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Annual Outcome Report - Wellbeing Service 2020-21

We are thrilled to be able to share some of the latest data and annual figures for the CCG commissioned Wellbeing Service, provided by Primary Care Cheshire.


Here are some highlights from the team working on the Wellbeing Service over 2020-2021:

  • The Wellbeing Coordinators have supported a total of 1447 patients during this year, receiving 1327 new referrals

  • Despite new services being created via NHSE as part of the Additional Roles Scheme and the introduction of similar services via new Link Workers since 2019, the overall caseload for the Wellbeing Coordinators has increased by 549 patients and 467 new referrals compared with the previous reporting year 2019-20.

  • We now have a full team of 10 Wellbeing coordinators, as well as 3 Link Workers enabling PCC to boost our services to patients and provide great support to practices, helping patients’ wellbeing and those facing bereavement and unemployment especially through the challenges of COVID 19.

  • Collectively the 10 Coordinators have made over 4596 individual contacts to patients over the year.

  • We have also had 45 referrals from North West Ambulance Service between 19th June 2020 – 31st March 2021 supporting the avoidance of hospital admissions, as well as reducing the need for clinicians and Social Services/Community Care teams input.


Our Wellbeing team use questionnaires known as PAM and ONS4 to measure a patients' wellbeing, here are some of the incredible results seen from these outcome measures:

  • The average increase of PAM scores for the year is 6.8 points. The highest score improvement being 29.9 points.

  • The average increase over the year on the ONS4 outcome measure is 10 points, the highest score improvement being 27 points.

  • 86% of patients who completed the ONS4 impact measure during this year reported an increase in their sense of general wellbeing following the interventions of a Wellbeing Coordinator.

  • Encouragingly, 42% of patients reported a positive increase in their medical wellbeing following intervention by a Wellbeing Coordinator this year. (As reflected in PAM scores)

  • All the impact measure figures are encouraging especially considering the impact COVID-19 has had on the general population and their sense of wellbeing. Only 5% of ONS4 and 4% of PAM outcomes had decreased during this year; which again – given the worldwide increase of cases in anxiety and mental health, this is incredibly encouraging and proves that the Wellbeing Services are having a positive impact for our patient population here in West Cheshire.


None of the above figures or statistics include the 1200+ additional shielding (CEV) patients the Wellbeing Coordinators and Primary Care Cheshire staff team supported during the initial COVID-19 wave and subsequent lockdowns over 2020-21 to ensure access medicines, food and other essential services continued whilst shielding.


Here is just some of the great feedback we have had about our Wellbeing Services team -



Patient Feedback 2020-21


“I just wanted to email to say a massive thank you for everything that you have done for me and my 2 babies. Without you I honesty do not know where I would be. You helped me out of my nightmare and into this house. You didn’t give up on me when many people have done (me myself included). Your effort and persistence with me is unbelievable.

I seriously and genuinely can’t thank you enough.” (Neston & Willaston PCN)


“The Wellbeing Coordinator listens to me a lot. They help me feel less lonely”

(One Ellesmere Port PCN)


“It’s very good to have someone who gives support and care when no one else is bothered.

The Wellbeing Coordinator helped emotionally and proactively. It has been hard being stuck inside for 3 months. The Coordinator has provided support when I needed and helped sort important issues, this service has given me a lifeline. Excellent service thank you.” (Rural Alliance PCN)


“The knowledgeable, beneficial and extremely helpful approach shown to us by the Wellbeing Coordinator has been extremely helpful. We feel more able to continue our independence thanks to Primary Care Cheshire.” (Chester South PCN)



“The Wellbeing Service gave me somewhere to express how I was feeling and to signpost me to help that I needed.” (Chester East PCN)

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