What’s this project all about?
This activity is part of Healthy Working Life, a joint programme of the West Yorkshire Combined Authority and NHS West Yorkshire Integrated Care Board.
As part of the Three Long-term Conditions and Mental Health Project, the Burmantofts, Harehills and Richmond Primary Care Network, uses a neighbourhood-based approach to care. In collaboration with patients and general practices the aim is to help people stay well, feel heard and remain independent.
For 64-year-old Eileen (not real name), it has meant better health, more confidence and a stronger connection with the support around her. Eileen lives with several long-term conditions, including asthma, type 2 diabetes, high blood pressure, obesity and the effects of a previous stroke. She also has ongoing back pain. Like many people managing complex health needs, she was feeling overwhelmed.
Despite previously keeping her diabetes under control, Eileen’s blood sugar levels rose sharply. Her HbA1c - a blood test that shows average blood sugar levels over the last two to three months - had climbed to 126, putting her at risk of serious complications.
During a home visit from the neighbourhood proactive care team, Eileen explained why she had stopped taking metformin, a diabetes medicine, because it was causing stomach problems. Although she had raised the issue before, she felt her concerns had not been properly addressed. She was also recording consistently high blood pressure and was under strain from family pressures and her own health worries.
A team built around the person
Before meeting Eileen, the multi-disciplinary team (MDT) reviewed her medical history so they could understand her needs and plan the right support.
The team included a pharmacist, care coordinator, clinician and social prescriber - professionals working together to support both physical and mental wellbeing. A pharmacist took time to explore Eileen’s concerns in detail, particularly the side effects of her medication.
“The first step was listening,” said Liz Ward, Service Lead for the Health Population Management Hub and Women's Health Hub at Burmantofts, Harehills and Richmond Primary Care Network. “Eileen had been living with the side effects and felt nobody was hearing her. Once we understood that, we could make decisions together.”
Together, they agreed to try a different version of metformin that is often gentler on the stomach. The team also explained the risks of poorly controlled diabetes in plain language and helped Eileen understand how treatment could protect her long-term health. Regular follow-up phone calls helped build trust and kept her connected to the team.
“Consistency really matters,” said Liz. “By checking in regularly, we were able to answer questions quickly, keep her motivated and make sure small issues didn’t become bigger ones.”
The team arranged for Eileen to check her blood pressure at home. Reviewing the results together helped her feel involved in decisions about increasing ramipril, a medicine used to lower blood pressure and protect the heart and kidneys.
Looking at the big picture
The support went beyond medication. The social prescriber and care coordinator talked through Eileen’s day-to-day challenges, emotional wellbeing and what mattered most to her. Together, they created a personalised care plan, including:
- referral to a dietitian for support with managing diabetes
- signposting to local exercise and activity groups
- referral to pain management support for her back
- referral to primary care mental health services, which she engaged with for the first time
- support with applying for a Blue Badge to help with mobility
- practical help with rebooking missed appointments and reminders
The team also recognised the importance of Eileen’s family support network.
Real improvements in health and confidence
The results speak for themselves. Eileen’s HbA1c dropped from 126 to 73, likely because she was able to take her medication more regularly. She became more involved in decisions about her treatment and open to extra support, including mental health and dietetic services. She also agreed to changes in her blood pressure treatment after shared discussions with the team.
Although she chose not to increase her diabetes medication further, she said she felt more in control and was willing to focus on lifestyle changes. Perhaps most importantly, trust had started to return.
“This shows what can happen when people feel listened to,” said Liz. “By treating the whole person, not just the condition, we can improve health in a way that lasts.”
Work as a health outcome
Eileen’s story highlights that when people are healthier, more mobile and better supported emotionally, they are more likely to stay independent, take part in their communities and, where appropriate, remain in or return to work.
Neighbourhood proactive care is showing that by listening early, coordinating support and removing barriers, healthcare teams can improve not only medical outcomes, but wider life outcomes too.
What happens next
Eileen will continue to receive support, including:
- follow-up blood tests and blood pressure checks with the practice nurse
- ongoing support from the dietitian
- another HbA1c review in three months
- continued MDT support when needed to help manage her long-term conditions
Liz concludes: “For the team supporting her, it is a reminder that health outcomes are not only measured in test results, but in trust, confidence and quality of life.”
You can also read the neighbourhood proactive care helps Eileen take back control of her health case study as a PDF.