Social Prescribing In Hertfordshire

Social Prescribing inHertfordshireConnecting Peoplefor Health and WellbeingTim AnfilogoffDr Marie-Anne EssamPaul O’Hare

What problems were we trying tosolve? 2011 HertsHelp commissioned – to improveinformation and advice (quality and accessibility) 2014 HertsHelp wanting ‘local face’– ‘Reverse care law’ (most accessible to people with leastneed)– GPs wanting ‘fixers’ to reduce pressure– Commissioners wanting more integration(Better Care Fund)– Public Health commissioning local arts andexercise pilots– Carers’ champions in primary care

20% of GP face toFace time spent onnon-medical issues NHS small playerin determininghealth NB: We didn’t knowlanguage of SP –but we were doingit 3

How big is formal care?

How does carer health compare togeneral population? 2 x as likely to suffer poor health (NHS Plan 2019) 7 x as lonely -carers-suffering-loneliness-epidemic/ Carers (aged 25 – 34) 2 x as likely to have severe or extremeanxiety/ depression; carers (45 – 54) 2 x as likely to be inpain/ discomfort (National GP Survey 2018) Strained carers more likely to die than non-carers 23% risk of stroke in spousal carers experiencing strain Self-identified health problems (HVCCG primary care survey,2016): musculoskeletal (53%) stress (41%) depression (35%) Caring linked to risk of depressive and anxiety disorders andsuicidal ideation independent of other life stressors

Association of Directors of AdultsSocial Services

Engaging the Voluntary Sector Build on HertsHelp infrastructure Navigators will not do anyone else’s job They would support and co-ordinae, engaging thecommunity - and ‘experts’ if needed 4 West Herts events to discuss model (April 2014) 4 local events across West Herts (June 2014) Following engagement published specificationand invited bids (July 2014) First cases, November 2014

So how did it work?HertsHelp Offer Web – Hertshelp.netText – HertsHelp to 81025Email – info@hertshelp.netSkype - HertsHelp0300 1234 044Minicom on 0300 456 2364Fax 0300 456 2365Telephone 0300 1234 044 or Text HertsHelp to 81025Face to Face advice – arrange on 0300 1234 044Advocacy – via professional referralCommunication Toolkit - BSL, Makaton, Braille Service

Scheme (as at September 2016)Scheme NavigatorSt Albans tfordThree RiversProjects andfrequent attendernavigatorRelief NavigatorHertsmerenavigatorSinglepractice pilot

The Good News (Hertfordshire) There is support out there It is getting easier to findwww.hertsdirect.org 3,662 contacts per month In September 2018 triaged people to 149 differentorganisations Community Navigators provide HertsHelpinformation face to face to people who need moresupport/motivation (nudge?)

Role in IntegrationCommunity Navigator Scheme, April 2016 – Feb 2017 1,978 referrals52% from GP surgeries24% from Social Care7% from HertsHelp (ie clear they need face toface support) Also: voluntaries, housing services,neighbourhood policing, rapid response,Community NHS Trust . NB Navigator role on Multi-Specialty Teams

Joining the National Debate Presented to RCGP conference (October 2015)on community navigators – met with SPNetwork Joined national SP Steering Group January 2016 Highly Commended, HSJ Awards (CommunityHealth Services Redesign) 2016 High Sheriff’s Award (Partnership Working),2017

http://westminsterresearch.wmin.ac.uk/19629/

Evaluation DataA review of the evidence assessingimpact of social prescribing onhealthcare demand and costimplicationsPolley, M., Bertotti, M., Kimberlee, R., Pilkington, K., and Refsum, C.http://westminsterresearch.wmin.ac.uk/19629/

Integrating and Forming theHospital and Community NavigationService (HCNS)A County-wide Hospital Discharge &Social Prescribing Service

What is the service? Funded by Herts County Council, East and North CCG andHerts Valleys CCG Integration of three pre-existing services– Home and Hospital Support– Community Navigators– Herts Help in the Home Being delivered in partnership by seven voluntary sectororganisations Service to work with 750 - 1000 service users per month

Challenges & Solutions Joint commissioningForming a new partnership - TrustStaff Buy-In – Change ManagementStructure - Forming locality Teams/Matrix managementSpreading the message - Comms3 Referral Routes – HertsHelp/Urgent3 Systems & 3 way Reporting – shared systemKey – Joined up Vision, shared values, clear operatingmodels

Presence Hospital Based TeamsCommunity Navigator clinics in GP surgeriesCommunity Navigator clinics for social work teamsMental Health ProjectsMST’S. MDT’sHealth & Wellbeing Board MeetingsHousingBuilding on community partnerships

Scheme as at May 2019PartnershipBoardSeniorManagementTeamWest AreaManagerMary-Ann LindsayWestAdministratorAlex HallLocality ManagerDacorumVacantNavigator FTENaomiNavigator FTEDebbieNavigator FTEBryonyNavigator FTELyndaLocality ManagerWatford & 3RFarahMahmoodNavigator FTEStephen WEast AreaManagerMatt CharlesLocality ManagerSt Albans &HertsmereZoe ColeNavigator FTEKim CarrollNavigator FTERachelHaglandNavigator FTENavigator FTEDeniseRobinsonNavigator FTENavigator (2days)Sam RossNavigator (4days)AdrianKerry O’DellLouise DormerNavigator FTEKaren WrightNavigator FTEEastAdministratorKirsty GriffinLocality ManagerStev & NHKatie FarrellNavigator FTEGinny BrownNavigator FTESam BruceNavigator FTELisa MardleNavigator FTENicola ReintjesNavigator (FTE)AlisonVacantNavigator (3days)Sarah SalesNavigator (3days)AnjaliNavigator (3days)HarmeshBhundalNavigator (3days)ChristineNavigator (2.5days)Rachel OtiNavigator (3days)JanetNavigator (2days)KathleenBaileyNavigator FTEVacantLocality ManagerWel/Hat & LLVAngela SmithNavigator FTEFiona BrownLocality ManagerULV & SVVYvette LaffoleyNavigator FTEHelene EvansNavigator FTEAlisonColemanNavigator FTENavigator FTETheresaCastiglioneNavigator FTESylvia HallGopalee PatelNavigator (4days)Louise CaseyNavigator (4days)Simon MarlowNavigator (3days)Jose GarciaNavigator (2days)Keelie CiceroNavigator (2days)VacantNavigator (2days)Claire SmithNavigator (3days)DebbieLawrence

The NHS Plan Part of ‘personalisation’ agenda 1,000 new (and ‘additional’) SP workers for England,funded at 100% for 5 years One per Primary Care Network (exist from mid May) Plan (in partnership with LA and volsec) led by CCGmust be in place by end June Money on stream from 1 July BMA and NHSE agree: ‘Emerging practice suggeststhat many networks may choose to fund a localvoluntary sector organisation to employ the linkworkers and run the service of behalf of the network.”

HVCCG Strategy March spoke at target events with GPs about NHSESummary Guide and our intentions April engagements (x 2) with Voluntary Sector (60 volorgs attended) May wrote to PCNs with offer of strategic support As at 23 June 13/16 PCNs interested in working withvolorgs as hosts of their LWs (only one definitely ‘going italone’) Volorgs applying to take part by end June Meanwhile, STP has adopted a vision and the Hospitaland Community Navigator scheme has designed newoperating model which allows full integration

NO WRONG DOORHolistic Face to FaceLink Worker Social Prescribing(Community Navigators)Light to Medium SP(Supported signposting, volunteersocial prescribing, complex end ofHertsHelp telephone service)Signposting (Active Signposting in primarycare, direct access to HertsHelp,HertsDirect, Libraries, voluntary groups,District Council front of house - for thosewho can manage themselves)Skilled Triage

Can’t besignpostedAble to besignposted?Senior eReferralAll providers of holistic SPshould apply the same basiccriteria here when meetingTriage for(apparent)complexitySignpost toservicesAllocate to holisticsocial prescribingWorkermakes plan withclientLiaison with referringGP/SW ongoing with clientconsent and whereappropriatePCN staff to their LINKWORKERAllocate tolight/medium briefintervention etcWhere level of complexityis reviewed workers mayprioritise the relationshipwith client - and getadditional support andsupervision if needed - orwhere appropriate passclient to different levelDelivers plan/reviews/ceasesundeliverable planClose case/pass batonFollow up at sixmonthsClear ‘closure’ process. Whowill ‘keep eye’ on ‘vulnerable’clients; who client gets back intouch with etc

Scheme Manager. HVCCG/HCC. Community Navigator . Dacorum. Relief Navigator Community Navigator . St Albans and Harpenden. Hertsmere navigator Single practice pilot. Community . Three Rivers. Community Navigator . Watford. Projects and frequent attender navigator. Scheme (as at September 2016)