Improving health and wellbeing using a preventative multidisciplinary approach in targeted community settings Abertawe Medical Partnership on behalf of The City Health Network within Abertawe Bro Morgannwg University Health Board

This project was funded between January 2019 and March 2020.

  • Project led by Abertawe Medical Partnership within Abertawe Bro Morgannwg (ABM) University Health Board, in partnership with City Health Cluster, Swansea.
  • Aiming to reduce the demand for GP services by improving the health and wellbeing of targeted communities in a deprived area of South Wales.
  • Will adapt a successful approach from Canada to provide a weekly preventative, multidisciplinary health care service at residential retirement complexes.

The City Cluster area of Swansea has high levels of deprivation, ethnic diversity and emergency inpatient admissions. Primary care services, which are already stretched to capacity and experiencing staff and funding shortages, need to adapt to meet the changing needs of this diverse and growing population.

This project aims to adopt a preventative approach to health and wellbeing by providing a multidisciplinary team (MDT) in City Cluster community settings to offer an alternative to people directly accessing GP services as the first point of contact for health care issues. By offering an MDT where patients live, the project will help them to promptly access the most appropriate services, as well as enabling better levels of self-care.

The inspiration for the intervention was a successful community-based health promotion programme developed by McMaster University in Canada, which significantly reduced emergency calls and increased quality of life for older people by introducing an MDT to low-income apartment buildings. 

The City Cluster service will be delivered within two residential retirement complexes on a weekly basis by an MDT led by a GP, and including a pharmacist and advanced paramedic, along with local area coordinators who will help people to make social connections.

This innovation differs from current services in that it provides a holistic health care and promotion service for a targeted community setting at the point of contact, as well as building a more efficient and supported workforce.

Caseload data, questionnaires and patient engagement exercises will be used to evaluate the project’s success in delivering improved MDT working relationships, reduced attendances at GP practices and better patient health and wellbeing.

Contact information

For more information about this project, please contact Julian Smith, City Health Network Business Development and Implementation Manager.

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