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Social prescribing April 2017- March 2018 Tower Hamlets CCG Network 6 – Bromley by Bow and Mile End East

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Page 1: Social prescribing - Bromley by Bow Centre · 2 Introduction Social prescribing (SP) at the Bromley by bow Centre has been offered to patients of local GP practices for many years

Social prescribing April 2017- March 2018

Tower Hamlets CCG Network 6 – Bromley by Bow

and Mile End East

Page 2: Social prescribing - Bromley by Bow Centre · 2 Introduction Social prescribing (SP) at the Bromley by bow Centre has been offered to patients of local GP practices for many years

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Introduction Social prescribing (SP) at the Bromley by bow Centre has been offered to patients of local GP practices for many years. The service began to attract a small amount of external CCG funding in 2014. The service in Mile End East and Bromley by Bow (CCG Network 6) is now jointly commissioned by Tower Hamlets CCG (via Tower Hamlets GP Care Group) and the GP practices that form Network 6. The service takes referrals from GP practices and helps to support people with non-medical needs and address problems caused by the social determinants of ill health. The service provides a one-to-one personalised intervention that helps people explore issues and identify next steps. The service coordinators (SPC) link people with a wide range of community services to provide them with on-going help and support to improve health and wellbeing. During this reporting period, the service received referrals from five GP practices with a joint patient population of around 37,000. The SP work was carried out by a team of two social prescribing coordinators (SPC) The Network 6 service became part of a wider pilot roll-out across Tower Hamlets borough, commissioned by Tower Hamlets CCG via the GP Care Group (CIC) during this period. The pilot covers eight network and 36 practices. More information on the borough pilot is available at https://www.towerhamletstogether.com/our-work/social-prescribing-service

Page 3: Social prescribing - Bromley by Bow Centre · 2 Introduction Social prescribing (SP) at the Bromley by bow Centre has been offered to patients of local GP practices for many years

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Headlines

643 referrals were received into the service this period

348 client support sessions were provided

797 onward referrals were made to 123 different community organisations

93 different health care professional referred into the scheme

100% of respondents to the annual GP practice survey wished to see the

social prescribing service continue

Additional trust funding was secured for a Bangladeshi social prescribing

coordinator (SPC) who is able to support patients in Bengali

The service has developed to see the majority of patients at in-practice

clinics with consultation notes added to patient records on EMIS

The service has ongoing engagement with national development of SP:

Participating in first national social prescribing research conference

Supporting the Mayor of London’s Strategy for social prescribing

Inputting into the development of a national SP guide

Becoming a NHSE test site for feasibility of national SP link-worker training

Running a series of four SP seminars at the Centre and hosting numerous SP

visits and consultations to share good practice

Page 4: Social prescribing - Bromley by Bow Centre · 2 Introduction Social prescribing (SP) at the Bromley by bow Centre has been offered to patients of local GP practices for many years

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Referrals

Referrals received – Tower Hamlets Network 6

April 2017 – March 2018

GP Practice Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Totals

%

Bromley by

Bow

Centre

14 23 18 3 10 21 13 9 9 8 25 15 168

26

St Paul’s

Way

4 3 8 8 7 9 9 13 11 14 7 7 100

16

Merchant

Street

1 3 8 3 3 2 5 3 4 1 4 6 43

7

St Andrew’s 37 28 24 20 20 17 39 35 6 39 4 26 295

46

Stroudley

Walk

3 4 3 3 0 1 4 2 3 3 3 2 31

5

XX Place 1 1

>0.01

Self-referral 1 3 1 5

>0.01

Total 60 64 61 38 40 50 70 62 34 65 43 56 643

100

Page 5: Social prescribing - Bromley by Bow Centre · 2 Introduction Social prescribing (SP) at the Bromley by bow Centre has been offered to patients of local GP practices for many years

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Total referrers by job responsibility

Number of different referrers this period 93 different health care professionals referred into the social prescribing scheme this reporting period

The social prescribing intervention

Levels of engagement Number of referrals

% of referrals

Direct referral to specific service for one clear need

254 39%

LEVEL 0 Referrals unable to contact 91 14%

LEVEL 1 Phone assessment/support 140 22%

LEVEL 2 One-off 1-2-1 client session 94 15%

LEVEL 3 Multiple 1-2-1 client sessions 64 10%

Total 643 100

Total number of 1-2-1 client support sessions provided for clients referred this period

265 n/a

Total 1-2-1 sessions including cases still active from previous period

348 n/a

Did not attend or unable to attend at least one session during SP process (DNA/E)

60 9%

Health care professional Totals

GP

Centre

372

Practice nurse/nurse

practitioner

80

Health Care Assistant 26

Patient assistant/receptionist 125

Practice manager 2

Other (Psychologist/Pharmacy) 4

Self-referral

10

]

Not stated 24

Total 643

Page 6: Social prescribing - Bromley by Bow Centre · 2 Introduction Social prescribing (SP) at the Bromley by bow Centre has been offered to patients of local GP practices for many years

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Direct referrals by service

A direct referral occurs when the referring clinician ticks areas of specific support the client requires at the Bromley by Bow Centre but does not request a one-to-one intervention with the SPC. Where clear needs are identified such as social welfare or housing support, it is expedient to ensure the client gets the relevant support they need in a timely manner. These services can then refer back to SP if additional support is required.

Main Service directly

requested by health care

professional

Apr 17 – Mar 18

Health Trainers

Centre

44

Fit for Life 78

Social Welfare Advice 90

Employment 34

Macmillan social prescribing 7

Social care 1

TOTAL 254

Social prescribing coordinator

ticked on referral form

389

Page 7: Social prescribing - Bromley by Bow Centre · 2 Introduction Social prescribing (SP) at the Bromley by bow Centre has been offered to patients of local GP practices for many years

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Onward referrals A total of 797 onward referrals were made by SPCs to 123 different community organisations. 546 were referred and 251 were signposted.

SP onward referral organisations Apr 17 – Mar 18

Ability Bow Local Authority - OT

Adult care assessment Local Link Headway

Age UK - Appian Court Local Link REAL advocacy

BBBC - 50 + employment course Local MP surgery

BBBC - Advice Team Macmillan Social Prescribing Service

BBBC - Digital Inclusion Marner Children's Centre

BBBC - East End Energy Fit MEND Programme

BBBC - EastXChange Merchant Street Surgery Walking Group

BBBC - Employment Advice MIND TH & Newham

BBBC - ESOL classes Move on up - supported housing for young people

BBBC - Fit 4 All National Theatre drama group

BBBC - Gardening Group Newham Housing provision - Solicitor to provide legal aid

BBBC - Getting on With Money NHS Choices Website

BBBC - Health Trainers Our Parks

BBBC - Social Care Poplar Union and St Katherine's Precinct

BBBC - Housing solicitor Providence Row

BBBC Yoga Mondays Quit right - smoking cessation

Bengali relaxation resource Real Advocacy

Bethnal Green Buddhist centre Recovery College and Bengali relaxation resources

Better Leisure Centres Redbridge Foodbank

Better Leisure Centres - Women’s swimming Redbridge IAPT service

Bikeworks - Cycle training Reset

Birkbeck University Linc Centre exercise class

Bow Foodbank Linc Centre Yoga

Bow Haven & WellOne & Compass diabetes group Link Age Plus

Breathing Space Local Authority - OT

Brightside grant for books and activities for client's son Local Link Headway

Citizens Advice Bureau Rethink

Capitalise bed service Shelter - Housing Helpline

Central Foundation Girls School Gym St Pauls Way Centre - Walking Group

Community Learning Disabilities services Poplar Harca Friday 2pm session

Compass group for type 2 diabetes Poplar Harca Hot Spots women’s group at the Brownfield Community Centre.

Compass type 2 diabetes workshop & Christmas lunch activities

St. Katherine's Precinct

Compass Wellbeing - counselling Step forward service

Continence support Supply yoga

Core Arts Taxi Card

Diabetes Centre TH Crisis grant

Dial A Ride TH Law Centre, TH Legal Advice & Toynbee Hall

Down to earth and housing solicitor 10/08 TH Local offer website

Early help hub TH summer activities for children/

Page 8: Social prescribing - Bromley by Bow Centre · 2 Introduction Social prescribing (SP) at the Bromley by bow Centre has been offered to patients of local GP practices for many years

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SP onward referral organisations continued

East London Bereavement counselling The Cabin Poplar Harca healthy eating sessions

Enterprise Tower Hamlets Start up ready The Mix - young people’s support line

EntitledTo Website Time Out - free London Activities and Well One website

First love Food bank Tower Hamlets Carers Centre and Rethink

Fit for Life – Tower Hamlets Tower Hamlets College

Furry tales Tower Hamlets crisis grant

Gamcare Tower Hamlets Friends and Neighbours

Getting on with Money Tower Hamlets Learning Disability Team & Real advocacy

Goodgym Tower Hamlets Legal Advice Centre

Groundwork London Toyhouse

HC1 form application & live well cook and eat poplar harca

Toyhouse - Mello parents course

Headspace and Dorothy Rowe Toyhouse & Homeswapper website

Headspace App Toyhouse intergenerational project

Heart 2 Heart Play Toynbee Hall debt service & Christmas activities

Housing Links service Turn 2 Us

Iam Swimming at Mile end University of the third Age Tower Hamlets

iamtowerhamlets WellOne website

Idea Store Wellone website - walking football session & Friday free swimming

Inspire Consortium www.towerhamletsmums. com

Kingsley Hall - Ballroom dancing Young at Heart & iamtowerhamlets

Learning disability team Young at Heart - Better Leisure Centres

Legal Advice Centre - Employment Lawyer

Linc Centre exercise class

Linc Centre Yoga

Link Age Plus

Page 9: Social prescribing - Bromley by Bow Centre · 2 Introduction Social prescribing (SP) at the Bromley by bow Centre has been offered to patients of local GP practices for many years

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Client data

Support need identified at initial referral

Patients can be referred for more than one need.

Age and gender of referrals

0

50

100

150

200

250

0

20

40

60

80

100

120

Not stated Under 19 19-29 30-39 40-49 50-59 60-69 70+

Female

Male

Page 10: Social prescribing - Bromley by Bow Centre · 2 Introduction Social prescribing (SP) at the Bromley by bow Centre has been offered to patients of local GP practices for many years

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Ethnicity of referrals

Ethnicity

Number

Percentage

African 27 4

Other Asian background, please describe 8 1 Other Black / African / Caribbean background 9 1 Other Mixed / Multiple ethnic background 3 >0.01

Arab 3 >0.01

Asian / Asian British 49 8

Bangladeshi 212 33

Black / African / Caribbean / Black British 23 4 British or mixed British 3 >0.01

Caribbean 17 3 Chinese 6 >0.1

Gypsy or Irish Traveller 1 >0.01

Indian or British Indian 2 >0.01

Irish 7 1 Mixed / Multiple ethnic groups 2 >0.01

Other ethnic group 55 9

Polish 1 >0.01

White 66 10

White and Asian 1 >0.01

White and Black African 4 >0.01

White and Black Caribbean 3 >0.01

White British/Scottish/Welsh/English 76 12 White other 39 6 Not stated 26 4 Total 643

Page 11: Social prescribing - Bromley by Bow Centre · 2 Introduction Social prescribing (SP) at the Bromley by bow Centre has been offered to patients of local GP practices for many years

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Outcomes

Annual survey of healthcare professionals 35 responses to this survey were received from Network 6 as part of the borough evaluation. Results are summarised below. .

Overall responses on the service

- 100% of respondents wish to see the social prescribing service continue - 95% felt that social prescribing brought wellbeing to their patients - 98% felt that social prescribing brought wellbeing to them in their profession

Respondents were asked about the impact if the service was withdrawn

- 78% agreed or strongly agreed that if would affect the ability of their patients to address the

social determinants of health - 78% agreed or strongly agreed that it would affect the ability of patients to engage with their

health

- 55% agreed or strongly agreed they would try to take on some of the support themselves by finding appropriate services

- 35% agreed or strongly agreed they would steer away from opening up holistic conversations because they wouldn’t have the knowledge/confidence to refer to appropriate organisations.

MyCaW wellbeing measure The MYCaW, Measure Yourself Concerns and Wellbeing tool was introduced across Tower Hamlets borough and is used with patients in Network 6. The MYCaW tool measures changes in the impact of two self-identified concerns and wellbeing as a result of the SP service intervention.

1

A baseline measure is taken during the first session and where possible, a follow-up is done approximately 12 weeks afterwards. Patients score from zero (not bothering me at all) to six (bothers me greatly). The small number in this sample is due to the early introduction of the tool in the Tower Hamlets borough scheme and common challenges in securing follow-up measures around service capacity and contacting people previously supported. Typically, more baseline than follow-up measures are secured. .

MYCaW

Baseline borough (n=37)

Baseline Network 6 only (n=14)

12 week follow-up borough (n=37)

12 week follow-up Network 6 (n=14)

Concern 1 5.47 5.13 3.94 2.73

Concern 2 5.58 4.87 4.18 3.07

Wellbeing 4.74 4.37 3.78 2.87

1 http://www.bris.ac.uk/primaryhealthcare/resources/mymop/sisters

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Case study examples

Case one A young single mother with recent experience of domestic violence was referred to the service in April. The client was suffering from severe depression and social isolation following her relocation to the area and was experiencing financial hardship due to a reduction in her benefits and rejection of an application for personal independence payments (PIP). The client was unable to cover the costs of day to day subsistence and was becoming increasingly anxious about her situation. The client was supported over six sessions by the SPC who made a series of referrals that ensured the client’s PIP was reinstated and back-dated. A full benefits check ensured she received all the correct benefits. She was supported to make an application for child maintenance and for Foodbank services. She now feels able to support her children and has paid all her bills with no outstanding debts. She feels more resilient and continues to work on getting better. She continues to learn about support and services she may be ready to access in the future.

Case two A 60+female was initially referred for weight management support and help with finding physical activities. Following a number of face-to-face appointments with the SP she disclosed incidences of early-life abuse and her resulting depression and anxiety. She was successfully referred to Fit for Life weight management and completed the 12 week programme. She accessed a recommended Well One website and signed up for Yoga and Women’s swimming sessions which are helping her become more active and feel connected to local services and residents. This was the first time she had spoken openly about her life events. After four appointments the client was supported to make a self-referral to Compass Wellbeing (talking therapy).She now feels ready to share her story with her son with whom she has a close and supportive relationship.

Case three A 60+ male was seen in an in-practice clinic, following a referral from his GP. During the session a telephone conversation was conducted with his wife at his request. The client talked with the SPC about his health struggles and how they were impacting his quality of life. He later disclosed a cancer diagnosis and said he was struggling to cope. He was very concerned about rapid weight loss and had not received a nutritionist appointment following referral by his GP. The client is dependent on his wife for practical and emotional support and spends a lot of time at home. His wife was concerned he was becoming isolated. The SPC referred him to Macmillan Social Prescribing who supported him to access cancer-specific support sessions, specialist yoga and he secured a one-off Macmillan financial grant to cover costs incurred due to his diagnosis. The SPC also referred him and his wife to the London Buddhist Centre for meditation and yoga classes, followed up his nutritionist referral, secured an appointment and recommended further services for support when they are both ready. These included Compass Wellbeing (talking therapy), Tower Hamlets Carers Centre, local social activities and Age UK London Home Help service.

“I have never told anyone about what happened to me, not even my family but now I feel safe and so much better” for sharing it”

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Focus groups and interviews Nine one-to-one interviews were conducted by a team member not involved in direct delivery of the service. Two of the nine interviews were held in a small group setting, five were face-to-face and four were carried out by telephone. A short extract is shown below.

Respondents were asked about the reasons they were referred to SP:

‘I was extremely anxious and unable to go out’

‘My GP knew I needed more help’

‘I want to find work but it’s hard with my caring role’

‘Panic attacks and feeling overwhelmed’

‘My sister recommended it and I self-referred’

‘As a working single parent I have housing and money problems’

‘My Diabetes nurse referred me to improve health and fitness’

‘I have had many problems with my health’

Experience of the first session with the SPC;

‘I felt relaxed because it was easy to talk, I wasn’t nervous’

‘The SPC was so understanding and caring. It really warmed my heart, it’s a pleasant experience’

‘I was excited about the possibilities for classes that could help me’

‘I felt good when I left as I knew there were services that could help me’

‘I was glad there seemed to be some other things to help me’

‘I felt listened to and understood’

‘We talked about many things that could help me’

‘The SPC is easy to approach and gave me time’

When asked about the services recommended to them: All respondents said they are accessing recommended services or have plans to do so

Asked how SP has helped them;

‘It has improved my health and pain levels’

‘It has helped take my mind off my problems’

‘It has helped with my anxiety’

‘Before I couldn’t leave the house, now I’m travelling on public transport’

‘I’m more relaxed and I feel I’m making progress’

‘Things are beginning to move forward’

‘It feels like things are possible for me’

‘I feel more supported’

“I was experiencing anxiety and found it difficult leave the house. With social prescribing support I have joined social groups and I am now travelling on public transport on my own”

Page 14: Social prescribing - Bromley by Bow Centre · 2 Introduction Social prescribing (SP) at the Bromley by bow Centre has been offered to patients of local GP practices for many years

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Report Authors

Janet Coan – Social prescribing development lead [email protected] Anny Ash – Social prescribing manager [email protected]

Bromley by Bow Centre © Frank Creber

Contact

Bromley by Bow centre, St Leonard’s Street, London E3 3BT

020 8709 9848

Charity number 1041653