Integrated Plus Social Prescribing Evaluation Report (September 2014 - August 2018)

Dudley CVS

Integrated Plus Impact Evaluation

Final Report 26th March 2019

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

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

Dudley CVS Integrated Plus Impact Evaluation Final Report 4 C-DUC158 David Waterfall

Date:

26th March 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

Š 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

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Integrated Plus Impact Evaluation, Final Report

Contents Page

Section

5

Key Findings

7

1

Introduction

7 7 7

1.1 1.2 1.3

Commission Summary Report Purpose Agreed Methodology

8

2

Integrated Plus

8 8 9 10 11

2.1 2.2 2.3 2.4 2.5

Dudley CVS Service Model Staffing Intervention Types Integrated Plus Pathway

12

3

Social Prescribing Context

12 13

3.1 3.2

Introduction History

15

4

Evaluation Methodology

15 15

4.1 4.2

Approaches Data Validation

16

5

Service Demographics

16 17 19 20

5.1 5.2 5.3 5.4

Clients Client Feedback Inward Referrals Outward Referrals

23

6

Performance

23 23 25 28 30 33 35 38 40 42

6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 6.10

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

46

7

Service Reductions

46 46 48 50 51

7.1 7.2 7.3 7.4 7.5

Efficiencies A&E Admissions Inpatients Admissions DSCRO Data Overall GP Surgery Data

David Waterfall, www.dpwaterfall.com

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Integrated Plus Impact Evaluation, Final Report

53

8

Multi-Disciplinary Teams

53 53 55 57

8.1 8.2 8.3 8.4

Approach Integrated Plus Role Link Officer Role Future Development

59

9

Budget

59 60 61

9.1 9.2 9.3

Clients Expenditure Headings Value for Money

62

10

Lessons Learned

62

10.1

Learning

65

11

Future Delivery

65 65 66 67 68 69

11.1 11.2 11.3 11.4 11.5 11.6

Future Funding Of Integrated Plus Immediate Recommendations Long-Term Recommendations NHS Long Term Plan Personalised Care Operating Model Social Prescribing Common Outcomes Framework

71

Appendices

72 84 97 101 104

A B C D E

Outcome and Indicator Data Client Stories GP Data Overall Survey 2018 – GP and Health Clinicians NHS England Care Models

David Waterfall, www.dpwaterfall.com

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Integrated Plus Impact Evaluation, Final Report

Key Findings Service Overview 

Integrated Plus has had a total budget of some £1.785 million over full four years of delivery, September 2014 to August 2018.



During this time it has supported 2,720 clients, from a total of 3,756 referrals; equating to an average acceptance rate of 72%.



This produces an average unit cost of some £657 per patient.



In terms of a typical patient referral to Integrated Plus; 60% are aged 64 and over, 37% are aged between 24 – 63, 58% are female, 71% have no caring responsibility, 25% are referred due to isolation issues, 17% because of a long term health condition and 16% due to depression. There is a high correlation between isolation and depression of patients supported.



94% of clients rate the service as 4 or 5 stars (out of 5), 96% consider Integrated Plus has had an impact on them (of which 28% consider this to be significant), and 79% feel that Integrated Plus has helped them to access services and activities suitable to their needs

Performance 

Following Integrated Plus, client change for each of the seven core outcomes was: 1

2

3

4

5

6

7



Finance; an 81% reduction in those patients that were not managing, and also an increase of 48% for those who were managing. The greatest enhancement in an indicator was “I have enough money to meet basic needs” Physical Health; an 82% reduction in those patients that were not managing, and also an increase of 29% for those who were managing. The greatest enhancement in an indicator was “I am managing long term conditions well”.

Mental Health; an 76% reduction in those patients that were not managing, and also an increase of 58% for those who were managing. The greatest enhancement in an indicator was “Feeling optimistic about the future” Social Contact; an 80% reduction in those patients that were not managing, and also an increase of 35% for those who were managing. The greatest enhancement in an indicator was ““I regularly have face to face social contact with people who are not family members” Housing; an 82% reduction in patients that were not managing, and also an increase of 24% for those who were managing. The greatest enhancement in an indicator was “I feel able to keep up with my rent” Safety; an 83% reduction in those patients that were not managing, and also an increase of 24% for those who were managing. The greatest enhancement in an indicator was “I feel I have people I can contact”.

Learning; an 72% reduction in those patients that were not managing, and also an increase of 10% for those who were managing. The greatest enhancement in an indicator was “I feel happy in my retirement”

In broader terms, following the intervention 46% fewer clients report poor quality of life, and 45% fewer clients report poor wellbeing.

David Waterfall, www.dpwaterfall.com

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Integrated Plus Impact Evaluation, Final Report



For hospital data, there are significant reductions in A&E attendance after Integrated Plus with a 14% reduction after 6 months, increasing to a 17% reduction after 12 months. Regarding inpatient admissions, after Integrated Plus there is a 14% reduction after 6 months, increasing to a 15% reduction after 12 months. In terms of hospital cost avoidance, data shows £751,400 for reductions in Inpatients, and £58,305 in reduced A&E admissions; totaling £809,705



For GP data, of the 43 surgeries engaged; 34 had a decrease in surgery consultations, 21 had a decrease in telephone consultations, and 26 had a decrease in home visits. In terms of GP cost avoidance, data shows £73,115 in fewer GP Consultations, and £16,400 for fewer GP Home Visits; totaling £89,915. The surgery with the greatest extent of cost avoidance was Wychbury Medical Centre/Cradley Road Medical Practice, with a cost avoidance of £11,135 (from 306 referrals, of which 189 supported)



Through surveying of GPs, 100% of surgeries rated Integrated Plus as good or excellent, and 89% felt that the Link Officers added value to the current Multi-Disciplinary Team meetings. All surgeries agreed that Integrated Plus had helped to reduce inappropriate GP consultations, and most surgeries felt that “Reduces isolation and loneliness” was a key benefit for patients. Wider benefits included, “Our main Link Officer has an excellent rapport with our patients, nothing is too much trouble for him and he is literally only a phone call away. He attends all MTD meetings and has good input from the patients he sees.”

Future Direction 

Dudley CCG has committed to funding the Integrated Plus service from 1st April 2019, maintaining its current staff levels of 1 manager, 5 Link Officers, 5 Link Support Workers and some administrational support on a 3 year rolling contract. This will ensure the continued delivery of social prescribing interventions for patients across Dudley borough on behalf of GPs.



From 1st April 2019, the total contract value per year of the service will be £464,300. Contract management costs will reduce to 4% of the total yearly contract value.



Link Officers will continue to attend the Multi-Disciplinary Team meetings (MDTs). Once all of the 10 new Integrated Care Teams (ICTs) are in place and operating in each locality, the Link Officers will attend these to ensure the non-clinical needs of patients are discussed and taken into account and subsequently patients supported with social prescribing interventions.



In the short-term, it is planned that the referral criteria to the Integrated Plus service will remain the same. This is patients aged 16 upwards who frequently present at their GP practice, are on the top 2% at high risk of admission and any vulnerable person in need on non-clinical support identified by their GP. However, over the next 6-12 months the referral criteria may change, possibly with increased staff levels so the service can be aligned to the social prescribing vision outlined in the NHS Long Term Plan.



Over the next 12 months, the service aims to try and reduce its waiting times so that patients can be seen more quickly. Further discussions about how this could be achieved alongside how the service could ensure it is aligned to the NHS Long Term Plan will take place.

David Waterfall, www.dpwaterfall.com

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Dudley CVS

1

Introduction

1.1

Commission Summary

Integrated Plus Impact Evaluation, Final Report

David Waterfall was appointed by Dudley CVS to work alongside the team to collate and analyse data regarding the Integrated Plus social prescribing service, 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 for Integrated Plus, and to subsequently provide a detailed analysis of this information 2. Secondly to present the overall performance of Integrated Plus so that Dudley CVS and stakeholders can understand the full extent of social value that has been created It is also acknowledged that this report utilises an immense amount of data provided by statutory sector stakeholders. As such it is also the intention that this report allows partners to recognise which external datasets provide meaningful insight, and that in moving forward partners may therefore work together to make such information more readily available.

1.3

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

David Waterfall, www.dpwaterfall.com

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Integrated Plus Impact Evaluation, Final Report

2

Integrated Plus

2.1

Dudley CVS Dudley CVS delivers Integrated Plus. 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 was established in 1973 and is incorporated as a limited company (1998105) and a registered charity (517766).

Dudley CVS’s vision is for a borough that has caring, vibrant and strong communities where everyone can fulfil their potential.

We try to achieve this through our mission: connecting and inspiring people and organisations to achieve positive change, while championing their value to partners and the wider community.

2.2

Service Model In early 2014, Dudley CVS with support from Dudley CCG, identified an opportunity to develop and deliver an innovative, flexible and complementary service called ‘Integrated Plus’.

Overall Aims Connecting people with others Nurturing new friendships Helping people find purpose in their lives

Specific Aims & Outcomes Improving mental health and wellbeing Helping people become more active and involved in their own communities Helping people become socially connected with others and less isolated Improving their quality of life Supporting people to make a difference in their community eg through volunteering and becoming active citizens Represent the voluntary sector at MDTs Increased awareness and profile of the voluntary sector to health clinicians

Medical Outcomes Reduced avoidable patient demand on GP surgeries Reduced avoidable A&E attendances and hospital admissions

David Waterfall, www.dpwaterfall.com

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Integrated Plus Impact Evaluation, Final Report

The service was set up to trial a different approach to supporting people in their own homes, where possible to ensure the non-clinical needs of patients are taken into account via Link Officers at the new multi-disciplinary team meetings established in 2014/15.

Integrated Plus offers 1-2-1 social prescribing support to patients aged 16 and over who are:   

On the top 2% at high risk of hospital admission/readmission (identified through a risk stratification tool) Frequent visitors of GP surgeries (identified by GPs across all Dudley borough practices) Vulnerable and registered at a Dudley GP Practice who is in need of non-clinical, social support.

The Integrated Plus approach involves the following:         

It combines a flexible, non-clinical, holistic package of support.

Focuses on the whole person’s needs whatever they might be to jointly find solutions to problems faced.

Support is independent and impartial.

Support is provided in peoples own homes, where possible, so that the service can build a true picture of the person, their living conditions and family support networks.

Staff have a ‘can do’ approach and attitude as the service is not tied by organisational boundaries and cultures.

Staff do what they can to help whatever the support needs are.

Quality time is spent with people, actively listening to their needs and aspirations.

Staff ensure people are accessing services appropriate to their needs.

Staff help people to navigate the health and social care system.

This service enables the new health and social care model to be more than just a medical approach. It brings to the table a focus on the social and economic needs of patients.

2.3

Staffing Integrated Plus currently has 13 staff. 1 manager, 5 Locality Link Officers, 5 Link Support Workers (LSWs) and administrational support. The team expanded in April 2018 to 2 new A&E High Intensity Link Workers who deliver the A&E High Intensity Social Prescribing project which is currently part-funded by Dudley CCG and the Department of Health. 

Roles of frontline staff The 5 Locality Link Officers are the strategic and managerial leads for the Integrated Plus service in the 5 localities. Their main duties involve:  Attending all the MDTs in their locality.  Being responsible for referrals into the service and caseload management.  Conducting the initial home visits to get to know the person, what matters to them, undertake our bespoke holistic assessment and identify and agree goals with the person.  Being responsible for follow up 1-2-1 patient support either provided by themselves or with support from their support worker.  Taking responsibility for the more vulnerable and complex patient issues.

David Waterfall, www.dpwaterfall.com

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

Integrated Plus Impact Evaluation, Final Report

Link Support Workers The 5 Link Support Workers main duties involve:  Providing support to their Locality Link Officer eg entering data on our IT system, administrational work etc.  Providing 1-2-1 mentoring support to patients on behalf of their Link Officer when needs arise eg helping people with non-contribution based benefit forms such as Personal Independent Payments, Attendance Allowance, taking people to services and activities when the person’s confidence is low.  Conducting the final bespoke Integrated Plus assessment and identifying any further support needs.  Seeking feedback on the service provided.

2.4

Intervention Types The following provides examples of some of the intervention types provided by the Integrated Plus team: 

Accessing services on offer  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.



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).



Getting around  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  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 voucher’s.  Help people to live as independently as possible in their own homes by helping to arrange home adaptations, telecare etc.

David Waterfall, www.dpwaterfall.com

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Integrated Plus Impact Evaluation, Final Report

Connecting and supporting people  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.



2.5

Integrated Plus Pathway Patients Join The Integrated Plus Service    

Referrals at MDT meetings by MDT staff and referrals open to all GPs at each practice via referral form Patients contacted to explain the Integrated Plus service First home visit booked in Data logged on PSIAMS (referral information, whether client has accepted or declined service)

Live Case Management         

First home visit conducted by Locality Link Officer Integrated Plus service explained in detail during home visit Time spent getting to know the person eg what matters to them, needs, aspirations Data agreement signed by patient Bespoke holistic assessment carried out by Locality Link Officer Action plan agreed with patient Actions/interventions carried out by Locality Link Officer/Link Support Worker/patient Progress on non-clinical interventions fed into MDT meetings by Locality Link Officer Ongoing data added onto PSIAMS system

Completion Of The Service/Support    

Final assessment/review carried out with patients by Link Support Worker in persons own home Any new needs or goals identified are fed back to Locality Link Officer and followed up if appropriate by the Link Officer and/or Link Support Worker Patient stories written up with input/consent from patients by the Link Support Workers Patients exited on PSIAMS system by Link Officer and/or Link Support worker

David Waterfall, www.dpwaterfall.com

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Integrated Plus Impact Evaluation, Final Report

3

Social Prescribing Context

3.1

Introduction Social prescribing is most usually defined as: “Social Prescribing is an initiative that links patients in primary care with sources of support within the community. It provides GPs with a non-medical referral option that can operate alongside existing treatments to improve health and wellbeing”.

The British Medical Journal describes social prescribing as activity that connects people to community groups and services, through the support of ‘link workers’, who:    

Take referrals from local agencies Give people time Co-produce a plan to meet the person’s wellbeing needs, based on ‘what matters to me’ Introduce people to community groups and services

NHS England suggests that social prescribing, sometimes referred to as community referral, is a means of enabling GPs, nurses and other primary care professionals to refer people to a range of local, non-clinical services.

Recognising that people’s health is determined primarily by a range of social, economic and environmental factors, social prescribing seeks to address people’s needs in a holistic way.

It also aims to support individuals to take greater control of their own health and wellbeing.

Social prescribing is designed to support people with a wide range of social, emotional or practical needs, and many schemes are focussed on improving mental health and physical well-being. Those who could benefit from social prescribing schemes include people with mild or long-term mental health problems, vulnerable groups, people who are socially isolated, and those who frequently attend either primary or secondary health care. It is estimated that around 20% of patients consult their general practitioner (GP) for what is primarily a social problem (Low Commission, 2015). It has been suggested that referral to a social prescribing service could reduce this pressure on GPs. Schemes can involve a variety of activities which are typically provided by voluntary and community sector organisations. Examples include volunteering, arts activities, group learning, gardening, befriending, cookery, healthy eating advice and a range of sports.

There are many different models and levels for social prescribing, but most involve a link worker or navigator who work with people to access local sources of support. Social prescribing contributes to a range of broader government objectives, for example in relation to employment, volunteering and learning.

3.2

History

David Waterfall, www.dpwaterfall.com

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Integrated Plus Impact Evaluation, Final Report

Social prescribing and similar approaches have been used in the NHS for many years. The concept of social prescribing has often been described by people at recent events, conferences and meetings as ‘old school social work’. Some schemes date back to the 1980s and 1990s, for example, the Bromley by Bow Centre was established in 1984 and in more recent years, a Hackney social prescribing project in 2013, Rotherham social prescribing project in 2012 and Dudley’s Integrated Plus social prescribing scheme in 2014.

Over the past few years, interest in the model has expanded in the NHS and there are more than 100 schemes currently running in the UK, more than 25 of which are in London. The number of social prescribing schemes funded specifically in the NHS has risen to 60% coverage across the country and social prescribing has developed into a kind of social movement. A national GP online survey conducted in July 2018 reported that 1 in 4 GPs regularly refer their patients to a social prescribing scheme in their area.

NHS England now has a dedicated team focusing on social prescribing and each region has a dedicated social prescribing network which brings together projects to network, share learning and good practice. Social prescribing conferences are held both nationally once a year and regionally more frequently. The National Social Prescribing Network has a dedicated website containing lots of news and resources and a blog [https://www.socialprescribingnetwork.com].

Within the last two years, the Department of Health has made available match-funding for social prescribing schemes. Dudley’s Integrated Plus project was successful in securing the first round of this funding with match funding from Dudley CCG, to expand its current project to run a ‘High Intensity User of A&E Social Prescribing project’. This project commenced in April 2018 and is now starting to see a reduction from this patient cohort in avoidable A&E attendances and hospital admissions.

Social prescribing was highlighted in the 2006 White Paper Our health Our Care Our Say as a mechanism for promoting health, independence and access to local services. The objectives of social prescribing also support the principles set out in subsequent NHS policy documents, including the NHS Five Year Forward View (2014), which encourages a focus on prevention and wellbeing, patient-centred care, and better integration of services, as well as highlighting the role of the third sector in delivering services that promote wellbeing. More recently, the General Practice Forward View (2016) has also emphasised the role of voluntary sector organisations – including through social prescribing specifically – in efforts to reduce pressure on GP services.

NHS England is currently developing a 10 year national social prescribing strategy and is encouraging Government to increase investment for social prescribing schemes so that there is more coverage of schemes across the country. NHS England has also recognised the need for direct investment into front-line voluntary and community sector organisations who take referrals from social prescribing schemes. Local and/or national investment for frontline voluntary organisations is an important component to such schemes to help with their sustainability, in managing capacity and for opportunities for innovation and creativity in meetings patients’ needs.

The Royal College of General Practitioners is also very supportive of social prescribing. There is national consensus to teach social prescribing theory within UK medical schools. There are

David Waterfall, www.dpwaterfall.com

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aspirations to have a social prescribing champion in each medical school and a new National Social Prescribing Day has been launched for 14th March.

Dudley’s Integrated Plus Project is actively involved in national and regional social prescribing agendas and has been part of regional events and some national meetings regarding the 10 year social prescribing strategy and plans.

During February and March 2019, Integrated Plus staff delivered a social prescribing peer learning programme for other projects around the country. The aim of this programme is to share our learning of implementing social prescribing, to encourage peer to peer support across projects, help support new projects getting started and develop a plan for work force development of social prescribing staff.

David Waterfall, www.dpwaterfall.com

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Integrated Plus Impact Evaluation, Final Report

4

Evaluation Methodology

4.1

Approaches The methodology has been developed in close discussion with Dudley CVS and Dudley CCG; creating an approach that uses the most up-to-date information that can be shared and analysed within the resources available to provide clear evidence on the performance of Integrated Plus.

In outline key methods and data sources has included:

4.2



MDT Surveying; a survey of 279 GPs and other clinicians who attend the MDTs, to understand their motivations and benefits



Client Surveying; ongoing outcome surveying of clients collected by Integrated Plus staff during client support. The Integrated Plus service uses their own bespoke client outcome assessment tool which is used when first engaging a client and again at the end of support. In addition to this, Integrated Plus staff carries out a customer service review questionnaire to find out a client’s experience of the service. This is conducted on all clients who have accessed the service and who have agreed to provide feedback. Client support is not long term but approximately for a 3 – 4 month duration.



DSCRO Data; analysis of Data Services for Commissioners Regional Offices (DSCRO) data.

As the law says 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.



Referral Data; gathering referral monitoring data that includes data provided on inward referrals and data collected on all outward referrals made.



Case Studies; involving client’s feedback and consent.

Data Validation Given the importance of having robust and accurate data, significant effort has been used to gain reliable information from the Secondary Uses Service (SUS), which is the single, comprehensive repository for healthcare data in England which enables a range of reporting and analyses to support the NHS in the delivery of healthcare services.

An existing procedure is in place within the CCG for ensuring accurate data, as the SUS uses its own validation process when a provider is submitting a file, and rejects anything that does not meet their predefined rules. The Commissioning Support Unit downloads the SUS data, checking the number of rows at each point of the process when extracting the information from SUS to loading into the data warehouse. In addition, the CSU runs local validation rules which will be challenged monthly with the providers via the reconciliation process, for example queries on multiple attendances on the same day.

David Waterfall, www.dpwaterfall.com

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Integrated Plus Impact Evaluation, Final Report

5

Service Demographics

5.1

Clients Clients may be identified as follows: 

Age Range The vast majority of referrals (60%) have been patients in the older age groups ie 64 and over, however a high number of working age adults aged between 18 - 63 have also been referred (39%).

Age Range 16 to 17 18 to 23 24 to 48 49 to 63 64 to 79 80 + Unknown



Clients 1 (0.02%) 90 (2.39%) 686 (18.26%) 707 (18.82%) 925 (24.62%) 1,330 (35.41%) 17 (0.4%)

16 to 17 18 to 23 24 to 48 49 to 63 64 to 79 80 +

Ethnicity Data gathered at the first home visit indicates that referrals of patients from black and minority ethnic (BME) communities that have been supported through the service accounts for 6%.



Gender Gender

Clients

Female

2,172 (58%)

Male

Male

1,583 (42%)

Transgender



Female

1 (<1%)

Transgender

Caring Responsibilities

Caring

No Caring responsibility

Clients

No Caring responsibility Has a carer Is a carer Is a carer and has a carer

David Waterfall, www.dpwaterfall.com

1,918 (71%) 497 (18%) 278 (10%) 27 (1%)

Has a carer Is a carer Is a carer and has a carer

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5.2

Integrated Plus Impact Evaluation, Final Report

Client Feedback Feedback gained from final client reviews conducted about the IP service shows: 



Star Rating of Service (1 poor, 5 high) 5 star

393

62%

4 star

203

32%

3 star

34

5%

2 star

4

1%

1 star

3

0%

637

100%

500 400 300 200 100 0 5 star

4 star

3 star

2 star

1 star

Do you feel you have benefitted from the service?

400





A great deal

291

44%

A lot

258

39%

A little

85

13%

Very little

20

3%

654

100%

300 200 100 0 A great deal

A lot

A little

Very little

A lot

A little

Very little

Do you feel your needs were understood?

500

A great deal

386

59%

A lot

241

37%

300

A little

21

3%

200

Very little

6

1%

100

654

100%

400

0 A great deal

How aware of services and activities available in your community are you now as a result of the service?

Extremely aware

161

25%

Very aware

319

49%

A little aware

91

14%

Not very aware

31

5%

N/A

52

8%

654

100%

David Waterfall, www.dpwaterfall.com

350 300 250 200 150 100 50 0 Extremely Very aware aware

A little aware

Not very aware

N/A

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

How much do you feel the service helped you to access services and activities suitable to your needs?

A great deal

241

37%

A lot

228

35%

A little

43

7%

Very little

22

3%

N/A



120

18%

654

100%

200 100 0 A great deal

A lot

A little

Very little

N/A

What have been the benefits of the Integrated Plus approach for you?

Being listened to

648

14%

625

14%

607

13%

Independent and flexible approach

599

13%

Helped find solutions to problems faced

565

12%

Explored my needs/aspirations

524

11%

474

10%

368

8%

Spent time with me

149

3%

Being listened to

4559

100%

Spent time with me No hidden agendas

Went extra mile for me Helped build confidence and self-esteem Unlocked my potential



300

Unlocked my potential Helped build confidence and self-esteem Went extra mile for me Explored my needs/aspirations Helped find solutions to problems faced Independent and flexible approach No hidden agendas

0

200

400

600

800

To what extent has the service impacted on you?

250 Significant impact

184

28%

Great impact

176

27%

Good impact

213

33%

Minor impact

55

8%

No impact

18

3%

Not answered

8

1%

654

100%

David Waterfall, www.dpwaterfall.com

200 150 100 50 0

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5.3

Integrated Plus Impact Evaluation, Final Report

Inward Referrals 

Referral Rates Since 1st September 2014 – 31st August 2018 the service has received referrals from all GP Practices across Dudley borough. Overall, 3,756 referrals were made to the service during September 2014 – August 2018, averaging 78 new referrals each month. Referral numbers for each locality are as follows:  Sedgely, Coseley and Gornal – 843  Dudley & Netherton – 600  Halesowen & Quarry Bank – 761  Stourbridge, Wollescote and Lye – 856  Kingswinford, Amblecote and Brierley Hill – 696 To date, the service has had a high patient acceptance rate with 72% of patients referred to the service accessing support from Integrated Plus. Data shows that:  2,720 out of 3,756 accepted the service (72%)  514 out of 3,756 declined the service (14%)  352 out of 3,756 could not be contacted after 3 follow up calls (9%)  113 out of 3,756 did not wish to access the full service (ie home visit, discussion and assessment) and were instead sent information in the post about local services and activities (3%)  39 out of 3,756 were inappropriate referrals eg patients did not understand why they had been referred or instead they needed a referral to social services (1%)  18 out of 3,756 did not attend appointments – (0.4%)



Reason for Referral and Presenting Issue Identifying the stated referral reason, and also the presenting issues recorded by Link Officers on first appointment: Reason

Referral

Presenting

Isolation

1,768

1,497

Long term health issues

1,245

1,088

Depression

1,155

913

Other eg suicide attempt, palliative, anger issues, can’t cope at home, financial etc

818

528

Household issues

457

576

Frequent presenter

364

188

Other mental health issues

359

252

Drug or alcohol

206

116

Family relationships

179

333

Learning disability support

128

92

Bereavement

121

195

Dementia

117

106

Stress

107

309

0

34

Lack of basic numeracy and literacy

David Waterfall, www.dpwaterfall.com

Page 19 of 105

Dudley CVS



Integrated Plus Impact Evaluation, Final Report

Multiple Reasons for Referral Highest reasons for referrals by connected/multiple presenting issues per patient:          

5.4

Isolation and depression – 271 Isolation and long term conditions – 222 Isolation, depression and long term conditions – 120 Isolation and other mental health condition – 61 Frequent presenter and isolation – 41 Frequent presenter, isolation and depression – 38 Frequent presenter, isolation, long term health issues and other mental health condition – 35 Frequent presenter, isolation, depression and long term health issues – 31 Frequent presenter and depression - 18 Frequent presenter and long term health issues - 17

Outward Referrals As appropriate to the needs and wishes of the client, referrals are made outward to a variety of other services and organisations: 

Referrals to Services A total of 3,299 referrals have been made, acknowledging that a client may be referred to several services during their time with IP. These have been to 136 different services, most frequently to the Winter Warmth Service (225 referrals), with those being referred to 100 or more times shown below: Service Referrals, by Service (100+ Referrals) 250 200 150 100 50 0

These were made to three sectors – statutory, voluntary and NHS - with the most commonplace being to statutory sector services (2,113 referrals):

David Waterfall, www.dpwaterfall.com

Page 20 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

Organisation Referrals, by Sector 2500 2000 1500 1000 500 0 Statutory

Voluntary sector

NHS

Referrals also covered several types of support, with the most commonplace being ‘care and support’ (1,302 referrals), with those themes having 100 or more referrals shown below: Service Referrals, by Theme (100+ Referrals) 1400 1200 1000 800 600 400 200 0 Care and Support Social, leisure and wellbeing

Peer support

Learning

Carer's support Disability support

It is interesting to note that the most typical response in each category should determine that the most commonplace outward service referral would be to a ‘statutory’ sector provider for ‘Winter Warmth’ as a ‘care and support’ service – which is the reality of the referral data. 

Referrals to Organisations A total of 6,511 referrals have been made, acknowledging that a client may be referred to several organisations during their time with IP. These have been to 567 different organisations, most frequently to Age UK Dudley (417 referrals), with those being referred to 100 or more times shown below: Organisation Referrals, by Organisation (100+ Referrals) 450 400 350 300 250 200 150 100 50 0

David Waterfall, www.dpwaterfall.com

Page 21 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

These were made to six sectors, with the most commonplace being to the voluntary sector (4,518 referrals): Organisation Referrals, by Sector 5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0 Voluntary Sector

Statutory

Private

NHS

National Government

Faith

Referrals also covered several types of support, with the most commonplace being ‘Social, leisure & wellbeing’ (1,911 referrals), with those themes having 100 or more referrals shown below:

2500

Organisation Referrals, by Theme (100+ Referrals)

2000 1500 1000 500 0

It is interesting to note that the most typical response in each category should determine that the most commonplace outward organisation referral would be to a ‘voluntary’ sector provider to Age UK Dudley specifically for a ‘Social, leisure & wellbeing’ service – which is the reality of the referral data.

David Waterfall, www.dpwaterfall.com

Page 22 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

6

Performance

6.1

Target Areas Integrated Plus has gained data 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.

Each of the seven main areas have a number of indicators against which specific measurements were taken. Clients are engaged at the first contact with Integrated Plus and surveyed on how they feel in relation to these areas, and then they are surveyed again at the conclusion of the support. The performance for each is detailed in Appendix A and summarised in the following sections.

6.2

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

Overall; Not managing (need support), Already receiving support, Managing ok Indicator; I am able to manage my money well Indicator; I have enough money to meet basic needs (eg food, bills, heating) Indicator; I have savings I can use if I need to Indicator; I feel able to manage my debts

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

Already receiving support

Managing ok

Start (#)

183

129

285

Latest (#)

35

139

422

81%

8%

48%

Change (%)

This reveals that after IP support, there was an 81% reduction change in those patients that were not managing, and also an increase of 48% for those who were managing. Further detail may be shows below:

David Waterfall, www.dpwaterfall.com

Page 23 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

Finance (None + Rarely)

50% 40% 30% 20% 10% 0% I am able to manage my money well

I have enough money to meet basic needs?

Start

I have savings I can use if I need to

I feel able to manage my debts

Latest

Finance (Often + All the Time)

100% 80% 60% 40% 20% 0% 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

Start

I feel able to manage my debts

Latest

These graphs illustrate the baseline position before IP (the grey line) and compare that to the same indicator after IP (the green line), to show differences in patient ratings. In the first graph this shows that the percentage of patients that were not managing (through a rating of 1 ‘not at all’ or 2 ‘rarely managing’) before IP was reduced across all indicators by the end of the IP support. The greatest of these was those not managing for “I have savings I can use if I need to” with a start of 40% and a reduced end point of 32%. In 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 77% and an increased end point of 86%.

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

David Waterfall, www.dpwaterfall.com

Often + All (4 + 5)

Start

Latest

Change

Start

Latest

Change

46

27

41%

162

181

12%

32

13

59%

190

213

12%

98

78

20%

127

140

10%

30

13

57%

45

65

44%

Page 24 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

Change by Score; Start to Latest

70% 60% 50% 40% 30% 20% 10% 0% I am able to manage my money well

I have enough money to meet basic needs?

1+2

I have savings I can use if I need to

I feel able to manage my debts

4+5

This chart shows the change between before and after IP, 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 from IP. The chart shows that indicators have beneficial change of at least 10% in all indicators, with the greatest enhancement for patients being in “I have enough money to meet basic needs” for the lowest ratings with a 59% change.

6.3

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

Overall; Not managing (need support), Already receiving support, Managing ok Indicator; I feel able to manage my personal care Indicator; I feel able to manage my medication Indicator; I am managing long term conditions well Indicator; I am able to easily and independently leave my property Indicator; I feel I am able to partake in exercise on a weekly basis Indicator; I feel I have a balanced diet Indicator; I feel I am coping with my caring duties

The overall position at start and latest reviews, and hence the change achieved during Integrated Plus:

Start (#) Latest (#) Change (%)

Not Managing (need support) 175

Already receiving support 203

Managing ok 219

32

284

283

82%

40%

29%

This reveals that after IP support, there was an 82% reduction change in those patients that were not managing, and also an increase of 29% for those who were managing. Further detail may be shows below:

David Waterfall, www.dpwaterfall.com

Page 25 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

Physical Health (None + Rarely) 70% 60% 50% 40% 30% 20% 10% 0% I feel able to manage my personal care

I feel able to manage my medication

I am managing I am able to long term easily and conditions well independently...

Start

I feel able to partake in exercise...

I feel I have a balanced diet

I feel I am coping with my caring duties

I feel I have a balanced diet

I feel I am coping with my caring duties

Latest

Physical Health (Often + All the Time) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% I feel able to manage my personal care

I feel able to manage my medication

I am managing I am able to long term easily and conditions well independently...

Start

I feel able to partake in exercise...

Latest

These graphs illustrate the baseline position before IP (the grey line) and compare that to the same indicator after IP (the green line), to show differences in patient ratings. In the first graph this shows that the percentage of patients that were not managing (through a rating of 1 ‘not at all’ or 2 ‘rarely managing’) before IP was reduced across all indicators by the end of the IP support. The greatest of these was those not managing for “I feel able to partake in exercise on a weekly basis.” with a start of 62% and a reduced end point of 51%.

In 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 feel I have a balanced diet” with a start of 53% and an increased end point of 65%.

In terms of the degree of change across the individual indicators:

David Waterfall, www.dpwaterfall.com

Page 26 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

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

Often + All (4 + 5)

Start

Latest

Change

Start

Latest

Change

30

29

3%

176

180

2%

31

24

23%

187

194

4%

36

25

31%

110

136

24%

107

87

19%

97

116

20%

153

127

17%

60

74

23%

58

41

29%

131

160

22%

3

3

0%

34

39

15%

Change by Score; Start to Latest

35% 30% 25% 20% 15% 10% 5% 0% I feel able to manage my personal care

I feel able to manage my medication

I am managing I am able to long term easily and conditions well independently...

1+2

I feel able to partake in exercise...

I feel I have a I feel I am coping balanced diet with my caring duties

4+5

This chart shows the change between before and after IP, 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 from IP. The chart shows that indicators have beneficial change in all indicators, with the greatest enhancement for patients being in â&#x20AC;&#x153;I am managing long term conditions wellâ&#x20AC;? for the lowest ratings with a 31% change.

David Waterfall, www.dpwaterfall.com

Page 27 of 105

Dudley CVS

6.4

Integrated Plus Impact Evaluation, Final Report

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

Overall; Not managing (need support), Already receiving support, Managing ok 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 Integrated Plus: Not Managing (need support)

Already receiving support

Managing ok

Start (#)

203

217

177

Latest (#)

48

270

280

76%

24%

58%

Change (%)

This reveals that after IP support, there was an 76% reduction change in those patients that were not managing, and also an increase of 58% for those who were managing. Further detail may be shows below: Mental Health (None + Rarely) 60% 50% 40% 30% 20% 10% 0%

Start

David Waterfall, www.dpwaterfall.com

Latest

Page 28 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

Mental Health (Often + All the Time) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Start

Latest

These graphs illustrate the baseline position before IP (the grey line) and compare that to the same indicator after IP (the green line), to show differences in patient ratings. In the first graph this shows that the percentage of patients that were not managing (through a rating of 1 ‘not at all’ or 2 ‘rarely managing’) before IP was reduced across all indicators by the end of the IP support. The greatest of these was those not managing for “I've been feeling useful” with a start of 49% and a reduced end point of 26%. In 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've been thinking clearly” with a start of 48% and an increased end point of 83%.

In terms of the degree of change across the individual indicators: None + Rarely (1 + 2)

Often + All (4 + 5)

Start

Latest

Change

Start

Latest

Change

Feeling optimistic about the future

109

63

42%

52

91

75%

I've been feeling useful

121

65

46%

74

98

32%

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 I’ve been able to make up my own mind about things I am free from suicidal thoughts

126

87

31%

49

81

65%

78

37

53%

99

138

39%

63

31

51%

119

151

27%

62

41

34%

118

145

23%

30

19

37%

170

190

12%

43

25

42%

168

200

19%

David Waterfall, www.dpwaterfall.com

Page 29 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

I am free from selfharming thoughts/actions I feel able to control my anger

30

20

33%

199

213

7%

10

8

20%

209

221

6%

Change by Score; Start to Latest 80% 70% 60% 50% 40% 30% 20% 10% 0%

1+2

4+5

This chart shows the change between before and after IP, 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 from IP. The chart shows that indicators have beneficial change in all indicators of at least 7%, with the greatest enhancement for patients being in “Feeling optimistic about the future” for the highest ratings with a 75% change.

6.5

Social Contact The Social Contact target held an overall statement and six indicators:  Overall; Not managing (need support), Already receiving support, Managing ok  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 Integrated Plus:

David Waterfall, www.dpwaterfall.com

Page 30 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

Not Managing (need support)

Already receiving support

Managing ok

Start (#)

230

85

281

Latest (#)

45

176

378

80%

107%

35%

Change (%)

This reveals that after IP support, there was an 80% reduction change in those patients that were not managing, and also an increase of 35% for those who were managing. Further detail may be shows below: Social Contact (None + Rarely)

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

I regularly have I have friends I can face to face talk with... social...

I feel I have enough social contact...

Start

I regularly help I feel comfortable I feel my out in my mixing with religious/spiritual community people needs...

Latest

Social Contact (Often + All the Time)

70% 60% 50% 40% 30% 20% 10% 0% I regularly have face to face social...

I have friends I can talk with...

Start

I feel I have enough social contact...

I regularly help I feel comfortable I feel my out in my mixing with religious/spiritual community people needs...

Latest

These graphs illustrate the baseline position before IP (the grey line) and compare that to the same indicator after IP (the green line), to show differences in patient ratings. In the first graph this shows that the percentage of patients that were not managing (through a rating of 1 ‘not at all’ or 2 ‘rarely managing’) before IP was reduced across all indicators by the end of the IP 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 49% and a reduced end point of 28%. In the second graph the trend is replicated in that the percentage

David Waterfall, www.dpwaterfall.com

Page 31 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

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 regularly have face to face social contact with people who are not family members” with a start of 34% and an increased end point of 55%.

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 being met

70%

Often + All (4 + 5)

Start

Latest

Change

Start

Latest

Change

121

69

43%

83

135

63%

109

82

25%

91

116

27%

87

47

46%

97

135

39%

220

215

2%

11

16

45%

58

34

41%

130

154

18%

20

9

55%

85

94

11%

Change by Score; Start to Latest

60% 50% 40% 30% 20% 10% 0% I regularly have I have friends I can I feel I have enough I regularly help out I feel comfortable I feel my face to face social... talk with... social contact... in my community mixing with people religious/spiritual needs...

1+2

David Waterfall, www.dpwaterfall.com

4+5

Page 32 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

This chart shows the change between before and after IP, 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 from IP. The chart shows that indicators have beneficial change in all indicators of at least 2%, with the greatest enhancement for patients being in ““I regularly have face to face social contact with people who are not family members” for the highest ratings with a 63% change.

6.6

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

Overall; Not managing (need support), Already receiving support, Managing ok Indicator; I feel secure in my tenancy Indicator; I am sleeping in a safe place every night Indicator; I feel able to keep up with my rent/ mortgage Indicator; I feel happy where I am living Indicator; I feel my accommodation is suitable for my needs/family Indicator; I am able to heat my home adequately Indicator; I feel my home is a safe environment

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

Already receiving support

Managing ok

Start (#)

138

69

390

Latest (#)

25

91

482

82%

32%

24%

Change (%)

This reveals that after IP support, there was an 82% reduction change in those patients that were not managing, and also an increase of 24% for those who were managing. Further detail may be shows below: Housing (None + Rarely) 14% 12% 10% 8% 6% 4% 2% 0% I feel secure in I am sleeping in I feel able to my tenancy a safe place keep up with every... my rent...

Start

David Waterfall, www.dpwaterfall.com

I feel happy where I am living

I feel my I am able to I feel my home accommodation heat my home is a safe is suitable... adequately environment

Latest

Page 33 of 105

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Integrated Plus Impact Evaluation, Final Report

Housing (Often + All the Time) 120% 100% 80% 60% 40% 20% 0% I feel secure in I am sleeping in I feel able to my tenancy a safe place keep up with my every... rent...

I feel happy where I am living

Start

I feel my I am able to I feel my home accommodation heat my home is a safe is suitable... adequately environment

Latest

These graphs illustrate the baseline position before IP (the grey line) and compare that to the same indicator after IP (the green line), to show differences in patient ratings. In the first graph this shows that the percentage of patients that were not managing (through a rating of 1 ‘not at all’ or 2 ‘rarely managing’) before IP was reduced across all indicators by the end of the IP support. The greatest of these was those not managing for “I am able to heat my home adequately” with a start of 8% and a reduced end point of 3%. In 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 feel my home is a safe environment” with a start of 79% and an increased end point of 87%.

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 David Waterfall, www.dpwaterfall.com

Often + All (4 + 5)

Start

Latest

Change

Start

Latest

Change

13

5

62%

113

122

8%

7

3

57%

234

239

2%

10

3

70%

118

122

3%

29

20

31%

190

202

6%

25

22

12%

184

197

7%

20

8

60%

214

229

7%

14

10

29%

194

216

11%

Page 34 of 105

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Integrated Plus Impact Evaluation, Final Report

Change by Score; Start to Latest 80% 70% 60% 50% 40% 30% 20% 10% 0% I feel secure in I am sleeping in I feel able to I feel happy I feel my I am able to heat I feel my home is my tenancy a safe place keep up with my where I am living accommodation my home a safe every... rent... is suitable... adequately environment

1+2

4+5

This chart shows the change between before and after IP, 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 from IP. The chart shows that indicators have beneficial change in all indicators of at least 2%, with significantly greater changes for the lowest ratings, and with the greatest enhancement for patients being in “I feel able to keep up with my rent/ mortgage” for the lowest ratings with a 70% change.

6.7

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

Overall; Not managing (need support), Already receiving support, Managing ok Indicator; I feel safe where I live Indicator; I feel safe with my partner Indicator; I feel safe with friends Indicator; I feel safe with family Indicator; I feel safe from harm/exploitation Indicator; I feel I have people I can contact in an emergency

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

Already receiving support

Managing ok

Start (#)

83

89

424

Latest (#)

14

57

527

83%

-36%

24%

Change (%)

David Waterfall, www.dpwaterfall.com

Page 35 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

This reveals that after IP support, there was an 83% reduction change in those patients that were not managing, and also an increase of 24% for those who were managing. Further detail may be shows below: Safety (None + Rarely)

6% 5% 4% 3% 2% 1% 0%

I feel safe where I I feel safe with my I feel safe with live partner friends

Start

I feel safe with I feel safe from family harm/exploitation

I feel I have people I can contact...

Latest

Safety (Often + All the Time)

120% 100% 80% 60% 40% 20% 0%

I feel safe where I I feel safe with my I feel safe with live partner friends

Start

I feel safe with I feel safe from family harm/exploitation

I feel I have people I can contact...

Latest

These graphs illustrate the baseline position before IP (the grey line) and compare that to the same indicator after IP (the green line), to show differences in patient ratings. In the first graph this shows that the percentage of patients that were not managing (through a rating of 1 ‘not at all’ or 2 ‘rarely managing’) before IP was reduced across all indicators by the end of the IP support. Although there was little improvement in any indicator, the greatest of these was those not managing for “I feel safe from harm/exploitation” with a start of 5% and a reduced end point of 2%. In 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. Although such increases were slight, the greatest of these was those managing well with “I feel safe where I live” with a start of 90% and an increased end point of 92%.

David Waterfall, www.dpwaterfall.com

Page 36 of 105

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Integrated Plus Impact Evaluation, Final Report

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

Often + All (4 + 5)

Start

Latest

Change

Start

Latest

Change

12

10

17%

223

228

2%

0

0

0

82

81

-1%

7

4

43%

190

194

2%

4

4

0%

221

222

0%

12

6

50%

226

229

1%

2

3

-50%

236

239

1%

Change by Score; Start to Latest 60% 40% 20% 0% I feel safe where I I feel safe with my live partner

I feel safe with friends

I feel safe with family

I feel safe from I feel I have people harm/exploitation I can contact...

-20% -40% -60% 1+2

4+5

This chart shows the change between before and after IP, 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 from IP. The chart shows that some indicators have experienced negative change during the intervention; however this is due to the very small numbers involved expressing negative ratings. For example the greatest change is a negative indicator being â&#x20AC;&#x153;I feel I have people I can contact in an emergencyâ&#x20AC;? that has a decrease of 50%, however this is simply as the numbers of patients with low ratings has increased from 2 to 3.

David Waterfall, www.dpwaterfall.com

Page 37 of 105

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6.8

Integrated Plus Impact Evaluation, Final Report

Learning The Learning target held an overall statement and six indicators:  Overall; Not managing (need support), Already receiving support, Managing ok  Indicator; I feel happy with my current employment  Indicator; I feel happy in my retirement  Indicator; I have opportunities to learn new skills  Indicator; I feel able to find work  Indicator; I feel motivated to find work  Indicator; I 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 Integrated Plus: Not Managing (need support)

Already receiving support

Managing ok

Start (#)

116

53

420

Latest (#)

32

97

461

72%

83%

10%

Change (%)

This reveals that after IP support, there was an 72% reduction change in those patients that were not managing, and also an increase of 10% for those who were managing. Further detail may be shown below: Learning (None + Rarely) 40% 35% 30% 25% 20% 15% 10% 5% 0% I feel happy with I feel happy in my I have my current retirement opportunities to employment learn new skills

Start

I feel able to find I feel motivated to I feel able to work work find work despite having a...

Latest

Learning (Often + All the Time) 30% 25% 20% 15% 10% 5% 0% I feel happy with I feel happy in my my current retirement employment

I have opportunities to learn new skills

Start David Waterfall, www.dpwaterfall.com

I feel able to find I feel motivated to I feel able to work work find work despite having a...

Latest Page 38 of 105

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Integrated Plus Impact Evaluation, Final Report

These graphs illustrate the baseline position before IP (the grey line) and compare that to the same indicator after IP (the green line), to show differences in patient ratings. In the first graph this shows that the percentage of patients that were not managing (through a rating of 1 ‘not at all’ or 2 ‘rarely managing’) before IP was reduced across all indicators by the end of the IP support. The greatest of these was those not managing for “I have opportunities to learn new skills” with a start of 34% and a reduced end point of 26%. In 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 opportunities to learn new skills” with a start of 10% and an increased end point of 16%.

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

Often + All (4 + 5)

Start

Latest

Change

Start

Latest

Change

5

3

40%

8

11

38%

6

2

67%

58

66

14%

85

65

24%

24

39

63%

47

38

19%

6

10

67%

34

28

18%

13

16

23%

47

38

19%

11

15

36%

Change by Score; Start to Latest 70% 60% 50% 40% 30% 20% 10% 0% I feel happy with my current employment

I feel happy in my retirement

I have opportunities to learn new skills

1+2

David Waterfall, www.dpwaterfall.com

I feel able to find I feel motivated to I feel able to work work find work despite having a...

4+5

Page 39 of 105

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This chart shows the change between before and after IP, 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 from IP. The chart shows that indicators have beneficial change in all indicators of at least 14%, with significantly greater changes for the lowest ratings, and with the greatest enhancement for patients being in â&#x20AC;&#x153;I feel happy in my retirementâ&#x20AC;? for the lowest ratings with a 67% change.

6.9

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

31%

6%

183

35

81%

Physical Health

29%

5%

175

32

82%

Mental Health

34%

8%

203

48

76%

Social Contact

39%

8%

230

45

80%

Housing

23%

4%

138

25

82%

Safety

14%

2%

83

14

83%

Learning

20%

5%

116

32

72%

Not Managing (need support) 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Finance

Physical Health Mental Health

Social Contact

Start

Housing

Safety

Learning

Latest

The overall changes may be illustrated below:

David Waterfall, www.dpwaterfall.com

Page 40 of 105

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Integrated Plus Impact Evaluation, Final Report

Not Managing (need support)

Finance

85% 80%

Learning

Physical Health

75% 70% 65%

Mental Health

Safety

Social Contact

Housing

Change

“I feel safer now, really secure. The (Integrated Plus) service is fantastic – although my GP had tried to help I was getting nowhere. They are someone to turn to when you feel you have no one and I can’t thank them enough. Since he came on the scene it’s all gone one way, and that’s up.

He made me aware of places I didn’t even know existed and I dread to think what my situation would be if he hadn’t helped me. If I can give a mark to represent his support it would be 10 out of 10, he has given me a lot of backing. I’m really chuffed”.

This shows that those not managing have had beneficial changes (i.e. a reduction in numbers) in all target areas; the greatest being ‘Safety’ with an 83% positive change.

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: Managing OK Start %

Latest %

Start #

Latest #

Change

Finance

48%

71%

285

422

48%

Physical Health

37%

47%

219

283

29%

Mental Health

30%

47%

177

280

58%

Social Contact

47%

63%

281

378

35%

Housing

65%

81%

390

482

24%

Safety

71%

88%

424

527

24%

Learning

71%

78%

420

461

10%

Managing OK 100% 80% 60% 40% 20% 0% Finance

Physical Health Mental Health Social Contact

Start

Housing

Safety

Learning

Latest

The overall changes may be illustrated below:

David Waterfall, www.dpwaterfall.com

Page 41 of 105

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Managing OK “This has really got me back into mixing with people again and took me out of my old lifestyle. Before this I couldn’t leave the house due to anxiety. At that time I could have quite easily ended it all.

Between Integrated Plus and Summit house it has pretty much saved my life. The three principles group was like a penny dropping – the past can’t hurt me because it’s done and dusted. It’s been a real game changer for me and Summit house has offered everything I needed under one roof”.

Finance

Learning

60% 50% 40% 30% 20% 10% 0%

Physical Health

Safety

Mental Health

Housing

Social Contact

Change

This shows that those managing ok have had beneficial changes (i.e. an increase in numbers) in all target areas; the greatest being ‘Mental health’ with a 48% positive change.

6.10 Wider Achievements Aside from the seven main target outcome areas, IP has achieved a number of additional changes for its clients spanning, quality of life, wellbeing, peer support, and financial betterment. 

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 intervention. Feedback includes: 1 Start End

# 32 10

2 % 13% 4%

# 64 42

3 % 26% 17%

# 109 120

4 % 44% 49%

# 36 58

5 % 15% 23%

# 6 17

% 2% 7%

In terms of change from start to end this can be illustrated as: Quality of Life 50% 40% 30% 20% 10% 0% 1+2

David Waterfall, www.dpwaterfall.com

Start

Latest

4+5

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This shows that during the intervention the percentage of clients considering they have poor quality of life (ratings of 1 or 2) has decreased (from 96 clients to 52), and also the percentage of those clients considering they have good quality of life (ratings of 4 or 5) has increased (from 42 to 75). Overall this is a change of some 46% fewer clients reporting poor quality of life, and also a change of 79% of clients reporting good quality of life. 

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 intervention.

Feedback includes: 1 Start End

# 28 11

2 % 11% 4%

# 64 40

3 % 26% 16%

# 109 89

4 % 44% 36%

# 40 86

5 % 16% 35%

# 6 22

% 2% 9%

In terms of change from start to end this can be illustrated as: Wellbeing

50% 40% 30% 20% 10% 0% 1+2

Start

Latest

4+5

This shows that during the intervention the percentage of clients considering they have poor wellbeing (ratings of 1 or 2) has decreased (from 92 clients to 51), and also the percentage of those clients considering they have good wellbeing (ratings of 4 or 5) has increased (from 46 to 108). Overall this is a change of some 45% fewer clients reporting poor wellbeing, and also a change of 135% of clients reporting good wellbeing. 

Peer Support IP has established the delivery of several peer networks.

“I could have just stayed at home and given up.

I wished I would have known about this five years ago. I’ve got what I really want, it’s lifted me and I have a laugh. I can feel a change in myself – I feel more alive to be honest. If I hadn’t have gone to the doctors and been referred to Integrated Plus none of this would have happened, it’s the Link Officer’s help that’s got me here and I thank him very much”.

Two of the popular peer networks include:

David Waterfall, www.dpwaterfall.com

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Integrated Plus Impact Evaluation, Final Report



Airtime; set up through funding received from The Health Foundation in 2016.

Airtime is a social peer-led support group for people living with COPD. Its purpose is to help people better self-manage their COPD, connect with others living with COPD and engage in social activities to reduce isolation. Airtime is open to anyone living with COPD and GPs can also refer their patients. Funding was secured from The Health Foundation through a joint funding application submitted by Dudley CCG and Dudley CVS. Airtime has recently secured £5000 match funding from Dudley CCG and Public Health for it to continue. Airtime no longer has a dedicated coordinator but is supported by the Integrated Plus staff.



Monday Men’s Group; originally set up in 2015 by the Link Officer for Stourbridge, Wollescote and Lye as a result of many men with mental health problems, particularly single men being referred. Many were isolated and found it difficult to engage socially. Many had been divorced, had experienced bereavement or were unemployed. It was not uncommon for these men to feel low self-esteem and that they had limited economic and social usefulness. The group meets every Monday at a local church and enables men to connect with other and engage in social activities.

Case studies are included in Appendix B for reference. In summary the ability for clients to take ownership and run their own groups, with decreasing IP support to develop confidence and independence, is hugely valuable. This increases peer-to-peer support provision, enables people to better self-manage their condition (such as COPD), renews interest in hobbies and pass-times, whilst reducing isolation. 

Financial Betterment Once the financial section of the assessment has been completed with clients, the IP team are able to identify whether patients living in poverty require additional support, such as:    

Applying for non-means tested/ non-contribution based benefits such as PIP or AA Help with getting benefits re-instated Referring patients onto specialist benefit and debt advisors such as Citizens Advice Helping patients living in extreme poverty apply for short-term or one-off emergency grants through Charitable Trusts eg food, clothing, paying bills etc

Key financial data includes:   

Total amount of individual grants awarded: £2,440.60 for eight clients, between September 2016 and August 2018 Total amount of back dated benefits such as PIP and AA: £34,606.30 between September 2016 and August 2018 Total amount of reinstated benefits: £7,104.28 total in a single month for 19 clients, equating to a projected 12-month total of £85,251.36

Total amount of new benefits being claimed (through direct IP support, or in collaboration with other benefit services):

David Waterfall, www.dpwaterfall.com

Page 44 of 105

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Integrated Plus Impact Evaluation, Final Report

Total £ per month PIP AA ESA Carers allowance JSA Pension Credit Housing benefit

£15,704.55 £22,328.76 £4345.60 £1291.80 £292.40 £165.66 £567.92 £44,696.69

Total £ (12 month forecast) £188,454.60 £267,945.12 £52,147.20 £15,501.60 £3,508.80 £1,987.91 £6,815.04 £536,360.27

Helping clients with such benefit support helps in a variety of ways, including:    

To get and out about more using taxis due to statutory and third sector transport services being cut Have cleaners in to help around the home, improving hygiene and health Pay for gardeners to help with gardening when the person is unable to do this themselves, enhancing happiness and reducing the risk of trips and falls Buying aids and adaptations to the home, improving independence and ability to cope

It should be noted that when the IP team had additional capacity through the expanded number of LSWs, the level of support provided to clients to assist with financial betterment was significantly increased. When LSW capacity is stretched, the inability to offer more of this form of support is routinely questioned by clients.

“Since being with Integrated Plus I feel can be open and honest with my family. I did not think they would be as supportive as they have been. Attending Atlantic House is helping me cope with my anxieties and panic attacks. The groups are helping me as I am able to discuss issues with people who are in the same situation as me.

I cannot thank Integrated Plus enough. Without their help and support I would not have accessed Atlantic House’s services and would not have been able to get to this point in my life.”

David Waterfall, www.dpwaterfall.com

Page 45 of 105

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Integrated Plus Impact Evaluation, Final Report

7

Service Reductions

7.1

Efficiencies Information has been gained for three key areas of health data:   

7.2

A&E Admissions; gained from DSCRO data Inpatients Admissions; gained from DSCRO data GP Surgery Data; gained from direct surveying with surgeries

A&E Admissions Data shows significant reductions in A&E attendance after IP with the impact increasing from a 14% reduction after 6 months following IP (227 incidents less overall), to a 17% reduction 12 months after IP (507 incidents less overall).

Furthermore, over both timeframes 47% of patients had fewer incidents following IP; 473 individuals after 6 months, and 637 after 12 months. Conversely 40% of patients increased incidents; 401 after 6 months, and 549 after 12 months.

Of those with fewer incidents, 6 months following IP there was an average of 1.9 fewer incidents per patient totalling 888 less incidents, and 12 months after IP an average of 2.5 fewer incidents per patient totalling 1,605 less incidents. Of these patients with fewer incidents, the baseline level of incidents before IP may be illustrated as: Patients With Fewer Instances; Baseline Incidents 6 Months After IP

12Months After IP

60%

50%

50%

40%

40%

30%

30%

20%

20%

10%

10%

0%

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

0

2

4

6

8 10 12 14 16 18 20

This shows that in both timeframes, while there are reductions for patients that previously visited on up to 19 occasions; the most frequent was a single incident.

When compared to those patients that experienced an increase in attendance after IP, 6 months following IP there was an average of 1.6 additional incidents per patient totalling 661 more incidents, and 12 months after IP an average of 2.0 extra incidents per patient totalling 1,098 additional incidents. Of these patients with more incidents, the baseline level of incidents before IP may be illustrated as:

David Waterfall, www.dpwaterfall.com

Page 46 of 105

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Integrated Plus Impact Evaluation, Final Report

Patients With Increased Instances; Baseline Incidents 6 Months After IP

12Months After IP

80% 60% 40% 20% 0% 0

2

4

6

8 10 12 14 16 18 20

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

2

4

6

8 10 12 14 16 18 20

This shows that in both timeframes, while increases were experiences for several patients, the vast majority (over 60% in both timeframes) had not had an incident before IP. Of these patients that had not attended before, most (over 65%) only had a single incident following IP, as shown below: Patients With Increased Instances; Post-IP Incidents 6 Months After IP

12Months After IP

80%

80%

60%

60%

40%

40%

20%

20%

0% 1

2

3

4

0%

5

1

2

3

4

5

A summary of the DSCRO A&E data is included below, split for ease between 6 months and 12 months following IP: 6 Months

12 Months

Before Service Contact

1,613

2,997

After Service Contact

1,386

2,490

Reduction (incidents)

227

507

Reduced by

14%

17%

Patients with fewer incidents

473 (47%)

637 (47%)

Patients with more incidents

401 (40%)

549 (40%)

Patients with unchanged incidents

139 (14%)

178 (13%)

David Waterfall, www.dpwaterfall.com

Page 47 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

Patients with fewer incidents Most frequent reduction in incidence

1

1

Average fewer incidents/ patient

1.9

2.5

Incidents reduced

888

1,605

Most frequent increase in incidence

1

1

Average increase incidents/ patient

1.6

2.0

Incidents increased

661

1,098

Patients with more incidents

In terms of cost avoidance, current data indicates that a single A&E attendance costs £115 per person. As such, after 6 months 227 fewer incidents overall equates to £26,105. However, if a focus is solely on the 473 patients that have had a total of 888 fewer incidents, this equates to £102,120. After 12 months 507 fewer incidents overall equates to £58,305.

However, if a similar focus is solely on the 637 patients that have had a total of 1,605 fewer incidents, this equates to £184,575.

7.3

Inpatients Admissions Data shows significant reductions in inpatient admissions after IP with the impact increasing from a 14% reduction after 6 months following IP (211 incidents less overall), to a 15% reduction 12 months after IP (442 incidents less overall).

Furthermore, over both timeframes 49% of patients had fewer incidents following IP; 530 individuals after 6 months, and 698 after 12 months. Conversely 40% of patients increased incidents after 6 months (429 extra incidents), and 37% after 12 months (528 incidents more).

Of those with fewer incidents, 6 months following IP there was an average of 1.75 fewer incidents per patient totalling 925 less incidents, and 12 months after IP an average of 2.39 fewer incidents per patient totalling 1,665 less incidents. Of these patients with fewer incidents, the baseline level of incidents before IP may be illustrated as: Patients With Fewer Instances; Baseline Incidents 6 Months After IP

60%

12Months After IP

40% 35% 30% 25% 20% 15% 10% 5% 0%

50% 40% 30% 20% 10% 0% 0 2 4 6 8 10 12 14 16 18 20

David Waterfall, www.dpwaterfall.com

0 2 4 6 8 10 12 14 16 18 20

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Integrated Plus Impact Evaluation, Final Report

This shows that in both timeframes, while there are reductions for patients that previously visited on up to 20 occasions; the most frequent was a single incident.

When compared to those patients that experienced an increase in attendance after IP, 6 months following IP there was an average of 1.6 additional incidents per patient totalling 714 more incidents, and 12 months after IP an average of 2.3 more incidents per patient totalling 1,223 extra incidents. Of these patients with increased incidents, the baseline level of incidents before IP may be illustrated as:

Patients With Increased Instances; Baseline Incidents 6 Months After IP

12Months After IP

80%

70% 60%

60%

50% 40%

40%

30% 20%

20% 10%

0%

0%

0 1 2 3 4 5 6 7 8 9 10

0 1 2 3 4 5 6 7 8 9 10 This shows that in both timeframes, while increases were experiences for several patients, the vast majority (approximately 60% in both timeframes) had not had an incident before IP. Of these patients that had not attended before, most (at least 60%) only had a single incident following IP, as shown below: Patients With Increased Instances; Post-IP Incidents 6 Months After IP

12Months After IP

70% 60% 50% 40% 30% 20% 10% 0% 1

2

3

4

5

80% 70% 60% 50% 40% 30% 20% 10% 0% 1

2

3

4

5

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

David Waterfall, www.dpwaterfall.com

Page 49 of 105

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Integrated Plus Impact Evaluation, Final Report

6 Months

12 Months

Before Service Contact

1,528

2,931

After Service Contact

1,317

2,489

Reduction (incidents)

211

442

Reduced by

14%

15%

Patients with fewer incidents

123 (11%)

190 (13%)

Patients with more incidents

530 (49%)

698 (49%)

Patients with unchanged incidents

429 (40%)

528 (37%)

Most frequent reduction in incidence

1

1

Average fewer incidents/ patient

1.75

2.39

Incidents reduced

925

1,665

Most frequent increase in incidence

1

1

Average increase incidents/ patient

1.66

2.32

Incidents increased

714

1,223

Patients with fewer incidents

Patients with more incidents

In terms of cost avoidance, current data indicates that a non-elected hospital admission (unplanned admission for operations or treatments) is £1,700 per person. As such, after 6 months 211 fewer incidents overall equates to £358,700. However, if a focus is solely on the 530 patients that have had a total of 925 fewer incidents, this equates to £1,572,500. After 12 months 442 fewer incidents overall equates to £751,400. However, if a similar focus is solely on the 698 patients that have had a total of 1,665 fewer incidents, this equates to £2,830,500.

7.4

DSCRO Data Overall For ease of reference, DSCRO data may be summarised as follows: A&E

Inpatients

Number of episodes before IP

2,997

2,931

Number of episodes 12 months after IP

2,490

2,489

#

-507

-442

%

17%

15%

#

-637

-698

%

-47%

-49%

Cost per episode

£115

£1,700

Cost avoidance

£58,305

£751,400

Change in episodes Patients with fewer episodes

David Waterfall, www.dpwaterfall.com

Page 50 of 105

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Integrated Plus Impact Evaluation, Final Report

This demonstrates that reductions in both types of admission were identified compared to before Integrated Plus, with a total potential cost saving of some £810,000.

7.5

GP Surgery Data Data has been gained on three key aspects; GP Telephone Consultations, GP Home Visits, and GP Consultations. Full graphs are included in Appendix C, with summary findings below: 

GP Telephone Consultations Of the 43 GP surgeries, six months following IP 20 surgeries have had an increase in telephone consultations accounting for 169 additional consultations, 21 have had a decrease totalling 163 less, and two surgeries have had the same level when compared to six months before the date or referral to IP. This produces an overall gain of six telephone consultations, which at an average cost of £30 per consultation equates to an increase of £180. With a total of 2,720 patients supported, this equates to a cost per patient of £0.07. As the majority of surgeries have experienced benefits due to IP, these surgeries in isolation have had a cost avoidance of some £4,890. The full change is shown in Appendix C, with bars to the right of the central line representing increases, and those to the left decreases.



GP Home Visits Of the 43 GP surgeries, six months following IP 15 surgeries have had an increase in telephone consultations accounting for 111 additional consultations, 26 have had a decrease totalling 275 less, and two surgeries have had the same level when compared to six months before the date or referral to IP. This produces an overall reduction of 164 home visits, which at an average cost of £100 equates to a cost avoidance of £16,400.

With a total of 2,720 patients supported, this equates to a cost avoidance per patient of £6.03. As the majority of surgeries have experienced benefits due to IP, these surgeries in isolation have had a cost avoidance of some £27,500. The full change is shown in Appendix C, with bars to the right of the central line representing increases, and those to the left decreases.



GP Consultations Of the 43 GP surgeries, six months following IP 8 surgeries have had an increase in consultations accounting for 63 additional consultations, 34 have had a decrease totalling 2,125 less, and one surgery has had the same level when compared to six months before the date or referral to IP. This produces an overall reduction of 2,089 consultations, which at an average cost of £35 equates to a cost avoidance of £73,115. With a total of 2,720 patients supported, this equates to a cost avoidance per patient of £26.88. As the majority of surgeries have experienced benefits due to IP, these surgeries in isolation have had a cost avoidance of some £75,320. The full change is shown in Appendix C, with bars to the right of the central line representing increases, and those to the left decreases.

David Waterfall, www.dpwaterfall.com

Page 51 of 105

Dudley CVS



Integrated Plus Impact Evaluation, Final Report

GP Comparisons A detailed comparison across all GPs is also included in Appendix C, showing a stark decrease in patient interactions overall, split between the three types of category.

It is interesting to note that the top ten surgeries that receive the greatest benefit from IP for each of the three categories, four surgeries appear in all three categories: 

Lower Gornal Medical Practice; cost avoidance of £8,985 (99 referrals, 71 supported)



Wychbury Medical Centre/Cradley Road Medical Practice; cost avoidance of £11,135 (306 referrals, 189 supported)



Lion Health/Norton; cost avoidance of £7,785 (360 referrals, 253 supported)



AW. Surgeries (Albion House/Withymoor)); cost avoidance of £8,635 (146 referrals, 125 supported)

These four surgeries alone total over £36,000 of cost avoidance; with 638 patients supported this equates to a unit cost of £57.27 cost avoidance per patient.

“Due to this disability I have had to give up work and I am now virtually housebound.

The link officer has opened up a lot of possibilities for me by encouraging me to become involved with a number of activities which has been a massive help, she has done really well and it has made a huge difference to my life.”

David Waterfall, www.dpwaterfall.com

GP comments: “Great service to have as part of the MDT” “Very happy with the service, it has helped our patients a lot” “Wonderful service that is hugely beneficial to our most vulnerable patients”

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8

Multi-Disciplinary Teams

8.1

Approach GP surgeries, and wider Multi-Disciplinary Team members, were asked specifically to consider the presence of the Multi-Disciplinary Teams and their views of IP and the Link Officers. 55 responses have been gained, with a copy of the Survey in Appendix D, and feedback summarised below.

8.2

Integrated Plus Role Feedback from questions includes: ď&#x201A;ˇ

How would you rate the Integrated Plus service?

Excellent

30

Good

25

Average

0

Poor

0

Very poor

0

Total

40 30 20 10

55 0 Excellent

ď&#x201A;ˇ

Good

Average

Poor

Very poor

What benefits do you feel the Integrated Plus service brings to your patients specifically (multiple options allowed)?

Reduces isolation + loneliness

43

Increases involvement in VCS activities

39

Increases social networks

29

Improves health + wellbeing

27

Increase person's independence

26

Resolves/reduces financial issues

25

Improves quality of life

24

Encourages responsibility of own health

23

Increases self-management of health

22

Strengthens community resilience

22

Enables greater control over own life

22

David Waterfall, www.dpwaterfall.com

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50 45 40 35 30 25 20 15 10 5 0

ď&#x201A;ˇ

Overall, what is it about the Integrated Plus service that you (as a GP or other MDT member) are finding most beneficial (multiple options allowed)?

Considers social needs of patients

41

Connects patients into VCS activities

30

Quality time in patients' home

26

Resolves patient problems

25

Improves GP knowledge of VCS services

25

Considers whole needs of person + family

22

Enables patients to become less reliant

21

Increases VCS involvement in new care model

21

Reduces demand on GP time

17

Helps tackle inequalities and poverty

16

Helps to avoid primary care costs

11

Helps support peer to peer support

11

Other (please specify)

David Waterfall, www.dpwaterfall.com

1

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45 40 35 30 25 20 15 10 5 0

The comments provided to support the ‘other’ category was, “I feel the IP service meets so many of a patient's needs that are otherwise not necessarily seen as a priority but go so much towards recovery.” 

To what extent, do you feel Integrated Plus has helped to reduce inappropriate GP consultations at your practice?

A great deal

11

A lot A moderate amount

11

A little

11

Very Little Total

8.3

15 0 48

16 14 12 10 8 6 4 2 0 A great deal

A lot

A moderate amount

A little

Very Little

Link Officer Role Feedback from questions includes: 

To what extent, do you feel the Link Officers add value to the current MDT meetings?

A great deal

32

A lot A moderate amount

17

A little

1

Very Little

0

Total 

5

55

35 30 25 20 15 10 5 0 A great deal

A lot

A moderate amount

A little

Very Little

In what ways do you feel the Link Officers add value to the MDTs?

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Discusses Patient Options Increases Productivity Increases Knowledge Better Supports Work

45 40 35 30 25 20 15 10 5 0

39 31 27 15

Other

8

Don't know

1

Discusses Increases Increases Better Patient Productivity Knowledge Supports Options Work

Other

Don't know

Wider comments included to support the ‘other’ category:   





 



Gives a new dimension to the work that we do and allows clinicians to spend more time on the clinical work they are trained to do.

Great referral path for patients who present with isolation and loneliness, increases patients involvement in voluntary and community I don't attend the MDT, however we have found our support worker a very professional and knowledgeable support mechanism. He is very personable and endeavours to do his best to support the patients that are referred on to him.

Our main Link Officer has an excellent rapport with our patients, nothing is too much trouble for him and he is literally only a phone call away. He attends all MTD meetings and has good input from the patients he sees.

There is a great deal of knowledge and determination from my locality link officer.

She has often times given me insight into the local services and helped people through. very helpful to know what services are available also going with patients for PIP assessments sorting out benefits etc We haven't had a representative present for the last few meetings and miss their input

To what extent, do you feel Link Officers are pivotal to MDTs going forward (ie the 10 new Integrated Community Teams)?

30 A great deal

28

A lot

19

A moderate amount A little

8.4

25 20 15

7 1

Very Little

0

Total

55

10 5 0 A great deal

A lot

A moderate amount

A little

Very Little

Future Development

David Waterfall, www.dpwaterfall.com

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Feedback from questions includes: 

Do you feel the Integrated Plus service could be improved or changed in some way?

40 Yes

19

No

34

30 20 10

Total

53

0 Yes

No

Of those that responded some form of improvement may be possible, detail included:  





        

     

Better advertising and patients to self-refer.

I feel if they could help with few things 1) running clubs according to the local needs - for eg- my patients want to grow vegetables and have meal together -so they understand healthy cooking and community feel - if integrated team could get an allotment from the council and help with this -welcomed 2) some of my patients want to go for walk in the park but with small team - if there are clubs they could sign up to themselves -its appreciated.

I think the service is excellent, my guess is that that's due to the personable involvement of our attached worker. However, in general all services can be improved. So my answer was very general.

I would love to have a much Local / surgery wise service - if you can attach a link officer to 1 or 2 surgeries to help grow vegetables / make dinners / park runs etc where pts can come to surgery and then taken somewhere .- a lot of pts has asked if this can be done as they trust coming to the surgery - I would not mind to be a pilot Surgery.

Involving IP services with patients in temporary placements/Interim placements and supporting them returning to own environment.

More hours per practice.

More ongoing support to patients and follow up to ensure they remain engaged with social networks.

More patient contact time.

More staff to enable shorter waiting lists.

More staff to reduce waiting lists.

More workers.

Patient self-referral.

Reduced waiting time. Why do they need one hour to assess the patient at first visit; surely 30mins would suffice? GPs are expected to far more in their 10 mins consultations.

Shorter waiting times.

Shorter waiting times for interventions.

Targeted home visits for frequent attendees.

There is a significant delay from referral to assessment (more than 4 weeks).

You need more capacity. Patients shouldn't have to wait too long for a first appointment, and you need the resource to follow up more patients.

Other Comments

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Wider comments provided include:        



  



As a mental health nurse the input from the IP officers has been invaluable.

Easy accessible service and willing to help with the right pathway for our vulnerable patients.

Good service. I think it should be scaled up again.

Great service to have as part of MDT. I have always experienced a good working relationship with the IP link workers and found their intervention to be invaluable.

I have always found the link workers to be helpful and professional.

Really useful service.

Social prescribing is a valued and evidence based intervention. The service needs to match the demand. Having waiting lists of more than 5 weeks is no help to stretched GP services and their patients.

Sometimes vulnerable /isolated people will not respond to phone calls or letters but proactive approach to contact hem is helpful as integrated team are the final call for help sometimes.

Very confident in the role of it services.

Very happy with the service, has helped a lot of our patients.

We are very happy with Integrated plus's input, Jason attends MDT meetings monthly and informs the team of who he is seeing etc. Nothing is too much trouble for Jason and the team. I am very happy working alongside integrated plus.

Wonderful service that is hugely beneficial to our most vulnerable patients. Thank you.

David Waterfall, www.dpwaterfall.com

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9

Budget

9.1

Clients Integrated Plus has had a total budget of some £1.785 million over full four years of delivery, September 2014 to August 2018. The forecast budget for September 2018 to August 2019 is £440,607. Key figures include: Year 1 2 3 4 5

Timeframe September 2014 – August 2015 September 2015 – August 2016 Sept 2016 – Aug 2017 Sept 2017 – Aug 2018 Sept 2018 – Aug 2019

Budget (£)

Referrals

Supported

Rate

387,950

595

485

82%

367,250

1,020

828

81%

533,666

1,166

765

66%

497,327

975

642

66%

440,607

Still recording. To March 2019; 564 referrals, 437 accepted = 77% rate

In the full four year timeframe, Integrated Plus has supported 2,720 clients, from a total of 3,756 referrals; equating to an average of a 72% acceptance rate. However acceptance rates have dropped from approximately 81% across years 2014 to 2016, to some 66% across 2016 to 2018.

600,000

900 800

500,000 700 400,000

600 500

300,000 400 200,000

300 200

100,000 100 0

0 Year 1, 14-15

Year 2, 15-16

Total Budget

Year 3, 16-17

Year 4, 17-18

Supported

This shows that while the total budget is generally increasing over time (in green dotted trendline), the numbers of those supported is decreasing over time (in red dotted trendline).

9.2

Expenditure Headings

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Budgets were considered in terms of revenue, overheads and capital spend, summarised below:

Year 1 2 3 4 5

Revenue (£)

Timeframe September 2014 – August 2015 September 2015 – August 2016 Sept 2016 – Aug 2017 Sept 2017 – Aug 2018 Sept 2018 – Aug 2019

Overheads (£)

Capital (£)

Total Budget (£)

309,500

73,450

5,000

387,950

296,500

70,750

0

367,250

429,466

101,200

3,000

533,666

412,645

81,681

3,000

497,327

373,895

69,712

0

440,607

When considering budget levels and numbers of clients supported, the budget breakdown by heading, and associated heading unit cost may be illustrated below: Budget by Heading

Unit Cost (£, per Budget Heading)

600,000

700

500,000

600 500

400,000

400

300,000

300

200,000

200

100,000

100 0

0 £

Year 1, 14- Year 2, 15- Year 3, 16- Year 4, 1715 16 17 18

Capital

Overheads

Revenue

£

Year 1, 14-15 Year 2, 15-16 Year 3, 16-17 Year 4, 17-18

UC/ Revenue UC/ Capital

UC/ O'heads

This shows that aside from the initial start-up year unit costings have increased year on year; from £444 in 2015-16, through £698 in 2016-17, to £766 by 2017-18. This increase reflects primarily increases in the revenue budget; with unit cost for solely revenue expenditure increasing by over 75% between 2015-16 (£358) and 2017-18 (£636).

Overall, unit costings per year for total budget are:    

9.3

Year Year Year Year

1, 2, 3, 4,

14-15 15-16 16-17 17-18

- unit - unit - unit - unit

costing costing costing costing

of of of of

£800 £444 £698 £766

Value for Money

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Dudley CVS are keen to ensure that value for money is a core feature of the service’s delivery.

Key points to note are that: 

Integrated Plus has no control over the number of referrals received, and also has limited control over whether clients accept the service or not. This impacts significantly on variations in unit costs.



Additional funds for the Link Support Workers through NHS vanguard money was not to increase the number of referrals to the service. The LSWs were recruited to help bridge a gap on capacity issues. Due to initially having the 5 link officers Integrated Plus found that there was no time to do the final assessment/follow up work for outcome measurements and to help out with lower level client support such as chaperoning to services if the client confidence was low, helping with PIP/AA forms etc. The LSWs don’t take referrals but help the Link Officers with their client work. This had an impact on revenue funds, and hence overall costing levels.



The 15% management fee in place (amounting to £68,781 in the last full year of delivery Sept 2017 – Aug 2018) is a standard provision with many third sector providers, and represents a calculated recharge to cover the proportion of Dudley CVS’ core costs that the service utilises.



The service now receives less funding on a 3 yearly basis ie £464,300 per year for the same number of staff. Several areas of the original yearly budget have been reduced or cut. These include the staff salary for administrational support, promotional budget, staff training budgets, voluntary sector events budget and contract management budget.



Contract management costs are now much less. The total contract value from 1st April 2019 to 31st March 2020 is £464,300 including management costs, of which contract management is £19,350 equating to some 4% of total overheads and revenue.



These overall budget totals may be set against the context of cost avoidance in place, demonstrated elsewhere in this report as covering:  £751,400; Inpatients  £73,115; GP Consultations  £58,305; A&E admissions  £16,400; GP Home Visits

David Waterfall, www.dpwaterfall.com

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Integrated Plus Impact Evaluation, Final Report

Lessons Learned

10.1 Learning Delivery since September 2014 has provided the team with a wealth of insight into which aspects of delivery are most efficient and the various ways that the service creates lasting benefit for patients. Key areas of learning cover: 

Work with GPs and Other Health Clinicians      



Nationally/Regionally   



Valued by GPs, built trust and maintained positive relationships over 4 years.

Well respected service.

Link Officers were part of MDTs at the beginning which helped to forge strong relationships and help clinical staff to understand the service interventions.

The service ensures that the social inclusion and other non-clinical needs are taken into account at MDTs. GPs see Link Officers as pivotal to MDTs/ICTs from the GP survey results.

The service has helped to show that the social non-clinical interventions are important alongside psychological and physical interventions.

Integrated Plus was an early implementer of social prescribing which started in 2014 in comparison to other social prescribing schemes around the country.

The service has shared its learning across the country through the delivery of its Dudley Social Prescribing Peer Learning Programme.

Contributed to the National social prescribing agenda by being part of the National Social Prescribing Network and West Midlands Regional Network.

Referrals    



    

Referral numbers are healthy.

Good service acceptance rate – 72% over 4 years.

Receive referrals from all GP surgeries, some much higher numbers than others.

Top 2% of patients at high risk of hospital admission may not always be appropriate for the service. Focus is less about prevention and more about dealing with crisis issues.

No access to patient lists at MDTs on frequent attenders of GP surgeries. These are not discussed or explored in MDTs. If the service had these lists it could be more targeted with referrals and who the service supports.

Staff do not always know if a referral is appropriate or not until a first visit is conducted in the person’s home.

Referrals on EMIS are not always coded correctly which leads to problems with data analysis.

No control over referral numbers or acceptance rates.

Waiting lists of 8-12 weeks for the service and this can vary.

Not all referrals are appropriate for the service eg some are palliative, some referred because they need a social care assessment only, some patients are in care homes or some patients do not feel they have any social/non-clinical needs.

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

Integrated Plus Impact Evaluation, Final Report

Service Approach   



The Team    



Strong and supportive team ethos.

Opportunities to share learning and offer peer support.

Good learning and development opportunities through training.

Access to clinical supervisions.

Access to Data and Monitoring   







The flexible approach works with patients, spending quality time with patients, listening to their needs, what matters to them is valued.

Independent, impartial and flexible approach is valued by patients supported.

The service has been able to stimulate and support patients to lead on new social and peer-led activities eg Men’s Group and Airtime COPD network.

Over the last 4 months the service has had to spend time, with limited capacity, to recode referrals in GP practices for evaluation purposes.

Staff do not have remote access to EMIS in which to enter data onto the system and conduct analysis on the number of GP consultations for evaluation purposes.

First 2 years of delivering the project there was limited capacity to conduct the follow up bespoke assessment to capture outcomes and to help offer mentoring support to patients such as chaperoning to an activity a few times if their confidence is low. Additional funding for the 5 Support Workers helped the service to increase capacity for this.

Monitoring requirements of the service has evolved and changed over time which has resulted in the service needing to spend more time on data collection and analysis which there has been limited capacity to do.

Over time, social prescribing schemes have been asked to complete more patient health assessments such as PAM, PROMs. Integrated Plus developed their own bespoke social/non-clinical assessment to capture outcomes. Although using health assessments such as PAM would be useful data to collect using nationally validated tools, completing additional assessments would require more time spent with patients which would increase the length of home visits and follow up support. The first home visits take approximately 1.5 – 2.5 hours at present. A large proportion of time is spent building rapport, getting to know the person and what matters to them.

Increasing assessment time would impact on the person-centred approach and service capacity.

Patient Support  



High expectations from patients about what the service can do and achieve with short-term interventions Some patients referred have complex needs and are quite dependent on a range of services. It is difficult to make much change with the person when support is shortterm, approximately 3 months, and when there are waiting times for other services.

Some patients where their needs are complex require support first in areas of money, dealing with debts, family issues, household issues before the service can support them in engaging in other social and wellbeing activities.

David Waterfall, www.dpwaterfall.com

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

 



Not all patients referred have the ability or mind-set to motivate themselves to make positive change to their lives even though staff instigate change talk and use techniques such as motivational interviewing and solution focused therapy.

Unpredictability of patient risks to staff.

Sometimes the service receives limited information on risks to staff from patients on referral.

Outward Referrals    



Funding cuts to the voluntary sector has resulted in a lack of capacity in some areas such as long term support workers, transport services, befriending etc.

Some voluntary sector services have closed and some organisations have reduced the diversity of services offered such as LGBT support, luncheon clubs etc.

Relied on the good will on the voluntary sector to take referrals .

Waiting times for other services in which to refer patients to can result in the service working with patients for longer than anticipated. Staff have experienced waiting lists for social care assessments, carers assessments, mental health provision and befriending.

Lack of funding and staff time to help stimulate, support and sustain social peer networks.

David Waterfall, www.dpwaterfall.com

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Integrated Plus Impact Evaluation, Final Report

Future Delivery

11.1 Future Funding Of Integrated Plus The Integrated Plus Social Prescribing Service will continue to be funded by Dudley CCG on a 3 year rolling contract as part of the new 10 year integrated care model for Dudley. This will enable the continuation of social prescribing interventions to be provided to patients across Dudley borough.

From 1st April 2019, the total contract value per year will be £464,300. Contract management costs will reduce to 4% of the total yearly contract value.

Locality Link Officers will continue to attend the MDTs at each practice. Once these practice based MDTs have developed into a series of 10 new Integrated Community Teams (ICTs) serving the larger populations in 5 localities the Link Officers will integrate into these ICTs and attend the weekly meetings. This will ensure the non-clinical needs of patients continue to be met as part of the ICTs and the voluntary sector represented at such meetings. In order to ensure there is full attendance from Integrated Plus at all of the MDTs/ICTs on occasion the Link Support Workers will attend them when the Locality Link Officers are on annual leave or absent from work.

11.2 Immediate Recommendations In order to ensure social prescribing is delivered in Dudley as part of the new integrated care model, it is recommended to maintain current staff levels of 1 manager, 5 Locality Link Officers, 5 Support Workers and some administrational staff time.

GPs benefit and value the current patient referral criteria as the age range is broad and there is some flexibility in who we support. The current criteria is patients aged 16 upwards who:   

Frequently present at their GP practice Are on the top 2% at high risk of hospital admission (identified and discussed in the MultiDisciplinary Team/Integrated Community Team meetings) Any vulnerable person in need of non-clinical support identified by GPs in GP consultations facing issues such as isolation/loneliness, mild/moderate depression, long term health issues, drug or alcohol issues etc.

Referrals are only open to:  

All GPs at each surgery within Dudley borough, regardless of whether they attend MDT meetings All core staff who attend the MDTs (eg social worker, mental health clinician, district nurse, GP etc)

Currently, patients cannot self-refer, we do not support people living in care homes and we do not accept referrals from all health clinicians due to capacity even though many health clinicians do contact with us wanting to refer people to the service. By other health clinicians we mean all social workers working for Dudley MBC and all clinicians working for Dudley Group.

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Restricting the referral criteria, for example, by age groups or presenting issues, could potentially decrease referral numbers, make the client work less diverse and increase the unit cost per patient making the service less cost effective.

Integrated Plus staff have found at times that the top 2% of patients at high risk of hospital admission are not always the most appropriate patients for the service to support. At the current MDT meetings some palliative patients are discussed as well as some patients in care homes. There is very little suitable social prescribing interventions that can be offered these patients and the interventions are less preventative. The current MDT meetings also do not circulate specific lists of frequent presenters at their surgeries. These would be useful lists to have access to so the support can be better targeted to this patient cohort thus helping to reduce pressure on GP surgeries more. Widening the service referral criteria to the top 5% or 30% would help the service to target patients who are currently less intensive users of health services. This would enable a wider range of preventative benefits to be realised, particularly in areas such as mental health and wellbeing. This would also better align the Integrated Plus service to the NHS Long Term Plan and Universal Personalised Care model (more detail provided towards the end of this section).

In light of local plans, if the implementation of MDTs or ICTs specifically for children and young people goes ahead, it is recommended to change the service age range criteria to people over the age of 18 and over 25 for people with learning disabilities. If specific MDTs or ICTs are developed for children and young people then these patients could be supported through this additional service (either delivered by Dudley CVS or another provider)

11.3 Long-Term Recommendations The average number of referrals over the last 4 years has been 939. The average service acceptance rate across 4 years has been 72%. Over the next few years, the service aims to reach between 900-1100 new referrals per year with a 70% – 80% service acceptance rate.

Based on a 70% service acceptance rate of 1100 new referrals the unit cost would be £602 per patient supported. Based on 80% service acceptance rate of 1100 new referrals the unit costs would be £527 per patient supported.

The GP survey highlighted a desire from GPs for Integrated Plus to try and reduce its waiting times. The waiting times do vary from month to month but currently they are between 6 – 12 weeks. In order to try and reduce waiting times, it is recommended to enhance the Link Support Worker roles so they can take responsibility for all client interventions for patients re-referred to the service and to explore the option of implementing a triage process. These would result in Link Support Workers taking responsibility for supporting patients presenting with less complex needs.

The Integrated Plus service would benefit from match-funding from the local authority (public health and/or social care) as well as Dudley CCG. Given the possibility for preventative benefits and the links to the health and wellbeing strategy. Some social prescribing projects around the country such as Rotherham and Hackney have benefitted from receiving funding for frontline voluntary and community sector groups and organisations. This has helped social prescribing projects to be more flexible and responsive to better meet patient needs and gaps in service provision as well as helping to build capacity

David Waterfall, www.dpwaterfall.com

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in the voluntary sector. Through the Integrated Plus new Urgent Care High Intensity Social Prescribing Project, funding was secured funding through the Department of Health for a voluntary sector fund. This funding is only available to support high intensity user clients and not the wider Integrated Plus service clients, however, the funding is proving to be really valuable in establishing creative and innovative support solutions delivered by the voluntary sector. This funding of £50,000 per year, is managed by Integrated Plus and funding is allocated to the voluntary sector via spot purchasing arrangements or block contracts.

NHS England has recognised the need and value of direct funding being made available locally to frontline voluntary groups who take referrals from social prescribing schemes. They are encouraging areas locally to try and pool financial resources together from Local Authorities, CCGs and other partners to make available resources that could fund new services, activities and peer-led networks. Other ways could also be explored to diversify the funding base for frontline voluntary sector groups. Options include widening opportunities for direct payment and individual health budget holders to purchase services, and encouraging more frequent self-funding of certain activities.

Future considerations of the Integrated Plus service could also focus on whether additional health assessments could be conducted with patients such as the Patient Activation Measures (PAM). Currently, the service uses its own bespoke social assessment which uses scaling and WEMWBS. Using additional assessments would require reviewing capacity of the current service and potential impact on patient time in the first home visit. Patient feedback on our service has shown that they value the quality time spent with them, listening and discussing what matters to them and what they would like to achieve. Consideration would need to be given as to whether using additional assessments would impact on this by reducing the person centred and flexible approach that is used. Merging our assessment with others could be explored.

11.4 NHS Long Term Plan The new NHS Long Term Plan outlines plans for social prescribing to be mainstreamed in primary care. To help achieve this, NHS England will be allocating funding for a 1000 new link workers across the country with one link worker serving a patient population between 30-50,000 patients. Options could be explored with Dudley CCG for tapping into this new resource once it becomes available to enhance the capacity of the current Integrated Plus team. Additional Link Workers as part of the 10 new Primary Care Networks (PCNs) could help the service to:    

Take on more patient referrals.

Widen its referral criteria..

Help to reduce waiting times.

Increase capacity to help facilitate, support and nurture peer support social networks.

The Universal Personalised Care document sets out how the NHS Long Term Plan commitments for personalised care will be delivered. It introduces the comprehensive model for personalised care, comprising six, evidence-based standard components, intended to improve health and wellbeing outcomes and quality of care, whilst also enhancing value for money.

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The document outlines the importance of a person centred approach, focusing on the person’s strengths and increasing patient choice and control over their health care. The Integrated Plus service for the past 4 years has delivered an approach that already aligns itself to the long term plan ethos and goals. For example:       





The service discusses and explores with clients what matters to them in relation to nonclinical, social support.

Quality time is spent with clients actively listening to their story and ensuring their voices are heard.

Focus is on the whole person and their needs as well as their strengths, passions, hopes and challenges.

Focus is on making the most of a client’s potential and service support interventions and goals are discussed and agreed with the client.

The service helps connect clients to a wide range of community based services and activities, predominately delivered by the voluntary sector.

Focus is on wellbeing and building a client’s individual resilience.

Staff support people to engage in peer support groups so they can better manage long term conditions and mental health issues such as Airtime, The Monday Men’s Group and Friday Friends.

Clients are provided with a menu of support options in relation to services and activities, however, clients have choice and control over what services and activities they may wish to engage in.

Staff provide mentoring support to help build clients confidence and enable them to overcome barriers.

The comprehensive model for personalised care diagram (Appendix E) shows support intervention types for people with complex needs (5%), people with long term physical and mental health conditions (30%) and whole population (100%) as part of the Long Perm Plan.

At present, the MDTs in Dudley primarily focus on the top 2% of patients at each practice who are at high risk of hospital admission. Integrated Plus takes referrals for patients who are on top 2%, frequent visitors of GP surgeries and any vulnerable person over the age of 16 who is in need of non-clinical support.

11.5 Personalised Care Operating Model The Personalised Care Operating Model diagram (Appendix E) describes that all local agencies should be able to refer people to a ‘link worker’ to connect them into community based support. Over the past 4 years, Integrated Plus has been approached many times by various health clinicians working across the healthcare system (who are not part of the MDT teams) who would like to be able to refer to the service. However, currently the staff levels wouldn’t enable the service to cope with this demand. Current waiting times are between 6 – 12 weeks.

The negative effect of widening the referral criteria at this stage to all agencies without enhancing staff levels would be increased waiting times to approximately, 4 – 6 months.

11.6 Social Prescribing Common Outcomes Framework NHS England has developed a Common Outcomes Framework for social prescribing projects around the country. The framework outlines some key areas for social prescribing projects

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to try and monitor to evidence value and cost avoidance. Integrated Plus follows some elements of this framework relevant to our model of delivery. The service captures the following output data: 1 2 3 4 5 6

Number of clients referred into Integrated Plus, number of clients directly benefitting from social prescribing and the number of clients rejecting a referral Age range and ethnicity of clients referred Number and types of presenting issues from referral and presenting issues found by Link Officers during first visits Referrals coming into the social prescribing service by practice and by MDT team members Number of services and activities clients referred to Outward referral numbers by sector and theme eg statutory, voluntary sector, private sector, NHS

The Common Outcomes Framework has several suggested outcomes: 

Impact On People Integrated Plus uses its own bespoke non-clinical and social assessment which is very similar to the outcome star and incorporates the Short Warwick Edinburgh Mental WellBeing Scale. The assessment enables the collection and analysis of progress made in areas of: finance, isolation, learning, quality of life, wellbeing, mental health, physical health, housing, safety, drug and alcohol, criminal activity and sexual health.

In addition to the above, the service captures data on clients engaged in volunteering, clients who have secured employment and client satisfaction with the support they have received.



Impact On Health And Care System  

Number of GP consultations, home visits and telephone consultations 6 months before referral and 6 months after Number of unplanned hospital admissions and A&E attendances 6 and 12 months before referral and 6 and 12 months after support.

It should be noted that the service doesn’t currently capture information on the number of bed stays as the service does not provide support to clients as soon as they are discharged from hospital. The service also does not capture information on medication usage and social care packages as the service focuses on non-clinical support.



Impact On Community Groups Once the survey, currently being developed by NHS England has been developed, the service will circulate to local voluntary organisations and community groups in Dudley borough to assess the impact of referrals on them.

David Waterfall, www.dpwaterfall.com

Page 69 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

The summary guide also outlines some key plans and guidance for the development of social prescribing projects some of which are mentioned below. Integrated Plus will respond to some of these outlined below: 

Coding Integrated Plus currently has its own coding for referrals into our service and for those who have declined support which is built into EMIS Web. As SNOMED CT is currently being deployed across all GP IT systems and will replace Read coding, the service could potentially going forward start to use the new National codes   



871691000000100 | Social prescribing offered (finding) 871711000000103 | Social prescribing declined (situation) 871731000000106 | Referral to social prescribing service (procedure).

Workforce Development The document mentions that for social prescribing to work successfully, link workers need suitable support and training. It also states that the wider workforce have an understanding of social prescribing to enable appropriate referrals. Over the past 4 years, staff have received a wide range of training opportunities some of which have included: lone working, personal resilience, conversations with vulnerable people, motivational interviewing, mentoring, solution focused techniques, leadership and management training to name a few.

During this year, the service has also been rolling out a social prescribing peer learning programme for other social prescribing projects around the country. This has enables the service to share its successes and learning about what has worked well and challenges faced. Part of this programme is also about exploring new ideas for workforce development of link workers which may involve implementing a bespoke qualification.

The Integrated Plus team would be willing to organise training sessions for local referral agencies to better understand what social prescribing is and what makes an appropriate social prescribing referral.

The Manager of the Integrated Plus service is part of the Regional Social Prescribing Network which is also collectively exploring options for workforce development.

All the above options for the future delivery of our Integrated Plus service requires further thought and discussion with Dudley CCG and other local partners before any service changes are implemented.

David Waterfall, www.dpwaterfall.com

Page 70 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

Appendices A

Outcome and Indicator Data

B

Client Stories

C

GP Data Overall

D

Survey 2018 â&#x20AC;&#x201C; GP and Health Clinicians

E

NHS England Care Models

David Waterfall, www.dpwaterfall.com

Page 71 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

Appendix A - Outcome and Indicator Data Finance Overall Not Managing (need support) No.

Already receiving support

%

No.

%

Managing ok No.

Total

%

No.

%

Start

183

31%

129

22%

285

48%

597

100%

Latest

35

6%

139

23%

422

71%

596

100%

Indicators

Start 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

Latest 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

1 – None of 2 - Rarely 3 – Some of 4 - Often the time the time No. % No. % No. % No. %

5 – All of the time No. %

N/A No.

%

29

12%

17

7%

39

16%

28

11%

134

54%

0

0%

21

9%

11

4%

25

10%

27

11%

163

66%

0

0%

79

32%

19

8%

21

9%

12

5%

115

47%

1

0%

22 9% 8 3% 7 3% 18 7% 1 – None of 2 - Rarely 3 – Some of 4 - Often the time the time No. % No. % No. % No. %

27 11% 5 – All of the time No. %

165 67% N/A No.

%

17

7%

10

4%

39

16%

36

15%

145

59%

0

0%

8

3%

5

2%

21

9%

34

14%

179

72%

0

0%

58

23%

20

8%

29

12%

21

9%

119

48%

0

0%

8

3%

5

2%

10

4%

20

8%

45

18%

159

64%

Change Start Overall Not Managing (need support) Already receiving support Managing ok

David Waterfall, www.dpwaterfall.com

No. 183 129 285

Latest % 31% 22% 48%

No. 35 139 422

% 6% 23% 71%

Change % 81% 8% 48%

Page 72 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

Start No. 1 – None of the time and 2 Rarely 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

%

No.

Change %

%

46

19%

27

11%

41%

32

13%

13

5%

59%

98 30 Start

40% 12%

78 32% 13 5% Latest No. %

20% 57% Change %

No. 4 – Often and 5 – All of the time 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

Latest

%

162

66%

181

73%

12%

190

77%

213

86%

12%

127 45

51% 18%

140 65

57% 26%

10% 44%

Physical Health Overall Not Managing (need support) No.

Already receiving support

%

No.

%

Managing ok No.

Total

%

No.

%

Start

175

29%

203

34%

219

37%

597

100%

Latest

32

5%

284

47%

283

47%

599

100%

Indicators

Start I feel able to manage my personal care I feel able to manage my medication I am managing long term conditions well I am able to easily and independently...

1 – None of 2 - Rarely 3 – Some of 4 - Often the time the time No. % No. % No. % No. %

5 – All of the time No. %

N/A No.

%

15

6%

15

6%

41

17%

38

15%

138

56%

0

0%

19

8%

12

5%

24

10%

27

11%

160

65%

5

2%

13

5%

23

9%

84

34%

59

24%

51

21%

17

7%

74

30%

33

13%

43

17%

25

10%

72

29%

0

0%

David Waterfall, www.dpwaterfall.com

Page 73 of 105

Dudley CVS

I feel able to partake in exercise...

I feel I have a balanced diet I feel I am coping with my caring duties

Latest I feel able to manage my personal care I feel able to manage my medication I am managing long term conditions well I am able to easily and independently...

I feel able to partake in exercise...

I feel I have a balanced diet I feel I am coping with my caring duties

Integrated Plus Impact Evaluation, Final Report

114

46%

39

16%

34

14%

31

13%

29

12%

0

0%

31

13%

27

11%

58

23%

59

24%

72

29%

0

0%

1 0% 2 1% 15 6% 20 8% 1 – None of 2 - Rarely 3 – Some of 4 - Often the time the time No. % No. % No. % No. %

14 6% 5 – All of the time No. %

195 79% N/A No.

%

13

5%

16

6%

38

15%

38

15%

142

57%

0

0%

14

6%

10

4%

24

10%

27

11%

167

68%

5

2%

10

4%

15

6%

69

28%

77

31%

59

24%

17

7%

64

26%

23

9%

42

17%

37

15%

79

32%

2

1%

81

33%

46

19%

46

19%

29

12%

45

18%

0

0%

17

7%

24

10%

46

19%

72

29%

88

36%

0

0%

1

0%

2

1%

10

4%

20

8%

19

8%

195

79%

5% 47% 47%

Change % 82% 40% 29% Change %

Change Start Overall Not Managing (need support) Already receiving support Managing ok

No. 175 203 219

Latest % 29% 34% 37%

No. 32 284 283

Start No. 1 – None of the time and 2 Rarely I feel able to manage my personal care I feel able to manage my medication I am managing long term conditions well I am able to easily and independently...

I feel able to partake in exercise...

I feel I have a balanced diet I feel I am coping with my caring duties

David Waterfall, www.dpwaterfall.com

%

Latest %

No.

%

30

12%

29

12%

3%

31

13%

24

10%

23%

36

15%

25

10%

31%

107

43%

87

35%

19%

153 58

62% 23%

127 41

51% 17%

17% 29%

3

1%

3

1%

0%

Page 74 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

Start No. 4 – Often and 5 – All of the time I feel able to manage my personal care I feel able to manage my medication I am managing long term conditions well I am able to easily and independently...

I feel able to partake in exercise...

I feel I have a balanced diet I feel I am coping with my caring duties

Latest %

No.

Change %

%

176

71%

180

73%

2%

187

76%

194

79%

4%

110

45%

136

55%

24%

97

39%

116

47%

20%

60 131

24% 53%

74 160

30% 65%

23% 22%

34

14%

39

16%

15%

Mental Health Overall Not Managing (need support) No.

Already receiving support

%

No.

%

Managing ok No.

Total

%

No.

%

Start

203

34%

217

36%

177

30%

597

100%

Latest

48

8%

270

45%

280

47%

598

100%

Indicators

Start 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 I've been able to make up my own mind...

I am free from suicidal thoughts

1 – None of 2 - Rarely 3 – Some of 4 - Often the time the time No. % No. % No. % No. %

5 – All of the time No. %

N/A No.

%

40 62 68

16% 25% 28%

69 59 58

28% 24% 23%

86 52 72

35% 21% 29%

43 54 43

17% 22% 17%

9 20 6

4% 8% 2%

0 0 0

0% 0% 0%

41 28

17% 11%

37 35

15% 14%

70 65

28% 26%

74 75

30% 30%

25 44

10% 18%

0 0

0% 0%

23

9%

39

16%

67

27%

59

24%

59

24%

0

0%

10

4%

20

8%

47

19%

75

30%

95

38%

0

0%

27

4%

16

8%

36

19%

31

30%

137

38%

0

0%

David Waterfall, www.dpwaterfall.com

Page 75 of 105

Dudley CVS

I am free from selfharming thoughts...

I feel able to control my anger

Latest 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 I've been able to make up my own mind...

I am free from suicidal thoughts I am free from selfharming thoughts...

I feel able to control my anger

Integrated Plus Impact Evaluation, Final Report

21

4%

9

8%

18

19%

29

30%

4 4% 6 8% 28 19% 43 30% 1 – None of 2 - Rarely 3 – Some of 4 - Often the time the time No. % No. % No. % No. %

170

38%

0

0%

166 38% 5 – All of the time No. %

0

0% N/A

No.

%

27 37 35

11% 15% 14%

36 28 52

15% 11% 21%

93 84 79

38% 34% 32%

75 67 65

30% 27% 26%

16 31 16

6% 13% 6%

0 0 0

0% 0% 0%

19 16

8% 9%

18 15

7% 8%

72 0

29% 0%

106 97

43% 53%

32 54

13% 30%

0 0

0% 0%

13

5%

28

11%

61

25%

75

30%

70

28%

0

0%

8

3%

11

4%

38

15%

82

33%

108

44%

0

0%

15

3%

10

4%

22

15%

32

33%

168

44%

0

0%

15

3%

5

4%

14

15%

22

33%

191

44%

0

0%

3

3%

5

4%

18

15%

39

33%

182

44%

0

0%

Change Start Overall Not Managing (need support) Already receiving support Managing ok

No. 203 217 177

Latest % 34% 36% 30%

No. 48 270 280

Start No. 1 – None of the time and 2 Rarely 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 I've been able to make up my own mind...

I am free from suicidal thoughts

David Waterfall, www.dpwaterfall.com

% 8% 45% 47% Latest

%

No.

%

Change % 76% 24% 58% Change %

109 121 126

44% 49% 51%

63 65 87

26% 26% 35%

42% 46% 31%

78 63

32% 26%

37 31

15% 17%

53% 51%

62

25%

41

17%

34%

30 43

12% 12%

19 25

8% 8%

37% 42%

Page 76 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

I am free from self-harming thoughts...

I feel able to control my anger

30 10 Start No.

4 – Often and 5 – All of the time 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 I've been able to make up my own mind...

I am free from suicidal thoughts I am free from self-harming thoughts...

I feel able to control my anger

12% 12%

20 8 Latest

%

No.

8% 8%

33% 20% Change %

%

52 74 49

21% 30% 20%

91 98 81

37% 40% 33%

75% 32% 65%

99 119

40% 48%

138 151

56% 83%

39% 27%

118

48%

145

59%

23%

170 168

69% 69%

190 200

77% 77%

12% 19%

199 209

69% 69%

213 221

77% 77%

7% 6%

Social Contact Overall Not Managing (need support) No.

%

Already receiving support No.

%

Managing ok No.

Total

%

No.

%

Start

230

39%

85

14%

281

47%

596

100%

Latest

45

8%

176

29%

378

63%

599

100%

Indicators

Start I regularly have face to face social...

I have friends I can talk with...

I feel I have enough social contact...

I regularly help out in my community

1 – None of 2 - Rarely 3 – Some of 4 - Often the time the time No. % No. % No. % No. %

5 – All of the time No. %

N/A No.

%

62

25%

59

24%

43

17%

48

19%

35

14%

0

0%

58

23%

51

21%

47

19%

48

19%

43

17%

0

0%

34

14%

53

21%

63

26%

49

20%

48

19%

0

0%

201

81%

19

8%

16

6%

8

3%

3

1%

0

0%

David Waterfall, www.dpwaterfall.com

Page 77 of 105

Dudley CVS

I feel comfortable mixing with people I feel my religious/spiritual needs...

Integrated Plus Impact Evaluation, Final Report

20

8%

38

15%

59

24%

55

22%

10 4% 10 4% 18 7% 20 8% 1 – None of 2 - Rarely 3 – Some of 4 - Often the time the time No. % No. % No. % No. %

Latest I regularly have face to face social...

29 I have friends I can talk with...

42 I feel I have enough social contact...

18 I regularly help out in my community 198 I feel comfortable mixing with people 10 I feel my religious/spiritual needs... 4

75

30%

65 26% 5 – All of the time No. %

0

0%

124 50% N/A No.

%

12%

40

16%

43

17%

82

33%

53

21%

0

0%

17%

40

16%

49

20%

62

25%

54

22%

0

0%

7%

29

12%

65

26%

68

28%

67

27%

0

0%

80%

17

7%

16

6%

10

4%

6

2%

0

0%

4%

24

10%

59

24%

58

23%

96

39%

0

0%

2%

5

2%

23

9%

18

7%

76

31%

121

49%

Change Start Overall Not Managing (need support) Already receiving support Managing ok

No. 230 85 281

Latest % 39% 14% 47%

No. 45 176 378

Start No. 1 – None of the time and 2 Rarely I regularly have face to face social...

I have friends I can talk with...

I feel I have enough social contact...

I regularly help out in my community I feel comfortable mixing with people I feel my religious/spiritual needs...

David Waterfall, www.dpwaterfall.com

8% 29% 63% Latest

%

No.

%

Change % 80% 107% 35% Change %

121 109

49% 44%

69 82

28% 33%

43% 25%

87

35%

47

19%

46%

220

89%

215

87%

2%

58

23%

34

14%

41%

20 Start

8%

4%

55% Change %

No. 4 – Often and 5 – All of the time I regularly have face to face social...

I have friends I can talk with...

%

%

83 91

34% 37%

9 Latest No.

135 116

%

55% 47%

63% 27%

Page 78 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

I feel I have enough social contact...

I regularly help out in my community I feel comfortable mixing with people I feel my religious/spiritual needs...

97

39%

135

55%

39%

11

4%

16

6%

45%

130

53%

154

62%

18%

85

34%

94

38%

11%

Housing Overall Not Managing (need support) No. Start Latest

% 138

25

Already receiving support No.

%

Managing ok No.

Total

%

No.

%

23%

69

12%

390

65%

597

100%

4%

91

15%

482

81%

598

100%

Indicators 1 – None of 2 - Rarely 3 – Some of the time the time Start No. % No. % No. % I feel secure in my tenancy 7 3% 6 2% 6 2% I am sleeping in a safe place every...

6 2% 1 0% 6 2% I feel able to keep up with my rent...

5 2% 5 2% 3 1% I feel happy where I am living 19 8% 10 4% 28 11% I feel my accommodation is suitable...

17 7% 8 3% 38 15% I am able to heat my home adequately 10 4% 10 4% 13 5% I feel my home is a safe environment 7 3% 7 3% 39 16% 1 – None of 2 - Rarely 3 – Some of the time the time Latest No. % No. % No. % I feel secure in my tenancy 4 2% 1 0% 4 2% I am sleeping in a safe place every...

3 1% 0 0% 5 2% I feel able to keep up with my rent...

1 0% 2 1% 4 2%

David Waterfall, www.dpwaterfall.com

4 - Often No. 5

% 2%

5 – All of the time No. % 108 44%

10

4%

224

5

2%

29

N/A No. 115

% 47%

91%

0

0%

113

46%

116

47%

12%

161

65%

0

0%

41

17%

143

58%

0

0%

11

4%

203

82%

0

0%

0

0%

46 19% 4 - Often No. 7

% 3%

148 60% 5 – All of the time No. % 115 47%

9

4%

230

5

2%

117

N/A No. 116

% 47%

93%

0

0%

47%

118

48%

Page 79 of 105

Dudley CVS

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

Integrated Plus Impact Evaluation, Final Report

12

5%

8

3%

24

10%

29

12%

173

70%

1

0%

11

4%

11

4%

28

11%

33

13%

164

66%

0

0%

4

2%

4

2%

10

4%

13

5%

216

87%

0

0%

4

2%

6

2%

21

9%

40

16%

176

71%

0

0%

Change Start Overall Not Managing (need support) Already receiving support Managing ok

No. 138 69 390

Latest % 23% 12% 65%

No. 25 91 482

Start No. 1 – None of the time and 2 Rarely I feel secure in my tenancy I am sleeping in a safe place every...

I feel able to keep up with my rent...

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

David Waterfall, www.dpwaterfall.com

4% 15% 81% Latest

%

No.

13

5%

5

2%

62%

7

3%

3

1%

57%

10 29

4% 12%

3 20

1% 8%

70% 31%

25

10%

22

9%

12%

20

8%

8

3%

60%

14 Start

6%

4%

29% Change %

No. 4 – Often and 5 – All of the time I feel secure in my tenancy I am sleeping in a safe place every...

I feel able to keep up with my rent...

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

%

Change % 82% 32% 24% Change %

%

%

10 Latest No.

%

113

46%

122

49%

8%

234

95%

239

97%

2%

118 190

48% 77%

122 202

49% 82%

3% 6%

184

74%

197

80%

7%

214

87%

229

93%

7%

194

79%

216

87%

11%

Page 80 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

Safety Overall Not Managing (need support) No.

%

Already receiving support No.

%

Managing ok No.

Total

%

No.

%

Start

83

14%

89

15%

424

71%

596

100%

Latest

14

2%

57

10%

527

88%

598

100%

Indicators 1 – None of 2 - Rarely 3 – Some of the time the time Start No. % No. % No. % I feel safe where I live 8 3% 4 2% 12 5% I feel safe with my partner 0 0% 0 0% 2 1% I feel safe with friends 6 2% 1 0% 5 2% I feel safe with family 2 1% 2 1% 9 4% I feel safe from harm/exploitation 6 2% 6 2% 9 4% I feel I have people I can contact...

0 0% 2 1% 9 4% 1 – None of 2 - Rarely 3 – Some of the time the time Latest No. % No. % No. % I feel safe where I live 8 3% 2 1% 9 4% I feel safe with my partner 0 0% 0 0% 2 1% I feel safe with friends 3 1% 1 0% 3 1% I feel safe with family 1 0% 3 1% 9 4% I feel safe from harm/exploitation 4 2% 2 1% 12 5% I feel I have people I can contact...

0 0% 3 1% 5 2%

4 - Often No. 30 4 5 11

% 12% 2% 2% 4%

5 – All of the time No. % 193 78% 78 32% 185 75% 210 85%

12

5%

214

15 6% 4 - Often

N/A No. 0 163 45 13

% 0% 66% 18% 5%

87%

0

0%

0

0%

No. 24 2 4 7

% 10% 1% 2% 3%

221 89% 5 – All of the time No. % 204 83% 79 32% 190 77% 215 87%

11

4%

218

13

5%

226

N/A No. 0 164 46 12

% 0% 66% 19% 5%

88%

0

0%

91%

0

0%

Change Start Overall Not Managing (need support) Already receiving support Managing ok

No. 83 89 424

Latest % 14% 15% 71%

No. 14 57 527

Start No.

% 2% 10% 88% Latest

%

No.

%

Change % 83% -36% 24% Change %

1 – None of the time and 2 Rarely

David Waterfall, www.dpwaterfall.com

Page 81 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

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...

12 0 7 4

5% 0% 3% 2%

12 2 Start

4 4

4% 0% 2% 2%

17% 0 43% 0%

5%

6

2%

50%

1%

3 Latest

1%

-50% Change %

No. 4 – Often and 5 – All of the time 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...

10 0

%

No.

%

223 82 190 221

90% 33% 77% 89%

228 81 194 222

92% 33% 79% 90%

2% -1% 2% 0%

226

91%

229

93%

1%

236

96%

239

97%

1%

Learning Overall Not Managing (need support) No.

Already receiving support

%

No.

%

Managing ok No.

Total

%

No.

%

Start

116

20%

53

9%

420

71%

589

100%

Latest

32

5%

97

16%

461

78%

590

100%

Indicators

Start 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...

1 – None of 2 - Rarely 3 – Some of 4 - Often the time the time No. % No. % No. % No. %

5 – All of the time No. %

N/A No.

%

4

2%

1

0%

2

1%

5

2%

3

1%

232

94%

1

0%

5

2%

19

8%

21

9%

37

15%

164

66%

50 44

20% 18%

35 3

14% 1%

26 4

11% 2%

6 2

2% 1%

18 4

7% 2%

112 190

45% 77%

30

12%

4

2%

9

4%

2

1%

11

4%

191

77%

41

17%

6

2%

6

2%

5

2%

6

2%

183

74%

David Waterfall, www.dpwaterfall.com

Page 82 of 105

Dudley CVS

Latest 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...

Integrated Plus Impact Evaluation, Final Report

1 – None of 2 - Rarely 3 – Some of 4 - Often the time the time No. % No. % No. % No. %

5 – All of the time No. %

N/A No.

%

1

0%

2

1%

2

1%

7

3%

4

2%

231

94%

1

0%

1

0%

17

7%

27

11%

39

16%

162

66%

36 27

15% 11%

29 11

12% 4%

33 8

13% 3%

15 3

6% 1%

24 7

10% 3%

110 191

45% 77%

19

8%

9

4%

13

5%

6

2%

10

4%

190

77%

28

11%

10

4%

12

5%

5

2%

10

4%

182

74%

5% 16% 78% %

Change % 72% 83% 10% Change %

Change Start Overall Not Managing (need support) Already receiving support Managing ok

No. 116 53 420

Latest % 20% 9% 71%

No. 32 97 461

Start No. 1 – None of the time and 2 Rarely 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...

David Waterfall, www.dpwaterfall.com

Latest %

No.

5 6

2% 2%

3 2

1% 1%

40% 67%

85 47 34

34% 19% 14%

65 38 28

26% 15% 11%

24% 19% 18%

47 Start

19%

38 15% Latest No. %

19% Change %

No. 4 – Often and 5 – All of the time 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...

%

%

8 58

3% 23%

11 66

4% 27%

38% 14%

24 6 13

10% 2% 5%

39 10 16

16% 4% 6%

63% 67% 23%

11

4%

15

6%

36%

Page 83 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

Appendix B - Client Stories Bored to Tears – Airtime COPD Social Peer Network – helping to reduce isolation and enable peer support There are over 6000 people in Dudley who have been diagnosed with COPD, or Chronic Obstructive Pulmonary Disease, and most likely many more undiagnosed. Initially, Airtime received a £25,000 grant for 12 months from the Health Foundation as a result of a collaborative bid submitted by Dudley CCG, Integrated Plus and Healthwatch Dudley. Airtime now receives a grant of £5000 from Dudley CCG and Public Health. The group is facilitated by Integrated Plus and Healthwatch Dudley, and have been meeting since 2016 at DY1 Community Building on Stafford Street, where the group is held each Thursday from 1pm. The aim of the group is to provide a peer-led group supporting people with respiratory conditions, to reduce social isolation and take pressure off the NHS by reducing hospital admissions and GP surgery appointments that relate to the disease, by providing a safe, caring environment for people to learn how to control and manage their condition better, meet with others experiencing similar challenges, and to take part in enjoyable activities, with lashings of tea and cake of course.

Airtime Dudley has made a particular impact on the life of Angela, who has been attending the group since August 2016. At this time, Angela was feeling increasingly low in mood, had become very isolated, and had no peer groups – in fact she was, in her own words, “bored to tears”. Angela has made many friends through attending Airtime, and being part of the group has had a wider impact on her, and others. She now supports Airtime through identifying speakers to attend and present to the group. Through Airtime, Angela came into contact with Healthwatch Dudley and gave a talk to The Peoples Network about Airtime. She went on to become a member of The Peoples Network and now supports recruitment within the NHS, and sits on the Voluntary Sector Innovation Fund panel. She was also part of a team tasked with simplifying Dudley Safeguarding online process. Angela keeps a portfolio of all the work she does with Dudley Healthwatch and The Peoples Network, and explained that ‘I would never have been connected with the if it wasn’t for Airtime’.

Angela has also gone on to support the creation of a general social group – ‘Friday Friends’, and has supported people with other conditions, such as ME, to make friends and connect. She has even completed a sponsored walk for The Lung Foundation, raising £100. Angela also has begun to meet some new friend’s she has made at a local social club.

Along with some other members of the Airtime Group, Angela worked on simplifying information for Dudley Council employees. A large book, detailing many long term health conditions and illnesses.

These are now condensed to a simple A4 handout, giving a brief explanation of each condition or illness.

David Waterfall, www.dpwaterfall.com

Page 84 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

Through Winter Warmth attending Airtime to give a talk on their services, Angela has had a new boiler installed at home, as well as a wet room and stair lift installed into her property after Winter Warmth put her in contact with Dudley Home Improvement Service.

Angela has kept a portfolio of all the work she has been involved in with the council and Healthwatch Dudley, and is very proud of the changes she has helped to implement. Angela said that she would never have been in a position to be asked to do this work without being a member of Airtime. It was due to Airtime that those connections were made and cultivated.

The Airtime project was evaluated by Coventry University, who has produced a short video on their findings, in which Angela, and other members of the group feature. Angela feels coming to the group has transformed her life. ‘Airtime has given me quality of life, has built my confidence and I have made lots of good friends. We’re not labelled as no good, not fit for anything…I’ve had a new lease of life.

Airtime Dudley is free and runs each Thursday from 1pm – 3pm at DY1 Community Building, Stafford Street, Dudley, DY1 1RT and is open to anyone suffering with a chronic ling conditions such as COPD, pulmonary fibrosis or bronchiectasis.

Airtime members making wooden planters, and Airtime members taking part in seated Tai Chi

David Waterfall, www.dpwaterfall.com

Page 85 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

A place to connect and make lasting friendships: Lye Men’s Group (a story shared

by Gary Hastie – Link Support Worker for Stourbridge, Wollescote and Lye) The idea for The Men’s Group began in 2015 when my colleague Nick Tromans, the Integrated Plus Locality Link Officer for Stourbridge, Wollescote and Lye, had a high number of referrals for men with similar mental health needs and social isolation. This led Nick to Reverend Simon Falshaw the Vicar from Christ Church in Lye and they discussed the need to offer a place for men to come and connect with each other. The church was interested in supporting the idea and offered the church hall as a place to host the group. A successful funding bid to the Near Neighbours Fund was approved and this helped start the group and pay for room hire.

The main factor for the success of the group is the volunteers who help run the group, they set up the room, serve refreshments and ensure a warm and friendly welcome to everybody who attends. They can empathise with the group because they have had similar experiences and are well placed to offer peer to peer support. Andrew was the first volunteer and he fostered an atmosphere of calm, respect and empathy. Unfortunately, Andrew died suddenly in 2017 but his ethos remains within the group. Nick and I are involved in some aspects of the running of the group but the volunteers are the mainstay of the group and are vital and committed to its ongoing success.

The group has blossomed and three years on it is still going strong. We have men aged from 19 to 90 in the group. Over 130 men have attended the group in total and there are around 20-25 men from a pool of about 40 who attend every week. Over the past few years we have had lots of activities at the group including, Get Cooking courses, glass engraving, bread making and well-being sessions. The group also have regular cooked breakfasts, pool and darts tournaments and celebrations for Eid and Christmas. There is no pressure for anybody to be involved in the activities and they are welcome to come and have a cup of tea and do their own thing.

Peer support reduces loneliness and isolation and improves self-esteem and confidence, this is certainly evident in the group. Many positive and enduring friendships have been made by those attending. People attend together and those in the group with limited mobility and difficulty attending have lifts arranged with friends they have met in the group. If somebody has not attended

David Waterfall, www.dpwaterfall.com

Page 86 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

in a while, people rally round and see if they can help. Friends meet outside of the group and do social activities together and meet at each other’s homes independent of the group, some have even gone on holiday together. Another major reason for the success of the group is the non-judgemental attitude of all who attend and volunteer, it is inspiring and makes for a smoothly run and supportive group.

Barry began attending the group supported by his wife and Nick and he has now become a regular attendee. He has made new friends who he looks forward to spending time with in the group. His friendships have developed further and he now meets up with his new friends outside of the group at home and in social situations. Barry said he was not aware of any groups or activities like this in his local area and he said the group and the friendships he has made have ‘lifted me off the floor and given me something to look forward to.’

Those men who attend who can afford to make a donation can contribute to the running of the session. Using an asset-based approach and working in partnerships with the local council and other organisations has enabled the group to run for little cost and has further helped the success of the group.

David Waterfall, www.dpwaterfall.com

Page 87 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

Christmas meal at the Apple Tree, Coseley (a story shared by Georgia Pearsall – Link Support Worker for Sedgely, Coseley and Gornal)

East Coseley Big Local’s annual Christmas Meal took place at the Apple Tree pub in Coseley on Monday 3rd December. Jason and I were kindly invited to come along with clients that we have worked with over the past year who reside in Coseley. Ten of our Integrated Plus clients came along and joined in with the festivities. Below are photos of our clients and comments of what they thought of the meal.

This is Karen (left) and Irene (right). We met Karen recently, as a local Coseley client we invited her along to the meal.

Karen said she enjoyed the meal as this enabled her to talk to other people and it has made her feel more involved in the community.

Karen and Irene are hoping to meet up soon when shopping in Coseley!

We met Betty and her son Trevor in the summer.

We helped Betty claim attendance allowance and a blue badge, so she is able to get out and about more easily and pay for the help she needs. Trevor is a keen volunteer at a local service. “The meal has been lovely and would recommend it to anyone who is feeling lonely.

It is a break from being on your own.”

David Waterfall, www.dpwaterfall.com

Page 88 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

From left to right, this is Gordon, Gwen and her friend Dorothy. Gordon is 92 and is used to being on his own, but feels that getting out to speak to other people is nice, especially around Christmas time.

Gwen and Dorothy thought it was lovely to have a Christmas treat like this locally. Although they have been good friends for over 40 years, they now find it difficult to get out so they are really thankful that they were asked to come along to the meal.

It is clear to see that gatherings like this help combat loneliness and how speaking with other people can really make a difference to someoneâ&#x20AC;&#x2122;s happiness, especially at Christmas time. During this meal, some of our clients saw people that they hadnâ&#x20AC;&#x2122;t seen in a long time and were able to chat with them. From an Integrated Plus perspective, it was humbling to observe the sense of community in the room.

David Waterfall, www.dpwaterfall.com

Page 89 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

Joan’s experiences of Integrated Plus (a story shared by Georgia Pearsall – Link Support Worker for Sedgely, Coseley and Gornal) Joan was known to us through her late husband as he was a client of Integrated Plus. She reached out to us early on, when she was struggling to come to terms with her loss. Joan sought support with her loss, debt, lack of money and isolation. Due to prior phone calls with Joan before our visit, we were aware that she was finding it difficult to pay for daily essentials, so we took over a number of food back parcels to ease the burden.

“When my husband was ill, Jason and my family were the ones that helped the most in those dark times”.

On our initial assessment Joan explained that she had numerous long term conditions, such as diabetes, spondylitis, hypertension, depression and anxiety. She explained that she had not been managing her health conditions well and had been having seizures as a result. In terms of benefits, Joan had a claim for Universal Credit that was in progression and had been awarded Bereavement allowance following information given by us. Due to her anxiety, Joan was also struggling to get out and relied on her family for help.

We had agreed on a number of actions together with Joan from our first visit. We applied for help with funeral payments, helped Joan apply for Personal Independence Payments, contacted Walsall Citizens Advice for an appointment due to debts and we referred Joan to Creative Support – a service that supports people on a one to one basis to become more confident and active in their community.

We also contacted Access for a referral to Occupational Therapy as Joan was struggling with daily activities due to her mobility/long term conditions. We called the On-call Opticians service for Joan to have a home eye appointment as she was not able to get out to attend her diabetic eye examinations. We also gave Joan the number for Samaritans for times when she felt she needed to speak to someone urgently.

Following our claim for funeral payments, Joan received £1,675 to help towards this. Joan has since told us that this was a great help towards being able to pay her family back for the help that they provided initially for the funeral.

“Although things are still raw for me in this area, having Jason and Georgia around relieved the burden of pressure on me” After calling to claim for PIP, we helped with the PIP form when it arrived. Joan had a home appointment and we were present to support her through it. A few weeks later Joan was awarded standard rate daily living. With a back payment of £1,118 from January to June.

We also chaperoned Joan to access Walsall CAB where an advisor helped her apply for a Debt Relief Order to rid her of numerous debts that she had accrued. This was a lengthy process but once this had been sorted, Joan said she felt like a weight had been lifted and that she no longer had to worry about letters threatening court action whilst she was still grieving the loss of her husband. Joan now also has been awarded the South Staffs Assure Tariff which reduces her water bill due to lack of income and difficult life circumstances, this was due to the Citizens Advice advising Joan to apply.

Before Joan had been awarded PIP, we helped with 5 lots of foodbank parcels due to lack of income during a short term period. We also helped her get a fuel voucher as Joan’s electricity and gas had

David Waterfall, www.dpwaterfall.com

Page 90 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

turned off due to not having any money on the metre. Fortunately, a week after this date the payment of PIP had been awarded and Joan now has enough money for food, gas and electricity.

“I know Jason and Georgia are there if I need them, it’s a great comfort” We referred Joan to creative support in order for her to have a support worker and to help her get out into the community. Joan does now have a support worker, and although she doesn’t feel ready to join groups yet, she feels happy that there is a support worker on hand to offer help with issues such as form filling, paying bills and for general social support.

“I feel stronger and more articulate now.

I can now say how I feel as before I found it hard to word this”.

Due to the Occupational Therapy visit to look at help she could have around the home, Joan has been given a rail over the bath, a toilet frame and an extra rail on the stairs. Joan was scared of falling in the bath and on the stairs so these aids have made her feel more confident with getting around the home and the risk of falling has lessened.

“Jason and Georgia were never patronising and always spoke to me on a level I understood, if things weren’t clear, I felt that I was able to ask them to explain without me feeling stupid. They also gave me time out when I couldn’t get my words out due to emotional distress”.

David Waterfall, www.dpwaterfall.com

Page 91 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

Gary supported to live closer to family (a story shared by Rebecca Woodall – Link Support Worker for Halesowen & Quarry Bank) Gary has several long term health conditions including Hidradenitis Suppurativa, osteoarthritis and depression. His GP referred him as he felt that Integrated Plus could help identify support for Gary’s isolation and depression, and possible support with his health conditions. Following a home visit Sue (Link Officer) identified that Gary was struggling financially and was unable to afford to put the heating on, meaning that Gary stayed in bed a lot during the day in order to keep warm. This was negatively impacting on the state of his physical and mental health.

Sue identified that Gary claimed Employment Support Allowance (ESA) but suspected that had been incorrectly allocated by the Department of Work and Pensions (DWP) to the wrong ‘Group’ meaning he was missing out on receiving a higher rate of benefit. Sue queried this with the DWP and Gary was asked to complete a new ESA application form. Becky (Link Support Worker) helped Gary with this as he really struggled to do this on his own without support. Gary was successful with this and, as a result, he is now receiving over £20 a week extra (due to being able to claim a disability premium) and has received £530 in back payment!

We also helped Gary complete a Personal Independence Payment (PIP) application form as Sue thought this was a benefit Gary might be entitled to due to difficulties Gary was having with his mobility in and outside of the home. Whilst Becky was helping Gary to apply for PIP he disclosed that he had been feeling very low in mood (partly due to stresses with benefits issues). Becky gave him the details for the Samaritans and informed his GP of her concerns. Gary is now receiving regular counselling (via the surgery) which he is finding very helpful.

Gary told Sue that he would like to move to a different area due to his poor health and having a very problematic neighbour. Sue gave Gary details about local sheltered housing schemes which would suit his lifestyle and ongoing health conditions. Gary felt confident to visit one of the newly refurbished schemes himself and found it was located close to his elderly mum – an added bonus.

The manager there helped him complete an application form and he was advised to complete a Dudley Housing application form online. Gary asked Integrated Plus for help at this point as he is not computer literate. Becky gave him details of local Dudley Housing Support drop in locations including the Hope Centre. When he attended an appointment there, he not only had help with completing a housing application form but also with an application for a 60% reduction in his water bill!

Sue also signposted Gary to Dudley Winter Warmth, Solutions4Health and Dudley Self Management Programme. She suggested to Gary that he might like to join a local charity in a sponsor capacity supporting people with alcohol addictions – he is thinking about this and is now aware of local groups that meet nearby. Gary is now looking forward to the future as he is delighted to have moved into his new flat and is able to see more of his mum. He is eager to become ’part of a community’ as the residents in the housing scheme have regular coffee mornings, fish and chip suppers and go the local pub for lunch. Gary is also looking forward to being able to spend this winter being up and about as his new flat is much warmer. His increased income means that he will be able to put the heating on more often!

“Integrated Plus is a great service – out of the darkness cometh the light! Thank you so much to Sue Bloomer and Rebecca Woodall at Integrated Plus for getting me where I am today” – Gary Weston

David Waterfall, www.dpwaterfall.com

Page 92 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

Mr D wins pool tournament at Men’s Group! (a story shared by Rebecca Woodall – Link Support Worker for Halesowen & Quarry Bank) Mr D was referred to Integrated Plus by a Mental Health Nurse at a Multi-Disciplinary Team (MDT) meeting at his surgery. Mr D was a regular visitor to the surgery and the Mental Health Nurse felt that Integrated Plus could help identify support for Mr D’s isolation, depression and long term health conditions.

Following a home visit, the Link Officer (Sue) identified that Mr D enjoys being active and busy and was interested in joining a social group. She told him about a local Men’s Group on Mondays held at Christ Church, Lye. He was keen to attend so Sue offered to take him there the following week.

During his visit he played cards, enjoyed some refreshments and won the pool tournament! He thoroughly enjoyed it and said that he would like to attend weekly but was unsure whether he could afford the bus fare.

As Mr D has various long term health conditions, Sue identified that he might be eligible for a Disabled Person’s Bus Pass. She asked Becky, the Link Support Worker, to help him complete the relevant application form. As a result, Mr D was awarded a Disabled Person’s Bus Pass which he now uses daily. This free pass enables him to access free bus, train and Metro services during off peak hours and also take free Ring and Ride journeys.

Mr D told Becky that he thought that his health conditions had deteriorated since he first applied for Personal Independence Payment (PIP) and he was struggling more with his mobility and completing daily tasks both in and outside the home. Becky is planning to take Mr D to Citizens Advice for specialist support with completing a new PIP application form to see if he is entitled to increased payments.

Mr D was also signposted to Dudley Winter Warmth, an RSPB (Royal Society for the Protection of Birds) group in Stourbridge, and local volunteering opportunities helping to support others. Further to Sue telling Mr D about adult learning courses, he has enrolled on to an IT course starting in January 2019.

Mr D is now looking forward to the future and plans to attend the Men’s Group for many years to come! In a short period of time with Integrated Plus, very positive changes have taken place for Mr D, and he values the support we have been providing.

David Waterfall, www.dpwaterfall.com

Page 93 of 105

Dudley CVS

Integrated Plus Impact Evaluation, Final Report

Fara helped to grow in confidence (a story shared by Aiesha Parker – Link Support Worker for Dudley & Netherton) Fara was referred to Integrated Plus through the multi-disciplinary team meeting at her GP’s surgery.

Fara, who has autism spectrum disorder and mental health needs, was very isolated at the time, with low confidence and low mood. Fara’s mom wasn’t supported by other health professionals to look at how she can support her daughter to live a happy and fulfilling life, and tended to ‘hide her away’ from family, as they didn’t understand how Fara’s conditions affected her and her needs.

When Fara and her mom first met with the Link Officer, it was discovered that Fara struggled with managing money, didn’t have many social groups or activities to engage with and had been feeling anxious and unmotivated to take part in daily tasks such as washing and eating. It was also discovered that Fara’s mom was concerned about Child Benefit ending for Fara soon, as she was about to turn 19.

The Link Officer who worked with Fara and her mom introduced Fara to Lunch on the Run, a social enterprise based at DY1 community building. Lunch on the Run helps adults with learning disabilities to develop skills in food preparation, hygiene and catering, customer service and to develop their confidence and daily living skills. The Link Officer also supported Fara’s mom to access a full benefit check, and information about the Parent and Carer’s Forum and Langston Society.

Lunch on the Run were able to offer Fara a traineeship, which she thoroughly enjoyed. Fara previously struggled with eating outside of the home, but due to her confidence growing since joining Lunch on the Run, Fara now feels much more comfortable eating with others in public places. Through a referral made to Citizens Advice, Fara is now in receipt of Personal Independence Payment and is awaiting a formal diagnosis for Autism Spectrum Disorder, which will open up many doors of support and information for Fara and her mom. Fara is more confident and sociable, and Fara’s mom has said that as a result of Integrated Plus’s work, she feels ‘stronger’ and more ‘knowledgeable and understanding’ of Fara’s needs. Fara’s mom has also said that she feels Integrated Plus has made a ‘huge difference’ to their lives and that she now has a ‘whole different perspective’ of Fara and is better equipped to support her daughter.

David Waterfall, www.dpwaterfall.com

Page 94 of 105

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Integrated Plus Impact Evaluation, Final Report

Catherine helped to get alcohol detox (a story shared by Lorraine Hipkiss â&#x20AC;&#x201C; Link Support Worker for Kingswinford, Amblecote & Brierley Hill) Catherine was referred to Integrated Plus via a MDT meeting where concerns were raised by the mental health worker. Catherine desperately needed to be able to access psychological therapies due to past trauma she had experienced. As a result, Catherine was suffering with severe anxiety, depression, panic attacks and agoraphobia. Catherine was not able to access the therapeutic support she required due to being heavily dependent upon alcohol. Catherine was ready to engage and wanted support from Atlantic House to undergo a detox but due to her mental health struggled to leave her home. The Link Officer suggested that Integrated Plus may be able to work with Catherine to help her to overcome these barriers.

The Link Officer went to visit Catherine at her home and conducted a holistic assessment. Catherine was able to talk freely with the Link Officer without fear of being judged. She explained how she had been using alcohol as a crutch to give her the confidence to go out and face the world when suffering greatly with her mental health. Catherine explained that she regularly had thoughts of suicide and frequently self-harms. Catherine had a supportive family but she did not want to tell them about her dependency on alcohol or her possible future detox, as she felt that she was letting them down and did not want to look bad in their eyes.

Catherine lives in a privately rented house that she originally moved into with her ex-partner. At the time Catherine was only having to pay half towards the bills but since they have split up she has been finding it difficult to pay her bills and find additional money to top up her housing benefit. Catherine has had to borrow a lot of money from her family which is causing her a lot of addition stress and worry.

As a result of drinking large amounts of alcohol on a daily basis for a long period of time, Catherine is now suffering with nerve damage in both her feet and hands and this has often caused her to fall down the stairs as she cannot feel any sensation in her feet.

The Link Officer and Catherine agreed that the two main areas that needed to be addressed first were the alcohol dependency and her housing situation. This would mean that Catherine could access the mental health support that she required and find a property that was more suitable for her needs, both financially and physically. Catherine decided that she felt it would be a good idea to tackle her housing situation once she had completed her detox.

Initially, the Link Support Worker chaperoned Catherine to CGL Atlantic House drop in to be triaged and assessed for an alcohol detox. The Link Support Worker was able to build up a good rapport with Catherine, she had worked in drug and alcohol services previously so was able to offer lots of support.

The Link Support Worker continued to chaperone Catherine on several occasions to appointments until she received her date for an inpatient detox at Bushey Fields Hospital. It was important that Catherine had an inpatient detox due to alcohol related seizures she was experiencing.

Catherine underwent her detox as arranged and she has now successfully completed it. She has since been able to start attending a relapse prevention course at Atlantic House which she went to independently. Catherine said that she coped really well, much better that she thought she would and she is fully intending on completing the course. Catherine said she realises how important it is to maintain her sobriety and build on her confidence. She is even considering going to the womens

David Waterfall, www.dpwaterfall.com

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Integrated Plus Impact Evaluation, Final Report

group that is also held at Atlantic House. Catherine would not have been able to access this support initially if it wasn’t for the help she received from Integrated Plus.

Now that she is alcohol free, Catherine is waiting to see the mental health nurse at her GP surgery where she will begin to access the therapy that she requires to work through her numerous issues.

Catherine’s family became aware of her detox a few days before she was due to be admitted to Bushey Fields. They have been extremely supportive, visiting Catherine in Bushey Fields and they visit regularly now that Catherine is back at home. Catherine has also been to the council’s housing support service where she received assistance to apply to go on the housing register. It was not be too long now before Catherine will be able to start searching for a home that is right for her, a fresh start.

“Since working with Integrated Plus I feel can be open and honest with my family. I did not think they would be as supportive as they have been.

Attending Atlantic House is helping me cope with my anxieties and panic attacks. The groups are helping me as I am able to discuss issues with people who are in the same situation as me.

I cannot thank Integrated Plus enough. Without their help and support I would not have accessed Atlantic House’s services and would not have been able to get to this point in my life.”

David Waterfall, www.dpwaterfall.com

Page 96 of 105

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Appendix C - GP Data Overall GP Telephone Consultations Feldon Lane Surgery/Hawne Lane St Margaretâ&#x20AC;&#x2122;s Well Surgery/Halesowen Medical Practice Pedmore Road Surgery Keelinge House Surgery Steppingstones Medical Practice Links medical Practice Coseley Medical Centre High Oak Surgery Woodsetton Medical Centre Eve Hill Medical Practice Three Villages medical Practice Summerhill Surgery/Summerfield group Moss Grove Surgery St James Medical Practice (Dr Jalota) Dudley Partnership for Health Stourside Medical Practice/Abbey Medical Practice Wordsley Green Health Centre Meadowbrook Road Surgery Lapal medical Practice Cross Street Health centre Waterfront Surgery Northway Medical Centre Thorns Road Surgery St James Medical Practice (Dr Porter) Ridgeway Surgery Netherton Health centre Clement Road Medical centre Central Clinic Bath Street Medical Centre Rangeways Road Surgery Bean Road Medical Practice Alexandra Medical Centre The Limes Medical Centre Castle Meadows Surgery Lion Health/Norton Kingswinford medical Practice Chapel Street Surgery Quincy Rise Surgery Quarry bank medical centre AW. Surgeries (Albion House/Withymoor)) The Greens Health Centre Lower Gornal Medical Practice Wychbury Medical Centre/Cradley Road Medical Practice -70

-60

-50

-40

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-20

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GP Home Visits

Three Villages medical Practice Feldon Lane Surgery/Hawne Lane Keelinge House Surgery Dudley Partnership for Health Wordsley Green Health Centre St James Medical Practice (Dr Porter) Pedmore Road Surgery High Oak Surgery Alexandra Medical Centre Links medical Practice Castle Meadows Surgery St James Medical Practice (Dr Jalota) Quarry bank medical centre Northway Medical Centre Meadowbrook Road Surgery Summerhill Surgery/Summerfield group Coseley Medical Centre Thorns Road Surgery Stourside Medical Practice/Abbey Medical Practice Chapel Street Surgery Quincy Rise Surgery Clement Road Medical centre Netherton Health centre Cross Street Health centre Central Clinic Waterfront Surgery Ridgeway Surgery Woodsetton Medical Centre The Greens Health Centre Eve Hill Medical Practice Moss Grove Surgery Bath Street Medical Centre The Limes Medical Centre Rangeways Road Surgery Bean Road Medical Practice St Margaretâ&#x20AC;&#x2122;s Well Surgery/Halesowen Medical Practice Lapal medical Practice Steppingstones Medical Practice Kingswinford medical Practice Wychbury Medical Centre/Cradley Road Medical Practice AW. Surgeries (Albion House/Withymoor)) Lower Gornal Medical Practice Lion Health/Norton -50

-40

-30

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GP Consultations St James Medical Practice (Dr Porter) Feldon Lane Surgery/Hawne Lane Cross Street Health centre Meadowbrook Road Surgery Moss Grove Surgery Alexandra Medical Centre Steppingstones Medical Practice Wordsley Green Health Centre Bath Street Medical Centre Quarry bank medical centre Clement Road Medical centre Castle Meadows Surgery St James Medical Practice (Dr Jalota) High Oak Surgery The Greens Health Centre Quincy Rise Surgery Ridgeway Surgery Thorns Road Surgery Summerhill Surgery/Summerfield group Central Clinic Stourside Medical Practice/Abbey Medical Practice Three Villages medical Practice Chapel Street Surgery Netherton Health centre Kingswinford medical Practice Bean Road Medical Practice Dudley Partnership for Health Keelinge House Surgery The Limes Medical Centre Lapal medical Practice St Margaretâ&#x20AC;&#x2122;s Well Surgery/Halesowen Medical Practice Northway Medical Centre Pedmore Road Surgery Woodsetton Medical Centre Coseley Medical Centre Waterfront Surgery Lion Health/Norton Lower Gornal Medical Practice AW. Surgeries (Albion House/Withymoor)) Links medical Practice Eve Hill Medical Practice Rangeways Road Surgery Wychbury Medical Centre/Cradley Road Medical Practice -200

-150

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Overall Change for All Three Types Wychbury Medical Centre/Cradley Road Medical Practice # Consultations Change

Woodsetton Medical Centre

# Home Visits Change

Three Villages medical Practice The Limes Medical Centre

# Telephone Consultation Change

Summerhill Surgery/Summerfield group Steppingstones Medical Practice St James Medical Practice (Dr Jalota) Ridgeway Surgery Quincy Rise Surgery Pedmore Road Surgery Netherton Health centre Meadowbrook Road Surgery Lion Health/Norton Lapal medical Practice Keelinge House Surgery Feldon Lane Surgery/Hawne Lane Dudley Partnership for Health Coseley Medical Centre Chapel Street Surgery Castle Meadows Surgery Bath Street Medical Centre Alexandra Medical Centre

-150

-130

-110

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-70

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Appendix D - Survey 2018, GP and Health Clinicians

Integrated Plus Survey 2018 (for GPs and health clinicians) Integrated Plus has been in operation since September 2014 and is funded by Dudley CCG as part of Dudley’s new care model. Link Officers attend the Multi-Disciplinary Team meetings (MDTs) and the whole Integrated Plus team support patients to become more active, connected and involved in their communities.

Integrated Plus also helps patients to access non-means tested benefits (such as PIP/AA and Carers Allowance etc), access poverty grants through charitable trusts, chaperone patients to services and activities up to 3 times if their confidence is low and supports new networks such as the Monday Men’s Group and Airtime (COPD social network).

We are really keen to find out, from GPs (and other health clinicians) your views about Integrated Plus and its future delivery.

We would be grateful if you could take a few minutes to complete this short survey.

From 1 to 5 (5 being excellent, 1 being poor) how would you rate the Integrated Plus service?

5 – Excellent 4 – Good 3 – Average 2 – Poor 1 – Very poor

To what extent, do you feel the Link Officers add value to the current MDT meetings?

A great deal A lot A little Very little None

In what ways do you feel the Link Officers add value to the MDT meetings?

Increases the productivity of my work by reducing patient demand on primary care services such as community nursing, mental health services etc More diverse patient intervention options discussed at MDTs Better supports my work Increases my knowledge and understanding of support services available in the community Don’t know

David Waterfall, www.dpwaterfall.com

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Other comments:

To what extent, do you feel Link Officers are pivotal to MDTs going forward (ie the 10 new Integrated Community Teams)?

A great deal A lot A little Very little None

What benefits do you feel the Integrated Plus service brings to your PATIENTS specifically (you can tick more than one box)?

Reduces isolation/loneliness Improves health and wellbeing Improves quality of life Increases patients involvement in voluntary and community led activities Encourages and supports patients to take greater responsibility over their own health and wellbeing Enables patients to have increased ability to better self-manage their health issues Strengthens individual resilience Increases social networks Increases a personâ&#x20AC;&#x2122;s independence Enables patients to have greater control over their own life Resolves/reduces financial issues

Other (please state)

David Waterfall, www.dpwaterfall.com

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Overall, what is it about the Integrated Plus service that you (as a GP or other MDT member) are finding most beneficial (you can tick more than one box)?

Takes into account the social inclusion/non-clinical needs of patients Takes into account the whole needs of the person and their family Helps to resolve problems and issues faced by patients Connects patients into voluntary and community led activities Quality time is spent with patients in their home, actively listening to their needs and aspirations Reduces demand and pressure on GP time (eg in dealing with frequent presenters/visitors) Enables and supports patients to become less reliant on medical services Helps to avoid primary care costs by reducing GP consultations Improves GP (and health clinicians) knowledge of voluntary and community sector services available Increases the active involvement of the voluntary and community sector in the new care model Helps tackle inequalities and poverty Helps support peer to peer support of patients

Other (please state)

To what extent, do you feel Integrated Plus has helped to reduce inappropriate GP consultations at your practice?

A great deal A lot A little Very little None N/A

Do you feel the Integrated Plus service could be improved or changed in some way?

Yes No

If yes, please state what ways it could be improved or changed

Please provide any other comments or feedback here if you wish.

Thank you for your time in completing this survey.

David Waterfall, www.dpwaterfall.com

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Appendix E â&#x20AC;&#x201C; NHS England Care Models