Case Study: Ways to Wellness

Ways to Wellness comprises of a “hub” model of working in which a non-medical link worker trained in behaviour change methods offers a holistic and personalised service to identify meaningful health and wellness goals, as well as connecting clients, when indicated, to community and voluntary groups and resources.

Project Location

Aligned SDGs

INDIGO Key facts and figures

INDIGO project
- INDIGO-POJ-0120
Commissioner
Intermediary
Investor
Provider
Funds
- Commissioning Better Outcomes Fund - United Kingdom
- Social Outcomes Fund - United Kingdom

Launch date

March 2015
Start of service provision

April 2015
Capital raised (minimum)

GBP 1.65m

(USD 2.52m)
Service users

8k+

Target population

People with long-term health conditions (such as Chronic Obstructive Pulmonary Disorder, Asthma, Diabetes Type 1 or 2, Coronary Heart Disease, Heart Failure, or Epilepsy), social isolation, frequent attenders at GP or hospitals due to poor understanding of condition, anxiety or depression (in addition to a long-term condition), poor health but with scope to improve with lifestyle change, poor English literacy. They must be aged 40-74 and living in areas of Newcastle West which experience high socio-economic deprivation.

Ways to Wellness report on BBC Look North, 9 November 2021

The challenge

Over 15 million people in England suffer from long-term conditions (LTCs) related to their health. They experience poorer health outcomes and reduced quality of life as a result. They are proportionately higher users of health services (GP appointments, prescription drugs, outpatient services and in-patient hospital bed days). LTCs account for 70% of health and social care costs in England, and around 55% of GP appointments are with patients with one or more LTCs.

West Newcastle upon Tyne is among the 40th most deprived areas in England. 18% of residents are recorded as living with a long term condition (LTC) and the receipt of sickness or disability-related benefits is higher than the national average.

Enabling people with LTC to self manage their condition can improve their life quality and reduce demand for health and care services, but health authorities often lack the funding to support this kind of service.

The solution

Social prescribing is increasingly being seen as a way of addressing complex health issues, particularly for people with long-term conditions. While some small scale community-based activities have been funded in the past by local and health authorities, the evidence base for this approach remains limited. Taking a SIB approach has enabled long-term funding for social prescribing on a scale that wouldn’t have been funded otherwise.

Ways to Wellness is a social prescribing intervention targeting people aged 40-74 living in areas of high socio-economic deprivation who have long term health conditions. Ways to Wellness Link Workers offer support to patients referred by primary care, helping them to identify meaningful health and wellness goals, and provide support to help them access community and voluntary groups and resources. The Ways to Wellness intervention is predicted to save £10.8 million in secondary care costs, and a further £13.6m to other public services.

The impact

A Newcastle University report found that once engaged with the service, patients reported positive physical and behavioural changes, including weight loss, increased physical activity and improved mental health. Patients also reported increased self-confidence and control, reduced social isolation and greater resilience.

The report concludes that: "findings suggest that tackling complex and long-term health problems requires an extensive holistic approach not possible in routine primary care. This model of social prescribing, which takes into account physical, mental health, social and economic issues, was successful for patients who engaged with the service. Future research on a larger scale is required to assess when and for whom social prescribing is clinically and cost effective".

Ways to Wellness - Jack's experience

Prof Chris Drinkwater, Chair of Ways to Wellness, discusses social prescribing for long term health conditions

To be successful, social prescribing programmes require joint ownership from health, social care and the voluntary and community sector and need to be deeply rooted in the local circumstances

Prof Chris Drinkwater, Chair, Ways to Wellness

Outcomes framework

There are two primary outcomes:

1. Improved self-management of LTC, leading to greater sense of well-being, reduced isolation and fewer GP visits (as measured through Triangle Consulting's Well-being Star) – 30% of the outcome payments)

2. Reduced cost of secondary healthcare services as a result of improvement in self-management of LTC (70% of the outcome payments), measured against a counterfactual

Defining robust outcomes

A Deep Dive Report produced by Ecorys UK and ATQ Consultants as part of the Commissioning Better Outcomes Fund Evaluation highlights that many outcome metrics were tried, but were discounted for either being unmeasurable or not a direct or reliable proxy for the outcome sought. Due to the innovative nature of the project there was limited available evidence to draw on. Although all parties appeared on board with the measurement approach, stakeholders commented that the approach will not capture all the potential cost savings generated by the project.

The project has had to restrict its referral criteria based on what data can be accessed and they did not fully know whether the outcomes metrics would work. Quite a few stakeholders were nervous about some aspects of the measurement approach. Specifically, stakeholders raised two concerns:

Whether the intervention will lead to cost savings for the Clinical Commissioning Group (CCG), or whether the CCG will have to pay outcomes even though they will not know whether the project has really saved them money.
Whether the Well-being Star is robust enough to evidence outcomes, due to the fact that it is based on (subjective) patient self-assessments (though this was only raised by one stakeholder).

Source: Ways to Wellness Social Impact Bond: The UK's First Health SIB, 2015.

Outcome achievement

Patient Referrals

Ways to Wellness has received over 6,500 referrals has engaged and supported 3,400 patients since the service started (April 2015 – July 2019).
5,000 patients have engaged on the service to date; 2,900 patients are currently engaged with the service.

Well-being Star– Outcome A

> 3,400 patients who have been with Ways to Wellness for six months or more have completed a Well-being Star
Average Ways to Wellness improvement = 3.2 points (target is 1.5 points)
The top three areas of patient improvement in well-being are: (a) lifestyle, (b) work, volunteering and other activities, and (c) feeling positive.

Secondary Care (hospital) cost reduction – Outcome B

Payments started in the autumn of 2017 due to the long-term nature of the service and the delayed impact on hospital use.
9% lower average annual secondary care cost per patient across the full eligible Ways to Wellness cohort in 2018/19 compared to matched comparison cohort (8% lower in 2017/18).
35% lower secondary care costs in past two years (2017/18 & 2018/19) after scaling applied to account for the proportion of patients who have engaged on the service.
Annual savings are >£1.2 million in 2017/18 and £1.3 million in 2018/19 with net savings for the CCG of £757,000 after cost of 4 years of service delivery.

Source: Tara Case. September 2019. Presentation. Social Outcomes Conference 2019.

Development timeline

2011

Voluntary Organisations' Network North East (VONNE) commissions initial work to explore the potential of using SIBs to implement social prescribing interventions
March 2013

A steering group, which included the Newcastle West CCG (now part of Newcastle Gateshead CCG), is set up to develop the SIB proposal
September 2013

Commissioning Better Outcomes Fund and Social Outcomes Fund application submitted and subsequently approved for funding
October 2013

Refinement of operational plan and financial model
December 2013

Discussion with prospective social investors
2014

Outcome metrics and PbR structure developed and refined
2014

Service provider procurment process
July 2014

Social investor (Bridges Fund Management) agreed
January 2015

Final agreement to fund from Commissioning Better Outcomes Fund and Social Outcomes Fund
February 2015

Contracts between CCG, Ways to Wellness and Bridges Fund Management signed
February 2015

Contracts between Ways to Wellness and service providers signed
March 2015

SIB is launched
April 2015

Service is mobilised
July 2015

Service is launched

Project insights

Developing a SIB within health services
Local health commissioning is complex due to the split between the CCG, NHS England and Public Health, the last of which is further split between Public Health England and local authorities. This means that different commissioners benefit from different outcomes. Ideally, the SIB would reflect the benefits of improved outcomes to all the commissioners, all of whom would contribute payments based on the achievement of those outcomes. This proved challenging, however, as no other public bodies were willing to co-commission the SIB due to funding constraints. Consequently, only the direct benefit to the CCG is reflected in the SIB outcomes and business case.
Creating an intervention that is funded only by the organisation that reaps the direct benefits is a challenge, and limits the scope of the SIB. It remains challenging for a local commissioner to fund outcomes which generate benefits to other commissioners – in this case NHS England and the local authority – and/or to persuade such beneficiaries to make a contribution to payments. The fragmentation of health commissioning means that some of the outcomes and benefits of the SIB (e.g. to primary care) are not being measured and paid for.
Source: Ways to Wellness Social Impact Bond: The UK's First Health SIB, 2015.
The role of Ways to Wellness Ltd. as the prime social contractor
The Ways to Wellness SIB is a pioneering collaboration between local GPs, the CCG, local VCSE organisations and social investors. Ways to Wellness Ltd, the trading arm of the Ways to Wellness Trust, is the social prime contractor in the SIB and manages the contracts with the CCG, investors and the four service providers. It acts as the central contract management body for the work. Its main roles are to:
- Hold a seven-year contract with the Newcastle West CCG (now part of Newcastle Gateshead CCG) whereby the CCG agrees to pay for the provision of social prescribing services to their patients.
- Raise finance from and hold contracts with social investor (whose investment pays for the cost of the service in the early years ahead of the performance measures being achieved and paid for).
- Procure services via contracts with Service Providers (who will employ Link Workers and deliver the Ways to Wellness service).
Ways to Wellness Ltd also:
- Oversees and administer the patient referral process in the first two years.
- Provides some of the initial training for Link Workers to help embed the core values and performance management.
- Works with external evaluators who are interested in the Project.
Source: Ways to Wellness, 2018.
The role of the Link Worker
Link Workers are central to the Ways to Wellness service. They provide support and signposting to help service users to achieve their goals and address their concerns or issues, and are instrumental in establishing effective relationships across the system.
A study undertaken by the Institute of Health and Society at Newcastle University found that the report and quality of the relationship between the Link Worker and service user was central to achieving well-being, as well as key to successfully linking service users into a wide range of community, voluntary and NHS services identified as relevant to their situation. The Link Worker social prescribing programme engendered feelings of control and self-confidence, reduced isolation and led to positive physical changes and mental health, greater resilience and effective coping strategies. The study shows that the key elements of the model are that it is:
- long-term in nature;
- addresses the co-existence of multi-morbidity, mental health problems and social isolation; and, where applicable;
- tackles related socio-economic issues
Source: Link Worker social prescribing to improve health and well-being for people with long-term conditions: a qualitative study of service user perceptions, 2017.

Contact details

For further information on the Newcastle Ways to Wellness SIB, you can contact:

Tara Case, Chief Executive Officer, Ways to Wellness; Chris Drinkwater, Chair, Ways to Wellness; Dr Guy Pilkington, Assistant Chair, Newcastle Gateshead CCG; Philippa Dodds, Delivery Project Lead (Newcastle), Newcastle Gateshead CCG