Hertfordshire and West Essex Sustainability and Transformation Plan

A Healthier Future Hertfordshire & West Essex

Sustainability & Transformation Plan

Embedding Social Prescribing in

Tim AnfilogoffHead of Community Resilience

Herts Valleys CCG

1. Why SP?2. The STP’s direction of travel on SP3. The Vision4. The Assets5. The Gaps6. Our Plans7. Evaluation

20% of GP face to face time spent on social issues

Case Example: IAPT couldn’t work with her (too chaotic). Link worker persisted: found debt, imminent eviction, not paying bills, benefits stopped…

Client: ‘Once the threat of eviction [was] removed…I felt a weight had lifted and I could now concentrate on me and on tackling the depression… I still feel that I have something to give and ultimately I want to get back into work and I would like to look at volunteering as a way of doing this…’’

SP workstream within Prevention Programme Working group chaired by DPH (HCC) Model for SP work agreed in outline Build on existing work across footprint Link to national evidence of best models and

practice Clinical ambassador appointed Focus on risks to voluntary sector providers -

need to address systemically

1. Chapter 2 FYFV – including Carers as part of prevention work (NHSE First Wave STP Carers)

2. Community First – Herts CC and CCGs integrated approach to low level/preventive support, IAG, harnessing communities

3. Essex CC and W Essex CCG working on Community mobilisation, patient/user activation, shared IAG and self-care [Community Support Network]

4. Transformation requires focus on system and integration (between and within sectors)

and clarity of offer

Social prescribing infrastructure◦ Increasingly integrated triage through HertsHelp

and West Essex Care Navigation Individual SP schemes in place◦ Community Navigators (W Herts)◦ Carers’ Champions (Herts, primary and acute)◦ Hospital Discharge Support Service (Age UK, Herts) ◦ Smart Life (West Essex)◦ Community Agents (West Essex)◦ Lifestyle Service (West Essex)

Wide range of ‘prescriptions’ in community

New resource from HMG for social care (£2bn nationally)

STP strategic framework helps capitalise (£450k of new monies in Herts for SP)

Chance to test and evaluate at scale

HertsHelp Offer Web – Hertshelp.net Text – HertsHelp to 81025 Email – info@hertshelp.net Skype - HertsHelp Minicom on 0300 456 2364 Fax 0300 456 2365 Telephone 0300 1234 044 or Text HertsHelp to 81025 Face to Face advice – arrange on 0300 1234 044 Advocacy – via professional referral Communication Toolkit - BSL, Makaton, Braille Service

0300 1234 044

Herts Help contacts Feb 2017

Total contacts to Gateway 1,781People with LTCs 350Carers identified 80Referrals from Primary Care 122Discreet agencies referred on to 130

Herts Valleys Community Navigator Scheme…

GP Social Care Other

Community NavigatorScheme

Other ‘universal’ services’Voluntary Sector

Referral back to statutory services if

needed

Client needs face to face visit/support (motivation, confidence, explanation, ‘hand-holding’)

Referral pathway (West Essex) • Email WestEssexCareNavigation@nhs.net• Tel 0300 303 9988• Via Frontline

Refer to WestEssexCareNavigation Partnership

• Triage will ascertain a persons need and then navigate to; Smart Life, Community Agents, Essex Lifestyle Service or Other

Referral will be triaged and navigated to the

right service

• Each service will provide their service and support person to improve health and social well being

Intervention provided by relevant service

• Service will assess if needs are still being met and provide additional support if needed.

6 and 12 month follow up

Role in IntegrationCommunity Navigator Scheme, April 2016 – Feb 2017

• 1,978 referrals • 52% from GP surgeries• 24% from Social Care• 7% from Herts Help (ie needed face to face

support)• Also: volorgs, mh services, neighbourhood

policing, rapid response, housing, Community NHS Trust….

• NB Navigator role on Multi-Specialty Teams

5. Gaps• SP not yet at scale

and ‘patchy’ • ‘Prescriptions’ under

pressure* • Networks ‘broken’ • Hard to prioritise

time and resource for developing networks

• Funding for voluntary sector

*(though SP ‘brokers’ help create solutions)

6. Plans• Preserve what is best • Whole system design –

integrating prescribing and prescriptions

• Ensure SP and Carers’ Agenda fully linked

• Focus relentlessly on:– Prevent health being

permanently compromised– Reduce ‘burden’ on primary

care (and other stakeholders)Engage community and voluntary sector in design

SP not the ‘only kid on the block’

• Brokerage, Health Coaching, Self Care, Self Management, Peer Mentoring, Health Trainers…etc - SP crucial part of a system

• Collaborative Partnership launch in W Essex, April 2017 – lack of collectivism previously key stumbling block (interim Essex evaluation)

• Integration is the key to:– Maximising Value– Sharing the benefits and the challenges– Making sense to busy GPs and the public– Engaging communities

Elements for a successful SP strategy

• Outreach/case-finding/lower level ‘risk stratification’ (eg addressing loneliness before it causes pathology) – eg Safe and Well model

• Reacting positively (SP and MECC etc)

• Asset based community development

• Supporting the engaged citizen

• Promoting and upscaling volunteering

Maximising impact• Integrating commissioning: Promoting SP’s role

across voluntary and statutory sector systems • Integrating access (and the network) with

HertsHelp (Herts) and W Essex Care Navigation Partnership and piloting outreach/risk stratification

• Building volunteer SP support in primary care, Timebanking etc (adds value to SP infrastructure)

• Build/encourage/support local ‘community resilience forums’

7. Evaluation

• Local qualitative evaluations (eg Graduate Trainee dissertation)

• PH to develop evaluation models for SP at scale

• Linking systems to track outcomes across the system (from prevention into acute) – West Essex

Evaluation, reporting and KPI’s(West Essex – report due June 2017)

Clients supported from a health source:• Number of enquiries (incoming referrals) • New Cases• Activities and referrals• Case close high level outcomes (client still living at

home, client outcomes achieved, improved quality of life)• Case close frequency of GP visits and A&E visits• Follow up (6 &12 months) same high level outcomes plus

receiving further help, frequency of GP visits and A&E visits

Contact Details

• Tim Anfilogoff (HVCCG) tim.anfilogoff@hertsvalleysccg.nhs.uk

• Piers Simey (HCC PH)piers.simey@hertfordshire.gov.uk

• Kirsty O’Callaghan (W Essex CCG)k.o'callaghan@nhs.net

• Krishna Ramkhelawon (ECC PH) Krishna.Ramkhelawon2@essex.gov.uk

• Ruth Harrington (HCC CWB)ruth.harrington@hertfordshire.gov.uk