The social and economic impact of integrated plus service copy 2 by DudleyCVS

The Social and Economic Impact of the Integrated Plus Service Main Evaluation Report 1st September 2014 â&#x20AC;&#x201C; 18th July 2017

Supporting people to become more involved, connected and active in their communities

Contents Executive Summary………………………………………………………………………………..……………...…3 - 5 Chapter One……………………………………………………………………………………………………………6 1

Introduction

Chapter Two: Policy Context………………………………………………………………………………………7 - 10 2 2.1 2.3 2.4 2.5

What is social prescribing? Levels of social prescribing Does social prescribing work? How does social prescribing fit in with the wider health and social care economy? National evidence in support of social prescribing – review by Westminster University

Chapter Three: About Integrated Plus………...………………………………………………………………11 - 14 3 3.1 3.2 3.3 3.4 3.5 3.6

Rationale for Integrated Plus Negative impact of not putting the service in place Aims and design of Integrated Plus Desired outcomes of Integrated Plus Integrated Plus approach Integrated Plus intervention types Integrated Plus model and support pathway

Chapter Four: Learning from Integrated Plus……………………………………………………………….15 - 17 4 4.1 4.2

Implementation: what went well and why? What went less well and why? Key lessons learnt

Chapter Five: Integrated Plus activities, outputs and outcomes……………………………………..18 - 39 5 5.1 5.2 5.3 5.4

Capacity modelling Referrals-in and out of Integrated Plus Patient demographic data Social impact data Stimulating Peer support and social relationships

Chapter Six: Economic Impact………………………………………………………………………………….40 - 42 6

Impact on the demand for primary and secondary care

Chapter Seven: People’s stories………………………………………………………………………………..43 - 52 7 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8

Pat who lives alone Andrew in his mid-fifties Client X with complex needs Mary’s journey with finding accommodation Mr X helped to resolve debt issues Barry feeling isolated and lonely Mr P helped to build his confidence Jean feeling isolated and depressed Mr C helped to increase his income

Appendix………………………………………………………………………………………………………………53 - 62 Names of organisations, services and activities where outward referrals have been made

Author (s) Kate Green – (Integrated Plus Manager) Mark Ellerby - Cloudberry Innovation and Development (www.psiams.com)

Executive Summary This report provides information about progress, learning and the social and economic impact of the Integrated Plus service from 1st September 2014 – 18th July 2017. As part of the new care model implemented in Dudley borough, Dudley CCG/Dudley CVS identified an opportunity to support the development and delivery of an innovative, flexible and complementary service called ‘Integrated Plus’. The service was set up to offer a level 4 social prescribing (description of level 4 social prescribing is provided on page 7) support to patients on the top 2% at high risk of hospital admission and frequent visitors of GP surgeries. This would enable the New Care Model provision to be more than just a medical approach thus supporting the transformation of healthcare by focusing on the social and economic needs of patients and prevention. The service aimed to:     

Enable patients to access support from local voluntary and community organisations, with a view to improving health and wellbeing, and their ability to self-manage. Enable voluntary sector representation at multi-disciplinary team meetings via the Link Officers to ensure non-clinical needs of patients was considered. Support patients to become more active and involved in their communities. Support patients to access services appropriate to their needs and which they are entitled to. Reduce pressure on medical services.

Main findings This report draws on a variety of data sources which are detailed in the introduction to this report. Referrals in and out of the Integrated Plus service During 1st September 2014 – 18th July 2017, a total of 2,619 referrals were made to the Integrated Plus service.    

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2,021 out of 2,619 accepted support from the Integrated Plus service (77% of referrals). Over 35 months, 5,766 onward referrals were made to 363 organisations (patients being referred to more than one organisation). 2,508 referrals were made to 84 specific services and activities delivered by organisations (patients being referred to more than one service/activity). 74% of referrals were to voluntary sector organisations. Some service types received particularly high numbers of referrals. These were services tackling isolation such as befriending (AgeUK Dudley, Royal Voluntary Service, Age Concern), mental health services (Creative Support, Dudley Mind, Rethink), bereavement counselling (Cruse), dementia services (Alzheimer’s Society) and welfare benefit support services (Citizens Advice). Although 74% of onward referral destinations were to voluntary sector organisations, when looking at referrals to specific services provided by organisations, a high proportion were also to local authority services (71%), in particular Adult Social Care and Public Health. These services included: telecare, adult community learning, carers network, Dudley Home Improvement Service, Libraries, Winter Warmth and self-management programmes. A high percentage of referrals were also to transport services such as Ring and Ride and Driving Miss Daisy. A high percentage of referrals were also to the Department of Work and Pensions to help resolve welfare benefit issues through support from Integrated Plus staff. The high demand for services such as befriending, community transport, Adult Social Care services highlights the importance of services that aim to reduce dependence and social isolation. The high demand for mental health services shows that mental health issues have been a high presenting issue for patients referred to Integrated Plus. 3

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When looking at referrals to organisations by theme 43% were to health and wellbeing type provision such as befriending, social activities, learning activities, leisure. When looking at referrals to services by theme 47% were to care and support type services such as aids and adaptions, telecare, carers network, winter warmth and support the home.

The percentages above indicate that Integrated Plus has enabled patients to become more active and involved in their communities through 71% of referrals going to voluntary sector organisations and 43% of referrals being to health and wellbeing type services and activities. Data does demonstrate a need for Adult Social Care and Public Health services through 47% of referrals being to social care services eg telecare, carer’s network, home improvements, winter warmth, selfmanagement programmes. These service referrals highlight the importance of support in helping people to remain independent in their own homes, peer support and enabling patients to better self-manage long term conditions. Feedback from patients supported on the quality of the Integrated Plus service    

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64% of patients rated the Integrated Plus service as a 5 star excellent service. 30% of patients rated the Integrated Plus service as a 4 star good service. 43% of patients supported stated that they feel they have benefited from the service a great deal. 40% of patients supported stated that they feel they have benefited a lot from the service. 27% of patients supported feel extremely well aware of services and activities in their community. 51% feel very aware of services and activities in their community. 45% of patients feel that the service has helped them a great deal to access services and activities in the community. 34% of patients feel that the service has helped them a lot to access services and activities in the community. The areas where patients feel they have benefited the most from the Integrated Plus approach has been in the following areas: being listened to, having staff spend quality time with them, independent and flexible approach, feeling that there are no hidden agendas (eg staff aren’t assessing them to allocate a financial budget) and helping patients to find solutions to problems faced.

Reducing demand on primary and secondary care Data extracted from EMIS in 39 surgeries and data extracted from DSCRO on secondary care data shows a reduction in GP consultations, GP home visits, A&E attendance and emergency admissions for patients supported through Integrated Plus. However, there has been a 15% increase in demand for GP telephone consultations. Primary care data Data on 438 (22%) patients referred to Integrated Plus was extracted from EMIS in 39 GP surgeries (surgeries that had used the EMIS Integrated Plus code). From this data:   

GP visits reduced by 24% GP home visits reduced by 15% GP telephone consultations has increased by 15%

Overall, cost avoidance of £17,965 *The service has faced challenges in getting access to data from EMIS for every patient referred due to data protection/sharing. Going forward Integrated Plus is aiming to secure data sharing agreements with each practice so that data on every patient referred can be accessed and analysed.

Secondary care data    

A&E attendances over a 6 month period reduced by 13%, cost -£9,568.80 Emergency admissions over a 6 month period reduced by 13%, cost -£91,772.24 A&E attendances over a 12 month period reduced by 4%, cost -£5,023.62 Emergency admissions over a 12 month period reduced by 7%, cost -£82,278.56

Outcomes The areas where patients reported the most beneficial outcomes from Integrated Plus support have been in feeling less isolated and happier, improved quality of life, reduced stress and anxiety, improved wellbeing, increased social relationships, feeling better able to cope with day to day life, being able to get and about more, increased confidence and self-esteem and improved healthy life styles. (Full breakdown on outcome data is provided in chapter five of this report). Most support from Integrated Plus has been in helping patients to navigate the health and social care system, resolving welfare issues, helping to draw in additional income through Personal Independent Payments and Attendance Allowance, helping people to engage in more community based social and leisure type activities. Support has also been in helping with transport eg accompanying patients to social activities for the first few times when their confidence is low. PSIAMS cost saving methodology to the wider state through Integrated Plus PSIAMS has a cost avoidance methodology based on social triage assessments (STAs) carried out with patients. Calculations are based on a scenario of the estimated costs to the state if no interventions are provided and 12 month projected estimated costs to the state after interventions/support from Integrated Plus. For example, likelihood/higher probability that support from Integrated Plus would reduce dependency or usage of mainstream services. Costs are calculated on the following:         

Finance – debt advice, accessing foodbanks, financial support/advice Employment – cost of claiming Employment Support Allowance, Job Seekers Allowance for a 12 month period 12 months before and after support Alcohol/drug use – cost of drug/alcohol services Safety – costs to state from being a victim of crime Sexual health – costs of accessing sexual health services Criminal activity – costs to state from criminal activity Mental health – costs of primary and secondary mental health services Physical health – costs to adult social care Housing status – costs to state from homelessness, rent arrears

Costs to the wider state are taken from information and statistics provided by the following: Department for Work and Pensions, Tax Payers Alliance, BRE Trust, Health and Safety Executive, Kings Fund, Family Planning Association, Brook, Terrance Higgins Trust, Public Health England, Citizen Advice Bureaux, Money Advice Service, Office of National Statistics, NHS. The new STA was developed and licensed by Cloudberry Innovation and Development in August 2016 and was used by Integrated Plus staff from 1st September 2016. STAs that have been carried out between 1st September 2016 – 18th July 2017 for 156 patients (7% of referrals to Integrated Plus) shows an estimated £781,822.08 cost avoidance to wider the state as a result of Integrated Plus interventions.

Chapter One: Introduction Aims of this report This report has been developed to achieve the following aims:    

Assess the impact of Integrated Plus for its key stakeholders Assess whether the aims and outcomes have been achieved Provide analysis of cost savings and efficiencies to the NHS and the wider state Establish a business case for future funding

About this report This evaluation report provides assessment of the social and economic impact of the service between 1st September 2014 – 18th July 2017. Further evaluation reports will be produced as currently the service is funded until August 2018. This report draws on a variety of data sources:       

Analysis of patient case management data collected by Integrated Plus staff. Analysis of evaluation data captured through 1-2-1 patient reviews. Analysis of evaluation data captured through 1-2-1 patient interviews. Case studies developed with patients supported. An online survey aimed at GPs and health clinicians referring to the Integrated Plus service. Analysis of social and economic data collected through PSIAMS CRM system used by the Integrated Plus service, data from EMIS in 39 practices and secondary data from DSCRO. Discussions with Integrated Plus staff about their learning from delivering the service.

Chapter Two: Policy Context What is social prescribing? 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 peopleâ&#x20AC;&#x2122;s health is determined primarily by a range of social, economic and environmental factors, social prescribing seeks to address peopleâ&#x20AC;&#x2122;s needs in a holistic way. It also aims to support individuals to take greater control of their own health and wellbeing. Social prescribing 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 works with people to access local sources of support. The Bromley by Bow Centre in London is one of the oldest and best-known social prescribing projects. Staff at the Centre work with patients, often over several sessions, to help them get involved in more than 30 local services ranging from swimming lessons to legal advice. 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. Levels of social prescribing Level 1 Level 2 Level 3 Level 4

Online directory of community services which people can access themselves No face to face or telephone support provided GPs and other health clinicians refer patients to a range of community services themselves during clinical appointments Staff or volunteers signpost people to services using online directories Face to face support in community venues Paid link officers/navigators visit patients in their own homes Support offers signposting, help with form filling, taking to services if confidence is low, helping people engage in peer support or volunteering Holistic assessments carried out to look at whole needs of a person Stimulating/supporting new activities based on needs eg new social meet ups, peer support

Does social prescribing work? There is emerging evidence that social prescribing can lead to a range of positive health and well-being outcomes. Studies have pointed to improvements in areas such as quality of life and emotional wellbeing, mental and general wellbeing, and levels of depression and anxiety. For example, a study into a social prescribing project in Bristol found improvements in anxiety levels and in feelings about general health and quality of life. In general, social prescribing schemes appear to result in high levels of satisfaction from participants, primary care professionals and commissioners. Social prescribing schemes may also lead to a reduction in the use of NHS services. A study of a scheme in Rotherham (a liaison service helping patients access support from more than 20 voluntary and community sector organisations), showed that for more than 8 in 10 patients referred to the scheme who were followed up three to four months later, there were reductions in NHS use in terms of accident and 7

emergency (A&E) attendance, outpatient appointments and inpatient admissions. The Bristol study also showed reductions in general practice attendance rates for most people who had received the social prescription. However, robust and systematic evidence on the effectiveness of social prescribing is very limited. Many studies are small scale, do not have a control group, focus on progress rather than outcomes, or relate to individual interventions rather than the social prescribing model. Much of the evidence available is qualitative, and relies on self-reported outcomes. Researchers have also highlighted the challenges of measuring the outcomes of complex interventions, or making meaningful comparisons between very different schemes. Determining the cost, resource implications and cost effectiveness of social prescribing is particularly difficult. The Bristol study found that positive health and wellbeing outcomes came at a higher cost than routine GP care over the period of a year, but other research has highlighted the importance of looking at cost effectiveness over a longer period of time. Exploratory economic analysis of the Rotherham scheme, for example, suggested that the scheme could pay for itself over 18–24 months in terms of reduced NHS use. Several studies highlight the importance of measuring the wider social value generated through social prescribing, for example through reducing welfare benefit claims. Again, this can be difficult to measure, and may require a longer- term approach. How does social prescribing fit in with the wider health and social care economy? Social prescribing and similar approaches have been used in the NHS for many years, with several schemes dating back to the 1990s, and some even earlier (the Bromley by Bow Centre was established in 1984). However, interest in the model has expanded in the past decade or so. More than 100 schemes are currently running in the UK, more than 25 of which are in London. Social prescribing was highlighted in 2006 in the 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. In addition, social prescribing contributes to a range of broader government objectives, for example in relation to employment, volunteering and learning. Although the National Institute for Health and Care Excellence does not provide guidance on social prescribing specifically, some of its guidelines relating to mental health include initiatives that could be described as social prescribing activities. There is also an increasing amount of guidance on social prescribing available for commissioners and others in the NHS and local government, as well a new Social Prescribing Network set up to provide support and share practice on social prescribing at a local and national level. In June 2016, NHS England appointed a national clinical champion for social prescribing to advocate for schemes and share lessons from successful social prescribing projects. National evidence in support of social prescribing A review of the evidence assessing impact of social prescribing on healthcare demand and cost implications – University of Westminster (June 2017) The National Social Prescribing Team with the University of Westminster gathered evidence from 94 social prescribing projects from around the country. The aim was to review evidence assessing the impact of social prescribing on healthcare demand. Seven of these studies looked at the effect on demand for GP practices, reporting an average 28% reduction in demand for GP services following referral. Results of the 7 studies ranged from 2% to 70% reduction in demand for GP practices. 8

Five studies looked at the effect on Accident and Emergency attendances reporting an average fall in attendance following referral. Results ranged from 8% to 26.8% fall in attendance. Five studies looked at the effect on demand for other secondary care services. Three reported a fall in emergency hospital admissions in the months following referral ranging from 6%, 7% and 33.6%. One reported statistically significant drops in secondary care referrals at 12 months (55%) and 18 months (64%) and the other projected reductions in demand of consultant psychiatrists per annum per patient and community mental health team nurse consultations per annum per patient. However, in contrast, one study showed that the likelihood of referral to secondary mental health care more than doubled after referral. Eight studies calculated value for money assessments such as cost benefit analysis. None of the studies used the traditional cost-effectiveness or full cost-utility analysis. Estimates varied widely from an annual Return on Investment of 0.11p (in the first year of operations) to 0.43p. Four studies carried out broader Social Return on Investment (SROI) calculations. Studies varied in the combination of stakeholders and benefits selected for inclusion in SROI calculations. Patients, Local Authorities and The Department for Work and Pensions were commonly cited stakeholders. Improved mental wellbeing outcomes and higher rates of employment were examples of positive externalities considered in SROI but excluded from ROI analysis. The mean SROI was ÂŁ2.3 per ÂŁ1 invested in the first year. Conclusion Demand data presents a mixed picture. In the case of GP attendance and secondary care referrals, findings were contradictory. In the case of A&E attendance, findings were spread over a wide range. Both points raise issues about consistency of findings. Despite this, for the most part, social prescribing was reported to have a protective effect on service demand, though the extent of this impact needs to be contextualised. Any reported reduction in demand for health services applies only to the cohort of patients referred to social prescribing, and in one study, only for subgroups who completed the interventions. In some cases, patients who failed to engage fully with social prescribing had much higher rates of health service use both before and after referral (Dayson and Bashir, 2014). This point is pertinent to value assessments. Firstly, it implies that the service could achieve greater value for money if it were better targeted on the population that completes and responds to it. Secondly, it raises questions about the marginal utility that social prescribing provides in relation to other services designed to reduce demand on services. Given a finite budget, a more effective use of resources might be to commission more targeted interventions designed for the population of patients placing the greatest burden on services (Bertotti et al, 2015). The quality of the data also means that results need to be interpreted with caution. The number of evaluations meeting the inclusion criteria was small. Only one of the studies was a randomised controlled trial (Grant et al, 2000) and few were published in peer-reviewed journals. Evaluations were often subject to high drop-off rates at follow-up meaning these studies had reduced power to show a statistically significant outcome. In some cases, statistical significance was not discussed at all. Where a high number of patients were lost to follow up, studies were at risk of bias as predominantly patients who had completed the intervention gave feedback. Most studies sought to determine the effect of social prescribing on demand by comparing rates of use before and after referral, rather than between a control and an intervention group. This does not truly isolate the effect of the intervention as it fails to eliminate the impact of what would have occurred anyway over time. It is also important to note that no conclusions can be made about the long-term impact of social prescribing, as the time to follow up was often short.

The quality of ROI estimates suffered from a lack of accurate data to inform the calculations. Some studies used only patient reported use of services or GP reports of perceived drops in demand, both of which are subject to recall bias in these non-blinded trials leading to potentially inaccurate estimates. One paper had extrapolated their demand figures from the results of similar studies in other parts of the UK, which is at risk of inaccuracy (Farenden et al, 2015). SROI calculations used inconsistent combinations of potential benefits making it difficult to compare studies based on SROI as they did not always compare like with like. In conclusion, the evidence for social prescribing is broadly supportive of its potential to reduce demand on primary and secondary care. The quality of that evidence is weak, however, and without further evaluation, it would be premature to conclude that a proof of concept for demand reduction had been established. Similarly, the evidence that social prescribing delivers cost savings to the health service over and above operating costs is encouraging but by no means proven or fully quantified. Despite these findings, social prescribing continues to grow in scope and scale across the UK. There are a number of possible reasons for this. Link worker social prescribing schemes often include a number of interventions, some of which are evidence-based and some of which are not. The success or otherwise of a link worker model will depend on the combined success of each intervention. It may be disingenuous therefore, to conclude that paucity of evidence to support the effectiveness of a link worker model implies paucity of evidence for individual interventions. These interventions may still be worthwhile uses of healthcare resources and this could explain their persistence and growth in the UK. Equally, paucity of evidence to support the link worker model should not preclude further evaluation of it. It is more challenging to gain the standard of evidence for complex interventions that is routinely expected of simpler ones. In fact, the standard of evidence to date on the link worker social prescribing model is approximately the standard expected for a complex intervention at this stage in its development (Craig et al, 2006). Another reason why social prescribing continues to grow, despite shortcomings in the quality of evidence to support demand reduction, may be the effect that social prescribing reportedly has on the health and wellbeing of patients. The social prescribing narrative is compelling and much of the qualitative evidence shows that these services are very well liked by patients and GPs alike (Smith and Skivington, 2016). Furthermore, in an increasing proportion of projects, the cost of funding is shared with external stakeholders to the NHS (Kimberlee, 2016). Sharing the cost of social prescribing improves ROI and makes it a more affordable and worthwhile intervention for the health service to consider. It also makes sense to the non NHS stakeholder, if sufficient benefits of social prescribing accrue to them too. Joint funding may thus make social prescribing link worker projects such as these more likely to proceed and become more embedded in local communities. The sum of all benefits accruing to all stakeholders is presented in the Social Return on Investment (SROI) figures and makes the case for either joint funding or subsidy of the projects to realise maximum positive externalities. For this reason, a growing proportion of social prescribing projects are now jointly developed and funded between Clinical Commissioning Groups and local government. This arrangement recognises the unique place that social prescribing has, sitting at the true interface of health and social care.

Chapter Three: About Integrated Plus What is Integrated Plus (social prescribing) – the rationale? As part of the new care model implemented in Dudley borough, Dudley CCG/Dudley CVS identified an opportunity to support the development and delivery of an innovative, flexible and complementary service called ‘Integrated Plus’. The service was set up to offer a level 4 social prescribing support to patients on the top 2% at high risk of hospital admission and frequent visitors of GP surgeries. This would enable service provision to be more than just a medical approach thus supporting the transformation of healthcare by focusing on the social and economic needs of patients and prevention. The service involves:    

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5 Locality Link Officers attending all 46 MDT meetings so that the social inclusion needs of vulnerable people could be taken into consideration as well as clinical support needs. Locality Link Officers conducting patient home visits to ascertain their non-clinical support needs and then to connect vulnerable people to non-medical sources of social and emotional support. Mapping what services and community led activities are on offer in localities and identifying gaps in current service provision. Raising the profile and value of the diverse services and activities on offer from the voluntary and community sector to individuals and health professionals (physical/mental health, primary/secondary care, and health and social care) in each of the five localities. 5 Link Support Workers were an addition to the team commencing in 2016/17 who provide 1-2-1 patient support with and on behalf of the Locality Link Officers. They also gather follow up STA data and collect feedback on the service.

Negative impact of not putting the service in place   

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MDTs would only focus on the clinical needs of vulnerable people and not address the social and economic needs such as debt, housing, isolation, family relationship breakdowns etc. No engagement of the voluntary and community sector in the new care model. Missed opportunities to engage and connect patients to a wide range of voluntary and community sector services which can help to reduce isolation, resolve debt issues, ensure people are accessing all the benefits they are entitled to etc. Services as part of the new care model would lack focus on enabling people to contribute to their communities and use their assets and skills eg volunteering, peer support etc. Some referrals via GPs to voluntary sector services were taking place but this was ad-hoc and were not focusing specifically on frequent visitors of GP surgeries and the top 2% of people at high risk of hospital admission. It would be difficult for GPs to keep abreast of the number of diverse services and activities on offer from the voluntary and community sector.

The above highlighted a clear need for Integrated Plus as part of the new care model. Aims and design of the service Aims -

Ensure non-clinical needs of patients are discussed/considered at MDTs. Ensure patients are supported with non-clinical needs/issues. Ensure representation of the voluntary and community sector in the new care model. Support patients to contribute to their community eg through volunteering, peer support etc.

Desired outcomes -

Increase patient awareness of community activities and support available. Ensure people are accessing services appropriate to their needs and that they are entitled to. 11

Improve quality of life by reducing isolation, helping to resolve debt issues, volunteering etc. Reduce demand on medical services. Increase awareness of the voluntary and community sector (VCS) with GPs and other health clinicians working as part of the MDT teams.

How the aims and outcomes intended to be achieved -

Having Link Officers present at all 46 MDTs representing the VCS and focusing on the non-clinical needs of patients discussed at MDTs. Providing patients with 1-2-1 holistic support in their own homes with non-clinical issues eg isolation, housing, finance etc. Providing support that is independent, impartial and flexible. Spending quality time with people actively listening to their needs and aspirations. Looking at the whole needs of a person, regardless of what those needs might be and jointly find solutions to problems faced. Connecting patients to a range of services and activities provided by the voluntary, statutory and private sectors. Feeding in on non-clinical patient interventions at MDT meetings. Helping to support the set-up of new social and peer-led activities. Helping people contribute to their community eg through volunteering, peer support etc.

Integrated Plus approach        

It combines a flexible, non-clinical, holistic package of support. We focus on the whole person’s needs whatever they might be to jointly find solutions to problems faced. Support is independent and impartial. We have a ‘can do’ approach and attitude as we are not tied by organisational boundaries and cultures. We do what we can to help whatever the support needs are. We spend time with people, actively listening to their needs and aspirations. We ensure people are accessing services appropriate to their needs. We help people to navigate the health and social care system.

IP intervention types The following provides examples of some of the intervention types provided by the Integrated Plus team: Accessing services on offer     

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

Advocacy  

We help people apply for Personal Independent Payments and Attendance Allowance. We 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 

We help people access disabled bus passes and connect people to transport services such as Ring and Ride. 12

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We issue emergency one-day travel passes when people are in crisis and have no money to attend benefit appeals appointments. We accompany people to services/activities up to a maximum of three times if their confidence is low.

Building a home    

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

Connecting and supporting people      

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

Integrated Plus Model (IP) NHS services Referral to IP

MDT

Peer Support Networks

Private sector services

Wider VCS services

Local Authority services

Peer 2 Peer Support

Volunteering

Integrated Plus support pathway Patients join the Integrated Plus service     

Referrals at MDTs Referral form via GPs/other MDT staff Patients contacted to explain the Integrated Plus service First home visits 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 Data agreement signed by patient Full holistic assessment carried out by Locality Link Officer Needs and aspirations of patients explored 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

Exiting the service    

Final assessment/review carried out with patients by Link Support Worker 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 from service by Link Officer and/or Link Support worker 14

Chapter Four: Learning from Integrated Plus Implementation What went well in terms of implementation and why? -

Recruited highly skilled staff with diverse skills and experiences. Good, consistent number of referrals. Referral numbers increased quickly after the first two months of the service commencing. High patient acceptance rate of service – 77% (2,021 out of 2,619). Referrals received from all 46 GP surgeries (although some practices refer more patients than others). Non-clinical interventions/input has been valued and well received at MDTs. Good feedback from patients supported. Non-clinical interventions are valued and demonstrate a need for social prescribing in the new care model. Referrals from Integrated Plus to organisations and services in the voluntary, statutory and private sectors have been well received. High patient onward referral numbers to services in voluntary, statutory and private sectors. Areas where patients benefit the most from Integrated Plus is in the areas of reducing isolation, increasing income, helping people navigate the health and social care system, employment, life skills, improving mental health. Data gathered so far on GP visits has shown a reduction in patient GP visits and GP home visits (an increase in GP telephone consultations). Data gathered on secondary care data from DSCRO shows a reduction in A&E attendances and emergency admissions. Feedback from GPs/health clinicians has shown increased awareness of voluntary and community sector services The service has been able to stimulate and support patients to lead on new social/peer-led activities eg men’s social meet ups, women’s meet-ups and Air Time – COPD social peer network. External funding was drawn into the borough for Air Time – a partnership bid with Dudley CCG, Health Watch Dudley, Integrated Plus and the Dudley Respiratory Assessment Team.

What went less well and why? Referral destinations -

Local funding cuts to the voluntary and community sector (VCS) has resulted in reduced capacity in service provision which has resulted in Integrated Plus staff having to pick up more longer term support interventions eg help with benefit form filling, housing applications etc. Some services have closed due to funding cuts. Some services due to funding cuts now charge people for their services. People either can’t afford to pay for them or choose not to pay for them eg respite, befriending, day activities for older people etc. Services such as befriending schemes have struggled to recruit enough volunteers to deliver befriending services to cope with increasing demand. Cuts to services has also meant less referral destinations for social care eg respite services now charge for their services. Social workers have reported less referral routes for people they support and in need of respite. Some services have been redesigned due to the funding cuts which has meant a lack of longer term support interventions for patients, particularly, in the area of mental health, financial management support, benefit/debt advice etc. A range of services have long waiting lists which has resulted in some patients becoming dependent on our support, their situations getting worse or support needs getting more complex. Waiting lists have been experienced with social care, patient’s been allocated longer term support workers eg mental health provision (Creative Support and Heantun Housing etc). Expectation for the VCS to play an active and bigger role in the New Care Model with supporting patients has led to increased demand on the VCS, in particular from Integrated Plus. To date, 15

there has been a lack of financial investment in the VCS to deal with increased capacity and/or to develop new schemes/activities based on new needs being identified by the Integrated Plus team. Referrals to Integrated Plus -

Managing the number of referrals with other work tasks is challenging eg Link Officers attending MDTs/LMDTs takes approximately 21.5 hours (17%) every 4 weeks for each Link Officer. Link Support Workers don,t conduct first home visits but conduct 1-2-1 patient support and follow up patient reviews. This leaves approximately 83 hours to carry out 1-2-1 support with patients (66%) every 4 weeks. After conducting a capacity modelling exercise, it was identified that Integrated Plus has the capacity to work with 7 new client referrals per month/per locality, 35 per month for the whole service. The average number of referrals actually received is 15 a month per locality, 75 a month for whole service. Service is currently overstretched. Managing waiting times of referrals has been difficult at times eg at some periods, waiting times for patients to have a first home visit from Integrated Plus has been 4-6 weeks. Not all referrals are appropriate for our service eg some are palliative, some referred because they need of a social care assessment only, or some patients are already in care homes. Difficult to ascertain out of the referrals whether the patients are on the top 2% or not. Lack of patients referred to Integrated Plus that are frequent visitors of GP surgeries. These frequent flyer lists are not available at MDTs. This is an area whether we could possibly make the most impact.

Patient support -

High expectations from patients about what we can do and achieve in 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 for the person with our support when our support is short term support eg average of 3 month interventions per patient. Some patients where their needs are complex require support first in areas of money, dealing with debts, family issues, household issues before Integrated Plus staff can support them in engaging in other social activities/services and learning, peer support, self-management programmes. Not all patients referred have the ability or mind-set to motivate themselves to make positive change to their lives.

MDTs/LMDTs -

Quality of the MDT and LMDT meetings varies. Capacity has been an issue with a lack of time to attend the mental health MDTs to provide input.

Data -

Capturing and recording data for evaluation is time consuming. There is a need to review what data we capture so more time can be spent with supporting patients and picking up more referrals. Not having a shared IT system across the health and social care system. If we had a shared IT system, time could be saved not having to chase up information eg who is a patientâ&#x20AC;&#x2122;s social worker, trying to find out whether a fire safety check has already been conducted by the West Midlands Fire Service. Difficulty getting access to primary and secondary care data for our cost saving work due to data protection/sharing. During the first two years of the service being delivered there was a lack of staff capacity to follow up on patient reviews for evaluation data. Having 2 new Link Support Workers in August 2016 and 3 in January 2017 has helped with this issue but full evaluation processes have started late into the service. This resulted in Integrated Plus not having data on all patients supported.

Key learning What were the key lessons learnt from this scheme? -

People have a lack of awareness about what services they are entitled to and the diverse range of services and activities available to them in the community. Independent, impartial and flexible approach is valued by people supported. People value been listened to and having Integrated Plus staff spend quality time with them. Joined up working across health professionals provides better quality of care and shared expertise. Non-clinical interventions/support is just as valuable as clinical interventions eg reduce isolation, maximise a person income, helping to resolve debt issues etc. Potential for more joined up working across partners to nurture and stimulate more peer networks and social activities. Better joined up working on gaps/needs to influence commissioning. Lack of investment in the voluntary sector has meant that some patient needs were unable to be met. More support has been provided than expected in helping patients to navigate the health and social care system and helping them to resolve issues or get relevant support in place.

What are the recommendations for improvement and future sustainability? Improvement -

Review and prioritise what data we capture to free up more staff time to work with patients. Have clearer focus/definition of patient cohorts to work with eg focus on frequent visitors of GP surgeries. This would help with refining evaluation and cost savings. Work more collaboratively with partners to develop new ideas to meet new gaps and needs. Need for investment in the voluntary and community sector in developing new services and activities to meet need. Allocate more time in nurturing and enabling social connectedness activities and peer support networks in partnership with GP surgeries to target more frequent visitors.

Future sustainability -

Social prescribing not being seen as an added value service but funded as a mainstream service in the new care model.

Chapter Five: Integrated Plus activities, outputs and social outcomes Capacity modelling This section provides information on staff time spent on different elements of delivering the Integrated Plus service and how many new patient referrals staff have capacity to work with. Time spent supporting each patient ranges from 1-5 months, average time spent per patient is 3 months.

CLIENT WORK: MAXIMUM SUPPORT - 17 HOURS PER PATIENT Closing off clients/reviews Connecting for P2P support

CLIENT WORK: MINIMUM SUPPORT - 6 HOURS PER PATIENT Closing off clients/re views

Data entry

First home visit

Taking to services if confidence is low Direct 1-2-1 support eg form filling

Research/ making referrals

First home visit

Staff time spent every four weeks   



Attending MDT/LMDT meetings – 17% Patient support - home visits, carrying out 1-2-1 patient support, follow up final patient review meetings – 66% Other Integrated Plus work - Integrated Plus team meetings, Integrated Plus client review meetings, Integrated Plus staff away days, supervisions of staff, clinical supervisions, Dudley CVS staff meetings, Dudley CVS AGM – 15% Stimulating/supporting new activities – supporting patients with setting up peer support or new social activities eg Monday Men’s Club – 3%

*(5,052 hours have been spent conducting first home visits, approx. 19,753 hours conducting 1-2-1 support for patients and 495 hours has been spent by Link Support Workers conducting final follow up review meetings with patients). Based on the above chart, Integrated Plus has the capacity to work with 7 new clients every 4 weeks, 35 new clients per month for whole project, 420 new clients per year.

Integrated Plus Referrals This section provides an overview of Integrated Plus referral patterns. It covers both referrals-in to Integrated Pus (eg by GPs, MDT staff) and referrals-out (i.e. to voluntary, statutory and private sector organisations and services). Data also covers age ranges, gender, ethnicity and presenting issues of patients referred. Data provided is between 1st September 2014 – 18th July 2017.

Referrals-in to Integrated Plus A total of 2,619 referrals received. 2,500

2,000

1,500

1,000

2021

500

328

181

DECLINED

UNABLE TO CONTACT

DID NOT WISH TO ACCESS FULL SERVICE

DNA

0 ACCEPTED SERVICE

INAPPROPRIATE WAITING TO BE REFERRAL CONTACTED

*inappropriate referrals mainly due to GPs requesting a social care assessment only for patients. Referral numbers by the five localities     

Sedgely, Coseley and Gornal Kingswinford, Amblecote and Brierley Hill Stourbridge, Wollescote and Lye Halesowen & Quarry Bank Dudley & Netherton

566 463 577 532 481

Average number of referrals over 35 months;  

Whole service – 75 a month Per locality – 15 a month

Age ranges of patients referred-in  31% are aged 80+  22% are aged between 64 – 79  18% are aged between 49 – 63  18% are aged between 24 – 48  3.6% are aged between 16 – 23  6.4% unknown age due to lack of information on referral form/people declining service 19

Gender of patients referred-in  42% male  58% female  0.07% transgender Ethnicity Majority of referred patients are from white ethnic background (66%). 4.6% from other ethnic backgrounds. 29% either unknown or patients preferred not to say. GP practice Referrals have been received by all 46 GP practices over 35 months, however, the volume of referrals-in to Integrated Plus varied considerably by practice. 9 practices referred over 50 patients, 27 practices over 20 patients, 15 practices under 20 patients. Referrals by GP practices and by MDT staff Number of referrals directly from GPs Alexandra Medical Centre AW. Surgeries (Albion House) AW. Surgeries (Withymoor) Bath Street Medical Centre Bean Road Medical Practice Bilston Street Surgery (now closed) Castle Meadows Surgery Central Clinic Chapel Street Surgery Clement Road Medical centre Coseley Medical Centre Cradley Road Medical Practice Crestfield Surgery Cross Street Health centre Dudley Partnership for Health Eve Hill Medical Practice Feldon Lane Surgery Hawne lane Surgery High Oak Surgery Keelinge House Surgery Kingswinford medical Practice Lapal medical Practice Links medical Practice Lion Health Lower Gornal Medical Practice Meadowbrook Road Surgery Moss Grove Surgery Netherton Health centre Northway Medical Centre Norton Medical Practice Pedmore Road Surgery Quarry bank medical centre Quincy Rise Surgery Rangeways Road Surgery Ridgeway Surgery St James Medical Practice (Dr Porter)

10 50 8 22 16 8 25 27 5 7 94 0 26 22 20 101 71 4 14 44 27 25 30 118 35 29 31 25 46 26 103 28 7 78 41 7

Patients registered practices referred by other MDT staff (not GPs) 4 42 5 7 9 4 6 3 1 1 56 7 8 9 5 12 26 0 2 11 9 8 10 77 26 15 15 14 15 8 12 9 1 10 17 3 20

St James Medical Practice (Dr White) St Margaret’s Well Surgery Steppingstones Medical Practice Stourside Medical Practice Summerfield Group Practice Summerhill Surgery The Greens Health Centre The Limes Medical Centre Thorns Road Surgery Three Villages medical Practice Waterfront Surgery Woodsetton Medical Centre Wordsley Green Health Centre Wychbury Medical Centre

5 48 21 24 1 4 36 28 23 65 7 38 34 167

5 29 12 9 0 5 14 7 13 14 19 18 11 33

Other referral routes 232 from other referral routes such as Dudley CVS Carers co-ordinator, AgeUK Social Prescribing service, mental health etc. Findings from supporting patients referred Disability Profound complex disabilities Temporary disability after illness Multiple disability Emotional/behavioural difficulties Other physical disability Hearing impairment Visual impairment Other medical condition Disability affecting mobility Mental health difficulty

3 4 5 88 94 105 117 280 340 380

Caring responsibilities   

Has a carer – 340 Is a carer – 205 Is a carer and has a carer – 23

Presenting issues by referrer and Link Officer Reason Isolated/lonely Depression Other mental health Family relationship problems LTC Dementia Frequent presenter Household issues Learning disability support Bereavement Drug/alcohol

Number (by referrer) 1,222 808 224 112 873 67 263 309 74 78 141

Number (by LLO) 841 624 150 227 743 59 124 401 67 143 87 21

Stress Lack of basic literacy and numeracy Other eg suicide attempt, palliative, anger issues, can,t cope at home, financial etc

84 0 565

218 23 316

Presenting issues broken down by age groups

Lack of basic literacy and numeracy 14 12 10 8 6 4 2 0 18 - 23

24 - 48

49 - 63

64 - 78

Dementia 40 30 20 10 0 16 - 17

18 - 23

24 - 48

49 - 63

64 - 78

80 plus

64 - 78

80 plus

Drugs and alcohol 45 40 35 30 25 20 15 10 5 0 16 - 17

18 - 23

24 - 48

49 - 63

Bereavement 45 40 35 30 25 20 15 10 5 0 16 - 17

18 - 23

24 - 48

49 - 63

64 - 78

80 plus

Depression 200 150 100 50 0 16 - 17

18 - 23

24 - 48

49 - 63

64 - 78

80 plus

Family relationship issues 80 60 40 20 0 16 - 17

18 - 23

24 - 48

49 - 63

64 - 78

80 plus

Frequent GP attenders 35 30 25 20 15 10 5 0 16 - 17

18 - 23

24 - 48

49 - 63

64 - 78

80 plus

Isolation 300 250 200 150 100 50 0 16 - 17

18 - 23

24 - 48

49 - 63

64 - 78

80 plus

Household issues 120 100 80 60 40 20 0 16 - 17

18 - 23

24 - 48

49 - 63

64 - 78

80 plus

Learning Disability Support needs 30 25 20 15 10 5 0 16 - 17

18 - 23

24 - 48

49 - 63

64 - 78

80 plus

64 - 78

80 plus

Long term health issues 300 250 200 150 100 50 0 16 - 17

18 - 23

24 - 48

49 - 63

Other mental health issues 50 40 30 20 10 0 16 - 17

18 - 23

24 - 48

49 - 63

64 - 78

80 plus

Stress and anxiety 80 60 40 20 0 16 - 17

18 - 23

24 - 48

49 - 63

64 - 78

80 plus

64 - 78

80 plus

Other issues 80 60 40 20 0 16 - 17

18 - 23

24 - 48

49 - 63

Referrals-out from Integrated Plus Over 35 months there were 5,766 onward connections/referrals (patients being referred to more than one organisation) made to 363 organisations and 2,508 connections/referrals (patients being referred to more than one service) made to 84 services/projects/activities. 74% of referrals were to services provided by the voluntary and community sector. Some service types received particularly high numbers of referrals. These were services tackling isolation such as befriending (AgeUK Dudley, Royal Voluntary Service, Age Concern), mental health services (Creative Support, Dudley Mind, Rethink), bereavement counselling (Cruse), dementia services (Alzheimerâ&#x20AC;&#x2122;s Society) and welfare benefit support services (Citizens Advice). Although 74% of onward referral destinations were to voluntary sector organisations, when looking at referrals to specific services provided by organisations, a higher proportion were to local authority services (71%), in particular adult social care and Public Health. These services included: telecare, adult community learning, carers network, Dudley Home Improvement Service, Libraries, Winter Warmth, transport services and self-management programmes. A high percentage of referrals were also to transport services such as Ring and Ride and Driving Miss Daisy. A high percentage of referrals were also to the Department of Work and Pensions to help resolve welfare benefit issues through support from Integrated Plus staff. The high demand for services such as befriending, community transport, adult social care services highlights the importance of services that aim to reduce dependence and social isolation. The high demand for mental health services shows that mental health issues have been a high presenting issue for patients referred to Integrated Plus.

Highest referrals to organisations and services Good Neighbour Scheme (AgeUK Dudley) CADEL (Citizens Advice Dudley) Dudley and Walsall Mental Health Trust Zion Christian Centre Zion Christian Centre Silverline Halesowen College Over 50s Club KFC Quality Meals Queensway for Retired Citizens Amblecote Christian Centre Adult Social Care (falls prevention) Get Cooking (DMBC) Dudley Crossroads Home Instead Fix a home (AgeUK Dudley) West Midlands Fire Service Mindful Gifts Dudley Assisted Living Team (DMBC) Enabling Community Support (DMBC) Deaf Support Service Short Cross Methodist Church Royal British Legion Halesowen Cruse Bereavement Care University of the Third Age Royal Voluntary Service Age Concern Stourbridge St james Church - Wollaston Citizens Advice Dudley Beacon Centre for the Blind Springboard (AgeUk Dudley) Dudley Home Improvement Service (DMBC) Alzheimer's Society Driving Miss Daisy Creative Support Adult Social Care (telecare services) Citizens Advice Halesowen Adult Community Learning (DMBC) Rethink Mental Illness Health Trainers Dudley Self Management Team Monday Mens Club Home Library Service (DMBC) Winter Warmth (DMBC) Carers Network (DMBC) Department for Work and Pensions Ring and Ride Adult Social Care (DMBC) Social Prescribing (AgeUk Dudley) Dudley Mind AgeUK Dudley 0

100

200

300

400

500

600

Issues and challenges faced with onward referrals destinations The biggest areas where Integrated Plus has found difficulties with onward referral destinations has been due to reduced capacity, particularly in the voluntary sector. This has mainly been due to funding cuts. Increasing demand for services with diminishing resources is bringing about many challenges to the health, social care and voluntary sector. Befriending There has been an increasing need for befriending services for people who are housebound. Befriending services are at full capacity and are struggling to recruit enough volunteers to help. Some befriending services now charge and patients either do not wish to pay for befriending or cannot afford to pay for such services. Befriending services not being able to cope with the numbers has resulted in such services not being available to everyone where a need has been identified. Respite In Dudley borough there is a shortage of respite services and those services that do exit were once free of charge but now have introduced a fee. Respite services for dementia is costly. Transport There has been increasing demand for transport services so people can become more active and involved in their communities. Locally there has been funding cuts for transport services. We have found that some vulnerable people struggle to travel alone to services outside of their locality. Driving Miss Daisy is a personalised transport service. This service does charge a fee, however, many people have accessed this service via Integrated Plus. This service is now at full capacity. 1-2-1 support services There is a need for some services to be delivered via home visits because of people being housebound due to agoraphobia, disability or other mental health issues. Many services currently require people to attend appointments at their offices or in clinics. We have found that mental health issues are exacerbated by debt issues and there is currently a lack of capacity for services such as Citizens Advice to visit patients in their homes to support with such issues who are housebound. There is a lack of one to one support services for people with issues of drug dependency. Some people referred to us are not ready for group support and struggle to travel to services outside of their locality. Connections/referrals to organisations 5,766 connections/referrals to 363 organisations (patients referred to more than 1 organisation)

Referrals by sectors 4500 4000 3500 3000 2500 2000 1500 1000 500 0 Voluntary sector

NHS

Statutory

Private sector

National Government

Faith sector

Referrals to organisations by theme

Referrals to organisations by theme 3000 2500 2000 1500 1000 500 0

2,508 connections made to 84 service/projects/activities (patients referred to more than 1

service/activity)

Referrals to projects/services by sector 2000 1800 1600 1400 1200 1000 800 600 400 200 0 Voluntary sector

NHS

Statutory

Referrals to services/activities provided by organisations by theme

Referrals to services by theme 1400

1200

1000

800

600

400

200

Social impact This section draws on a combination of quantitative and qualitative data to provide an assessment of the social impact of Integrated Plus. Four data sources provide the basis for this assessment. The first being patient experience of the service gathered through 1-2-1 reviews, second being feedback from GPs/health clinicians who have referred patients to Integrated Plus, thirdly, feedback from interviews conducted with 35 patients on a range of social impacts and fourthly, data gathered from PSIAMS new Social Triage Assessment which commenced in September 2016. Patient experience of Integrated Plus Star rating of service (1 being very poor service, 5 being excellent service)

1% 5% 30%

5 star excellent service 4 star good service

64%

3 star average service 2 star poor service

Do you feel you have benefitted from the service?

13%

4% 43%

A great deal A lot

40%

A little Very little

*reasons for patients reporting very little benefit is due to waiting lists for services, services needed not being available or patients not feeling that the referral to Integrated Plus was required.

Do you feel your needs were understood?

3% A great deal

38%

A lot

59%

A little Very little

How aware of services and activities available in your community are you now as a result of the service? 5% 3%

27%

14%

Extremely well aware Very aware A little aware Not very aware

51%

N/A

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

9% 8%

A great deal

45%

A lot A little

34%

Very little N/A

What have been the benefits of the Integrated Plus approach for you? 200 180 160 140 120 100 80 60 40 20 0

To what extent has the service impacted on you?

10% 3% 28% Significant impact Great impact

28%

Good impact

31%

Mnor impact No impact

GP/health clinician feedback on Integrated Plus service A survey was conducted in 2015 to gather views from GPs and other health clinicians who had made referrals to the Integrated Plus service. 16 GPs/health clinicians responded to the survey. Although the number of GPs/health clinicians responded to the survey was lower than anticipated, results showed: Star rating of the Integrated Plus service 62.50% - 5 star excellent service 37.50% - 4 star good service Added value that Link Officers bring to MDTs 68.75% - a great deal 31.25% - a lot Link Officers being pivotal to MDTs in the future 50% - a great deal 43.75% - a lot 6.25% - a little What GPs and other health clinicians are finding most beneficial about Integrated Plus?       

67% stated that they like the service as it takes into account the social inclusion needs of their patients. 75% stated that the service works with patients in an integrated and holistic way. 67% stated that the service is valuable as Link Officers spend quality time with patients. 58% stated that they feel the service improves patients’ health and wellbeing. 58% stated that the service brokers patients into community and voluntary led activities. 67% stated that it is independent, flexible and a non-clinical service. 8% stated that they are now seeing patients less in their surgeries.

Other comments made in survey respondents We have a very professional locality link worker. (Ruth Edwards) Excellent service with good feedback from patients. (Jason Mann) The things I have got our link worker involved in go well, I do suspect there is more that could be done, so rather than waiting for referrals a proactive approach would increase impact. (Steve Mann) An excellent service of which a number of our patients have benefitted from. Keep up the good work! (Penny Massey) A fantastic service. A real game changer. (Rebecca Willetts) Nick Tromans has been a star, totally appreciate his support. Working so closely with us, provides real opportunity. (Heidi Davis)

1-2-1 patient interviews 1-2-1 qualitative interviews with 35 patients that had accessed the Integrated Plus service were conducted during 2015/16. A number of examples of social outcomes emerged from these interviews. The areas where the biggest outcomes were reported included areas of:             

Improved quality of life Increased friendships Reduction in crisis situations Reduced isolation Reduced stress and anxiety Improved wellbeing Feelings of increased motivation Feeling more connected and involved in the community Improved healthy lifestyles Increased confidence and self-esteem Feeling better able to cope with life Feeling less isolated and happier Patients being better able to get out and about and engage in social activities

Reduced loneliness and isolation A common theme emerged throughout the interviews of loneliness and isolation. During the interviews patients reported loneliness and isolation being triggered by various different reasons. Some had lost contact with friends, some had recently experienced bereavement, some felt isolated because of a disability and some reported lacking in confidence to go out. Out of nearly all the interviews, patients reported that they were unaware of the diverse range of activities taking place in communities before support from Integrated Plus. Some patients spoke about the lack of IT skills to search for activities online and some were unaware where to look online. Mr A supported started to develop his IT skills through attending a local IT course. This helped him to be more proficient with online shopping and in using social media platforms, such as Facebook. The patient stated that the only companion was his cat and that he didn,t find it easy to make friends. The patient reported that with the support of the link officer he now feels he has more of a social life, his life is enriched and his confidence has grown. “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.” (Mr A) Ms P reported that she felt lonely and isolated and hadn’t accessed any activities in a long time. Integrated Plus helped Ms P into volunteering for Age Concern as it would enable her to meet new people and provide an opportunity to support others. In the interview Ms P rated the Integrated Plus service as 5 star excellent service. “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”. (Ms P)

Some patients reported that having staff accompanying them the first few times to a social activity was really helpful in building their confidence. One patient stated that “they would not have attended the social club if support hadn’t been offered”. Improved wellbeing Improvements in mental wellbeing and quality of life were particularly evident from the interviews. 66% of patients reported that they felt better able to cope with life, 69% reported reduced stress and anxiety, 56% felt overall improved wellbeing and 63% reported gaining increased friendships by engaging in social activities. Improved wellbeing was reported by some patients being due to engaging in peer support with others or engaging in volunteering. Housing and welfare Common issues emerged that exacerbate peoples stress and that was in relation to debt, benefits and housing issues. 66% of patients interviewed reported that their stress levels had reduced due to staff helping them to resolve debt issues and housing problems. For example, a patient was helped by a member of the Integrated Plus team to find suitable accessible accommodation for her disability which wasn’t getting resolved very quickly through other channels. The member of staff supported the patient with finding suitable accommodation and helped moving some of her belongings and liaised with the patient’s GP and her pharmacy to ensure her prescribed drugs continued to be prescribed and delivered to her new address. Mr X was helped to find suitable housing in an Extra Care Sheltered Housing Scheme following the death of his wife, not feeling safe in his house and due to suffering from several falls. The patient now helps to call the bingo in the communal activities.

“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 the link officer 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”. (Mr X) Breakdown on outcomes reported by percentage from the 35 1-2-1 patient interviews Finances/debts Housing status Now have enough money to live on – 25% Now have secure and safe accommodation – 38% Now accessing financial support – 25% Accommodation now meets needs – 28% Better able to manage own finances – 22% Now feel supported by social networks – 16% Feeling safe in my community Feel safer in my community/where I live – 28% Feel comfortable in my peer groups – 28% Feel safe in my relationship – 16% Mental health Better able to cope with life – 66% Feel less isolated – 66% Feel happier – 63% Reduced stress and anxiety – 69% Feel more motivated – 38% Feel have improved wellbeing – 56% Feel more involved in community – 38% Increased friendships – 63%

Physical health Now able to get out and about – 47% Improved healthy lifestyle – 44% Increased confidence and self-esteem – 41% Able to manage medication – 9% Better able to manage personal care – 16% Able to communicate needs – 25% Life skills Now supported in health and social care – 25% Reduction in crisis situations – 38% Better quality of life – 50% Improved access to statutory services – 22% Family/carers feel better able to cope – 16% 35

Encouraging and supporting peer support and volunteering In addition to supporting people to become more active and involved in their communities, Integrated Plus supports people to connect with others for peer support and enables people to access volunteering opportunities. Since the service began 597 people have been supported to access peer network activities, 24 people have been supported into volunteering and 5 people have been helped to reconnect with family and friends. Peer support activities have included: For Men’s Monday Club, Making Waves - Air Time for COPD, Mental Health Peer Support, self-management programmes, carers network, The Haven Peer Support Group with mental health issues, Stourbridge Women’s Peer Group, Dudley Parent Carer Forum and Dudley Carers Forum. New activities have also been initiated in collaboration with patients and organisations. Examples of this include:

For Men Monday Club The For Men Monday Club started in July 2015, following a discussion led by a Locality Link Officer and involving Lye Church and Dudley and Walsall Mental Health Trust. The context for this discussion was a concern for the wellbeing of local men with mental health conditions and the fact that nationally:  

Suicide remains the most common cause of death in men under the age of 35. Men are three times more likely to commit suicide than women (and it is thought that men are less likely to seek help such as talking to someone or visiting their GP for advice).

The Link Officer had noticed that many of the men with mental health problems referred to Integrated Plus in the Stourbridge, Wollescote and Lye locality, particularly single men, were isolated and found it difficult to engage socially. Many had been recently 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 Club would make good use of existing connections with voluntary organisations, Christian faith groups and local mosques, and health professionals. It would create a place where men could meet socially, have a hot drink and a light breakfast, read newspapers or play games such as chess, pool, etc. A grant was obtained to initially help set up the club and since then many donations from local funders/businesses have been made. The club now has over 70 men attending. The Club is a good opportunity to pick up information or find out what support might be available. It is also a place where other voluntary organisations can attend with clients or just be on hand to give advice. The Club is good at providing peer support: attendees often feel more comfortable talking about their problems here than in another setting. Simon, a recent starter, said: “It’s really worth coming to the group; I enjoy taking part, sharing banter about football and trying out those delicious meals we’re cooking! Everyone gets involved in setting up and there is always someone prepared to listen”. An activity takes place at most sessions and there is usually something for everyone. This has included, for example, a six week Get Cooking course, indoor sports such as bowls and relaxation sessions on mindfulness. Alternatively, attendees can sit quietly, if they wish. The cooking course has proved particularly popular and has provided an opportunity to learn how to cook nutritious and affordable meals.

Making Waves ‘Airtime’: A social peer network for people with respiratory conditions In July 2016, a new initiative was set up in Dudley for members of the community with COPD (chronic obstructive pulmonary disease), Pulmonary Fibrosis, Bronchiectasis and other related respiratory conditions. ‘Airtime’ is a weekly social peer-led group supporting people with respiratory conditions in the Dudley Borough. The project is currently delivered by Integrated Plus in partnership with Dudley Clinical Commissioning Group (CCG), the Dudley Respiratory Team and Healthwatch Dudley. COPD is a major health problem in the UK, a disease that lowers self-esteem, reduces mobility and negatively affects quality of life. The main aim of ‘Airtime’ is to reduce social isolation and take pressure off the NHS by reducing hospital and GP admissions relating to the disease, providing a safe, caring environment for people to learn how to control their symptoms, meet others in similar situations and learn new things by taking part in enjoyable activities. Nina Gee, Airtime coordinator, Dudley CVS said, “By providing an environment for people to meet and to have a weekly focus, they are more equipped to manage their symptoms and to feel a greater sense of belonging.” The sessions are fun, engaging and welcoming with a wide range of activities such as Tai Chi, seated yoga, art therapy, laughter yoga, seated aerobics, singing therapy, quizzes and bingo, mindfulness and meditation as well as health talks on mental health, medication and diet. There is fantastic collaborative work taking place between the Air Time group and the Dudley Respiratory Team. Respiratory Nurses take turns to attend the Air Time sessions so people can discuss any concerns they have about their condition. Over the past few months the Dudley Respiratory Team have also been offering additional Pulmonary Rehab sessions one hour before Air Time starts at the DY1 venue. This gives the opportunity for people who have previously been through pulmonary rehab sessions the opportunity for follow up sessions. The group sessions are totally free and offer tea, coffee and a buffet lunch. People who attend Air Time have told us: “The reason why I come to Airtime is to meet people, have a chat, get some exercise and enjoy the company!” “I don’t get out much, I live on my own and really enjoy the company. The people are so friendly and make you feel welcome, my only complaint is that time goes too quickly!” “Getting out and attending Air Time has made me able to come off my medication for anxiety!” “Since the death of my wife, Air Time has helped me start to enjoy life again” There are also 6 similar projects currently running across the East and West Midlands all funded by The Health Foundation. The group session is free and open to anyone with COPD (chronic obstructive pulmonary disease) and related respiratory conditions and takes place every Thursday @ 1pm- 3pm at the DY1 Community Building, Stafford Street, Dudley. 37

PSIAMS New Social Triage Assessment (STA) In August 2016, PSIAMS introduced a revised social triage assessment (STA), developed and licenced by Cloudberry Innovation and Development. The STA provides an assessment tool to help staff identify issues, action plan and capture the impact of their work with people. Used in conjunction with PSIAMS results can be shown instantly, enabling faster transfer of data and speeding up support for the induvial. This was used by the Integrated Plus team from 1st September 2016 with patients referred to the service. The assessment focuses on the following areas and is designed to be used at the first patient home visit and the final follow up patient visit.           

Finance – debts, money, savings, financial management abilities Housing – feeling safe, accommodation, rent/mortgage payments, neighbour disputes Employment – barriers to gaining employment, skills, qualifications, job security Life skills – basic literacy and numeracy, life skills, training, career/personal development Sexual health – safe sex, sexual behaviour, sexual health advice Physical health – managing medication, independence, personal care, access to healthcare, diet, exercise Safety – safety in community, safety at home, relationships Alcohol/drugs – intake, risk Criminal activity – anger management, risk of harm, criminal convictions Mental health – motivation, wellbeing, suicidal thoughts Family and community – trust, pride, contribution to the community Figure 1

Figure 1- provides information on the percentage of people are experiencing problems across the 11 STA areas that are either unsupported or supported by relevant organisations.

Analysis of the data shows that the biggest areas where the most benefit is gained from Integrated Plus interventions is in practical support (figure 1) such as:  

Finance – helping to complete benefit forms to increase a person’s income Family and community – helping people to resolve family issues and contributing to their community through volunteering, peer support. Physical heath – helping people to access 38



services and activities that help to maintain independence, access social care, access public health services and other health, physical and wellbeing activities. Mental health – helping people to access mental health services in primary care or the voluntary sector or take part in wellbeing activities, peer support or volunteering to help overcome feelings of low mood, depression. Housing – helping to complete housing applications, working with the Local Authority to resolve housing issues, aids/adaptations etc

The STA also provides information on the type of support they need and with a review shows the movement towards self-management of support areas (figure 2). Figure 2

Figure 2 – shows the degree of movement towards people being able to self-manage their support needs following interventions with the IP Team. In the table below shows the support bands.

Chapter Six: Impact on primary and secondary care data and wider state The cost of delivering the Integrated Plus service is as follows: Year 1 (Sept 2014– August 2015 £387,950

Year 2 (Sept 2015 – August 2016) £367,250

Year 3 (Sept 2016 – August 2017) £367,250 Additional investment for 5 Link Support Workers of £156,416 from Vanguard

Year 4 (Sept 2017 – August 2018) £367,250 Additional investment for 5 Link Support Workers of £156,416 from Vanguard

Integrated Plus is delivered through one manage, five Link Officers, five Link Support Workers and one administrator. Primary care Data on 438 (22%) patients referred to Integrated Plus was extracted from EMIS in 39 GP surgeries (surgeries that had used the EMIS Integrated Plus code). From this data:   

GP visits reduced by 24% GP home visits reduced by 15% GP telephone consultations has increased by 15%

Overall, cost saving of £17,965 *The service has faced challenges in getting access to data from EMIS for every patient referred due to data protection/sharing. Going forward Integrated Plus is aiming to secure data sharing agreements with each practice so that data on every patient referred can be accessed and analysed. Secondary care For secondary care data two types of NHS costs are considered:  

A&E Attendance Emergency admissions

The following average costs of the above NHS services have been used in the cost calculations:  

A&E Attendance - £119.61 per patient Emergency Admission - £1,582.28 per patient

Cost comparisons The following tables provide the cost comparisons for each hospital episode and the total costs associated with all episodes within a 6 and 12 month period. For some patients referred (417) DSCRO could not match the NHS number to SUS. This means that either they all have no activity either before or after referral to the service, or there was a problem with the NHS numbers provided i.e. not valid, not enough characters.

Table 1: 6 month interventions

A&E Attendance (392 patients) Total cost of A&E Attendance Emergency admission (339 patients) Total cost of emergency admission

Patients referred to Integrated Plus between 1st September 2014 – 31st December 2016 Total number of visits Total number of visits 6 by patients 6 months months after Integrated before Integrated Plus Plus intervention intervention 607 524

-83 (13% reduction)

£72,603.27

£63,034.47

-£9,568.80

434

376

-58 (13% reduction)

£686,709.52

£594,937.28

-£91,772.24

Total cost

-£101,341.04

Table 2: 12 month interventions

A&E Attendance (522 patients) Total cost of A&E Attendance Emergency admission (441 patients) Total cost of emergency admission

Patients referred to Integrated Plus between 1st September 2014 – 31st December 2016 Total number of visits Total number of visits by patients 12 months 12 months after before Integrated Plus Integrated Plus intervention intervention 1033 991

-42 (4% reduction)

£123,557.13

£118,533.51

-£5023.62

740

688

-52 (7% reduction)

£1,170,887.20

£1,088,608.64

-£82,278.56

Total cost

-£87,302.18

PSIAMS cost saving methodology PSIAMS has a cost avoidance methodology based on the social triage assessments carried out with patients. Calculations are based on a scenario of the estimated costs to the state if no interventions are provided and 12 month projected estimated costs to the state after interventions/support from Integrated Plus. Costs are calculated on the following:         

Finance – debt advice, accessing foodbanks, financial support/advice Employment – cost of claiming Employment Support Allowance for a 12 month period Alcohol/drug use – cost of drug/alcohol services Safety – costs to state from being a victim of crime Sexual health – costs of accessing sexual health services Criminal activity – costs to state from criminal activity Mental health – costs of primary and secondary mental health services Physical health – costs to adult social care Housing status – costs to state from homelessness, rent arrears

Costs to the wider health and social care economy are based on information and research from the following: Department for Work and Pensions, Tax Payers Alliance, BRE Trust, Health and Safety 41

Executive, Kings Fund, Family Planning Association, Brook, Terrance Higgins Trust, Public Health England, Citizen Advice Bureaux, Money Advice Service, Office of National Statistics, NHS. STAs that have been carried out between 1st September 2016 â&#x20AC;&#x201C; 18th July 2017 for 156 patients (7% of referrals to Integrated Plus) shows an estimated ÂŁ781,822.08 cost avoidance to wider the state as a result of Integrated Plus interventions.

Chapter Seven: Peoples stories Story One – Pat lives alone Pat is 74 and living alone, she has some friends and family nearby but she was feeling lonely and isolated. A referral was made to Integrated Plus by the Ridgeway Surgery. Pat identified that she was feeling very low, this depression was largely due to being at home alone and not having regular engagement with others. Pat expressed a desire to help other people, she had been actively involved with community groups in the past but had not accessed any groups for quite some time. The first time Pat met the Link Officer it gave her an opportunity to openly discuss issues and give the Link Officer the chance to identify possible services that Pat may wish to access. After the initial assessment, Pat said she felt a lot better knowing that she could make some meaningful changes and that she had been listened to. During the second meeting some possible services that Pat may wish to access were discussed. Amongst the services talked about were a gentle exercise group, a knit and natter group at a local church and a volunteer opportunity with Age Concern Sedgley. Pat was most interested in volunteering with Age Concern as it would enable her to meet new people and provide an opportunity to support others. A time was arranged to go down with the Link Officer and have an informal conversation with Denise the Manager. Soon after the meeting the relevant paperwork was completed and an induction date was agreed. Pat now volunteers with Age Concern two days a week. She pursued the other opportunities that were discussed but at the moment feels that her volunteering is keeping her busy enough. Volunteering has increased her motivation and she has started knitting again in her spare time. When asked about her experience Pat said “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”. Denise commenting on their new volunteer said “No matter what you ask her to do she will do it no problem, she is a great asset to the team.

Story Two: Andrew in his mid-50s Andrew is in his mid-50s and suffers from a medical condition which affects his mobility. He had lived all his life with his mother, in the family home, until she passed away in 2002 and since then has lived alone. He has no other family members and no close friends. A referral was made by Three Villages Medical Practice to Integrated Plus at a Multi-Disciplinary Team meeting because he suffered from social isolation and loneliness. Andrew had worked at a local supermarket for 25 years, but developed a medical condition and had to take early retirement. Andrew only left his home once a week to visit the local supermarket where he used to work. His only companion was his cat. Andrew felt he was okay living a solitary life because this was all he had ever done. Andrew doesn’t find it easy to make friends and became emotional, saying that this was the first time in his life he had been able to open up to someone. He also felt disappointed that he had lost contact with a friend when he became ill and would love to be in touch with him again. The Link Officer was able to identify a range of support within the voluntary sector, based on Andrew’s interests including; Summit House, who hold a men’s social group twice a month, Age UK Dudley, who offer 1-1 and group IT sessions. He is now attending the group sessions, which has enabled him to meet new friends and socialise. Andrew is also going on day trips. Although he is not able to walk far, he enjoys the social aspect of the coach journey and is considering purchasing a mobility scooter, which he can then take with him. In the mean-time, with the Link Officers help, Andrew is now registered with Shop Mobility and is now able to hire a mobility scooter. The Link Officer was able to locate his lost friend and they are now reacquainted. Andrew is now going out more; he is learning new IT skills, which is helping him to be more proficient with on-line shopping and using social media platforms, such as Facebook. He is meeting new friends and socializing. Andrew now feels he has more of a social life, his life is enriched and his confidence is growing. Andrew stated “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.”

Story Three: Client X Client X was referred to Integrated Plus by Dudley Talking Therapy Service. During the initial assessment, client X was very anxious and consumed two large glasses of vodka. The client discussed their alcohol dependency and expressed concerns relating to the high levels of anxiety they were experiencing. Client X disclosed drinking around two bottles of vodka a day and only left the house to buy alcohol. The client was very distressed and upset by what was happening and also concerned about running out of money from savings. Client X had always worked until two years ago when their high pressure job got too much to bear. Client X resigned and planned to take some time out before seeking further employment but the alcohol consumption became chaotic. Client X was concerned that when the savings ran out there would be no money to purchase alcohol. Client X was also fearful of seizures and potentially life threatening withdrawal symptoms. The Link Officer offered help to access the right services. The Link Officer helped client X apply for Employment Support Allowance as client X was not in a fit state to be seeking work at that time. As the client was very anxious and not comfortable talking on the phone the Link officer liaised with the practice to get the relevant supporting documentation. Client X was awarded the benefit soon after. An appointment was made for client X to be triaged at a alcohol support service based in Brierley Hill the following week but client x had concerns that he had to attend three to four appointments before being able to access their detox programme and that the service was located at the other side of the borough. We contacted surrounding drug and alcohol services to see if they could help but they could not support the client due to client X paying council tax to Dudley MBC. In the mean time we were able to provide the client with a food parcel and toiletries as the client had very little in the house. Client X tried to attend his initial appointment at the alcohol service based in Brierley Hill but had problems with the bus ride which ended up being a very distressing situation. Following this and against advice the client decided to self-detox over a weekend and was prepared to go into hospital if required. Client X saw the weekend through and got through the worst of the withdrawal symptoms. The Link Officer helped client X to liaise with the practice to get medication prescribed for anxiety. Client X was becoming more stable on medication and abstaining from alcohol use. Other issues were disclosed to the Link Officer in regards to the reasons for the alcohol consumption so a referral was made to Summit House with a view to client X receiving specific support. A referral was also made to Supporting People to obtain a support worker to help client X build confidence. Client X responded fantastically well to the support. Over time the client started attending regular support groups at Summit House. Healthwatch Dudley also met with client X at home to capture the client’s experiences of services. “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”. (Client X) “Client X was assessed at Summit House and presented as suffering with severe anxiety. Client X informed the guidance worker that due to social isolation the client would find it difficult to engage in group work. What a difference four months makes. I really feel that the services at Summit House have met client X’s holistic needs. Client X is now a popular person at Summit House and is very focused on their recovery and future”. Pamela Holloway – Summit House Client X has started facilitating a Three Principles group at a residential rehabilitation service in Birmingham and is scheduled to deliver another in the city shortly. The client has engaged in training courses and is looking forward to starting a substance misuse course in the coming weeks. Client X has come so far in such a short amount of time and in their own words the client ‘just can’t believe it’. Client X is hoping to secure employment in a similar field in the near future as the client has found an area that they are truly passionate about and committed to. Everyone would like to wish client X the very best for the future and feel confident that the client will meet their goals and aspirations in good time. 45

Story Four: Mary’s journey in finding suitable accommodation After injuring her leg in a traffic accident in her home country of Nigeria, Mary visited the UK to receive specialist medical treatment. Following treatment, issues became apparent in regards to where funding was going to come from to pay for Mary’s accommodation. Adult Social Services was expected by the UK Border Agency to fund accommodation for Mary due to her substantial level of need. However, Mary was not eligible for local authority housing after her asylum claim failed. Mary was at risk of being homeless. At this point, pending the result of a new Home Office application, Adult Social Care provided accommodation for Mary in a hotel. Due to difficulties in finding appropriate accommodation, Mary had no choice but to stay in the hotel for a long period of time which caused Mary much distress. Having no recourse to public funds, Mary survived on food bank packages provided by Halesowen Churches Together Welcome Group and the goodwill of her friends from a local church. It was at this point that Mary was referred to a Locality Link Officer by the Primary Mental Health Care Services to see what additional support could be offered to help improve Mary’s quality of life. The Link Officer and a Mental Health Nurse conducted a joint visit. Due to suffering from depression and anxiety, Mary was referred for counselling support through the Enhanced Primary Care Mental Health Trust. The Link Officer contacted Mary’s social worker to see if Integrated Plus could offer any additional support with finding alternative and suitable accommodation for Mary. The social worker had been searching for alternative accommodation for some time without success. Adult Social Care has no legal obligation to support Mary while her renewed Home Office application is unresolved, but continued to do so in good will. The Link Officer involved the local MP to apply pressure on the Home Office to have her application seen to as a matter of urgency, as well as to enquire with Adult Social Care about what else could be done to house her appropriately. The Link Officer supported Mary with visiting proposed housing options, however, many were unsuitable due to Mary’s disability. Some difficulties with the current accommodation meant that Mary had to be re-housed quickly which put stress and pressure on both Mary and the social worker. Fully accessible temporary accommodation was found where Mary was provided with three meals each day. Following this, the Link Officer continued to liaise with Adult Social Care and advocate on Mary’s behalf in the search for more suitable and independent accommodation. After two weeks Mary was temporarily moved into an adapted local authority flat. The Link Officer supported Mary with moving some of her belongings and liaised with Mary’s GP and her pharmacy to ensure her prescribed drugs continued to be prescribed and delivered to her new address. Mary’s solicitor has persuaded the Home Office to accept her application via the post, thus negating the need for a long and painful journey to Liverpool. The Link Officer continues to liaise with Ian Austin MP to continue to apply pressure on the Home Office in relation to her application for residency.

Story Five: Mr X helped to resolve debt issues X had a long career in the building trade and was in a loving relationship with his partner of 15 years. Unfortunately, X’s partner passed away very suddenly in 2016. Around this time, X also lost another family member and was having to deal with the bereavement of two people very close to him. Shortly after this, X was diagnosed with osteoporosis, and was signed off work. Since then, X’s household bills spiralled out of control, as he had only been receiving Statutory Sick Pay and his partner had previously managed all of the household finances. X was referred to Integrated Plus by his GP, and he started working with a Locality Link Officer. The Officer supported X to access a Gateway Appointment at Citizens Advice, so that X could receive help in managing his finances and debts. Citizens Advice carried out a benefit check, to ensure that X was receiving all the benefits he was entitled to. Citizens Advice were also able to liaise with his creditors, to arrange a payment plan. All in all, with the help of Citizens Advice, X has been able to organise his council tax, housing benefit, bank, electric and gas debts and is now making contributions to these, which he is able to afford. Around the time that X’s partner passed away, X had also received a parking ticket. Due to the other issues taking priority at the time, this remained unpaid, and was starting to develop into a substantial amount of debt. The Officer approached the creditors with whom the debt lay with, and asked whether anything could be done, due to the extenuating circumstances. They agreed that X would be able to complete and return a form and they would then consider the situation. A Link Support Worker helped X to complete the form. Unfortunately, they refused to take into account the extenuating circumstances, and directed the Link Support Worker to the Local Authority. The Support Worker contacted Dudley Council and after many long conversations and emails, they agreed to waive the debt, providing the original parking ticket fee was paid within 2 weeks. X went down to the council and paid the original charge, which he was able to afford, and the matter has now been closed. X commented saying that this was a ‘massive weight off his shoulders’ and said that he finally feels that ‘things are moving forward’ for him. Due to X’s diagnosis of osteoporosis, he is unable to go back to his previous job in the building trade. However, X was successful in applying for a handy person’s role in a nearby shopping centre. He is due to start work full time, and is looking forward to being around customers, and being in a better position financially. X has also been spending time with old friends, and is now in a much more positive place. X has said that he “can’t thank the Integrated Plus team enough”, and that he feels a “huge weight has been lifted off my shoulders”.

Story Six: Barry connected into social activities to reduce his feelings of isolation and depression Barry is an ex-service man, having served in both the Army and Navy for over 25 years. Barry has several long term health conditions, including Diabetes and Arthritis and he is also visually impaired. He was referred to Integrated Plus by his GP due to him feeling isolated and depressed. Barry had no friends and said he felt ‘worthless.’ A particular frustration felt by Barry was his lack of independence and mobility due to his inability to drive anymore. Barry said he felt he was “getting under my wife’s feet being at home all the time” and he felt this was causing a strain on their relationship. When Barry met the Locality Link Officer for Stourbridge, Wollescote and Lye, Barry admitted to the Link Officer he was ‘lonely and bored.’ This was not easy for a proud ex-soldier, who had travelled the world and experienced hostile situations, to admit to. The Link Officer suggested to Barry to consider attending The Monday Men’s Club at Christ Church in Lye to enable to him to meet other people who are also experiencing loneliness and isolation. The Men’s Club has been a major success story with a regular and consistent number of about twenty men visiting every Monday morning between 10 am and 1pm. So far, around 70 men in total have attended. There are refreshments, a pool table, darts board, cards, games and newspapers. Lots of activities take place including, breakfast mornings, get cooking, pool and darts competitions and bread making sessions. Last year a Christmas Lunch was well attended and enjoyed by the men. A supportive and nonjudgemental camaraderie and atmosphere is fostered and this is respected by the men who attend. At the Monday morning activities, men also share their knowledge and skills and lead on sharing these with others. For example, one regular attender has shared his knowledge of cooking curries with others. Barry began attending the Monday activities supported by his wife and he has now become a regular attendee. He has made new friends who he looks forward to spending time with others. His friendships have developed further and he now meets up with his new friends outside of the Monday activities at home and in social situations. Barry said he was not aware of any activities like this in his local area and he said the friendships he has made have “lifted me off the floor and given me something to look forward to”. Barry’s wife commented that she is also happy with the positive impact it has had on him.

Story Seven: Mr. P helped with improving his confidence to access local services Mr. P has a learning disability and was having little contact with others, only seeing his brother occasionally. Mr. P lost his job a few years ago which significantly knocked his confidence and he struggled to build routine into everyday life, feeling frustrated and isolated as a result. Mr. P was referred to Integrated Plus via a Care Co-ordinator in the north of Dudley. He was referred to the service as he frequently attended the practice and the Care Co-ordinator and GP felt he would benefit from accessing social opportunities and support. Jason Griffiths, the Link Officer for Sedgely, Coseley and Gornal met with Mr. P at the practice and discussed his circumstances at length. It was clear that he was frustrated with his current situation. Mr. P wanted to meet new people who he felt would understand him and offer him an opportunity to get out of the house more. Several services were identified which were of interest and Jason accompanied Mr. P to Dudley Voices for Choice (DVfC). DVfC are a user led charitable organisation that supports people with learning disabilities and autism to speak up for themselves. They have been supporting people across the borough for over ten years. They offered him an opportunity to volunteer and access their social day on a Friday where he could meet people, gain new skills and hone his existing pool playing talents. To enable Mr. P to access the social events we applied for a Network West Midlands concessionary travel pass, accompanied with a supporting letter from his GP, this came through successfully in under two weeks. Further conversations with Mr. P identified that his long term goal was to gain employment but he did not feel ready due to low confidence and because of a previous poor employment experience. We discussed Employment Plus, a Local authority service who support people with a learning disability and/or autism into paid employment. They work in a person centered way at a pace that suits the individual and ensure employers offer suitable support for people with learning disabilities. They were able to help Mr. P settle into a mandatory DWP Work Programme delivered by the Salvation Army. There he has been able to gain employability skills and has been accessing numeracy, literacy and IT courses. Since initially engaging with Integrated Plus and DVfC, Mr. P has also accessed further support through Dudley Advocacy and has volunteered at a local Gap Club. These are social clubs for adults with a learning disability and learning difficulties delivered by Langstone Society at community venues across the borough. This has given him the confidence to take on other volunteering roles including one at a bike shop where he enjoyed meeting new people and gaining customer service skills. Having had conversations with Mr. P, his Care Co-ordinator and the voluntary sector supporting organisations, we felt that it was important to have a number of services for Mr. P to draw upon. This meant that he was clear of when and where he could access specific support. DVfC are continuing to work with Mr. P and to help him get the right balance when managing his busy schedule. He is keen to move into employment and is currently gaining new skills and enjoying socialising in environments he feels comfortable in. “Jason (Link Officer) has helped me a lot, he has given me my confidence back. He is a very kind person. I am getting on well with people and beating everyone at pool. My life is getting better and I feel I will get back into work.” Mr. P “Mr. P’s coming in to the practice a lot a less, I’m here but I haven’t seen him. He used to come in a lot. Mr. P is a social person, it’s great that suitable services have been identified.” Care Coordinator “Since we first met Mr. P we have witnessed his confidence grow and willingness to engage in new activities increase. He is now an integral part of our team and makes invaluable contributions to our service. We look forward to continuing to be a part of his journey.’ Sarah DVfC

Story Eight: Jean suffering from isolation and depression Jean was referred to the Integrated Plus service in March 2017 by her GP who thought she would benefit from the service. Jean’s GP was based in Brierley Hill so she was referred to the Kingswinford, Amblecote and Brierley Hill locality. The GP referral said Jean’s issues were around her depression and social isolation. The Link Officer went out and visited Jean and her husband Albert at their home. During the visit Jean told the link officer that she had suffered from depression since her 30s (Jean is now in her 80s) when she gave birth to her daughter. During this time Jean had electro-convulsive therapy that was effective for a time. Jean also has other health issues, such as a heart problem, for which she has a pacemaker, and she has memory problems that impacts on her ability to remember and complete tasks. Jean eventually had to give up work at Marks and Spencer’s due to her health issues worsening. As a result of this Jean has found that she is not going out very often and her social circle has shrunk dramatically. Jean’s health problems have also impacted on her and Albert’s daily life. They had resorted to living on mainly sandwiches and soups for meals because when Jean is particularly down she cannot cope with cooking a full main meal. The link officer suggested that they might be interested in looking at The Gourmet Food Care service that delivers hot, nutritious meals, ready to eat, to the home. Both Jean and Albert thought this would be a good service for them so the link officer said she would send out the information. When the conversation turned to how Jean and Albert were coping financially the link officer was told that they are just about coping on their pensions. The link officer asked if they had ever tried to claim Attendance Allowance due to Jean’s health problems. Jean was unsure but Albert said they had never tried to claim this. Albert went on to say that he did not think they would be entitled to in anyway as they have a small amount of money saved. The link officer told them that the fact that they have savings will not impact on the decision made for Attendance Allowance as the benefit is not means tested, so the DWP will not look at other income. The link officer offered to help them apply for this benefit. Albert and Jean said they would like to try but insisted that they would not get it but they had nothing to lose in trying. The link support worker went out to visit Jean and Albert a few days later and helped them to fill in the application for Attendance Allowance. Albert was still sure that they would not be given Attendance Allowance. The link support worker also took the information about The Gourmet Food Care Service that the link officer had said she would supply. Six weeks later the link support worker called Albert and Jean to see if she could arrange to visit them again to complete a follow up assessment and service review. Albert answered the phone and said that they would really like the link support worker to visit again. Albert also told the link support worker that they had received a letter from the DWP confirming that they had been awarded Attendance Allowance at a rate of £56 a week. Albert was really surprised and extremely grateful that they had been given this extra money and said it would be a huge help. The link support worker made an appointment to visit Jean and Albert at their home and went out a couple of days after the telephone conversation. During this visit Albert told the link support worker how the extra money will be of help to them both. Because of Jean’s and Albert’s health issues they find it increasingly difficult to cook good food, so the Attendance Allowance money is allowing them to afford to buy quality ready meals from Marks and Spencer’s, where Jean used to work. This have taken a huge weight off them both because the last time Jean tried to cook she cut her thumb quite badly while peeling potatoes. Jean is now also attending a social group where she can play bingo and meet new people. This was important to Jean because, in her words, she is a people person. Jean now also attends a seated exercise group which she says has been beneficial and she feels better when she goes. She is also meeting new people and feels her social life is getting better. Albert agrees with this as recently Jean has been having more good days than she was having previously. 50

Story Nine: Mr C Mr C, who is in his late 50s, lives alone and has a learning disability. He is registered as partially sighted and has glaucoma, for which he is under the care of his local hospital. He is also partially deaf. Mr C travels on the bus regularly as he volunteers at a local care home each week. He enjoys volunteering and spending time with people. He has gained many qualifications and certificates over the years. He is on a limited budget. Mr C was referred to Integrated Plus by his GP (via a Multi-Disciplinary Team meeting) because he suffers from isolation, long term health conditions and an unhealthy diet. Through face to face intervention with Mr C, the Link Officer was able to identify a range of support organisations in the local community. The Link Officer provided Mr C with guidance and information regarding a number of services and activities based on his circumstances and interests. Some of these included the Vision Support Service, Citizens Advice and applying for a Disabled Person’s Bus Pass. The Link Officer asked the Link Support Worker to make a referral to the Vision Support Service. Mr C was visited within a week of the referral being made and was given aids to assist him with daily living tasks. They provided a large bright lamp (so that Mr C is able to read his correspondence easily) and a white stick so that he is safer when crossing the road. Mr C commented that he is “very happy” with the lamp and stated that “it’s easier to clean” his home with the increased light in the room. The Vision Support Service then referred Mr C to the Birmingham Midlands Eye Centre to see whether he needs any further magnification aids. The Link Support Worker helped Mr C complete a Disabled Person’s Bus Pass application form and gather the paper evidence needed. Mr C was paying £24.50 a fortnight for a bus pass in order to travel to his volunteer placement. Within 2 weeks of the application being sent he was awarded a Disabled Person’s Bus Pass. This was important for Mr C as it saves him money and this means that he is able to continue in his volunteering which stops him feeling isolated. Mr C mentioned that the communal light outside his flat was not working. As Mr C is partially sighted this meant that he was not able to gain easy access to his home. The Link Support Worker made a call to the Housing Association and the communal light was fixed within 2 days, meaning that Mr C is now able to confidently enter his home safely. Subsequently, the boiler in Mr Cs home has now been fixed he now has access to hot water and heating. It was identified by the Link Officer that Mr C was not paying his TV licence or his water bill. With support, Mr C was proactive and made an appointment to see Citizens Advice and they helped Mr C set up a payment plan for his TV licence. In addition, both Integrated Plus and Citizens Advice have jointly helped Mr C apply for a discounted water bill. Mr C commented that he is now “feeling much better” and is pursuing some of his hobbies such as decorating his home and growing plants. He has also started to play darts again! Mr C has started to address his unhealthy eating and drinking habits, feels better and looks visibly healthier. The Disabled Person’s Bus Pass enables him to access free bus, train and metro services during off peak hours and also free Ring and Ride journeys. In a short period of time with Integrated Plus support, very positive changes have taken plan for Mr C, and he values the ongoing support we are providing.

Story Ten: Ivan, 68 isolated and struggling with housing Ivan is 68 and lived alone in a three bedroom house after the death of his wife in 2014. He has two daughters and one son. Since his wife was nursed to her passing at home his daughters found it very hard to visit the family home. One daughter was the only member to visit and provided him with all his informal care. He has lived with a condition that affects his mobility for over 20 years and has recently received knee surgery. He is a long term sufferer with stress, anxiety and depression which has been exacerbated by his wife’s death and the death of his son in 1992. Ivan’s GP made a referral to Integrated Plus via a Multi-disciplinary Team meeting to support with his stress, anxiety and depression. Upon assessment it became apparent that much of his stress, anxiety and depression was due to his housing situation, as well as his issues around bereavement. He previously requested to be moved to an Extra Care housing scheme but his application was denied. He was given the impression that someone would be in touch with him to discuss options, but he heard nothing. Over the coming weeks and months he fell deeper into depression. After an attempted burglary he did not feel safe in his own home and was also having regular falls. As he was unable to get upstairs he was sleeping in an armchair in the living room. His anxiety was growing as his only visiting daughter was scheduled to receive a major operation in the north and would be unable to support him for many weeks. Furthermore the assessment identified that he had an interest in improving his IT skills, and getting out and about socially. The link officer liaised with Adult Social Care and arranged for another assessment to be completed; taking into account his more recent mobility issues since his knee surgery and his daughters scheduled operation. The link officer sat with him during this assessment and supported him to provide all the information required to provide a full assessment of his needs. The link officer also escorted him to Age UK’s Springboard Project at Merry Hill Waterfront and encouraged him to access support at The White House; recommending the services available to him there. Finally the link officer placed a referral to Living Well, Feeling Safe to improve the security on his home. Ivan attended The White House for support and had a number of security improvements on his home to make him feel safe until he moved. These included a security light at the rear of the property, a key safe, and an intercom system. Ivan’s assessment was taken back to the Housing Association panel and he was allocated an apartment in a new Extra Care Housing Scheme in Cradley Heath. He is loving his new accommodation and has made quite a few friends with the other residents. In being part of the first wave of occupants he is involved in forming the residents committee and calls the bingo each session. He also enjoys eating his breakfast each morning in the canteen as pictured. “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 Terry 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”. (Mr Ivan Carter)

Appendix Names of organisations where onward connections/referrals have been made Organisation All Saints Church, Sedgely Blackheath Central Methodist Church Blackheath Islamic Community Centre Buddhist Centre, Cradley Heath CARES Sandwell Carters Lane Baptist Church Champions Church Chawn Hill Church Christ Church, Quarry Bank Christians Against Poverty Dudley Methodist Church Flame Church, Blackheath Ghausia Mosque & Welfare Association Gig Mill Church Halesowen United Church Hasbury Christian Fellowship Hasbury Methodist Church Hurst Green Family Church Hurst Green Methodist Church Kingswinford Christian Centre Overend Methodist Mission Providence Methodist Church, Lye Quinton Methodist Church activities Revival Fires Romsley Methodist Church Short Cross Methodist Church Shree Gujarati Hindu Centre St Michael and All Angels Church St Michael's Church Lunch Club St Peters Church, Cradley St Peters Church, Pedmore St. James' Church - Wollaston St. Paul's Church Blackheath Stourbridge Roman Catholic Church United Church Lye Warley Baptist Church Quinton Methodist Church Department for work and pensions A.W. Surgeries (Albion House) Central Clinic Surgery (Dudley) Dudley & Walsall Mental Health Trust Dudley Group NHS Foundation Trust Lion Health Medical Practice Netherton Health Centre Sandwell Hospital

Referral numbers 2 12 2 2 9 4 1 6 2 2 2 2 1 2 2 5 8 2 11 2 1 17 25 2 5 61 1 2 47 7 34 90 6 2 6 2 1 208 1 1 42 1 4 2 2

Sector faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith faith government NHS NHS NHS NHS NHS NHS NHS 53

St James Medical Practice (Dr Porter) Urgent Care Centre Bras 4 All Care Home Select Centro (Bus Pass) Driving Miss Daisy KFC Quality Meals Knitted Knockers UK Mindful Gifts On Call Opticians Slimming World Specsavers You wear it well Wiltshire Foods Accessible Transport Group, Ring & Ride Blackheath Library Bromsgrove Council Childrenâ&#x20AC;&#x2122;s Centres Connexions Crystal Leisure Centre Dudley College Dudley Leisure Centre Dudley MBC Dudley North Childrenâ&#x20AC;&#x2122;s Centre Cluster Dudley Wood Library Fircroft College Haden Hill Leisure Centre Halesowen College Halesowen College Over 50s Club Halesowen Leisure Centre Halesowen Library Hunting Tree Park Healthy Hub Kidderminster College Kingswinford Library Leasowes Adult Education Leasowes Leisure Centre Leasowes Park Activities Our Lady & St. Kenelm RC Primary Portway Leisure Centre Public Health Sandwell Council Solutions 4 Health Staffordshire Care Advice Line The Crestwood School The Dormston School Thorns Community College Triple PPP (Positive Parenting Programme) Vision Support Service Warm Zones Sandwell

1 1 1 21 3 111 47 1 58 7 9 7 1 24 213 15 5 2 2 1 1 2 110 2 1 1 11 1 46 24 6 37 2 1 26 2 9 1 15 6 17 4 1 2 1 2 1 37 6

NHS NHS private private private private private private private private private private private private statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory statutory 54

West Midlands Fire Service Dudley Carers Forum Action Heart Action on Hearing Loss African Caribbean Befriending Service (Dudley) Age Concern Sedgley & District Age Concern Stourbridge & Halesowen Age UK Dudley Age UK Sandwell AgeUK Hereford and Worcester Agewell Community Hub Alcoholics Anonymous Alzheimer's Society Amblecote Christian Centre Amblecote Phoenix - National Council for Divorced, Separated and Widowed Amy's Oven Aquarius Art Space Arthritis Research UK Autism Black Country Social Club Autism Connect Autism Drop In Autism West Midlands Baggeridge Active Retirement Group Beacon - Halesowen Beacon - Stourbridge Beacon - Wolverhampton Beacon Extra Care Beanstalk Berith & Camphill Partnership Betel - gardening services Bethel Chapel Lunch Club Better Understanding of Dementia Birmingham Adult Dyslexia Group Birmingham and District Tinnitus Group Black Country Artists Black Country Fibromyalgia Support Group Black Country Foodbank Black Country Housing Group Black Country Impact Black Country Neurological Alliance Blackheath Live at Home Scheme Blind Veterans UK Blue Badge Network Bounce Back to Health and Happiness British Dyslexia Association British Heart Foundation British Red Cross

58 25 3 13 2 15 90 482 9 4 6 4 106 50

statutory voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary

3 2 1 35 9 2 2 2 12 2 9 4 95 2 2 7 4 13 4 1 2 2 22 31 18 1 13 21 1 26 2 1 4 11

British Trust for Conservation Volunteers Brockmoor & District Community Association Building Bridges BURT Community Transport Buzz Youth Theatre Company Carers UK Carters Lane Church 6.5 Special Luncheon Club Castle & Crystal Credit Union Cats Protection League Centre for Equality & Diversity Chemistry Cafe Arts Group Cherish Bereavement Support Churches Housing Association of Dudley & District - CHADD Citizens Advice Bureau (Dudley) Citizens Advice Bureau (Halesowen) Citizens Advice (Sandwell) Citizens Advice (Walsall) Cloverleaf Colley Gate Gardening Club Combat Stress - The Veterans Mental Health Charity Community Association of Norton Cornbow Quilters Cornerstone Cradley Community Centre Cradley Heath Community Link Cradley Heath Creative Creative Support CRI Atlantic House Recovery Project Cruse Bereavement Care Crystal Bowls Club Cystitis and Overactive Bladder Foundation DeafPlus - debt advice Diabetes UK Disability in Action Disabled Bowls Association Discover U Dudley & District Amateur Radio Society Dudley Advocacy Dudley Al Karim Foundation Dudley Asian Women's Network Dudley Autistic Support Group Dudley Canal Trust Dudley Caribbean and Friends Dudley Counselling Centre Dudley Crossroads Dudley Hearts Undergoing Support (H.U.G.S.) Dudley Macular Disease Support Group Dudley Mind Dudley Parent Carer Forum

4 2 25 4

voluntary voluntary voluntary voluntary

2 4 7 5 1 4 5 1 28 91 120 12 1 2 4 2 4 6 3 18 4 6 113 28 75 2 8 2 12 7 1 2 2 36 1 15 4 10 1 16 53 10 1 261 5

voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary 56

Dudley Rheumatoid Arthritis Support Group Dudley Stroke Association Dudley Voices for Choice Dudley Widows and Friends Circle Ehsas Carers Enville Street Dramatic Society Epic Cafe Epilepsy Association For Men Monday Club Fibromyalgia Support Group Francis Brett Young Society Friends @ Beacon Future Proof by Agewell CIC Good Companions - Sitting Service and Companionship Good News Recycling - CIA Christians in Action Groundwork West Midlands Halas Homes Halesowen & Dudley Yemeni Community Association Halesowen and District Scout Group Halesowen Asian Elderly Association Halesowen Flower Club Halesowen in Bloom Halesowen Neighbourhood Watch Halesowen Tennis Club Headway Black Country Health Exchange Healthwatch Dudley Heantun Housing Hearing Dogs for the Deaf Helping Hands Home Instead Home Matters Supporting People Ltd Home Start Hope Centre Ideal for All - Independent Living Centre IRIS Sandwell INSIGHT House Loaves and Fishes Just Straight Talk Kaleidoscope Kids Orchard Kingswinford Community Centre Langstone Society Lapal Scouts Life Centre Debt Advice Life Line Options Lower Gornal Darby and Joan Lunch on the Run Lutley Community Association

28 35 24 1 4 4 1 7 173 1 1 2 1 7 3 2 11 5 1 8 1 4 2 1 13 149 37 40 2 2 55 2 1 36 1 1 3 1 11 5 1 1 19 1 2 3 1 3 19

Lutley Day Centre Luncheon Club Lye Community Events Lye Community project MacMillan Cancer Support Macular Society Dudley Support Group Making Smiles Man Made Dudley

20 2 4 2 14 6 1

voluntary voluntary voluntary voluntary voluntary voluntary voluntary

Mary Stevens Hospice Mental Health Peer to Peer Support Group Midland Heart Miles and Smiles Club Multiple Sclerosis Society (Dudley & District Branch) Narcotics Anonymous

4 2 26 8 6 2

voluntary voluntary voluntary voluntary voluntary voluntary

National Association of People Abused in Childhood (NAPAC) National Domestic Violence Helpline National Osteoporosis Group Net Cafe, Lye Netherton Photographic Society Nine Locks Community Association Norton Community Centre Norton Sunshine Club Nova Training - Lye, Stourbridge, Dudley OCD Action Old Hill Angling Club Olive Hill Primary Omega Care for Life (Bereavement) Oxfam Parkinson's Disease Society UK Dudley Branch Pay Plan Pedmore Senior Citizens Club (Saint Peters) Pets as Therapy Phase Trust Physically Handicapped and Able Bodied Club Pinnacle Support PTSD Action Charity PTSD Resolution

6 2 9 10 6 1 3 1 2 2 2 2 15 2 11 1 1 1 4 2 3 3 2

Quarry Bank Community Association Queens Alexandra's Royal Naval Nursing Service Queens Cross Network Queensway Centre for Retired Citizens Quinbourne Centre R.S.P.B.

17 1 10 48 2 2

voluntary voluntary voluntary voluntary voluntary voluntary

2 6 11 2 130 3

voluntary voluntary voluntary voluntary voluntary voluntary

Recovery Near You Refugee and Migrant Centre, Wolverhampton Relate (Sandwell and Dudley) Remploy - Putting Ability First Rethink Mental Illness Romsley and Hunnington History Society

Royal Air Forces Association Royal British Legion (Halesowen)

1 voluntary 67 voluntary

Royal National Institute of Blind People (RNIB) - Birmingham Royal Signals Association Royal Voluntary Service Salvation Army Samaritans Sandwell Deaf Community Association Saneline Scope (Stourbridge) Sedgley & District Community Association Sedgley Townswomen's Guild Self Help Painting Group - Sedgley Senior Citizens Enterprise Woodwork Group Shelter Shopmobility Wolverhampton Sickle Cell and Thalassaemia Support Group Side By Side Theatre Company Stourbridge Silverline (Befriending Service) Smile Smilers Club SODA South Staffordshire Council Spurgeons - Young Carers SSAFA Forces Help Dudley Division St Basils St. Paul's Community & Learning Centre St. Thomas's Community Network Step Change Stepping Out Day Centre Steps to Work

20 2 82 19 41 4 4 3 1 6 2 2 4 2 1 6 46 2 1 1 1 6 12 2 2 3 24 3 11

Stourbridge Bereavement Support Group Stourbridge Historical Society Stourbridge Institute Stourbridge Womenâ&#x20AC;&#x2122;s Peer Group

18 7 1 12

voluntary voluntary voluntary voluntary

Stourbug Summit House Support Ltd - Brindley House Sunday Friends Support for Murder and Manslaughter Supporting Companions Tandrusti Health Education Project Telephone preference service The Coach Community Arts and Crafts Centre The Hope Centre The ME Association (Myalgic Encephalopathy Chronic Fatigue Syndrome) The National Autistic Society The Royal British Legion

11 19 14 1 29 11 4 7 16

voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary voluntary

3 voluntary 1 voluntary 2 voluntary 59

The Wednesday Club - Sedgley The Welcome Group The Wildlife Trust for Birmingham and the Black Country The Y project Time Out Top Church Training Towns Womenâ&#x20AC;&#x2122;s Guild (Halesowen) Triumph Over Autism Dudley Support Turn 2 Us: Fighting UK Poverty Universal Support Project University of the Third Age (U3A) Up and downs Support Group Unicorn Day Centre for Disabled People Victim Support Volunteer Walkers - Greyhound Trust Wall Heath Community Association Way Foundation - Widowed and Young Welcome Group Halesowen West Midlands Family Mediation Service West Midlands Guild of Woodworkers What Centre White House Cancer Support Wolverhampton Citizens Advice Bureau Woodside Community Association Wordsley & District Community Association Writing West Midlands Yemeni Community Association (Sandwell) Youth Hub Zion Christian Centre

2 1 1 1 20 1 5 2 3 2 77 2 1 17 2 4 1 1 1 2 4 33 9 4 4 6 1 1 46

Connections to services/projects/activities Service Dudley Talking Therapy Service Enhanced Primary Mental Health Service Mental Health Floating Support Mental Health Primary Care Team The Crisis Team Adult Community Learning (ACL) Adult Social Care Adult Social Care - Continence Service Adult Social Care (falls prevention service) Adult Social Care (low vision support service) Adult Social Care (occupational therapy) Adult Social Care (safeguarding) Adult Social Care (telecare service) Adult Social Care (urgent care team) Adults Social Care (carers assessment) Blue Badge Scheme

Referral numbers 15 10 9 6 11 130 104 3 52 1 27 1 115 2 8 8

Sector NHS NHS NHS NHS NHS Statutory Statutory Statutory Statutory Statutory Statutory Statutory Statutory Statutory Statutory Statutory 60

Carers Network (DMBC) Community Engagement Service (OT) Community Offer Service Connexions Deaf Support Service Dementia gateway Directorate of Adult, Community & Housing Services (DACHS) Dudley Assisted Living Centre Dudley Children's Services Dudley Council Plus Dudley Domestic Violence and Abuse Support Service Dudley Health Visiting Service Dudley Home Improvement Service Dudley Mediation Service Dudley Self-Management Team Dudley Stroke Rehab Service Dudley Wheelchair Service Early Help Common Assessment Team (previously CAF) Enabling Community Support Gateway Referral Get Cooking

198 38 1 5 61 37 3 60 2 38 15 1 105 2 162 1 7 3 61 24 53

Statutory Statutory Statutory Statutory Statutory Statutory Statutory Statutory Statutory Statutory Statutory Statutory Statutory Statutory Statutory Statutory Statutory Statutory Statutory Statutory Statutory

Home library service Home Repairs Assistance Homelessness Prevention and Response Team Housing (DMBC) Let's Get Dudley Healthy let's Get Active Outdoors Living Well Feeling Safe Local Welfare Assistance Service Sandwell Adult Social Care Sandwell Lifestyle Choices (Health checks) Smoking cessation South Staffs Welfare Benefits Service Staffordshire Cares, Adult Social Care STAY ? Sandwell Telecare Assisting You Welfare Assistance Winter Warmth Wolverhampton Adult Education Service Wolverhampton Adult Social Care Wolverhampton Carers Support Wolverhampton Community and Wellbeing Hub Wolverhampton Floating Support Service Advice and information Age Concern 50+ Exercise Class

175 1 4 37 5 3 15 2 15 1 2 1 1 7 1 182 2 5 2 2 2 2 7

2 2 5 41 20

voluntary sector voluntary sector voluntary sector voluntary sector voluntary sector

Blue Light Programme Book and a Cuppa Bridges CADAL Carers co-ordinator (Dudley CVS)

Carters Lane Luncheon Club Daybreak (lunch club) Fix a home booklet Garden Pathways Get Set To Go Good neighbour scheme Leap Service stay active MacMillan CAB Making Waves - Air Time New Beginnings Domestic Abuse Support Service Pilates Classes (Halesowen) Shop Mobility Social Prescribing Springboard Stay Safe/small tasks Stepping Out United Church Halesowen Singing Group The Haven Peer Support Group for Moms with mental health problems Volunteer Centre DCVS Zion Christian Centre Luncheon Club

1 5 56 1 8 41 16 8 21 8 12 20 221 97 4 2 1

voluntary sector voluntary sector voluntary sector voluntary sector voluntary sector voluntary sector voluntary sector voluntary sector voluntary sector voluntary sector voluntary sector voluntary sector voluntary sector voluntary sector voluntary sector voluntary sector voluntary sector

1 voluntary sector 16 voluntary sector 46 voluntary sector