Better Care FundBusiness Case

Date: 31.07.15 (updated Dec 2015, for implementation phase info.)

Project Title: Social Prescribing Pilot

Version: v.3.7 – SH/MA/BP 221215

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PURPOSE OF DOCUMENTThe purpose of this document is to establish why the effort and time involved in delivering the project is worth the investment, and to obtain approval for the scheme.

The document needs to outline the rationale for the investment and estimate the costs of developing and implementing the proposal. The document needs to summarise the benefits and risks of proceeding with the scheme and quantify any savings gained.

Project Details:Project Name Social Prescribing Pilot Scheme

Sponsor Andrew Taylor & Michael Scorer

Project Manager Matilda Allen

Date 22nd December 2015

Document History:Version Date Author Amendment History1.0 06/15 SH/MA/BP Investment Proposal – Senior Management Review2.0 07/15 SH/MA/BP Proposal - Better Care Fund Steering Group – for comment2.0 07/15 SH/MA/BP Proposal - Better Care Together Programme Board – for comment3.3 08/15 SH/MA/BP Business Case – Public Health Commissioning & Governance3.4 08/15 SH/MA/BP Business Case – CCG Finance & QIPP Committee

3.7 12/15 SH/MA/BP Business Case – updated for sharing with partners throughout implementation phase

Reviewers: Name Job Title or Responsibility Date Version

Sue Hogarth Consultant, Public Health 08/15 all

Brenda Pratt Associate Director of Health & Social Care Integration 08/15 all

Michael Scorer Director, Better Care Fund 07/15 Proposal

Andrew Taylor Director of Public Health 07/15 Proposal

Approvals:Name Title or Responsibility Date Version

Michael Scorer Sponsor

Andrew Taylor Sponsor

LBWF Public Health Commissioning & Governance Group 8/15 3.3

CCG Finance & QIPP Committee 8/15 3.4LBWF/CCG Incorporation of minor amendments from above Committees 8/15 3.6BCT WS A Changes to the implementation plan phasing approved 22/15 3.7

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Contents

PURPOSE OF DOCUMENT..............................................................................................................2

1 Executive Summary ................................................................................................................4

2 Background & Context ............................................................................................................6

3 Current Service Provision .......................................................................................................7

4 Where Do We Want to Be?.....................................................................................................7

5 Evidence Base ........................................................................................................................8

6 Objectives .............................................................................................................................10

7 Option Appraisal....................................................................................................................11

8 Summary of Benefits.............................................................................................................12

9 Stakeholder Involvement.......................................................................................................13

10 Implementation Plan .............................................................................................................13

11 Evaluation .............................................................................................................................14

12 Project Dependencies & Risks..............................................................................................14

13 Governance Arrangements ...................................................................................................16

14 Project Structure ...................................................................................................................17

15 Procurement Route ...............................................................................................................17

16 Cost Breakdown & Financial Appraisal .................................................................................17

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1 Executive SummaryThis section should include brief answers to the following:

1. Why is this important? 2. What is it that you want to do?3. Who will do it?4. What are the key outcomes (e.g. financial savings, quality, user experience, PH outcomes)5. What is the investment required?

What is social prescribing?

Social prescribing is a way of linking users of traditional health and social care services to non-clinical sources of support. The scheme is tailor-made for interventions that are led by the voluntary and community sector (VCS) and can result in:

better social and clinical outcomes for people with long-term conditions and their carers more cost-efficient and effective use of NHS and social care resources a wider, more diverse and responsive local provider base.

Why is it important?

Social prescribing is a critical component of a wider transformation programme that aims to streamline patient flows through the health and social care system. Without it, optimising the role of the VCS in the delivery of well co-ordinated ‘seamless’ care will remain difficult and limited consultation slots with statutory providers will continue to be heavily used by clients who fundamentally require non-clinical/non-specialist support.

The main aims of the social prescribing pilot scheme are to:

Facilitate access to a range of support services that will enable individuals to significantly improve their health and wellbeing.

Increase the role of the VCS in the provision of services and evaluate aspects of the service model prior to wider adoption across the borough.

Release specialist capacity across the system, so that individuals with the most intense health and social care needs can receive the care they require despite funding constraints.

Increase ‘whole system’ efficiency by preventing deterioration in the service user’s condition and by reducing duplication of care between organisations and professions.

Provide ‘seamless’ care by placing the service user at the centre of decision-making and designing packages of interventions around their needs irrespective of provider.

Who will do it?

Funding is being requested to recruit two social prescribers who will divide their time between a host GP practice and a community resource hub. These individuals will receive referrals from a wide range of health and social care practitioners and will organise non-clinical support packages for clients who have a high level of need but who do not meet eligibility criteria for statutory services. The pilot will run for 18 months from the end of Q3 2015/16 until the end of Q4 2016/17. This includes recruitment and induction time – it is likely that the social prescribers will start to take referrals by the start of Q1 2016/17.

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What is the investment required?

The cost of the pilot would be £67,558 in year one and £126,581 in year two. A breakdown of the costs is set out in the table below.

For the purposes of the pilot, costs are shared equally between the two organisations until the results of the evaluation are known. The costs for each organisation are £33,779 in 15/16 and £63,290 in 16/17 - a total of £97,069.

Social Prescribing - Indicative Costs

Type of Expenditure 15/16 16/17 Total

Social Prescribers - 1 x SO1, 1 x P02 for 15 mths £19,216 £76,865 £96,081GP Leads x 2 - 2.5 sessions per month £7,200 £14,400 £21,600Training £2,691 £0 £2,691Office Accommodation £1,500 £3,000 £4,500Equipment - IT, phones, faxes etc. £2,000 £500 £2,500Evaluation £0 £25,000 £25,000Contingency @ 21.5% £11,277 £30,490 £41,767Total £43,884 £150,255 £194,139

Cost to the WFCCG @ 50% 33,779 £63,290 £97,069Cost to the LBWF @ 50% 33,779 £63,290 £97,069

Will the investment generate savings?

It is difficult to forecast the value of savings that may be realised as a result of introducing social prescribing, but these could be significant. There is considerable potential for the VCS to take on activities that are currently provided by Health, Housing, Social Care and other services, and this would allow statutory resources to be targeted in a more effective way. Based on evaluations undertaken elsewhere, it is estimated that £2 will be saved for every £1 invested.1

What are the key outcomes?

The expected outcomes for service users include:

Improved health and wellbeing Increased confidence and self-esteem More opportunities for social contact Greater ability to manage own condition Increased independence and more control over decisions

The expected outcomes for statutory services and practitioners include:

1 The Rotherham Social Prescribing Pilot demonstrated savings of £3 for every £1 invested. We have taken a conservative approach and assumed that savings in Waltham Forest will be less than this, as our local VCS is relatively under-developed. The Rotherham pilot was evaluated by Sheffield Hallem University.

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Wider range of services being offered allows for a more holistic care package Clinical time of highly skilled professionals used more appropriately Diversity of providers helps statutory services manage the challenge of demographic change Preventing deterioration reduces future burdens on health and social care system Focuses decisions on the things that matter most to service users Builds social capital and community engagement

2 Background & ContextTo include:

Strategic rationale (e.g. Care Act compliance) National context (e.g. Personalisation, Choice, Five Year Forward View) Local context (e.g. JSNA, Health & Well Being Strategy, CSP, WEL Strategic Plan) Commissioning considerations (e.g. provider networks, market management)

Rationale for the investment

In deprived areas patients often visit a health professional for non-clinical reasons as a result of not knowing how to address the wider social issues that are having the biggest negative impact on their lives. Where health professionals are able identify patients wider needs during the short consultation time, they may have limited knowledge of the local support services available to address them. In spite of this, general practitioners, community nurses, health care assistants and reception staff have a unique, and in many cases long term, access to patients. This can help to identify or address additional health and social care needs before they escalate.

National context

Social prescribing is about using community-based services, alongside traditional statutory health and social care services to help improve health and wellbeing.

The Care Act 2014i sets out responsibilities for local authorities including duties to promote individual wellbeing, prevent needs for care and support, promote integration of care and support with health services, and provide information and advice. A successful social prescribing programme would help the local authority to meet these legal requirements.

Within a health context, it is increasingly accepted that services need to adopt a ‘more than medicine’ approach, which focuses on the individual, their aspirations, needs and assets and their context within the community. Simon Stevens has identified this as one of the key ways in which the NHS needs to change - moving from “a ‘factory’ model of care and repair” to one that focus on much wider individual and community engagement.

The Five Year Forward View sets out how the health service needs to change, arguing for a more engaged relationship with patients, carers and citizens. It argues that social connections, community participation and having a voice in local decisions are known to be factors that underpin good health. The Five Year Forward View makes specific commitments to support individuals in the management of their own health and pledges to provide better support for communities, carers and health related volunteering. This includes the commitment to work with voluntary sector partners to invest significantly in evidence-based approaches. Social prescribing, which provides a vital link between community based resources and traditional health services, is key to this work and the benefits are summarised in a presentation produced by NHS Englandii.

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Local context

The Waltham Forest Joint Strategic Needs Assessment (JSNA) identifies the following areas where Waltham Forest compares poorly against England averages, all of which could be mitigated or addressed by a successful social prescribing scheme:

- Childhood obesity (23.5% of Year 6 children are obese)- Children in poverty (estimated at 16,800 children – 30.4% of children in the borough)- Child wellbeing (WF is ranked 324th out of 354 areas in England)- Numbers of statutory homeless (1,045 acceptances in 12/13 compared to 311 in 10/11)- Long-term unemployed (11.4% of the population)- Admissions to hospital for falls (higher hospital admissions than comparators)- Excess winter deaths (an average of 87 per year from 2008-11)

Tackling the public health challenges outlined above, requires a response that goes beyond the boundaries of traditional health and social care services. Since many service users who experience poor outcomes present at primary care services regularly, introducing a social prescribing scheme will allow local stakeholders to address strategic priorities in a pro-active way.

3 Current Service ProvisionDescribe current service provision and explain why existing arrangements are not ideal. What have service users and practitioners told us about whether services meet their needs?

The current system nationally is inefficient and over-reliant on crisis driven responses. Too many people are in hospital who could be better cared for in community settings and this over-dependence on secondary care has meant that alternative lower-cost options are under-developed. The introduction of social prescribing – as part of a wider transformation programme – helps deliver a more sustainable health and social care economy by delivering practical support at earlier points in time (i.e. pre-crisis) and targeting interventions around the needs of residents, irrespective of provider.

Within the borough, access to non-clinical support services is variable. When compared to national averages, there has been relatively little investment in the VCS and recent reviews have confirmed that practitioners and service users find the sector difficult to navigate. Social prescribing helps with this by connecting users to the right services, first time – thereby streamlining access to support and reducing un-necessary assessments.

Capacity risks within the VCS are reviewed in more detail in Section 12.

4 Where Do We Want to Be?Describe what an improved arrangement looks like. Consider user experience, service quality and financial outcomes.

What would an improved arrangement look like?

By helping individuals navigate and use non-clinical resources appropriately, social prescribing promotes partnership working and helps build pathways that support self-management and prevention.

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Social prescribing empowers residents by giving them access to the resources they need to make better decisions about their own health and wellbeing. In this respect, the scheme supports communities to find their own solutions to a range of health and social care challenges and fosters ‘resilience’ at both an individual and ‘wider society’ level.

Proposed service model

To maximise the impact of the scheme, referrals will be accepted from a wide range of health and social care professionals. The referral pathway is outlined in the diagram below.

Sel f-Referra ls from the E Market Place

Referra ls from this source may be included in scope of

pi lot once the E Market Place i s operational

GP, HV, pharmacist & Social Work Referrals

Housing, Debt, Employment, Social Isolation & MH

Managed referra ls to be made to services including:

Ca l l res ident to discuss the type of support they would

l ike and to expla in the referra l process

Make an appointment or arrange for a home vis i t to be made by support service

Remind res ident of appointment

Get feedback from service and pass on to referrer

when 'request feedback' box on referra l form has

been ticked

GP, Health Visitor, pharmacist & Social Work Referrals

Poor Physical Activity & Dietary Advice

Send referra l to Single Point of Access

Send noti fi cation to referrer that referra l wi l l be

deal t with by the team above

GP, HV, pharmacist & Social Work Referrals

Anyone who has ever had a cancer diagnosis

Send referra l to loca l Macmi l lan Socia l

Prescribing Scheme

Send noti fi cation to referrer that referra l wi l l be deal t

with by the team above

Referrals from MH Pathway Manager, ICM Professional or Complex SW

SP to ca l l referrer to discuss options for res ident. SP to

recommend a support service or support package

depending on res ident needs

Pathway Manager or IC Profess ional to discuss options with res ident

Pathway Manager or IC Profess ional to confi rm

res idents decis ion with SP

SP to faci l i tate ava i labi l i ty of support service or

package. Communications with res ident managed

through Pathway Manager or IC Profess ional at a l l times

Health or Socia l Care Profess ional identi fies non-

cl inica l need during consul tation

Figure 2

Health or Socia l Care Profess ional & Service User discuss ion

Discuss ion ascerta ins whether service user would l ike support for an i ssue

Profess ional expla ins socia l prescribing and ga ins consent for referra l

E-referra l form completed and sent

Socia l Prescriber acknowledges receipt of

referra l and reviews

1xPO2 & 1xSO1

Tra ined in motivational interviewing and Coaching for Health

Post holders co-located, with time split across two locatons (One GP Practice &

One Community Hub)

Electronic referral forms to be loaded onto EMIS, RiO, MiDoS,

and others as neccessary.

Limited services in scope (circa 15-20).

Service groups to include: Poor physical activi ty and dietary advice; housing, debt

and employment; social isolation (inc. befriending, time banking, volunteering & community activity); menta l health, other.

Professionalswho can refer into the scheme include GPs, health visitors, pharmacists, social workers, ICM health professionals, and community matrons.

5 Evidence BaseSummarise outcomes from similar schemes that have been implemented elsewhere. Are the proposed interventions and changes to service models recommended by national bodies (e.g. Public Health England, NHS England, Royal Colleges, NICE etc.)

Policy context

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The role of social prescribing, as part of a ‘family of approaches’ that can be used by commissioners to mobilise community assets in order to increase health and wellbeing, is set out in a joint guide published by Public Health England and NHS Englandiii.

The report details powerful evidence for the benefits of community-centred approaches and makes a compelling case for change. The report calls for place-based approaches that develop local solutions, drawing on all the assets and resources of an area. To facilitate adoption of the new approaches, NHS England and the Coalition for Collaborative Care have published a joint handbook to strengthen personalised care and support planningiv.

Does social prescribing work?

There is now a strong body of evidence that shows that social prescribing can offer significant benefits to both patients and health & social care professionals.

There are a variety of models in existence ranging from directing individuals to electronic directories of servicesv to supported referrals from general practicevi. As the number of schemes grows, so does the body of evidence supporting its effectiveness. Outcomes to prove effectiveness, of course, depend on the range of services that are available within each scheme. An article in the British Journal of General Practicevii found that the act of prescribing has been shown to “enhance the engagement process in prescribed health-related activities such as weight-loss and exercise programmes”. Outcomes that have been noted as a result of social prescribing schemes are “enhanced self-esteem, improved mood, increased opportunities for social contact, increased self-efficacy and greater confidence”.

One studyviii has described social prescribing as the ‘missing link’, and found that for people whose most pressing needs go beyond the traditional remit of the general practitioner, “social prescribing not only provides a means to alternative support but also acts as a mechanism to strengthen community–professional partnerships”. A Review of ‘Arts on Prescription’ practice in the UKix has also found that social prescribing builds “social capital and community engagement, [as well as] enhancing health and wellbeing’.

The success of social prescribing has been found to rely onx “the presence of a link worker with a good knowledge of the voluntary sector and of community development principles and practice, and a flourishing local voluntary and community sector”.

The following have also been cited in a paper by Age Concernxi as benefits for general practice:

Reduced visits to general practice in the twelve months after assessment within a social prescribing scheme.

More appropriate use of clinicians’ time, allowing them to concentrate on medical issues during all consultations.

Increases in the range of services offered by the practice, allowing a more holistic care package.

Encouragement and support of self-care can support people with long-term conditions.

Rotherham Social Prescribing Pilot

The Rotherham Social Prescribing Pilot is one of the largest schemes of its kind and was delivered by Voluntary Action Rotherham on behalf of the CCG. It was funded for two years as part of a

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wider integrated care initiative and was implemented to help local GPs meet the non-clinical needs of patients with long-term conditions (LTCs).

The scheme has received a number of innovation awards and has been influential in shaping NHS policy at a national level. The scheme was evaluated by Sheffield Hallam University and findings demonstrate that social and economic benefits were created for three main stakeholder groups:

Patients with LTCs and their carers. These individuals experienced improvements in their mental health and became more independent, less isolated and more physically active. Service users began engaging with their local community and were able to access a range of welfare benefits that they were previously unaware of.

Local public sector organisations, in particular health bodies. These organisations benefitted because social prescribing patients used less secondary care resources, with referrals down by circa 20% in the 12 months following participation in the scheme. In addition, service users were generally more satisfied with the support they received and were more able to manage their condition.

Local voluntary and community sector. These groups benefitted as a result of improved access to funding from statutory organisations for the first time. Some providers were able to match their social prescribing activities with income from other sources, enhancing their service offer and improving the sustainability of their organisation.

Local developments

Within North East London, the most comprehensively evaluated scheme is Redbridge's 'First Response Service' (ReFRS). Key findings from this pilot project were:

53% of referrals were from GPs (from 20 surgeries) and 15% were from Police Officers.

Referrals were highest to Age UK, followed by Adult Social Services and Redbridge Council for Voluntary Services. All those referred to Adult Social Services were unknown to the service previously.

100% of GPs (from 12 surgeries) were satisfied with outcomes achieved for their patients and thought the service should be implemented permanently.

100% thought the service helped to better connect patients with wider community support services.

100% of service users were satisfied with the referrals made to organisations on their behalf.

When asked where they would find information if not through ReFRS, 64% of service users said they didn’t know.

6 ObjectivesWhy will an improvement in this area be a good fit with local strategic priorities?

The objectives of the social prescribing scheme are summarised below:

Promote health and wellbeing

Link service users to non-clinical sources of support in an effective and streamlined way

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Close gap in provision for patients who have a high level of need but fail to meet the threshold for access to statutory services

Decrease future burdens on the health and social care system by preventing deterioration in service users condition

Promote integration between statutory, community and VCS organisations

Wider public health outcomes

The scheme has the potential to help the Local Authority improve performance against a number of Public Health Outcomes Framework (PHOF) indicators, such as:

- Children in poverty - by providing parents with support around debt, income maximisation and housing costs.

- Number of 16-18 year olds not in education, employment or training - by connecting these individuals with training or employment opportunities.

- Utilising outdoor space for exercise and health reasons - by referring patients to the single point of access for exercise provision.

- Homeless households accepted for temporary accommodation – by acting early to prevent housing issues from escalating.

- Social isolation – by connecting adult service users and their carers to local support networks and community activities

- Fuel poverty - by referring patients to local interventions that improve damp or cold homes.

- Improving outcomes for adults with learning disabilities or those in contact with secondary mental health services - by connecting individuals to specialist services that are able to provide stable and appropriate accommodation.

- Improving employment rates for vulnerable service users (e.g. those with long term conditions, learning disabilities or mental health problems) - by connecting these individuals to specialised services that offer additional support.

The Marmot Review (2010) found that individuals from deprived communities who are marginalised in terms of access to information, support and services are more likely to:

experience greater co-morbidity present late to statutory services require more emergency or unscheduled care experience complications associated with poor management of their condition

This combination of factors means that, without support, service users from disadvantaged groups can be complex to manage and relatively expensive to treat. Solutions such a social prescribing that slow down the rate at which at which deterioration occurs, can increase life expectancy and reduce the need for more costly specialist care interventions.

7 Option AppraisalAre alternatives available to achieve the objectives? Describe each option and summarise the advantages and disadvantages of each approach; including an option for ‘do nothing’. Clearly identify the recommended option.

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Recent policy guidance points to an over-dependence on secondary care that has led to the ‘medicalisation’ of services and a disproportionate reliance on specialist interventions. Given the size of the challenge, organisations such as the Kings Fund, the Audit Commission and Nuffield Trust recommend that changes to service models are implemented at ‘scale and at pace’.

The various options for meeting the scheme’s objectives are summarised below:

Option 1: Do nothing

Advantages – no transitional costs would be incurred.

Disadvantages – those who require non-clinical support and early interventions will not receive the care they need. In the medium to long term, this will increase financial pressures on LBWF and the CCG and place more strain on an already over-burdened system.

Option 2: Signpost users to support services

Advantages – lower transitional costs. Some of the schemes in the Better Care Fund target improvements in this area and this will help service users and professionals navigate the health and social care system in a more effective way.

Disadvantages – these interventions do little to help frail and elderly residents, and those with complex needs, who are intensive users of statutory services. This option will lead to small incremental improvements, but does not address the need for ‘whole system’ change at scale and pace. Currently, health and social care practitioners do not have the capacity to signpost residents to support services in an effective way. The need for further staff training would be an additional cost.

Option 3: Implement a social prescribing scheme (this is the recommended option)

Advantages – evidence suggests that empowering residents to manage their own care in a supported and pro-active way reduces overall costs to the system. Studies show that implementing social prescribing improves service quality and increases health and wellbeing. This option helps meet the challenge of implementing change at scale and pace.

Disadvantages – higher transitional costs than other options

If the social prescribing scheme is not approved, staff employed by statutory organisations will find it difficult to 'hand off' clients to other parts of the local support economy. Over time, given the ageing population, this means that gaps in provision will widen and more strain will be placed on services that are, many would argue, already at full capacity.

8 Summary of BenefitsBased on previous sections (evidence base, proposed intervention or service model) provide a summary of the expected benefits.

Expected benefits can be summarised as follows:

- Improved well-being

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- Reduced social isolation and loneliness- Increased independence- Access to wider welfare benefits- Improved access to services- Reduced use of statutory health and social care services (circa 20%)- Reduced disease burden and increases in life expectancy- Clinical time of highly skilled professionals used more appropriately- Service users better equipped to manage own condition- Builds social capital and community engagement

9 Stakeholder InvolvementIdentify the key stakeholders. Have service users, staff and providers been consulted about the likely impact of the change?

A number of organisations have contributed to the design of the service and the consultation exercise included service users, VCS partners, neighbouring CCGs who run similar schemes and primary and community care colleagues.

10 Implementation PlanPlease summarise proposed arrangements for implementing the project.

A summary of the proposed project is outlined in the diagram below. The planned duration of the pilot is 18 months and a breakdown of referral trajectories is set out in Table 2.

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Objectives Project Deliverables

Enab

lers

Outcomes

Eval

uatio

n

Social Prescribing - Summary Project Plan for Pilot Scheme

Q3 15/16 Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17

• Integrate social prescribing into BCT Programme A Steering Group and establish project leads group.

• Identify cl inical lead. Identify one host GP practice (5-10 spoke practices) and preferred community hub.

• Recrui t two social prescribers (PO2&SO1) who wi ll divide their time between host locations.

• SPs to l iaise with support services to understand opportunities/constraints in terms of capacity, infra -s tructure, access cri teria

• Lia ise with support services within scope, us ing existing directories where poss.

• Des ign electronic referral form and ensure this can be made available in EMIS , RiO, MiDoS, and wherever else needed

• Devise data capture protocols that will enable scheme to be comp -rehensively evaluated.

• Commence service.

• Evaluation to be undertaken by 3rd party and include quantitative/ qualitative components.

• Prepare business case for implementing model at

Promote health and wellbeing

Link service users to non-cl inical sources of support in an effective and s treamlined

way

Close gap in provision for patients who have a high level

of need but fail to meet the threshold for access to

s tatutory services

Decrease future burdens on the health and social care

system by preventing deterioration in service users

condition

Promote integration between s tatutory, community and thi rd sector organisations

Spare box

Comprehensive

comm

unication and engagement plan. Training program

me for SPs. Peer review

and project support from external experts.

Enhanced self-esteem, improved mood, increased

opportunities for social contact and greater

confidence

Increased range of services offered to users allows for a more holistic care package.

Improved access to services with cl inical time of highly ski lled professionals used

more appropriately

Service users better equipped to manage own

condition, helping statutory bodies respond to challenge

of demographic change

Bui lds social capital and community engagement

Spare box

Reducedvisits to health professionals in the 12 m

onths after assessment w

ithin the social prescribing scheme. Step change in user reported

measures of confidence and independence.

Figure 1

11 EvaluationHow will the project be monitored and success evaluated? Where possible, measures should be quantifiable and divided into the following categories:

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(a) Process measures(b) Output or outcome measures(c) Service satisfaction measures

The social prescribing scheme is one of several projects that are being implemented as part of the Better Care Fund, which is a pooled funding arrangement between health and social care. The wider programme aims to improve the health and wellbeing of residents by ensuring that services are innovative, better integrated and designed around the needs of clients, rather than institutions.

As part of the evaluation, success will be evaluated in line with the measures set out in Table 3 below:

In addition, the cost-effectiveness or return on investment of the scheme will be calculated.

12 Project Dependencies & RisksPlease describe the impacts the project may have on other schemes or ‘business as usual’ activities. What are the key risks in proceeding with the recommended option? Each risk should be assigned a rating from the matrix below.

Project dependencies

The scheme links with other Better Care Fund developments and there are various dependencies with projects in the wider transformation programmes being managed by LBWF and the CCG.These are summarised in the diagram below:

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DRAFT v.4 BP 120815

Project yet to Start

Strong Dependency

Moderate Dependency

Better Care FundProject Dependency Map (1 of 2)

Health & Social Care - System of Managed Interventions

Key (1) BCF Programme Key (2)

Joint Planning Required

ProjectOperational

Occ

assi

onal

Use

rs

Electronic Portal (MIG)

Universal Health & Social Care

Record(Phase 1)

Single Point of Access

B.3

SingleAssessment,

Minor Aids and Adaptations

A.6

E-Market Place(impacts all

projects)A.1a

Single Integrated Health & Social

Care Directory of Services

(impacts all projects) A.1b

Optimising Role of Thi rd Sector in Health & Social Care Services

A.2 a ,b,c

Commissioning Telehealth &

TelecareA.3b

CareCoordination

Phase 1

CareCoordination Phases 2 & 3

Vulnerable and very dependent on support

(e.g. multiple co-morbidities, multiple

medications or very frail)

Vulnerable and dependent on support(e.g. some co-morbidities, some medications or frail)

Vulnerable but with potential to increase

independence(e.g. single long term condition and frail)

ICM Health ProfessionalsBands 7 & 6

supported by B4s

Occassional or event driven referrals to cl inical & non-clinical support services

1%CMs

21% to 30%

6% to 20%

2% to 5%

Inte

nsiv

eSu

ppor

tH

igh

Supp

ort

Mod

erat

e Su

ppor

t

Hea

lth&

Soc

ial C

are

-Sys

tem

of M

anag

ed In

terv

entio

ns

MD

Ts

CareCoordination

Phase 4

ICM Health Professionals (B5) and Non-Clinical Care Navigators (B4&5) and Volunteers

21% to 30%

GP Incentive Schemes(DES & LIS)

MentalHealth

Wel lness Service

Primary Care

Network(3 localities)

Low

Sup

port Less vulnerable with

potential to self manage

(e.g. single long term condition but less frail)

SocialPrescribing

A.5

Living Well Waltham

ForestA.2c

RapidResponse

(Phase 1)

Metro-politanFalls

AgeUK

RoE

CarersA.4Expert

Patient

blacktext

greytext

A

C

B

D

UnifiedAssessment

& Minor Aids A.3b

BuildingCapacity

3rd SectorA.2a

IAAA.2d

Local Area Coordination A.6

As the diagram illustrates, as well as being beneficial in its own right, the social prescribing scheme is part of a re-configuration of elements of the health and social care system. Maximising synergies between projects is essential if patient flows are to be optimised and this approach will increase efficiency, reduce duplication and allow resources to be deployed where they are most needed.

The timeline for the project will align with the Mental Health Wellness Service. The management of project synergies will be agreed nearer the time but is likely to include the sharing of certain project management, IT and evaluation costs. The clinical pathway for the Mental Health Wellness Service relies on social prescribers being in post by the autumn and so this is a key dependency.

Voluntary and community sector capacity

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Concerns were raised at the Better Care Together Board about whether the VCS in Waltham Forest has sufficient capacity to support a social prescribing scheme. Although this issue is recorded as a risk, it is thought to be manageable in the context of a pilot scheme. There are currently more than 250 organisations in the borough that provide activities and support to residents and the social prescribing team would work closely with about 15-20 of these.

Given new duties under the Care Act - and recognising that investment in the sector is relatively low - the Local Authority has commissioned an externally supported review. The report recommends that, over the next three years, investment in the sector needs to be more closely aligned with the strategic priorities of stakeholders and capacity ‘built up’ so that the sector can compete for contracts and external funding in ways that improve resilience and sustainability in the medium term. These developments will run alongside the social prescribing project and provide some assurance that long-standing capacity issues are being addressed in a pro-active way.

Project risks

Project risks are summarised in the table below.

Bui lding capaci ty and optimis ing the role of the thi rd sector are dedicated projects within Programme A of the Beter Care Fund. If recommendations of recent reviews are implemented, the l ikel ihood of a shortfa l l in capaci ty wi l l be reduced. In the context of the pi lot, ri sks are thought to be manageable, as services have yet to be extended across the borough.

Lack of capaci ty in VCS to receive referra ls Poss ible Minor Low

Low

Poss ible Major High

Inabi l i ty to embed referra l form into heal th and socia l care electronic systems

Discuss ions have a l ready begun with the relevant heal th and socia l care s taff and technica l advisers

Recrui tment needs to commence at earl ies t opportuni ty. Project Team have wide networks and are able to dis tribute information about the posts .

The project has a Steering Group with members from the loca l hea l th and socia l care economy who are ready made ‘champions ’ for the scheme. Cl inica l leads for the scheme wi l l be appointed. The socia l prescriber roles wi l l include a s igni ficant amount of community engagement.

This i s an external factor. Publ ic Heal th are currently responding to the national consul tation to secure thei r grant funding loca l ly.

Inabi l i ty to recrui t Socia l Prescribers

Lack of engagement from potentia l referrers

Cut in Publ ic Heal th Grant

Unl ikely Minor Very Low

Unl ikely Minor Very Low

Poss ible Minor

Total ScoreConsequenceLikelihood

Table 4 - Summary of Project Risks

Description of Risk Proposed Mitigation

13 Governance ArrangementsWhat governance forums will the project report into? Describe the approvals that are required.

The scheme sits within Programme A of the Better Care Fund. A summary of the governance arrangements is set out below.

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Workstream AImplementation Leads

Group

Better Care Together Programme Board

LBWF Management Board

CCG Finance & QIPP Committee

Better Care TogetherWork Stream A Steering

Group

14 Project StructureWhat structure will be put in place to deliver the project (e.g. steering group, implementation team and service user forums).

In addition to the Steering Group, an Implementation Group has been established with representation from the Local Authority, CCG, VCS and Health Watch. This group will oversee the implementation of the scheme once funding is approved.

A summary of potential partner (i.e. possible referral) organisations is attached as Appendix A.

15 Procurement RouteDescribe the proposed procurement route for the project.

The preferred scenario is that social prescribing staff are directly employed. The Project Team are looking into options for doing this and will be asking the Better Care Fund Steering Group for guidance and support.

16 Cost Breakdown & Financial AppraisalPlease consult the Finance Team when developing these. Explain how figures are derived and outline any relevant value for money considerations. Full costs should be used at all times.

Implementing the scheme on a pilot basis initially will allow stakeholders to determine the most appropriate service model for our local health and social care economy.

The scheme’s evaluation criteria will need to be agreed in advance and should include an assessment of the savings that are likely to be realised by each organisation individually, as well as the system as a whole. The outcome of the evaluation could then be used to determine a fair

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and proportionate funding formula for implementing the scheme on a recurrent basis, providing anticipated benefits have been delivered as planned.

For the purposes of the pilot, it is proposed that costs are shared equally between LBWF and the CCG. The total cost of the pilot per organisation is £97,069.

A summary of indicative costs is set out in the table below:

Social Prescribing - Indicative Costs

Type of Expenditure 15/16 16/17 Total

Social Prescribers - 1 x SO1, 1 x P02 for 15 mths £19,216 £76,865 £96,081GP Leads x 2 - 2.5 sessions per month £7,200 £14,400 £21,600Training £2,691 £0 £2,691Office Accommodation £1,500 £3,000 £4,500Equipment - IT, phones, faxes etc. £2,000 £500 £2,500Evaluation £0 £25,000 £25,000Contingency @ 21.5% £11,277 £30,490 £41,767Total £43,884 £150,255 £194,139

Cost to the WFCCG @ 50% 33,779 £63,290 £97,069Cost to the LBWF @ 50% 33,779 £63,290 £97,069

17 Continuation or Exit StrategyWhat is the exit strategy if the project is not performing to plan? How will adverse outcomes be mitigated? If the project is implemented on a pilot basis and is successful, how will mainstream funding be secured if there is agreement to continue?

The intention of the pilot is to test the preferred service model for social prescribing in Waltham Forest. As the project moves into its delivery phase, adjustments to the model will be made so that benefits for local residents and health and social care professionals are maximised. The Social Prescribing Steering Group will oversee these developments.

Whether the scheme is recurrently funded will depend on the outcome of the evaluation. The outcome of the evaluation could be used to determine a fair and proportionate allocation of funding if the scheme is implemented on a recurrent basis.

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Appendix A - Summary of Potential Partner Organisations

Issues Addressed

Organisation Services Provided

MH

& S

ocia

l Is

olat

ion

Hou

sing

Phy

sica

l Act

ivity

& D

iet

Deb

t & P

over

ty

Em

ploy

men

t

Oth

er

Hornbeam Centre

Nature walksHealthy eating caféCookery classesEnvironmental volunteering (brokerage with other organisations)

Y Y Y

Age UK Waltham Forest Befriending Y Y

Reaching out East

Support and advice on use of personal budgets for disabled peopleVolunteeringGroup activities and tripsAdvocacy

Y Y

The Mill Space and resources for local community activities Y

Stay Safe EastAdvocacy and advice for disabled and deaf victims of violence (domestic violence and other)

Y

Voluntary Action Volunteering brokerage Y Y

Papworth TrustDisabled facilities grantsHome Improvement supportHandy-person service

Y Y

London Fire Brigade Home fire safety visits Y

The Heet Project Provide heating and energy efficiency solutions to households in need Y

Citizens Advice Bureaux Advice and advocacy Y

Christians against poverty Debt and budgeting advice Y

Waltham Forest Community Credit Union

Budgeting adviceSavings/loans Y

MetropolitanHome from Hospital and Well-being at Home services. Time limited support to prevent admissions and facilitate discharge.

Y Y Y Y

Learning Disability Exchange Support for people with learning disabilities Y

Community Transport Transport services for vulnerable adults Y

WF Carers Association Support for carers Y

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Appendix B

Tips for Creating a Business Case

1. Be clear about the brief.

2. Make sure that you have a good, persuasive Executive Summary as this might be the only thing that is read in full.

3. Research via the internet as there may well be another organisation that has already done a case very similar to your own.

4. Ask colleagues if they know of anyone who has done a recent case similar to your own.

5. Identify all the different stakeholders who you will need help or buy in from.

6. Get the right people involved from the start.

7. Be realistic on your timescales - it generally takes longer than you think.

8. Write with the approver and decision maker in mind, as this will help you identify all of the possible objections and allow you to cover them off in the document.

9. Keep it as simple and jargon free as you can.

10. If terminology or technical terms are necessary make sure you explain them.

11. Write fast and edit slow.

12. Check all calculations carefully.

13. Make sure you are complying with all current guidelines and taking into account any developments which are imminent.

14. Make sure your desired outcomes are robust.

15. Hold core information centrally so you can use this time and time again.

16. Make sure you provide confidence and assurance through sound project and risk management arrangements.

17. Longer does not mean better. A shorter high quality case is often more powerful.

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Appendix C - Guidance Notes for Assessing Project Risks

Step 1: Assess the actual consequence of the event

Grade Delay/impact on project Number residents affected

Impact on services or organisation’s reputation

None No obvious harm 0 - 1 No service disruptionLow financial loss <£10k

Minor Minor delay (delay up to 1 month)

1 – 10 Financial loss £11k -£50k<3 days local media publicity

Moderate Small delay (1 month to 6 months)

11-100 > 3 days local media publicityFinancial loss £51k - £500kFailure of support services (including security)Underperformance against other targetsModerate business interruption

Major Major issue (more than 6 months delay)

100-1000 Adverse national publicityTemporary service closureIntermittent failure of critical serviceUnderperformance against key targets

Catastrophic Inability to continue/complete project

Many (>1000)

International adverse publicitySevere loss of reputationComplete breakdown of critical servicesMajor underperformance of key targetsSignificant overspendFinancial loss >£1 M

Step 2: Assess the likelihood of the event occurring/recurring

Examine what current controls are in place. Given the current arrangements, use the table below to assess the probability of the event occurring or recurring. Write this grade in the box on the risk assessment.

Likelihood DescriptionRare The event may occur only in exceptional circumstances given existing controlsUnlikely Not expected to occur given existing controlsPossible The event could recur occasionally given existing controlsLikely The event will probably occur again given existing controlsAlmost certain The event will occur frequently given existing controls

Step 3: Score

Likelihood Consequence None Minor Moderate Major CatastrophicRare Very low Very low low Moderate HighUnlikely Very low Very low low Moderate HighPossible Very low Low Moderate High HighLikely Low Low Moderate High HighAlmost certain Low Low Moderate High High

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i UK Government. 2014. ‘The Care Act’. Available at: http://www.legislation.gov.uk/ukpga/2014/23/contents/enacted

ii NHS England. 2015. ‘Social Prescribing’. Available at: http://www.vas.org.uk/UserFiles/File/Miscellaneous/lindsay.Manning.NHSEnglandStrategyTeam.PersonCentredPlanning_.Social_Prescribing.pdf

iii Public Health England, NHS England. 2015. ‘A guide to community-centred approaches for health and wellbeing. Full report.’ Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/417515/A_guide_to_community-centred_approaches_for_health_and_wellbeing__full_report_.pdf

iv Coalition for Collaborative Care and NHS England. 2015. ‘Personalised care and support planning handbook: The journey to person-centred care. Executive Summary. Available at: http://www.england.nhs.uk/wp-content/uploads/2015/01/pcsp-guid-exec-summ.pdf

v Open Bolton. ‘About Open Bolton’. Available at: http://www.openbolton.co.uk/about.aspx

vi Friedli, L et al. 2012. ‘Evaluation of Dundee Equally Well Sources of Support: Social Prescribing in Maryfield. Evaluation Report Four’. Available at: http://www.dundeepartnership.co.uk/sites/default/files/Social%20prescribing%20evaluation%20report.pdf

vii Brandling J, House W. 2009. ‘Social prescribing in general practice: adding meaning to medicine’. The British Journal of General Practice; 59(563):454-456.

viii South, J. et al. 2008. ‘Can social prescribing provide the missing link?’ Primary Health Care Research and Development. 9(04):310 - 318.

ix Bungay, H. Clift, S. 2010. ‘Arts on prescription: a review of practice in the UK. Perspect Public Health. Nov 130 (6): 2077-81.

x South, J. et al. 2008. ‘Can social prescribing provide the missing link?’ Primary Health Care Research and Development. 9(04):310 - 318.

xi Age Concern Yorkshire and Humber, and Age UK. ‘Social prescribing: A model for partnership working between primary care and the voluntary sector. Available at: http://www.ageconcernyorkshireandhumber.org.uk/uploads/files/Social%20Prescribing%20Report%20new.pdf