How Social Welfare Legal Advice And Social Prescribing Can Work .

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How Social Welfare Legal Advice and Social Prescribingcan work collaboratively in healthcare settings1

ContentsIntroduction . 3Acknowledgements . 4Executive Summary . 5Recommendations . 6Methodology . 9A note on terminology . 9The Case for Change . 11The Impact of COVID-19 . 12Models of operation . 14Findings . 17Funding. 17Management . 21Referral pathways . 22Onward referrals . 30Location . 30Working protocols and data sharing . 32Delivery methods . 36Relationships . 37Training . 42Scaling up . 45Conclusions . 46Appendices . 47Appendix A: Interview guide . 47Appendix B: Participating organisations . 482021Bromley by Bow InsightsBromley by Bow Centrewww.bbbc.org.ukinsights@bbbc.org.ukThe Bromley by Bow Centre is a charity, registered in England andWales no. 1041653 and Company Limited by Guarantee no. 29428402

IntroductionOver the past 15 years, social prescribing has steadily established itself as a crucial component ofprimary and social care settings, initially as very much a bottom-up, locally developed movement, andmore recently being adopted as national policy and rolled out. This mainstreaming has been cementedby NHS England’s decision to fund link workers as part of its commitment to widening the range ofskills and specialisms within each Primary Care Network (PCN), with a commitment to 1,000 in post byMarch 2021, rising to 5,500 over the following three years1. Whilst models of social prescribingschemes and its adoption within PCNs varies, the vast majority had at least one link worker in post byJuly 2020, and in August NHS England launched a scheme to incentivise the rapid recruitment of thenext 500 link workers.However, alongside this, there is concern that this commitment to universal access to socialprescribing as part of the NHS model, with funding for social prescribing schemes and link workerroles, but without consideration of the capacity of and connection with the crucial services that theyrefer into risks jeopardising the endeavour. Social welfare legal advice is one of the most prominentamongst the types of services that social prescribing refers onto meaning that the interconnectionbetween the two services is critical to the effective operation of social prescribing and theachievement of its intentions. Despite this, and although the issues it aims to resolve are oftenconsidered foundational within need hierarchies, social welfare legal advice has rarely been givencentral prominence in the discourse around social prescribing2.Social welfare legal advice services predate social prescribing and have a well-established sense ofidentity, with a growing number of these services offered within a healthcare setting in recent yearsand a growing evidence base of the benefits of this kind of working. Citizens Advice reports that itslocal services operate within 600 primary care settings. Benefits are considered to include reachingpeople earlier, addressing the social determinants of health for the most vulnerable who inevitablytend to access more healthcare and capitalising on referrals from trusted intermediaries.Despite this, the presence and operations of social welfare legal advice within healthcare settingsvaries significantly and there remains an absence of a defined model of best practice for how this canfunction and crucially, how it can interact and intersect with social prescribing services, ensuring asmooth journey for those being referred.In addition, whilst commitment to social prescribing, with resources to match, is increasinglybecoming reality, funding levels for social welfare legal advice have seen no corresponding rise,despite external factors such as welfare reform, increasing online migration of welfare systems andnow hardship caused by the COVID-19 pandemic point to continuing rises in the level and urgency ofneed. While there are no reliable figures available, it is estimated that only approximately 10 - 15 percent of GP practices currently host social welfare legal advice sessions. This sits a long way below theuniversal access to social prescribing which is now part of the NHS model of care and fundingsettlement for link workers within Primary Care Networks. More broadly, the Advice Services Alliance(ASA) estimate a funding gap of at least 13 million per year in the sector in London with more thanhalf of advice providers experiencing a reduction in funding levels over the past three years ial-prescribing/Genn, H. (2019) “When Law is Good for Your Health: Mitigating the Social Determinants of Health throughAccess to Justice” Current Legal Problems 72 (1) pp. 182 – 183.Available at: 522?guestAccessKey d8713ace-acad-4b018d1e-662209632ba43Advice Services Alliance (2020) Advising Londoners: An evaluation of the provision of social welfare adviceacross London. Available at: https://asauk.org.uk/projects/23

There is emerging evidence that where social prescribing schemes and social welfare legal advice docoexist within healthcare settings (most often in primary care) there is ample potential forcollaboration, increased efficiency and improved health and wider life outcomes for those accessingservices. However, there is also a risk that without sustained efforts to connect these services up atboth a strategic policy level and an operational one, they risk operating separately, having a mismatchin capacity levels and even competing for referrals meaning that this potential can go unfulfilled. Withthe onset of COVID-19, even greater challenges have emerged in relation to how joined up workingcan be effective when much of it is conducted remotely.This report, commissioned by the Mayor of London and The Legal Education Foundation, aims toexplore the ways in which well-integrated social prescribing and social welfare legal advice serviceprovision can be supported at all levels, with consideration of the roles of all stakeholders acrossLondon to make this happen. In order to understand this, interviews have been conducted withstakeholders in London and across the country, including clinicians, link workers, welfare advisers,project managers, commissioners and representative bodies, as well as utilising the Bromley by BowCentre’s experience as a pioneer of social prescribing services as well as a long-time social welfarelegal advice agency.AcknowledgementsThis study was undertaken in 2019 and 2020 by Jo Goodman, Sara Thomas and Ellie Pointing ofBromley by Bow Insights at the Bromley by Bow Centre. We would like to express our heartfelt thanksto the Mayor of London and The Legal Education Foundation for their support which made this reportpossible.We’d also like to thank all those organisations and individuals who gave their time to contribute bybeing interviewed or providing thoughts and ideas which have contributed to this report. The Advice Services AllianceAdvice UKOur colleagues from advice and social prescribing at the Bromley by Bow Centre and ourclinical colleagues at the Bromley by Bow Health PartnershipNational Citizens Advice, as well as Citizens Advice Bexley, Liverpool, Tower Hamlets, WalthamForest and WandsworthDundee City CouncilLiverpool Clinical Commissioning GroupGreater Manchester Health and Social Care PartnershipNHS Health ScotlandNHS Scotland ImprovementNorth Islington Primary Care NetworkScottish Public Health NetworkUCL Centre for Access to Justice4

Executive SummaryWith social prescribing link workers now firmly in position as part of multi-disciplinary teams atprimary care level as well as in some secondary and tertiary care settings, the lack of clarity on the roleof social welfare legal advice and where provision of timely, high quality advice fits into the biggerpicture is thrown into stark relief. As one of the primary onward referral destination routes for socialprescribing, and one that is critical to addressing the social determinants of health, it is vital thatprovision of social welfare legal advice has sufficient capacity and is well-integrated into both abroadened out understanding of care and clinical care pathways. The ongoing risks to health andeconomic uncertainty brought about by the COVID-19 pandemic makes this work more urgent thanever.This report aims to address the relationship between social welfare legal advice and social prescribingand how the two services can work together to address the needs of patients in London. Byinterviewing 17 professionals from across the advice and health policy and delivery landscape, wehave built a picture of current delivery and areas for development.Currently, the provision of social welfare legal advice in healthcare settings across London is patchyand due to uncertainty around funding and the separation in set-up arrangements between theservices, collaboration and joined-up working between advice and social prescribing services can befairly limited even where they operate in the same space, meaning some of the benefits of joined-upworking fail to be realised. There is much that could be done to address the current situation in termsof both policy improvements and practical support to encourage greater interconnection of servicesand a more joined-up experience for patients.At a policy level, consideration should be given to how the funding and status of social welfare legaladvice can be elevated and integrated into wider health and wellbeing agendas. This could involvebroadening the definition of care and working with partners at multiple levels including Health andWellbeing Boards and Integrated Care Systems. Sustainable funding must be a high priority andambitious aspirations around universal access to social welfare legal advice could form a core pillar ofLondon’s recovery from the COVID-19 pandemic. This consideration is particularly important at thisjuncture if we are to reduce the deepening of inequality and health inequality that is likely to happenover the next months and years.On a practical level, there are a number of things that could be provided to support joined-up deliveryon the ground including guidance and templates to support data sharing, training packages to improvemutual understanding between services and clinicians and support to develop appropriate referralpathways. These should balance the need to maintain a high level of quality in services but allow forlocal differentiation according to need and preferred ways of working.It is our aspiration that this report sets out a clear path for how the Mayor of London and partnerscould lead the way in taking further important steps in developing a population health approach thataddresses the needs of Londoners, and particularly creates a safety net for those who are mostdisadvantaged. By ensuring that high-quality, well-integrated support is available to address the socialdeterminants of health and utilising existing health pathways and community assets, universal accessto the services which help to secure a decent standard of living will be within reach for Londoners.5

RecommendationsThe position of social welfare legal advice and its role in London’s recovery The Mayor of London and partners should position social welfare legal advice as a core pillarof London’s recovery from the COVID-19 pandemic, with a core focus on ensuring adequatefunding and practical support for advice agencies to ensure ongoing viability. This should beintegrated into the work of the London Recovery Board around ensuring access to rights andentitlements and minimising hardship.An urgent review should take place looking at the risks of exclusion from services for the mostvulnerable including support needed by local and BAME-specific advice agencies and toolsneeded to make remote services more accessible for those who are digitally excluded or speakEnglish as a second language. This should also incorporate the role of healthcare agencies andsocial prescribing in ensuring the most vulnerable can be identified and referred as neededduring times of limited in person engagement.Funding Available funding should be targeted with due consideration of varying levels of deprivationand existing provision across the capital.Consideration should be given as to how funding can be drawn in to supplement NHS Englandfunding for link workers and enable an adequate level of social welfare legal advice services tomeet onward referral demand. This may involve roundtable events bringing in a range offunding stakeholders.The role of Health and Wellbeing Boards in ensuring adequate social welfare legal adviceprovision should be considered, including how this can be encouraged and potentially turnedinto a statutory duty.If funders are forthcoming, it may be wise to consider piloting multiple models of operation inthe initial period as this is still a relatively new area of delivery.Management A toolkit of guidance for managers should be produced to set out the core components ofmanagement of social welfare legal advice in a healthcare setting, along with guidance forsocial prescribing managers on effective service integration with social welfare legal advice.Consider incorporating an ‘embedding phase’ with possible additional management support inplans for new programmes.Referrals Partners should consider exploring ways of establishing automatic referral reminders withinpatient data management systems to trigger clinician referrals to social welfare legal adviceand social prescribing. This could initially be trialled with a small number of conditions toassess its effectiveness and the time implications for both clinicians and auxiliary services.Alongside this, broader routine screening questions for patients aimed at triggering socialwelfare legal advice referrals could be piloted to assess the impact on referral numbers andpatient health and wellbeing.6

A referral pathway quality framework should be established which provides key componentswhich should be present in any approach, while allowing for flexibility of approach. Theframework should incorporate expectations for:o How clinicians and other practice staff should identify need and refer onwards.o The journey for the client including where signposting is appropriate and where a fullreferral is needed, and differentiation in pathways for different types of issue tominimise risk of client dropout.o How appointments should be booked, with encouragement to use the same system asthe practice for full integration.o Turnaround of referrals, particularly for urgent social welfare legal advice demando How social welfare legal advisers and link workers should identify need for the otherservice and refer onwards.o Mapping of onward referral partners, particularly for specialist areas of advice.Location The management toolkit should incorporate guidance on how to maximise the benefits of colocation including through promotional activities and visibility in the practice, while alsomaintaining discretion for clients attending social welfare legal advice appointments to reducestigma.Guidance should be provided to health practices on what facilities are needed for socialprescribing and social welfare legal advice to be effectively delivered within the practicepremises.Consider engaging with NHS Property Services to negotiate for charges to be waived for adviceservices operating in practices.Working protocols and data sharing Provide model working protocols and data sharing policies and templates for adaptation byservices.Incorporate data protection issues into training for all parties.Undertake research with patients to understand their feelings around data sharing and howthis should be approached.Ensure guidance encourages regular review and service improvement feedback loops so thatlearning can be acted upon to refine processes.Consider piloting a single case management system approach (with appropriate dataprotection measures in place) to assess whether this is beneficial to the work of all parties.Delivery methods Work collaboratively with health stakeholders and patients to assess the range of apps whichalready exist to provide guidance to those on particular health pathways and consider gapsboth in content of existing apps and in the range of apps available.Provide a range of good practice case studies of alternative delivery methods e.g. volunteerled, remote online delivery and digital sessions.7

Relationships Incorporate the building of relationships into training for link workers and social welfare legaladvisers who will be working in healthcare settings as well as guidance for scheme managers,with separate focus on how to build relationships with different stakeholders e.g. practicemanagers, clinicians, reception and administration staff.In collaboration with the Practice Managers’ Association, consider how best to reach thisimportant group of staff members in order to raise the level of understanding of the valuesocial prescribing and social welfare legal advice to their practice and its operations.In guidance to schemes encourage actions which are likely to foster good workingrelationships including:o Information on how to initiate positive relationships with key staff members.o Encouragement for frontline staff to attend practice meetings.o Encouragement for consistency in staffing within practices.o Where possible ensuring that social welfare advisers and link workers are on site atthe same time and /have regular opportunities to check in with one another.Training Develop a standard package of training in conjunction with partners such as Advice UK, theAdvice Services Alliance, NHS England, the Royal College of GPs and Health Education Englandwith separate modules for:o Link workers, to incorporate basic knowledge of social welfare legal advice, how tospot issues, role boundaries and how to prepare a client for an advice appointment.o Social welfare legal advisers, to include understanding primary care, patient datamanagement systems and the role of link workers.o Clinical staff, covering the role of link workers and social welfare legal advisers, theissues they can support patients with and how they can support their role, as well ashow to work with clinical pathway referral systems and act as ‘problem noticers’. Thiscould also be incorporated into medical student training.o Practice managers, reception/telephony and administrative staff, to increaseunderstanding of the value of auxiliary services and how they can support theirpractice and its operations, as well as the support they need to function well.Provide support for this training to be delivered locally including through Health EducationEngland Training Hubs and incorporating involvement of local partners including the RCGP’slocal faculties, to enable training to also play a role in building effective local partnershipworking.Scaling up Ensure that frontline workers, service managers and service users are engaged in plans forscaling up and that multiple stakeholders are brought together to share learning withdecision-makers.Balance the need for standard levels of service with allowances for local flexibility based onwhat works best for those on the ground.Consideration should be given as to whether a new definition of care should be developed,which incorporates the right to support to ensure that a threshold of living conditions is met.As a first step, this could encompass universal access to social welfare legal advice, includingwhere necessary specialist legal advice. This would need to be delivered and overseen atborough and Integrated Care System levels.8

MethodologyThis research utilised snowball sampling to undertake interviews with commissioners, social welfarelegal advice services (individual providers and provider networks), healthcare managers andprofessionals (in both primary and secondary care), social prescribing scheme managers and linkworkers. As largely social prescribing and social welfare legal advice services co-exist in primary ratherthan secondary or tertiary care, there is a greater focus on this within the report, though relevantsecondary care examples are referenced where possible.In total 20 interviews were conducted, transcribed and coded, and thematic analysis was employed tounderstand key themes emerging from the interviews. The interview guide can be found in theAppendices along with a table of organisations from whom representatives were interviewed.In addition, there has been some secondary analysis of research reports and evaluations of schemes,as well as policy papers to generate a deeper understanding of the challenges and opportunities in thisarea. The Bromley by Bow Centre team involved in the creation of this report have also drawn on theorganisation’s long history of delivering both social prescribing and social welfare legal advice servicesin Tower Hamlets, East London.Research was primarily conducted prior to the onset of the COVID-19 pandemic which necessarilyinfluences the focus of the report. A limited number of additional interviews were conducted a fewmonths into the pandemic to gain as much understanding as possible as to how this was affectingservice delivery and any anticipation of ongoing changes in operations. As this was conducted after aninitial draft of the report was completed, the consideration of this impact has been somewhat limited.A note on terminologyWho is using and delivering the service?While clinicians and those in primary care tend to use ‘patient’ to refer to the individual they aresupporting, link workers and welfare advisers often use the term ‘client’. In addition, there is alsovariation in whether social prescribing professionals are referred to as ‘social prescribers’ or ‘linkworkers’. For the purposes of this report, we will be using the term link worker for social prescribingstaff members, while client will be used in relation to people accessing social prescribing and socialwelfare legal advice services and patient for those accessing health services.What do we mean by social prescribing and social welfare legal advice?Social PrescribingThe National Social Prescribing Network states that social prescribing “involves empoweringindividuals to improve their health and wellbeing and social welfare by connecting them to nonmedical and community support services”.It is a way for healthcare services (at present usually primary care) to refer people to a link workerwho is trained to use a holistic approach to support people’s health and wellbeing (in its broadestsense), by giving people time to focus on ‘what matters to me’. They then connect people tocommunity groups and statutory services for practical and emotional support.9

There is growing evidence that this: Improves individuals’ wellbeing and health outcomes, by tackling the wider determinants ofhealth, both immediate presenting issues and those of a longer-term nature (Institute forHealth and Human Development, 2017) 4.Increases people’s levels of understanding of the issues they face and how to resolve themand can increase levels of activation and self-efficacy (Elston et al., 2019)5.Supports community development and local partnership working (Dayson & Bashir, 2014)6Provides a cost saving to the NHS by reducing demand in primary care and A&E services(Polley & Pilkington, 2017)7Social Welfare Legal AdviceSocial welfare legal advice refers to the provision of advice predominantly relating to welfare benefits,debt and housing, though which may extend to energy advice, family, employment, education,immigration and consumer law. Individual services may provide advice in relation to clients’ rights in arange of these areas as well as onward referrals to services providing specialist support for differentareas or more complex cases. Within this report, when referring to social welfare legal advice services,it is in relation to organisations which have achieved independent accreditation (in either England8 orScotland9) that have demonstrated that they are easily accessible, effectively managed and employqualified staff with the skills and knowledge to meet the needs of their clients. Advice may also extendto legal representation, for example at tribunals, and may incorporate pro bono work by legal firms.4Institute for Health and Human Development (2017) The Social Prescribing service in the London Borough ofWaltham Forest final evaluation report. Available 866 The Social Prescribing service in the London Borough of Waltham Forest final evaluation report5Elston et al. (2019) Does a social prescribing 'holistic' link-worker for older people with complex, multimorbidityimprove well-being and frailty and reduce health and social care use and costs? A 12-month before-and-afterevaluation. Available at: https://pubmed.ncbi.nlm.nih.gov/31547895/6Centre for Regional Economic and Social Research (2014) The social and economic impact of the RotherhamSocial Prescribing Pilot Main Evaluation Report. Available Polley, M.J. and Pilkington, K. (2017) A Review of the Evidence Assessing the Impact of A review of the evidenceassessing impact of social prescribing on healthcare demand and cost implications.Available at: d-advice-partners/10

The Case for ChangeOver the past 15 years, there has been growing recognition of the benefits of social welfare legaladvice being co-located in healthcare settings, utilising the value of healthcare workers as trustedintermediaries10 to ensure legal matters across a wide range of areas of law are advised on andaddressed, and that clients are able to access their full benefit entitlement. This advice helps toimprove people’s social determinants of health (e.g. income, housing, employment etc) leading torelatively immediate improvements in short-term mental health and well-being, reducing financialstrain and generating considerable financial returns (Woodhead, Khondoker, Lomas & Raine, 2017) 11.Resolution of issues can involve navigating complex statutory systems and entitlements (includingaround health and disability related support, housing, employment and family law) to advocate forrights which are not always clear to those without access to information and so access to advice helpsto level the playing field for the most vulnerable.Example from practice: With seed funding from St George’s Hospital Charity, Citizens AdviceWandsworth established a social welfare legal advice service for patients who have experiencedmajor trauma and their families in 2015. The service has been found to

The position of social welfare legal advice and its role in London's recovery The Mayor of London and partners should position social welfare legal advice as a core pillar of Londons recovery from the OVID-19 pandemic, with a core focus on ensuring adequate funding and practical support for advice agencies to ensure ongoing viability.

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