Stockton Service Navigation Project Welcome, may name is Tom and I have here to raise awareness of the Stockton Service Navigation SSNP is a social prescribing service that aims to increase clients confidence, control and independence, while supporting them to reduce stress and isolation, improving clients quality of life.    We direct clients, based on there interests to a range of activities for example: walking groups creative arts groups exercise classes learning opportunities social group Etc to support individual’s health and well-being. The service also signpost and support clients to access other sources of support such as the Citizens Advice Bureau, education providers, counselling, volunteering opportunities and job clubs  

Service Aims Give Connect Get Active Keep Learning Take notice The service aims to help clients to take small but significant steps which will improve there health and wellbeing and make positive life changes. ​ Connect - With the people around you; your family, friends, colleagues and neighbours. We can help you find a social activity to help make new friendships. Get active - Physical activity makes us feel good. We can help you find an activity that you enjoy & suits your level of fitness; such as an exercise class or walking group. Learn - Learning new skills can give you a sense of achievement and a new confidence. We can help you find a creative arts class or a course which interests you. Give - Whether it's a thank you, a kind word or volunteering your time. Helping others makes you feel good about yourself and we can help you find the right opportunity. Take Notice/Get support - We can help you access the right kind of support such as benefit, debt or fuel poverty advice.

Common Client Themes Loneliness Welfare Reform Depression Low Income Poverty Opportunities Age Personal Barriers Skills/Knowledge Welfare Reform Low Self-Esteem Anxiety Social Isolation Through our work we have found that a significant percentage of SSNP clients are lonely and social isolated Often our clients are impacted by a variety of contributory factors including: low income (poverty), age, limited opportunities, impact of welfare reform. Many clients present with low levels of confidence, self esteem and many suffer with anxiety and depression. Case Study: An example of a client working with SSNP: Originally accessed the service due to isolation and feelings of low self worth. Even though she is a full time carer of her disabled daughter she felt she had nothing for herself, she was on medication for depression but felt this made her worse. Since working with the SSNP she has now stopped taking antidepressant medication, she now participates in numerous health walks, and groups. She is volunteering and sharing her experiences with others in the aim of using her experiences to assist others in making positive life changes. From taking steps and having services in place, she now attends the GP practice less, the expense of medication for her mental health no longer exists and she is using her skills to give back to the community. Low Confidence Depression

Supporting individuals No Wrong Door Approach Provide 1:1 and Group Sessions 4 Appointments per Client Supporting Client’s to Overcome Barriers Flexibility Our service has a No Wrong Door Approach Our clients can self refer or be referred by another service We support between 15-30 clients per navigator either on a 1:1 basis of in a group setting Each client is offered up to 4 appointments, in most instances clients only usually require 2-3 appointments per intervention In some instances clients may need more support to help them over barriers, for example low confidence or anxiety To meet the needs of the clients we provide with the option of meeting with the Navigator at our office or in a suitable location which is mutually agreed upon. For example: cafés, libraries or community venues. We do try to have clients meet us at the office or in a suitable venue as we like to get them out of the house and into the community.

Client Pathway Connect: Referral Follow Up Initial Contact Warwick Edinburgh Mental Well-Being Scale Post Assessment Connect: Social prescriptions co-created and introductions made to providers of community based activities… Aiming to improve the social connectedness of clients to engage, empower and build resilience. Referral Initial Contact Initial Assessment Client Goal Setting Advocacy Support Follow Up The client journey can be broken down into 6 steps. Client can be referred in via a third party or can self refer Client is contacted and the boundaries of the service are outlined to ensure clients expectations are managed with integrity An Initial Holistic Assessment is completed to determine the wider determinants of health Working with the client the navigator encourage the client to set goals and develop a personalised action plan The Navigator will support for clients to access services and make connections with their communities Destination tracking and follow up Warwick Edinburgh Mental Well-Being Scale Pre Assessment

Working within the Local Community Stockton And District Advice and Information Service Job Centres (Billingham, Thornaby & Stockton) GP Surgeries (4 drop-in services established) A Way Out (Refuge for Vulnerable Women) Accent Housing (Social Housing Provider) To facilitate client engagement and sign up we also provide a number of outreach/drop in sessions Stockton And District Advice and Information Service Job Centres; GP Offices; Queens Park Medical Centre & Tennant Street Medical Practice A Way Out Accent Housing

Partnership Working GP’s Job Centre’s VCSE Agencies Community Groups Adult Learning Providers Social Housing Our Staff Team have developed strong working relationships and networks with a number of organisations and groups to facilitate referral into SSNP. This has been achieved via completing an asset mapping assessment in 2017 which identified: Who offered support What at support was available Eligibility criteria The team them worked hard to find ways to close any gaps in support identified, for example; by offering free health and wellbeing programmes for anyone over the age of 16 years of age. The relationships developed by this and over exercises, benefit both our clients and partners, and enables navigators signpost effectively, provide accurate support and advice and facilitate access to local services. We now work with and extensive range of groups and organisations including; Alliance, Mind (Specialist Mental Health Interventions) Badminton Group, Craft courses, Billingham Baptist Church British Red Cross (Volunteering Opportunities) Butterwick Hospice (Bereavement Support and End of Life Care) Citizens Advice Bureau (Welfare , Financial advice and debt management support) Cruse Bereavement, Lifeline (Drug and Alcohol Support) Daisy Chain (Specialist Autism Support) Knitting Groups, Social Activity Groups Adult Learning Providers (Various)

Service Achievements Since the service was established in 2012. Over 2000 clients have been supported by the SSNP Navigator.

Service Achievements in 2017/18 100% Service Satisfaction 89% Increase in Knowledge 100% Service Accessibility 86% Increase in Social Interaction 95% Increase in Confidence £ 337 Clients Supported by 1 Navigator As you can see we have had some significant impacts and the service model also represents value for money. 1 Navigator supported 337 clients in 1 year.

Project Challenges Service Demand (1 WTE Navigator) Employment Opportunities Funding Cuts Barriers to engagement (Health & Social care) Buy in to a Social Prescribing model Communication with NHS Difficulty capturing impact in terms of medical data (prescriptions/appointments) The project has to deal with a number of challenges: The demand for the service is increasing Clients are increasingly struggling to find employment due to what they feel is a lack of opportunities. These leads to client having no confidence or hope. To over come this the project links clients to voluntary and social activities this can assist the client in regaining confidence, learning new skills, and also identify new opportunities, giving back hope. Funding cuts and increased demand on services is hampering health Services. SSNP works alongside several practices with the aim to alleviate the continued stretch on resources, with the primary purpose of reducing appointments booked, waiting times, and the rising cost of traditional medication. We have experienced difficulties establishing the SSNP within some GP practices within the Borough. There is a distinct need to intergrade the social and clinical models of health to ensure clients are provided with holistic support. This requires a joined up approach from health care practitioners and Social Prescribers (Navigators). Currently, we have established the service with Tennant Street and Queens Park Medical where we deliver valuable support to their patients through regular drop-in surgeries. The SSNP Navigator is currently unable to access NHS patient records (System 1), this access would provide a more robust assessment of need and support the development of an integrated care pathway (social and clinical). Current intelligence (data capture) does not permit the SSNP navigator to measure impact in context to potential reduced use of medical prescriptions and the number of appointments with the GP.

Meet the Team Strategic Development Management Support Project Delivery Nigel Brough Head of Projects nigel.brough@pcp.uk.net Toni McHale Project Development Manager toni.mchale@pcp.uk.net The team consists of (FTE) Navigator/Link Worker (Tom). Management support is provided through a Project Lead (Karen Grundy) who functionally line manages the SSNP Navigator (Tom). Additional capacity is provided in context to Strategic development by the PCP Senior Management team. Karen Grundy Project Lead karen.grundy@pcp.uk.net Tom Mohan Navigator/Link Worker tom.mohan@pcp.uk.net