Value-Adding Approach to Lot 7 Service Delivery

Through providing patient empowerment, behavioural change and digital solution support to CCGs, GPs and primary care staff, local authorities, and directly to patients and populations, SCW ensures patient engagement and empowerment activities add measurable value. This can be evidenced by the support we have already delivered to NHS vanguard pilots for Shared Decision Making and Patient Activation, our partnership-based delivery model for Integrated Lifestyle Services commissioned by local authorities, and delivering patient-facing digital healthcare solutions through supporting five major interoperability projects across the south of England. We deliver these services through a dedicated team of 160 transformation and change consultants, including primary care facing experts, and 130 digital transformation specialists. In addition, we host a ‘Public Health Action’ (PHA) team with significant experience of delivering behavioural change for patients and populations. 

We supplement this by working with partners such as Johns Hopkins University (for predictive analytics), the third sector (for developing community assets), and particularly the Dartmouth Institute for Health Policy and Clinical Practice, led by Dr Al Mulley. Dr Mulley is Professor of Medicine at Dartmouth Medical School and the International Visiting Fellow at the King’s Fund. Dartmouth’s ‘big idea’ is that shared decision-making and service user engagement are central to learning from variation within populations. They enable systems to deliver what individuals really value. Operationalising this will require new models of primary care and SCW’s transformation team are working closely to develop this model and communicate with health and care systems. SCW’s support will help systems to address:

  • The dependence of clinicians and patients on each other to make the high-quality decisions that determine the right care for individuals and the allocation of resources for populations – the essential ‘interdependence’ in a health and care system;
  • The belief that neither patients nor clinicians can make a good decision alone, and both need measures and tools to hold themselves accountable for performing well in their roles; these must be simple enough to embed real-time feedback and capture preferences within decision making processes;
  • Information asymmetry and failure to recognise the need to personalize based on what matters most to the individual;
  • Access to tools that support mutual accountability between commissioners, providers, senior leaders and policy makers.

The case study that follows this response describes our legacy work on Behavioural Change by Public Health Action (SCW’s in-house team of behaviour change experts) leveraging social marketing approaches and implementing behavioural insight work to facilitate change. While we have the ability to produce credible and thought-provoking reports and plans, we invest most energy in actually delivering and embedding change in the fabric of a local system. We are passionate about creating beneficial change at the front line. We take accountability for delivering transformation outcomes, and we optimise sustainability by ensuring that local care teams are fully engaged in the process. We have an appetite for sharing the pain and pressure of change, which helps build commitment, motivation and resilience in the individuals delivering it. This is our definition of partnership working. 


Extended Case Study: Empowering and Activating People at Scale to Improve Their Own Health

A decade ago, the south west of England saw a worrying rise in smoking rates with up to 26% of all adults smoking compared to the national average of 22%. Research showed that smoker activation levels were low and smokers did not feel empowered to seek help when they needed it. In most cases, their lack of confidence and their negative past experiences of trying to improve their health meant they preferred not to think about it. They felt overwhelmed with the task of changing their own behaviour.

In response to this deteriorating situation, SCW led a complex tobacco control and behaviour change programme across 15 NHS and local authority areas. This was an evidence-based programme with a compelling rationale, co-developed with regional Directors of Public Health based on national and international models of best practice. The aim was to drive behaviour change in the region through a coordinated and comprehensive mass media campaign to reduce smoking prevalence, combatting illegal tobacco, and supporting and enabling communities to deliver sustainable initiatives and link people to stop smoking services.


Evidence is clear that mass media campaigns, as part of comprehensive tobacco control efforts, are one of the most effective ways to change behaviour, encourage smokers to quit and empower them to manage their own health more effectively. Our ‘Be There Tomorrow’ campaign focused on changing behaviour in the socio-economic group C2DE (skilled working class, working class and non-working) as a positive change in this group would have the greatest impact on smoking prevalence and it was the group most likely to be empowered by positive messages. We developed messages that were hard-hitting yet carried a positive call to action that explained how smokers could improve their health – and the health of their loved ones.

Our work was evaluated through regular tracking surveys with smokers. These demonstrated the positive impact we had on changing behaviours among the local population and the value this generated. For example, one campaign had a one-off cost of 4pence per person compared to the estimated incremental health and care cost of £253.64 per smoker.


Over the course of the five years that we ran the programme, smoking rates dropped from 26% to 17%. This equates to 300,000 smokers in the south west who we empowered to actively change their behaviour and improve their health.

In addition to the reduction in smoking prevalence, other key achievements included:

  • Increasing ‘motivation to quit’ to the highest levels ever recorded in the south west, with more than 300,000 smokers (37%) reporting to have made a quit attempt in the previous 12 months (LVQ tracking)
  • 57,000 more smokers were aware of the symptoms of Chronic Obstructive Pulmonary Disease (COPD)
  • 60,000 fewer people smoked illegal tobacco and 100,000 fewer people were offered illegal tobacco
  • 400,000 more adults and children live in a smoke-free home following the Smoke Outside campaign (YouGov Surveys)
  • 244,000 more smokers were aware that hand rolling tobacco is as damaging as manufactured cigarettes as a result of the Wise-Up to Roll-Ups campaign


With a proven record of delivering tangible results in behaviour change at scale, we have transferred learning to other areas of health. For example, we delivered a large insight study in to changing the drinking behaviours of targeted populations and provided recommendations on how to activate and empower people to take responsibility for their own health management and reduce harm to themselves and others. Our expertise in these population health programmes has been instrumental in developing our offer for the Healthy Lifestyles programme, an integrated new model of care that enables less reliance on face-to-face interventions and greater emphasis on empowering individuals to look after themselves.

It is very encouraging to see the progress that the South West is making and the success they are achieving in shifting attitudes and behaviour surrounding smoking.

Kevin Fenton, Director of Health and Wellbeing, Public Health England

The social marketing insight work that Public Health Action has delivered for us under the South West Behaviour Change contract has been invaluable. Their work has always been of a very high standard and they are customer-focused from beginning to end.

Steve Brown, Assistant Director of Public Health, Devon County Council

It’s been fantastic working with them. We have a very small local stop smoking team and, without the real powerful help we get from a big organisation with things like media and really supporting our efforts to encourage people to give up smoking, we wouldn’t have achieved our target this year. It’s really that partnership between a much broader based organisation and our efforts at a local level that will help us control tobacco in society.

Maggie Rae, Director of Public Health, Wiltshire

How We Work with Partners in Lot 7

Specifically within this Lot, we will continue working with organisations such as Johns Hopkins University (for predictive analytics), the ‘third sector (for developing community assets), our interoperability partnership network and in particular a close partnership with Dartmouth Institute for Health Policy and Clinical Practice. Dartmouth develop, implement and evaluate across a range of conditions and facilitate Shared Decision Making (SDM) at scale. They are pioneers in developing new care models that use digital tools and health coaches to support self-care, building on the latest SDM research and incorporating clinician-patient collaboration into their design. Their ‘mutual accountability’ approach to culture change emerged from work with MCPs and PACSs to develop a Place-Based Learning Network, and has been well received by STPs in London and elsewhere in England.


Case Studies

An effective approach to training and supporting professionals to use SDM begins with an understanding of the sources of resistance. In its work with the NHS, Dartmouth has addressed these concerns at many levels, developing conceptual models that provide structure for training such as the ‘3 talk model’ (Team Talk, Option Talk, and Decision Talk). Partners engaged with Dartmouth to contextualise this work within STPs and build capacity for expanding at pace include SCW, UCL Partners, NAPC (Primary Care Homes), and RightCare delivery partners. SCW trainers were the first UK team to be accredited in House of Care and SDM and can deliver ‘train the trainer’ courses on personalised care and support planning, patient activation measures, health literacy and motivational interviewing. We applied learning from our work on the Somerset House of Care Programme, below.

SCW trained 400 people in the Somerset health community, including social care, community and third sector partners, and 82% of GP practices. The training led to a significant shift in attitudes and behaviours towards SDM, improvements in patient care and outcomes, and created more efficient, cost-effective services. The evaluation report showed 97% of attendees reported increased confidence to support SDM, 85% adapted their approach to supporting people with long-term conditions, and 58% reported that care planning had improved care to patients and reduced the need for appointments. To achieve this, we created an online resource library and trained in three tiers as follow:

  • Local level (GP practice): bespoke consultancy support including process mapping, service redesign, and training
  • Federation level (locality): SHOC Awareness Sessions to update on resources, training and implementation support available
  • County level (STP): SHOC Core Training, 1½  day Personalised Care & Support Planning training (on Year of Care model)


“The training gave me a ‘light bulb’ moment about preparing patients for their annual reviews. It acted as a useful reminder in these busy times, that putting a bit of time into empowering the patient can have positive rewards in terms of subsequent use of services as well as clinical outcomes.”   GP, Mine head

“It has been really interesting to see how the medical model is driven by tests, tasks and numbers, rather than by the individual. I am really positive about the opportunities care planning presents for partnership working and to get the voluntary sector and other services involved in healthcare.” Regional Lead, Age UK


We are supporting this Vanguard to integrate patient activation with the deployment of integrated care models through a complex care hub, enhanced primary care, and health coaching. This includes the capture and storage of PAM scores, with almost 4,000 PAMs collected to date, as illustrated below.

As the lead for the Vanguard’s formal evaluation, SCW is reporting back locally and to NHS England (National New Models of Care Team), explaining how patients are playing a role in the deployment of integrated care programmes and how individual patients are becoming more active, particularly through the identification (by health coaches) of individual patient case studies – an important engagement device for the local clinical community.

Health coaches: These case studies support the findings from our qualitative evaluation about the positive impact of health coaches on a number of aspects of physical and mental health, such as diabetes, weight loss and mood, and the positive impact on wider determinants of health, such as employment status and social isolation. We are now building ‘repeat collection of scores’ to facilitate quantitative analysis of how changes in PAM scores affect health and social care costs for a patient. 

Linking PAM, data sets and EMIS primary care systems: SCW includes the PAM scores we collect as a data component of the Symphony data set, which is an NHS Digital-approved patient-level linked data set across all settings of care, including social care. This allows for ongoing quantitative analysis of the effect activation has on activity and cost. SCW is also working with Somerset CCG and EMIS as a research pilot for EMIS primary care analytics. Through this research, we understand how activation can be played back through EMIS into primary care GPIT systems and live primary care settings, including clinical consultations. We are working with the system to explore additional mechanisms for collecting PAM scores at scale to measure activation levels across whole communities, which would include deploying PAM questionnaires to the Somerset Referral Management Centre, a contact and patient choice centre we operate that speaks to 3,000 Somerset patients each week. 

Public Health Action (PHA), SCWs in house team of behaviour change experts has in-depth experience in behaviour change tools and techniques and delivering preventative behavioural change programmes both for large populations and smaller patient groups. The service is closely involved in delivery of ILS, part of the statutory delivery requirement for local authorities. Our approach provides people with: 

  • Information/educational materials: digital for accurate, standardised messages and anywhere-anytime access
  • Sign-posting/referral of individuals to other sources of health and care support available from local agencies, businesses, charities, community groups and other community-based assets, linking health and social care, building a holistic, coordinated prevention approach
  • Support and advice accessed via a range of face-to-face and digital approaches as needs require
  • Coaching programmes delivered via face-to-face, digital self-taught, video consultations, in line with patient needs, preferences and lifestyles
  • Opportunities for connecting with other patients though support groups, digital peer-to-peer support, verified social media channels, digital forums and platforms
  • Non-digital solutions across all areas to support the population that is not digitally enabled.


An integrated approach provides a clear focus on prevention and early intervention, a key element of the 5YFV. To deliver this model, we link PHA, the wider SCW team, and our partners with support services separately commissioned by LAs and ‘Health’ to:

  • Deliver cost-effective digital and transformation projects at scale, focussing on improving the health of populations. For example, reducing smoking prevalence by 33% through integrated behaviour change campaigns
  • Provide digital solutions (e.g. shared care records, patient portals, social prescribing) in several STPs
  • Operate contact centres (e.g. a Referral Management Centre handling 4,500 patient calls a week in Somerset/BNSSG) where, beyond making Outpatient Bookings, we signpost people (e.g. smoking cessation) and are looking to transform contact centres into ‘activation centres’ and spread this learning across health and care systems at every touchpoint with citizens
  • Build relationships with community care organisations (e.g. with The Care Forum in BNSSG STP, an umbrella organisation for VCS organisations to deliver grass roots solutions to support healthier lifestyles)
  • Build effective partnerships with private sector organisations (e.g. our pilot with Microsoft in Frimley STP to integrate lifestyle data from wearable technologies into local care records) and third sector organisations, as per the following example.

To join up people, ideas and best practice across boundaries, we supported NHSE, CCGs and third sector organisations to put statutory ‘Patients in Control’ (PIC) principles at the heart of local strategies and service design. This included assessing applications and awarding funding (in a ‘Dragon’s Den’ style, using an independent panel with representatives from the NHS, academia, VCSOs, patients and public groups) to organisations that demonstrated promising initiatives around PIC and self-management. We also co-created the Patient Voice website, offering efficient funding application tools, a knowledge bank and a  learning and communications hub, and a patient voice region network – with regular networking events and a ‘find a buddy’ function to connect professionals and share experiences. The network we developed was so successful at engaging organisations that it has continued long after the funded programme finished, and our hub remains the ‘go-to’ resource for online learning and sharing of what works, as well as what does not.

SCW has in-house expertise across a range of complex evaluation methodologies, including globally recognised approaches and less traditional methods such as ‘most significant change’ and ‘contribution analysis’ for evaluating complex adaptive systems and articulating ‘value’ from a range of stakeholder viewpoints. We also work with partners such as Dartmouth to evaluate outcomes that matter most for patients, taxpayers, clinicians and staff. Where it adds value, we bring these evaluation partners together to provide an effective and integrated approach, including establishing baselines and demonstrating impact.

Analysing South Somerset’s integrated care models (Complex Care Hub, Enhanced Primary Care): SCW worked with the University of York to conduct propensity score matching, combined with a ‘difference in differences’ analysis (DiD) to establish detailed patient-level cohort case matching. Methodologically, this is analogous to a controlled before and after study and is considered a robust method for testing for an intervention’s effects in the absence of randomisation. Suitable controls are now being introduced to capture the ‘counterfactual’, i.e. what would have happened in the absence of an intervention. This relies on identifying one or more matched cohorts of control patients.

SCW worked with Somerset CCG to pioneer PHBs. Initially a national pilot site, we were early adopters of PHBs for eligible patients affected by either long-term neurological conditions (LTC), learning disabilities (LD), receiving Continuing Health Care (CHC) at home, or receiving CHC in transition from childhood to adulthood. By developing a robust operating model (described below) two years ahead of the government timeframe, we extended PHB from LTC and LD patients to all eligible patients, including children and transition to adult services, enabling Somerset CCG to extend PHB benefits to a greater proportion of their population.

“Having a Personal Health Budget that we have been able to spend on laundry services due to my incontinence, rather than paying for care, has meant my wife is able to spend her time caring for me knowing that this is sorted.” Young MND patient.

Our award-winning Hampshire Health Record (HHR) is an integrated regional health and social care record that supports care providers in Hampshire, Portsmouth and Southampton. It compromises longitudinal health and social care records for 3 million people, providing analysis and integrated insight into the whole population for 20 stakeholder organisations. Through the development of Hampshire Health Record Analytics solution (HHRA), SCW has taken integrated records beyond the agenda of a shared patient care record into advanced analytics for population profiling, clinical research and actuarial analysis. As part of our ongoing support to Portsmouth CCG and Hampshire County Council, our Development and Modelling Analytics team has delivered:

  • A linked and costed data set for healthcare activity for complex patients comprising acute, community, mental health, ambulance and primary care (GP attendances and prescriptions)
  • A financial model to provide costed activity by patient pathway for development of PHBs
  • An evaluation of the Year 1 cohort to identify impacts on the use of healthcare for patients involved in the programme
  • A social care data set for linking to healthcare records 
  • Documentation for national roll-out, through participation in the national Finance and Cohort Collaborative Development Group.

Alongside other exemplar sites (Tower Hamlets, Hammersmith and Fulham), we are supporting NHS Improvement’s (NHSI) investigations into payment innovation mechanisms for long-term conditions. NHSI used our work as a key case study in their guide for creating patient-level linked data sets. We are a member of NHSI’s Integrated Care Payment Forum, looking at practical applications for introducing ‘capitation’ into the Commissioning process. 

We are also working with the University of York Centre for Health Economics to support their latest research in developing economic modelling algorithms that can predict the outcome of changes across the ‘currencies’ of care. This is leading towards a scientific basis for the ‘transferability’ of cost observations across patient cohorts and demographics, and predicting the cost impacts of investment in the acute, social, community, or primary care. A prototype has been built and we are defining future direction for this with York and The Health Foundation. The image to the right shows how we are engaging with Somerset on capitation formulae – in this case how it can support ambitions for new models of care, outcomes based commissioning and personalised care. While current allocations are based primarily on an age-derived formula, our work on Big Data has established a formula approach based on conditions. Our ambition is to develop the insight to quantify other factors that drive cost for an individual, including socioeconomic factors (we link Experian social indicators into the data set), patient activation (we are collecting thousands of PAM scores), and other data that indicate the degree to which (low) activation drives cost, as identified through multivariate regression analysis.

SCW delivers a managed telehealth service for Somerset, including contract management of two telehealth suppliers (Tunstall, Safe Patient Systems) and clinical engagement to identify patients who would benefit from telehealth, based on the outcomes of risk stratification analysis we conducted. We deployed 680 units into the health community and supported 1,017 patients to install and maintain their equipment and link it to a dedicated clinical hub for escalations. We developed a ‘graduation programme’ for patients on telehealth so that the patient could, when ready, move to a less ‘technologically dependent’ routine of self-care and that the telehealth units themselves could be deployed to other patients.

We are working with Frimley STP to trial the use of wearable technology with 400 NHS staff volunteers. In a unique partnership with Microsoft, System C, and Graphnet Care Alliance that started in October 2017, we are testing how lifestyle data from wearable technology can influence behaviours, and how we can link this data into Berkshire’s integrated care records system, Connected Care. Each volunteer is given a Garmin activity tracker and asked to wear it 24/7 for a year. The yearlong pilot aims to learn how to interpret this information alongside traditional health and care information in order to prompt behaviour change in participants and support greater self-care. Alongside the pilot, we are developing a behaviour change offer based on public health messaging to provide volunteers with insights about their lifestyle to motivate behaviour change. “It is great to be working in partnership with SCW to bring together behaviour change goals and technology, to encourage self-care and understanding about what the potential future benefits are.” Sharon Boundy, Engagement Manager, Frimley Health Foundation Trust 

Want to see more

Why not browse the entire SCW case study library ?

SCW Case Studies