Issuu

Dudley CVS

Dudley High Intensity User (HIU) Social Prescribing Project Year 1 Evaluation April 2018 to March 2019

Final Report 30th August 2019

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

Document Control Client: Title: Report: Version: Reference: Author: Signature:

Dudley CVS Dudley HIU Social Prescribing Project Year 1 Evaluation Final Report 2 C-DUC170 David Waterfall

Date:

30th August 2019

Contact Postal:

Email: Web: Telephone: Twitter: LinkedIn:

David Waterfall 6 Willow Park Greasby Wirral CH49 2RY david@dpwaterfall.com www.dpwaterfall.com 07951 401 320 @dpwaterfall https://uk.linkedin.com/in/dpwaterfall

ÂŠ 2019 David Waterfall. No responsibility for loss or damage occasioned to any person acting or refraining from action as a result of any statement in this report can be accepted by David Waterfall.

David Waterfall, www.dpwaterfall.com

Page 2 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

Contents Page

Section

Introduction

4 4 4

1.1 1.2 1.3

Commission Summary Report Purpose Agreed Methodology

Background

5 5 5 6 6 7 8

2.1 2.2 2.3 2.4 2.5 2.6 2.7

Dudley CVS Integrated Plus Social Prescribing Service Dudley’s High Intensity User Social Prescribing Service HIU Service Delivery HIU Interventions Voluntary And Community Sector Fluid Floating Fund HIU Year 1 Targets

Performance - Outcomes

9 9 11 14 17 19 22 24 26 29

3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10

User Feedback Finance Physical Health Mental Health Social Contact Housing Safety Learning Target Areas Overall Wider Achievements

Performance – Emergency Service Avoidance

30 30 33

4.1 4.2 4.3

Efficiencies A&E Attendances Inpatient Admissions

Performance – Outward Referrals

36 36

5.1 5.2

Types of Referral Organisation Named Organisations Referred To

Service Users

37 37 37 38 38 38

6.1 6.2 6.3 6.4 6.5 6.6

Service Acceptance Age Range Gender Ethnicity Date of Referral Presenting Issues

Learning

40 40 41 41

7.1 7.2 7.3 7.4

KPI Achievement Good Practice Main Challenges Lessons Learnt

Appendices

Client Stories

David Waterfall, www.dpwaterfall.com

Page 3 of 46

Dudley CVS

Introduction

1.1

Commission Summary

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

David Waterfall was appointed by Dudley CVS to work alongside the team to collate and analyse data regarding the first year of delivery of the Dudley HIU Social Prescribing Project, and to use this information to produce an evidence-led evaluation report.

1.2

Report Purpose The purpose of this report is twofold; 1. Firstly to present data that has not been previously reported, and to subsequently provide an analysis of this information 2. Secondly to present the overall performance of the HIU project so that Dudley CVS and stakeholders can recognise lessons learned to date and use this insight to inform the remainder of delivery

1.3

Agreed Methodology The approach has been agreed in advance with the Dudley CVS, and has involved discussions with the team to understand the background to the service, as well as collation and analysis of documentation. Regular updates have also been held to review progress and discuss emerging findings.

David Waterfall, www.dpwaterfall.com

Page 4 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

Background

2.1

Dudley CVS Dudley CVS is an independent, second tier (umbrella) local infrastructure organisation supporting voluntary and community organisations, faith based organisations and social enterprises in Dudley borough. Dudley CVS’s vision is for a borough that has caring, vibrant and strong communities where everyone can fulfil their potential. Dudley CVS has delivered the Integrated Plus Social Prescribing service since 2014 and, and as a result the High Intensity User Social Prescribing project since 2018.

2.2

Integrated Plus Social Prescribing Service Integrated Plus is Dudley borough’s social prescribing service delivered by Dudley CVS as part of Dudley’s new care model. Integrated Plus is funded by Dudley CCG and has been in operation since 2014. The service covers Dudley CCG and Dudley MBC geographical area of Dudley borough based in the West Midlands. Integrated Plus provides GPs and MultiDisciplinary Team staff a referral destination into social prescribing whereby vulnerable people can access non-clinical social support, often in their own homes to help improve quality of life and wellbeing.

2.3

Dudley’s High Intensity User Social Prescribing Service Due to the success of the Integrated Plus service, Dudley CVS was approached by Dudley CCG in 2017 to explore whether the existing Integrated Plus service could be expanded using the same model but offering HIUs of emergency services more intensive and longerterm social prescribing interventions. The new service would combine the existing Integrated Plus approach alongside that of the HIU model implemented in Blackpool. Through Dudley CVS’s experience of delivering Integrated Plus, it was recognised that there was a gap in high end intensive support for people who are very dependent on emergency services. Expanding the existing Integrated Plus service would:  



Widen the current social prescribing offer to secondary care services Meet the NHS RightCare model threshold which is people who have a very high dependency on A&E, the Urgent Care Centre (UCC) and West Midlands Ambulance Service (WMAS). This patient cohort will be patients who live in Dudley borough. Offer a voluntary sector collaborative model of high intensity social prescribing support to those who are most vulnerable in society.

At the time, Dudley CVS was aware that the Department of Health was promoting a new Social Prescribing Health and Wellbeing Fund open to voluntary sector organisations. Matchfunding was required for applications so Dudley CCG and Dudley CVS took advantage of this opportunity and applied for the funding which would enable; the HIU project to be funded for 3 years rather than 2 to enable more time to be allocated to really testing out the model, and also mean that Dudley CVS would be able to apply for direct funding which could be spent in the voluntary sector to help establish new activities based on new needs. In early 2018, Dudley CVS and Dudley CCG were successful in securing the grant award and hence the HIU Social Prescribing project was born. David Waterfall, www.dpwaterfall.com

Page 5 of 46

Dudley CVS

2.4

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

HIU Service Delivery The service targets the most vulnerable socio-economic groups in Dudley borough who face multiple challenges from poverty, co-morbidities, substance misuse, unhealthy lifestyles, potentially risky behaviours, homelessness, mental health issues, relationship breakdowns, physical disabilities etc. They must be registered with a Dudley GP, aged 18 and over and having unscheduled care activity more than 12 times in any 12 month period. The service combines a flexible, non-clinical, holistic package of support, and is delivered by two HIU Link Workers who focus on the whole person’s needs whatever they might be to jointly find solutions to problems faced. The Link Workers meet each person in their own home, offering a personalised approach to sensitively ‘uncover’ the real reasons for them calling 999 or presenting frequently at A&E/UCC. They act as an advocate for each patient, guiding them through the complex journey and multi-faceted approach which has resulted in inappropriate use of unscheduled care. A collaborative approach to support is provided with voluntary organisations and the people themselves to ensure care and support is coproduced, person-centred and appropriate. Support has a strong emphasis on using an assets-based recovery approach and supports ‘goal striving’. A key element of this service is undertaking a voluntary sector collaborative social prescribing model. Link Workers identify, adapt and develop appropriate support solutions with voluntary sector organisations to meet each person’s needs. When support needs are identified and voluntary sector providers are not able to meet a particular need with their existing services, new ideas on tailored service solutions are developed and funded by Dudley CVS.

2.5

HIU Interventions Types of intervention provided are varied, and may include:

2.5.1

General Support         

2.5.2

Weekly catch-ups to check-in with people to see how they are doing Intensive and tailored support up to 6 months, building in an exit strategy with each person individually Spending quality time with people, actively listening to their needs Exploring peoples goals, aspirations, hopes and fears Helping people to engage in services appropriate to their needs Support recovery and encourage behavioural change Building people’s confidence to engage in services and community activities Taking people to services if their confidence is low or when struggling with anxiety Offers out of hours telephone support as an alternative to the emergency services

Advocacy  

Help people apply for Personal Independent Payments and Attendance Allowance. Accompany people to benefit tribunals if there confidence is low (this doesn’t involve acting as a representative for them during the tribunal meeting).

David Waterfall, www.dpwaterfall.com

Page 6 of 46

Dudley CVS

2.5.3

Accessing Services On Offer     

2.5.4

 

  

Ensure people have adequate heating and food by issuing food bank vouchers and signposting people to Public Health Winter Warmth scheme. Help to resolve housing issues. Help people access white goods vouchers. Help people to live as independently as possible in their own homes by helping to arrange home adaptations, telecare etc.

Connecting And Supporting People      

2.6

Help people access disabled bus passes and connect people to transport services such as Ring and Ride. Issue emergency one-day travel passes when people are in crisis and have no money to attend benefit appeals appointments. Accompany people to services/activities up to a maximum of three times if their confidence is low.

Building A Home 

2.5.6

Help people access work programmes and ESOL classes. Ensure people are getting the benefits they are entitled to. Support people with navigating the health and social care system. Connect people into services and activities that can help with all kinds of issues eg mental health, drug and alcohol addiction etc. Ensure people are getting the right care and support they need and are entitled to.

Getting Around 

2.5.5

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

Connect people into a wide range of social, leisure and faith based activities. Support people with family issues. Help people reconnect with friends or family. Connect people with each other to offer peer support. Connect people to peer-led networks and groups. Support people to run peer and social activities themselves.

Voluntary And Community Sector Fluid Floating Fund An important element of the HIU Social Prescribing Service was to establish a voluntary sector fluid floating fund whereby, new activities and services that would meet unmet needs could be established and funded. Over 3 years, Dudley CVS secured £150,000 (£50,000 each year) to purchase services in the voluntary sector either through block grant funding or on a spot-purchase arrangement. During the summer of year 2, Dudley CVS will be promoting the fund to the wider voluntary sector to encourage the submission of new ideas on services and activities to help support the service and meet HIU patient needs. The end of year 2 evaluation report will demonstrate the impact of the new services and activities for people supported by the voluntary sector.

David Waterfall, www.dpwaterfall.com

Page 7 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

A variety of services were commissioned in year 1 and are scheduled for delivery in year 2 onwards. These include: Financial support  1-2-1 support with benefit checks and applying for benefits, in people’s homes if needed  1-2-1 support with tribunals and appeals  1-2-1 support with managing debts in people’s homes if needed Mental     

health support Low level anxiety management programme 1-2-1 counselling Relationship counselling Talk, learn and change mental health support group Cinema afternoons to help people nurture new friendships

Creative activities  Weekly creative group activities  Art and home packages  Take 5 YouTube video creation on the 5 ways to wellbeing

2.7

HIU Year 1 Targets The first year of delivery held two KPIs: KPI Number of service users supported Number of new individuals contacted to offer service

Year 1 Target 50 90

In addition to KPIs, performance data has been recorded focusing on: 1 2 3

Outcomes Emergency Service Avoidance Outward Referrals

Each of these is addressed in the following sections.

David Waterfall, www.dpwaterfall.com

Page 8 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

Performance - Outcomes

3.1

User Feedback Integrated Plus has gained data from users against a number of outcomes and outputs, as follows: 1 2 3 4 5 6 7

Finance Physical Health Mental Health Social Contact Housing Safety Learning

In addition data is gained on ‘Drugs and Alcohol’, ‘Sexual Health’ and ‘Criminal Activity’ although as clients exhibit a significantly lower level of support (if any) in these three areas the findings are not covered within this evaluation report. Clients are engaged at the first contact with the service and surveyed on how they feel in relation to these areas, and then they are surveyed again at the conclusion of the support. Each of the main areas includes user feedback for:

3.2



An Overall Question; where users are asked to score on a scale of “Not managing (need support)”, “Already receiving support”, or “Managing ok”.



Several Indicators; each area has a number of indicators against which specific measurements were taken. Users score these on a scale of “1 - None of the time”, “2 – Rarely”, “3 - Some of the time”, “4 – Often”, “5 - All of the time”, or “N/A”.

Finance The Finance target held an overall statement and four indicators:    

Indicator; I Indicator; I Indicator; I Indicator; I

am able to manage my money well have enough money to meet basic needs (eg food, bills, heating) have savings I can use if I need to feel able to manage my debts

The overall position at start and latest reviews, and hence the change achieved during the service: Not Managing (need support)

Already receiving support

Managing ok

Start (#)

Latest (#)

100%

75%

86%

Change (%)

David Waterfall, www.dpwaterfall.com

Page 9 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

This reveals that after the support, there was a complete removal of any patients that were not managing, and also an increase of 86% for those who were managing. Further detail may be shown below in the two graphs that illustrate the baseline position before support (the grey line) and compare that to the same indicator after support (the green line), to show differences in patient ratings.

Finance (Often + All the Time)

90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

I am able to manage I have enough money my money well to meet basic needs? Start

I have savings I can use if I need to

I feel able to manage my debts

Latest

The first graph shows that the percentage of patients that were not managing (through a rating of 1 ‘not at all’ or 2 ‘rarely managing’) before support was reduced across all indicators by the end of the support. The greatest of these was those not managing for “I am able to manage my money well” with a start of 35% and a reduced end point of 10%.

Finance (None + Rarely) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% I am able to manage I have enough money my money well to meet basic needs? Start

I have savings I can use if I need to

I feel able to manage my debts

Latest

The second graph the trend is replicated in that the percentage of those reporting that they were managing (rating a 4 ‘Often’ or 5 ‘All of the time’) is increased across all indicators. The greatest of these was those managing well with “I have enough money to meet basic needs” with a start of 30% and an increased end point of 85%.

David Waterfall, www.dpwaterfall.com

Page 10 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

In terms of the degree of change across the individual indicators: None + Rarely (1 + 2) I am able to manage my money well I have enough money to meet basic needs I have savings I can use if I need to I feel able to manage my debts

Often + All (4 + 5)

Start

Latest

Change

Start

Latest

Change

71%

129%

83%

183%

100%

150%

Change by Score; Start to Latest

200% 180% 160% 140% 120% 100% 80% 60% 40% 20% 0% I am able to manage my money well

I have enough money I have savings I can use I feel able to manage to meet basic needs? if I need to my debts 1+2

4+5

This chart shows the change between before and after support, for both the lowest managing ratings (1 + 2, in blue) and also the highest manging ratings (4 + 5, in red); the larger the columns the greater the positive change as a result of the support. The chart shows that indicators have beneficial change in all indicators, with the greatest enhancement for patients being in “I have enough money to meet basic needs” for the highest ratings with a 183% change.

3.3

Physical Health The Physical Health target held an overall statement and seven indicators:       

Indicator; I Indicator; I Indicator; I Indicator; I Indicator; I Indicator; I Indicator; I

feel able to manage my personal care feel able to manage my medication am managing long term conditions well am able to easily and independently leave my property feel I am able to partake in exercise on a weekly basis feel I have a balanced diet feel I am coping with my caring duties

David Waterfall, www.dpwaterfall.com

Page 11 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

The overall position at start and latest reviews, and hence the change achieved during the service: Not Managing (need support)

Already receiving support

Managing ok

Start (#)

Latest (#)

88%

100%

17%

Change (%)

This reveals that after the support, there was an 88% reduction change in those patients that were not managing, and also an increase of 17% for those who were managing. Further detail may be shown below in the two graphs that illustrate the baseline position before support (the grey line) and compare that to the same indicator after support (the green line), to show differences in patient ratings:

The first graph shows that the percentage of patients that were not managing (through a rating of 1 ‘not at all’ or 2 ‘rarely managing’) before support was reduced across all indicators by the end of the support. The greatest of these was those not managing for “I am managing long term conditions well.” with a start of 55% and a reduced end point of 10%.

David Waterfall, www.dpwaterfall.com

Page 12 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

The second graph shows the trend is replicated in that the percentage of those reporting that they were managing (rating a 4 ‘Often’ or 5 ‘All of the time’) is increased across all indicators, aside from “I feel able to partake in exercise” that remains the same. The greatest of these was those managing well with “I feel I have a balanced diet” with a start of 25% and an increased end point of 55%. In terms of the degree of change across the individual indicators: None + Rarely (1 + 2) I feel able to manage my personal care I feel able to manage my medication I feel I am managing my long term condition/s well I am able to easily and independently leave my property I feel I am able to partake in exercise on a weekly basis I feel I have a balanced diet (eg 7 fruit/vegetables per day) I feel I am coping with my caring duties

David Waterfall, www.dpwaterfall.com

Often + All (4 + 5)

Start

Latest

Change

Start

Latest

Change

88%

57%

40%

45%

82%

50%

38%

25%

71%

120%

50%

-33%

Page 13 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

This chart shows the change between before and after support, for both the lowest managing ratings (1 + 2, in blue) and also the highest manging ratings (4 + 5, in red); the larger the columns the greater the positive change as a result of the support. The chart shows that indicators have beneficial change in all indicators except “I feel I am coping with my caring duties” that decreases by 33% (representing feedback from a single user). The greatest enhancement for patients being in “I feel I have a balanced diet” for the highest ratings with a 120% change.

3.4

Mental Health The Mental Health target held an overall statement and ten indicators:          

Indicator; Feeling optimistic about the future Indicator; I've been feeling useful Indicator; I've been feeling relaxed Indicator; I've been dealing with problems well Indicator; I've been thinking clearly Indicator; I've been feeling close to other people Indicator; I've been able to make up my own mind about things Indicator; I am free from suicidal thoughts Indicator; I am free from self-harming thoughts and actions Indicator; I feel able to control my anger

The overall position at start and latest reviews, and hence the change achieved during the service: Not Managing (need support)

Already receiving support

Managing ok

Start (#)

Latest (#)

93%

800%

150%

Change (%)

This reveals that after the support, there was a 93% reduction change in those patients that were not managing, and also an increase of 150% for those who were managing. Further detail may be shown below in the two graphs that illustrate the baseline position before support (the grey line) and compare that to the same indicator after support (the green line), to show differences in patient ratings:

David Waterfall, www.dpwaterfall.com

Page 14 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

The first graph shows that the percentage of patients that were not managing (through a rating of 1 ‘not at all’ or 2 ‘rarely managing’) before support was reduced across all indicators by the end of the support. The greatest of these was those not managing for “I've been feeling relaxed” with a start of 75% and a reduced end point of 20%.

David Waterfall, www.dpwaterfall.com

Page 15 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

None + Rarely (1 + 2) Feeling optimistic about the future I've been feeling useful I've been feeling relaxed I've been dealing with problems well I've been thinking clearly I've been feeling close to other people Iâ€™ve been able to make up my own mind about things I am free from suicidal thoughts I am free from selfharming thoughts/actions I feel able to control my anger

David Waterfall, www.dpwaterfall.com

Often + All (4 + 5)

Start

Latest

Change

Start

Latest

Change

80%

500%

77%

233%

73%

600%

63%

800%

75%

225%

71%

114%

50%

31%

45%

100%

45%

75%

38%

Page 16 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

This chart shows the change between before and after support, for both the lowest managing ratings (1 + 2, in blue) and also the highest manging ratings (4 + 5, in red); the larger the columns the greater the positive change as a result of the support. The chart shows that indicators have beneficial change in all indicators of at least 31%, with the greatest enhancement for patients being in “I've been dealing with problems well” for the highest ratings with an 800% change.

3.5

Social Contact The Social Contact target held an overall statement and six indicators:      

Indicator; I regularly have face to face social contact with people who are not family members (eg clubs, activities) Indicator; I have friends I can talk with regularly over the telephone/social media Indicator; I feel I have enough social contact with people so I am not lonely Indicator; I regularly help out in my community (eg volunteering, shopping for neighbours) Indicator; I feel comfortable mixing with people Indicator; I feel my religious/spiritual needs are being met

The overall position at start and latest reviews, and hence the change achieved during the service: Not Managing (need support)

Already receiving support

Managing ok

Start (#)

Latest (#)

89%

17%

140%

Change (%)

This reveals that after the support, there was an 89% reduction change in those patients that were not managing, and also an increase of 140% for those who were managing. Further detail may be shown below in the two graphs that illustrate the baseline position before support (the grey line) and compare that to the same indicator after support (the green line), to show differences in patient ratings:

David Waterfall, www.dpwaterfall.com

Page 17 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

The first graph shows that the percentage of patients that were not managing (through a rating of 1 ‘not at all’ or 2 ‘rarely managing’) before support was reduced across all indicators by the end of the support. The greatest of these was those not managing for “I regularly have face to face social contact with people who are not family members” with a start of 55% and a reduced end point of 10%.

The second graph shows the trend is replicated in that the percentage of those reporting that they were managing (rating a 4 ‘Often’ or 5 ‘All of the time’) is increased across all indicators. The greatest of these was those managing well with “I feel comfortable mixing with people” with a start of 26% and an increased end point of 60%. In terms of the degree of change across the individual indicators: None + Rarely (1 + 2) I regularly have face to face social contact with people who are not family members (eg clubs, activities) I have friends I can talk with regularly over the telephone/social media I feel I have enough social contact with people so I am not lonely I regularly help out in my community (eg volunteering, shopping for neighbours) I feel comfortable mixing with people I feel my religious/ spiritual needs are met David Waterfall, www.dpwaterfall.com

Often + All (4 + 5)

Start

Latest

Change

Start

Latest

Change

82%

50%

57%

67%

80%

11%

200%

83%

140%

-30%

Page 18 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

This chart shows the change between before and after support, for both the lowest managing ratings (1 + 2, in blue) and also the highest manging ratings (4 + 5, in red); the larger the columns the greater the positive change as a result of the support. The chart shows that indicators have beneficial change in all indicators aside from “I feel my religious/spiritual needs are being met” experiencing a 30% negative change accounting for three respondents. The greatest enhancement for patients being in “I regularly help out in my community” for the highest ratings with a 200% change.

3.6

Housing The Housing target held an overall statement and seven indicators:       

Indicator; I Indicator; I Indicator; I Indicator; I Indicator; I Indicator; I Indicator; I

feel secure in my tenancy am sleeping in a safe place every night feel able to keep up with my rent/ mortgage feel happy where I am living feel my accommodation is suitable for my needs/family am able to heat my home adequately feel my home is a safe environment

The overall position at start and latest reviews, and hence the change achieved during the service: Not Managing (need support)

Already receiving support

Managing ok

Start (#)

Latest (#)

100%

150%

50%

Change (%) David Waterfall, www.dpwaterfall.com

Page 19 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

This reveals that after the support, there was a 100% reduction change in those patients that were not managing, and also an increase of 50% for those who were managing. Further detail may be shown below in the two graphs that illustrate the baseline position before support (the grey line) and compare that to the same indicator after support (the green line), to show differences in patient ratings:

The first graph shows that the percentage of patients that were not managing (through a rating of 1 ‘not at all’ or 2 ‘rarely managing’) before support was reduced across all indicators by the end of the support. The greatest of these was those not managing for “I feel secure in my tenancy” with a start of 25% and a reduced end point of 5%.

David Waterfall, www.dpwaterfall.com

Page 20 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

In terms of the degree of change across the individual indicators: None + Rarely (1 + 2) I feel secure in my tenancy (eg risk of eviction) I am sleeping in a safe place every night I feel able to keep up to date with my rent/mortgage I feel happy where I am living I feel my accommodation is suitable I am able to heat my home adequately I feel my home is a safe environment eg fire, stairs, risk of falls etc

Often + All (4 + 5)

Start

Latest

Change

Start

Latest

Change

80%

15%

50%

100%

50%

18%

50%

15%

100%

18%

50%

23%

This chart shows the change between before and after support, for both the lowest managing ratings (1 + 2, in blue) and also the highest manging ratings (4 + 5, in red); the larger the columns the greater the positive change as a result of the support. The chart shows that indicators have beneficial change in all indicators, with significantly greater changes for the lowest ratings, and with the greatest enhancement for patients being in â€œI am able to heat my home adequatelyâ€? for the lowest ratings with a 100% change. David Waterfall, www.dpwaterfall.com

Page 21 of 46

Dudley CVS

3.7

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

Safety The Safety target held an overall statement and six indicators:      

Indicator; I Indicator; I Indicator; I Indicator; I Indicator; I Indicator; I

feel feel feel feel feel feel

safe where I live safe with my partner safe with friends safe with family safe from harm/exploitation I have people I can contact in an emergency

The overall position at start and latest reviews, and hence the change achieved during the service: Not Managing (need support)

Already receiving support

Managing ok

Start (#)

Latest (#)

100%

40%

Change (%)

This reveals that after the support, there was a 100% reduction change in those patients that were not managing, and also an increase of 8% for those who were managing. Further detail may be shown below in the two graphs that illustrate the baseline position before support (the grey line) and compare that to the same indicator after support (the green line), to show differences in patient ratings:

The first graph shows that the percentage of patients that were not managing (through a rating of 1 ‘not at all’ or 2 ‘rarely managing’) before support was reduced across all indicators by the end of the support. The greatest of these was those not managing for “I feel I have people I can contact in an emergency” with a start of 10% and a reduced end point of 0%.

David Waterfall, www.dpwaterfall.com

Page 22 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

The second graph shows the trend is replicated in that the percentage of those reporting that they were managing (rating a 4 ‘Often’ or 5 ‘All of the time’) is increased across most indicators, with the greatest of these was those managing well with “I feel I have people I can contact in an emergency” with a start of 60% and an increased end point of 85%. In terms of the degree of change across the individual indicators: None + Rarely (1 + 2) I feel safe where I live I feel safe with my partner I feel safe with friends I feel safe with family I feel safe from harm/exploitation I feel I have people I can contact in an emergency

David Waterfall, www.dpwaterfall.com

Often + All (4 + 5)

Start

Latest

Change

Start

Latest

Change

50%

33%

15%

42%

100%

Page 23 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

This chart shows the change between before and after support, for both the lowest managing ratings (1 + 2, in blue) and also the highest manging ratings (4 + 5, in red); the larger the columns above zero the greater the positive change as a result of the support. The chart shows that indicators have beneficial change in all indicators, with significantly greater changes for the lowest ratings, and with the greatest enhancement for patients being in “I feel I have people I can contact in an emergency ” for the lowest ratings with a 100% change.

3.8

Learning The Learning target held an overall statement and six indicators:      

Indicator; I Indicator; I Indicator; I Indicator; I Indicator; I Indicator; I

feel happy with my current employment feel happy in my retirement have opportunities to learn new skills feel able to find work feel motivated to find work feel able to work despite having a physical/mental health condition

The overall position at start and latest reviews, and hence the change achieved during the service: Not Managing (need support)

Already receiving support

Managing ok

Start (#)

Latest (#)

63%

75%

25%

Change (%)

This reveals that after the support, there was a 63% reduction change in those patients that were not managing, and also an increase of 25% for those who were managing. Further detail may be shown below in the two graphs that illustrate the baseline position before support (the grey line) and compare that to the same indicator after support (the green line), to show differences in patient ratings:

David Waterfall, www.dpwaterfall.com

Page 24 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

The first graph shows that the percentage of patients that were not managing (through a rating of 1 ‘not at all’ or 2 ‘rarely managing’) before support was reduced across all indicators that had responses by the end of the support. The greatest of these was those not managing for “I have opportunities to learn new skills” with a start of 60% and a reduced end point of 30%.

The second graph shows the trend is replicated in that the percentage of those reporting that they were managing (rating a 4 ‘Often’ or 5 ‘All of the time’) is increased across all indicators. The greatest of these was equally those managing well with “I feel happy in my retirement” and also “I feel able to work despite having a physical/mental health condition” both with a start of 5% and an increased end point of 10%. In terms of the degree of change across the individual indicators: None + Rarely (1 + 2) I feel happy with my current employment I feel happy in my retirement I have opportunities to learn new skills I feel able to find work I feel motivated to find work I feel able to work despite having a physical/mental health condition

David Waterfall, www.dpwaterfall.com

Start

Latest

Change

Often + All (4 + 5) Start

Latest

Change

50%

100%

50%

33%

21%

14%

100%

Page 25 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

This chart shows the change between before and after support, for both the lowest managing ratings (1 + 2, in blue) and also the highest manging ratings (4 + 5, in red); the larger the columns the greater the positive change as a result of the support. The chart shows that indicators have beneficial change in all indicators, with the greatest enhancement for patients being in “I feel happy in my retirement” and “I feel able to work despite having a physical/mental health condition” for the highest ratings each with a 100% change.

3.9

Target Areas Overall When considering all indicators together, the following headline figures exist for those that considered themselves to not be managing: Not Managing (need support) Start %

Latest %

Start #

Latest #

Change %

Finance

45%

100%

Physical Health

40%

88%

Mental Health

75%

93%

Social Contact

45%

89%

Housing

40%

100%

Safety

15%

100%

Learning

40%

15%

63%

David Waterfall, www.dpwaterfall.com

Page 26 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

This may be illustrated in a chart, where grey is the start position and green the end position â€“ whereby a lower green bar means that fewer patients reported being unable to manage at the end of the support.

Not Managing (need support)

80% 70% 60% 50% 40% 30% 20% 10% 0% Finance

Physical Health

Mental Health Start

Social Contact

Housing

Safety

Learning

Latest

The overall position may be illustrated below, indicating the change of patient feedback between the start of the support and the end of the support:

Change in Not Managing (need support) 100% 80%

Learning 63%

60% 40% 20% 0%

Safety 100%

Housing 100%

Finance 100% Physical Health 88%

This shows that those not managing have had significant beneficial changes (i.e. a reduction in Mental Health numbers) in all target areas of at least 63%, with several 93% having a 100% reduction meaning there were no patients reporting they were not managing at the end of Social Contact 89% the support.

At the other end of the spectrum when considering all indicators together, the following headline figures exist for those that considered themselves to be managing okay:

David Waterfall, www.dpwaterfall.com

Page 27 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

Managing Okay Start %

Latest %

Start #

Latest #

Change

Finance

35%

65%

86%

Physical Health

30%

35%

17%

Mental Health

20%

50%

150%

Social Contact

25%

60%

140%

Housing

50%

75%

50%

Safety

60%

65%

Learning

40%

50%

25%

This may be illustrated in a chart, where grey is the start position and green the end position – whereby a higher green bar means that more patients reported being better able to manage at the end of the support.

Managing OK 80% 70% 60% 50% 40% 30% 20% 10% 0% Finance

Physical Health

Mental Health Start

Social Contact

Housing

Safety

Learning

Latest

The overall position may be illustrated below, indicating the change of patient feedback between the start of the support and the end of the support: Finance 86% 150% Learning 25%

100%

Managing OK

Physical Health 17%

50% 0% Mental Health 150%

Safety 8%

Housing 50% David Waterfall, www.dpwaterfall.com

Social Contact 140%

This shows that those managing okay have had beneficial changes (i.e. an increase in numbers) in all target areas ranging from 8% to 150%; the greatest being ‘Mental health’ with a 150% positive change. Page 28 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

3.10 Wider Achievements Aside from the seven main target outcome areas, the service has achieved a number of additional changes for its clients in terms of quality of life and wellbeing: 3.10.1 Quality Of Life Clients are asked at the start to rate their overall quality of life from 1 to 5 (1 being low, 5 being high), with the question being repeated at the end of the support. Feedback is summarised below, and illustrated in terms of change from start to end: 1 # 8 0

Start End

2 % 62% 0%

# 3 0

3 % 23% 0%

# 2 7

100%

60% 40% 20% 0% 1+2 Latest

# 0 6

5 % 0% 46%

# 0 0

% 0% 0%

This shows that during the intervention the percentage of clients considering they have poor quality of life (ratings of 1 or 2) has been removed entirely (from 11 clients to no clients), and also the percentage of those clients considering they have good quality of life (ratings of 4 or 5) has been developed (from no clients, to 6).

80%

Start

4 % 15% 54%

4+5

3.10.2 Wellbeing Clients are asked at the start to rate their overall feeling of wellbeing from 1 to 5 (1 being low, 5 being high), with the question being repeated at the end of the support. Feedback is summarised below, and illustrated in terms of change from start to end: 1 Start End

# 6 0

2 % 46% 0%

# 5 0

3 % 38% 0%

90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1+2

4+5 Start

David Waterfall, www.dpwaterfall.com

# 2 4

4 % 15% 31%

# 0 8

5 % 0% 62%

# 0 1

% 0% 8%

This shows that during the intervention the percentage of clients considering they have poor wellbeing (ratings of 1 or 2) has been removed entirely (from 11 clients to clients), and also the percentage of those clients considering they have good quality of life (ratings of 4 or 5) has been developed (from no clients, to 9).

Latest Page 29 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

Performance â€“ Emergency Service Avoidance

4.1

Efficiencies Information has been gained for two key areas: ď‚ˇ ď‚ˇ

A&E Attendances Inpatient Admissions

These datasets are both gained from analysis of Data Services for Commissioners Regional Offices (DSCRO) data. As the law states commissioners are not allowed to access Personal Confidential Data (PCD) because they are not providing direct patient care, DSCRO provides an intermediary service that specialises in processing, analysing and packaging patient information within a secure environment into a format commissioners can legally use; anonymised patient level data. For both areas, comparative data has been gained for 6 months pre and also 6 months post support, and also for 12 months pre and post support.

4.2

A&E Attendances Data shows significant reductions in A&E attendance as a result of the support;

4.2.1

After Six Months There was an overall reduction of 11% in attendances (736 incidents pre support, 654 post = 82 incidents less overall). In terms of patient numbers; 64% of patients had fewer incidents (50 patients), and of these six months following the support there was an average of 4.9 fewer incidents per patient totalling 265 less incidents. Conversely, 31% (24 patients) experienced more attendances, with an average of 7.8 more incidents each totalling 183 additional attendances. After six months following support, the level of incidents six months before support may be illustrated as follows: Number of Incidents Pre Support Reduced Attendance Patients

Increased Attendance Patients 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0%

20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 0

8 10 12 14 16 18 20

David Waterfall, www.dpwaterfall.com

8 10 12 14 16 18 20 Page 30 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

This shows that there is little commonality in either set of patients in terms of a ‘type’ of patient that benefits more or less from the support, as there are both reductions and increases for patients that previously experienced from zero to 20 attendances. For example the original Integrated Plus project had evidence showing that 80% of patients experiencing reductions had at most two previous attendances; comparatively with this HIU project 80% of patients with reduced attendances had up to 12 previous attendances. 4.2.2

After 12 Months There was an overall reduction of 33% in attendances (1,438 incidents pre support, 965 post = 473 incidents less overall). In terms of patient numbers; 76% of patients had fewer incidents (60 patients), and of these six months following the support there was an average of 10.2 fewer incidents per patient totalling 646 less incidents. Conversely, 19% (15 patients) experienced more attendances, with an average of 12.2 more incidents each totalling 173 additional attendances. After 12 months following support, the level of incidents 12 months before support may be illustrated as follows: Number of Incidents Pre Support Reduced Attendance Patients 22% 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0%

Increased Attendance Patients 22% 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0%

8 10 12 14 16 18 20

This shows that there is little commonality in either set of patients in terms of a ‘type’ of patient that benefits more or less from the support, as there are both reductions and increases for patients that previously experienced from zero to 20 attendances. For example the original Integrated Plus project had evidence showing that 80% of patients experiencing reductions had at most three previous attendances; comparatively with this HIU project 80% of patients with reduced attendances had up to 15 previous attendances.

David Waterfall, www.dpwaterfall.com

Page 31 of 46

Dudley CVS

4.2.3

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

Comparative Data A summary of the A&E data is included below, split for ease between 6 months and 12 months following the support:

Before Service Contact After Service Contact Reduction (incidents) Reduced by

Patients with fewer incidents Patients with more incidents Patients with unchanged incidents

6 Months

12 Months

736 654 82 11%

1,438 965 473 33%

50 (64%) 24 (31%) 4 (5%)

60 (76%) 15 (19%) 4 (5%)

1 4.9 265

9 10.2 646

4 7.8 183

2 12.2 173

Patients with fewer incidents Most frequent reduction in incidence Average fewer incidents/ patient Incidents reduced

Patients with more incidents Most frequent increase in incidence Average increase incidents/ patient Incidents increased 4.2.4

Cost Avoidance In terms of cost avoidance, current data indicates that a single A&E attendance costs £115 per person. As such, after 6 months 82 fewer incidents overall equates to £9,430. However, if a focus is solely on the 50 patients that have had a total of 265 fewer incidents, this equates to £30,475. After 12 months 473 fewer incidents overall equates to £54,395. However, if a similar focus is solely on the 60 patients that have had a total of 646 fewer incidents, this equates to £74,290.

David Waterfall, www.dpwaterfall.com

Page 32 of 46

Dudley CVS

4.3

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

Inpatient Admissions Data shows significant reductions in inpatient admissions as a result of the support;

4.3.1

After Six Months There was an overall reduction of 20% in admissions (296 incidents pre support, 237 post = 59 incidents less overall). In terms of patient numbers; 51% of patients had fewer incidents (40 patients), and of these six months following the support there was an average of 2.9 fewer incidents per patient totalling 117 less admissions. Conversely, 29% (23 patients) experienced more attendances, with an average of 2.4 more incidents each totalling 58 additional admissions. After six months following support, the level of incidents six months before support may be illustrated as follows: Number of Admissions Pre Support Reduced Admissions Patients Increased Admissions Patients 35%

35%

30%

25%

20%

15%

10%

0% 0

8 10 12 14 16 18 20

This shows that there is general commonality with a â€˜typeâ€™ of patient that benefits more or less from the support; for those with reduced admissions after the support 55% had 4 or less admissions six months before the support, and conversely for those with increased admissions following support 55% had none or 1 admission six months before the support. This may suggest that where increased admissions are evident, these are not from frequent attendees and as such may represent natural occurrences. 4.3.2

After 12 Months There was an overall reduction of 41% in admissions (553 incidents pre support, 326 post = 227 incidents less overall). In terms of patient numbers; 75% of patients had fewer incidents (59 patients), and of these six months following the support there was an average of 4.3 fewer admissions per patient totalling 258 less incidents. Conversely, 13% (10 patients) experienced more admissions, with an average of 2.9 more incidents each totalling 31 additional incidents.

David Waterfall, www.dpwaterfall.com

Page 33 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

After 12 months following support, the level of admissions 12 months before support may be illustrated as follows: Number of Admissions Pre Support Reduced Admissions Patients Increased Admissions Patients 22% 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0%

22% 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 0 2 4 6 8 10 12 14 16 18 20

8 10 12 14 16 18 20

This shows that there is some commonality for the â€˜typeâ€™ of patient that benefits more from the support as 56% of patients had six or fewer admissions 12 months before the support. Conversely, there is little commonality with those patients that have increased admissions given 20% trends at none, 1 and 7 admissions 12 months before the support. 4.3.3

Comparative Data A summary of the A&E data is included below, split for ease between 6 months and 12 months following the support:

Before Service Contact After Service Contact Reduction (incidents) Reduced by

Patients with fewer incidents Patients with more incidents Patients with unchanged incidents

6 Months

12 Months

296 237 59 20%

553 326 227 41%

40 (51%) 23 (29%) 15 (19%)

59 (75%) 10 (13%) 10 (13%)

1 2.9 117

1 4.3 258

Patients with fewer incidents Most frequent reduction in incidence Average fewer incidents/ patient Incidents reduced

David Waterfall, www.dpwaterfall.com

Page 34 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

Patients with more incidents Most frequent increase in incidence Average increase incidents/ patient Incidents increased 4.3.4

1 2.5 58

1 2.9 31

Cost Avoidance In terms of cost avoidance, current data indicates that a single inpatient visit costs £1,700 per person. As such, after 6 months 59 fewer incidents overall equates to £100,300. However, if a focus is solely on the 40 patients that have had a total of 117 fewer incidents, this equates to £198,900. After 12 months 227 fewer incidents overall equates to £385,900. However, if a similar focus is solely on the 59 patients that have had a total of 258 fewer incidents, this equates to £438,600.

David Waterfall, www.dpwaterfall.com

Page 35 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

Performance â€“ Outward Referrals

5.1

Types of Referral Organisation During the first year of operation 52 outward referrals were made, with the most frequent being to the voluntary sector (32 referrals, 62% of total): Organisation Type

Number

Voluntary

Statutory

NHS

Private

National Government

Total

40 30 20 10 0

Voluntary

Statutory

NHS

Private

National Government

The majority of referrals have been for support with mental health issues, benefits and other financial support and transport services.

5.2

Named Organisations Referred To A total of 37 individual organisations were referred to, with the vast majority (31 organisations, 60%) receiving only a single referral based on the clientâ€™s specific needs. Those that received more than one referral are listed below: Repeat Referral

Number

Dudley Counselling Centre

Dudley and District Citizens Advice Bureau (CAB)

Age UK Dudley

Dudley Mind

Making Waves - Air Time

Top Church Training

Total

David Waterfall, www.dpwaterfall.com

Page 36 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

Service Users

6.1

Service Acceptance Of the 91 individuals referred, 84 accepted the service: Declined Service

Number

No ? Service Accepted

Yes ? Unable to make Contact/Letter Sent

Yes ? Did not attend Appointment

Yes ? Inappropriate Referral Total

1 91

Of the 84 that accepted the service, three had a carer and one was a carer.

6.2

Age Range Of the 84 that accepted the service the most commonplace age category was 40 to 49 (21 clients, and 25% of the clients), and it is interesting to note that both the modal and median age is 49, with the mean being 50: Age Range 16 to 19

Number 2

20 to 29

30 to 39

40 to 49

50 to 59

60 to 69

70 to 79

80 to 89

>90

Total

6.3

25 20 15 10 5 0 16 to 20 to 30 to 40 to 50 to 60 to 70 to 80 to 19 29 39 49 59 69 79 89

>90

Gender Of the 84 that accepted the service most were female (49 clients, 58%): Gender

Number

Female

Male

Transgender MTF

Unstated

Total

David Waterfall, www.dpwaterfall.com

Page 37 of 46

Dudley CVS

6.4

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

Ethnicity Of the 84 that accepted the service the most commonplace ethnicity was White (63 clients, 75%): Ethnicity White English/Welsh/Scottish/Northern Irish/British

6.5

Number 63

Unstated

Not specified / Not Known

Caribbean

White & Black Caribbean

Indian

Total

Date of Referral Of the 84 that accepted the service the date of referral indicates frequent months for referrals and acceptances were August to November 2018 (41 clients, 49%): Referral Date Number

Apr-18 May-18

0 0

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18 Jan-19

1 15

Feb-19

Mar-19

Total

6.6

14 12

4 2 0

Presenting Issues Acknowledging that a client may have exhibited one or more indicators (as per Link Worker assessment), of the 84 that accepted the service by far the most frequent indicator was for â€œLong Term Health Issuesâ€? (26 clients):

David Waterfall, www.dpwaterfall.com

Page 38 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

LLO Indicator 6 - Long Term Health Issues

Number

3 - Depression

2 - Isolation

4 - Drugs or Alcohol

7 - Stress

10 - Household Issues 12 - Other Mental Health Condition 14 - Lack of Basic Numeracy and Literacy

22 - Neighbour issues 15 - Purely medical issues

17 - Benefits 5 - Learning Disability Support 8 - Family Relationships

19 - Domestic violence 21 - Carers support needs

13 - Dementia

16 - Debt

20 15 10

5 5

16 - Debt

13 - Dementia

19 - Domestic violence

21 - Carers support needs

8 - Family Relationships

5 - Learning Disability Support

17 - Benefits

15 - Purely medical issues

22 - Neighbour issues

7 - Stress

174

14 - Lack of Basic Numeracy and Literacy

Total

12 - Other Mental Health Condition

10 - Household Issues

4 - Drugs or Alcohol

2 - Isolation

3 - Depression

6 - Long Term Health Issues

Within this, it is interesting to note that most clients presented with more than one LLO indicator (44 clients, 66% of those with recorded LLOs), with the most frequent situation being to present with two LLOs (25 clients, 37%):

Indicators Frequency

30 Number

David Waterfall, www.dpwaterfall.com

25 20 15 10 5 0 1

Number of LLOs Presenting With

Page 39 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

Learning The first year of delivery has provided the team with a wealth of insight into the scale of achievement, challenges experienced, which aspects of delivery are most efficient, and the implications for future delivery. Key areas of learning cover:

7.1

KPI Achievement The previous data evidences the achievement of the support, and in terms of the two KPIs for the first hear of delivery, performance stands at: KPI - Year 1 of Delivery Number of service users supported Number of new individuals contacted to offer service

Target 50 90

Actual 84 91

This evidences that 84 out of 91 HIU referral shave been supported; equating to a 92% patient service acceptance rate. Furthermore in the original proposal for this project, Dudley CCG estimated that a 30% reduction in annual unplanned emergency care usage for HIUs may be achievable with support from Link Workers. Evidence shows a 33% reduction in A&E attendances after 12 months , and a 41% reduction in inpatients admissions after 12 months. Overall across both A&E attendances and inpatient admissions after 12 months, this equates to 1,991 incidents before support and 1,291 after, producing a reduction of 700 incidents; a 35% reduction. This is above the CCG target of 30%.

7.2

Good Practice Below provides information on some key successes    

 

  

Built strong rapport and relationships with key stakeholders such as the Hospital, social care, WMAS, the urgent care centre and the voluntary sector. Gained a positive reputation both locally and nationally Managed to get the privacy impact assessment and data sharing agreements completed and in place with key stakeholders within 2 months of starting the project. Overcame some challenges in getting access to a list of high intensity users of unplanned emergency care within 2 months of the project starting. Direct patient social prescribing interventions commenced in June 2018. Established a bespoke HIU Core Group with key partners such as WMAS, Hospital and Police so that HIU patient lists can be discussed and their care and support coordinated. Two link workers have taken part in a variety of training including: solution focused therapy, motivational interview techniques, hoarding, asset-based approaches, suicide prevention, mentoring skills, benefits and high intensity user training from NHS England RightCare. Two Link Workers received 1-2-1 coaching from Rhian Monteith from the NHS England RightCare team. Put in place appropriate systems to record effective patient data and track the patient’s journey through our support interventions and our bespoke assessment. Developed appropriate and targeted promotional materials for the project.

David Waterfall, www.dpwaterfall.com

Page 40 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report



The service is one of the high intensity user lead projects around the country for NHS England RightCare Attended several national conferences organised by NHS England to network with other HIU projects Held and co-facilitated a West Midlands HIU Network meeting in Dudley borough Attended the conference organised by the Department of Health in October to share information with others about our project.

  

7.3

Main Challenges Overall, the project has progressed really well with very few challenges in the main. The key challenges we have faced have been in relation to the following: 



7.4

Initially getting the privacy impact assessment in place with Dudley CCG and the Commissioning Support Unit and the data sharing agreement signed with the hospital. This took some time which prevented the two Link Workers from being able to start supporting people. However, compared to other areas, delivering similar projects the service overcame this challenge quickly. Getting access to the A&E high intensity patient user list took some time which again prevented the two Link Workers from working with patients as quickly as the service would have liked. Staff involved learnt quickly that services do work in silos and services such as the hospital, WMAS, Urgent care centre have their own patient lists. It was difficult to get agreement on one overall list and individual services regularly contributing to one list. Working with people that have complex needs and/or chaotic lifestyles has brought about some challenges with getting client outcome assessments completed with them. This is due to concentration levels, basic literacy skills, dementia, learning disabilities etc.

Lessons Learnt Key lessons learnt to date include:  



  

There is a real need in Dudley borough for HIU social prescribing support, targeting high intensity users of unplanned emergency care. Spending quality time with this patient cohort can help unlock the real reasons for them using emergency services frequently which other services have not been able to achieve. Feedback from clients so far has been extremely positive regarding the bespoke support offered e.g. Shopping trips, confidence building, mentoring support, supporting with drug and alcohol issues, helping people engage in social activities. But the most important feedback given is the fact that clients can call one number and speak to us straight away when they are in need or distressed. HIU Link Worker roles offers a spring board between services whereby staff liaise with statutory and voluntary services. Link Workers work with clients like no other service has, hence the very high service acceptance rate. Working intensively with clients and having regular weekly contact is the key to success when preventing admissions.

David Waterfall, www.dpwaterfall.com

Page 41 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report



Out of hours telephone support is important when working with clients offering an alternative option to the emergency services. Link Workers getting to know the client means they can predict when they will feel at their most vulnerable and will feel at risk of calling emergency services or attending urgent care. The most important lesson learnt, is that Link Workers can provide as much support and involvement they can, however, sometimes you can’t change the outcome, or force behaviour change. In certain cases if the person does not wish for their circumstances to change Link Workers cannot change their view for them. The Link Worker role is challenging yet rewarding. Link Workers have visited many properties and been in some volatile situations. They have learnt to expect the unexpected and never under estimate a situation that they may be about to walk into and risk assessment on the spot is key. The two Link Workers have learnt a lot about each other as individuals and professionals. Link Workers have built both a very strong bond and working relationship. They can read each other and in certain situations know what the signs are to keep themselves safe. Importance of collaboration with key stakeholders such as Dudley CCG, hospital staff, WMAS staff and getting these stakeholders on board with the model. Such staff are key to sharing patient lists and helping to resolve data sharing agreements and issues. Along the way Link Workers have changed the language used with people as many have felt uncomfortable with the term high intensity user and feel that this stigmatises them in some way and can then act as a barrier to engagement.



David Waterfall, www.dpwaterfall.com

Page 42 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

Appendices A

Client Stories

David Waterfall, www.dpwaterfall.com

Page 43 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

Appendix A – Client Stories 1

Helping Joan to Join Group Activities Joan currently lives alone and has 3 children who have all grown up and left home. Joan has an array of medical issues such as Multiple Sclerosis and Fibromyalgia, but it was highlighted all admissions and 999 calls were of a social nature. On the first visit the Link Workers explored with Joan the nature of the calls and attendances, she expressed she was considerably “worried about her son” who is a heroin addict and was in and out of prison. She expressed she felt lonely and isolated and sat thinking all day about her son worrying and wondering if was alive & safe. She expressed she had “nobody to turn to about how she was feeling and felt if she went into hospital or spoke to paramedics they would have the answer but this was never the case”. Weekly contact started with Joan, a phone call and texting every other day. After researching, a group was identified for Joan and a Link Worker supported her to go. A Family & Friends group held at Birmingham City Hospital every other Wednesday evening 6 – 7.30pm. The group is for family and friends who have loved ones who are addicts, they get together to discuss and support one another. The group has been of great benefit to Joan as she was able to relate to other people and understood for sure that she was not the only person going through this with a family member. In addition, on the weeks where she does not attend the F&F groups, it was also identified for Joan to attend a disability group on a Wednesday evening and from this she feels she has made friends. Joan was one of the first clients to attend the HIU group ‘Take 5’ which commenced on 19 th June. Take 5 is provided by Creative Health CIC and is paid for as a grant from the voluntary sector fluid fund. She expressed to that she has “enjoyed the group” and that it was “something different”. Joan recently allowed her son to stay with her after he was released from prison, this was a challenging time as she knew as much as she wanted to help him, he needed to want to help himself. As a result of this, he has taken advantage of her stealing many of her valued items. Joan expressed to the Link Worker that she is upset with how he has behaved, however, now she has the social support around her she is able to talk and deal with the situation. She feels she will be able “to get through it a lot quicker and be a lot stronger” and for this she thanked the Link Worker for giving her the support and “introducing her to places where she feels she has made new friends”. Since engaging with these services and having the relevant support, Joan no longer attends A&E or contacts 999 as any questions she has she writes down in her diary and takes them along to the family & friends group. In terms of cost avoidance, Joan has a value of £15,145: A&E attendances 12 months before referral – 52 attendances Post date of referral – 9 attendances Reduction of 43 attendances (83%) Cost avoidance of £4,945 (£115 x 43)

David Waterfall, www.dpwaterfall.com

Hospital admissions 12 months before referral – 8 admissions Post date of referral – 2 admissions Reduction of 6 (75%) Cost avoidance £10,200 (£1700 x 6)

Page 44 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

Helping Katie to Build Her Confidence And Trust Katie is an 18 year HIU of 999 and A&E through taking overdoses and severe self-harming to the point that there is no area below her face that isn’t horrifically scarred from self-harm. Katie was a victim of child sexual exploitation when she was 13-17 years old, being used for sexual services for organised crime gangs. Katie has very little trust in people and professionals. Katie is still in the care system but is due to move to adult care soon. Her mental health is currently being assessed but preliminary reports suggest she is a ‘pathological liar’ as well as suffering psychosis and paranoia. Initially when the Link Worker met Katie she found it difficult to build a relationship as Katie is used to pushing boundaries with professionals and is known to dislike and even “hate them”. Katie was selfharming to cope with her past abuse and lack of any maternal or paternal love. Through many visits a good rapport was built between the Link Worker and Katie. The relationship formed is very therapeutic and has strong boundaries even though Katie does test these boundaries at times. The Link Worker was able to engage Katie with mental health services by attending her CPN appointments with her. The Link Worker would sometimes drive Katie to the appointments or catch a bus together. On other occasions Katie would go on her own or the CPN would conduct a home visit which was organised by the Link Worker and the CPN to give the best possible outcomes for engaging with Katie. With some clients it’s about attending a couple of appointments with them in the car or by public transport and then enabling the client to go independently, but with HIU clients the very reason things have broken down with their physical health, mental health and social issues is they are not at that stage where they will independently do things, and if it means Link Workers get a client engaging in the correct support and relying less on front line services then this is good. Link Workers do have time limits so they are mindful about the balance of independence being our main goal and a client not becoming over reliant on staff, but as long as it is made clear from the offset that this is a timed project and Link Workers will be looking to move towards independence, then this has been working well. The Link Worker supported Katie with her Personal Independent Payment medical check and she was successful in being awarded this benefit. Katie has also been connected into Dudley Counselling Centre for counselling where she has attended 2 sessions so far. The Link Worker also attends safeguarding multi agency meetings to help co-ordinate what works well. Katie is sometimes supported through out of hours telephone support when Katie is feeling she needs the support; this can be weekly. The Link Worker and Katie go out for regular coffees to get her out from the shared accommodation she lives in and to help build Katie’s confidence. Katie has stated she “values and needs the support that the Link Worker offers, and feels she has someone else to turn to”. “Thank you for being so supportive all the time and thank you so much for being there for me, it means so much”. Katie has really opened up to the Link Worker and initially she would play a lot of mind games, now she does not try this behaviour anymore due to tight boundaries.

David Waterfall, www.dpwaterfall.com

Page 45 of 46

Dudley CVS

Dudley HIU Social Prescribing Project Year 1 Evaluation, Final Report

In terms of cost avoidance, Katie has a value of £6,940: A&E attendances 12 months before referral – 20 attendances Post date of referral – 4 attendances Reduction of 16 attendances (80%) Cost avoidance £1,840 (£115 x 16)

Hospital admissions 12 months before referral – 3 admissions Post date of referral – 0 admissions Reduction 100% Cost avoidance £5,100 (£1700 x 3)

A letter from Helen – a patient who is currently supported by HIU service “I am Helen and after coping with numerous personal traumas in my life over the past ten years, I have suffered mental breakdowns. I tried so hard to fight the depressions, anxiety and panic attacks unaware of what was happening to me but the mental and physical pain became unbearable to the point where I wanted to end it all. I could see no way out, no future living like this to the point where I wanted to end it all. I fell into a very dark place, a place I called hell, self-harming, failed attempts to take my own life eventually using alcohol as my crutch in order to try to block out everything bad in my life which had a massive effect on my family life. I suppose I became an abusive drunk. I tried help from the ‘so called’ mental health system out there. I was desperate but in my opinion the system always badly let me down and abandoned me as a hopeless drunk and instead of addressing my problems behind my addiction they ‘talked at me’ and not ‘with me’. After another attempt to end it all I was given a life line by being introduced to Kelly Rea, my link worker from Integrated Plus. Kelly is always at the end of the phone and is caring and understanding and non-judgmental. She listens to my every needs of recovery. She takes me out for coffee and shopping has enabled me to laugh again and understand a future without pain. I look forward to her visits, helping me to feel normal again, free from being treated as a freak. She recused me from a hotel room where I had decided to die alone and unloved, she saved my life and I call her my guardian angel. I have stopped drinking now and my life has become precious although I know I still have a way to go. I have developed fight and not flight and it is with Kelly’s care and help that has saved my life and if my life can be saved from the ashes then I believe other lives can be saved too. This service in my opinion is vital to help other people from utter despair. I cannot explain in words what Kelly has done for me. She is the most wonderful person I have ever met, when my family gave up on me, she never did. Thank you.” Overview of support provided by Kelly Kelly has been working with Helen since August 2018. Support has ranged from 1-2-1 visits, connecting Helen into a range of services such as alcohol recovery services and helping to build Helen’s confidence by accompanying her out and about in the community.

David Waterfall, www.dpwaterfall.com

Page 46 of 46