1. 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

2. 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%)

3. 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

4. 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!

5. 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

6. 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

7. 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

8. 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!)

9. 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

10. 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

11. 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

12. 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)

13. 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…

14. More proactive Involve volunteers for ‘low level’ navigation
Staying in Touch calls and volunteer visits
Risk stratification of the ‘pre-vulnerable’ 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