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Palliative Care Cymru Implementation Board have given a grant to Compassionate Communities UK to run a programme of 2 sessions for the Federation leads to cover the whole of Wales. 

Dr Julian Abel, Dr Catherine Millington Sanders, from Compassionate Communities UK, along with Dr Helen Kingston, Senior GP Lead at Frome Medical Practice, and Jenny Hartnoll, Lead for Health Connections Mendip community development service, are running a programme in Wales to introduce the concepts and practice that has been successfully used in Frome in reducing emergency admissions to hospital across the whole population. Training days have been held in the Cardiff area of South Wales and plans are underway to run further days with all 7 of the Local Health Boards that commission and provide health care in Wales. They presented the project to Dr Richard Lewis, Arweinydd Cenedlaethol Proffesiynol ar gyfer Gofal Sylfaenol, GIG Cymru/National Professional Lead for Primary Care, NHS Wales and the Local Health Board Leads. This meeting generated much interest and enthusiasm to explore the project further to see if it can be applied across Wales. 

Interventions that have improved working lives for clinical teams, improved patient outcomes at the same time as delivering significant reductions in emergency admissions have been hard to come by. Evidence for the effectiveness of social prescribing schemes so far have not yielded the outcomes hoped for. However, over the last 3 years a successful complex intervention has taken place in Frome in Somerset, in which the 3 outcomes described above have been achieved. In addition to transformation of the practice, there has been a 30% reduction in emergency admissions to hospital across the whole population of Frome, a town of 30,000 people, in comparison to the rest of Somerset. At the same time, emergency admission costs have increased by 21% compared to 2013 – 4 figures across the county whilst in Frome they have reduced by 21%. The model is now being rolled out across the Mendip area of 115,000 population as well as in West Somerset. 

Although the model is complex there are 4 main components. 

  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 centredgoal setting and care planning including admissions avoidance, resuscitation and end of life discussions
  3. Network enhancement using the network mapping tool as a basis
  4. Connection into community resource through the embedded community development service Health Connections Mendip into the primary care team

The project has been run using quality improvement methodology to ensure that the changes are led by the clinical teams who do the work, being ground up in nature. Whatever changes are made must fit into working practices and must therefore be led by the teams who do the work. 


Training day Cardiff April 19th 2018