Proactive personalised care which goes beyond a GP appointment is the key to the success of an innovative NHS project which is improving the health of older people in Tewkesbury and surrounding areas.

More than 11,000 patients aged 65 and over were identified from GP lists and contacted as part of the project. Tewkesbury, West Cheltenham, Newent and Staunton Primary Care Network’s  proactive Health and Wellbeing Team are now working with those older members of the community to identify early signs of frailty and support those who need extra help.

After speaking to patients, the team mapped all existing services and support options in the local area and found gaps, the next step was trying to fill them.

So far this has included setting up new weekly strength and balance classes, tailored exercise plans for patients with obesity, pre-diabetes and diabetes and working side by side with the Social Prescribing link worker team.

Dr Jeremy Welch, GP at Mythe Medical Practice and Clinical Director for Tewkesbury, West Cheltenham, Newent and Staunton Primary Care Network, said:

“We found that over one third of the people we contacted had unmet and unvoiced needs. Many older people can be incredibly stoical and many said they ‘did not want to trouble the NHS as they knew it was struggling post COVID.”

Other innovations have seen the team proactively reach out to all patients diagnosed with cancer to offer community and psychological support to go alongside existing clinical treatments, introduce Dance with Parkinson’s classes, dementia choirs and carers support groups. Local councils and community groups have given backing to the project and also provided venues for the classes.

When it comes to joint working, the Health and Wellbeing Team connect with colleagues across health and social care to make sure each patient gets the advice or support they need. They refer to social prescribing link workers, community NHS services – including falls clinics and physiotherapy, adult social care support services, Age UK, Alzheimer’s Society, dementia nurses, weight loss services, mental health nurses, GPs and cancer support nurses to name just a few.

For Dr Welch and the Health and Wellbeing Team it is about more than just medical care and outcomes:

“The benefits of such initiatives are clear and we truly feel we are building community, building resilience and building happier and healthy lives in Tewkesbury. Alongside this, we know we are are supporting some of our area’s most vulnerable people and reducing health inequalities.”

“Working with local councils, health services and social care as well as the voluntary and community sector through the ILP (integrated locality partnership) the team are truly plugging the gaps that have existed between statutory services to proactively support so many people who would have otherwise struggled and deteriorated in silence. We are immensely grateful to One Gloucestershire partners for supporting this initiative.”

Dr Welch added:

“It has unlocked the world for so many isolated people and the chance to socialise with peers after classes and forge and rekindle friendships is heart-warming and life changing.”

The team are now busy working on the next facet of proactive support for patients with early signs of dementia.

Dr Welch said: ”

“Improved signposting, supporting earlier diagnosis and recognition, mapping existing support services and initiatives to help fill any gaps are all on the agenda – as we recognise how tough and upsetting dementia can be for patients, families, carers and loved ones.”

Helen Goodey, Director of Primary Care and Place at NHS Gloucestershire said:

“This is a fantastic example of what can be achieved through a proactive approach to health and wellbeing working across the NHS, local councils, social care and with a range of other public, voluntary and community sector partners. The team should be rightly proud of picking up a recent regional award which recognises their approach and the impact they have already made.”