Long-Term Health Conditions

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A woman in a Ways to Welness polo shirt chatting to a client with her back to the camera

  1. Background

Our long term conditions service launched in April 2015 in the west of Newcastle upon Tyne, where deprivation is higher than the average in England, life expectancy is lower and people with long term conditions experience high rates of unplanned admissions to hospital. 

This was the first health service in the world to use Social Impact Bond (SIB) investment. Public sector commissioners and local voluntary sector organisations worked with a specialist social investor to develop the contract terms and measurement approaches.

Ways to Wellness adds to and complements the medical support that people receive, to help them feel more confident to manage their long-term conditions and make positive lifestyle choices.

We provide patients with a link worker to help them identify and work to overcome their current barriers to managing their long-term conditions. The link workers will work with patients to produce an agreed action plan, which may include a range of activities, such as:

  • Getting involved in local groups and activities

  • Developing positive relationships

  • Accessing specialist services and support

  • Healthy eating and cooking

  • Getting more active

  • Getting support around benefits and welfare rights

We aim to improve patients’ quality of life and reduce their use of mainstream health services by enabling them to lead healthier lives and better manage their conditions. It also reduces the cost of meeting their needs, for the NHS and other public services.

Since 2022 the service has expanded into other parts of Newcastle and our referral criteria have been extended. 

2. Who We Help

The service is for people with certain long-term health conditions, aged 18-74, who attend participating GP practices in Newcastle upon Tyne. The eligible long-term health conditions are:

✅ Chronic breathing difficulties (COPD) or Asthma

✅ Diabetes (type 1 or type 2)

✅ Heart disease

✅ Epilepsy

✅ Thinning of the bones (osteoporosis)

✅ Hypertension

✅ Pre-diabetes (non-diabetic hyperglycaemia)

✅ Osteoarthritis of the hip/knee

✅ Any of the above with depression and/or anxiety

GPs, nurses and hospital and community healthcare professionals can make referrals to the service.

3. Impact

This set of videos tell some of the stories from our clients, commissioners and the people who set up our long-term conditions service.

Lisa talks about the impact of the Ways to Wellness long term conditions project on her life, and her plans for the future.

A GP and commissioner discusses the impact Ways to Wellness has had over its first six years.

Maria talks about the support she received from her link worker, through the Ways to Wellness long term conditions project

Some of our patients tell us about the impact Ways to Wellness has had on their lives.

This video tells the story of how Ways to Wellness came about, and the impact we've had in our first six years.

Continued. Patients discuss the impact Ways to Wellness has had on their lives.

4. Evaluation and Evidence

4 woman and a man stand side by side, smiling, in Ways to Wellness polo shirts

External Research

Newcastle and Durham Universities conducted a 34-month study evaluating the impact of the service, with the support of Ways to Wellness and funded by a £518,000 grant from the National Institute for Health Research (NIHR) Public Health Research Programme. 

The evaluation, focusing on people with Type 2 diabetes, included an analysis of the impact of the service on blood glucose control (HbA1c), blood pressure, cholesterol, weight, smoking, a full cost benefit analysis, and two ethnographic studies – one with link workers and the other with service users. 


This extensive quantitative and qualitative evaluation was completed in April 2021. More details of the research can be found on the project website: SPRING_NE Study, Newcastle University (ncl.ac.uk)

The National Lottery Community Fund’s Commissioning Better Outcomes Fund commissioned Ecorys and ATQ Consultants to evaluate Ways to Wellness at several stages of our development. More about the Fund can be found on the NLCF website: Commissioning Better Outcomes and Social Outcomes Fund | The National Lottery Community Fund (tnlcommunityfund.org.uk)


First report into Ways to Wellness: Commissioning Better Outcomes case study

Cover of the Ways to Wellness The First Six Years Report

Ways to Wellness Reports

Ways to Wellness has been committed to shared learning throughout the life of the project.

Our report, ‘Ways to Wellness: The First Six Years’ explains our approach in more detail, and what learned in the first six years of delivery. It’s also a celebration of our impact over this time, improving health and wellbeing for thousands of people.

6 year report – executive summary

6 year report – full report

Reflections on the development phase of Ways to Wellness

Ways to Wellness - reflections on development report, 2015

Ways to Wellness link worker survey on Covid-19 impact

Link worker survey on Covid impact report, 2021

5. Partners and Funders

  • A logo that reads NHS North East and North Cumbria

    Current Funder

    NHS North East and North Cumbria

  • Previous Funders

    Big Lottery

  • Previous Funders

    Big Ventures

  • Previous Funders

    Cabinet Office

Project Partners

A woman with short blonde hair sits chatting on a telephone

  • Benfield Park Medical Group

    Betts Avenue Medical Group

    Biddlestone Health Group

    Broadway Medical Group

    Cruddas Park Surgery

    Denton Park Medical Group

    Denton Turret Medical Centre

    Dilston Medical Centre

    Elswick Family Practice (previously Grainger)

    Fenham Hall Surgery

    Heaton Road Surgery

    Holmside Medical Group

    Kenton Medical Centre

    Newburn Surgery

    Newcastle Medical Centre

    Parkway Medical Centre

    Prospect House Medical Group

    Roseworth Surgery

    St Anthony's Health Centre

    The Park Medical Group

    Thornfield Medical Group

    Throckley Primary Care Centre

    Walker Medical Group

    West Road Medical Group

    Westerhope Medical Group

6. Patient Information

If you have any of the listed long-term health conditions, are aged 18 to 74, attend one of the participating GP practices and are interested in Ways to Wellness please ask your GP, nurse or other healthcare professional for more information.

Front cover of leaflet - Do you want to feel better?

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