Steps Towards Implementing Self Care

Steps towards implementing self-care: A focus on Social Prescribing for Commissioners January 2017 Steps towards implementing self-care: A focus on Social Prescribing for Commissioners Contents i. Foreword 3 ii. Executive summary co-produced by Londoners 4 1. Introduction – social prescribing and its alignment with self-care 6 1.1. What is social prescribing? 6 o Operating model for social prescribing and access to community based resources 9 o Factors associated with successful social prescribing schemes 10 1.2 Why does social prescribing matter? 10 o Building a business case 11 o Financial modelling 12 o Impact and implementation matrix 14 1.3 Social prescribing in London 15 o Map of social prescribing schemes in London 15 2. Steps towards implementation we have learned so far 16 2.1 Identifying the target population and local needs 16 2.2 Identifying local partners and assets 17 2.3 Funding and resources 18 2.4 Things to consider when developing local operating models 18 2.5 Contracting, governance and risk 18 3. Monitoring and evaluating social prescribing 21 4. Enabling approaches 23 5. Useful Websites 27 6. Acknowledgments 28 7. References 30 Appendix A; Appendix B; Appendix C; Appendix D; Social prescribing for children, young people, parents and carers 32 Examples of social prescribing interventions and activities 37 New care models (NHS England) 38 Potential funding sources for social prescribing 39 2  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners Foreword London is a vibrant city with diverse communities, assets and a deep reservoir of social capital. However, London also has significant inequalities in wealth, mental and physical health. In aspiring to be the world’s healthiest major global city, the London Health Commission’s report Better Health for London1 calls for coordinated action to enable Londoners to do more to look after themselves. This aspiration strongly aligns with NHS England’s vision for change, as set out in Chapter 2 of the Five Year Forward View, and its focus on how people powered health can be achieved through the ‘renewable energy of communities’. Since April 2015, Healthy London Partnership has galvanised leadership, forged strong links with national, regional and local partners and focused on evolving the evidence-base to demonstrate the value of person-centred and community-centred approaches. All five London Sustainability and Transformation plans (or STPs) identified a focus on social prescribing as a means of implementing a range of person-centred approaches in tandem with preventative initiatives and maximising the use of community based assets. We have drawn inspiration and learning from the early adopting innovators like Bromley-by-Bow, Rotherham, Bristol, City & Hackney and others in developing this commissioners’ resource. It aims to help local leaders to take the first steps towards implementing social prescribing for their populations. It is not a definitive guide but offers practical assistance on what we have learned so far from the best available evidence to support local implementation. We are encouraged by the depth and breadth of social prescribing schemes operational across London. This gives us confidence that local leaders have the necessary assets in place to build on to make social prescribing more widely available. The challenge therefore for commissioners is how can social prescribing, in time, become mainstream business - and systematically available to people of all ages across the capital, regardless of their mental and/or physical conditions. Healthy London Partnership intends to build on this resource in 2017 when additional resources and support will be available following further collaboration with NHS England, Public Health England, the Social Prescribing Network, Greater London Authority, London Councils, London branches of the Association of Directors of Adult Social Services (ADASS) and Association of Directors of Public Health (ADPH) and of course local STP, Clinical Commissioning Group, local authority, lay partner, voluntary and community sector input. We do hope you find this resource helpful. Graham MacKenzie SRO Personalisation & Self-Care Healthy London Partnership Chief Officer Wandsworth Clinical Commissioning Group 1 http://www.londonhealthcommission.org.uk/better-health-for-london/ Jane Barnacle SRO Personalisation & Self-Care Healthy London Partnership Regional Director – Patients & Information NHS England (London region) 3  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners Executive summary Co-produced with experts by experience from NHS North West London Collaboration of Clinical Commissioning Groups and the Healthy London Partnership What is social prescribing and why do we need it? Social prescribing is a way in which people living with long term conditions can get access to a variety of support they need but that doctors and nurses are not equipped to provide. Things like help with getting a job, housing, debt management and social contact. Help with these things is often available through local authorities, charities and local community organisations, but few people know about the full range of support available. Social prescribing means that the individual can build their support by working with a link person who does know, or who has expertise in finding out, what is available. Together with the link person, the individual can discuss their problems and identify the support that they need to manage their own health more effectively and meet their own personal goals. Social prescribing is built through the experience of people living with a range of health conditions, including long term conditions, disability and those with carer’s responsibilities. That support has to be centred around the needs and aspirations of the individual. Those providing support have to work together breaking through any silos to build the support around the individual. Social prescribing can help people to use the Five Ways to Wellbeing2 which were developed by the New Economics Foundation. They are; • Give • Connect • Keep learning • Be active • Take notice Social prescribing usually includes a range of voluntary activity (give), being and socialising with others (connect), often an element of learning (keep learning) and physical activity (be active), and with a need to be aware of what is going on around (take notice). It is therefore well placed to promote health and wellbeing. An interesting side effect of social prescriptions is that those who have used them, often go on to want to volunteer and help others themselves, creating an increase in community capacity. Social prescribing is not a new concept. It has been around for about 15 years, in various forms, from signposting services to holistic models involving referrals and active support3. This variation is reflected in London, which means that there are a range of models and experience in the capital which can be drawn on, including brokerage models for independent living. 2 New Economics Foundation (2008): https://www.gov.uk/government/publications/five-ways-to-mental-wellbeing 3 Kimberlee, R. (2015) What is social prescribing? Advances in Social Sciences Research Journal, 2 (1) http://eprints.uwe.ac.uk/24818/1/808-2245-1-PB.pdf 4  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners Getting started This paper is designed to help commissioners invest effectively in social prescribing. It does so first by setting out the steps needed to get started in Section 2: • Needs: Identify the target population and local needs • Assets: Identify local partners and community assets • Funding and resources: Work out funding, resources, contracting, governance and risk • Structures, processes and value for money: Set out the business case for the investment, citing ethical, economic and practical arguments • National standards and governance: Compliance with national standards and requirements for all providers Monitoring and evaluating All services need to be able to demonstrate their impact and value for money. This paper provides a framework for monitoring and evaluating in Section 3, drawn from the National Social Prescribing Network, which can be the basis for local discussion. Supporting social prescribing In Section 4 the paper identifies a range of activities needed to support social prescribing: • Training and activating the workforce: for social prescribing to be effective, GPs and nurses will need to know about it and trained link workers will be needed. Commissioners need to be sure that providers have a workforce with the appropriate knowledge, skills and attitudes. • Technology and digital solutions: Most (but not all) people use the internet and value the opportunity to be connected to sources of support online. The paper gives evidence to support this approach and examples of effective use of technology in supporting social prescribing and self-care. • Making the most of online directories: This paper discusses approaches to local directories and networks as a means of promoting awareness of smaller ‘hyper-local’ voluntary and community sector support. Additional resources Finally, the paper includes a summary of useful websites (Section 5); full list of references (Section 6); details of social prescribing for children, young people, parents and carers (Appendix A); service examples (Appendix B); and potential sources of funding (Appendix D). Healthy London Partnership team Healthy London Partnership team members that have developed this resource include Shaun Crowe, Brendan McLoughlin, Helen Davies, Jason Tong and Charlotte Owen. In section 6 we have also acknowledged the contributions of many individuals who have kindly contributed their time and expertise to this project. Special thanks need to be given to the North West London lay partners and Healthy London Partnership public champions for co-producing the executive summary, as well as Fran White and Cait Kielty-Adey (HLP Children & Young People programme) for leading the research and development of all content in Appendix A covering social prescribing for children, young people, parents and carers. 5  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners 1. Introduction - social prescribing and its alignment with self-care This document complements the HLP self-care resource “Steps towards implementing self-care: A resource for the NHS” (available in early 2017) and provides additional information and resources to support local action on social prescribing. It is aimed primarily at NHS commissioners but is likely to be useful to others involved in local partnerships which are crucial to the success of social prescribing. The Healthy London Partnership (HLP) is sharing this resource to support planning of new provision or the development, evaluation and scaling up of existing social prescribing schemes. It offers practical advice and information based on what is currently known and is being offered as ‘work-in-progress’ to which both local partnerships and national networks will continue to add over coming months and years. Commissioners and leaders across sectors are encouraged to initiate or expand their own work in this area, sharing their experience and learning, and continuing to engage with the Social Prescribing Network as it develops additional national guidance and resources. Different models for social prescribing exist. This document is designed to assist decision making and implementation in ways which best reflect local needs and local assets. It focuses primarily on people with long term health conditions, but the principles and practice are more widely applicable, including for prevention. It is also designed to be read with the Healthy London Partnership’s Personalisation and Self-Care Case for Change (Healthy London Partnership 2016)4 which calls for improved investment in person-centred and community-centred approaches. Healthy London Partnership sees social prescribing as a key vehicle to increase public utilisation of these resources. 1.1 What is social prescribing? Social prescribing ‘enables healthcare professionals to refer patients to a link worker, to co-design a non-clinical social prescription to improve their health and well-being’ (National Social Prescribing Network)5 Traditionally healthcare has been provided by health professionals, such as doctors, nurses, and occupational therapists based in a range of NHS settings including primary care. People’s health and their ability to manage it are influenced by a wide range of factors beyond the scope of these professionals’ practice. Such factors include employment, housing, debt, social networks and culture which have been estimated to account for 57% to 85% of the determinants of health status6. For those with long term conditions, these social determinants make a significant contribution to health and wellbeing as well as impacting on recovery and independence. Help with these factors is frequently available in communities, including local authority and community based organisations outside of the NHS (Buck D. & Gregory S. 2013, and Parsfield M. et al (eds) 2015)7. These organisations could provide opportunities for people to access information, advice and guidance, and they could also contribute to building their skills, knowledge and capacity. 4 https://www.myhealth.london.nhs.uk/system/files/Case%20for%20Change%20Summary%2011.pdf 5 https://www.westminster.ac.uk/patient-outcomes-in-health-research-group/projects/social-prescribing-network 6 http://www.kingsfund.org.uk/time-to-think-differently/trends/broader-determinants-health 7 http://www.kingsfund.org.uk/projects/improving-publics-health and https://www.thersa.org/discover/publications-and-articles/reports/community-capital-the- value-of-connected-communities 6  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners Social Prescribing acknowledges this range of factors which impact on health and wellbeing and the management of long term conditions, but may not be amenable to more traditional health interventions. It is a means whereby health professionals and others can signpost people to resources which can help with these aspects of their lives. It reflects the “social model of health”, which takes a broader view than the traditional medical model and recognises the part a wider range of partners, including individuals, carers and families, can play. Although the term ‘prescribing’ fits with a medical model, in this case the prescriptions are for non-medical interventions - for participation rather than pills. Medication which has been prescribed but not used has been estimated to cost the NHS in England £300m per year (York Health Economics Consortium/School of Pharmacy 2010)8. Social prescribing might be seen as the place where the NHS “meet” the community and its assets, as illustrated in figure one below. It builds on the experiences of implementing personalisation and models of care advocated by disabled people over many years, promoting person centred collaborative care9. It works best when NHS and local authority commissioners, GP and primary care teams, voluntary and community sectors all work together. NHS resources Social and services prescribing Community resources and services Figure One: The Social Prescribing Interface This makes social prescribing a good vehicle for improving integration of NHS, Local Authority and wider community resources, improving efficiency and making these resources known and more accessible to people who could benefit from them. It also puts the patient back at the heart of their own network, making connections between the range of relationships, activities and services that support their wellbeing. 8 http://discovery.ucl.ac.uk/1350234/1/Evaluation_of_NHS_Medicines_Waste__web_publication_version.pdf 9 http://coalitionforcollaborativecare.org.uk/tag/person-centred-care/ 7  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners Traditional health and care services Informal community based support Friends and family Person Figure Two: The relationship between people, person-centred approaches and appropriate support Social prescribing can stimulate creativity and innovation and enable access to a whole range of interventions, and activities, often developing locally through small groups connected to local communities and meeting local needs. Some of the core elements of existing social prescribing schemes are: • Partnership between the NHS and diverse voluntary sector, social enterprise, and community organisations; • Holistic assessment which takes account of the range of factors influencing health and wellbeing and reflects each individual’s priorities and goals; • Coordinated and personalised support plans, with information, advice and guidance aiming to support and motivate people, and build links to community assets and resources; • A focus on broader aims than traditional healthcare may be able to offer - including the well-being, effective functioning, and social connectedness of people and their families. Expert Patients Programme Social Prescribing Self-care 8  ACCESS/REFERAL Health & care services e.g. GP TRADITIONAL Person with health condition e.g. self-referral INNOVATIVE Community resource e.g London Fire Brigade/ social housing provider Steps towards implementing self-care: A focus on Social Prescribing for Commissioners Figure three shows how these elements can fit together. SOCIAL PRESCRIBING COMMUNITY RESOURCES “Services” e.g. debt advice Social Prescriptions inc • Employment/volunteering Education • Community activities • Physical activity • Community/faith networks • Timebanks Expert Patient Programme Personal budget brokerage Link worker provides • Holistic assessment • personal support planning • information advice & guidance Figure Three: Operating model for social prescribing & access to community based resources Many local social prescribing schemes provide access to support for healthier behaviours, such as exercise, healthy eating and improving mental wellbeing. Several schemes support networks and interaction, opportunities to access the benefits of the environment and green spaces, adult learning, the arts and culture. The specific content of schemes varies, but typically may include: • Provision of information and advice • Opportunities for arts and creativity • Physical activity • Learning and volunteering • Peer support • Befriending and self-help • Support with benefits, housing, debt, employment, legal advice or parenting More detailed examples of social prescribing interventions and activities are in Appendix B. 9  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners Integration, synergy, communication and feedback Funding GP/ Healthcare professional ‘buy-in’ Referral process Very simple, clear pathways Link Worker • Right Skills & attributes • Good communicator • Good listener • Joint decisions with patient • Quickly establish trust • Lay language • Empathy • Non-clinical • Mirror local community • Up-to-date & in- depth knowledge of services • Ability to motivate and empower • Skills to elicit behaviour change Patient Centred Care • Flexible service parameters • Time with patient and to accompany to group • Understand all needs • Most important concerns • Variable follow-up needs • Home visits • Personalised Patient ‘buy-in’ SP Service Provision • Good infrastructure, quality, provision and choice • Ability to have specialisation • Somewhere to get up-to-date information • Appropriate quality assurance Benefits Impact Outcomes Value for money Reduction in inequality Underpinned with evidence from research and evaluation Figure Four: Factors associated with successful social prescribing schemes. (National Social Prescribing Network, 2016) The national Social Prescribing Network has identified factors (National Social Prescribing Network)10 which underpin successful schemes (see figure four). 1.2 Why does social prescribing matter? There are ethical, economic and practical arguments which support investing in social prescribing schemes. CCGs are required by the Health and Social Care Act (2012) to secure continuous improvement in effectiveness, safety and patient experience, to ensure patients have choice and are involved in decisions, to promote innovation and reduce inequalities. They are required to integrate with provision of health-related or social care services where this may improve quality and outcomes11. 10 https://www.westminster.ac.uk/patient-outcomes-in-health-research-group/projects/social-prescribing-network 11 Health and Social Care Act (2012). The Act defines health-related services as those ‘that may have an effect on the health of individuals but are not health services or social care services’. http://www.legislation.gov.uk/ukpga/2012/7/section/26 10  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners All of London’s Sustainability and Transformation Plans (STPs) have identified social prescribing as a priority. Social prescribing helps to: • Meet changing needs • Deliver public expectations • Support positive change in the relationship between patients, carers, communities and health services. Representatives of patient, carer and public interest groups highlight that ‘standard treatment interventions – often reactive, episodic and narrowly medical – are increasingly out of kilter with the needs of the growing number of people with multiple, chronic health problems and disabilities. They deserve a more holistic, personalised offer, one that meets their needs, but also builds capacity to retain control and independence, and continue to achieve a good quality of life’ (National Voices 2014)12. Social prescribing can support local health economies to achieve the expectations set out in the Five Year Forward View for the NHS: • To empower patients to take much more control • Create new ways for voluntary organisations to work alongside the NHS • ‘Build on the energy and compassion that exists in communities’ Building a business case With the current financial challenges facing public services, the arguments for social prescribing are strengthened and more likely to be approved by CCG boards if the business case highlights the potential savings and benefits to the NHS as a result of the investment. This will include moving activity up stream, with people learning to care for their health better and so requiring less formal and/or emergency healthcare. Also, the experience of social prescribing schemes is that they often generate a workforce of peer supporters who have benefited and want to contribute more themselves (e.g. in City and Hackney13). There is a growing body of evidence demonstrating some specific benefits which may be achieved for patients and their local NHS through social prescribing including: • Reduced hospital admissions and A&E attendances • Reduced outpatient appointments • Reduced GP consultations • Improved health and wellbeing • Reduced social isolation • Increased engagement in health-related activities • Reduced reliance on medical prescriptions 12 http://www.nationalvoices.org.uk/sites/default/files/public/publications/person-centred-care-2020.pdf 13 https://youtu.be/PCxRLAM7wBQ 11  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners Social prescribing can alleviate pressures on the system. GPs are very busy, and this is not just with treating health conditions. For example, 80% of GPs reported that dealing with non-health queries results in reduced time to treat health issues and 46% reported this increased costs to the practice and NHS (Citizens’ Advice, 2015)14. Of those who used Citizens’ Advice Bureaux between January and March 2016, 46% had a long-term health problem (Citizens’ Advice 2016)15. A business case for social prescribing could be based on the objective of containing expenditure at current levels rather than necessarily reducing it. Three UK service evaluations include outcomes and impacts for the NHS such as: • 60% reduction in GP contact times in the 12 months following intervention compared to the previous 12 months (Bristol Wellspring Project; Kimberlee R. 2016)16. • 25% reduction in A&E attendance in the social prescribing group, with a 66% increase in A&E attendance by the control group. (City and Hackney Clinical Commissioning Group & University of East London 2014)17. • 17% reduction in A&E attendance and 7% reduction in non-elective in patient stays were reported in the 12 months post intervention compared to the 12 months before it from the most recent evaluation report from the Rotherham Social Prescribing Service (Dayson C. & Bennett E. 2016)18. Where Social Return on Investment (SROI) is reported, this is usually greater than to the NHS alone. The Bristol Wellspring project for example estimates a social return of £2.90 in year for each £1.00 invested. More information on Social Return on Investment (Cabinet Office 2009) can be found at the Social Value UK19 site. Financial Modelling • The Healthy London Partnership commissioned i5Health20 to model the potential financial benefits for London’s NHS of increased use of social prescribing. • Their model suggests that London potentially would have saved £110m between 2013 -16 if it had made greater use of social prescribing. • They used pseudonymised21 patient data to estimate potential NHS returns on investment based on evidence from social prescribing for London’s CCGs. Each CCG has now received a copy of this modelling. • They used the Hospital Episode Statistics for the last 3 years from this patient cohort to model potential historical savings and potential future savings (to 2020-21) of specific social interventions. • They did not include intervention costs in the calculation as they can vary significantly. For example, some provision relies on volunteer workforce, others paid workers, some will fund offices, others will rely on existing and free space etc. 14 https://www.citizensadvice.org.uk/Global/CitizensAdvice/Public%20services%20publications/CitizensAdvice_AVeryGeneralPractice_May2015.pdf 15 https://www.citizensadvice.org.uk/Global/Public/Advice%20trends/Advicetrends201516Q4.pdf 16 http://eprints.uwe.ac.uk/28452/ 17 http://www.health.org.uk/sites/health/files/City%20and%20Hackney%20CCG%20final%20report.pdf 18 http://www.varotherham.org.uk/evaluation/ 19 http://www.socialvalueuk.org/resources/sroi-guide/ 20 i5Health is a start-up company who work to support commissioners. They use clinical signatures at the patient level to calculate the value of healthcare initiatives for health services http://www.i5health.com/index.html 21 Pseudonymised data removes data which might identify a patient, but stills allows for that patient to be “tracked” through their use of NHS services. 12  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners • For example, in 2015-6, spend by the NHS in London on activity in secondary acute care for 4,794 people with mild to moderate MH conditions was £5,714,725. 1,892 of them may have benefited from a community arts scheme. If they had been referred and benefitted from the scheme in accordance with the cited evidence, the NHS in London potentially would have saved £1,416, 606 through reduced secondary care activity in that year (Table One). Table One: NHS patient activity & spend in London with potential reductions through the use of Arts on Prescription • When modelled forward, this leads to a potential average saving of £1,403,770 per year for London for this group benefitting from arts on prescription (Figure Five). • It is important to note that modelling for potential savings by initiative results in large variations due to differing impacts on secondary care health service usage. Current spend Opportunity/reduction Patients Activity Cost Patients Activity Cost 2015-16 4794 6067 £5,714,725 1892 1988 £1,416,606 Figure Five: Projected NHS in London savings through the use of Arts on Prescription • An orthogonal model (Figure Six) visually represents the range of initiatives according to modelled potential savings and ease of implementation. 13  Exercise on prescription Arts on Prescription Time banks Education on prescription Deaf Blindness Mobility Volunteer anorexia & bulimia care Dementia café/Food clubs Steps towards implementing self-care: A focus on Social Prescribing for Commissioners Impact higher Green Gyms Ecotherapy for substance misuse Information, Advice and guidance for adults Care of socially isolated patients and those living alone Volunteer befriending service lower Figure Six: Impact & Implementation matrix for social prescribing programmes in London This orthogonal model is designed to give an easily accessible indication of where commissioners can invest in relation to financial impact. It does not indicate the value of initiatives beyond financial return to the NHS. For example, education on prescription is in the harder to implement and low impact box, but there is good evidence for the benefits of education for people’s health, life chances and quality of life22. As part of the Realising the Value workstream23 NESTA have just released an economic modelling tool which is a pivot table allowing customisation to local CCGs to estimate returns on investment from approaches which were examined as part of this work (group activities, peer support, health coaching, and self-management24). Care of patient with problems related to primary support group (e.g family, carer etc) Books on prescription 22 https://www.kingsfund.org.uk/time-to-think-differently/trends/broader-determinants-health 23 Work led by NESTA in partnership with the Health Foundation and NHS England, to develop tools and resources to enable people to take an active role in their health and care http://www.nesta.org.uk/project/realising-value?gclid=CN_Tu7nF7tACFQS77Qod0toPrw 24 http://www.nesta.org.uk/publications/impact-and-cost-economic-modelling-tool-commissioners 14 Implementation easier harder Steps towards implementing self-care: A focus on Social Prescribing for Commissioners 1.3 Social Prescribing in London London Voluntary Services Council produces and regularly updates a social prescribing map for London which is available at http://www.lvsc.org.uk/advice-support/london-social-prescribing-map.aspx. HLP have cross-referenced this information with our own current intelligence (as of December 2016) to calculate that there are at least 51 different social prescribing schemes operating across 22 London Boroughs. There may be more schemes in areas we have not yet come into contact with. Figure Seven: Social prescribing schemes in London 15 Steps towards implementing self-care: A focus on Social Prescribing for Commissioners 2. Steps towards implementation 2.1 Identifying target population and local needs Social prescribing can potentially benefit a whole range of people. When setting it up or expanding it however, commissioners might want to actively offer it to targeted populations based on their specific locality or GP practice, or by their health condition, patterns of service uptake, or other criteria, including where it might prevent health conditions developing or worsening. The following are commonly identified target populations (Kinsella S 2015)25: • People with mental health conditions (from mild through to more severe and enduring) • People who are socially excluded, disadvantaged, isolated and vulnerable • People who frequently attend primary and secondary care • People with one or more long term conditions • People whose conditions are not necessarily well served by existing health and care services e.g. People with Asperger’s Syndrome. • People who require additional support to promote lifestyle changes for better health Local areas can determine their target population by using existing knowledge such as their Joint Strategic Needs Assessment, STPs, other planning processes and through risk stratification. Some NHS commissioners see benefits from social prescribing for ‘mainstream’ populations to meet the needs of people with lower level health needs across the whole life course. Some have used social prescribing to target patients with lower health self-efficacy who traditional health service approaches may have failed to engage. Agreement needs to be reached between local commissioners and providers about which population to target. This could be defined in relation to, for example; • Those who have one or more long term conditions • Those at specific activation levels on the Patient Activation Measure (PAM) scale or similar • Those who use >£x of medication per week • Those who attend >x number of clinical contacts per month • Those presenting with a social problem/social isolation, or presenting frequently to primary care with a range of diffuse issues • Those presenting with mild to moderate mental health conditions • Those known to have health conditions, but don’t currently use health services. • Those who live alone • Those at risk of developing or worsening health conditions (e.g. pre-diabetic) Data needs to be sourced to assist this decision, and then to help identify individuals who might benefit from a social prescription. The section on identifying target populations in the Healthy London Partnership’s self-care resource makes further suggestions, and information from other schemes can help to get a sense of the different target groups and the benefits being delivered locally (See useful websites in Section 5) 25 http://info.wirral.nhs.uk/document_uploads/evidence-reviews/Social%20Prescribing%20literature%20review%20v5.pdf 16  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners 2.2 Identifying local partners and assets It is very likely that relevant voluntary and community resources exist in all boroughs, but they may not be referred to as social prescribing or be easily visible to those in the NHS. It is important to understand what currently exists to maximise the benefits of any new investment. • Borough based voluntary sector councils: Commissioners can work with them to draw out existing community capacity, provide opportunities for all providers to get to know each other and therefore work more effectively together. The London Voluntary Service Council (LVSC) has a London social prescribing map26 which gives information on some of the services which currently exist in London. This is a useful starting place to begin your mapping. As well as describing what exists, this also provides links to information about the individual schemes, providing useful detail about the range of social prescribing services, and new schemes are invited to add their details to the map to keep it current. • Social housing providers: They have tenancy support teams, who will work with tenants to understand what their problems are and signpost them to potential sources of help (e.g. Family Mosaic who provide housing in London and the South East27). • Statutory provision: Some statutory services may be signposting people, e.g. o Health Champions28 o Health Trainers29 o Expert Patient Programmes30 o Community pharmacies31 o Care coordinators32 The National Social Prescribing Network has found that many existing schemes are initially shaped around local assets in the voluntary and community sectors and, over time, they build partnerships and capacity more widely across local communities. To help social prescribing develop further, local leadership then needs to be built across organisational boundaries and include CCGs, local authorities, voluntary sectors, GPs and local patient and carer groups. Without GP buy in social prescribing will struggle to develop locally – so leadership in this group is crucial. 26 http://www.lvsc.org.uk/advice-support/london-social-prescribing-map.aspx 27 http://www.fmcareandsupport.co.uk/what-we-do/navigator-and-link-services/ 28 http://www.altogetherbetter.org.uk/ 29 http://bjgp.org/content/62/602/454.short 30 http://www.wandsworthccg.nhs.uk/localservices/Self-Care/Pages/Wandsworth-Self-Management-Programme.aspx 31 http://psnc.org.uk/services-commissioning/essential-services/signposting/ 32 http://www.local.gov.uk/documents/10180/6927502/Case+study+Greenwich+-+Building+a+team+around+the+person.pdf/4ccfb003-ff7b-4093-af55- d392141a269b 17  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners 2.3 Funding and resources Voluntary sector partnerships are an essential feature of social prescribing, but many voluntary and community groups do not have the existing capacity and resources to be seeing more people directed through social prescribing. Commissioners and local providers will need to engage the sector to identify ways of making additional capacity available and identify what extra support or funding will be needed. Funding for longer periods is likely to be most effective when strategic partnerships and formalised working relationships have been established with local voluntary sector organisations. This should create the right environment for new systems which includes outcomes reporting, measurement and evaluation to be co-designed and implemented with partners and users. By fostering an agile approach and collaborative learning environment, this will provide a platform to support mobilisation, delivery and gives time for return on investment to be realised. Appendix D provides ideas about diverse sources of funding for social prescribing. 2.4 Things to consider when developing local operating models Different models for social prescribing exist. But there are emerging factors that are associated with successful schemes. The national Social Prescribing Network has identified those which are common to many (see Figure Four above). Existing and emerging NHS models may be relevant, notably the six principles developed by NHS England for New Care Models (see appendix C). The key feature for social prescribing is that a system is in place which actively supports people to find out about and access a range of resources which can help them with a variety of social issues which can affect their health and their ability to manage illness. Social prescribing should develop and transform relationships between patients and providers, and between the NHS and other sectors. Systems can build on exiting provision or commission anew. A potential operating model is illustrated in figure three above. 2.5 Contracting, governance and risk Contracting A range of contracting approaches can be used when developing social prescribing. They should be proportionate to the value and complexity of the services being provided. They may be; • Grants with local voluntary services to initiate a local scheme. NHS England has developed a ‘Bitesize guide’ which includes practical advice on deciding if this is a good way forward (NHS England 2015)33. • Short form of the NHS Standard Contract. Guidance and technical support are available and include advice on the workforce, liability and reporting issues commissioners and providers need to consider (NHS England 2016)34. • “Lead”, “Prime” or “Alliance” contracting (using the NHS Standard Contract. LH Alliances Ltd 2014)35. Commissioners enter into a contract with a single lead provider or prime contractor who then sub-contracts specific roles and responsibilities to other providers and remains responsible to the commissioners for the delivery of the entire service. 33 https://www.england.nhs.uk/wp-content/uploads/2015/02/nhs-bitesize-grants.rb-170215.pdf 34 https://www.england.nhs.uk/wp-content/uploads/2016/02/10-nhs-sc-16-17-shrt-frm-user-guid.pdf 35 https://www.kingsfund.org.uk/sites/files/kf/media/linda-hutchinson-alliance-contracting-27.03.14_0.pdf 18  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners National standards and requirements for all providers • Duty of care applies to all staff and volunteers o “You must aim to provide high quality care to the best of your ability and say if there are any reasons why you may be unable to do so” (Unison 2013)36. o Employers must provide all staff with clear roles and responsibilities, with appropriate training. • Information governance o NHS Digital provides a comprehensive range of advice and resources on confidentiality standards, legal requirements, and toolkits for NHS and partner organisations37. o The Information Commissioner’s Office also provides guidance on data protection, including self- assessment and advice for organisations holding personal data38. • Patient Safety o The NHS Improvement “Sign Up to Safety” campaign is intended to support ‘locally led, self-directed safety improvement’ and their website provides resources and advice to assist organisations to achieve continuous improvement39. • Quality o The National Quality Board provides advice and resources, including their 2015 report on Improving Experiences of Care (NHS England 2015ii)40. This includes a shared understanding of what a good experience of care means, and why it matters, developed with a wide range of partners including NHS, patient and professional groups. Governance and risk • Governance arrangements will need to be relevant to the local model used for social prescribing. One area of concern may be the management of risk. There are risks associated with referring people on to resources beyond the NHS, where there may be less regulation and formal monitoring. • There may be different levels of risk. For example supported navigation based in a GP practice would place more risk on the practice than simply providing information and signposting. • There is also risk to the individual if they do not use a local resource which could help them manage their health better. • Common sense should help commissioners, clinicians and others to understand and manage the balance of risks. • An accountable body can be identified for clinical and information governance, which monitors and takes decisions to manage risk. o Existing accountable partnership structures could be extended to include social prescribing. o A new implementation group could be established with a range of relevant stakeholders to be the accountable body. • Social prescribing is about people using a range of resources to help them manage their health. Many of those resources will be small and not have the knowledge or capacity to use NHS level clinical governance procedures. Local partnership agreement is therefore needed for how safety or other concerns will be managed. Some governance and risk issues will need explicit reference in contracts/grant agreements, e.g. safeguarding and mental capacity. Others will be more variable and draw on a variety of experience of good practice. 36 https://www.unison.org.uk/content/uploads/2013/06/On-line-Catalogue197863.pdf 37 http://systems.digital.nhs.uk/infogov 38 https://ico.org.uk/for-organisations/ 39 https://www.england.nhs.uk/signuptosafety/ 40 https://www.england.nhs.uk/wp-content/uploads/2013/08/imp-exp-care.pdf 19  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners • Commissioning options include o the devolution of responsibility for governance to a Commissioned Lead Provider. o the use of agreements between referrers and the places to which people are referred that all those who work there undergo e.g. safeguarding and other relevant training o careful collection of feedback and evaluation from those who have used resources (sometimes referred to as a “Trip Advisor” model) The Gloucestershire Voluntary & Community Sector Alliance has created with the CCG a “Kite Mark” for services to “indicate their credentials for taking part in this initiative”41 and requires completion of a questionnaire. 41 http://www.glosvcsalliance.org.uk/social-prescribing/ 20  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners 3. Monitoring and evaluating social prescribing All services need to be able to demonstrate their impact and value for money. The self-care resource includes a strategic framework which can be used to help commissioners of social prescribing consider the range of outcome domains and methods of evaluating them, including personal, health and wellbeing, quality of life and service activity (including return on investment). For social prescribing specifically, early discussion with local stakeholders can identify what matters to them and how to evaluate whether social prescribing helps. The national Social Prescribing Network surveyed people from general practice, voluntary organisations, patients, commissioners, charities and academics who identified some of the benefits of social prescribing schemes to date. Their findings (summarised below in Table Two) could provide a useful starting point for local discussions about the types of benefit stakeholders hope to see social prescribing deliver and, from there, identification of how progress will be monitored and impact will be captured. Physical & emotional health & wellbeing Cost effectiveness & sustainability Builds up local community Behaviour Change Capacity to build up the VCS Social determinants of ill-health • Improves resilience • Self-confidence • Self-esteem • Improve modifiable lifestyle factors • Improve mental health • Improve quality of life • Prevention • Reduction in frequent primary care use • Savings across the care pathway • Reduced prescribing of medicines • Increases awareness of what is available • Stronger links between VCS & HCP/Bodies • Community resilience • Nurture community assets • Lifestyle • Sustained change • Ability to self-care • Autonomy • Activation • Motivation • Learning new skills • More volunteering • Volunteer graduates running schemes • Addressing unmet needs of patients • Enhance social infrastructure • Better employability • Reduces isolation • Social welfare law advice • Reach marginalised groups • Increase skills Table Two: Benefits of Social Prescribing as identified by stakeholders (National Social Prescribing Network 2016)42 In addition, there is experience and learning from social prescribing evaluations below, and the national Social Prescribing Network aims to develop further advice and resources from 2017. • The Rotherham evaluation by Sheffield Hallam University provided a ‘monetised assessment’ based on reduction in NHS services and delivery of social benefits lasting for more than one year. Details of this and other aspects of their comprehensive approach to monitoring and evaluation are available (Drayson C. & Bashir N. 2014)43. 42 https://www.westminster.ac.uk/patient-outcomes-in-health-research-group/projects/social-prescribing-network 43 http://www4.shu.ac.uk/research/cresr/sites/shu.ac.uk/files/social-economic-impact-rotherham.pdf 21  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners • The Wellspring pilot in Bristol, evaluated by the University of the West of England, measured socio-economic impact using a pre- and post-intervention interview methodology. Their Wellspring Wellbeing Questionnaire was developed to include items that would be recognised by commissioners as suitable for providing evidence of impact. The tool itself, as well as other forms for the evaluation are all available as part of the evaluation report (Kimberlee R. et al 2014)44. • The City and Hackney social prescribing pilot was evaluated by the University of East London, and their economic evaluation included consideration of costs of staff time, GP consultations, A&E attendance, health status and other measures. Their report includes detail of the measures used, including the Mental Health Recovery Outcomes Star, interview schedules, and core activity and cost data (City & Hackney Clinical Commissioning Group & University of East London 2014)45. The Aesop46 outcomes framework has been developed by academic partners and Public Health England to evaluate and demonstrate the impact of the arts on health and wellbeing. This resource aims to support commissioners, funders, providers and practitioners to plan and develop appropriate evaluation methods for such initiatives. Measure Yourself Concerns and Wellbeing (MYCAW)47 has been developed by the University of Bristol Centre for Academic Primary Care and is a self-rated scale using self-defined problems and wellbeing. It has been developed with and used by cancer services. 44 http://www.wellspringhlc.org/content/POV%20Final%20Report%20March%202014%20(2).pdf 45 http://www.health.org.uk/sites/health/files/City%20and%20Hackney%20CCG%20final%20report.pdf 46 Aesop (Arts Enterprise with a Social Purpose) and PHE evaluation framework http://www.ae-sop.org/toolbox/phe-framework/ 47 http://www.bris.ac.uk/primaryhealthcare/resources/mymop/sisters/ 22  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners 4. Enabling approaches The aligned and supplementary self-care resource (available in early 2017) describes the importance of investing in patient activation, workforce development, and digital engagement. These approaches, and the advice in that resource, are directly relevant to developing successful social prescribing schemes. Additional information, specific to social prescribing is provided here. Workforce Integral to the success of social prescribing is the central role of link workers/ community navigators/ support brokers. Some areas employ health and care professionals in these roles. Others recruit local people, based in the community with excellent insight of local support networks and organisations. Many people who have experienced health conditions and have been helped by social prescribing want to help others themselves. Given the benefits of peer support this should be encouraged. Whoever is fulfilling the role will need some core skills backed with good understanding of local communities, voluntary sector provision and informal support networks. Health Education England have recently released a competency framework for care navigation which will help with this (Health Education England 2016)48. Social prescribing also requires GPs and practice teams to work differently. It provides opportunities to develop new roles for general practice staff as a means of offering people, families and carers genuine alternative options for support and access to help with social problems. To be effective the social prescribing system needs to be straight forward and simple to understand, with the whole practice team being able to describe how it works. Commissioners need to ensure that contracts identify the provider’s responsibilities for ensuring they have a workforce which has the appropriate knowledge, skills and attitudes (including basics such as risk management, information governance and safeguarding). Digital technology National Information Board’s Personalised Health and Care 2020: A framework for action49 sets out the role of digital technology in transforming outcomes for citizens and communities. Data and technology can lead to improved customer experience, convenience and choice; improved citizen- professional communications and shared decision-making; and realise efficiency savings. The ONS estimate that 82% of adults in Great Britain access the internet almost every day50. 81% of the UK population have a smart phone (Deloitte 2016)51. However there are also groups who are currently digitally excluded. Commissioners need to be conscious of this group too so that any development of digital services does not contribute to increasing inequalities. Increased levels of digital access present opportunities to digitally enable frontline professionals and digitally empower patients, and create new ways to connect people and organisations involved in social prescribing (through online directories for example). Digitally enabled support is not for everyone, but there is strong evidence that the majority of the population want choice provided through multiple means of access and personalisation through an online account (NHS England 2015iii). 48 https://www.hee.nhs.uk/sites/default/files/documents/Care%20Navigation%20Competency%20Framework_Final.pdf 49 https://www.gov.uk/government/publications/personalised-health-and-care-2020 50 https://www.ons.gov.uk/peoplepopulationandcommunity/householdcharacteristics/homeinternetandsocialmediausage/bulletins/ internetaccesshouseholdsandindividuals/2016 51 https://www.deloitte.co.uk/mobileuk/ 23  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners A more recent evaluation published by Tinder Foundation and NHS England (Tinder Foundation 2016)52 of the three-year Widening Digital Participation programme (an initiative set up to avoid inequalities resulting from digital exclusion) provides new evidence that socially excluded people can benefit from digital skills and enable them to take charge of their own health. The programme targeted and trained 221,941 people nationwide who fall into at least one category of social exclusion; people in receipt of benefits; disabled; the unemployed; BAME Groups and people aged 65 and over (see Table Three). This complements NHS England’s conjoint research that presents compelling evidence that the vast majority of people want self-service and access to health services in a variety of ways including digitally. There may also be opportunities to align future pan-London work in this area with the the Greater London Authority’s (GLA) strategy for digital inclusion (Mayor of London 2015)53. Health & Digital: Reducing Inequalities, Improving Society An evaluation of the Widening Digital Participation programme (July 2016) • 41% of those surveyed say they have learned to access health information online for the first time (a further 32% have learned to do this more effectively). • After learning about using the internet to manage health: i. 56% of learners went on to find information on the internet about health conditions, symptoms or tips for staying healthy. ii. 54% of learners in need of non-urgent medical advice said they would now go to the internet before consulting their GP, to look at sites such as NHS Choices. iii. 51% of learners have used the internet to explore ways to improve mental health and wellbeing. • 65% of respondents feel more informed about their health. • 21% of learners made fewer calls or visits to their GP, with 54% of those saving at least three calls in the three months before being surveyed and 40% saving at least three visits over this period. • 59% of respondents feel more confident using online tools to manage their health. • 10% of learners made fewer calls to NHS 111, with 42% of those saving at least three calls in the three months before being surveyed. • 52% of respondents feel less lonely or isolated and 62% feel happier as a result of more social contact. • 6% of learners made fewer visits to A&E, with 30% of these saving a minimum of three visits in the three months before being surveyed. Table Three: Impact of digital training for socially excluded groups (Tinder Foundation 2016) 52 http://nhs.tinderfoundation.org/wp-content/uploads/2016/07/Improving_Digital_Health_Skills_Report_2016.pdf 53 https://www.london.gov.uk/sites/default/files/a_digital_inclusion_strategy_for_london.pdf 24  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners Making the most of online directories Much of the debate surrounding choice centres on how to equip individuals, families, carers, community organisations and professionals with reliable and up-to-date information about the myriad of ‘hyper-local’ care and support options available within our neighbourhoods. In a social prescribing context, online directories have an important role in promoting local support, networks and volunteering opportunities to combat isolation, loneliness and alleviate social problems. Online directories should not replace social prescribing link workers but can provide invaluable assistance in planning and agreeing care plans around individual’s goals. Across London, mirroring the national picture, many local authorities have invested in local online directories as a means of improving public awareness and access to a range of local care and support options. Healthy London Partnership carried out a rapid review of online directories that revealed considerable variation in terms of investment, public utilisation and local provider buy-in towards the directories available across London. Existing directories range from CarePlace54provided across 19 London Boroughs and Shop4Support that provides services across the country to more bespoke local community directories (e.g. Hillingdon55) and formal local emarketplaces (e.g. Enfield56). In Harrow, My Community E-Purse57 utilises the CarePlace platform to support people to manage their own personal care budgets and to make direct payments. Harrow Council introduced My Community E-Purse as a means of increasing the number of local personal ‘care’ budget holders, stimulate new entrants to the market and to realise back-office efficiency savings. Over a four year period, My Community E-Purse has seen take-up of Personal Budgets rise to around 750 local residents. The application is also linked to developing a vibrant local marketplace, through CarePlace, which has seen Harrow move from two block contracts and eight niche providers to 900 plus care and support options available to local people over a 4 year period. Harrow has also made significant savings on the processing and management of their personal budgets. These savings have been realised by replacing manual activities with automated processes. This has resulted in the streamlining of the process, reduced back-office administration costs and reduction in service provider charges. The Healthy London Partnership rapid review made the following conclusions: 1. Online directories are widely available across London and have an important role in signposting the public and appropriate professionals to information on wider care and support options available in their communities 2. Online directories are underused community assets. More could be done to promote through online directories public information and access to a wider range of ‘hyper-local’ care and support provided by non-statutory voluntary and community sector organisations ‘up my street’. 54 https://www.careplace.org.uk/ 55 http://www.connecttosupporthillingdon.org/s4s/WhereILive/Council?pageId=1057&lockLA=True 56 http://adultsocialcaremarketplace.enfield.gov.uk/ 57 http://www.harrow.gov.uk/info/100010/health_and_social_care/1480/getting_the_right_care_and_support_for_you/2 25  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners 3. A modest amount of investment is required in some areas to make improvements so online directories become more customer friendly and better meet the needs of the public (e.g. predictive key word search, increased utilisation by voluntary and community sector organisations) 4. Further work needs to be carried out to understand how London’s existing online directories can operate in a way to aggregate information, possibly through a meta-database. This could enable the development of a new social prescribing distribution model that allows GP practices to refer, navigators to signpost and the public to access a wider array of support through a holistic and scalable model that provides channel choice but does not replace the option to have face-to-face contact with a link worker. The rollout of Patient Online58 and the emergence of Babylon Health59 and Dr Now60 are examples of online GP services. As public demand for virtual general practice grows then so will the need to develop online methods for carrying out consultations, tailored health advice and referring to social prescriptions in addition to medical prescriptions. Promoting awareness of smaller voluntary and community sector support organisations and networks NHS 111 has developed MiDoS61 which is supporting front-line health and social care professionals with quick and easy access to local service information, which is available in a choice of mobile devices. The aspiration is for this application to be also available to the public and to include voluntary sector provision. MiDoS, similar to all the local online directories, needs to strike a balance when considering clinical, information governance and legal risks in terms of promoting services provided by voluntary sector organisations of various operational size. Commissioners may consider local campaigns to raise awareness of the benefits associated with local directories of services; market position statements or kite mark standards encouraging compliance with locally agreed quality standards; ‘light touch’ assurance processes to attract smaller voluntary sector organisations to see the value and sign-up to online directories; and release funding to voluntary sector organisations to maintain and/ or host local directories to reduce the maintenance burden on the NHS. This may be a natural step as to remain relevant online directories will also need to evolve so they are maintained and monitored by local experts and communities themselves. The London Brokerage Network62 is an example of a self-maintained online brokerage which is for disabled people to find supporters for self-care (relating to personal budgets). ALISS63 in Scotland encourages people to upload and maintain their own entries. Further information relating to clinical governance and risk is contained elsewhere in this document – See Section 2.5 58 An NHS England programme which allows patients to book and cancel GP appointments, order repeat prescriptions, and access GP medical records online. https://www.england.nhs.uk/ourwork/pe/patient-online/ 59 An on line GP service, with the option of a video medical consultation, tailored health advice, and the delivery of prescriptions to an address of your choosing. It includes talking therapies as part of its offer and includes access to an on line health record. https://www.babylonhealth.com/ 60 An on line GP service which uses an evidence based algorithm to identify problems, a video medical consultation for confirmation of diagnosis and prescription of any treatment or advice, which is then sent to your location of choice. http://www.drnow.com/ 61 http://www.intuiti.co.uk/midos.html 62 http://www.londonbrokeragenetwork.com/Find-a-Broker 63 ALISS is a directory for health and wellbeing resources in Scotland. https://www.aliss.org/ 26  5. Useful Websites Networks Social Prescribing Network Steps towards implementing self-care: A focus on Social Prescribing for Commissioners https://www.westminster.ac.uk/patient-outcomes-in-health-research-group/projects/social-prescribing- network London Voluntary Service Council/Regional Voices for Better Health The LVSC has produced a social prescribing Map for London which has information about social prescribing projects and services across the capital. http://www.lvsc.org.uk/advice-support/london-social-prescribing-map.aspx Service examples The Bromley by Bow Centre, Tower Hamlets, London One of the pioneers of social prescribing within the NHS. Their website has information about the centre, how it operates and the services it provides. http://www.bbbc.org.uk/ Wellspring Healthy Living Centre, Bristol Another NHS pioneer, which has been evaluated by the University of the West of England. Information about the centre is available at their website; http://www.wellspringhlc.org.uk/ Social Prescribing Service, Rotherham Delivered by Voluntary Action Rotherham, an established and frequently referenced service. More information can be found at; http://www.varotherham.org.uk/social-prescribing-service/ Ways to Wellness, Newcastle An established partnership in Newcastle including charities, social enterprise and the NHS, working in deprived areas of Newcastle. http://waystowellness.org.uk/ City and Hackney social prescribing scheme, London A well evaluated scheme which has focused on isolated people over 50 and those with type 2 diabetes. http://www.health.org.uk/programmes/shine-2014/projects/social-prescribing-integrating- gp-and-community-health-assets Lambeth GP Food Co-op, London The GP food co-op builds gardens in GP surgeries in which people (especially those with long-term conditions) are supported to grow food. http://lgpfc.co.uk/ 27  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners 6. Acknowledgements In addition to the 115 people who attended our ‘Social prescribing in London’ event on 22 September, we would like to express our thanks to the following people for contributing to the development of this document. Sola Afuape Jessica Attard Jane Barnacle Marcello Bertotti Angela Bhan Ian Black Jessica Britton Andrew Carpenter Mairaed Carroll Gill Chambers Jane Connor Michael Davidson Helen Davies Vivien Ellis Richard Elphick Caroline Frostick Kenny Gibson Sharon Grant Emel Hakki Sharon Hanooman Melissa Hardwick Jonty Heaversedge Ben Holdroyd George Howard Manny Hussein Patrick Hutt Tessa Jelen Chris Jones Anwar Khan Cait Kielty-Adey David Leeman Lisa MacAlpine Donal Markey David Mphanza Lis Paice Charlotte Painter Marie Polley Aran Porter NW London Collaboration of CCGs Healthy London Partnership Healthy London Partnership University of East London NHS Bromley CCG Healthy London Partnership Public Champion NHS Newham CCG National Brokerage Network, HLP Public Champion National Housing Federation Healthy London Partnership LB Greenwich NHS Newham CCG Healthy London Partnership Dragon Café, Sidney De Haan Research Centre for Arts and Health LB Camden/NHS Camden CCG University of East London NHS England (London) Healthwatch, Haringey Family Action LB Waltham Forest/NHS Waltham Forest CCG Free Space Gallery, Kentish Town NHS Southwark CCG NHS Camden CCG Healthy London Partnership NW London Collaboration of CCGs NHS City & Hackney CCG Breathe Easy Westminster & Westminster Healthwatch LB Kingston/NHS Kingston CCG NHS Waltham Forest CCG Healthy London Partnership LB Kingston LB Waltham Forest NHS England NHS Kingston CCG NW London Collaboration of CCGs NHS City & Hackney CCG University of Westminster NW London Collaboration of CCGs 28  Sally Prus Onteeru Reddy Marissa Rose Ed Rosen David Russell Ray Sadler Kalwant Sahota Amrinder Sehgal Kat Sellers David Smith Gulden Sural Eileen Sutton Bev Taylor Jason Tong Sandra van der Freen Francesca White Paul White Mike Wilson Mike Wilson Roe Yvonneke Steps towards implementing self-care: A focus on Social Prescribing for Commissioners Healthy London Partnership LB Harrow NHS Islington CCG Lambeth GP Food Cooperative Just Add Spice Healthy London Partnership Public Champion NHS West London CCG NHS Wandsworth CCG National Housing Federation NHS Southwark CCG Family Action Healthy London Partnership NHS England Healthy London Partnership London Voluntary Services Council Healthy London Partnership NHS Southwark CCG Pembroke House, Walworth, SE London Healthwatch, Haringey NHS Southwark CCG 29  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners 7. 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Unison (2013) Duty of Care handbook - guide for health and social care staff, quoted in Information Governance Toolkit (HSCIE) Parsfield M. et al (eds)(2015): Community Capital - The value of connected communities. RSA. People Powered Health (2013): People helping people: peer support that changes lives. Nesta. Wanless D (2002): Securing our Future Health: Taking a Long-Term View. Final Report. HM Treasury. York Health Economics Consortium/School of Pharmacy, University of London (2010): Evaluation of the Scale, Causes and Costs of Waste Medicines: Final Report. 31  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners Appendix A: Social prescribing for children, young people, parents and carers This section is intended to help develop social prescribing for children, young people, parents and carers. It will address issues particular to this group, and should be read with the companion resources for self-care and social prescribing for adults for more general information. Why does social prescribing matter for children and young people? • A quarter of Londoners are children and young people, with this number predicted to rise by 13% by 2022. • Childhood and adolescence is a key period for establishing life-long health behaviours which develop in the context of family, school and the community. Early intervention and prevention promoting a sustainable healthy lifestyle is best achieved at a younger age when habits are easier to instigate and change before reaching adulthood64. • 40% of GP workload is for children and young people, yet 60% of GPs have not had training in paediatrics and child health. • Children and young people face a host of issues falling under the umbrella of social determinants of health; we know that these issues impact health and wellbeing yet cannot be addressed by the current health system. • Social prescribing provides a means to address these issues, but careful consideration of the needs, attitudes and behaviours of children and young people, their parents and carers will be necessary for social prescribing to be successful; grouping this population with adults and the elderly when designing and implementing social prescribing presents a barrier to success. • There is a need for children & young people and their families to have integrated care and partnership working between education, health and social care services. Living and working conditions Work environment Education Agriculture and food production Source: Dahlgren and Whitehead, 1991 Unemployment Water and sanitation Healthcare services Housing Age, sex and constitutional factors Figure Eight: Wider Determinants of Health (Dahlgren, G. & Whitehead, M. 1991) 64 https://www.nice.org.uk/news/article/make-healthy-choices-a-life-long-habit-to-prevent-early-death 32 a m r u t l u c , c i l a n d m d n o v i n r o o n c m e e - v n o i t a c m l o o c c s o u n n i t l y a n f i l n l l e a a d t a u r w i e s i t d e y c l i t o e e f i r o a o i k n c S t s d n o e n r s I s G Local population survey 50 45 40 35 30 25 20 15 10 5 0 Steps towards implementing self-care: A focus on Social Prescribing for Commissioners The Healthy London Partnership ran an engagement event with children and young people, and created surveys for children and young people and parents and carers to identify how social prescribing should operate best for this population; this co-production approach is imperative to ensure social prescribing is fit for purpose in a locality. Parents and carers The survey from parents and carers received 67 responses, with respondents being evenly spread across London65. The top issues parents and carers want support with include; 1. coping with stress and anxiety 2. education 3. child behaviour 4. self-confidence and self-esteem The survey also identified a number of barriers parents and carers experienced when accessing services. These are shown in figure 9 below. Travel & other costs Location of services Lack of assistance Inconvenient opening times Fear of going alone Other Figure Nine: Barriers to accessing services from parent and carer survey 65 The survey was advertised through parent and carer forums, Talk London, Twitter, parents groups on Facebook, netmums.com, mumsnet.com and was distributed among social prescribing colleagues to be promoted within their network on websites and e-bulletins. 33 Number of People Steps towards implementing self-care: A focus on Social Prescribing for Commissioners What can we learn from the survey? In order for social prescribing to work for parents and carers, the following ‘success factors’ should be considered: • Community resources tailored to local need • Flexible opening times at the weekends and evenings • Convenient locations which are close to places already visited • More options of where to go for help and advice • Multiple forms of access, including online and phone appointments and chats as well as face to face forms of help and advice • Community resources which incorporate an aspect of outdoor activities • A model which engages communities so friends and family can be aware of social prescribing, such as Families First. • Primary care is an important access point for help for parents of young children • Local needs should be explored to see what people want, where they go, and how they access help Children and young people The survey for children and young people received 19 responses, with respondents being evenly spread across London. There was also an engagement event with young people66. The top issues they would like support with are: 1. Coping with stress and anxiety 2. Sex and relationships 3. Exercise 4. Sleep 5. Long term conditions 12 10 8 6 4 2 0 Travel costs Location of services Inconvenient opening times Fear of going alone Lack of anonymity Figure Ten: Barriers to accessing services from young people’s survey 66 The survey was advertised through the Association for Young People’s Health, the Anna Freud centre, primary and secondary schools, the Greater London Authority outreach teams, the Young Persons forum, social prescribing colleagues. Although the number of responses was low, engagement was spread across boroughs. An engagement event run with children and young people was a mixed gender group of young people from different backgrounds. 34 Number of People Steps towards implementing self-care: A focus on Social Prescribing for Commissioners What can we learn from this survey and engagement event? In order for social prescribing to work for children and young people, the following ‘success factors’ should be considered: • Community resources tailored to needs • Flexible opening times on weekends and evenings • Convenient, local, one-stop shop community centres • Environments with friendly, welcoming qualities e.g. You’re Welcome • There needs to be a range of ways for people to access support e.g. online, face to face and over the telephone • Online forums and chats incorporated into models • Online information on websites in a ‘yellow pages’ style format • Family and friends can be helped to support young people • Education staff engaged in model • Opportunities which are attractive and relevant to children and young people What community resources are available for young people? Local boroughs need an awareness of what community resources currently exist, where children and young people in the local population go and who they come into contact with in order for signposting to work effectively. The key to social prescribing is to increase connections within the community to existing resources that can improve health and wellbeing. Those available for the general population may be relevant, but there are also some for younger people specifically, such as youth centres and schools which need to be considered. Local knowledge will help to understand where children and young people currently go. Workforce Children, young people, parents and carers show different preferences for who they go to for help and how they access help. Successful models should tailor social prescribing to suit these preferences and tap into their contacts. Engaging and raising awareness of social prescribing and training in social prescribing skills would be useful for a number of individuals in local populations. These people could act to bridge the gap between the individual and social prescriber, for those who do not go to their GP. A breakdown of suggestions is included below: Awareness of social prescribing Training in social prescribing skills Parents and family members Any statutory agency working with people at- risk Primary care mental health workers and nurses Any voluntary sector agency working with people at-risk Practice nurses Health visitors HR staff School nurses Teachers and education staff Teachers and education staff Faith leaders Faith leaders Organised club leaders (e.g. Scouts, sports) Organised club leaders (e.g. Scouts, sports) Family support workers Family support workers Table Four: Awareness and training for groups for social prescribing 35  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners Training programmes such as Me first and Making Every Contact Count can equip people that come into everyday contact with children, young people, parents and carers with the skills, behaviour and attitudes to identify people who could benefit from social prescribing. Online and digital The prevalence of online activity in children and young people represents both challenges and opportunities; whilst internet usage often contributes to problems affecting children and young people, this heavily utilised resource can be used in a model of social prescribing, for example: • Online directories with sophisticated filters to search for community services and help • Online self-referral services which remove the need for referral seeking • Online signposting through online forums and chat lines Example functionality from apps NHS Go is a health information and advice app coproduced by children and young people, featuring a directory of services and health topics tailored to those which are most important for children and young people. The app uses NHS Choices information, and features specialist content such as advice around Fresher’s Week when students are going to university, or ‘Exam Stress’ during exam season. The app uses self-signposting in a directory format, and is an example of good practice for those investing in digital social prescribing for children and young people. Silent Secret has been developed by children and young people themselves. It is for teenagers aged 11-19 to anonymously talk about what is on their mind in a safe and supportive online community. Users cannot comment on each other’s secrets, but can interact using these buttons: ‘heart’ to express love, ‘me2’ to express empathy, and ‘hug’ to express sympathy. A ‘get support’ button appears with each secret, enabling users to connect with tailored support organisations should they need to. Users say the app allows them to be honest without being judged, provides a space for support with people like them so they don’t feel alone, with one user even saying they wish the world was more like the app. It reaches users that may not wish to use face to face contact, and overcomes barriers for children and young people such as feeling unwelcomed and fear of going to get help. 36  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners Appendix B: Examples of social prescribing interventions and activities • Physical activity/ exercise – including gym based activity, team sports, dance class, yoga, T’ai chi. Goodgym67 is an example of an interesting service in which volunteers run to people’s homes to provide them with help and support and reduce isolation. • Opportunities for arts – including: arts and performance68 69, libraries, museums, heritage and cultural tourism70. • Food clubs, dementia cafes71 - valuable opportunities for social interaction, and for people to contribute. They can also be a source of good quality food. The casserole club72 encourages members to cook for others. • Green activity – participants become both physically and mentally healthier through contact with nature73. This can include: gardening and horticulture; growing food; walking in parks or the countryside; conservation activities and green gyms. • Volunteering - good evidence of the benefits of volunteering for health (Lee Y & Brudney J.L. 2008)74. • Peer support, whereby people who have experienced the same condition support each other has a good evidence base for increasing confidence wellbeing and social connectedness (People Powered Health 2013)75. • Learning /education can also be provided via prescription. There are clear health benefits of education (Feinstein L. et al 2006)76. • Time banks are “virtual banks” where people can deposit time they spend helping others and withdraw that time when they need help themselves. Everyone’s time is of equal value and transactions are facilitated and recorded by a time broker77. The time bank is essentially a mutual volunteering scheme, using time as currency; some studies have shown that time banking is more successful at reaching those on low incomes/areas of deprivation than traditional volunteering (Boyle D, Clarke S and Burns S (2006)78. Spice79 have evolved this into a paper currency based on units of time which can be “spent” with a range of organisations (including leisure and cultural venues), giving more flexibility to people on how they might exchange their time credit. 67 https://www.goodgym.org/ 68 https://www.jameswigg.co.uk/practice_info/kentish_town_improvement_fund 69 http://dragoncafe.co.uk/ 70 https://www.ucl.ac.uk/museums/research/museumsonprescription 71 http://www.nesta.org.uk/project/dementia-citizens 72 https://www.casseroleclub.com/ 73 http://hcga.org.uk/ 74 http://www.ivr.org.uk/component/ivr/the-impact-of-volunteering-on-successful-ageing 75 http://www.nesta.org.uk/publications/people-helping-people-peer-support-changes-lives 76 https://www.oecd.org/edu/innovation-education/37437718.pdf 77 http://www.rgtb.org.uk/ 78 https://www.jrf.org.uk/sites/default/files/jrf/migrated/files/9781859354674.pdf 79 www.justaddspice.org 37  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners Appendix C; New care models (NHS England) The NHS New Care Model programme is generating new models for contracts such as Multispecialty Community Provider (MCP). Outcomes which promote the use of social prescribing can be included. Payment for Performance models are being developed by NHS England which could contribute towards this. Over time these are likely to offer Innovative new ways of developing new relationships with local providers80. The six principles for new care models are shown in Figure Eleven. Voluntary, community and social enterprise and housing sectors are in- volved as key partners and enablers Carers are identified, supported and involved Volunteering and social action are recognised as key enablers 06 Care and support is person-centred: personalised, coordinated, and empowering 05 Six principles for new care models Services are created in partnership with citizens and communities 04 02 Focus is on equality and narrowing inequalities Figure Eleven: NHS-England principles for new care models 01 03 80 https://www.england.nhs.uk/ourwork/futurenhs/new-care-models/ 38  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners Appendix D; Potential funding sources for social prescribing New Care Model contracts e.g. Multispecialty Community Provider (MCP) Outcomes can be included in the commissioning of MCPs which promote the use of social prescribing (to deliver those commissioned outcomes). Payment for Performance models are being developed by NHS England which could contribute towards this. Best Practice Tariffs Designed to encourage delivery of best practice. They are currently being developed and not likely to be ready until 2018-19 commissioning round. Subject to development they may be a good vehicle for supporting implementation of social prescribing and self-care. CQUINs They are not applicable to primary care, but could be used with community and secondary care providers. The planning guidance for 2017-19 (NHS England & NHS improvement 2016)81 includes a CQUIN (no 11) to incentivise secondary care providers to use the PAM and train their staff in the use of personal care planning. QOF/Local Incentive Scheme Outcomes relating to social prescribing might be included, but QOF is under review and may come to an end (possibly replaced by New Care Models contracts). A more likely option to influence primary care activity is to include it in the core contract or any locally agreed service contracts with federations/ care networks. New service specification • Commissioners could develop and commission a new service specification to improve support for social prescribing and self-management. • They could draw on the Year of Care model developed originally for diabetes, but now being applied more generally to implementation of social prescribing and self-care82 83. • A range of provider models may be used, including newer types of organisation (e.g. MCP), new joint venture or lead (VCS) provider arrangements. These may be quicker to set up than other models. • Service contracts could include provision for the provider to receive a share of any savings which might accrue from the delivery of the service acting as a financial incentive for performance. Personal Health & Care Budgets Where individuals have agreement for a personal budget (for health and/or social care), they could use that budget to purchase social interventions. This would be independent of commissioners. 81 https://www.england.nhs.uk/ourwork/futurenhs/deliver-forward-view/ 82 http://www.yearofcare.co.uk/ 83 http://www.yearofcare.co.uk/year-care-solution 39  Steps towards implementing self-care: A focus on Social Prescribing for Commissioners Capitated Budgets • Capitated budgets allocate funds according to population numbers fitting certain criteria. They focus care on the individual, not on budget lines, and on outcomes rather than activity. • They can support joint investment from the commissioner side, and can be structured so that prevention and productivity are incentivised, by allowing for savings to be retained by providers, who also take on more risk. • Using capitated budgets to fund more integrated care (to which social prescribing contributes) in Valencia in Spain found84 o reduced costs by up to 26% o increase in hospital productivity of 76% o patient satisfaction rates of 91% • Useful information about this commissioning model is available from the North West London Integrated Care programme website85.Tower Hamlets have a consultation document which discusses issues relating to capitated budgets86. Social Impact Bonds • Social Impact Bonds (SIBs) draw in additional investment, where the return on investment is dependent upon the achievement of social outcomes, which may not be realised for a few years87 88. • They can therefore attract extra finance into the establishment and development of social prescribing, with a sharing of risk with others. • A SIB has been used to develop social prescribing in Newcastle89. • The Regional Voices website has useful information and further resources about using SIBs90 Grant and project funding • New initiatives could be funded through the allocation of existing local grant funding (e.g. from the LA or CCG). • Grants tend to be easier to award than contracts and are sometimes less bureaucratic to performance manage – which may be quicker and beneficial to the grantor and grantee. However, grant funding is increasingly in short supply. • The NHS Five Year Forward View (p14) commits the NHS to developing alternatives to complex NHS contracts for the charitable and voluntary sector, and an increased use of grants. Guidance for the NHS and sample agreements for grants is available91. • Grants from CCGs have been used to fund voluntary sector developments92. There are examples of money being allocated to a local VCS organisation which then awarded this as grants to other, usually smaller, VCS organisations to help deliver the CCG’s goals. • There is a government Social Outcomes Fund, which aims to “top up” funding for services which are commissioned to achieve outcomes93. 84 Oldham J et al (2012); Primary Care - the Central Function and Main Focus. Report of the Primary Care Working Group. Global Health Policy Summit 85 http://integration.healthiernorthwestlondon.nhs.uk/section/why-is-capitation-often-used-in-integrated-care-systems- 86 https://thcvs.org.uk/sites/default/files/Tower%20Hamlets%20capitated%20budget%20scope%20and%20scale%20proposals%20FINAL%20for%20 distribution%20to%20THIPP%2019.01.16.pdf 87 http://www.socialfinance.org.uk/services/social-impact-bonds/ 88 https://data.gov.uk/sib_knowledge_box/ 89 http://bridgesventures.com/bridges-commits-1-65m-first-active-social-impact-bond-uk-healthcare-sector/ 90 http://www.regionalvoices.org/SIB 91 https://www.england.nhs.uk/nhs-standard-contract/grant-agreement/ 92 http://www.regionalvoices.org/grants 93 https://www.gov.uk/government/publications/social-outcomes-fund-how-to-apply 40  Commercial sponsorship Steps towards implementing self-care: A focus on Social Prescribing for Commissioners This might take the form of: • funding in cash or support in kind – possibly aligned to Corporate Social Responsibility programmes. • loans at preferable rates • underwriting of a service It would need work with business organisations/local area enterprise teams. A business will want to be clear about what it will get in return for any contributions it might make. Donations/crowdfunding Funds can be sought from local people and philanthropists. • Fitzrovia Neighbourhood Association is funded by grants and seeks voluntary donations94. • Kentish Town Neighbourhood Fund is funded by voluntary donation. • The Lambeth GP Food Coop95 are seeking investors to develop their scheme through “community shares” which are a sort of localised crowdfunding96. The Bromley by Bow Centre draws on a range of funding sources, statutory, corporate, charitable and from generating income themselves. Their approach has enabled them to succeed for over 30 years, and their diversity of income source has perhaps contributed to this. 94 https://fitzrovia.org.uk/ 95 http://lgpfc.co.uk/about-us/ 96 http://communityshares.org.uk/find-out-more/what-are-community-shares 41