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General overview

Stage of development: Implementation

Policy sector: Health

Date outcomes contract signed: Mar 2015

Start date of service provision: Apr 2015

Anticipated completion date: Mar 2022

Actual completion date: Oct 2022

Capital raised (minimum): GBP 1.65m (USD 2.52m)

Service users: 8k+ individuals


Ways to Wellness comprises 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. The service comprises: (a) individual assessment, motivational interviewing and action planning, (b) completion of an initial Wellbeing Star assessment and subsequent Wellbeing Stars every six months thereafter to the duration of the intervention, (c) help to access community services (e.g. welfare rights advice, walking groups, physical activity classes, arts groups, continuing education), (d) promotion of volunteering opportunities, and (e) promotion of improved self-care and sustained behavioural changes related to healthier lifestyle choices.

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.



  • United Kingdom

Service delivery locations

  • North East: Newcastle Upon Tyne

Outcome metrics

  • Outcome A: Improved self-management of long term conditions (LTC) leading to greater sense of well-being, reduced social isolation and fewer GP visits. Improved self-management of long-term condition leading to a greater sense of well-being, reduced social isolation and fewer GP visits (30% of outcome payment). 8,500 targeted service users.
  • Outcome A, Metric 1: Payments on sliding scale based on 6-month completions of Traingle Consulting's Wellbeing Star after initial assessment. 100% of payments made if the latest Wellbeing Star completed is, on average, 1.4 points higher than the initial star. This reduces down to 0% if the point increase is less than 0.5.
  • Outcome B: Reduced cost of secondary healthcare services as a result of improvement in self-management of long term conditions (LTC). Reduction in cost of use of hospital services (reductions in GP visits are not counted because these services fall to NHS England, not the CCG), planned and unplanned admissions, use of out-patient and A&E services (70% of outcome payment). Counterfactual analysis completed - secondary care costs of patients in Newcastle West compared to patients with similar characteristics in Newcastle North and East using Hospital Episode Statistics from the North East Commissioning Service.
  • Outcome B, Metric 1: Measured reduction in average cost per patient of secondary care usage by this cohort compared to control group. Outcomes will be evidenced after 24 months. Full benefits measured over five years.
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