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Best integrated care model

Black Country GP Commissioning, Sandwell and Healthworks consortia


• Integrated care planning for very high intensive users – Swindon NHS Consortium

• Nene Commissioning Community Interest Company

• Dermatology community specialist services – Waltham Forest Federated GP Commissioning Consortium

• Black Country GP Commissioning, Sandwell and Healthworks consortia


Winner - Black Country GP Commissioning, Sandwell and Healthworks consortia


Sandwell has high levels of mental ill health in areas that are socially deprived with high unemployment.

Three consortia – Black Country GP Commissioning, Sandwell and Healthworks – have taken an innovative approach to develop an integrated model for primary care mental health. The aims of the model were to build emotional resilience, modernise mental health services and improve access and choice.

The consortia take the view that ‘with the right support and information, people are the best managers of their own and their family's mental health needs'.

The Sandwell primary care integrated model combines positive self-help, psycho-education, condition management, talking therapies and access to specialist support, all of which have been developed with service users who are ‘expert by experience' to ensure that the needs of the patient are reflected throughout the model.

The model includes a network of education, health, employment, mental health and social care providers and the consortia have discovered that ‘inter-agency working can target these issues in ways that make a real difference'.



In the local population, wellbeing has been improved through programmes such as a children and families centre offering

a crèche, and support and befriending activities for mums. These have shown very successful outcomes, with mothers becoming less lonely and isolated and developing a crucial social network for themselves and their children.

All local library staff are now trained in wellbeing, and libraries now offer creative writing classes, yoga, health improvement programmes and reading groups, which have been found to improve the general wellbeing, happiness and confidence of the participants.

Happiness events and fun, laughter and wellbeing programmes have been targeted at the whole population. They have been attended by professionals (fire brigade, police and ambulance services) and members of the public, as well as targeted groups (such as laughter yoga for South Asian women). They have been incredibly successful and are run across community venues and businesses in Sandwell.

In schools, the model provides confidence-building activities and teaches how to manage psychosomatic symptoms as well as tackling addiction, teenage pregnancy and other issues that are linked to self-esteem.

Other outcomes include 500 patients discharged from secondary to primary care with GP education, a conditions management programme, the integration of 63 counselling services to eradicate waiting lists and enable cross-referral, and the development of an IAPT service and integrated care pathways.

In their winning entry, the consortia said: ‘The London School of Economics quote

a figure of £30,000 for each year when people do not access health and social care programmes, but have a purposeful year.

‘It is difficult to estimate our effects in the long term, but we do know these programmes are making a difference.

‘The cost of a suicide to health is £1m. We have been told that these services have made the difference with people's life decisions, although that is impossible to quantify.'


Judge's comment

I really liked the ‘happiness and confidence' focus and sense of building community. The outcomes were very positive.

Julia Manning, chief executive, 2020Health

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