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Case study: Living well


4 September 2014

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A holistic pathfinder scheme in Cornwall is helping improve the health and wellbeing of patients who are often overlooked by the system
Since its launch in 2012, more than 600 people in Cornwall have seen their health and wellbeing improve thanks to an innovative approach called Living Well. It has helped to reduce hospital admissions, reduced people’s dependency on services and saved money. 

A holistic pathfinder scheme in Cornwall is helping improve the health and wellbeing of patients who are often overlooked by the system
Since its launch in 2012, more than 600 people in Cornwall have seen their health and wellbeing improve thanks to an innovative approach called Living Well. It has helped to reduce hospital admissions, reduced people’s dependency on services and saved money. 
It is available for people who have one or more long-term conditions, are at risk of being admitted to hospital and live in either Newquay or Penwith in west Cornwall. There are plans to roll out across the rest of Cornwall and the Isles of Scilly during the next 18 months. 
Living Well is a joined-up way of providing health and care services. It brings together Age UK Cornwall and the Isles of Scilly, the NHS, the two local authorities, community services and Volunteer Cornwall to provide bespoke, wraparound services that meet people’s needs and ambitions.  
Each person’s care and support begins with a conversation where they tell a changing lives co-ordinator from Age UK Cornwall what their ambition is. The co-ordinator acts as a conduit between the health service, local authority, and where appropriate a community group, to ensure the person’s ambitions are fulfilled. 
Living Well was initially piloted in Newquay (called the Newquay Pathfinder) and during its first year non-emergency hospital admissions reduced by 30%, on-going social care package costs reduced by 5.7%, and 23% of people said their mental health had improved. Multidisciplinary staff also reported an 87% improvement in the way they worked and felt their work was extremely meaningful. It has also helped communities to flourish and work better to support people by creating stronger links with the voluntary sector and community groups, such as coffee mornings and knitting groups. In Newquay, 10% of people who were supported by Living Well began to volunteer or set up support groups themselves. 
Most of the work would not be possible without an army of volunteers like Judy Eades, who gives up her time to help people. Being a Living Well volunteer has given Judy not only a renewed zest for life, but also an abundance of knitted jumpers and scarves. 
Judy and her friend Jenny Oke run a knit and natter group at the Age UK day centre in Newquay where, once a fortnight, people come together to have a gossip with their friends over balls of wool. Judy is one of 16 volunteers who have supported people through the Newquay Pathfinder. 
She said: “My background is in adult social care and after I retired I knew I wanted to help older people. When you go into someone’s home they are more at ease and you can break that barrier to help them and bring a little bit of laughter back into their life. We get to know people and do things that enhance their life.  
“I’m a friend; I’m not a district nurse and I don’t work for the council, but I do pass on information to my co-ordinator if there is a chance that someone’s health or wellbeing may be at risk, that’s the good thing about integrated working, we all have the same goal.”
The Newquay Pathfinder was the brain child of Judy’s daughter Lucy Clement, a District Nurse Manager, who works at Newquay Hospital. 
“I am so proud of what she has achieved; it’s helped so many people,” Judy beams. “The more I heard about it, the more I knew I wanted to volunteer and to be involved. 
“Carers and nurses are so busy, they have so many people who they need to look after, but we have got so much more time. We can do things that help make people’s lives so much more interesting and bring a little bit of joy back to their life.”
It’s not just the people Judy supports who are benefiting from Living Well; she says it has made a difference to her life. 
“It’s engaged me back in my life. It’s a wonderful thing; it’s fun, I’ve met new friends and I’ve started living my life again by being a volunteer.”
The knit and natter was born after a conversation Judy had with a woman she was supporting. 
“I asked her what did she like to do and she said knit,” Judy explains. “I used to visit her home and we’d talk and knit. It’s changed her life and I thought that more people would want to have somewhere where they could meet other people, talk and do something fun that keeps them alert. We heard that Age UK had a spare room at the day centre and decided to run a fortnightly session there. It started with about six to eight people, and it’s just gone from strength to strength.”
Judy is now on a mission to get Prince Charles – who she met at Clarence House in January – to learn more about Living Well at one of the knitting days. 
She said: “He was very interested in Living Well and what we were doing in Newquay. I’d love to see Prince Charles at one of the knit and natters and seeing for himself how much Living Well means to people.”
Community groups such as the Penzance Memory Café also play an important role to support people who may be feeling lonely and isolated. Like most men, David Gregory preferred to keep his feelings bottled up. Even when his wife Liz was diagnosed with dementia, he preferred to keep a tight lip. 
“My wife had dementia and, being a bloke, I didn’t tell anyone,” he said. “I kept everything bottled up: what I was going through and any difficulties I was having. I certainly didn’t tell anyone how I was feeling.”
However, as time went by David found it increasingly difficult to care for his wife without talking to anyone about what he was going through. 
“I soon found out that there were a lot of people in the same position as me,” David remembers. “I helped to set up the Penzance Memory Café as I knew that people needed somewhere where they could go to talk to other people and realise that they’re not alone.”
David, who is chairman of the Penzance Memory Café, knows first-hand the support the group gives people who are affected by dementia. 
“This group was a big help for me when Liz had dementia. I found it difficult talking to other people about her dementia, but I now support other men who are going through similar things. 
“Men also seem more open to share their feelings and usually when one man says they feel like crying and then does, other people also start crying; it’s a release for everyone.”
The memory café is one of the projects in Penwith that accepts referrals through the Living Well programme. The group provides not only a meeting place for carers, but also an opportunity for people with dementia to meet other people and take part in activities and quizzes to keep their mind active. 
Each group is run to meet its members’ needs by asking them what they would like to do, in-line with the Living Well ethos that everything begins with a guided conversation detailing what support people would like to achieve their personal goal. 
David says: “I think the Living Well approach is really good as it involves people in their care. We have people who come here and do activities like art – it’s great that they can do something like that again. One man painted using watercolours, which was lovely for both him and his wife, who said that he hadn’t painted for years. It’s nice when people can do things that they used to enjoy, such as painting.” 
 
Photo: Living Well service users participate in a Knit and Natter session in Newquay (Photographer: Tom Last)

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