Commissioning Social Prescribing in West Hertfordshire Paul O’Hare, Community Navigator Manager Dr Marie-Anne Essam, GP & Clinical Lead on Social Prescribing, Herts Valleys CCG

Determinants of Health Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute Health behaviours 30% (smoking 10%, diet/exercise 10%, alcohol 5%, poor sexual health 5%) Socio-Economic factors 40% (education 10%, employment 10%, income 10%, family/social support 5%, community safety 5%) Built Environment 10% (environmental quality 5%, built environment 5%) Clinical interventions 20% (access to care 10%, quality of care 10%)

Original Commissioning Approach Clinical and stakeholder ownership of the model and champions (not ideological but real world) Partnership with vol. sec commissioners (HCC) Influencing commissioners where services don’t exist but are needed Pragmatic integration (blurring of boundaries) to engage key local players in managing service Commitment not do other people’s jobs (and partners need to hear this) – added value not duplication Key role of navigator to (re-)engage people with their communities and ‘normal’ networks

Everyone has a GP Obvious place to promote social interventions to support clinical outcomes But they need help to find non-clinical solutions! And they only have ten minutes!

We kind of knew this… CAB research (ComRes survey 1,002 GPs 2015) GPs: 19% face to face time on non-clinical issues Cost to NHS c£400 million a year 49%: saw value (understanding communities) 29%: job satisfaction 80%: less time for other patients’ health needs Top three: relationships (92%); housing (77%); work/unemployment (76%) 31%: could advise patients adequately themselves

Some Integration Issues can be solved by navigator/voluntary sector Home Truths Survey 2013… Stakeholder group Perceptions of other services Priorities/ incentives Home Truths insight GPs Adult social care Poor relationship Low trust Referrals Slow, unresponsive Social care providers Anecdotal stories of poor quality home care Respite difficult to access No additional workload Do not wish to take on further responsibilities as they are already stretched Reduce work for GPs – home visits, “frequent fliers” Enabling self management of long term conditions Simple and speedy referral systems Feedback on the outcomes of referrals Clarity on service offers GPs have poor knowledge of local provision, even when the information is available in their surgeries. Clear communications First line of ASC comms to GPs should make clear how the issue affects GPs and how it can help them and their patients ASC to have regular presence at GP forums LMC, locality meetings TARGET and other training days

Integration Issues Home Truths Survey 2013 Stakeholder group Perceptions of other services Priorities/ incentives Home Truths insight Social workers GPs Inappropriate referrals Unrealistic/ inappropriate expectations Social care Anecdotal stories of poor quality home care Respite difficult to access Reduction in powers to refer have slowed system down Acute care Hospital discharge need to improve Enabling self directed support Managing demand for social care Supporting more older adults in the community Better early intervention and signposting Improved carer support Increased awareness of limitations of ASC - FACS and chargeable services Demand for more responsive services, working to GP surgery timetable An early intervention offer from social care is developing Greater involvement of frontline workers/managers in strategic decisions and service development

Stage One: From 2010 - Access to an Expert Triage of Community Services 30,000+ contacts per year now 12,000 entries on highly developed (and tested) database Much easier to market the voluntary sector Key plank in HCC response to Care Act Useful for seasonal campaigns eg, Keep Warm Stay Well Role in discharge team at Watford General Hospital Identifying carers etc But many people can’t/won’t ring (or refer!) 0300 123 4044

Stage Two: Community Navigator Scheme (commenced Nov 2014) Scheme Manager HVCCG/HCC Community Navigator Dacorum Relief Navigator Support Officer Community Navigator Hertsmere Community Navigator St Albans and Harpenden Three Rivers Watford Frequent Attenders Community Navigator* Stage Two: Community Navigator Scheme (commenced Nov 2014) Community Navigator Parkfield MC *Outreach via algorithm, NOT by referrals

How the scheme works… Not sure how to address presenting needs GP Social Care Other Not sure how to address presenting needs Community Navigator Voluntary Sector Other ‘universal’ services’ Referral back to statutory services if needed

Role on Multi-Specialist Teams Link voluntary sector into the process – ‘step up’ or ‘step down’ Improves potential for prevention/self care/resilience Often involved because statutory sector creates crisis through non-integration New Community Resilience Forum – trying to build networks and relationships

What we have learnt as commissioners Value front line experience (GP, volorg, social care) even if academic evidence not yet there Investment is clearly yielding value and savings and building resilience – now need to persuade federations to support cost of expansion? Provides the basis for a strategic, integrated voluntary sector response to prevention And a response integrated with the statutory sector (but constantly need to bring people along)

The Need to Scale Up Delivery Current Situation: Reactive GP, SW and other professionals referring Service User/patient rings Herts Help Depends on client/gatekeeper to see the ‘issue’ …however, with Herts Help and Community Navigators, we have a fantastic infrastructure to build on and become…

More proactive Involve volunteers for ‘low level’ navigation Staying in Touch calls and volunteer visits Risk stratification of the ‘pre-vulnerable’ 75+ - not waiting for them to ‘hit the system’ Developing the response to people discharged from hospital Look for more engagement with the community to work on ABCD More support to the voluntary sector