Shared learning database

Type and Title of Submission


Enthusiasm for life: creative stimulation and behaviour change for older people and others


Upstream trained mentors work with GPs, health and social care professionals and communities to identify older, more isolated (socially, psychologically, physically, financially) and often depressed people, and to engage them in stimulating, creative and social activities that increase self-confidence and independence. Mentors visit referrals to assess needs, overcome barriers and agree individually tailored programmes (c.12 weeks) that help people join existing community activities or encourage them to participate in small, informal Upstream activity groups close to home, where they can share experience and skills (from felt-making to circle dancing to reminiscence), engage in collaborative and intergenerational projects, be motivated to continue activities independently, and build supportive relationships within their communities. The project is continuously evaluated by the Peninsula Medical School and the service is currently being disseminated throughout Devon.


Public Health

Does the submission relate to the general implementation of all NICE guidance?


Does the submission relate to the implementation of a specific piece of NICE guidance?


Full title of NICE guidance:

PH6 - Behaviour change at population, community and individual levels

Category(s) that most closely reflects the nature of the submission:

Implementation policy

Is the submission industry-sponsored in any way?


Description of submission


To tackle isolation and depression among older people by developing, implementing, evaluating, promoting and widely disseminating a successful preventative service, in partnership with statutory and voluntary sector organisations, that changes people's behaviour in order to prolong active life, improve the quality of life, build independence and self-reliance, encourage people to take control of their own health within a community context, and be a cost-effective response to the ageing demographic challenge.


1. Individual and social change: To work in partnership with participants and communities to motivate people to remain healthy and independent and able to stay in their own homes for longer, with greater social connectivity, taking responsibility for their own health, with fewer visits to their GP and fewer inappropriate hospital admissions, reduced medication and reduced costs. 2. Local delivery change: To ensure that the service responds to changing health and social care priorities and to influence GPs and health and social care professionals to adopt the service as part of mainstream or commissioned provision; and to ensure that third sector representatives are accepted as part of the professional primary health care team to deliver health and well-being in the community. 3. Evaluation and wider influence on practice and policy change: To ensure rigorous independent evaluation of the service and to use the results to disseminate the lessons learned from the service to influence practice and policy nationally.


1. The project was initiated by a local GP in Mid Devon who recognised that many older people were coming into his surgery who actually needed some other kind of intervention close to home that would revive their interest and enthusiasm for life, motivate them to look after themselves better and reconnect with friends and community. Health professionals could patch people up with medication and clinical intervention but could not necessarily give them the will to live. 2. Working with other GPs and arts professionals, in discussion with the Primary Care Trust, Social Services, District Council and Voluntary sector, the project was planned for the use of stimulating, creative, learning, leisure and social activities for people who were isolated and considered 'at risk' by professionals, communities and themselves. This proposal was built on local and national priorities, including the National Strategic Framework for Older People, Modernising Social Services, Wanless Reports, Our Health. Our Care, Our Say, WHO Reports on Active Ageing and more. 3. With the help of the District Council, a Community Consultation took place and the subsequent Report played an important role in shaping the service. There was a preliminary 6-month Pilot Project with participants and a pilot report by the Peninsula Medical School. 4. The project won initial funding from the National Lottery's Healthy Living Centre programme for community-based health interventions and equality of opportunity in disadvantaged areas. 5. Throughout the project, close links have been maintained with the statutory authorities and local voluntary organisations, through a Steering Group and through continuous work with front-line staff (including GPs) to ensure that the project adapts to changing local and national priorities, and links to NHS reorganisation, practice-based commissioning, etc. Participants themselves have shaped the content and approach of the project throughout.


1. Individual and social change: Upstream has worked with more than 900 people in Mid Devon, approx 50% referred by GPs and health and social care professionals and 50% by community, families, friends and self-referrals. The PMS evaluation indicates psychological and social benefits, health behaviour and health benefits, and transformational change. Qualitative comments from professionals, mentors and participants reinforce the evidence (see attached quotes). 2. Local delivery change: GPs and health and social care professionals are changing their own behaviour as they see how the Upstream approach contributes to their work, especially after Upstream mentors joined health professional Reablement Teams. Through POPP funding in Devon, the voluntary sector is now represented on ALL Complex Care Teams, and a consortium of voluntary sector organisations, including Upstream, have been commissioned to deliver 'Community mentoring' Devon-wide. 3. Evaluation and wider influence on practice and policy change (see also 'monitoring and evaluation' below): Upstream has been used by the Department of Health as an example of good practice in a promotional DVD. It became one of the first DH Social Enterprise Pathfinders, and an NHS Live Leader. Case studies on Upstream are published by the I&DEA Newsletter, NHS Live, and the International Longevity Centre (Unlocking the Community). A development of Upstream's Manual on Community mentoring is published on Devon County Council's website. Upstream has made presentations at national and regional conferences, including Age Concern England, Culture South West, NHS Live, NIACE, South West Observatory, and Sport England; and Upstream has shared learning with several PCTS and Councils, Sheffield Hallam University, and the City of Edinburgh.

Results and evaluation

Built into the aims of Upstream was an initial 3-year evaluation by the Peninsula Medical School (PMS) published in the Journal of the Royal Society of Health (JRSH 2006; 126(3):134-142) Greaves & Farbus: 'Effects of creative and social activity on the health and well-being of socially isolated older people: outcomes from a multi-method observational study'. This used SF12 and GDS questionnaires for participants at baseline and after 6 and 12 months, and interviews with participants, outreach mentors and health professionals. The results show the benefits from the Upstream service. PMS are continuing their evaluation as the mentoring project is rolled out across Devon under the Department of Health 'Partnerships for Older People Projects' (POPP). The extended evaluation is based on a multi-site controlled approach looking at both effectivenesss and cost-effectiveness. Regular monitoring has also been undertaken through Annual Reports to the Big Lottery Fund on the original 5-year programme, followed by monthly reports, case studies and customer satisfaction surveys for the subsequent Link Age Plus (Department of Work & Pensions) and POPP projects. Upstream continuously consults with participants on the content and shape of the service. Participants themselves decide what activities they would like to do. For customer satisfaction surveys and some other questionnaires, Upstream uses 'consultation conversations', encouraging discussion within normal group activities that involve people at everyday accessible grassroots level. The Upstream approach is inclusive and produces genuine representational responses.

Key learning points

Positive points: 1. The key to success is motivation and self-confidence, having a good reason to want to stay healthy. Many people are unlikely to take better care of their health simply because they are told its good for them. Whatever their problems or age, people are capable of undergoing remarkable changes, learn new things, take new interest in life, enthuse each other, and find life worth living. 2. The Upstream approach of individual and group mentoring, people taking responsibility for their own health behaviour, and independent sustainability within local communities, is relevant to a wide range of health and social care issues, including obesity, falls prevention, intergenerational work, community safety, even teenage pregnancy. 3. Well-being is a balance of good physical, mental and social health. Large co-operative projects play a valuable part in social integration, whilst benefits of the project to individuals is multiplied by benefits to families and communities. Warning notes: 1. The third sector needs to show evidence of effectiveness and quality of performance if government priorities for contracting service delivery are to be fulfilled but, at the same time, health professionals, managers and policy makers need to make a leap of faith and overcome traditional suspicion of the third sector. 2. Community mentors are trained professionals and must be costed accordingly. High quality will not be achieved if it is assumed that the third sector is always a cheap option. However, mentors will be able to save costs by relieving primary care of inappropriate and high-cost interventions and by saving hospital admissions and reducing hospital stays. 3. PCT and local authority commissioning procedures are in many cases not yet fully developed; nor is GP practice-based commissioning. If initiatives like Upstream are to deliver the necessary services, commissioning needs to catch up with the changes.

This submission was shortlisted for the 2008 Shared Learning Award.

View the supporting material

Contact Details

Name:Simon Goodenough
Job Title:Director
Address:Glebe House, Church Street
Postcode:EX17 2AQ
Phone:01363 777575


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This page was last updated: 28 September 2008

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Selected, reliable information for health and social care in one place

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.