The Rotherham model Patients in Control of their Care Social Prescribing The Rotherham model Patients in Control of their Care

Background The NHS Challenge Increasing numbers with long term conditions Above average unplanned hospital admissions Unable to fund prevention without freeing up money from the acute sector How can VCS help? Development of Rotherham Social Prescribing Co-production workshops – agreement of model linked to integrated case management pilot Business case submitted to Rotherham CCG Initial pilot proposal – 10 GP practices, but 26 signed up! 6 months to recruit staff team, set up systems and join first GP meetings Pilot funded by Rotherham CCG from non-recurrent funding

What is Social Prescribing What is Social Prescribing? Strengthening individuals, strengthening communities Social prescribing (sometimes called community referral) is a framework for linking patients with non-medical needs affecting their health, well-being and ability to self-manage to sources of support within the community. PRESCRIPTION Exercise / healthy lifestyles Self-management programmes Social and leisure Arts and crafts Befriending/mentoring Confidence building Learning/training Money – benefits, debt, fuel poverty Housing/adaptations Carers support Dementia support Transport/mobility Advocacy LTC Social Worker It’s been excellent for the patients, in having access to such a medley of support services where you can interlink An recent article in Primary Care Today on social prescribing points out that the NHS focus has always been on the Acute Sector, but 90% of care happens in primary care. It suggests that at a time when everyone in the NHS is struggling for resources, General Practice needs to look out there at the resources we have in the community and find ways to use them more effectively, and this pilot provides the infrastructure to enable this.

Rotherham Social Prescribing Model Key Features LTC Matron One-stop shop – there are numerous possible agencies to refer to so makes it easier referring to one Social prescribing integral to integrated case management teams Patient selection by GPs - using risk stratification Single infrastructure organisation (VAR) manages contract ( 26 partners) VAR employs and manages 5 link workers Co-produced action plan and menu of support activities Funding to expand VCS capacity and fill gaps in provision VAR Advisors attend GP MDT meetings, visit patients and refer on to appropriate VCS services Only patients referred to VAR Advisors by participating GP Practices are eligible for social prescribing

Rotherham Social Prescribing Model Integrated LTC Case Management Team Voluntary and Community Sector Advisor (VCSA) Funded VCS Service Community Activity (non-funded) Assessment Patient is on risk tool Patient has non-medical needs Menu of options Feedback Feedback

SPS funding Sustainable funding Social Prescribing Patient Journey Month 0 Month 1 Month 2 Month 3 Month 4 X weeks X hours X sessions Patient Outcome Towards Independence Maintaining Independence Patient continues to access service (patient self funds) VCS provider Service 1 Patient continues to access service (external funding sustains service) SPS Funded Patient referred on to sustainable activities / service VCS provider Service 2 GP VCSA SPS Referral in Referral Out VCSA FOLLOW UP Patient attends peer-led group SPS Funded SPS funded Provider Service VCS provider Service 3 No sustainable outcome for patient SPS funding Sustainable funding

The Story So Far……… 1974 referrals in to SPS since Sep 2012 Key Statistics 1974 referrals in to SPS since Sep 2012 referrals on to VCS Services 700 referrals on to non-VCS Services 65% referrals aged 75+ 42% live alone 37% have an informal carer 5% BME GP Quote: Gives them a focus/purpose and goal to achieve. Integrates back into the community, especially the socially isolated. Supports and educates patients Outcomes 55% - fewer outpatients appointments 48% - fewer hospital admissions 43% - fewer A&E Attendances 83% - progress on at least one outcome area 76% - financial benefits (£275,000 in additional benefits since Sep 2012) 69% - less isolated 54% - more active

Social prescribing - Success factors VCS is integral to case management in primary care CCG champion / streamlined and effective Steering Group Simple referral processes for GPs GP ‘buy in’ to social prescribing Adequate resourcing of VCS services VAR’s ability to support groups Patient Quote: I was on my own, I was totally on my own… Each day I’m getting better and better….before I could hardly walk…I’m feeling very positive, each day I get up and I just can’t believe how much I’ve come on Social prescribing funded services as pathways to independence Robust (and secure) patient data management to demonstrate impact Link workers recognised by GPs as professional and an equal player in integrated care teams Quality VCS staff – particularly Link Workers GPs recognise the importance of social relationships as an alternative to medication Development of community hubs and local community services Pathways to independence, not an end in themselves

NHS National Award for Social Prescribing

Case Study Patient V Patient is registered blind and has angina High anxiety levels – rings 999 frequently when support workers aren’t there Limited friends and rarely goes anywhere independently, no confidence Referred to SENSE art and craft group, disabled swimming session and befriending services. Re-arranged his support worker hours to cover weekends by doing other activities in the week. He has now met lady that attends the same group, they have fallen in love, are moving in together and getting married Outcome: patient is more confident, more independent, much happier and less isolated Outcome: patients rarely rings 999, more satisfied with support package and will be reducing the hours of support needed Outcome: patients value SENSE group so much they are to continue it themselves by self-funding and applying for grants

Patient feedback

Thank You Questions? Janet Wheatley on 01709 829821 or janet.wheatley@varotherham.org.uk Linda Jarrold on 01709 834449 or linda.jarrold@varotherham.org.uk External evaluation interim report (December 2013)  http://www.shu.ac.uk/research/cresr/reports Voluntary Action Rotherham, The Spectrum, Coke Hill, Rotherham, S60 2HX; Tel: 01709 829821, Fax: 01709 829822. VAR is a company limited by guarantee, Registered Charity Number: 1075995, Registered Company Number: 2222190.