Catching up with NHS Wales Award winners: The Cwmtawe Pathway Service

Nearly a year on from winning the award for Delivering Person-Centred Services at the NHS Wales Awards 2023, we talk to the Cwmtawe Cluster Team based in Swansea to reflect on their project that is providing person-centred care for patients with complex needs.

How did the work come about?

Swansea and Neath Port Talbot cluster mapping data showed that across the Swansea Bay University Health Board domestic violence was an issue to be tackled. A meeting with the Domestic Abuse Hub, Cluster and Health Board representatives took place and stakeholders felt that a post addressing the ‘Key 3’ issues (Domestic Violence, Substance Misuse and Mental Health) was essential. It was also felt that a worker based within primary care would enable robust partnership working between sectors. Swansea Council for Voluntary Service (SCVS), the umbrella support charity for Swansea advised they could support the service and ensure that patients had improved knowledge of local provision with their involvement. The Cwmtawe Pathway Service was approved to begin in July 2021 to address the issues faced by individuals. It also provides systemic support to family members as needed.

Tell us about the project?

The service provides ‘person-centred care’, allowing time, space and flexibility to co-produce meaningful interventions that tackle the multiple unmet needs and/or issues faced. Some of the aims of the service are to: reduce demand on GPs, provide better support for patients to take responsibility for their own health, improve access to other sources of support and identify ‘hidden causes’ of poor physical and mental health issues.

What have been the challenges?

  • Safeguarding is a major consideration with regards to complex needs work, ensuring that cross cluster roles effectively dovetail into practice procedures across the geographical cluster footprint. To ensure processes were robust, a safeguarding pilot project was set up to ensure that issues were discussed, systems aligned and any barriers to progress were identified and challenged appropriately.
  • It became clear that additional resource was needed. Patients with high levels of risk/multiple unmet needs requiring a Team Around the Family / Multidisciplinary Team (TAF/MDT) approach was incredibly time consuming. Capacity was increased by employing a complex needs support worker.
  • Health and Social Care use different systems. By improving partnerships and communication have resulted in the service being flagged at key strategic meetings and improved data sharing procedures within the cluster itself, including development of a multi-agency Mental Health Virtual Ward that meets fortnightly.

What impact has the work had?

The pilot demonstrated for the 83 referrals and additional 19 beneficiaries (family members):

  • A 60% reduction in demand on GPs from patients referred to the project,
  • 98% of patients supported are taking responsibility for their own health and wellbeing,
  • 98% of patients referred have improved access to other sources of support,
  • ‘hidden causes’ of poor physical and mental health have been identified in 100% of cases,
  • in all cases, safeguarding issues have been identified and addressed as appropriate,
  • nearly 70% of referrals engaged in support over a period of 12 weeks (average) – an excellent outcome considering this cohort is ‘hard to engage’,
  • an economic return on investment by Swansea University identified potential savings, for a 12-person sample, ranged between £400,000 (lower range) and £860,000 (upper range) per year.

What happens next?

It is an understatement to say that the cluster was thrilled and honoured to win the NHS Wales Award for Delivering Person-Centred Care. The judges visit in the summer of 2023, presented the team with an opportunity to showcase the work but more importantly to give our service users a ‘voice’ and allow them to talk about the service and the impact that the support has had on their lives.

“Thank you… No one else has given me a choice or told me that there was an alternative…”

It goes without saying that some of these testimonials were nothing short of life changing. The project has achieved so much in a relatively short space of time and is a fantastic example of what real partnership and perseverance can achieve.

SCVS Director, Amanda Carr said. ‘The project is a shining example of how true partnership working can deliver benefits for all those involved-reducing demand on the precious time of GPs and delivering support to individuals when they need it. Our partnership with the Cwmtawe Cluster is well established and we look forward to developing more innovative approaches to delivering support to partners and those in need in the future’

Discussions are currently taking place at the Pan Cluster Planning Group to consider how this initiative can be further rolled out across the region.It is hoped that achieving national recognition will help with this.

The Cwmtawe Pathway Service within the Cwmtawe Cluster forms part of a Service Model for Mental Health and Wellbeing which puts patients at the centre, ensuring that they receive appropriate support for their needs. The Health Board is currently looking at this model as an example of excellent practice and is promoting this model working collaboratively with the Regional Partnership Board.

If you would like to connect or find out more about this work, please contact Debra.morgan8@wales.nhs.uk.

Winners for the NHS Wales Awards 2024 will be announced on Thursday 24 October. Find out more at nhsawards.wales.