• Led by Willow Bank Partnership Community Interest Company in Stoke on Trent.
  • Focusing on families with complex health and social care needs.
  • Piloting a family-based service that to allows for more ‘agile’ health care delivery by commissioning family-based interventions to improve health outcomes and reduce health care costs.
  • The project is running for a year from September 2014.

Stoke-on-Trent experiences a high prevalence of long-term conditions and data demonstrates that lack of communication and coordination across services exacerbates the problem.

This pilot involves 20 families from Willow Bank’s patient list. A ‘family negotiator’ works with the families to understand their health situation, identify agreed goals and develop an action plan.

Families are selected where there:

  • are conditions and behaviours affecting the whole family, e.g. more than one family member is diabetic or obese, or a child has poorly controlled asthma.
  • is evidence of high inappropriate service use, e.g. due to mental health issues or associated problems.

They will ‘micro-commission’ local services and provide ongoing support using a virtual budget, personalising services to individuals within families, and enhancing their capacity to adopt healthier lifestyles.

The team are testing the family-based service delivery and commissioning models developed using subjective and objective measures of health before, during and after the pilot.

They will measure outcomes of both the project as a whole, and for sub-sets of families with particular health or service use issues.

Benefits

Research for this project demonstrated that by addressing family needs, £1.2 million could potentially be saved by the NHS for every 80 families with complex needs.

Improvements seen as a result of the project will be specific to the families involved, however, overall aspects being assessed include:

  • attendance at appointments and concordance with medication
  • diabetes clinical status
  • obesity measures such as weight loss and blood pressure
  • asthma control measures.

The team expect to see improved capacity for condition management, measured through standardised wellbeing indicators and patient feedback.

The project will inform the kind of local infrastructure needed to support family-based interventions and will provide recommendations to providers and commissioners for the broader roll-out of the model.

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