Community Wellbeing Service

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The Community Wellbeing Service is a new initiative delivered by the Health Inclusion Team (HIT) at Southampton Primary Care Limited (SPCL). The service is designed to support individuals who are not currently engaging with healthcare but meet a defined set of criteria, based on the CORE20PLUS5 health inequality framework.

Our aim is to proactively identify these patients, assess their needs quickly, and support them on a personalised path toward better health. Ultimately, we help patients re-engage with primary care in a more consistent and sustainable way.

The approach to improving health and wellbeing is structured into three key levels of prevention:

Healthy Ageing – Primary Prevention:
Supporting people to stay well for longer by focusing on lifestyle factors, early risk identification, and self-management. This includes healthy eating, physical activity, smoking cessation, and social engagement.
Preventing Progression – Secondary Prevention:
Working with patients who are at risk of developing serious conditions or have long-term conditions that are not well-managed. We provide proactive interventions to stabilise their health and reduce deterioration.
Optimising Multidisciplinary Team (MDT) Working – Tertiary Prevention:
For patients with complex needs or multiple conditions, we coordinate care across services, including social care, primary care, and community teams. This helps prevent avoidable crises and hospital admissions. As part of this work, the Health Inclusion Team also delivers outreach programmes, including home visits, vaccinations for housebound patients, frailty assessments, and health checks. These are designed to reduce barriers, reach underserved populations, and ensure nobody falls through the gaps in care.

At the heart of our service is a bespoke wellbeing questionnaire, developed in collaboration with the University of Southampton. This tool, called iMatter, consists of approximately 40 questions drawn from validated NHS questionnaires. It helps us identify areas of focus and generate a wellbeing score and visual summary, which is shared with the patient during shared decision-making to develop a personalised care plan.

To support this, we use a dedicated digital platform powered by Healum. Patients enrolled in the service can download the SPCL Wellbeing app, available on the Google Play Store and Apple App Store. Through the app, patients can access goal-setting tools, health content, local activities, recipes, exercises, and personalised resources to help them stay on track.

Our HIT team works alongside patients—both digitally and in the community—to co-design achievable steps that support long-term health and wellbeing.