Compassionate Communities UK Wales

Compassionate Communities UK Wales

In 2017 a pilot project was undertaken in Wales. The Royal College of General Practitioners and Marie Curie who had been working together for over four years to support the critical role of general practice in its focus on serious illness and end of life care joined forces with Byw Nawr (Live Now), the Welsh Government supported initiative in Wales.  The aim was to work in partnership with the charity, Compassionate Communities UK who brought expertise and a proven track record in implementing the principles of compassionate communities to the Welsh Health Boards, to present the very successful ‘Frome model’.  

A pilot project was launched and events were held outlining the key components of the model for consideration in planning future projects. The Frome model has already proven transformative with population emergency admissions reductions. Its foundations are based on 4 main principles: 

  1. Reliable system of identification of those in need of support in GP surgeries and hospitals through setting up an internal hub with the GP practice
  2. Patient centred goal setting and care planning including admissions avoidance, resuscitation and end of life discussions
  3. Robust network mapping + enhancement: with connections between primary care and community development services, using the network mapping tool
  4. Linkage to the vast variety of community resources, whether this be friendship groups, Talking Cafes or specific activities

Currently, the outcome of the pilot project resulted in Compassionate Communities UK working with two Welsh University Health Boards in rolling out a locally adapted version of the Frome Model, focused on an enhanced model of primary care and compassionate communities. 

Aneurin Bevan University Health Board has commissioned Compassionate Communities UK (CC-UK) to lead the projects underway in Blaenau Gwent East and West and Caerphilly North Neighbourhood Care Networks (NCNs). Working with Dr Helen Kingston from Frome Medical Practice and Jenny Hartnoll, lead for Health Connections Mendip, the NCNs are taking the essential ingredients of the complete Frome Model and adapting these for local context. Dr Julian Abel from CC-UK, project lead, says “there is sometimes a misunderstanding that the Frome Model should be replicated in other areas. This is not the case. There are key functions of the overall model which are adapted to local circumstance”.

The projects have two major components. 

  1. The first is building and enhancing a programme of compassionate communities. Gwent is blessed with strong communities and the extensive community activities are the basis for compassionate communities. The project will help to activate community members to become champions of well-being, through knowing what goes on in their community. Conversations naturally take place in daily life, whether this is in cafes, with friends and neighbours, with hairdressers or the many other facets of community life. Simply knowing where help is available means that local support can be offered should people be interested to follow up any ideas.  
  2. The second arm of the project is the development of hubs of expertise inside GP surgeries.  This means that each surgery will know how to access community support, including the one to one work provided of the Community Connectors, employed by the Information, Advice and Assistance service. The Community Connectors can help and support those individuals who can benefit from the variety of solutions to problems that arise as a consequence of physical and mental ill health, as well as complex issues including loneliness, isolation, finance and job issues amongst others. Each GP surgery has a lead GP, helping to embed the compassionate communities’ approach inside the surgery. Extra staff, consisting of administrative support, nurses and allied health professionals, as well as dedicated time for the lead GP have been funded by the Aneurin Bevan University Health Board, via successful bids to the NHS Wales Transformation Fund.   

The project has three main aims. The first is to improve population health and well-being through combining compassionate communities with an enhanced model of primary care. The second is improving working lives of clinical teams by broadening the many ways that people can be helped.  Through bringing in a compassionate communities approach the range of options clinical teams have for helping their patients in a way that is most meaningful is hugely increased.  The help given to patients is directed toward what matters most to them and this is often more than just health issues.  Being able to address what has previously been insoluble problems, such as difficult life circumstances, anxiety and depression, loneliness etc., the clinical teams are not left with a sense of not being able to help patients in a meaningful way.   This improves job satisfaction and creates the opportunity for primary care teams to share workload with the broader team members that have been employed. The third is reduced population emergency admissions, which happens when people have their problems resolved and have the support they need to improve both their health and well-being. The overall project is a joined-up initiative between Aneurin Bevan University Health Board, The Public Health Team, Social Services and the local councils.  

A similar programme is underway in the South West cluster of Cardiff & Vale University Health Board.  Compassionate Communities UK is assisting the project leads to develop their locally adapted version of the Frome Model. The outcomes goals for all projects remain the same.  


Integrated Well-being Networks (IWN) at Aneurin Bevan Gwent Public Health Team

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