Case Study

System change case study: Ways to Wellness

by | Nov 3, 2021

Youth Futures Foundation has gathered this case study to help applicants to our Connected Futures Fund understand the kinds of things that might be involved in collective local efforts to change the ways that systems work. We recognise that the fund is not like ordinary project funding, and we hope you will find some of these case studies helpful prompts as you think through your application.

You do not have to copy or draw on this example at all. It is only an example, and it won’t all be relevant to you and your context – feel free to take what you need, and ignore the rest.

We will not give preference to applications that look like this example. We want to see your ideas for changing how things work.

Ways to Wellness, Newcastle upon Tyne

What is it?

Ways to Wellness is a “social prescribing” service for people living with long-term health conditions, such as diabetes, heart disease or chronic obstructive pulmonary disorder. The service covers the west of Newcastle upon Tyne, an area of high deprivation, with below average life expectancy, where people are more likely to develop health conditions in mid-life. It aims to help people manage their health conditions themselves, improving their wellbeing and quality of life, while reducing demand on the NHS.

The programme is commissioned by the local NHS clinical commissioning group, on an outcomes-based contract with payments tied to improved wellbeing and reductions in hospital care costs. 86% of people supported by Ways to Wellness report improvements in their wellbeing and quality of life. There has been a 14% reduction in GP consultations, and a 27% reduction in hospital admissions, as people take more active control of their health.

How does it work?

GPs refer people to a “link worker”, who starts by listening to them to find out their goals and understand the barriers they face. They then develop an action plan together, with a mix of:

  • Steps the person can take by themselves – e.g. exercise, healthy eating
  • Support to help them address the barriers they face – from stopping smoking to advice with benefits or housing

The link worker encourages and supports the person to put their plan into practice, and identifies appropriate sources of support, from statutory services to community groups. For example, they may help someone find a walking club, or a community group that offers cooking classes. These often reflect people’s interests – joining a choir or dance class rather than going to a gym. Link workers also give people the practical and emotional support they need to take up these opportunities. Similarly, where community groups need extra resources to support someone, Ways to Wellness can provide additional funding so that they aren’t overwhelmed.

What makes this an example of systems change? 

Although link workers are based in GP practices, they are employed by VCS organisations embedded in the local community. The programme acts as a bridge, moving healthcare beyond the NHS and a focus on illness and treating people’s medical conditions, into their everyday social and emotional life to help them take control of their health.

At the heart of social prescribing is a cultural shift away from a clinical model of doing things to patients, towards a recognition that people are more than their health condition – from “what’s the matter with you?” to “what matters to you?”.

It has also led to wider change. Following the success of Ways to Wellness and other pioneers of social prescribing, in 2019 NHS England committed to funding link workers across the whole country.

Elements of systems change: 

  • Rethinking relationships with service users (from patients to people)
  • Delivering innovative services at scale to create better outcomes across the system
  • Reorienting existing services and resources (to focus on prevention and strengths, rather than treatment and managing problems)
  • Asking new questions to encourage new ways of thinking and working (from “what’s the matter with you” to “what matters to you”)
  • Using data and evaluation to build local buy-in and make the case for wider change


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