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Developing a joint action plan for social prescribing. 21 st May 2019. Primary outcome. To develop a joint action plan for embedding Link Workers into Primary Care Networks and their local communities. Other outcomes.
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Developing a joint action plan for social prescribing 21st May 2019
Primary outcome To develop a joint action plan for embedding Link Workers into Primary Care Networks and their local communities
Other outcomes • Understand the context in which social prescribing operates in a wider community • Develop understanding of the link worker role and its key functions • Understand key evidence of what social prescribing incorporates, the role of PCNs and expectations being placed upon them • Understanding what social prescribing needs to deliver and how it can be delivered • Create a joint plan which describes how PCNs can work with community partners to take a proactive approach to managing population health through social prescribing.
Contents • Network Neighbourhood schemes and Local area coordination • Briefing on social prescribing & primary care Network • Service framework & implementation guidance • Group work for joint planning
Network Neighbourhood Schemes and local area coordinationMatthew BickNeil Da-Costa
Network Neighbourhood Scheme • One of two in-house NNS (Selly Oak being the other) • Covers 7.3 wards which make up Perry Barr Constituency • Commenced in September 2018 • Asset mapping commenced and is ongoing • Approach will be ‘rooted’ within the VCSE sector • Organisation assessments pending May 2019 onwards • Networking and information sharing sessions held (gaps identified) • Small grants programme pending (may/June 18) aimed at: - Investing in and supporting voluntary and community sector organisations - Providing new activities for older people and communities – where gaps have been identified by older people (via social workers and GPs) - Increasing/improving the accessibility of existing activities • Working relationship established with the local social work teams • Developing partnership working arrangements with key stakeholder delivery agencies Partnership Steering Group established
Whole Person, Whole Family, Whole System Local Area Coordinators support: • People not yet known to services to help build resilience and remain part of their community (avoiding need for services) • People at risk of becoming dependent on services to remain strong in their own community diverting the need for more expensive “formal service” responses. (reduce demand) • People already dependent on services to become less so and more resilient in their own community.
It’s about.... • A good life and active citizenship • Strengths and expertise of all people in our communities • Building individual, family capacity and resilience • Nurturing more welcoming, inclusive and supportive communities • Natural, supportive relationships, contribution, valued roles • Supporting natural, sustainable solutions in communities • Reducing need for/dependency on services
A personal, local, human approach Defined geographical area – Located in/Connected with Community Conversation focused on a good life Build on the assets and contribution of people and the community Whole person, whole family Voluntary relationship – introductions not referrals Not time limited but avoids dependency
Comprehensive Model for Personalised Care Published January 2019 Full array of delivery support actions that will be taken nationally to ensure effective implementation of; • shared decision-making • enabling choice, including legal rights to choice; • supported self-management • personal health budgets and integrated personal budgets • social prescribing and community based support
Primary Care Networks Formed according to national guidance and local principles • 15 PCNs – 10 Sandwell, 5 in West Birmingham • Between 21,000 to 73,000 patients • Between 3 and 9 practices • Placed-based - each PCN working across same nursing, mental health and local authority provision • PCNs will deliver network-level services, beginning with Extended Access
Primary Care Networks – Go Live 1 July 2019 What are they? • Practices working together and with other local health and care providers • Providing care in different ways to match different people’s need • Focus on prevention, patient choice and self care • Use of data and technology • Making best use of collective resources across practices Why are they needed? • Represent the building blocks of place-based models of care provision and are the key to preserving the integrity of NHS service provision going forward • Offer care on a scale which is small enough for patients to get the continuous and personalised care they value, but large enough, in their partnership with others in the local health and care system to be resilient What will be better for patients? • Access to a wider range of professionals than may have been available in individual practices • Improved/shorter waiting times that are focused around the access needs of those using services. • Improved access to a wider range of services and support through use of the resources and partners within the Network • Provide a focus on increasing access to care locally (place based care), and avoiding admission/attendance at hospital where appropriate • An increased focus on prevention and personalised care
Expectations • PCNs expected to take a proactive approach to managing population health • Assess the needs of their local populations to identify people who would benefit from targeted, proactive support.
Challenges • Collaboration in primary care takes time; strong relationships, a shared vision and effective leadership are all crucial. Much rests on primary care networks which are still a relatively untested model. • Ensuring integration exists with voluntary/community sector and the wider health and care systemand ‘Place’.
Priorities • Ensuring PCNs are supported to implement social prescribing • Work with partners to focus on social prescribing and the role it can play system wide • Building resilient and sustainable communities • Monitor impact and evaluate over time
Link Workers • Announcement around the new GP contract for 19/20 includes additional workforce within networks which includes social prescribing. • £34,113 per PCN • Model role specifications published as a guide • July 2019 - first Link Workers to be recruited
Link Workers • Link workers integral part of the core general practice model throughout England – not just ‘wrap around’ support • Network DES used to specify requirements • Reimbursing 100% of the cost of funding for social prescribing link workers - 5 year commitment • Networks can choose to fund a local voluntary sector organisation to employ link workers and run the service on behalf of the network. “
Service framework • supports the wider ‘personalised care’ programme by focusing on the wider determinants of health and well-being. • aims to provide non-clinical support to improve health and wellbeing for social, emotional and practical problems. • to treat the causes behind the physical/medical symptoms rather than focusing on medical interventions. • expand the options available for patients when attending a primary care (GP practice) consultation. The service will need to have high awareness of local services available as well as form strong relationships with the Primary Care, the voluntary & community sector, secondary care and the patients they serve.
Universal vs targeted social prescribing Universal social prescribing • the system as a whole has a role to play in ensuring people have the tools in place to lead a happy and healthy life. • In partnership with local authorities and the Voluntary and Community Sector (VCS), there is a joint commitment to develop and support community groups, to deliver services in local communities and to keep people healthy and well (and out of hospital and GP surgeries). VCS organisations already provide a wide range of social prescribing interventions. • guidance focuses on targeted social prescribing in Primary care, services operating in this setting need to be mindful of the ‘place’ in which they function. Targeted social prescribing • developed within the context of a strategic framework of self-care and prevention. • Embedding Link Workers into PCNs is a means of targeted social prescribing. • the service framework has been developed to provide guidance on what the service could include within a primary care setting. • number of ‘must haves’, but the models are agile enough to work in the context of any local community. • PCNs need to be work in partnership with their communities to make the service work at place based levels (see above).
Group work 3) Partnerships • Who are the key stakeholders for what’s needed to make social prescribing successful? • What does each partner have to offer? • Their assets, skills and knowledge. • Projects, activities and interests involved in • Potential for collaboration and how can we avoid duplication to maximise impact?
Group work 4) Workforce development • what knowledge, skills and experience do link workers need to have? • what support will link workers need? • steps needed to ensure link workers are embedded into team • What will happen in first 3 months/12 months?
Group work 5) Primary Care Networks How can PCNs work with their community partners to take a proactive approach to managing population health through social prescribing and tackle the wider health needs of their local populations?
Evaluation and next steps • I understand… • the context in which social prescribing operates in the wider community • the key evidence of what social prescribing incorporates, role of PCNs and the expectations being placed upon them what social prescribing needs to deliver and how it can be delivered • The key functions of the Link Worker and what support they need. • The joint plan which describes how PCNs can work with community partners to take a proactive approach to managing population health through social prescribing.
