Rhondda GP Cluster Wellbeing Coordinator

Evaluation Report

April – December 2017

Contents

1. Overview

2. Findings

3. Evaluation

4. Discussion

Appendices

1. Case Studies

2. Testimonials

1. Overview ‘Social Prescribing’ in the Rhondda Valleys. Social prescribing, sometimes referred to as community referral, is a means of enabling GPs, nurses and other primary care professionals to refer people to a range of local, non-clinical services. Recognising that people’s health is determined primarily by a range of social, economic and environmental factors, social prescribing seeks to address people’s needs in a holistic way. It also aims to support individuals to take greater control of their own health. Social prescribing can involve a variety of activities, which are typically provided by voluntary and community sector organisations. Examples include; volunteering, benefits advice, arts activities, gardening, debt advice, health & wellbeing courses, befriending schemes and local community social groups. Those who could benefit from social prescribing include people with mild or long-term mental health problems, vulnerable groups, people who are socially isolated, and those who frequently attend primary health care. In 2017, the Rhondda GP cluster invested in a ‘Social Prescribing’ project, which included the employment of the Rhondda GP Cluster Wellbeing Coordinator, Lucy Foster.

Lucy commenced her employment in April 2017, her role is to better connect primary care with a range of services available across the community and public sectors and in so doing, ensure that individuals gain access to the support they need to overcome the social determinants that impact on their health and well-being, tackle the underlying causes of ill health and promote self-help. Lucy works with referred patients to address their needs through identifying their interests and supporting them to access community activities, facilities and services.

There is a significant emphasis on supporting patients and finding out what matters to them followed by matching their interests and needs with what is available within their community. Lucy provides support and assistance to patients for non-medical issues such as debt management, welfare advice and housing problems along with issues of social isolation and loneliness, all of which may have a significance impact on a patient’s health and wellbeing. By identifying community solutions and connecting patients to provision in the voluntary sector can reduce the number of GP visits and/or impact on the appropriateness of the appointment. The post is hosted by the county voluntary council for RCT (Interlink), who act as an umbrella organisation for over 500 community and voluntary members. Lucy has unlimited access to Interlink members who are an invaluable resource in terms of services, activities, advice and groups. This added value to the post gives Lucy greater knowledge and understanding of voluntary sector and community provision available for patients. Examples include, camera clubs, knitting groups, women’s institute and a whole plethora of services and activities that’s hidden in our communities. In addition Interlink hosts Community coordinator posts for older people. Lucy benefits from access to their knowledge and experience There are additional outcomes to this post; 1.Grow Rhondda: Lucy currently coordinates referrals from GP’s to the new Project led by Men’s sheds where by gardening activities in Ysbyty George Thomas are on offer for those aged 18 and over who are socially isolated and have mild mental health problems. This is another fantastic opportunity in which Lucy can refer the clients she sees, but also gives this post an extra arm. Lucy is supporting the referral process by screening all referrals and ensuring the patients who are referred would benefit from the project activities, are ready to engage in these activities and that they meet the agreed referral criteria. 2.Create Your Space: Create your space is a Big Lottery funded project ran by Welcome to Our Woods. This project covers four GP surgeries in the area. They have gained just over £2 million in order to empower and provide better opportunities for community members. They invited Lucy to sit on the operational group as health and wellbeing and social prescribing is part of its plan. This way all activities and projects set up would meet the needs identified by Lucy through her consultations with patients. Overall, the role of the GP wellbeing coordinator has had a positive effect. Results show that patients are engaging in services, are better informed and feel valued. We are pleased with its progress and success in such a short space of operation.

2. Findings Referral information Below is a table of the referral data collated from the following quarters. QTR 1: April – June 17 QTR 2: July – September 17 QTR 3: October – December 17

2017

QTR 1 QTR 2 QTR 3 TOTAL

Total number of referrals

63 86 111 260

Number attending consultation

14 19 26 59

Number resolved solely by telephone intervention

44 53 62 159

Did not attend

2 7 13 22

Did not engage

3 7 10 20

Number of queries from other Organisations e.g. CMHT, Communities first, local groups.

13 22 38 73

Number of onward referrals made

75 116 179 370

Number Of Signposts made 92 88 134 314

A total of 260 patients were referred and either seen via a face-to-face appointment or contacted by telephone. All patients were given the choice to visit the coordinator at their preferred surgery or engage by telephone. The number of telephone consultations is higher than face-to-face appointments with 61% of patients opting for telephone appointments. Feedback from patients reveals a number of reasons for this:

Not having the time to attend the surgery

Not being able to afford travel expenses to attend the surgery

Patients are housebound

Requiring support immediately therefore cannot wait for the next surgery rota slot.

Prefer to discuss issues via phone and be directed for help the same day

Feel able to open up more via telephone

No embarrassment getting emotional during appointment In the nine months’ operation of the project, 370 onward referrals were made into community services and voluntary agencies, with some patients requiring as many as 10 referrals to different agencies. A total of 314 signposts to community activities were made, some patients receiving more than one signpost. The patients who ‘did not attend’ (8%) where due to illness, these patients were offered the choice to re - book the appointment or have a telephone consultation. The patients who ‘did not engage’ were due to illness, both mental and physical. Some patients stated that they were unwell or did not feel ready to discuss problems and engage with others. We learned that 7% of patients returned to the service mainly by self-referral or the administration team. These are included in the numbers shown above as they were in need of help for a different reason. This shows that the patients found the service helpful and knew where to turn, therefore not needing a GP appointment. The number of enquiries from other organisations has increased every quarter. Many of the queries are regarding information on local activities and advice on local services. Enquiries have been received from the Mental Health Primary Care team, Communities First engagement workers, Social services and business support staff at surgeries. The service is being recognised and utilised by other agencies working with patients.

Reason for referral The primary reason for patient referral was recorded for the operating time of April – December and is shown in the pie chart below.

It is noted however, that the primary reason for referral often masked other issues. Some of the patients accessing the service are vulnerable with complex lives, looking for someone to support them to tackle their presenting need and also underlying needs, which were identified through gentle, supportive conversation with the Coordinator. It is through a reciprocal conversation that underlying needs are identified; the underpinning question is ‘what matters to you?’ the Coordinator uses this approach to explore what the patient really wants to work on and the outcomes they wish to achieve. The outcomes they want are co-produced and patients are supported to understand how they can take action to achieve them. The patient experience is empowering and supportive which is borne out by the feedback patients have given.

Other issues identified apart from primary reason for referral:

7%

11%

7%

5%

22%8%

3%

8%

2%

6%

4%

5%

6%

6%

Debt concerns Benefit advice/appeals

Property maintinance Support aids at home

Mental Health Learning difficulties

Chronic illnes including cancer Transport Issues

Harassment Loneliness

Disabilities Homelessness

Carers Employment

There are now 13 GP practices throughout the Rhondda Valleys, and the map above demonstrates how the practices are positioned throughout the two valleys that make up Rhondda. Due to constraints of room availability within the practices, it was not possible to site the Co-ordinator in every practice, and so it was decided that the Co-ordinator would be sited in 7 of the practices on a fortnightly rota basis. A dedicated email address was set up for the co-ordinator so that referrals could be received irrespective of where the co-ordinator is working on the day that the referral was made. Once the referral is received, the co-ordinator contacts the patient and through discussion with the patient, agrees the most appropriate surgery for the patient to attend, or the needs of the patient are discussed over the telephone. Below is a chart illustrating the number of referrals received from practices in the Rhondda. The chart also states how many referrals came from the GPs themselves, business support staff at the surgery and other referrals that came in from Pharmacy, Nurses, other professionals and the patients themselves.

Referrals from GP Practices:

Referral beakdown including other professionals:

Pharmacy Testimonial:

My name is Irram Irshad and I am a Cluster Pharmacist, employed by Cwm Taf University Health

Board, working in Primary Care. I am based in three GP surgeries: Cwm Gwyrdd Medical Centre in

Gilfach Goch, St Andrews Surgery in Tonypandy and New Tynewydd Surgery in Treherbert.

I hold medication review clinics in all of my practices and the majority of patients I see are elderly

with multiple chronic disease conditions. These patients are often depressed, living alone with

little/no family or support in the area and are frequently isolated. As a clinician it is often difficult

for me to know who to contact to help these patients, previously I would have to make referrals to

Social Services. This has not been the case since Lucy Foster joined our area as the GP Wellbeing

Community Coordinator. Not to put too fine a point upon it, she has, quite frankly, been a lifesaver

for me and my colleagues.

Not a single week goes by where I’m not referring patients to Lucy and from the feedback I have

received, the patients are engaging with the service she is providing to them. I had the privilege of

observing Lucy when she came into one of my clinics in Cwm Gwyrdd to speak to a patient who had

significant issues with depression and bereavement. I was very impressed with Lucy and quite

grateful that she was able to help. It is so easy to send her an email and receive a quick response. I

then don’t have to worry about those patients, as I know they will receive an excellent service.

I sincerely hope that Lucy’s post will not only be renewed, but made permanent, and I would

recommend increasing her team, as there are so many patients who require this type of service, that

over time demand will only increase. I really would struggle in my role without the ongoing support

from Lucy, and ultimately it would be the patients who miss out.

Kind regards Miss Irram Irshad, MRPharmS, IP, SP,Cluster Pharmacist, CTUHB

Outward referrals A Total of 370 onward referrals have been made by the wellbeing coordinator for the period of April – 18th December 2017. The referral is requested from each organisation, some asking for emails with some basic details about the patient yet most agencies require more detailed forms to be submitted. The forms requiring completion by the coordinator are time consuming , and sometimes patients may require or more interventions. There are certain criteria to meet, therefore the Coordinator takes the time to explain in great detail how the patient meets that criteria, add all relevant contact details including family members and other agencies working with the individual.

Outward referrals made April – Dec 2017:

Signposting As well as referrals to agencies a total of 314 signposts were made to a plethora of community support groups and community activities. The difference between a referral and signpost is the fact that no form or criteria is required.

Survey Results Three separate evaluation surveys were disseminated in November and December 2017. One to patients, one t practice staff and the other to service providers.

1. Patients Survey: for patients who have engaged in the service from April to June 2017. In order to get a true reflection of the impact of the service, we felt it would be best to ask all patients from quarter one to complete a survey that was provided by post. That way we could determine if the support offered has a lasting effect on each patient. A total of 45 surveys were sent out and 31 were returned. (69%)

2. Practice Staff Survey: This was conducted via survey monkey in order to capture the impact of the service from the perspective of all practice staff including; Managers, GP’s, Nurses and business support.

3. Provider Survey: This was conducted via survey monkey. It was sent to all agencies, organisations and services that the wellbeing coordinator had referred or signposted to from the time of operation April – December 2017.

Patient survey results

1. How would you rate the information you received?

Very Good: 90%

Good: 10%

2. How would you rate the support you received?

Very Good: 71%

Good: 29 %

3. What has been most helpful about this service for you?

The variety of activities signposted to

The friendliness of coordinator

The one to one support

The coordinator herself

The information provided

The referrals made helped me better my life

Someone who listens

Someone who promises to help and delivers

4.Would you use this service again in the future?

Yes: 87% No: 13%

5.Have you found the service useful?

Yes: 93% No: 7%

6. Have you accessed any of the activities, groups or services suggested to you?

Yes: 91%

No: 9%

If YES, how did they help you in your day-to-day living?

Made new friends

Reduced social isolation

Improved confidence

Helped with stress

Felt like I was not alone

Made me feel happier

Learned new things

If NO, can you say why?

Didn’t feel like taking part due to ill health

Was too anxious

Was afraid to try something new

Wasn’t the correct time for me

The days were unsuitable

7. What difference did using the GP Wellbeing Coordinator make to you?

Put me in touch with the right people

Just having someone to listen to me made a difference

Helped lift my spirits

Referred me to people I never knew existed

Sourced the professional help needed

Put me on the best course

Got me out of the house

Stopped me from self-harming

Put an end to my loneliness

Helped my confidence within the GP practice

Made me realise these a light at the end of the tunnel

I now feel valued

8. Can you think of any positive changes that have happened in your life since

using the GP Wellbeing Coordinator service?

Gave me something to wake up for

Stopped my antidepressants

Changed my outlook on my GP surgery

New found confidence

Raised self esteem

Improved health

Improved mental illness

Improved anxiety attacks

Increased knowledge of support available

Better relationships

Links with community

Now have found the meaning of community spirit

I’ve got a new job

I’m claiming the correct benefits

I have had help to appeal my PIP claim

I have won my appeal for correct benefits

I have a warmer home thanks to your referral

I’m no longer homeless

I have a care package that fits my needs

I now have respite

Finally have a social worker

9. Working with the GP Wellbeing Coordinator has made me feel better -

Strongly Agree: 92% Agree: 7%

10. If we could improve the GP Wellbeing service experience for people, what

would you like to see happen?

Make it a permanent service at my practice

No changes needed

It’s fantastic as it is

Mainstream this service please

Any further comments:

My family are forever in your debt as the support you provided helped us a great

deal

I will never forget what you have done for me as long as I live

I don’t think people who fund you realise just how much you do for people

Thank you for listening

Very thorough service

Brilliant communication

Brilliant support and advice

Amazing service

I never knew all those services were out there until you came along

Practice Survey results

Q5. How has the service been beneficial for your patients?

It has provided a direct referral pathway to help with social problems.

Not sure as not used.

Gave them hope that there is more help available beyond our surgery.

Providing locally based support + advice.

Very beneficial, quicker access to services from an understanding professional, better than not being able to get through to Social Services for hours on end.

In signposting useful organisations to help with social support/financial worries/referrals to expert patient programme.

I think this service is good for patients.

Not used the service.

Has been useful in providing financial information and help to fix boilers etc. finding areas in community that can support them.

Has helped some of our patients.

Very useful in enhancing their social aspirations.

Not been fed back to me so no idea.

Not sure. Referred 1 pt directly. Not sure how many picked up from the waiting room.

Patient have someone who has time who can listen and signpost which ordinary services dont cover.

Helped the patient access community activities.

Q6. How has the service been beneficial to you/your practice?

Having the ability to refer directly to one individual who acts on the referrals quickly, efficiently and provides information on what has been done.

Shown our patients that we are supportive and can meet their needs not just for their physical health but their overall wellbeing.

Aid to DE medicalising problems

It has saved me time and her knowledge of what organisations are out there to support people is up to date so more resources available.

It gives us an extra option to offer the patient then just doctor.

Not used the service

Very easy service to refer into. pts can self refer, so admin team can direct pt to the community coordinator.

We feel we can do more to help our patients by being able to offer them this service.

not sure. not had any formal feedback/statistics.

signposted patients to appropriate help and advice thereby freeing up GP appts.

I feel I can offer help to those with more social issues / i feel it probably has helped with my frequent attenders.

promote social prescribing and a named resource.

not sure re benefit but has involved the admin team also to refer, taking on much more of a holistic culture.

Extra help and support who can meet the needs of our patients.

Saved me a lot of time when I should be focussing on medication reviews and clinical aspects of care. Also gives me piece of mind that the patient is receiving the support they need in all aspects of their life.

Q7. What impact has the service had on patient consultations?

It has provided the clinicians with a "one stop shop" referral path with regards to social issues.

Not used the service.

Not sure, that is difficult to measure but it doesn't really matter does it? The answer is simple its having an impact on people's lives. that will eventually stop them from coming to the see the Gp for social reasons. the only way we can tell is if we keep the service going. that way it becomes part of primary care and our practice and in time everyone will know how to access Lucy. 8 months is not enough to tell.

Difficult to say if has any impact on demand but it is useful to have a service that you can direct or refer a patient to when other factors are affecting patient's wellbeing.

Patients are engaging with the service; it is improving their quality of life.

Another tool to manage troublesome social issues.

Unfortunately, not a great uptake

Positive impact being able to talk to patients about this service.

I feel it is a great option to discuss in management plans and has possibly reduced my consulting rate with certain patients.

not sure. not been able to measure.

It doesn’t feel like it has.

The patient has not returned in over 3 months.

Offers an additional avenue to go down, easy to explore options of finding groups etc that pt could attend. we would not have the time to find out up to date community information. Make the consultation easier and quicker.

Q8. Do you have any comments on the value of the service or recommendations for improvements?

We have received numerous verbal positive feedback from patients who have felt that this service has benefitted them.

Lucy does feedback, either via email or face to face but maybe it would be an idea to access patients notes so that it's logged with further detail? Just a thought? Overall i love it!.

I work in 3 surgeries, Cwm Gwyrdd, St Andrews and New Tynewydd and the Wellbeing Co-Ordinator assigned to these practices has been a very valuable resource.

I think it is working very well and Lucy seems very eager to help patients.

keep the service going and make any improvements will help the patients

More interaction needed with patients sat in waiting room

I would value its continuation; I think we would need to run it for longer to come up with the final model best suited for primary care

I think it has become a important part of the services we can offer to help address the wellbeing of our patients in the broadest sense. I feel this is a very valuable service and has an important role within the PC team

would not consider continuing if had to self-fund due to small numbers using the service.

I am now more likely to refer to community coordinator whether they are cluster funded or not.

Brilliant service, would be lost without it!

Provider survey results

Summery: Results show the impact it has had since the time of operation. The overall consensus states that the service is of added value to each practice, providers have had greater uptake and patients have stated they feel listened to and supported. However, not everyone has accessed the service to date. Every new project takes time and we believe that it is still early days.

3. Evaluation

Two practices from the Rhondda Cluster area were chosen for evaluating the impact of having the Rhondda Cluster Wellbeing Co-ordinator attached to the practice. These two practices were selected, as they were the practices who referred the most patients to the Rhondda Well Being co-ordinator during the period April 2017 - September 2017. A total of 144 patients for the whole of the Rhondda cluster were referred to the Rhondda Cluster Well-Being Co-ordinator during this period of time. A total of 49 patients (34%), were referred from these two practices during this time period. The records of 47 patients (32%) were reviewed. Two patients were excluded due to them being unidentifiable.

There were 21 patients referred in April, May and June 2016, which allowed a review

period of all practice contacts recorded on the practice clinical system of 6 months

before referral and 6 months after referral to the Well Being Co-ordinator .

There were 8 patients referred in July that allowed a review period of all contacts

with the practice recorded on the clinical system for 5 months before referral to the

Wellbeing Co-ordinator and the 5 months after referral.

9 patients were referred in August allowing a review of the clinical records for the

period of 4 months prior to referral and 4 months after referral to the Wellbeing co-

ordinator.

And the remaining 9 patients were referred in September which allowed a review of

all contacts recorded on the practice clinical system of 3 months prior to referral and

3 month after referral.

Although patients can self-refer into the service or be referred by any member of the primary healthcare team from within the practice or by health professionals external to the practice e.g. optometrist, all of the patients reviewed had been referred to the well-being co-ordinator by a GP. There was no data recorded on the patients’ clinical record to indicate referral to the well-being co-ordinator by any other member of the primary healthcare team, although information recorded by the co-ordinator does indicate that there have been referrals made by other professionals. For the period 1st October 16 to 31st March 17 of the 21 patients reviewed the combined total number of contacts for both practices was 92. For the period 1st April 17 to 30th September 17 the total number of combined contacts for the same patients was 65. For one of the practices I was able to identify if the patient made contact with the practice prior to seeing the well-being co-ordinator for a general health problem e.g. stomach pain or for an issue that was effecting their mental health e.g. debt, loneliness etc. In total there were 27 contacts made for general health problems and 34 contacts made for other issues affecting the patients’ health. In the 6 month period following referral to the Wellbeing Co-ordinator 39 contacts were for general health queries and 13 contacts were for other health problems.

For the period of 1st March 16 to 31st July 17 for the 8 patients reviewed the combined total number of contacts for both practices was 28. For the period 1st August to 21st December 17 the total number of combined contacts for the same patients was 31. In the one practice in which I was able to split the reason for consultations, 3 consultations prior to the referral were for social issues affecting their health and there were no consultations for this reason in the following 5 months, however the number of consultations for general health issues did increase from 5 to 8. During the period 1st May 17 to 31st August 17 the total combined number of contacts with the practices for the 9 patients identified was 39, with 5 contacts identified as being for social issues. In the 4 month period following referral to the Well-being co-ordinator the total number of contacts for the same patients for both practices is 28, with 3 being for social issues. And finally in the 3 month period 1st July 17 to 30 Sept 17 There were 15 patient contacts in total for both practices with 2 being identified as relating to social issues and 27 contacts over the following 3 month period with 7 contacts being identified as relating to social issues. The total number of contacts for both practices regardless of the presenting complaint for the periods detailed above prior to seeing the wellbeing co-ordinator is 174 with the total number of contacts made after seeing the wellbeing co-ordinator being 151.

With regard to the patients identified as presenting with a complaint that was linked to a social issue in the one practice in which these patients could be identified, prior to seeing the well-being co-ordinator they contacted the practice 49 times during the whole time period of the evaluation and 23 times after. Whilst they attended 36 times for a general health issue prior to being referred to the co-ordinator and 51 times for general health issues after.

4. Discussion Identifying Gaps in services Within this period of operation (April – December) a number of gaps have been identified:

Lack of befriending services for the under 50.

Lack of Mental Health peer support groups within the upper Rhondda Fawr, Mid Rhondda Fawr and lower Rhondda Fach.

No Cancer Support group in Rhondda (nearest is in Mountain Ash).

Lack of support groups offering help during the initial stages of bereavement.

Lack of information on Social Care Services

Building community capacity is not an aim of the service at the point of delivery. However, the Coordinator is employed by Interlink, the County Voluntary Council for RCT, which is connected to a variety of strategic platforms in health and social care and in community development. The Coordinator is therefore able to feed in information regarding needs that are not currently being met. Further work is needed to ensure that this information gets to the right place and to translate the identification of needs into activities that meet them.

Partnership working: Wellbeing coordinator made extra time to take part in the following –

Presentations to partners promoting the service

Attending PPG meetings

Writing press releases

Hosting Coffee and cake information mornings

Links with local PCSO’s have been made

Primary Care Mental Health The local support worker from the CMHT contacts the wellbeing coordinator on a weekly basis, asking for information on local groups and activities. This post has proven to be of great help to other orginisations and a point of call for individuals wanting to access support for their clients. Some of their clients are referred onto the coordinator, as their time is due to end. Others require information regarding courses, support groups and activities therefor the coordinator passes on the relevant information and records all queries for reporting.

Private & confidential

Primary Care Mental Health Support Service RE: Interlink wellbeing co-ordinator. I am a support worker based within the Primary Care Mental Health Support Service for Rhondda Cynon Taff. Part of the work I do is signposting individuals to third sector support throughout this area. Being able to contact the co-ordinators and ask for advice about what is available and appropriate for the individuals I work with has been an invaluable resource and I use this service often to assist the people of the area. Lucy Foster and Karen Powell along with other members of Interlink have been extremely helpful and is often a first port of call for myself and other members of my team. Yours sincerely Emma Lambert

Primary Care Mental Health Support worker

Appendices 1. Case Studies 1. Background: Mr P was referred to me via the practice nurse in June where I helped improve his loneliness and isolation through activities in the local community. He currently resides in a sheltered housing complex for the elderly and being only 48 years old this was getting him down. I had helped with a housing application in order to move to Powys as he only has friends in that area but sadly, nothing came of it. Although he was actively engaging in the coaching programme led by communities first his housing situation was getting worse. His belongings from India where he had lived for 6 years had been delivered and this caused great stress, as his flat is too small to accommodate everything. Staring at the four walls in an extremely dark room surrounded by boxes had a vast impact on his mental health. Suffering with a brain injury affects his confidence in asking for help and yet again did not know where to turn. He also needs help complete forms. Mr P then self-referred to me for further support. Intervention: On visiting me at the surgery Mr P had explained that he was grateful for the support I had previously shown him and believed only I would be able to help, as he has no family or support network in this area. RCT Housing had advised him that in order to be

able to register for new accommodation he would need written consent from his current housing association. Every time he asked his housing manager for this he was dismissed and told, “Your lucky to have a roof over your head! You won’t get a house with RCT so you may as well stay here!” I therefore contacted RCT housing for advice, put in a referral to supporting people in order to help Mr. P with his application and provide him with a support worker. I also contacted the housing manager to explain the issues and difficulties we were having. I listed the actions needed to move forward and he agreed to co-operate in order to help Mr. P’s wellbeing. I then liaised with him by dealing with his requests such as sending letters of support written by myself, His GP and mentor from Communities First. How this made a difference: Written consent was finally given after weeks of communication. Mr P is now on the housing register and I have been able to collate numerous letters of support to help with his application. Having someone to coordinate this whole process has benefitted Mr. P and he now sees a light at the end of the tunnel. Supporting people have begun working with him also, meaning Mr P does not feel so alone. His mental health is improving and he has begun volunteering. Patient Feedback: “You are so kind; I don’t know how I could have coped without you. The thought of having to live there for another 6 months until I didn’t need written permission to leave was killing me. Now there’s hope. Since moving to wales you are the only one who’s had the time for me. Thank you.” 2. Background: Mrs T was referred by her GP who booked her an appointment to see me.

She was suffering from stress and anxiety and explained that her husband was sectioned

and taken to the Mental Health unit at the RGH that week. Seeing this woman so

distressed I comforted her as best as I could and listened to her for over 45 minutes. She

stated that her husband had suffered with Cancer for some time and that she was his main

carer. He had recently been acting strange hearing voices and becoming paranoid and had

attempted to leave her. This new bout of stress and anxiety prompted me to think of Mind

and the Active Monitoring scheme.

Intervention: Knowing that she is a carer I referred her to the carers support network and asked for counselling ASAP. Having someone to talk to at this difficult time was a high priority, as she had no family or friends in the area. I also referred her to the mind practitioner. The carer’s project got in touch to say there is a waiting list of up to 6 weeks, therefore I signposted Mrs T to Rowan tree cancer support. They were able to offer her free transport to counselling sessions, which are run in Mountain Ash due to her caring for her husband with Cancer. Mrs T visited the Mind practitioner but unfortunately did not find this helpful. She gave feedback on this service, which I acted upon appropriately. I continued to call Mrs T every week in order to check that the counselling was helping and to see whether she needed further support. I provided information on Social services before closing the case.

How this has made a difference: Mrs T found engaging with the wellbeing coordinator of

great help. Although one of the referrals didn’t work well, it goes to show that not all

services will be appropriate. The counselling sessions offered by Rowan tree were a great

success helping Mrs T to talk though all anxieties she was faced with. Her husband has

now begun home visits weekly and Mrs T feels stronger to deal with his return now a

variety of things have been put in place.

Patient Feedback: “Your work is so thorough; I wish all services were like this”.

“Thank you for taking the time to contact all the people who have helped. I could not have

done this in my frame of mind. Every time I spoke to someone, I cried. You’ll never know

how much this means to me.”

3. Background: Mrs W emailed me asking for support. She had been given a leaflet by the admin team at her surgery. She explained in her email that her daughter who is 16 years of age is currently suffering from seizers and isn’t having any support from her comprehensive school. She had 23 seizers in one week on the school yard and was left on the cold floor. Mrs W was off work with stress and was looking after her daughter who was not attending school. She needed advice on accessing further education elsewhere and asked for counselling to enable her daughter to open up about any anxieties triggering the seizers at school. She did not know where to start. Intervention: I contacted Mrs W to thank her for the email and explained that I was happy to help her and her daughter. I contacted CAHMS to make sure the daughter was known to them, who explained she had a meeting with their psychologist the following week. I then booked her an appointment with a counsellor from Eye to Eye. They currently work in all comprehensive schools in RCT but because the daughter wasn’t in school at the time and may not return, I was able to explain the issues and get her seen out in the community. I provided Mrs W with information on the local Citizen Advice Bureau drop in sessions and SNAP Cymru, who help provide advice on legalities and school policies. Finally, I made enquires to Hen Felin Training centre for people with needs/disabilities, who then contacted Mrs W. How this made a difference: Mrs W has returned to work. She met with the school who are now paying the daughter to study to become a primary school teacher at Hen Felin. She has not had a seizure since and is happy learning at her new setting and sees a counsellor every week. Patient Feedback: “I’m so grateful for your help. You put me in touch with people I didn’t know even existed and it’s a huge relief to me and my family. I’m so lucky to have had a chat to the admin team about my issues that day, that leaflet helped me find you.” 4. Background: Mrs J was referred by the pharmacist. She was housebound without any family following her husband’s passing. Her only friends live in the Bridgend area. She felt very lonely and isolated. Intervention: I spoke with Mrs J on the phone who expressed that no fuss or help was required. She didn’t want to bother anyone and felt that she wasn’t worthy of help. “I’m 80 now love so there’s no hope for me!” she said. I explained my role and the variety of things she could engage with in her community. By planting the seed, she eventually came around to listening to the list of activities on offer. She explained that she used to love arts and crafts and stopped attending due to bereavement. “The main thing I need is someone to talk too,” she said. She was scared to leave the house. I explained that baby steps were needed and I could help build her confidence by putting in a volunteer for companionship, explaining later she may feel better and able to join the local Art class. She agreed.

Therefore, I referred Mrs J to Age Connects Morgannwg Befriending service and she was very pleased. She also asked me to visit her saying “Do you do house calls? Because you have such a caring voice.” I explained unfortunately I only saw patients at the surgery. “Well that is such a shame because if everyone could have a visit from you then their spirits would defiantly be lifted!” How this has made a difference: Mrs J had 6 weeks of support from the befriending service and she now attends the local Art class. Feedback: “I never knew about this service until I spoke to the pharmacist. I didn’t want help or think I even needed help. I only explained how lonely I was and you rang! That one phone call changed everything, thank you!” 5. Background: Mrs E contacted me via phone explaining her GP had presented her with my card. She wanted information on what support was available for her husband who suffers with his mental Health. She was very distressed stating that she was also taking anti-depressants due to her low mood. By talking to Mrs E on the phone for 25 minutes I was able to dig deeper as to why she was so stressed. She wasn’t sleeping, cared for her husband who spent most days asleep due to depression, was off work with stress and had money worries. Intervention: I referred Mrs E to valleys steps who were running a mindfulness session the following week. I had a specialist benefits advisor from the Citizens Advice Bureau visit her home to conduct a benefits check for them both and help apply for the correct benefits. I referred her husband to Social services and the EPP (Expert Patient Programme) sessions on “How to live with chronic depression”. How this has made a difference: Mrs E no longer takes anti-depressants and had attended 3 weeks out of the 6 of the mindfulness course. They both claim the correct benefit and are £72.50 per week better off. Mr E has a social worker and Mrs E has returned to work a happier and less stressed woman. Feedback: “What a brilliant idea this is. Having you in place and a service that can do so much is invaluable” “What a few months it’s been. All the stress has gone now thanks to you and my GP”

2.Testemonials

I have found the role of Lucy Foster to be of great help to our Primary Mental Health Care Services. I have Lucy to be very helpful in letting us know promptly what is available locally for our patients. I feel that she is very approachable and an excellent resource to hand. Bridget Bradwell Primary Mental Health Care Team.

Hello I am pleased to offer a letter of support and recognition of the works and services you have carried out on behalf of Adrienne and her daughter Lisa. I have been a family friend for over thirty years and have been privy to the many difficulties the family have experienced due to ill health issues. I was made aware of the deterioration in the healthcare being provided and general circumstances of the family some three months ago and as such offered my services of help to try to alleviate the pressures, stress and anxiety the family were feeling at the time. I initially tried to establish the medical background and facts concerning the ongoing circumstances. I was finding it extremely difficult and almost impossible to make headway due to the lack of detailed information and the complexities of the medical, emotional and personal situation within the family unit. It was only a when Adrienne casually mentioned that a meeting was arranged with a support worker and a telephone conversation ensued that I became aware of the GP Wellbeing Coordinator Service, namely Lucy Foster, was already engaged with the family welfare. Since that time the family situation has generally improved with a Care Package in situ, and although not fully suitable to the immediate needs of the family, hopefully can be reviewed and upgraded. This would not have been achieved without the services of the GP Wellbeing Coordinator Service provider, and the good work carried out by Lucy Foster, regards Jeff Lewis Social Care Worker.