EvaluationoftheEastMertonSocialPrescribingPilotJuly2018

ReportbyHealthyDialoguesLtd.

Pilotdeliveredby:

2

Contents

3

EastMertonSocialPrescribingPilotHighlights 2

ExecutiveSummary 4

Introduction 6

ThePilot:AnOverview 10

Evaluation:WhatWeDid 12

Results 14

KeyFactorsForSuccess 23

TheSocialPrescribingPilotPathwayReview 25

Recommendations 29

Conclusion 32

References 34

Appendices 37

-  AppendixA:PatientexperiencesofSocialPrescribing 38

-  AppendixB:GPPracticeFocusGroups 46

-  AppendixC:InterviewswithStakeholdersandSPC 51

-  AppendixD:InterviewswiththeVoluntaryandCommunitySectorServices 57

-  AppendixE:SocialPrescribingInterventionObservations 64

TheEastMertonSocialPrescribingPilot

MertonCCGandMertonCouncilsetouttotestamodelofSocialPrescribingthatwould

connectmedicalcarewithlocalvoluntaryandcommunityresources.Itsaimswereto

improvepatienthealthandwellbeingandreducepressuresonlocalGPandA&Eservices.

TheMertonVoluntaryServiceCouncilSocialPrescribingCoordinator(SPC)deliveredthe

pilotthroughtwoGPPractices,WidewayMedicalCentreandTamworthHouseMedical

Centre.

ThisreportisasummativeevaluationoftheEastMertonSocialPrescribingprogramme’s

firstyearandareviewofitspathway.

EvaluationFindings

Overalltheprogrammewasamarkedsuccess.Thepilotsawasignificantincreaseinhealth

andwellbeingaswellassignificantdecreasesinbothGPappointmentsandA&E

attendancesinpatientsreferredtotheservice.

Conversationswithpatientsandstakeholdersalikeshowedthatthepilotwashighlyvalued

andseenasanecessaryservicethatfilledagapinlocalneeds.Patientscreditedthe

programmetoimprovingtheirwellbeing,bringingthembacktorecoveryandlinkingthem

tosupportclosetotheirdoorstepsthattheydidnototherwiseknowabout.

GPsvaluedthattheyareabletoprovideadditionalsupportforpatientswithwiderhealth

andwellbeingneedsfromwithinthepracticeandasaresultGPsnotedthatsomepatients

requiredfewerappointmentswiththem.Thosefromthevoluntaryandcommunitysector

servicesspokepositivelyabouthowtheprogrammefillsaneedinMertonofproviding

holisticsupportforpatients.

ExecutiveSummary

4

Conclusion

ThepilotdemonstratedamodelofSocialPrescribingthatfitswellwithintheEastMerton

context.Thesuccessoftheprogrammeistestamenttothecommitmentandexpertiseof

theImplementationGroup,theSPCandchampionGPs,theflexibilityandsimplicityofthe

service,strongengagementandtheprogramme’svisibilitywithinthepractices.

Thekeyfactorsforsuccessareoutlinedandrecommendationsforup-scalingthe

programmeareprovidedinthisreport.

Nextsteps

FromApril2018twoadditionalSPCshavebeenrecruitedandtheprogrammehasbegunto

berolledoutacrossatotalof9GPpracticesineastMerton.

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WorkinginpartnershipMertonCCG,MertonCouncilandMertonVoluntaryServiceCouncilsetouttopilotamodelofSocialPrescribingthatwouldconnectclinicalserviceswithlocalvoluntaryandcommunityservices.ItsaimsweretoimprovepatienthealthandwellbeingandreducepressuresonlocalGPandA&Eservices.

Thisreportisanevaluationofthefirstyearofthepilot.FirstitwillprovideanoverviewofSocialPrescribing,thepilotandhowitwasevaluated.Itwillthenpresenttheresultsoftheevaluationintermsofwhowasengagedbytheserviceandtheiroutcomes.Finally,thereportwillhighlightsomeofthekeyfactorsthatcontributedtothesuccessofthepilotandpresentaqualitativereviewofthepilot’sSocialPrescribingpathwayandrecommendationsforupscalingtheprogramme.

ACaseforChangeThecaseforcommunity-basedmodelsforhealthandwellbeingpromotionsuchasSocialPrescribingisstrong.TheFiveYearForwardView(NHSEngland,2014)emphasisesthatNHSsystemsareincreasinglyunderpressureasourpopulationliveslongerwithmorecomplexhealthissues.DemandsonGPservicesarealsoincreasingatatimewhenfunding

andworkforceresourcesarereducing(Bairdetal,2016).

AccordingtotheDepartmentofHealth(2015),peoplewithlongtermconditionsarethemostfrequentusersofhealthcareservices,accountingfor50%ofallGPappointments

and70%ofallinpatientbeddays.Citizen’sAdvice(2016)estimatesthat20%ofGPappointmentsareforpatientswhoneednon-medicalhelporsupport.

ThesustainabilityoftheNHSanditssystemsisreliantonaradicalupgradeofpreventionandpublichealthwork.TheFiveYearForwardViewhighlightsseveralwaysinwhichthis

canbeachieved,including:

Introduction

6

•  Empoweringpatientsbyimprovingtheiraccesstotherightinformation

•  Supportingpatientstomanagetheirownhealth

•  Buildingstrongerpartnershipswiththevoluntaryandcommunitysectors(NHSEngland

2014).

Additionally,theCareActof2014putsdutiesandresponsibilitiesonlocalauthoritiesto

promotewellbeingandensurepeoplehaveaccesstotheinformationandadvicethey

needtomakedecisionsabouttheircareandsupport.Existingresourcesfromwithinthe

localcommunitycanensurethatpeoplehaveaccesstoarangeofhighquality,appropriate

servicestochoosefromintheareatheylivein.

SouthwestLondonSustainabilityandTransformationplan(SWLCCG,2016)goesonestep

furtherwithambitionstodelivermorecareinthecommunityandimplementrobust

multidisciplinarycommunityworksupportedbySocialPrescribing.

WhatisSocialPrescribing?

SocialPrescribingprovidesGPswithanon-medicalreferraloptionthatcanoperate

alongsideexistingclinicaltreatmentstoimprovehealthandwell-beingandaddressthe

socialdeterminantsofhealth-theconditionsinwhichpeopleareborn,grow,live,workand

age(WHO,2018).

TheNationalSocialPrescribingNetworkdescribeSocialPrescribingas-

“AmeansofenablingGP’sandotherfrontlinehealthcareprofessionalstoreferpatientsto

alinkworker-toprovidethemwithafacetofaceconversationduringwhichtheycan

learnaboutthepossibilitiesanddesigntheirownpersonalisedsolutions,i.e.‘co-produce’

their‘socialprescription’-sothatpeoplewithsocial,emotionalorpracticalneedsare

empoweredtofindsolutionswhichwillimprovetheirhealthandwellbeing,oftenusing

servicesprovidedbythevoluntary,communityandsocialenterprisesector”

-  SocialPrescribingNetworkConferenceReport(2016)

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Thesocial,emotionalandpracticalneedscanhaveasignificantimpactonimprovingand

maintaininghealthandwellbeingandhelpwiththesesocialdeterminantsaretypically

availablewithinlocalcommunities(Parsfieldetal,2015).

WhatistheevidenceforSocialPrescribing?

EvaluationoftheeffectsofSocialPrescribingisgrowing.Mostrecentstudiesareshowing

improvementsinpatientengagementandwellbeingandareductioninhealthcareusage

followingaSocialPrescribingintervention.Forexample,awellbeingSocialPrescribing

programmebasedinRotherhamfoundthatpatientsshowedsignificantimprovementin

wellbeing,depressionandanxietyandapotentialreductioninGPappointmentsthree

monthsfollowingaSocialPrescribingintervention(Kimberleeetal,2013).

ADundeeprogrammereportedthatpatients,includingthosewhocanbedifficultto

engageandsupport,foundtheschemeappropriatetotheirneeds,helpfulandaccessible

witharangeofactivitiesandsupport.Additionally,pre-andpost-interventiondatashows

significantimprovementsinwellbeingandfunctionalability(Frieldli,2012).

Asix-monthpilotschemeinTowerHamletsshowedthatpatientsgotinvolvedinarangeof

activitiesasaresultoftheSocialPrescribinginterventionincludingvolunteering,takinga

course,gainingaqualification,stoppingsmoking,startingahobbyandgainingcontrolover

theirfinancialsituation.35%ofpatientstookuponeortworeferredservicesand75%

statedthattheirissuewaspartiallyorfullyresolvedandthattheyweresatisfiedfollowing

theintervention(Hogarthetal,2013).

AsystematicreviewoftheevidenceoftheimpactofSocialPrescribingonhealthcare

demandandcostimplicationsshowedaveragereductioninGPappointmentsby28%and

A&Eattendanceby24%followingareferraltoSocialPrescribing.Italsoshoweda

statisticallysignificantreductioninreferralstohospital(Pollyetal,2017).

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Cost-effectivenessofSocialPrescribing

Thelong-termcostbenefitsofSocialPrescribingarenotyetclear.However,short-term

cost-effectivenesshasbeenestimatedfortheDoncasterSocialPrescribingprogramme.

Itusedcost-utilityanalysistoevaluatecost-benefitsofpatient’simprovementsinhealth-

relatedqualityoflife.Theprogrammeestimatedthatevery£1spentontheservice

producedmorethan£10ofbenefitsintermsofbetterhealth(SheffieldHallamUniversity,

2016).

EastMertonModelofHealthandWellbeing

In2014,apopulationhealthneedsassessmentfoundthatpeopledieyoungerinEast

MertonwhencomparedwithWestMerton,particularlyfromcardiovasculardiseaseand

cancer,withlargerdifferencesseeninyoungerpeople.Theassessmentlookedatexisting

community-basedmodelstotransformcareforlong-termconditionsandhighlightedthe

opportunitytomakeimaginativeandeffectiveuseofcommunity-basedapproaches(Dent,

2014).

Inresponsetothis,MertonCCGaredevelopinganewmodelofcaretomeetthehealth

andsocialcareneedsforthepeopleofEastMerton.ThisEastMertonHealthand

Wellbeingprogrammeisablueprintfortransformationacrosstheboroughthatworks

beyondservicedeliverytobuildanddevelopasocialmodelofhealththatlooksatthe

wellbeingofindividuals.Additionally,itlookstoaddressthegapbetweenshrinkingNHS

resourcesandincreasingdemandonservices.

OneofthepiecesofworkwithinthismodelwastopilotaSocialPrescribingprogramme

thatutilisesacollaborativepathwaydesignedtofreeupGPprofessionaltimewhile

connectingpeopletotheircommunityandcommunityresources.

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TheEastMertonSocialPrescribingpilotprogrammewasfundedbyMertonPartnership,

MertonCCGandMertonCouncilPublicHealthtorunforjustoveroneyearfromJanuary

2017.Thepilotbegantoseepatientsfromthe1stofFebruary2017.

Thepilotwasguidedbyanimplementationgroupofstakeholdersfromthevoluntaryand

communitysector,CCG,LocalAuthorityandGeneralPractice.Thepilotprogrammewas

deliveredbyMertonVoluntaryServiceCouncil,whoemployedaSocialPrescribing

Coordinator(SPC).

TwoGPpracticesinEastMerton;TamworthHouseMedicalCentreandWideWayMedical

Centre,wereselectedtohostthepilotprogrammeastheywereideallylocatedwithinthe

eastofMerton.TheSPCworkedatbothpracticesfortwodaysaweekeachandwasvisible

asafullyintegratedmemberofthepracticeteams.

Thepilotaimedtopromoteself-help,socialengagementandresiliencetoitspopulationin

EastMertonby:

•  Providingamodelofservicedeliverythatconnectsmedicalcarewithlocalresources;

and

•  Establishingacollaborativepathwaybetweentheprimarycareandvoluntaryand

communityservices.

Theoverarchingaimsofthepilotwereto:

•  Improvethehealthandwellbeingofpatientsbyprovidingaccesstonon-medical

support.

•  Reducegeneralpracticeclinicalworkloadwhileincreasingskill-mixwithinprimarycare.

•  ReduceavoidablecostsincludingA&Eattendancesandhospitaladmissions.

ThePilot:AnOverview

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Typically,GPswouldreferpatientstotheprogrammeiftheypresentedwiththefollowing

criteria:

•  FrequentattendancetoGPservices

•  Socialisolation

•  Mild/moderatementalhealthissues

•  Socialneeds

•  Recenthospitaladmissions

TheSPCwouldbookaone-hourinitialconsultationappointmentandofferthepatienta

needsassessmentthatisstructuredaroundtheWellbeingSTAR(Figure5,page18).The

SPCandpatientwouldthenagreeaplanofactionbasedonthatneedsassessmentthat

mayincludemakingareferralorsignpostingtoactivitiesprovidedbythelocalvoluntary

andcommunitysector,basicassistancewithformfilling,benefitseligibilitychecksor

engagementwithmentalhealthservices.WhereneededtheSPCwouldofferafollow-up

appointmentatthree-monthlyintervals.

FromApril2018theprogrammehasbeguntoberolledoutacrossallninepracticesinEast

Merton,withtwoadditionalSPCs.

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Thisevaluationemployedamixed-methodsapproachtoreviewhoweffectivetheSocial

PrescribingpilotisinimprovingthehealthandwellbeingofpatientsandreducingGP

practiceclinicalworkload.Theevaluationlookedattheprocessesinvolvedinthe

developmentoftheSocialPrescribingpilot,itsimpactandpotentialbyexploringallthe

differentfacetswithintheSocialPrescribingPilotLogicModel(Figure1).

PatientdatawascollectedfromtheGPdatabaseEMISandtheOutcomesSTAR-ahealth

andwellbeingquestionnairethatpatientscompletedateachvisit(figure5,page18).The

researchersspokewitharangeofpeopleinvolvedintheprogrammeabouttheir

experiencesofthepilotandviewsonthefollowing:pathway,accesstoengagement,

communicationanddatatransferandscalability.

Thefollowingpeopleparticipatedininterviewsorfocusgroupsforthisevaluation:

•  GPpracticestaff

•  Patients

•  SocialPrescribingCoordinator

•  ImplementationGroupmembersandstakeholders

•  Voluntaryandcommunityserviceproviders

Additionally,theevaluatorsobservedtheSocialPrescribinginterventionsatthebeginning

ofthepilotandtowardstheendofthepilottofeedbackonthebehaviourchange

conversations.Eachofthequalitativeanalysesaresummarisedintheappendices.

Evaluation:WhatWeDid

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Figure1:EastMertonSocialPrescribingPilotLogicModel.

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Theresultsinthisreportarepresentedasananalysisofpatientdemographics,reasonsfor

referralandoutcomes.Additionally,theinterviewsandfocusgroupshaveprovidedinsight

astothekeyfactorsofsuccess,howthepilotpathwayworksandrecommendationsfor

upscalingin2018.

TheresearchersundertookananalysisofthepatientsthathavebeenreferredtotheSocial

Prescribingprogrammeinthefirstyearofthepilot(1stFebruary2017to31stJanuary

2018).Theanalysisthatfollowsprovidesanoverviewofthosereferred,theirwellbeing,GP

appointmentsandA&Eattendances.

Patientdemographics

Inthe12monthpilotperiodbetweenthe1stofFebruary2017to31stJanuary2018316

patientswerereferredtotheEastMertonSocialPrescribingprogramme,250ofwhom

werefromtheWideWayMedicalCentreand66fromTamworthHouseMedicalCentre

(seefigure2).Whatfollowsisabreakdownofthesereferralsbyage,genderandethnicity.

Ageandgender

ThereisgenerallygoodengagementwithallagegroupsfortheSocialPrescribing

programme.Thelargestproportionofpatients(15%)arebetween40and49yearsofage

andmorewomen(71%)havebeenreferredtotheprogrammethanmen(29%).

Results

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Figure2.NumberofSocialPrescribingpatientsbyage-group,genderandpractice

Ethnicity

Overhalf(55%)ofpatientsreferredwerewhite,followedbyblack(24%)andAsian(10%).

Theethnicityreachoftheprogrammegenerallyreflectstheethnicmake-upofthelocal

area(Dent,2014).

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Figure3.NumberofSocialPrescribingpatientsbyethnicity,genderandpractice

Reasonsforreferral

Theresearcherslookedatthereasonsforreferraltoreviewwhichpatientswerebeing

referredtotheserviceandwhethertheagreedeligibilitycriteriawasappropriateforthe

needsofthepatientsandtheprogramme.

OuranalysisofthereasonforreferraltotheSocialPrescribingprogrammewasbasedon

theSPCdataratherthanGPpracticedata.Thismeansthatthereasonsasdeterminedby

theSPCmaydifferfromtheGP’soriginalreasons.Theresearchersadaptedthisapproach

becausetheSPCdatawasmorecomplete.

ThemajorityofthepatientsreferredtotheSocialPrescribingprogrammewerereferred

formorethanonereason.Themostcommonreasoncitedwasmild/moderatemental

healthissues(seefigure4).Thenextmostcommonreasonscitedwasforlong-term

physicalcondition(s)whichwasnotwithintheagreedreferralcriteriafortheintervention.

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Theseresultsareindicativeofwhichpatientsareeligiblefortheprogrammeandfuture

evaluationscanreviewtheeligibilitycriteriamoreclearlyonceallGPsareroutinely

followinganagreedreferralprocess.

Figure4.Reasonsforreferral

Outcomes

Wellbeing

AteachSocialPrescribingappointment,theSPCasksthepatientstofillintheWellbeing

Star.Therearesomeoccasionswhenthepatientdoesnotcompletethequestionnaire,this

istypicallyduetolanguagebarriers,learningdisabilityoremotionaldistressatthetimeof

theappointment.

TheWellbeingStarisareliableandvalidtool(Mackeithetal,2010andMackeith,2011),

thatlooksateighthealthandwell-beingsub-categoriesthatpatientsrateonascale

rangingfrom1(notthinkingaboutit)to5(asgoodasitcanbe).

Theresultsaredisplayedinastardiagramthatthepatientscanseeandcomparewith

previousresultsateachappointment(Mackeith,2014).TheStaranditssub-categoriesare

showninFigure5.

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Figure5:TheWellbeingStar

Figure6:TheNumberofStarreadingsperpatient.

DuringthepilottheSPCsaw206

patients,187ofwhomhadaStar

assessment.100patientshadonlyhad

oneassessmentbytheendofthe

pilotperiod.Seventy-fivepatients

completedtwoStarassessmentsand

12completedthree.

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Figure7.DistributionofoverallWellbeingscoresduringfirstandlatestSPCsession

Analysisshowsthataltogether,

patientswhoattendedSocial

Prescribingexperiencedan

improvementintheiroverallwellbeing

score(seefigure7).

Thepatient’saveragescoreatthefirst

appointmentwas2.8(SD=0.80).This

increasedto3.5(SD=0.83)bytheir

lastappointment.

Pairsamplest-testanalysisshowsthat

thisisasignificantincrease(t(86)=1.99;

p=0.00).

AlleightdomainsoftheSTARmeasureimprovedatthreemonthfollowup,withthegreatestin

the‘lifestyle’domainandtheleastinthe‘whereyoulive’domain(Figure8).Astatistically

significantincreasewasfoundacrosseachdomain.Figure8.WellbeingscoresduringfirstandlatestSPCsession

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GPappointmentsThenumberofGPappointmentsapatientattendsbeforeandafterengagingwiththe

programmecanindicatewhetherthereisanyimpactonclinicaloutcomes.

Toimprovetheaccuracyoftheassessment,thedaythepatientwasfirstseenbytheSPC

andaStarassessmentcarriedoutwasusedasthebaselinedate.Theresearcherslookedat

thenumberofGPappointmentsatthreeandsixmonthspre-andpostSocialPrescribing

intervention.

ThreemonthchangeinGPappointments

Atthepointofdatacollection,therewere138patientsseenbytheSPCatleast3months

beforethedatacollectionpoint.ThisallowedthestudytoexaminetheirGPappointment

ratesthreesmonthsbeforeandthreeafterfirstseeingtheSPC.Inall,theytookup1,641

appointmentsbeforetheSocialPrescribinginterventionand1,098afterwards,

representingareductionof543appointments(33%)inthepilotyear.

Figure9:DistributionofGPappointments,threemonthspre-andpostSocialPrescribing

Theaveragenumberof

appointmentsperpatient

reducedfrom11.9(SD=9.48)

to8(SD=6.85).

Pairedsamplest-testanalysis

showsthatthisisastatistically

significantreductioninthe

numberofappointments

(t(137)=1.98;p=0.00).

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SixmonthchangeinGPappointments

Atthepointofdatacollection,therewere101patientsseenbytheSPCforwhomthere

wassixmonthspre-andpostGPappointmentfigures.Altogethertheytookup2,013

appointmentsbeforetheSocialPrescribinginterventionand1,790afterwards,thisisa

reductionof233appointments.

Figure10:DistributionofGPappointments,sixmonthspre-andpostSocialPrescribing

Theaveragenumber

ofappointmentsper

patientreducedfrom

20(SD=14.08)to18

(SD=13.18).

Howeverthis

reductionisnot

statistically

significant

(t(100)=1.98;p=

0.08).

A&Eattendances

ThepilotalsoexaminedtheeffectofSocialPrescribingonA&Eattendancestoascertain

howitmayimpactonthewiderhealthcaresystem.

ThreemonthchangeinA&Eattendances

Duringthepilot,60patientsattendedA&E39timesinthethreemonthsbeforetheSP

interventionand20timesafterwards(areductionof19overall).Theaveragenumber

21

ofappointmentsperpatientdroppedfrom0.65(SD=1.31)to0.33(SD=0.73).Thisisnotastatisticallysignificantdecrease(t(59)=2.00;p=0.11).

SixmonthchangeinA&EattendancesThepilotsaw43patientswhoattendedA&EinthesixmonthsbeforetheSocialPrescribingintervention.IntotaltheyvisitedA&E60timesbeforeand31timesafterwards,leadingtoareductionof29visitsoverall.

Figure11:DistributionofA&Eattendances,sixmonthspre-andpostSocialPrescribing

Theaveragenumberofappointmentsperpatientdroppedfrom1.4(SD=1.65)to0.7(SD=0.93)(seeFigure11).Thisisastatisticallysignificantdecrease(t(59)=2.01;p=0.04).

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Overall,thoseinterviewedspokeverypositivelyabouttheprogramme.Theyfeltthatthe

pilothadbeensetupsuccessfully,isrunningsmoothlyandprovidingstronghealthand

wellbeingoutcomesforpatientsbyconnectingthemtoresourcesavailabletothemin

theirowncommunity.

Thekeyfactorsforsuccesshavebeendrawnfromtheinterviewsandfocusgroupsandare

outlinedbelow.

Mobilisation

•  StrongengagementwithintheImplementationGroupensuredthatallkey

stakeholdershadagreedonwhattheSocialPrescribingmodellookedlikeandwhatthe

referralcriteriawas.

•  ByusingtheexistingsystemswithinthepracticestheSocialPrescribingprogramme

andSPCwaseasilyembeddedwithintheGPPractices.

•  WheretherewasstrongengagementandvisibilityoftheSPCwithinthepractice,

morereferralstotheprogrammewereseen.

•  ByensuringtheearlysetupofITsystemstheSPChadaccesstopatient’scase

managementsystemsandcouldbookpatientappointmentsstraightawayand

understandthecircumstancesaroundwhytheywerereferred.

•  TheGPChampionwaskeyintranslatingthe‘blue-sky’ideasinthepilotstrategyinto

practicalsolutionsfortheprojectplanandpathway.Hehadalsobeenkeytoraisingthe

profileoftheprogrammeandchampioningtheprogrammeinhisownpractice.

KeyFactorsforSuccess

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SocialPrescribingappointments

•  Patientsareseenwithintwoweeksofreferralwhichenabledthemtoaddresstheir

issuesorconcernsquicklythroughvoluntaryandcommunitychannels.

•  TheWellbeingToolsurveyaddedstructuretotheSocialPrescribingappointments.This

helpedpatientstothinkabouttheirsituationmorethoroughlyandallowedthe

evaluatorstoseetheimpactofSocialPrescribingonthepatient’shealthandwellbeing

overtime.

•  TherelaxedpersonalapproachoftheSPChelpedbuildgoodrapportandatrusting

relationshipwiththepatients.AdditionallytheSPCsabilitytoaddresssomeissues

‘thereandthen’helpedpatientstotakethatfirststeptowardssupportingtheir

recoverywhichwasvaluedhighlybypatients.

•  TheSPC’sstronglinkstothecommunityandbreadthofknowledgeofsupport

availableenabledpatientstoaccesstheavailableappropriatesupportrightaway.

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ThisfinalpartofthisreportisaqualitativereviewoftheSocialPrescribingPilotPathwayanditskeyfeatures,asdescribedbythepatientsandprofessionalswespokewith.

Thekeyfeaturesinclude:referralprocessesanddatacollection,theSPCappointmentsystemandreferralsandsignpostingtothevoluntaryandcommunityserviceSector.Thesearesummarisedinthefollowingpages.

Figure12representsthepilotSocialPrescribingpathwayasoutlinedbythepeopleinterviewedthroughouttheyear.

Figure12:EastMertonSocialPrescribingPilotPathway

SocialPrescribingPilotPathwayReview

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GP

SPC

Voluntaryand

CommunityServices

AdhocFeedback

VariedFeedback

•  AllreferralsarebyGP•  Onepracticedescribesathree-step

approachtomakingareferral

•  SPCreviewsreferralformorEMISdataandcallspatienttoarrangefirstappointment

•  SPCwillseepatienteverythreemonthsuntildischarge

•  SPCrecommendsvoluntaryandcommunityservicesandsignpostsorsupportspatient’sfirstcontactwiththeservice.

•  SPCmaycalltheservicetofollow-uppatient

Referralprocessesanddatacollection

AtthebeginningofthepathwaytheGPscreenspatientsandthenrefersthoseeligiblefor

theprogrammetotheSPC.

ThereferralprocessisdescribedbythetwoGPpracticesindifferentways.Whilst

WidewayMedicalCentreGPsfinditaquickandeasyprocess,TamworthHouseMedical

CentreGPsdescribeathree-stepprocessthattheybelievecouldbesimplified(see

AppendixB).Futureprogrammeswouldbenefitfromco-designingthereferralprocesses

sothatitfitswellwithinthepracticesexistingsystemsandGPswillfindquickandeasyto

do.

CurrentlynotallGPscompletetheagreedreferralformandinsteaduseothermeanssuch

asemailstomakeareferral.ThissometimesmadeitdifficultfortheSPCtohaveafull

understandingofthecontextofthereferralasdetailsthatwereintheagreedreferralform

werefrequentlymissing.Additionally,theassessorsfoundthatthereasonsforreferralas

recordedbytheSPCwereoftendifferentfromthereasonsstatedbytheGP.Clear

guidelinesonthereferralcriteriawillhelpalignthediscrepanciesbetweenGPsandthe

SPConwhyapatientisreferred.

Thetwopracticesalsodescribethedifferentlevelsoffeedbacktheyreceiveregardingthe

patientinterventiononcetheGPhasreferredtotheSocialPrescribingprogramme.Some

GPsfeelthattheyreceivedgoodfeedbackonthepatientfollowingtheirfirstSocial

Prescribingappointment,whereasothersfeeltheywouldbenefitfromamoresystematic

approachtoreceivingfeedback.Astandardisedcomprehensiveapproachtoproviding

feedbackonreferralsagreedbyallpartieswillpreventanygapsincommunication

betweentheSocialPrescribingprogrammeandthecliniciansreferringtothem.

26

27

Finally,bothpracticestaffandpatientshaverecommendedtoallowreferralsfromthe

practice’swiderclinicalteamwithaviewthatthiswillspeedupreferralsforpatientsand

preventunnecessaryGPappointments.

TheSocialPrescribingintervention

AstheSocialPrescribingprogrammeprogressedthroughitspilotyeartheSPChastried

andtesteddifferentwaystoapproachsessionswiththepatients.Additionally,the

evaluatorobservedappointmentsatthebeginningoftheyearusingtheBehaviourChange

CounsellingIndex(Laneetal,2005)andmadesomesmallrecommendationsregardingthe

intervention.TheserecommendationsweretakenonboardbytheSPCandeffective

improvementswereseenwhentheappointmentswereobservedforasecondtime

towardstheendofthepilotyear.

SPCappointmentsystem

OnceapatienthasbeenreferredtotheprogrammetheSPCwillseethemface-to-facefor

45minutesatthree-monthlyintervals.Thiswasmodeledonbestpracticegleamedfrom

othersuccessfulSocialPrescribingmodelsacrossthecountry.Thepatients,SPCand

practiceclinicalteamhaveeachhighlightedthatthereisroomforflexibilityinthis

approachsothatthereareoptionsforpatientswhocannotattendfacetoface

appointmentsduringworkhoursandtheSPCstimecanbeusedmoreefficiently.

Currently,thereisnodischargeguidelineorpolicythattheprogrammefollows,ratherthe

patientwillseetheSPCuntiltheynolongerneedtheserviceortheystopattending.This

hasnotposedanyissuesfortheprogrammeinthisoneyearpilot.However,awelldefined

setofguidelinesondischargingpatientswillempowertheSPCtosupportclientsto

transitionawayfromtheserviceoncetheycompletetheintervention.

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Referralsandsignpostingtothevoluntaryandcommunity

servicesector

TheroutefromtheSocialPrescribingprogrammetothevoluntaryandcommunitysector

variesfromservicetoserviceanddependingontheneedsofthepatient.Forexample,

someservicesrequirepatientstoself-referwhichtheSPCwillsignpostthepatientto,

whereastheSPCcanrefertootherservicesdirectly.Incaseswherepatientswould

benefitfromsupporttotakethatfirststeptheSPCwillmakeaphonecalltotheserviceto

initiatetheprocess.

QuiteoftenserviceswillbeunawarethattheSocialPrescribingProgrammehassignposted

tothemorbecauseofpatientconfidentialityareunabletoreportifapatienthasbeenin

contactwiththem.Asaresult,thefeedbackregardingtheoutcomesofthesereferralsis

oftennotpossibleorisinconsistent.Itisthereforenotpossibletoevaluatewhatreferrals

orsignpostsareworkingwellandforwhom.

Thefindingswithinthisreportwerepresentedanddiscussedwithrepresentativesofthe

ImplementationGroupandthefollowingrecommendationswereagreed.

ReferralProcessesandDataCollection

1.  ThereferralprocessfromGPtoSPCbeco-designedwitharepresentativefromeach

practiceandtheSPCduringthemobilisationphaseorassoonaspossible,andthe

referralcriteriabereviewedaspartofthisprocess.Thiswillensurethatthereferral

processfitswellwithinthepractice’sexistingsystemsandclinicianshavean

opportunitytoinputtoitsdesigntoensurethatit’sfeasibleforthemtouse.

2.  TheSPCtoacceptreferralsfromthepractices’widerclinicalteamtospeedupreferrals

timesandfreeupGPappointments.

3.  AsystematicapproachfortheSPCtofeedbacktotheclinicianontheoutcomesofthe

SocialPrescribingintervention.Thiscouldbeasimpleprocesssuchasprovidingverbal

feedbackatteammeetingsoremails.

SocialPrescribingIntervention

4.  SPCshaveexperienceortrainingonbehaviourchangeconversationssotheyhavethe

skillstobuildrapportwithpatients,supportthemtobuildtheirself-efficacyand

navigatearoundbarrierstochange.

5.  FutureprogrammesbuildonbestpracticeastriedandtestedbytheSPC.

6.  Appointmentsfollowaclearstructurethatwillincludecollaborativeagendasetting,a

needsassessmentincludingusingSTAROutcomesandreferring/signposting.Where

patientsareunabletocompletetheSTAROutcomessurvey,thisshouldberecorded.

7.  TheSPCsignposttoamaximumoftwovoluntaryandcommunityservicesatatime

(wherepossible)soastonotoverwhelmthepatientandcausethemtodisengage.

8.  Theinterventionconcludewithawrittenagreementofstepstobetakensothatthey

canberecordedandreviewedatfurtherappointments.

Recommendations

29

SPCAppointmentSystem

9.  TheSocialPrescribingprogrammeshouldexploreandtesttheoptionofaflexible

appointmentsystemwherebyoncetheSPChasmadeinitialcontactwiththepatient,

incaseswherea45minuteface-to-faceappointmentisnotrequiredtheoptionofa

telephoneappointmentorreferraltoapracticehealthchampionisavailable.Thiswill

freeupappointmentspacesforadditionalpatients.

10.  AsetofpatientdischargeguidelinesbeagreedbetweentheSPCsandclinicalteamso

thatpatientswhohavecompletedtheprogrammecanhaveasmoothtransitionaway

fromtheservice.

ReferralsandSignpostingtotheVoluntaryandCommunity

ServiceSector

11.  TheSocialPrescribingprogrammeengageswiththeservicestheyreferintomost

frequentlytoco-designaprocessforprovidingfeedbackontheresultsofthereferral,

includinganypatientoutcomes.

12.  Theprogrammeimplementsasystematicapproachtoobtainingfeedbackfrom

patients.IdeallytheSPCascertainswhetherthepatientfollowed-uponthereferralor

signposting,howtheyratedtheserviceandverbalfeedbackontheirviewsonthe

service.ThiswouldberecordedbytheSPCsforanalysis.

TheresultingrecommendedpathwayforEastMertonSocialPrescribingprogrammeis

presentedinFigure13.

30

Figure13:EastMertonSocialPrescribingFuturePathwayProposal

31

GPPracticeClinicalTeam

SPC

Voluntaryand

CommunityServices

SystematicfeedbacktoGP

Feedbackfromkeyservicesand

patients

•  ReferralsbyGPs,practicenursesandpracticepharmacist

•  Co-designreferralsystem

•  Flexibleappointmentsystem•  StructuredSocialPrescribing

Interventionsusingbehaviourchangeconversationalskills

•  Signposts/referralstonomorethantwoservicesatatime.

•  Co-designfeedbacklooptoSPCwithkeyservices

MertonCCGandMertonCouncilPublicHealthteamsetouttoimplementanewmodelof

caretoaddresshealthinequalitiesinEastMerton.ThisSocialPrescribingpilotmodel

wouldprovideGPswithanoptiontorefertheirpatientstonon-medicalsupportforthe

widerdeterminantsofhealthandconnectthemtotheircommunityandtheresources

withinit.

Thisevaluationreviewedtheprocessesandoutcomesofthemodel,specificallythepilot

pathwayandwhethertheprogrammewouldimpactonthehealthandwellbeingof

patients,GPclinicalworkloadandavoidablecostssuchasA&Eattendances.

MertonVoluntaryServiceCouncildeliveredthepilotthroughtwoGPPractices,Wideway

MedicalCentreandTamworthHouseMedicalCentre.Thepathwayandprocesseswere

modeledonbestpracticefromotherprogrammesinthecountry.

Overallthepilotwasasuccess.Theprogrammewaseffectivelysetupandembedded

withintheGPpracticesandgeneratedahighnumberofreferrals.

Positiveoutcomeswereseeninpatient’shealthandwellbeingandthepatients

interviewedreportedstronghealthoutcomesandbetterself-managementasaresultof

visitingtheSPC.AdditionallyGPappointmentsandA&Eattendancessignificantlyreduced

inthosereferredtotheprogrammewhichcanbringhugecostsavingsforbothGP

practicesandCCGs.

Interviewee’sattributethesuccessoftheprogrammetogoodplanning,thedriveand

expertiseoftheGPleadsandtheskillsandbreadthoflocalknowledgeoftheSPC,GPLead

andImplementationGroup.

Conclusion

32

NextSteps

Duetothesuccessseeninthispilotyeartheprogrammewillbeextendedandexpanded

acrossEastMertonwithinninepracticesfromApril2018.Recommendationsoutlinedin

thisreporthighlightareaswheretheSocialPrescribingpathwaycanbeperfectedforthe

comingyears.

33

Bairdetal.(2016)Understandingpressuresingeneralpractice.TheKing’sFund.

Braun,V.andClarke,V.(2006)Usingthematicanalysisinpsychology.QualitativeResearch

inPsychology[online].3(2),pp.77-101.

Burd,H.&Hallsworth,M.(2016).Makingthechange:Behaviouralfactorsinperson-and

communitycentredapproachesforhealthandwellbeing.Accessedat:

https://www.nesta.org.uk/sites/default/files/making_the_change.rtv_.pdf

CareAct(2014),Chapter23,accessedat:

http://www.legislation.gov.uk/ukpga/2014/23/pdfs/ukpga_20140023_en.pdf

Citizen’sAdvice(2016)Averygeneralpractice:HowmuchtimedoGPsspendonissues

otherthanhealth?

https://www.citizensadvice.org.uk/Global/CitizensAdvice/

Public%20services%20publications/CitizensAdvice_AVeryGeneralPractice_May2015.pdf

Dayson,C.,Bennet,E(2016)EvaluationofDoncasterSocialPrescribingService:

understandingoutcomesandimpact.SheffieldHallamUniversity.Accessedat:

http://www4.shu.ac.uk/research/cresr/sites/shu.ac.uk/files/eval-doncaster-social-

prescribing-service.pdf

DepartmentofHealth(2015)Policypaper:2010to2015governmentpolicy:longterm

healthconditions,availableat:

www.gov.uk/government/publications/2010-to-2015-government-policy-long-term-

health-conditions/2010-to-2015-government-policy-long-term-health-conditions

References

34

Dent(2014).TheHealthNeedsofEastMerton.PHAST.Accessedat:

https://www2.merton.gov.uk/merton_the_health_needs_of_east_merton.pdf

Frieldli,L.etal(2012).EvaluationofDundeeEquallyWellSourcesofSupport:Social

PrescribinginMaryfield.EvaluationReportFour.

Hogarth,S.etal(2013)SocialPrescriberPilotProjectEvaluation,January–June2013.The

BromleybyBowCentre.

LaneC,Huws-ThomasM,HoodK,RollnickS,EdwardsK,RoblingM.(2005)Measuring

adaptationsofmotivationalinterviewing:thedevelopmentandvalidationofthebehavior

changecounselingindex(BECCI).PatientEducationandCounseling2005;56:166-173.

MacKeith,J.andBurns,S.(2010)TheWellbeingStar:UserGuide,Brighton:Triangle

ConsultingSocialEnterprise

MacKeith,J.(2011).ThedevelopmentoftheOutcomesStar:aparticipatoryapproachto

assessmentandoutcomemeasurement.Housing,CareandSupport,14(3),98-106.

Mackeith,J.(2014).AssessingthereliabilityoftheOutcomesStarinresearchand

practice.Housing,CareandSupport,17(4),188-197.

NHSEngland,(2014)FiveYearForwardView.Accessedat:

https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

35

ParsfieldM.etal(eds)(2015):CommunityCapital-Thevalueofconnectedcommunities.

RSA.

PolleyMetal(2017).Reviewofevidenceassessingimpactofsocialprescribingon

healthcaredemandandcostimplications.Report.

https://www.westminster.ac.uk/file/107671/download

SouthwestLondonCollaborativeCommissioningGroup(2016)SouthwestLondon

SustainabilityPlan.Accessedat:

https://www.swlondon.nhs.uk/our-plan/our-plan-for-south-west-london/

WHO(2018)Aboutsocialdeterminantsofhealth.Accessedat:

http://www.who.int/social_determinants/sdh_definition/en/

36

AppendixA:PatientexperiencesofSocialPrescribing

AppendixB:GPPracticeFocusGroups

AppendixC:InterviewswithStakeholdersandSPC

AppendixD:InterviewswiththeVoluntaryandCommunityServices

AppendixE:SocialPrescribingInterventionObservations

Appendices

37

ThisevaluationsoughttoattaintheviewsofthepatientswhoattendedtheEastMerton

SocialPrescribingpilotonhowtheyfoundtheprogramme.Theresearchersspokewitha

totaloftwelvepatientsthroughtelephoneinterviewsandonefocusgroup(seeTable1).

Table1:Patientparticipantgroup.

Inordertorecruitpatientstoparticipateinthisevaluationwecontactedparticipantsfrom

arandomlistofpatientswhohadvisitedtheSocialPrescribingprogrammeoneormore

times.Twenty-threepatientsweretelephonedbytheresearch.Ofthosethatcouldbe

reached,threedeclinedtobeinterviewed,twocouldnotbecontactedattheagreedtime

andsixprovidedatelephoneinterview.Theresearchersstoppedcontactingpatients

whentheyreacheddatasaturation.Additionally,sixpatientswhowerecontactedbythe

SPCagreedtoparticipateinafocusgroup.

Thefocusgroupwasheldatthelocalcommunitycentre.Participantsweregiven£10

vouchersfortheirparticipation.

PatientsExperiencesofSocialPrescribing

FocusGroupPatients InterviewPatients

-  Female–carer(age40-49)

-  Female(age-40-49)

-  Male(age70+)

-  Female(age60-69)

-  Female(age40-49)

-  Female(age-30-39)

-  Male(age50-59)

-  Female(age-50-59)

-  Female(age-40-49)

-  Female-carer(age-30-39)

-  Female(age-40-49)

-  Male(50-59)

AppendixA

38

Theresearchersusedopen-endquestionedinboththetelephoneinterviewsandfocus

groups.Thisallowedustoexploretherangeoftopicswhileencouragingparticipantsto

expresstheirownperspectiveindetail.

Thefocusgrouplastedforonehourwhilethetelephoneinterviewslastedbetweenfive

and30minutes.Theywererecorded,transcribedandanalysedusingtheoreticalthematic

analysis.Thekeythemesarepresentedbelow.

GettingthatfirstappointmentAllparticipantstheresearchersspokewithhadnotheardoftheSocialPrescribing

programmeuntiltheirGPtoldthemaboutitandmadetheirreferral.InmostcasestheGP

gaveadescriptionoftheprogrammeandofferedtomakeareferral.Inthreecasesthe

patientsweregivenaleaflettotakeawayandreadmore.InallbutonecasestheSPC

calledthepatientwithinaweekofreferralandanappointmentwassetupwithintwo

weeks.

“Weweredealingwithmydepressionandtimeoffworkandthenextissuewasproblems

withdebtfrombeingoffwork.TheGPtoldmeabouttheservicesandhowtheywereright

thereinthepractice.”

Mostpatientswerecomplimentaryaboutthespeedatwhichtheywereabletoseethe

SPCaftertheywerereferred;usuallybetweenoneandthreeweeks.However,two

patientsdidnotfeelthattheywereabletoseetheSPCasquicklyasneeded.Onepatient

experiencedalongdelayasaresultofanerrorinthereferralprocess.

Fivepatientsfeltthattheywouldbenefitfromamoreflexibleapproachtothe

appointmentsystem.Thisincludedmoreregularappointmentsforthosepatientswho

needitandtheoptionofdrop-insessions.

AppendixA

39

Twopatientsmentionedthattheywouldhavepreferredtohavemoreflexibilityinhowto

reachtheirSPC.Currently,patientshavetocallthroughtotheirpracticereception,leavea

messageandwaitfortheirSPCtocallthemback.AlthoughtheSPChasalwaysresponded

totheminatimelyfashion,theyfeltthattheservicewouldbealittlebitmorehelpifthey

wereabletocallorevenemailtheSPCdirectlywhentheyneededto.

“Itwouldbebetterifhecouldbethereeveryday,orifthereisanyotherwayofcontacting

him.Idon’thavehisnumber,soIhavetocallthesurgeryandafterafewdayshecallsme

backandgivesmeatimeIcancomeintothesurgery.Ifwouldbegreatifwecouldgeta

contactnumbertogetstraighttohim.”

Thefocusgroupdiscussedhowtheywouldhavebenefitedmorehadtheybeenreferredto

theSPprogrammemuchsooner.Theyfeltthattheservicecouldbebetteradvertisedso

thatitcanreachthosepatientswhoneeditbeforetheirsituationbecomesmuchworse.

“Whenyouareinastate,therearesomanyotherthingsgoingon,anyhelpissomething…

oneofthemainthingsisthatIfoundreallyhardisthatIhadtohitrockbottombefore

knowingabouttheSocialPrescribing.YousitintheGPsallthetimeandthere’sthewall

withtheleaflets,andthereisnothingthereaboutSocialPrescribing.Ihadneverheardofit

before.IhadneverheardofthecontactsthattheSPCgaveme.”

“IhadhitthepointwhereIfeltsooverwhelmedthatIdidn’tknowwheretoturnto,I

literallylivedowntheroadandIdidn’tknowtheserviceswerejustthere.”

“ItwasnotuntilIsawhim(theSPC)didIfindoutaboutthingsthatcouldhavehelpedmy

parents10yearsago.Itmademeverysad.”

AppendixA

40

TheWellbeingtoolFouroftheintervieweestalkedabouttheWellbeingtoolasausefulwayofexaminingtheircurrent

situation.

TheydescribedhowtheSPCwouldworkthroughtheWellbeingStarquestionnaireatthebeginning

oftheirappointment.EachtopicintheOutcomesSTARactsasaprompttotalkabouttheirsituation

andhighlightanyissuesthattheycouldworkontogetherwittheSPC.

“TheSTARmakesyouthinkaboutthings,insteadofsaying“everythingisfine”itmakesyourealise

youaren’tbeingtrulyhonestwithyourself”

Thequestionnairealsoservesasareminderofwhattheytalkedaboutattheirlastmeetingand

whathaschangedsincethen.

“Itgivessomeperspectiveonhowyouarefeelingandrememberwhathasimprovedandwhatis

good”

FlexibilityofapproachAllthepatientswespokewithappreciatedtherelaxedandflexibleapproachoftheSPCduringtheir

appointmentsforanumberofreasons.Forexample,theSPCgavethetimetoexploretheir

situation;patientshaduptoonehourtotalkintheirinitialmeetings.ParticipantsstatedtheSPC

usesthattimetolistenwithoutrushing,jumpingtosolutionsormakingjudgements.

“Heisthepersonthatmakesyoufeelthatwhatyouaredoingisok,andeverythingthatyouare

doingisjustwhatyoushouldbedoing.”

“Heisveryopen,verygoodonhowheleadstheconversation,heopensthingsupandmakesyou

thinkaboutyoursituation.”

“Itismorenurturing,whereastheGPhasonlygot10minutes.”

AppendixA

41

AdditionallyahugevaluetothepatientswastheSPC’sabilityto‘simplypickupthephone

thereandthen’tocontactservices,especiallyattimeswhenpatientsweregoingthrougha

crisisandfeelunabletotakethatfirststep.

“[TheSPC]isabletositwithyou.Youarefrightenedtopickupthephone,oryoudon’t

remember,butheskipsthatandsays:rightwearegoingtofilloutyourformsnow,wecan

phonethemforyounow….Youareatthispointwhereyouarefeelingthat‘thereisnohelp

forme,Ican’tcope’.It’sareliefthatthereissomeoneinthecommunitythatwasworking

almostonourside.Tohelpustakethatstepaheadandtoalmostkeepaneyeonyou.It

hasbeenamazing.”

Patientsdidsaythattheywouldbenefitfrommoreregularappointments.Currently,

patientswhoseetheSPCregularlyhaveappointmentsatsix-weekintervals.Forsomeof

thepatients,thisistoolongagap.

“Thereisnooutsideappointmenttoseehowthereferralwentandifitworked.”

LinkswiththecommunityMostintervieweesdescribedthewealthofinformationthattheSPChastohandand

providestothem.TheyappreciatetheknowledgeandconnectionstheSPChaswiththe

serviceswithinthecommunity.

“HegotmeintouchwithplacesIdidn’teventhinkabout,Ididn’tknowthatwasthere,yet

itwasacrosstheroad”

“IhadtohittothepointwhereIfeltsooverwhelmedthatIdidn’tknowwheretoturnto,I

literallylivedowntheroadandIdidn’tknowtheserviceswerejustthere.”

AppendixA

42

Theydescribedthesimpleprocessbywhichtheyareprovidedinformationabouttheir

community.SometimestheSPCwouldprintoutinformationforthem,orgivethema

leaflet.SometimestheySPCwouldmakethatfirstphonecalltotheservicetogettheball

rolling.

“[TheSPC]calledthecommunitycentrerightawayandtoldmewhenIcouldgothereand

gavemeatimetable.‘Thesearetheirdetails’.”

Oftheservicesbroughtup,theCommonsideCommunityCentrewasmentionedmost

oftenandmostfavourably.Manyofthepatientswespoketowerereferredtothe

communitynavigatoremployedatthecentrewhowasabletotalkthroughtheirproblems

withthemandprovidearangeofpracticalsupporttothem.

Mostpatientsfeltthattheygotthesupporttheyneededinthecommunity.However,two

patientsdidmentionthattheywouldhavelikedtohavegonetosomesupportservicesfor

carers.Thesepatientscarefortheirelderlyparentswhileworkingfulltime,andtherefore

areunabletoattendduringtheopeninghoursoftheseservices.Positively,theywereable

togetthesupporttheyneededthroughtheCommonsidecommunitynavigatorinstead.

Fourpatientstalkedaboutthementalhealthsupporttheywerereferredto.Oncetheyhad

receivedthementalhealthsupporttheywereverypleasedwiththeservice.Theydid

howeverdiscusslongwaitingtimesbeforegettingtheirfirstappointment.

WhattheservicehasdoneforthemMostpatientstalkedfavourablyabouttheserviceandhowithelpedconnectthemtothe

resourcestheyneededorhelpedthemtryoutnewthingsthatwouldbenefitthem,suchas

volunteeringorsocialactivities.Otherscredittheprogrammeforhelpingbringthemback

torecovery.

AppendixA

43

“Igotinvolvedinvolunteering,itkeepingmeoccupiedandfocusedonwhatwasgoodand

offthedepressionitself.Thatwasgood.”

“HeaskedmewhatIlikedoing,ItoldhimthatIenjoyedmakingcardsandheputmein

touchwiththelocalcardmakinggroupwhichIwentto.”

OnepatientfeltthatalthoughtheSPCwasabletoconnecttoactivitiesthatshewouldnot

haveotherwiseused,shedidnotgetthehelpshespecificallyneededtohelphermanage

herdebtissues.

“Thebasicswerethere,whenImentionedmyfinancialproblems;hegavemeinformation

onhousingbenefitsandtaxcredits,buttheyweren’trelevanttomysituation.Ineeded

helpwithsortingoutmydebt.”

EightofthepatientscreditedtheSPservicetohelpingbringthembacktorecovery.For

example,onepatientsaidshewouldnothavebeenbacktoworkifitwerenotforthe

service.Anothersaidsheiscopingalotbetterandismanagingherdepressionalotbetter

becauseofvisitingtheservice.Yetanothersaidsheisabletohelpherselfandotherswith

thesimpleyetreallyhelpfulinformationshegotfromtheservice.

“Iwouldnothavebeenbacktoworkifitwasn’tforthehelpIgot,andIwouldprobablybe

onanti-depressants”

ThelocationoftheserviceTheconsensusamongthefocusgroupwasthattheroomoftheirSocialPrescribing

appointmentwasnotideal.Theydiscussedhowthedeskfeltlikeabarrierandtheroom

wasveryclinicalanduncomfortable.Theysuggestedremovingthedeskandhaving

comfortablechairs.Theyalsosuggestedusingadifferentlocationsothattheyareless

exposedwhengoingtotheSPCforhelp.

AppendixA

44

“Itwasatthedoctorssurgerysoitfeltabitformal.Itfeltverymedical,Idon’tknow

whetheritwastherightplaceforit.”

“Youareinyourcommunity,andtherearepeoplethatknowyou.Iwasinthissituation

whereIcouldn’tcope,andIdidn’twantpeopletoknowIcouldn’tcopeanditwasgoingto

thedoctor,itwasjustanotherthing.Ifitwaslikeacommunitycentrewhereyoujustwalk

inthedoorandpeoplearealwayscominginandout…orevenupstairs,thatwouldbe

better”

Overall,patientswerepleasedwiththeservicetheyreceivedfromtheirSPCandthrough

theservicestheyweresignpostedtointhecommunity.Elevenofthe12patientswespoke

towouldrecommendSocialPrescribingtoothers.

AppendixA

45

ToexploretheSocialPrescribingprogrammefromaclinician’spointofviewwehelda

focusgroupateachpilotpractice.ParticipantsincludedGPs,GPRegistrars,PracticeNurses

andaCCGPrescribingPharmacist.

WeaskedtheClinicalTeamateachpracticetomapoutapatient’sSocialPrescribing

pathwayfromtheGPs’viewpoint.

TheydescribedtheprocessestowhichpatientsareidentifiedandreferredtotheSocial

Prescribingappointmentandwhathappensnext.Ateachstagetheywereaskedto

describewhatworkedwellandwhatcouldbeimproved.Keythemesareoutlinedbelow.

ThePatientJourneyEachpatientjourneycanvarydependingonhowtheyareidentified,whattheirneedsare

andhowtheyrespondtotheservice.Figure1outlineswhatatypicalpatientjourneycan

looklikefromtheeyesofaclinician.

Figure1:Patientjourneyfromclinicianperspective

GPPracticeFocusGroups

1 PatientisidentifiedbyapracticestaffmemberandisgivenaSocialPrescribingbooklet.

2 TheGPwillseethepatientandifthepatientiswillingtheGPwillmakeareferraltotheSPC

3 ThepracticeadministratorreceivesthereferralformandforwardsittotheSPC

4 TheSPCreviewsthepatient’snotes,makesaTriagecallandbooksanappointment

5 TheSPCseesthepatientandupdatesthepatientnotesonEMIS

AppendixB

46

IdentifyingPatientsPatientsareidentifiedthroughanumberofmeans,forexample,throughGP

appointments,lunchtimediscussionsbetweencliniciansandduringpatientdressings.

Additionally,WidewayMedicalCentrediscussedhowthereceptionteamhavebeengreat

atidentifyingpatientswhentheycomeinforfrequentappointments,orwhenapatients

expressesaneedthatcannotbeaddressedbythemedicalteam.TamworthHouseMedical

Centrehavenotyetinvolvedtheirreceptionteaminidentifyingpatients.

Therearevastdifferencesbetweenthepracticesinthenumbersofpatientsbeing

referred.WidewayMedicalCentrearereferringsomanythattheSPChasbuiltawaiting

list,whereasTamworthHouseMedicalCentredonotfillalltheSPCappointments.

TamworthHouseMedicalCentrediscussedhowtheywouldlikemoreinformationfrom

WidewayMedicalCentreonwhotheyarereferringthroughandhowtheyareidentifying

them.

MakingthereferralTheteamatTamworthHouseMedicalCentredescribea“three-step”processtomaking

thereferral(seefigure2):

1.  Codingthereferraltype

2.  FillinginthereferralformforadministrationteamtoemailtotheSPC

3.  Givingthepatienttheleaflet

Theyfeltthatthiscouldbesimplifiedbychangingthereferraltoa1-2lineemailsent

directlytotheSPC.TheSPCcanlookupadditionalinformationthroughthepatientnotes

heldontheEMIS.

Conversely,WidewayMedicalCentrefeltthereferralprocesswasrelativelysimpleastheir

referralformsareautomaticallypopulatedbytheEMISsystem.Theydidnotfeelany

valuablechangescouldbemade.

AppendixB

47

Figure2:TamworthHouseMedicalCentre’sFocusGroupFeedback

ThenumberofpatientsseenbytheSPCTherewassomediscussioninbothmeetingsregardinghowmanypatientstheSPCbooks

foreachday.CurrentlytheSPCreserves45minutesforeachpatient.Healsoallowsfor15

minutesbeforeandaftereachappointmenttoreviewandupdatepatientnotes,make

referralsandplanning.Althoughbothpracticeswouldlikemorepatientsseeninaday,

theybothrecognisedthevalueofallowingthepatienttohavethattimewiththeSPC.

Bothpracticesidentifiedtheopportunitytointroducesomeflexibilitytotheappointments,

forexample,sometimecouldbeallocatedfordrop-insessions.Internet,telephoneand

videoappointmentswerealsodiscussedasanoptiontoexplorefurtherwiththeideathat

itcanfreeupsomeappointmenttimeandbeflexibletothepatientsneeds(seefigure3as

example).

AppendixB

48

Figure3:WidewayMedicalCentre’sFocusGroupFeedback

WhomakesthereferralsAtpresent,referralstotheSPCarebythepracticeGPsonly.Bothpracticesdiscussedhow

thiscouldbeopenedupsomewhattobroadenthereachoftheSPCandtolessenthe

workloadoftheGP.Currently,ifthepracticenurseorreceptionistidentifiesapatientwho

maybenefittheSPC,theyhavetoinformtheGPwhothenmakesthereferral.

Practicenurses,pharmacistsandperhapsevenreceptionswerediscussedasoptions.

FeedbackfollowingareferralTheTamworthHouseMedicalCentreteamexpressedthattheywouldlikemoreupdates

fromtheSPContheirpatients’progress.Thiscouldbeintheformofregularverbal

feedback,forexampleatteammeetings,orviaanemailedsummary.

AppendixB

49

Theyfeltthatthiswouldhelpthemseemoreofthevalueoftheserviceforthepatient.

Thesummaryshouldinclude:

•  Howmanypatientsarereferred

•  Howmanypatientsareseen

•  Whatfurtherfollow-upsorplanshavebeenmade

TheteamwelcomedtheSPCtoattendtheirteammeetingsandjointhemintheir

discussionsregardingeligiblepatientsandtheprogressoftheirpatients.

ImpactWidewayMedicalCentrehavebeguntoseetheimpactoftheSocialPrescribing

programmeontheirpatients.Theyhavefoundthatoneortwofrequentattendershave

beenattendinglessfrequently.

“Patientswhocomeinfordepressionandareprescribedanti-depressantsoftencomeback

lessdepressedandnolongerneedingtheirmedicationbecausetheyhavebeenreferredto

thesocialprescriberforarelatedissuelikehousingorloneliness”

BothpracticesfeltthatthepresenceoftheSPCinthepracticewasverypositiveasthereis

aneedfortheserviceandtheSPChasmoretimetobeabletospendwithpatients.

“Weoftenseepatientsthatwecan’tdoanythingforbecausetheirissuesareabouttheir

housing,financesorisolation,itisreallyvaluabletohavethatoptionwithinthesurgeryfor

thepatient.”

AppendixB

50

SevenstakeholdersidentifiedfromtheImplementationGroupwereinterviewedtoelicittheirviewsontheSPpilot,mobilisationprocessandexpectationsforthisevaluation.Thestakeholderswere:

•  RayHautot,SocialPrescribingCoordinator

•  KhadiruMahdi,ChiefExecutiveoftheMVSC

•  DrAmandaKilloran,FormerPublicHealthConsultantatLondonBoroughofMerton

•  DrMohanSekeram,GPLeadforSocialPrescribingfromWideWayMedicalCentre.

•  JohnDimmer,HeadofPolicy,StrategyandPartnershipsforLondonBoroughofMerton.

•  Anne-MarieLiew,formerCommunityDevelopmentCoordinatorforLondonBoroughofMerton

•  DrDouglasHing,GPandMertonCCGClinicalDirector

Semi-structuredinterviewsusingopen-endedquestionswereconductedtoallowthesestakeholderstoexpresstheirownperspectiveindetail.Thequestionsweredeveloped

basedontheprocessesoutlinedinthelogicmodel.Eachinterviewlastedbetween20-60minutes.Theywererecordedandanalysedusingtheoreticalthematicanalysis.Thekeythemesaroundhopes,challengesandsuccessareoutlined.

HopesforSocialPrescribingPilot“WewantGPsrecognisingthattheyareacommunityorganisation”

-KhadiruMahdi

“Givingpeopleanotheroutletbyshowingthemotherwaysofsustainingtheirwellbeing.”

-KhadiruMahdi

InterviewswithStakeholdersandSPC

AppendixC

51

StakeholdersareverypositiveabouttheSocialPrescribingpilotandfeelthatitfitswell

withinthestrategiccontextofEastMerton.Stakeholderexpectations/hopesinclude:

•  Demonstrationofasuccessfulmodelofdeliverythatconnectsbio-medicalcareto

communityresourcesandfitswiththeEastMertoncontext

•  Healthandwellbeingimprovementinresidentsbyprovidingaccesstonon-medical

supportthataddressestheirwiderneeds

•  Demonstrationthatitisasustainablemodel

•  Establishacollaborativepathwaybetweenprimarycarevoluntary,communityand

statutoryservicesandutilisecommunityresourcesmoreeffectively

•  EstablishapracticelearningnetworkaspartofwidertransformationworkforEast

Merton

HopesforthisEvaluation“WewanttounderstandwhatthemosteffectiveSocialPrescribingpathwayis,particularly

asembeddedinGeneralPractice,ifrobustcanbeplannedtobetakenupinpracticesin

EastMerton”

-DrAmandaKilloran

ThereareseveralkeyresearchquestionsthestakeholdershopetoexploreintheSocial

Prescribingpilot.Theseinclude:

•  Communityresources:Arewemakingbestuseofexistingcommunityresourcesand

offeringthingslikeaccesstoreadingandgardeningclubs?Whatdoestheevaluation

recommendforthevolunteeringstrategy?

•  Patientoutcomes:AreweseeingimprovedwellbeingofpatientsasaresultoftheSocial

Prescribingintervention?Arewedemonstratinggoodoutcomesforpatientswhoare

notbenefitingfrommedicalinterventions?

•  GPworkload:IstheSPpilotresultinginfewerGPappointmentsforthesepatients?Orif

patientsareengagingintheirownhealthmore,willitleadtomoreGPappointments?

AppendixC

52

•  Aformativeevaluation:Thereisageneralconsensusamongthestakeholdergroupthat

theywanttounderstandthe‘nutsandbolts’ofhowthepathwayisworking.

•  Strengthsandweaknesses:Overallthestakeholdergroupwouldliketoknowwhatis

workingwellandwhatcanbeimprovedtoensurecost-effectivenessand

embeddednessoftheSocialPrescribingprogramme.

•  SharingLearning:Providetheevidencethatthisisworking,notjustaboutthepatients,

toensurethatwehavesomelearningfortheGPs,sotheycanseethatthisismakinga

differenceforthepatients.

Barrierstomobilisation/ConcernsaboutSPpilot Weaskedthestakeholdersquestionsaroundthechallengesandbarrierstosettingupthis

SocialPrescribingPilot.Thegeneralconsensusfromthegroupswasthatanypotential

challengeswereanticipatedandaddressedearlyonduringmobilisation.

“Iamveryproudthattheprogrammeisupandrunningsosuccessfullyandthiscanbeseen

highnumberpatientsarealreadygoingthrough.”

-DrAmandaKilloran

ThesteeringgroupwasabletodrawfromlearningfromapreviousCommunityNavigator

programmeinMertonthatsomemembershadbeenleadingon.Keylearningpointsfrom

thisprogrammeshowedthatgoodvisibilityandengagementwiththeGPswaskeyto

ensuringtheprogrammeiswelcomeandconnectedtothesystemswithinthepractice.

SettingupITsystemssuchasEMISandestablishingwheretheSocialPrescribing

Coordinatorwillbebasedwithinthepracticetakestimetoagreeandarrange.TheEast

MertonPilotteamensuredthatthesesystemsweresetuppriortotheSPCcominginto

postandsomeoftheengagementwithinthepracticeshadbegin.Thisenabledhimtostart

seeingpatientsrightattheoutset.

AppendixC

53

Onestakeholderreportedthatthesetupdidtakesometimeandrecommendedthatmore

timeandresourcesshouldbeallowedtopreparefortheimplementationphaseaheadof

thegolivedate.

“Fleshingoutthefinerdetailsoflogisticsisjustasimportantastheoverallvisiontoputting

itintopractice”

-AnneMarieLiew

Sherecommendedprovidingabriefingtoeverystaffmemberatthepractices,including

receptionstaff,sothateveryoneknowswhatisgoingon,hasanopportunitytoask

questionsandfeelsthattheirparttoplayisvalued.

“Everypracticememberisanimportantpartofthecogintheprocessandshouldfeelpart

ofthewiderdialogue”

-AnneMarieLiew

ShehighlightedtheimportanceofenablingtheSPCandpracticestafftofeedbacktoeach

otheroncetheprogrammeisupandrunning,onhowitisworkingandhowthepatients

arerespondingtoit.Shealsorecommendedthatco-designoftheprogrammewithacross-

sectionofthepracticestafffromtheonsetwillencouragegenuinebuy-inatalllevels

ratherthansimplyinname.

TheSPCalsohighlightedthatthereissubstantialtrainingthatisrequiredbeforeanSPCis

readytousethesystemswithinthepracticeandseepatientsandthisneedstobe

accountedforwithintheimplementationphase.

Allstakeholdersraisedconcernsaroundthecapacityofcommunityandvoluntaryservices

inEastMertonandtheirabilitytodealwiththeincreasedvolumeofreferralsgenerated

viatheSPserviceonceitgainedmomentum.Therewasalsoaconcernwhetherexisting

servicescateredtotheneedsofethnicminoritypopulations.Insomecasesthepatientsdo

notmeetthecriteriafortheendservicesastheyresideoutsideoftheborough;inthese

casestheSPClookstoservicesbeyondEastMerton.

AppendixC

54

WithregardstodeliveringSocialPrescribing,themethodformeasuringpatients’wellbeing

isthroughuseoftheWellbeingStar.TheSPChighlightedthatthisisnotalways

appropriateforpatients,particularlyiftherearecommunicationissuessuchasalanguage

barrierorliteracyissue,oriftherethepatientisdistressed.Additionally,thereferral

formsarenotalwayscompletedinfullbytheGPswhichcanleavetheSPCfeelingnotfully

preparedforhispatient,althoughtheinformationcanoftenbefoundwithinthepatient’s

records.

Successes/EnablersOverallthestakeholdergroupspokeverypositivelyaboutthepilotprogrammeand

attributeditssuccessfulsetuptoseveralfactorsincluding:

•  CommitmentandsharedexpertiseoftheImplementationGroup

•  UsinglearningfromSPpilotsacrossthecountryandcarefullyplanningmobilisationof

theprogramme

•  FlexibilityandsimplicityoftheserviceandEndServicestomeetthediverseandoften

complexneedsofthepatients

SuccessfulPlanningThestakeholdersdiscussedanumberoffactorsthattheyaddressedinthemobilisation

phasetoensurethatitisembeddedwithintheGPpracticesfromtheoutset.Thesewere

anticipatedbybuildingonlearningfromotherprogrammesandincluded:

•  StrongengagementwithintheImplementationGrouptoensureallkeystakeholders

agreedonwhattheSocialPrescribingmodellookedlikeandwhatthereferralcriteria

was.

•  UsingtheexistingsystemswithinthepracticestoensurethatSPCiseasilyembedded

withinGPPractices

•  StrongengagementandvisibilitywithallPracticestaffandpatients

•  EnsuringearlysetupofITsystemsensuringSPChadaccesstopatient’scase

managementsystemsandcouldbookpatientappointmentsstraightaway

AppendixC

55

ChampionsofthePilotOneofthestakeholdersdiscussedthestrongsenseofcommitmenttothepilotandtheadvantageofhavingupfrontfundingfromtheCCGandtheLocalAuthoritytostrengthenstrategiccommitment.

TheleadGPswerekeyintranslatingthe‘blue-sky’ideaswithinthepilotstrategyintopracticalsolutions,draftingtheprojectplan,andvisualisingthepathway.Theyalsoledand

championedtheprogrammewithintheirPractices.

TheSPCisalsoseenasakeycontributortothesuccessofthepilotsofar.Hisexperienceandbackgroundgiveshimskillsandcompetencetodelivereffectively.Hislocalknowledge

andnetworksenablesanunderstandingofwhatwidersupportisavailableforpatientsinthecommunity.Hisgoodlisteningskillsenableseffectiveconsultations.

“Fortunately,wehadsomebodywhounderstandstheboroughverywellandunderstandsthecommunitysectorverywell.Healsoengagedwiththestaffinthepracticesverywell.”

-  KhadiruMahdi

Additionally,thecommunityorganisationshavebeenwillinglytakingonthereferralsfromthepatientsandthepatientshavebeenutilisingthisresource.

“Wehave10minutesappointmentsandwearecurrentlygeareduptowardsamedicalmodelwherewegivesomethingtothepatientstotakeawaywiththem…whenpatientsraisesocialissues…wecannowcapturethatandreallymakeadifferenceandsayIknow

someonewhocanhelpwiththat.”

-DrMohanSekeram

“The[SPC]isabletodealwithconcernsthatwerebeyondremitofthe[SPC]…andtheGPcanseestraightawaytheinterventionandwhathashappenedinthefollowup.”

-KhadiruMahdi

AppendixC

56

TounderstandhowtheSocialPrescribingprogrammeworksalongsidethecommunityand

voluntaryservices,wespoketofourservicesthattheSocialPrescribingCoordinatorhas

beenreferringpatientsinto,theseare:

•  CommonsideCommunityDevelopmentTrust

•  AgeUKMerton

•  MertonIAPTservice

•  MertonVoluntaryServiceCouncil’svolunteeringservice(MVSC).

Themainaimwastounderstandreferralpathways,communicationbetweentheSPCand

endservices,whattheythoughtabouttheinterventioningeneralandanythoughtsthey

hadaboutscalabilityandfactorswewouldneedtoconsider.

“Ithinkit’sgoodtohavethatkindofholisticviewofpeople'swellbeing,thatisnotjust

medical;itcanbemuchwiderthanthat-socialandcommunityconnections.Ithinkit’sa

positivesignthatthathasbeenrecognised”

Overalltheserviceswerequitepositiveabouttheeffectivenessoftheinterventionandfelt

thatitwasneededinEastMerton.Theconversationshighlightedtheneedtodevelop

robustreferralpathwaysandsystemstocapturenumbersandfeedback.

Thekeythemesareoutlined.

FirstContactwithSocialPrescribingPilotServiceswespoketoknewabouttheSPpilotbeforeitstartedorintheinitialmonths.

SomeknewthepilotwascomingtoMertonastheyhadbeenworkingcloselywith

WidewayMedicalCentreandtheleadGP.OthersestablishedlinkswiththeSPCandthe

pilotatmeetingssuchastheMentalHealthForum.

InterviewswiththeVoluntaryandCommunitySectorServices

AppendixD

57

TheSPChimselfwasafamiliarfiguretomostservicesashehasworkedintheBorough

previouslyandisawareofalotoflocalorganisations.

“He(SPC)hadafairlygoodgraspoftheworkwedohereandIhadamemoryofhimand

howheworks.Sofairlyeasytoestablishaworkingrelationship”

ReferralPathwayandCommunication

“TheSPChasgivenalotofhisclientsourdetails,whetherthat’sactuallyresultedinthem

comingtoaccessourservicesIdon'tknow.Itdoesn'tmeantheyhaven't,butit’scertainly

notbeensomethingthathasbeenobviousfromoursideofthings”

Acleardistinctionbetween‘Referral’and‘Signposting’wasmadebyoneoftheservices

andtheconsensuswasthattheprocessbywhichindividualsmaketheirwayfromtheSPC

totheirserviceswassignposting.

ThereisnoreferralformandnouniformwayinwhichtheSPCcommunicatesinformation

aboutpatientswhoaresignpostedtoendservices.Twooutoffourservicessaidthatthey

knewtheSPCwasgivingoutinformationabouttheirservices,butaswithotherself-

referralstheywerenotabletosayhowmanypeopleaccessedtheirserviceasaresultof

theintervention.

OneservicereceivesthecontactdetailsofpatientssignpostedtothembytheSPCviaan

emailandthen,basedonthedetailstheyaregiven,theyeitherpostoutaletter,

telephoneoremailtheseindividuals.Otherservicesrequirepatientstoself-refer.Dueto

thedifferencesinapproach,feedbackfromservicesiseithernotavailableoriscollected

andgiventotheSPCindifferentways.

AppendixD

58

“Welethimleadonthis.Ifheisn’tgettingtheinformationhewouldletusknow.Herings/

popsinwithalistofpeople.Welethismonitoringneedsleadusratherthaninventsome

monitoringforourselves”

ThefrequencyofinteractionwiththeSPCvaries;insomecases,theSPCdropsinweekly,is

inregularcommunicationoveremails,orjustmeetsservicesatcommoneventsand

meetings.TheSPCisbasedinthesameofficeastheMVSCvolunteeringservicewhich

makescommunicationeasier.

ServicesrecognisedtheimportanceoflettingtheSPCknowaboutanychangesthatwere

takingplaceintheirservicesandmakingsuretheinformationhehadforthemwasnotout

ofdate.ThepathwaydescribedbystakeholdersissummarisedinFigure4.

Figure4:SignpostingandfeedbackPathway

1 SPCspeakstopatientsandassessestheirneeds.

2 Patient is given leaflets/ information about service and encouraged to make

contactbySPC.InothercasestheSPCmakesareferral.

3 Patientcomestoserviceandmay/maynotidentifyasbeingsentbytheSPC

4 Patientmay/maynotaccessservicebasedonsuitabilityandinsomecasespatientmaybesignpostedtootherrelevantservices

5 Feedback toSPC is varied; there isno formalmechanismand is ledby theSPC.

SPCmightapproachservicesthemselvestocheckifpatientshavesignposted,orcheckwithpatientswhentheycomebackforsecondappointment

AppendixD

59

Numbersanddemographicsofpatientssignposted

OneservicerecordedasurgeinthenumberofpeoplecomingthroughbetweenMarchand

Mayandhad40extrapeopleaccessingtheirservices.Anotherservicehad10people

signpostedand8ofwhomtheycouldcontact.TherestcouldnottracktheirSocial

Prescribingreferralsandwerenotabletocomment.

Oneservicereportedthattherewasagreaterrepresentationofolder,whiteworking-class

individualssignpostedtothemfromthepilot.

OneservicementionedthattheywouldideallyliketohavemorereferralsfromBME

populations,men,olderadultsandthosewithlong-termconditionsandworkwiththeSPC

aroundthis.

CapacityofEndServices

Theservicesthatcouldcommentonthevolumeofreferralstheyreceivefeltthatthey

couldcopewiththedemandintheshortterm.Shouldtheprogrammebeexpandedor

extended,thiswouldneedtobediscussedwithcommissioners.Theyfeltthatneedsofthe

peoplebeingreferredisalsoanimportantpartoftheconsideration.

Theendservicesalsotalkedabouttheoptionofacceptingsignpostsintoservicesthey

chargedfororforservicesthatareunderutilised.Oneserviceistryingtoincreaseuptake

ratesandsaidtheywouldwelcomemorenumberofreferralscomingintotheservice

(targetgroupsmentionedabove).

ScalabilityConsiderations

Servicestalkedaboutseveralfactorsthatneedtobeconsiderediftheinterventionwereto

beupscaled.Theseinclude:

AppendixD

60

Robustreferralandfeedbackpathways-ServicesareopentoworkingwithSPCtolookat

howreferralpathwaysandsystemscanbesetuptoenablebetterdatacaptureand

feedbackbetweenservices.Forexample,datasharingagreementsorsimplyaskingthose

whoself-referwheretheyheardabouttheservice.

Understandingpatientneed-Toascertainwhetherpatientsneedareferralserviceora

signpostingservice.

“IfIgavealeaflettoaclient,didtheclientreallygototheagency?Wasthereany

hesitationinthere,wasthereanythingthatwasmissed.Ifthat'snotworking,thendoIfill

thereferralformordoIcalltheGPpractice”

DataProtection-Ifthepilotisup-scaled,dataprotectionandsharingagreementswill

havetoberevisited.Itisimportanttonotbecometooencumberedinprocessesand

maintainabalance.Organisationstakingpartwillneedtrainingaroundsharing

informationwithpeopleandthiscouldbesomethingthattheMVSCcouldsupportwith.

“IfitdoesgoBoroughwide,theproblemisthatitbecomesencumberedwithlotsofcontrol

andprotectionsystems-whicharegoodinthemselvesbutcanstymiesomeoftheenergy

thatwehavehadintheearlystages”

GPcommitment-TherewasrecognitionthattheleadGPinWideWayismassively

committedtothisandhasbeenchampioningthepilot.Ifthepilotweretoexpand,other

GPpracticesneedtoembracethisapproachandbefullycommittedtoitsdevelopment.

“Idon’tknowifotherGPsareasenthusiasticasthem.Theyhavetodoitiftheyhavetodo

it,notbecausetheylovetheirjob.SoifsomeGPsorotherprofessionalsinthepractice

werethinkingthat‘ohgoshthisisanotherthingthatIneedtofitinourdailyjobs’,that

wouldthenkillsomeofitseffectiveness.So,wehavetosellitassomethingthathelpstheir

effectivenessandnotsomethingthataddstotheirto-dolist”

AppendixD

61

BuildingCapacitywithintheVoluntarySector-Serviceswereclearthatiftheprojectwere

tobeupscaled,therewouldneedtobefundingputintothevoluntarysector.Therewere

somesuggestionsincludingpayingtheorganisationperpersonpervisit.Ifthiswasnot

possible,thentoworkinpartnershiptolookforfundingopportunitiesorreallocate

fundingfromdeadprojects.

“Asthevoluntarysectorisreliedonmoreandmoretofillingapsandpickupservices,on

theonehanditisgettinglessandlessfundingandontheotherhandmoreandmore

referrals.Atsomepoint,thatisnotgoingtowork.Youcanonlyscaleitupifyoucanfund

thevoluntarysectortoabsorbtheincreaseddemand”

GeographicalConsiderations-ExpandingtootherareasinEastMertonaswellaspossibly

havingaserviceinWestMertonsothatthereisabalanceacrosstheborough.

Considerothersimilarmodels-Stakeholderstalkedaboutothersimilarinterventionssuch

astheLivingWellprojectwithinAgeUK,carenavigators,communitynavigatorsbasedout

oftheNelsonHealthCentreandCommonsideTrustandtheFireSafeandWell

coordinators.Itwouldbeworthlookingatsynergiesandhowthesedifferentprojects

couldworktogether.

LinkinginwithFundingopportunities-HousingandregenerationpartnerslikeMerton

HousingandUnitedLivingarewillingtoworkwithlocalstakeholdersarounddesigning

servicesthatmeettheneedsofthelocalpopulation.Theyhaveexpressedaninterestin

workingwiththeSPCanddonotwanttoduplicateeffortsorsetupsomethingthatdoes

nothavesynergywiththeSPPilot.Thiscouldbeexploredwithotherorganisationslike

ClarionHousingaswell.

AppendixD

62

LimitationsofSPPilot

“Itishardtomanageboththecapacityofthatandknowwhatdifferencethesignposting

hasmade…Iknowtherearesomeamazingcasestudies,whereSPChasbeenabletorefer

someoneandthatpersonhasgonefromstrengthtostrength,butlikeIsaid,ifyoujust

signpostsomeone,it’squitehardtoreallytrackthatagainstanyimprovementthathave

beenmadeinthatperson'slife”

ServicesspokeaboutsomeofthelimitationsoftheSPPilot:

•  Signpostingsystemthatmakesitdifficulttotrackuptakeandprovidefeedbackor

prepareforanyupscaling.

•  Endservicesnotknowingwhattheactualinterventionis,howmanytimesdoesthe

patientgetseenetc.whichmakesitdifficultforthemtothinkaboutimpacts.

•  Therewereconcernsthatforcertainvulnerablegroupsforexampleolderpeople,

signpostingwouldnotbeaseffectiveasareferral.

•  TheSPinterventionisbasedonthepremisethattherearewiderservicesthatcanmeet

patientneeds.Thereisaconcernthattheremightnotbeenoughservicesorcapacity

withinthoseservicestoaddressneedsoracceptsignposts.

“Whereitfallsdownis,it’safantasticideareferringpeople/signpostingpeopletoservices,

butthereareincreasinglyfewerservices.Ifyoudon'thaveanywheretosignpostpeopleto,

thenthemodelfallsdown”

AppendixD

63

Observationmethodology

TheassessorsobservedfiveSocialPrescribingconsultationsinJuly2017,includingtwofirstappointmentsandthreefollow-upappointments.Thepurposeoftheobservationswasto

getanunderstandingofthestructureoftheconsultations,thecommunicationbetweentheSPCandpatientandreferralprocess.

ObservationswereratedontheBehaviourChangeCounsellingChecklistthatlooksatperson-centredmethodsforbehaviourchangecounselling(Laneetal,2005).Eachitemof

thechecklistisratedonaLikertscaleof0-4wherebyahigherscorereflectsstrongerbehaviourchangecounsellingskills.Notallitemsonthechecklistarerelevantforallconsultations,soanaveragescorefortherelevantitemsarerecordedforeachconsultation.Theobserversalsorecordedwhatwentwellandwhatcouldbeimproved.

TheSocialPrescribingconsultation

PatientsareseenbytheSPCbetweenonetofourtimesatthree-monthintervals,dependingontheirneedsandexpectations.Thetimefortheconsultationvariesbetween15minutesto1hour.Priortomeetingthepatient,theSPCgathersasmuchinformationas

theycanaboutthepatient’sbackgroundandreasonforreferralusingEMISandthereferralform.

TheSPCbeginstheconsultationbywelcomingthepatientandensuringtheyarecomfortable.Heexplainsthereasonforreferral,describeswhatSocialPrescribingisand

asksthepatienttofillintheSTARquestionnairewhereappropriate.Duringthistime,thepatientisabletodiscussin-depththeirpersonalcircumstancesandreasonforreferral.

SocialPrescribingInterventionObservations

64

AppendixE

TheSPCoffersreferraloptionsandsignpostingthroughoutthediscussionwhenthe

opportunityarises.Theconsultationendswithanagreementtomeetatalaterdateto

reviewthecontactwiththeendservices.

Whatwentwell

TheSPCratesverywellontheBehaviourChangeCounsellingChecklistwithanaverage

scoreof3.2outofapossible4;hisstrengthsinclude:encouragingthepatienttotalkabout

theirbehaviourandstatusquo,acknowledgingchallengesandbeingsensitiveand

understandingtothepatientsconcerns.

Overall,itisclearthattheSPCisfriendly,approachableandskilledatmakingthepatients

feelatease.Heisalsoflexibleinofferingappointmentsofvaryinglengthstomeet

individualneeds.Patientsareabletodiscusstheirpersonalcircumstancesin-depthand

cantalkaboutarangeofissueswithoutstricttimeconstraints.

TheSPCrecallsthepatient’sinformationfrompriormeetingsandfrommedicalrecords.

Heregularlyrecognises,acknowledgesandpraisesthepatient’sstrengths,intentionsand

behavioursthatlead

TheSPCalsohasawealthofknowledgeofthelocalservicesavailabletothepatientsand

providessupportandguidancetothepatientsastohowtheycanaccesstheseservices.

65

AppendixE

SuggestionsforimprovementsafterJuly2017observations

-  Theconsultationscouldoftenbenefitfromhavingaclearerstructure.Attheoutset,

whentalkingaboutwhatwillbecoveredduringtheappointment,itwouldbebeneficial

toaskthepatientwhattheywouldliketodiscussandsettingajointagenda.

-  Restrictthenumberofreferralopportunitiesofferedtothepatientasthiscanbe

overwhelming.Tonarrowthefocus,thepatientcanbeaskedwhattheyhopeto

achieve/whatsolutionwouldworkbestforthem.Alternatively,whenthereareseveral

options,theycanbeshowna‘menuofoptions’andaskedwhich1-2serviceswould

theyliketobeginwith.Thiswouldalsoensurethatadviceandsignpostingistailoredto

theneedsexpressedbythepatientsandthattheyhavemoreownershiponnextsteps.

-  Insteadofaverbalagreement,itwouldbemorebeneficialtohaveawrittenplanof

actionwhichhasbeendiscussedandagreedwiththepatient’sactiveparticipation.

Evidenceshowsthatawrittenagreementofbehaviourchangeisastrongindicatorof

positivebehaviourchange.

FollowupdiscussionwiththeSocialPrescribing

CoordinatorinAugust2017

ThesesuggestionswerediscussedwiththeSPCwhoputthemintopracticefromAugust

2017.FeedbackfromtheSPConthechangeshasbeenpositive.Hefeltthatthechanges

haveallowedthepatienttohavemorecontroloverhissignpostingandthathehas

becomemoreflexibleinhisapproachtoallowingthepatienttosettheirownpriorities

withtheirconsultationwithhim.

66

AppendixE

DecemberObservations:

TheresearchersreturnedtoobservetwomoreconsultationsinDecember2017.We

observedtwo2ndsessionappointments.Duringthoseobservationsweratedthe

interactionusingtheBehaviourChangeCounsellingChecklist,theSPCscoredanaverageof

3.9outofapossible4,exhibitingthattheSPCwasstronginhisuseofbehaviourchange

counsellingskills.

DuringtheconsultationstheSPChadstructuredtheconsultationsinaclearway,allowing

thepatientstoco-createtheagenda.TheSPChadstrongrapportwiththepatientsanda

relaxedapproach.Thesignpostingandreferralswereinresponsetothepatients’

expressedneedandactionplanswereagreed.

67

AppendixE

68

EvaluationoftheEastMertonSocialPrescribingPilotbyHealthyDialoguesLtd,July2018.If

youwouldliketolearnmoreaboutthisevaluationpleasecontact:

info@healthydialogues.co.uk.

TheEastMertonSocialPrescribingPilotwasdeliveredbyMertonCCG,MertonCounciland

MertonVoluntaryServiceCouncil.IfyouwouldliketoknowmoreabouttheMertonSocial

Prescribingprogrammeyoucancontact:public.health@merton.gov.uk.