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Cluster's health and well-being initiative shortlisted for national award


A service that helps people with complex health and well-being needs while taking pressure off GPs has received national recognition.

The Cwmtawe Pathway Service offers support to those struggling with substance misuse, mental health and domestic abuse, including sexual violence.

Its support can also extend to family members affected by these issues.

The pilot project is funded by the Cwmtawe Local Cluster Collaborative (LCC) and works in partnership with Swansea Council for Voluntary Service (SCVS).

It provides patient-centred care by working with each person to agree meaningful interventions that tackle their unmet needs or issues.

Pictured: Project co-ordinator, Cara Lougher.

It was introduced in 2021 after mental health, domestic abuse and substance misuse were identified as three areas where the cluster – which covers Morriston, Clydach and Llansamlet - wanted to provide additional services.

The service has now gained national recognition after being shortlisted in the 2023 NHS Wales Awards.

Project co-ordinator Cara Lougher said: “The service provides person-centred care to individuals who usually have multiple unmet needs.

“They are typically people who have been seeking support from their GP but often require further support.

“We tried to create a service which helps them to access other local services in whichever way they want to be seen or heard.

“So, we look at how they want to be contacted, whether they want to be seen in the surgery or in the community and how often.

“We aim to make sure people with poor mental health, who struggle with substance misuse or are domestic abuse victims feel supported and cared for.”

Initially, an assessment is carried out to understand each person’s individual issues and needs.

A bespoke package of support is then put together relating to the needs and goals that person would like to achieve or would need support with.

They are then given one-to-one support which can include education around trauma, sleep and nutrition, help with getting support from local authorities or mental health team, help to navigate appropriate services – and more.

“We do a lot of risk assessments to help people feel safe and secure in themselves and then look to build resilience and give them skills and education,” Cara added.

“We look holistically at what the causes of their difficulties are, as well as what may cause stress or be a trigger.

“The service offers quite broad support to fit whatever is needed for each person and we offer support to families who are affected too, whether it’s children or parents and carers.

“Part of a support plan could involve working with someone on their well-being, which could include working with a GP, nurse or prescribing team.

“It could also then include the need to support them to look after themselves a bit better, so we would remind them of the basics of well-being.

“Then there is a sustainable element where we help them to access longer-term support from our key partners, such as substance support or domestic abuse services.”

The introduction of the service has resulted in a 60 per cent reduction in the demand on GPs, as well as a 98 per cent increase in patients having improved access to other sources of support.

70 people, including family members, benefited from the service during its initial 18-month period.

The service is now hoping for further success after being shortlisted at the NHS Wales Awards, in the Delivering Person-Centred Services category.

The awards recognise how innovative ideas for change can make a significant difference to the patients who need care, the organisations who provide care, and the health and care system as a whole.

It is an opportunity to showcase hardworking and inspiring teams working together, striving to improve healthcare practices and patient care across Wales.

Of being shortlisted, Cara said: “I have always been proud of what we offer as a service but to hear it from other people, including patients and how it has helped them, was amazing.”

Mike Garner, Cwmtawe LCC lead, said: “We invested in this project which has clearly proven its benefits to patients and the NHS as a whole.

“We couldn’t have anticipated it would be as successful as it has been and that is all down to Cara and the team.

“Being shortlisted for this award is a brilliant feather in the cap.”

SCVS Director Amanda Carr said: “We are really proud of this project and the positive difference it is making to people in the Cwmtawe LCC.

“Our partnership with Cwmtawe LCC, as well as other local clusters, has a history of developing innovative, high impact person-centred services.

“We are delighted the Cwmtawe Pathway Project is receiving national recognition.”

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