Long-Term Health Conditions
Quick Links:
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.
The project was designed to complement medical support that people receive from GPs, with individualised link worker support to help them feel more confident in managing their long-term conditions and making positive lifestyle choices.
Using a tool called a ‘Wellbeing Star’, their link worker helps them identify and work to overcome current barriers to managing long-term conditions, producing an agreed action plan that include activities like:
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.
In 2022 the service expanded into other parts of Newcastle and our referral criteria were extended.
2. Who we help
Although it is currently operating at capacity and is therefore not accepting new clients, the service is for people with certain long-term health conditions, aged 18-74, who attend participating GP practices in Newcastle upon Tyne. The long-term health conditions it supports people with 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
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
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
Second report into Ways to Wellness: Commissioning Better Outcomes Evaluation (2021)
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 early approach in more detail, and what we 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.
Six year report – executive summary
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
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
-
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
