Questions and answers

What is Living Well?

Living Well aims to help people who are socially isolated and highly dependent on health and social care services to improve their quality of life. It starts with a conversation to understand the person’s story and what will make life better. It aims to reconnect people with their communities – facilitating change rather than fixing problems, building on the support infrastructure that’s already there.

Pathfinder (Newquay), Penwith Pioneer (West Cornwall), Living Well East Cornwall – these are the test beds for wider implementation (Integrated Care Communities) and are all part of the whole Living Well approach. This is a partnership between the voluntary sector, health, social care and local people. All health providers, the CCG and the Council are signed up to Living Well.

Target cohort

Has the original cohort of patients with two long-term conditions now changed to include frail patients? Does this include people with dementia? Is there a set of criteria?

The criteria are likely to include people who are frail and specifically includes people with dementia:

  • A minimum of two long term conditions from the following:

Diabetes, respiratory (COPD), heart failure, memory loss, dementia, Parkinson’s, Hypertension, stroke, have a history of falls, osteoporosis, risk of repeat infection (Urinary Tract Infection or Pneumonia)

  • A social care package in place where:-
    • The value is £50 per week or below
    • The value is £200 per week or above
    • This includes lunchtime visits
    • The person has received support from the Early Intervention Service three times or more within the last 12 months.
    • The person has been supported through an urgent response or emergency duty three times or more within the last 12 months.
Who is involved in identifying patients to be included in the target number of 1,000?

This starts with the GP practice reviewing a list of people identified using a risk stratification tool. GPs, district nurses, community matrons, community therapy teams and others also use their knowledge of their own caseloads to help identify people who are likely to benefit.

Do hospitals refer into the project?

They can do, and there is an Age UK Cornwall worker assigned to West Cornwall Hospital to support the discharge process, which will result in more people being identified. The team currently works with around 25 people per month.

Are you up to the target or oversubscribed?

Currently there are just over 800 people who have had a ‘guided conversation’, but there are many more people identified. There is an ambition that this becomes a whole system change, but Penwith and East Cornwall are still a test phase and we need to focus on proving that they deliver the Triple Aims (improved health and wellbeing, improved experience of care, reduced cost of care).

What is a guided conversation?

It is simply a conversation guided by the person about what’s important in their life, with the aim of identifying their goals and a plan of how to achieve them. It is not scripted, but likely to include discussion about the person’s lifestyle, health, family and social circumstances. The volunteers are trained in motivational interviewing techniques as well as promoting self-management of the long term conditions we’re focusing on.

Who carries out the initial patient assessment?

An Age UK Cornwall worker is attached to each practice and has the initial guided conversation with the person. Co-coordinators are assigned to specific practices and supported by a team of voluntary workers. There are now 12 co-ordinators in total across the three sites – Newquay, Penwith and East Cornwall.

How are the patients referred? Is it still essentially GP referral or has it been widened to include patients referred from acute and community hospitals, as part of discharge planning?

Referrals are coming from a range of health and social care practitioners at present.

Has the ethos changed or been expanded since the Newquay Pathfinder?

There are core ‘ingredients’ that are common to Newquay, Penwith and now the East of the county, but how they are put together may differ. These are the guided conversation, shared escalation triggers, community mapping and networking, local conversation group, practitioner workshops and the underpinning values and culture. The local community assets are a vital part of the approach and will differ in each area, which will have an impact on the way the programme takes shape.

 Will assets be shared east and west?

This isn’t about imposing a project onto a community, but empowering a community to connect their existing assets together and helping people who have become isolated to reconnect. So it’s not about sharing assets but making the most of what is already in place – for example in Penwith there are over 600 community groups and activities and so far we have made links with 40 of them.

How many people are in the programme now?

There are just over 800 now, and the cohort is growing by around 150 people each month.

Are all the GPs signed up to the project, or are some surgeries not involved?

All the practices in the test sites are involved and have identified people as part of the cohort. There are ongoing discussions with the GP locality commissioning groups and individual practices about how to embed this in everything that is done and link strongly with the locality plans. 


What is the total number of volunteers recruited?

There are 67 volunteers currently working on this programe. Volunteer Cornwall provides support in terms of recruitment, DBS checking and making connections with local voluntary organsiations e.g. British Red Cross and Penwith Community Development Trust – so the total number of volunteers involved in this approach is actually more than this.

What is the WTE number?

This is difficult to quantify as volunteers offer their time alongside other commitments e.g. caring roles. The time given would cost £1.7m at minimum wage. The programme support people who have been highly dependent to help themselves, and to help others – in many cases people have become volunteers themselves, either formally (through an agency like Age UK) or informally (offering regular support to someone who needs it). We are seeing around 20 per cent of people who were being supported by the programme going on to become volunteers themselves.

What information is given to a potential volunteer?

Many people have shown an interest and have started by having a conversation with the team leader or a member of staff at the GP practice, to get a better feel for the role. There is a formal recruitment and induction process managed by Volunteer Cornwall.

Does the volunteering ‘task’ vary according to volunteers’ wishes/capabilities?

The interview process draws out the sorts of skills that a volunteer has to offer and they can be matched to a range of opportunities, including Living Well. Interestingly, a number of volunteers in Newquay have said that regardless of future funding, they will carry on, now they know what to do.

Who is assessing, supervising, supporting volunteers and how does the supervision work in practice?

Each volunteer is under the supervision of the co-ordinator assigned to the GP practice. There are volunteer team meetings, plus regular contact and feedback.

Who backs up the volunteers at weekends/bank holidays?

At the moment, the support is offered Monday to Friday during office hours. However, some volunteers give their time outside of those hours.

Are the volunteers able to claim travel and other related expenses?

Yes, these expenses are reimbursed.

Is the aim that volunteers should act as an adjunct to the current health/social services but then eventually take over some of the tasks that are currently done by paid staff?

No. This is not a cheaper version of what we already have, nor is it an add-on service to refer to. This is a fundamental change in practice by every member of the care team, in which the volunteer worker is an equal partner and each member has skills and expertise to offer. This isn’t about shifting jobs from one team to another but about creating unique support for each individual, based on what matters most to them.

What do the volunteers actually do?

This depends entirely on what the person identifies as the things they want to achieve, the things that matter most to them, through the guided conversation. To give an example, in the words of one of the volunteers:

“The co-ordinator introduced me to a lady with severely ulcerated legs who may have had gangrene – there was a question about whether her foot or toes should be amputated. She’d been rushed to hospital previously. She’d got in trouble for non-payment of council tax and her house needed deep cleaning. We managed to get her a bank account established and her bills are being paid. She is beginning to take an interest. She had cancelled two operations in the past because she couldn’t find anyone to look after her cats. I took her to hospital because she was asked to be there at 7.30 in the morning. I went and got her and took her in. It took an hour and a half for someone to come and talk to her. Then they wouldn’t do the op because she hadn’t arranged for someone to look after her overnight, so I took her home again. She’s now got another date – this time she’s agreed to stay in overnight because we’ve found a way to look after her cats and I’ve arranged a relief carer for my wife so that I can take her in again. The co-ordinator arranged for an advocate to deal with her council tax – she had had bailiffs around several times but they’d gone again because there was nothing there of any value. The forms to fill in to claim exemption due to her depression were 42 pages long. The form itself frightens her, it literally frightens her. Her hands are trembling – that’s why she doesn’t open her post. She is now worried that the GP will not sign the form because the form says ‘severe mental impairment’, but she doesn’t want to say that she is severely mentally impaired because she’s worried that they will put her away somewhere. We’re trying to be the catalyst to connect bits of the system around her, to deal with the council and get the operation done. No-one was otherwise helping her in a way that would help her deal with all those problems, and she couldn’t deal with them herself.”

Is this approach resulting in a reduction in social and/or healthcare involvement or is it generating more work?

We are already seeing a 20 per cent increase in quality of life using a nationally validated tool (Short Warwickshire & Edinburgh Mental Wellbeing Scale) and a reduction in acute hospital activity, among other areas. The first results for the Penwith cohort will be published early in February 2015.

As the Pathfinder/Living Well project moves into the rest of Cornwall, how might this affect the work being carried out in the Penwith area?

The Living Well programme is now running in Newquay, Penwith and the East. We would need to identify funding to expand it any further. We are in the middle of a detailed learning exercise at the moment and will soon be in a position to share that.

How is the programme managing ‘shared care plans’ with rehabilitation teams and / or STEPS services?

Part of the project is the implementation of an IT solution that will link together all the different systems staff use in their organsiations to make sure that frontline staff have the information they need to support people at the right time. This will have strict governance around it to ensure that only people who need to have access to the information. By definition, the people in the cohort are already in receipt of NHS care and have care records that the coordinator feeds into. The volunteer’s work is reported back to the co-ordinator and logged. Alongside this, regular practitioner workshops are helping local teams and individuals to understand each other’s’ roles and to identify better working practices.

Evaluation being used to evaluate the programme?

The Triple Aims are: improved health and wellbeing; improved experience of care; and reduced cost of care. The evaluation framework has been agreed across all partners and includes a quality of life tool, practitioner survey and financial modeling to understand the cost impact.

Who is involved in evaluating the programme and what independent scrutiny is in place?

The following bodies are involved in evaluating and overseeing Living Well:

  • Public Health Cornwall, overseen by Public Health England
  • Healthwatch Cornwall
  • NHS Improving Quality
  • The Nuffield Trust
  • Academic Health Science Network
  • University of Exeter
  • University of Plymouth
  • Plus independent financial modeling.
Is there a direct effect on reducing emergency and other hospital admissions for the people being supported?

The data run we’re currently doing looks at trends of admission rates, before and after a person’s involvement in the programme. So far we are seeing a reduction in activity and results are due out shortly.

Is there a control group of patients?

There is a ‘matched control’ group identified through a genetic typing technique.

 Is the Newquay project still ongoing and have the original number of volunteers been maintained?

Yes. The original cohort was 128 people and the volunteers are now able to support more. There is a minimal drop-out rate among volunteers – some have dropped out in order to go on to employment. Cornwall has the highest rate of volunteering in the county – around 30 per cent of the population volunteers compared to 22 per cent nationally.

Is Living Well enhancing the existing service to patients? Or replacing parts of it?

Both – the evidence from Newquay demonstrated a reduction in activity overall across health and social care; practitioners are very positive about their ability to have a greater impact as part of an integrated team approach; the people themselves have reported significantly improved wellbeing.


Which month did the project start in and when does it end?

Penwith began in March 2014 and will run until October 2015. Newquay is ongoing and the East started taking referrals at the beginning of October 2014.

What’s the budget?

Funding has come from the Duchy Health charity, Age UK reserves and the Cabinet Office, with local health and social care organsiations committing resources in terms of staff time. The cost per person is approximately £400 and so far we are seeing a 3:1 return on investment.

What happens if and when the funding runs out?

To be honest – we don’t know. The current funding is a ‘mixed bag’ and that might be the way to proceed. It’s a chicken and egg situation – we need to provide the evidence that this approach works on a large scale but that also needs a commitment to funding in the meantime.

Is future Age UK funding dependent on a positive evaluation?


What is the current state of play regarding the private sector (ie domiciliary care providers)?

Through the local authority we are working with local providers but it is still early days. One of the learning points for us has been that we need to start this conversation earlier next time.