well-being and self-care; the building is surrounded by land that would be suitable for a small community garden, which could offer a space and a reason for people to socialise, learn, be active, and grow food together in a safe, secure and supported environment. This could also include participatory arts, e.g. social sofa.

There is a multi-purpose room with a sprung floor suitable for exercise classes or peer support groups. A pre-diabetes education lifestyle group, Kernow Yoga for back pain, Pilates classes for the staff and/or patients are all possibilities. These would enable a wider focus on aspects of mental health, social isolation, and giving a space for inter-generational peer support.

Potential interventions might include a diabetes walking group. As buses to the practice only run once an hour, there are long waiting times for patients, and the community centre is already creating a space for a café for people to use when attending the surgery, which will provide a space and opportunity for conversations and peer support.

The Q Lab also found that promoting and finding peer support services can be challenging and so through mapping and then support a hub of resources this will enable easier connections between people in need and services available to support.

If successful we would hope to disseminate our ideas widely within our locality and the Q community by developing an online toolkit for other practices/ CCGs to utilise.

Our approach as a project team with the support of the Q community and Q exchange would be:

Discover (September 2018 — February 2019) — data gathering of health needs, community assets, liaising with Gloucester Public Health and existing community champions, learning from exemplary sites, and recruiting a “community connector” to lead this work.
Co-design (October 2018 — March 2019) — Provide health coaching training to the ‘community connector’, recruit and train 10 champions with lived experience in the priority areas, facilitating co-design sessions with staff, Patient Participation Group, and the local community, and training the whole practice team in coaching skills.
Deliver (February 2019 onwards) — tests of change following the quality improvement approach, measuring for improvement defining measures, for example using process (number of contacts and connections), outcome (patient satisfaction, patient activation measure (PAM) levels, and clinical outcomes), and balancing (staff satisfaction, number of GP attendances) measures. Our discovery phase will include scoping measures and collecting baseline data.
Evaluate and share (July 2019 onwards) — share results with the Q community and other areas who would like to implement this model through a blog and social media, and an implementation toolkit for the spread.

The funding offered by the Q Exchange will give backfill to enable a team of practice staff to carry out the activities above, scoping, data gathering, and co-design activities with members of the local community, as well as fund visits to exemplary sites (e.g. Frome, Bromley-by-Bow), training in health coaching conversations, and remuneration to patient champions.

How you can contribute

Leave a comment -- what do you think of this idea, can you help us?
Click the blue support this idea button!
Share this idea with someone who would be interested -- use #ChurchdownConnections on Twitter
We are looking for:
Experts in peer support, community-based asset mapping, and social prescribing to act as an advisory faculty for the project team.
Networkers to make connections with similar projects in other parts of the country.
Critical friends to provide challenge particularly in relation to measurement and evaluation.
Promoters to act as a champion for the project and to share learning from the project team as the project develops
Fixers with specific areas of expertise particularly seeking support in setting up a directory of services, in facilitating a co-design workshop, in providing improvement coaching to the project team, and in identifying appropriate training to meet identified training needs.
Visits to exemplar sites will be arranged as Q visits and open to members of the Q community to participate. Learning from exemplar visits will be shared with members of the Q community through the Q website.

Further information

Evidence base (DOCX, 30KB)

Reviewer feedback

This is a great project because…

It's a well developed example from primary care taking a community assets approach looking holistically at the mental and physical health needs of patients.

By the time of the event we encourage the project team to think more about…

How you will build on and connect with other work underway in this territory and use the Q community to share learning throughout the project.

Comments

Sharon Drewett 2 Dec 2018

Good afternoon hive. We remain undecided which measurements to use to measure the potential impact of our project and wonder if any of you have experience/advice?

We are thinking of looking at a combination of "hard" data (e.g. hospital admission rates/GP attendances) and "soft" data (e.g. wellbeing or activation scores). I suspect with such a small intervention over a short time frame, the latter will prove more useful?

The ONS Wellbeing Score and PAM (Patient Activation Measure) are possibilities. Do any of you have experience in these or any other, possibly more useful, scores to measure wellbeing and/or activation?
1. Gregory Lucas-Mouat 3 Dec 2018
  
  Hi Sharon, although i'm no longer directly involved with the Community Wellbeing Service, I can report that the CWS as a countywide scheme uses both the ONS and PAM as wellbeing measures and seem to have a pretty good response/completion rate. The key thing is that when delivering the ONS or PAM, it's important that the purpose and utility of the measure is explained and that it's not treated as a paper exercise otherwise the 'readings' you take will not be accurate or be of much use to practitioner or patient. The CWS also uses the SWEMWBS for patients with MH conditions and has a similar response/completion rate. 12 weeks between scores i.e. entry and exit seems to be the standard in providing useful data to show improvement in wellbeing or otherwise.
Sarah Williams 30 Aug 2018

Hi

there is some great work going on in Wessex vida the CLARHC which has used an online tool to link up t=exactly the sort of community resources that you refer to, but also key social networks/ family members/ friends/ peer workers. I'd highly recommend that you get in touch with them, share ideas etc .. https://www.clahrc-wessex.nihr.ac.uk/engagement-with-self-directed-support

all the best

Sarah
1. Sharon Drewett 22 Nov 2018
  
  Sorry for the delay in replying Sarah; life has been busy at the coalface and getting our exciting project off the ground!
  
  Thanks so much for sharing information about the work CLARHC are doing. It looks really interesting and, as you say, might be a great add on to our model. I look forward to connecting with them.
Matthew Mezey 24 Aug 2018

Want to learn more about what Coproduction is - and isn't? Want help and advice with your own improvement project's co-production challenges?

Do join next month's zoom video call with Q's Coproduction SIG and Coproduction expert Carol Munt.

To register go here: https://q.health.org.uk/event/what-is-coproduction-and-how-can-you-make-it-work-for-your-improvement-project-with-carol-munt-zoom-call-14-sept-12-30pm/

Bring your challenges!
1. Hein le Roux 27 Aug 2018
  
  Thanks Matthew, I have signed up. I am particularly interested in how general practices can work with their patient participation groups to support local care delivery. A specific example would be in better identifying and connecting carers to third sector support services (Carer's Gloucestershire in our area) and this builds on many of foundation stones of our Churchdown Connections bid.
Deon Louw 30 Jul 2018

Hi. I'm mindful of the primary care origin of your idea but would be keen on exploring how this could inform the vast amount of patients shared with acute care. We have a Q-Exchange project on ED frequent attenders and the focus on mental health is a shared concern, particularly when it comes to patients coping with long-term conditions. I previously worked in Gloucester and Cheltenham EDs but based in Oxford now, so it would be a shared learning outcome. One major question for me would be how you link in with ED.
1. Hein le Roux 27 Aug 2018
  
  Deon, I have just come across this HF paper which supports our direction of travel:
  
  https://www.health.org.uk/sites/health/files/Reducing-Emergency-Admissions-long-term-conditions-briefing.pdf
2. Hein le Roux 27 Aug 2018
  
  Thank you Deon, you make a really valid point and I think this is something we could look to explore. As you describe, patients (particularly those with long term conditions and mental health challenges) are often making contact with many different services and professionals and are not getting their needs met. This leads to increased cost, duplication of effort and more importantly poorer health and wellbeing outcomes for these often vulnerable people. As healthcare moves from competition between providers to a more collaborative population based way of working (STP / ICS / Accountable care) with integrated place based care delivery at it's heart I believe there will be an opportunity to improve the care we deliver by better understanding the patient's journey.
  
  Sorry for the long answer, but absolutely yes to collaboration particularly on understanding frequent attenders so we can better meet their needs and direct them to more appropriate interventions including social prescribing and community assets.
Thomas John Rose 24 Jul 2018

Hi, I'm currently working on two process maps that may be of interest to your project. One is on establishing a Social Prescribing network ant the other is on a Patient Self Management programme for people with Long term conditions. Please let me know if you would like more information on either of these topics. Regards Tom
1. Hein le Roux 27 Aug 2018
  
  Apologies for the delay in getting back to you Tom, yes please share both process maps. Many thanks.
Sally Ashton 20 Jun 2018

Great idea to build on existing relationships for the greater good.
Caitlin Lord 19 Jun 2018

Really interested to see all the enthusiasm and this process taking shape.

Fully supportive of direction on this to de-medicalise our model for all the reasons given already.

My thoughts are around how to make this real and particularly how it can add value to the work of others already in the community supporting this shift. In part this picks up on Dan and Greg's points .

I would see this role as complementing CWS in building up the local "social prescription" options. Really like the ideas around art, nature and physical activities.

In the spirit of ABCD, and in recognition that these activities are beneficial to all, this support might not set out to be specific to any one LTC.

Alongside this capacity building, this person could have a very important role in championing co-production and development of partnership culture (patient and professionals) in the practice.

This is embryonic in most practices and has great potential. Simon Stevens talks about finding new sources of value through different relationships with people and communities. This would fit that perfectly.

Of course there are a number of partners that would be really useful to engage. To mention a few:

CSW
Independence Trust
The Producers (Co-design group )
Reconnect LTC support
The Live Better Self-Management Education Programme

In this scenario, the role of supporting individuals to identify their needs and identify activities and support would remain with the CSW, with this person being a bridge to the CWS service, supporting the practice's closer engagement with the service.

Dividing the role in this way avoids this person becoming overwhelmed and supports this to add value to existing offers and be sustainable beyond the Q-lab term.

All very positive. With everyone's support, I am hopeful of getting through to the next round !
1. Hein le Roux 19 Jun 2018
  
  Thanks Caitlin, these bids are an iterative process. The strength of the Q exchange is that people share views that we may not have previously considered which then helps us to challenge some of our earlier assumptions. On the back of your helpful comments I have spoken to our CCG colleague, Jules Ford (Senior Commissioning Manager at Glos CCG for Social Prescribing) to clarify some points. We are seeking to build on and plug into the existing Gloucestershire model, but with a place-based focus which is 'hyper local' with practice staff acting as connectors for the Churchdown community's population. This will be a cultural change for both patients and staff and where appropriate, we will aim to demedicalise patient care and ask them 'what matters to them'. This way of working is very reliant on building on local relationships that already exist in the Churchdown community and connecting patients to things they think are important to them rather than health care professionals telling them what they should be doing. In other words, it's about co-producing care by taking a coaching approach with patients focusing on wellness rather then illness. Thank you once again.
Hein le Roux 19 Jun 2018

thanks Helen, we are excited and a key part of our work will be sharing our learning with our health communities.
Hein le Roux 19 Jun 2018

Thanks Seema, that is an important point and we are aware of the power of twitter and social media. Initially we will also deploy that old fashioned, but highly effective tool called 'word of mouth'. With the community centre next door, we aim to link our work with the wider community agenda. Also, we are working with our patient participation group to ensure co-production. Our CCG is supportive of our proposal and, if successful, we could link this to their wider messaging.
Hein le Roux 19 Jun 2018

Thanks Tom, I agree and from my experience the best outcomes occur when people are motivated to do things for themselves. If we over-medicalise our life challenges, this can cause dependence where as this proposal is about independence which often comes from self-belief.
Liza Pickett 18 Jun 2018

This project does come at an exciting time for Churchdown as a community. The new surgery has been anticipated for nearly 20 years and has been very positively received by patients. There is much support already available within our community for people who are isolated, depressed or wanting improve their health, however, we often don't have time to source this as busy GPs. The idea of our Connectors will help us work in partnership with our patients to help them manage their own health more effectively and further develop beneficial links with our community.
Natasha Swinscoe 18 Jun 2018

A really exciting project bid demonstrating so many opportunities for collaboration and trying new approaches. I hope the bid is successful as the comments demonstrate there is so much support for it, I'm then looking forward to the evaluation so we can help others to adopt (and adapt) the things you find work well. Good luck!
Seema Srivastava 18 Jun 2018

Fantastic idea which I am sure will strengthen the local community and enable people to have to skills to help each other. I wondered what communication channels will be used to connect the population of Churchdown with this work? Thanks Seema
1. Hein le Roux 27 Aug 2018
  
  Thanks Seema, we are considering the use of communication channels like facebook, twitter and blogs to spread our messages and engage people. We are also going to rely on traditional 'word of mouth' building on the statistic that 85% of people have some contact with their local GP practice in a year. Given our already strong informal community connections and our active patient participation group we hope that our project aspirations will spread quickly into our community.
2. Nathalie Delaney 18 Jun 2018
  
  Thank you Seema -- that's a really helpful prompt -- Sharon/Hein do you know what communcation channels are already in place in Churchdown?
Helen Smith 17 Jun 2018

Great idea, key to enabling and empowering people to manage their own health and well being. Really positive to see the connections you are making in your area from the comments made so far.

Great to see how you get on with this and so we can consider how we might scale up in the SW.

Good luck!
1. Hein le Roux 27 Aug 2018
  
  Thank you Helen, a key part of our bid is to share our learning (and to learn from others).
2. Nathalie Delaney 18 Jun 2018
  
  Thank you Helen!
Andy Hamilton 15 Jun 2018

The project seems to capture a moment of change for the village with the GP practice moving to a new purpose built location next to the community centre. Having outdoor and communal space should help facilitate physical connection for peer groups and support networks, which is powerful for people with mental health problems, and those suffering social isolation and loneliness. The proximity to the community centre is a great opportunity to collaborate as a 'hub' for wellbeing in village life.

As a GP trainee moving through rotations, it always takes a significant amount of time to get to know a new community, the local practitioners and referral pathways. It often feels like there could be so much more we could do for patients, or more appropriate sources of help, but just don't know how to access services locally in a new location. Large training practices like Churchdown host multiple GP, nursing and allied professionals in training, and this project would be a great way to help those staff integrate quickly into the community, as well as new receptionists, admin and secretarial staff.

The role of community connector would help to de-medicalise things for people with lifestyle and social problems presenting to the practice, Using some of the funding to train this role should provide sustainability for the project in years to come.
Tom Agombar 14 Jun 2018

As a GP working daily with patients struggling to deal with many different health problems - but also aware of the many different sources of support that are available out in the community - this project seems to fill a crucial gap.

Many people come to see me because they already know me, I'm easily accessible and they know they'll be listened to. But often I'm not actually the best person to help them. There are many better sources of support out there in the community - from bridge clubs to "Men's Sheds" or "walking for health" groups. The difficulty is motivating patients to engage with these groups and linking them into the peer support that is available. That's where this project comes in - helping patients in primary care engage with the peer support that is all around them.

I feel that implementing this kind of change in primary care, where 90% of daily patient contacts happen, is crucial to the long-term sustainability of the NHS as a whole.
Gregory Lucas-Mouat 14 Jun 2018

Hi there, my name is Greg and I manage the Community Wellbeing Service for Gloucester. The CWS has replaced what was the previously separate social prescribing pilot and village agent scheme and brought them together into one single service. The CWS is a countywide scheme and open to anyone living in the county or registered with a GP practice in the county and aged 16+.

The CWS for Gloucester actually includes Churchdown and also as a resident of Churchdown myself (for over 20 years) I am particularly interested in what Churchdown Surgery are looking to implement if they were successful with their funding bid.

At the CWS for Gloucester, the majority of referrals we are getting are directly from GPs and the main reasons people are being referred to the service is for Social Isolation, Loneliness and Mental Health. There is clearly a need for people in Gloucester (and Gloucestershire) to find ways to connect to services and their local communities and the CWS has been commissioned precisely for this; to reduce pressure on primary care services i.e. mainly GP practices.

Having looked into Churchdown Surgery's proposal, I personally feel that it would complement the service we are providing and make for a much closer working relationship with the GP practice and the wider community in Churchdown. Peer support and shared experience is particularly powerful in motivating people and at the CWS we are keen to engage with any practice, service, organisation or group that is committed to promoting positive health outcomes. I understand there are always concerns about duplication of work or 'stepping on toes' but I can assure you that for the CWS in Gloucester, collaboration and co-working are at the centre of what we do.

Our remit is to support individuals to discover that they often have the power themselves to effect real change in their lives and we do this by providing people with information, guidance and advice so that they can make informed decisions about accessing services (be they statutory or voluntary sector) and to know what is available in their local area or community. I think that what Churchdown surgery is proposing would work extremely well alongside the Community Wellbeing Service, particularly in sharing knowledge of community based activities or organisations but also co-delivering positive outcomes.

At the CWS, we know how busy GPs are and the limited time they have in which to see numerous people on a daily basis. We have more time available to us to spend time with patients, listening to their needs and supporting them through coaching and motivational conversations to promote independence, resilience and self-reliance. Anything that would act as a bridge between the surgery and our service is most welcome and I am excited about the prospect of strengthening our relationship in Churchdown.
1. Hein le Roux 14 Jun 2018
  
  Thanks Greg, you are quite right that this is a bid which at its heart is about community collaboration. We are also committed to sharing our learning both locally and nationally with interested GP practices and their communities. From my own experiences with my patients, I know that when people are motivated to improve their health, it is amazing what they can achieve. I always remember the gentleman with type 2 diabetes who was on insulin. Following some motivational interviewing, he decided to beat his diabetes, lost 2 stone in weight and came off all his medication. His solution was not more healthcare and it remains one of the best professional experiences of my career. I also agree about your observations concerning loneliness and social isolation which is affecting so many older people including carers. There are so many 'assets' in our community that we want to connect people up to.
Sharon Drewett 14 Jun 2018

Thank you all for your comments and helpful suggestions so far!
As busy GPs working in a large practice we are increasingly aware that health outcomes are often determined by lifestyle and social factors such as loneliness. We have just moved into new premises in the middle of the practice area and are keen to become further embedded in our community with a focus on empowering patients to look after their own health, support each other and their community.
We know that 85% of people visit their GP surgery each year (RCGP) and we are therefore in an excellent position to help patients connect to the many excellent peer support groups available in Churchdown.
We plan to provide health coaching training for a member of our reception team and create a new role of "community connector" to help patients identify which community activity or group might best suit their individual needs. We plan to involve patients and other stakeholders such as the community centre next door, our cluster Community Frailty Matron and the local Community Wellbeing Service (previously social prescribing) in helping us develop and implement this idea.

We would also like to develop a small allotment area on land next to our new surgery which we hope will become another successful peer-support initiative.
We are already working with our staff, patients and community to develop this exciting project idea and hope we are successful in securing the funding to realise our vision.
Dan Beale-Cocks 12 Jun 2018

Have you heard of the Mental Health and Well Being Partnership board? They have a large stakeholder meeting (about 100 people attend) where you can get a lot of SU and 3rd sector response.

I'd like to mention your idea to the MH&WBPB Steering Committee next month. The joint commissioner for MH in Gloucestershire attends, and I want to see what he thinks.

I know the LA and CCG are looking at the wider determinants for mental health. It's part of the suicide prevention strategy, and I'm sure it'll be parts of other MH strategies too.
1. Nathalie Delaney 18 Jun 2018
  
  Hello! Replying on behalf of Sharon who says, "Thank you, and yes please!"
Hawys Tomos 12 Jun 2018

Great to see the Q Lab work referenced and built upon in this bid. Mapping the community’s assets and matching them to health needs sounds like a good idea, and I’m intrigued to see what kind of matches are made. Making the GP surgery a kind of community hub made me think of the work at Oxford Terrace and Rawling Road Medical Group in Gateshead. I couldn’t find much on their website to describe the work they do, but I did find this article / paper: ‘The Value of Asset Based Community Engagement and Social Prescribing in General Practice’ (http://www.altogetherbetter.org.uk/Data/Sites/1/publications/--the-value-of-asset-based-community-engagement-and-social-prescribing-in-general-practice.pdf), which might be of interest.
1. Hein le Roux 27 Aug 2018
  
  Thank you for sharing Hawys, as a jobbing GP your article struck home as it is what I experience. The traditional medical model needs to evolve both from a workforce point of view, but more importantly as society is changing and people realise that the traditional 'pill for every ill' often is not the answer to their challenges. Local asset based community development and social prescribing can really help people improve their own lives and in the process free up clinical team time to focus on medically unwell patients.
2. Nathalie Delaney 12 Jun 2018
  
  That's really helpful, thank you for sharing the link :D
Paul Gimson 12 Jun 2018

Great idea. Good luck with this as I think it would be really interesting. Might be worth getting in a visual facilitator to draw the map, I've seen a few things like that done and really effective.
1. Hein le Roux 27 Aug 2018
  
  Thanks Paul, our project is quite intuitive at heart which is at odds with the more medical model many of us are used to working within. Hence, I like your idea of visual facilitation and the drawing of maps as I believe it shows people what is possible. We can explore this idea.
2. Nathalie Delaney 12 Jun 2018
  
  Thank you Paul -- that's a fantastic idea to get a visual facilitator in to do the map, what did you think of our visual video?
Kevin Hunter 12 Jun 2018

I think this is a brilliant idea and looking forward to seeing the impact it will make on the Churchdown and wider Gloucestershire communities. The toolkit sounds like a great way to easily enable spread and adoption of the approach across the region.
1. Hein le Roux 27 Aug 2018
  
  Thank you Kevin, yes spread and adoption are key to our idea particularly to other practices in our GP practice cluster and then, if people are interested, onto our wider Gloucester locality and then onto our Gloucestershire STP / ICS (and even wider). From anecdotal evidence, we know that many patients and staff prefer to receive and deliver care in this more holistic way.
2. Nathalie Delaney 12 Jun 2018
  
  Thanks Kev and thank you for supporting the idea!
Sally King 9 Jun 2018

This sounds fantastic, and although not just about primary care, I wonder if there is some learning from the Gloucester City Homes led project which is working to understand what a regeneration plan that doesn’t just focus on housing might look like for 2 areas of Gloucester City. I’d be very happy to try and connect the right people. I also think that If you’re goals is to create an empowered population, it would be crucial to link with other health and care providers that your registered population come into contact with? Again please use me to make the right connections.

Good luck and just ask if I can help in any way.
1. Hein leRoux 10 Jun 2018
  
  Thanks Sally, like Nathalie says we will need help in terms of connecting. Our goal is very much around empowerment, particularly through co-production with our community. As we know, there is so much that people can do to improve their own health, so a coaching approach will be crucial. We are also looking to focus on the social determinants of ill health through these connections.
2. Nathalie Delaney 9 Jun 2018
  
  Hi Sally -- this is exactly the help we need connecting into the right people thank you for the offer, we will be in touch!
Hannah gorf 9 Jun 2018

fantastic! Fits with what Gloucestershire are already doing with social prescribing and cultural commissioning. Just a note that social prescribing in the county is now called Community Well-being Service, not Community Connectors. Please remember to engage carers!!! There is a lot of work about to happen around support for carers locally - happy to discuss.
1. Hein leRoux 10 Jun 2018
  
  Yes Hannah, carer's really are the unsung hero's of our communities. We want to connect into what exists already rather then duplicate or compete and we believe our proposal fits into our CCG's and our One Gloucestershire STP's direction of travel. Better identifying, valuing and supporting carers in our community is important to both the community of Churchdown and also the GP practice. We would want to share our learning and improvements around carers with other GP practices and the communities they serve.
2. Nathalie Delaney 9 Jun 2018
  
  Thank you Hannah -- would be great to find out more about your work with carers and how we can link in!
Joanna Garrett 8 Jun 2018

This sounds like a great idea to bring the community together to promote improvements to health and social care utilising existing resources.
1. Hein leRoux 10 Jun 2018
  
  Yes thanks, also the answers are so often not healthcare related for example loneliness and social isolation.
2. Nathalie Delaney 8 Jun 2018
  
  Thank you Joanna :D
anne pullyblank 6 Jun 2018

This is a great idea. You could think about prescriptions for prehabilitation which improves outcomes from surgery with this model. You could cook the food you grow and improve nutrition via cooking classes. The possibilities are endless....
1. Hein leRoux 10 Jun 2018
  
  Thanks Anne, love the pre-hab idea so patients go into surgery as fit as possible and this fits into our idea of wellness rather then illness.
2. Nathalie Delaney 8 Jun 2018
  
  Thank you Anne -- these are great ideas!
Dan Beale-Cocks 18 May 2018

This looks like an exciting idea!

I have a few questions.

How does this fit in with existing social prescribing activity in Gloucestershire? (I found them a bit tricky to use. I'm glad they exist, but I need a bit of a clearer signup to activity. I guess the jargon term is "hot handover" - I need someone to sign me up to something, and then to check I went to the first meeting.)

Will you link up with other organisations doing sort of similar activity? For example, The Independence Trust has some nice work in their Stroud branch. And they're working with 2gether to provide gardening groups at a 2g site.

But this looks exciting, and I can't wait to see how it proceeds. Good luck!
1. Hein leRoux 10 Jun 2018
  
  Thanks for your comments and I agree, this builds on social prescribing and what is there already. The vision is around supporting individuals in the community to see their own health in terms of wellbeing rather then the more traditional illness model. There is so much great work already happening around Gloucestershire, both in formal social prescribing, but also in other informal ways as you point out. We want to connect to all these offers so our patients, where appropriate, can improve their own health by focusing on their own social determinants of health. Should we be successful, we would want other GP practices to share, in the best traditions of quality improvement, our learning and improvements so they can be replicated for their own communities. Clearly co-production is really important in our proposal.
2. Nathalie Delaney 20 May 2018
  
  This is a really good point, thank you Dan! I've asked Hein as he's more aware of what's happening locally, and absolutely this project would link into existing services. Our aim is initially to start really small and hyper-local at the Churchdown level so that what we are doing is achievable and easy to measure rather than go too big too soon! In terms of social prescribing, Hein says this is really "social prescribing (now called community connectors) plus plus" as it is about linking the community centre and GP practice together to being seen as part of community: thank you for the recommendation to link into 2gether and the Independence Trust!