Fig. 1.

Diagram 1: Team vision map. This concept map was created to identify the “team vision” emerging from the 6 core stakeholder interviews. It identifies the target areas of the pilot scheme as: loneliness and isolation; frequent attenders at GP practices; health inequalities; poorly managed diseases; high cost to NHS and social services, all of which pivot around people with low agency. The findings from this first part of the study were presented at a meeting of stakeholders including GPs and practice managers for feedback and also formed part of the Phase 1 interim report