“Patients circumstances are really improving, the Connectors are having a great impact”

— GP (Pinhoe Surgery)

Data & Research

This pilot project places particular emphasis on using both quantitative and qualitative data to inform and shape practice on the ground.

Data on referrals to Wellbeing Exeter, and their impact on GP visits, hospital admissions and demands on social care is being  collected anonymously, and being used to track patterns of statutory service use. This work is being carried out by the South West Academic Health Science Network and Public Health Devon.  A qualitative study, by a team from Plymouth University, looking at the experiences of patients, GPs and community connectors throughout the referral and social prescribing process will complement this.

Through Integrated Care Exeter (ICE), work on risk stratification (identifying the risk of ill health in the population through data analysis) by the data team at Public Health Devon in partnership with local South West Academic Health Science Network and Exeter GPs, has developed a systemic way to identify people and communities who could benefit from early interventions.

The ICE Risk Stratification Tool brings together data from a number of different sources to create maps of the city to help partners to identify  patterns of need across the city, risk factors and protective factors, and develop whole system cost methodologies. In time this data will feed practice, locality and city-wide dashboards and heat maps that can be used at operational or strategic level for planning and targeting purposes.

The team is exploring how to use the model for proactive identification; personal care, support and escalation plans; social prescribing and preventative work. Wellbeing Exeter’s Community Builders and Connectors have been feeding into this work, by providing detailed qualitative information, gained through their work on the ground in the relevant neighbourhoods, to paint a picture of community life, as lived, to complement the quantitative data.

Learning from the community resilience work, the learning and development programme, and in particular the work of the Community Builders is being captured by the Devon Community Foundation team who co-ordinate the Wellbeing Exeter network.  Builders are participating in a series of Action Learning sets which will help them reflect on and share their experiences working in the community, and adapt their practice as they go along. The sets also provide an opportunity to identify key learning points from the individual experiences of builders on the ground, and understand how this learning can feed into future work.

Find more information in the documents below:

Public Health England: Community Centred & Asset Based examples: Wellbeing Exeter

ICE Practice Summary Report Exeter (15 practices) Apr-17

Integrated Care Exeter Risk Stratification Model A3 Summary June 2017

Mosaic Frailty Risk Stratification Summaries April 2017 v2 Group and Maps only (14 practices)

HSJ2017 Service Redesign Integrated Care for Exeter Review June 2017 Final draft

Community Engagement Review Sept 2017

ICE Social Prescribing Evaluation Report SWAHSN final 130218