1. Developing a joint action plan for social prescribing
21st May 2019

2. Primary outcome
To develop a joint action plan for embedding Link Workers into Primary Care Networks and their local communities

3. Other outcomes
Understand the context in which social prescribing operates in a wider community
Develop understanding of the link worker role and its key functions
Understand key evidence of what social prescribing incorporates, the role of PCNs and expectations being placed upon them
Understanding what social prescribing needs to deliver and how it can be delivered
Create a joint plan which describes how PCNs can work with community partners to take a proactive approach to managing population health through social prescribing.

4. Contents Network Neighbourhood schemes and Local area coordination
Briefing on social prescribing & primary care Network
Service framework & implementation guidance
Group work for joint planning

5. Context

6. Network Neighbourhood Schemes and local area coordination Matthew Bick Neil Da-Costa

7. Network Neighbourhood Scheme
One of two in-house NNS (Selly Oak being the other)
Covers 7.3 wards which make up Perry Barr Constituency
Commenced in September 2018
Asset mapping commenced and is ongoing
Approach will be ‘rooted’ within the VCSE sector
Organisation assessments pending May 2019 onwards
Networking and information sharing sessions held (gaps identified)
Small grants programme pending (may/June 18) aimed at:
- Investing in and supporting voluntary and community sector organisations
- Providing new activities for older people and communities – where gaps have been identified by older people (via social workers and GPs)
- Increasing/improving the accessibility of existing activities
Working relationship established with the local social work teams
Developing partnership working arrangements with key stakeholder delivery agencies Partnership Steering Group established

8. Local Area Coordination in Birmingham
Is a long term evidence based approach to….
Helping disabled people, people with mental health needs and older people (and their families/carers) to stay strong, connected and contributing as citizens
Building more welcoming, inclusive and supportive communities- people helping people
Make services more personal, local, flexible, accountable and efficient – so services become a back up to local solutions
Build resilience to reduce pressure on services

9. Whole Person, Whole Family, Whole System
Local Area Coordinators support:
People not yet known to services to help build resilience and remain part of their community (avoiding need for services)
People at risk of becoming dependent on services to remain strong in their own community diverting the need for more expensive “formal service” responses. (reduce demand)
People already dependent on services to become less so and more resilient in their own community.
This slide reinforces the varied nature of the role.
As part of simplifying the system and maintaining trusting relationships, Local Area Coordinators work alongside people before crisis (building resilience), in crisis at risk of becoming dependent on services ((diverting people from services to sustainable, natural solutions within communities) and people already dependent on services (reducing dependency and cost wherever possible).
This is done in strong partnership with the person, their family and service and community partners
It’s not just a preventive approach, but works alongside people across not only service labels and age groups, but also to build resilience, support at crisis (to build non service solutions wherever possible
A SOFT, NATURAL WAY OF CONNECTING

10. It’s about.... A good life and active citizenship
Strengths and expertise of all people in our communities
Building individual, family capacity and resilience
Nurturing more welcoming, inclusive and supportive communities
Natural, supportive relationships, contribution, valued roles
Supporting natural, sustainable solutions in communities
Reducing need for/dependency on services
An approach alongside people with disabilities, mental health needs, older people, their families to build and pursue their vision for a good life, stay strong, safe, connected as valued, contributing citizens in their local communities
Building more welcoming, inclusive and supportive communities
Creating conditions where people can…..

11. A personal, local, human approach
Defined geographical area – Located in/Connected with Community
Conversation focused on a good life
Build on the assets and contribution of people and the community
Whole person, whole family
Voluntary relationship – introductions not referrals
Not time limited but avoids dependency
Take time to get to know individuals, families, communities – strengths, aspirations, needs
Learning conversations – important to/for
What’s life like now, how would you like it to be?
Supporting change, building resilience
Supportive relationships, contribution
Staying strong, choice and control
Local Area Coordinators support:
People not yet known to services to help build resilience and remain part of their community (staying strong – avoiding need for services)
People at risk of becoming dependent on services to remain strong in their own community diverting the need for more expensive “formal service” responses. (reduce demand)
People already dependent on services to become less so and more resilient in their own community.

12. Social prescribing & Primary Care Networks

13. Comprehensive Model for Personalised Care
Published January 2019
Full array of delivery support actions that will be taken nationally to ensure effective implementation of;
shared decision-making
enabling choice, including legal rights to choice;
supported self-management
personal health budgets and integrated personal budgets
social prescribing and community based support

14. Primary Care Networks
Formed according to national guidance and local principles
15 PCNs – 10 Sandwell, 5 in West Birmingham
Between 21,000 to 73,000 patients
Between 3 and 9 practices
Placed-based - each PCN working across same nursing, mental health and local authority provision
PCNs will deliver network-level services, beginning with Extended Access

15. Primary Care Networks – Go Live 1 July 2019
What are they?
Practices working together and with other local health and care providers
Providing care in different ways to match different people’s need
Focus on prevention, patient choice and self care
Use of data and technology
Making best use of collective resources across practices
Why are they needed?
Represent the building blocks of place-based models of care provision and are the key to preserving the integrity of NHS service provision going forward
Offer care on a scale which is small enough for patients to get the continuous and personalised care they value, but large enough, in their partnership with others in the local health and care system to be resilient
What will be better for patients?
Access to a wider range of professionals than may have been available in individual practices
Improved/shorter waiting times that are focused around the access needs of those using services.
Improved access to a wider range of services and support through use of the resources and partners within the Network
Provide a focus on increasing access to care locally (place based care), and avoiding admission/attendance at hospital where appropriate
An increased focus on prevention and personalised care

16. Expectations
PCNs expected to take a proactive approach to managing population health
Assess the needs of their local populations to identify people who would benefit from targeted, proactive support. 

17. Challenges
Collaboration in primary care takes time; strong relationships, a shared vision and effective leadership are all crucial. Much rests on primary care networks which are still a relatively untested model. 
Ensuring integration exists with voluntary/community sector and the wider health and care system and ‘Place’.

18. Priorities Ensuring PCNs are supported to implement social prescribing
Work with partners to focus on social prescribing and the role it can play system wide
Building resilient and sustainable communities
Monitor impact and evaluate over time

19. Link Workers
Announcement around the new GP contract for 19/20 includes additional workforce within networks which includes social prescribing.
£34,113 per PCN
Model role specifications published as a guide
July first Link Workers to be recruited

20. Link Workers
Link workers integral part of the core general practice model throughout England – not just ‘wrap around’ support
Network DES used to specify requirements
Reimbursing 100% of the cost of funding for social prescribing link workers - 5 year commitment
Networks can choose to fund a local voluntary sector organisation to employ link workers and run the service on behalf of the network. “

21. 2) Service framework and implementation guidance

22. Service framework
supports the wider ‘personalised care’ programme by focusing on the wider determinants of health and well-being.
aims to provide non-clinical support to improve health and wellbeing for social, emotional and practical problems.
to treat the causes behind the physical/medical symptoms rather than focusing on medical interventions.
expand the options available for patients when attending a primary care (GP practice) consultation. The service will need to have high awareness of local services available as well as form strong relationships with the Primary Care, the voluntary & community sector, secondary care and the patients they serve.

23. Model for social prescribing

24. Universal vs targeted social prescribing
Universal social prescribing
the system as a whole has a role to play in ensuring people have the tools in place to lead a happy and healthy life.
In partnership with local authorities and the Voluntary and Community Sector (VCS), there is a joint commitment to develop and support community groups, to deliver services in local communities and to keep people healthy and well (and out of hospital and GP surgeries). VCS organisations already provide a wide range of social prescribing interventions.
guidance focuses on targeted social prescribing in Primary care, services operating in this setting need to be mindful of the ‘place’ in which they function.
Targeted social prescribing
developed within the context of a strategic framework of self-care and prevention.
Embedding Link Workers into PCNs is a means of targeted social prescribing.
the service framework has been developed to provide guidance on what the service could include within a primary care setting.
number of ‘must haves’, but the models are agile enough to work in the context of any local community.
PCNs need to be work in partnership with their communities to make the service work at place based levels (see above).

25. Service framework

26. Outcomes

27. Group work 3) Partnerships
Who are the key stakeholders for what’s needed to make social prescribing successful?
What does each partner have to offer?
Their assets, skills and knowledge.
Projects, activities and interests involved in
Potential for collaboration and how can we avoid duplication to maximise impact?

28. Group work 4) Workforce development
what knowledge, skills and experience do link workers need to have?
what support will link workers need?
steps needed to ensure link workers are embedded into team
What will happen in first 3 months/12 months?

29. Group work
5) Primary Care Networks How can PCNs work with their community partners to take a proactive approach to managing population health through social prescribing and tackle the wider health needs of their local populations?

30. Evaluation and next steps
I understand…
the context in which social prescribing operates in the wider community
the key evidence of what social prescribing incorporates, role of PCNs and the expectations being placed upon them what social prescribing needs to deliver and how it can be delivered
The key functions of the Link Worker and what support they need.
The joint plan which describes how PCNs can work with community partners to take a proactive approach to managing population health through social prescribing.

31. THANK YOU