8. St Austell Healthcare

8. St Austell Healthcare


St Austell has high levels of long-term unemployment and socio-economic deprivation as well as a high prevalence of chronic disease and obesity. The primary care home model offered a framework for one large practice to redesign services and offer new ones in partnership with a wide range of statutory and voluntary sector organisations. Its vision is to provide sustainable services to its patients, meeting unmet needs and enabling people to access non-clinical solutions.

How things are changing

The primary care home has established integrated, multidisciplinary teams and opened up access to many non-clinical activities which can address the wider determinants of ill-health. It has focussed on three key workstreams: social prescribing, integration of health and social care and workforce development. The result is better and new services, less duplication and more skills development for staff.

Many of the practice’s patients are the frail elderly who are physically inactive, often socially isolated and lonely. Poverty and unemployment are also major challenges. The practice engaged with community providers, employing a social prescribing facilitator who sees patients and refers them to resources ranging from walking groups to Zumba, pilates classes and a canoe club, to increase their physical activity, improve their diet and reduce isolation. The pilot resulted in 52 out of 150 patients completing 12 weeks of the programme, of those 94% saw an increase in their wellbeing score and 62% had lost weight.

An integration manager role has been created to improve hospital discharges, the treatment of complex patients and palliative care. Home visits are being managed better and duplication has been reduced. GPs had been making 30 home visits a day but many patients were also being visited by district nurses, community matrons and the mental health team. Community nurses and district nurses have also been co-located at the practice’s acute hub which sees urgent same-day cases.

The PCH has concentrated on skills development for staff and diversifying the multidisciplinary team. A pharmacist is part of the practice team carrying out medication reviews. There is a nurse-led minor illness team, with the team internally trained and an acute visiting service using emergency care practitioners.

Lessons learnt: It takes time to build the relationships between organisations needed to make this work. Time to lead is essential.


Kernow Clinical Commissioning Group, Cornwall Partnership Foundation NHS Trust (community and mental health trust), Cornwall County Council, St Austell Town Council, the Eden Project, Public Health England, Age UK, Pentreath (a mental health charity) and some big local employers including St Austell Brewery.