EvaluationoftheEastMertonSocialPrescribingPilotJuly2018
ReportbyHealthyDialoguesLtd.
Pilotdeliveredby:
2
Contents
3
EastMertonSocialPrescribingPilotHighlights 2
ExecutiveSummary 4
Introduction 6
ThePilot:AnOverview 10
Evaluation:WhatWeDid 12
Results 14
KeyFactorsForSuccess 23
TheSocialPrescribingPilotPathwayReview 25
Recommendations 29
Conclusion 32
References 34
Appendices 37
- AppendixA:PatientexperiencesofSocialPrescribing 38
- AppendixB:GPPracticeFocusGroups 46
- AppendixC:InterviewswithStakeholdersandSPC 51
- AppendixD:InterviewswiththeVoluntaryandCommunitySectorServices 57
- AppendixE:SocialPrescribingInterventionObservations 64
TheEastMertonSocialPrescribingPilot
MertonCCGandMertonCouncilsetouttotestamodelofSocialPrescribingthatwould
connectmedicalcarewithlocalvoluntaryandcommunityresources.Itsaimswereto
improvepatienthealthandwellbeingandreducepressuresonlocalGPandA&Eservices.
TheMertonVoluntaryServiceCouncilSocialPrescribingCoordinator(SPC)deliveredthe
pilotthroughtwoGPPractices,WidewayMedicalCentreandTamworthHouseMedical
Centre.
ThisreportisasummativeevaluationoftheEastMertonSocialPrescribingprogramme’s
firstyearandareviewofitspathway.
EvaluationFindings
Overalltheprogrammewasamarkedsuccess.Thepilotsawasignificantincreaseinhealth
andwellbeingaswellassignificantdecreasesinbothGPappointmentsandA&E
attendancesinpatientsreferredtotheservice.
Conversationswithpatientsandstakeholdersalikeshowedthatthepilotwashighlyvalued
andseenasanecessaryservicethatfilledagapinlocalneeds.Patientscreditedthe
programmetoimprovingtheirwellbeing,bringingthembacktorecoveryandlinkingthem
tosupportclosetotheirdoorstepsthattheydidnototherwiseknowabout.
GPsvaluedthattheyareabletoprovideadditionalsupportforpatientswithwiderhealth
andwellbeingneedsfromwithinthepracticeandasaresultGPsnotedthatsomepatients
requiredfewerappointmentswiththem.Thosefromthevoluntaryandcommunitysector
servicesspokepositivelyabouthowtheprogrammefillsaneedinMertonofproviding
holisticsupportforpatients.
ExecutiveSummary
4
Conclusion
ThepilotdemonstratedamodelofSocialPrescribingthatfitswellwithintheEastMerton
context.Thesuccessoftheprogrammeistestamenttothecommitmentandexpertiseof
theImplementationGroup,theSPCandchampionGPs,theflexibilityandsimplicityofthe
service,strongengagementandtheprogramme’svisibilitywithinthepractices.
Thekeyfactorsforsuccessareoutlinedandrecommendationsforup-scalingthe
programmeareprovidedinthisreport.
Nextsteps
FromApril2018twoadditionalSPCshavebeenrecruitedandtheprogrammehasbegunto
berolledoutacrossatotalof9GPpracticesineastMerton.
5
WorkinginpartnershipMertonCCG,MertonCouncilandMertonVoluntaryServiceCouncilsetouttopilotamodelofSocialPrescribingthatwouldconnectclinicalserviceswithlocalvoluntaryandcommunityservices.ItsaimsweretoimprovepatienthealthandwellbeingandreducepressuresonlocalGPandA&Eservices.
Thisreportisanevaluationofthefirstyearofthepilot.FirstitwillprovideanoverviewofSocialPrescribing,thepilotandhowitwasevaluated.Itwillthenpresenttheresultsoftheevaluationintermsofwhowasengagedbytheserviceandtheiroutcomes.Finally,thereportwillhighlightsomeofthekeyfactorsthatcontributedtothesuccessofthepilotandpresentaqualitativereviewofthepilot’sSocialPrescribingpathwayandrecommendationsforupscalingtheprogramme.
ACaseforChangeThecaseforcommunity-basedmodelsforhealthandwellbeingpromotionsuchasSocialPrescribingisstrong.TheFiveYearForwardView(NHSEngland,2014)emphasisesthatNHSsystemsareincreasinglyunderpressureasourpopulationliveslongerwithmorecomplexhealthissues.DemandsonGPservicesarealsoincreasingatatimewhenfunding
andworkforceresourcesarereducing(Bairdetal,2016).
AccordingtotheDepartmentofHealth(2015),peoplewithlongtermconditionsarethemostfrequentusersofhealthcareservices,accountingfor50%ofallGPappointments
and70%ofallinpatientbeddays.Citizen’sAdvice(2016)estimatesthat20%ofGPappointmentsareforpatientswhoneednon-medicalhelporsupport.
ThesustainabilityoftheNHSanditssystemsisreliantonaradicalupgradeofpreventionandpublichealthwork.TheFiveYearForwardViewhighlightsseveralwaysinwhichthis
canbeachieved,including:
Introduction
6
• Empoweringpatientsbyimprovingtheiraccesstotherightinformation
• Supportingpatientstomanagetheirownhealth
• Buildingstrongerpartnershipswiththevoluntaryandcommunitysectors(NHSEngland
2014).
Additionally,theCareActof2014putsdutiesandresponsibilitiesonlocalauthoritiesto
promotewellbeingandensurepeoplehaveaccesstotheinformationandadvicethey
needtomakedecisionsabouttheircareandsupport.Existingresourcesfromwithinthe
localcommunitycanensurethatpeoplehaveaccesstoarangeofhighquality,appropriate
servicestochoosefromintheareatheylivein.
SouthwestLondonSustainabilityandTransformationplan(SWLCCG,2016)goesonestep
furtherwithambitionstodelivermorecareinthecommunityandimplementrobust
multidisciplinarycommunityworksupportedbySocialPrescribing.
WhatisSocialPrescribing?
SocialPrescribingprovidesGPswithanon-medicalreferraloptionthatcanoperate
alongsideexistingclinicaltreatmentstoimprovehealthandwell-beingandaddressthe
socialdeterminantsofhealth-theconditionsinwhichpeopleareborn,grow,live,workand
age(WHO,2018).
TheNationalSocialPrescribingNetworkdescribeSocialPrescribingas-
“AmeansofenablingGP’sandotherfrontlinehealthcareprofessionalstoreferpatientsto
alinkworker-toprovidethemwithafacetofaceconversationduringwhichtheycan
learnaboutthepossibilitiesanddesigntheirownpersonalisedsolutions,i.e.‘co-produce’
their‘socialprescription’-sothatpeoplewithsocial,emotionalorpracticalneedsare
empoweredtofindsolutionswhichwillimprovetheirhealthandwellbeing,oftenusing
servicesprovidedbythevoluntary,communityandsocialenterprisesector”
- SocialPrescribingNetworkConferenceReport(2016)
7
Thesocial,emotionalandpracticalneedscanhaveasignificantimpactonimprovingand
maintaininghealthandwellbeingandhelpwiththesesocialdeterminantsaretypically
availablewithinlocalcommunities(Parsfieldetal,2015).
WhatistheevidenceforSocialPrescribing?
EvaluationoftheeffectsofSocialPrescribingisgrowing.Mostrecentstudiesareshowing
improvementsinpatientengagementandwellbeingandareductioninhealthcareusage
followingaSocialPrescribingintervention.Forexample,awellbeingSocialPrescribing
programmebasedinRotherhamfoundthatpatientsshowedsignificantimprovementin
wellbeing,depressionandanxietyandapotentialreductioninGPappointmentsthree
monthsfollowingaSocialPrescribingintervention(Kimberleeetal,2013).
ADundeeprogrammereportedthatpatients,includingthosewhocanbedifficultto
engageandsupport,foundtheschemeappropriatetotheirneeds,helpfulandaccessible
witharangeofactivitiesandsupport.Additionally,pre-andpost-interventiondatashows
significantimprovementsinwellbeingandfunctionalability(Frieldli,2012).
Asix-monthpilotschemeinTowerHamletsshowedthatpatientsgotinvolvedinarangeof
activitiesasaresultoftheSocialPrescribinginterventionincludingvolunteering,takinga
course,gainingaqualification,stoppingsmoking,startingahobbyandgainingcontrolover
theirfinancialsituation.35%ofpatientstookuponeortworeferredservicesand75%
statedthattheirissuewaspartiallyorfullyresolvedandthattheyweresatisfiedfollowing
theintervention(Hogarthetal,2013).
AsystematicreviewoftheevidenceoftheimpactofSocialPrescribingonhealthcare
demandandcostimplicationsshowedaveragereductioninGPappointmentsby28%and
A&Eattendanceby24%followingareferraltoSocialPrescribing.Italsoshoweda
statisticallysignificantreductioninreferralstohospital(Pollyetal,2017).
8
Cost-effectivenessofSocialPrescribing
Thelong-termcostbenefitsofSocialPrescribingarenotyetclear.However,short-term
cost-effectivenesshasbeenestimatedfortheDoncasterSocialPrescribingprogramme.
Itusedcost-utilityanalysistoevaluatecost-benefitsofpatient’simprovementsinhealth-
relatedqualityoflife.Theprogrammeestimatedthatevery£1spentontheservice
producedmorethan£10ofbenefitsintermsofbetterhealth(SheffieldHallamUniversity,
2016).
EastMertonModelofHealthandWellbeing
In2014,apopulationhealthneedsassessmentfoundthatpeopledieyoungerinEast
MertonwhencomparedwithWestMerton,particularlyfromcardiovasculardiseaseand
cancer,withlargerdifferencesseeninyoungerpeople.Theassessmentlookedatexisting
community-basedmodelstotransformcareforlong-termconditionsandhighlightedthe
opportunitytomakeimaginativeandeffectiveuseofcommunity-basedapproaches(Dent,
2014).
Inresponsetothis,MertonCCGaredevelopinganewmodelofcaretomeetthehealth
andsocialcareneedsforthepeopleofEastMerton.ThisEastMertonHealthand
Wellbeingprogrammeisablueprintfortransformationacrosstheboroughthatworks
beyondservicedeliverytobuildanddevelopasocialmodelofhealththatlooksatthe
wellbeingofindividuals.Additionally,itlookstoaddressthegapbetweenshrinkingNHS
resourcesandincreasingdemandonservices.
OneofthepiecesofworkwithinthismodelwastopilotaSocialPrescribingprogramme
thatutilisesacollaborativepathwaydesignedtofreeupGPprofessionaltimewhile
connectingpeopletotheircommunityandcommunityresources.
9
TheEastMertonSocialPrescribingpilotprogrammewasfundedbyMertonPartnership,
MertonCCGandMertonCouncilPublicHealthtorunforjustoveroneyearfromJanuary
2017.Thepilotbegantoseepatientsfromthe1stofFebruary2017.
Thepilotwasguidedbyanimplementationgroupofstakeholdersfromthevoluntaryand
communitysector,CCG,LocalAuthorityandGeneralPractice.Thepilotprogrammewas
deliveredbyMertonVoluntaryServiceCouncil,whoemployedaSocialPrescribing
Coordinator(SPC).
TwoGPpracticesinEastMerton;TamworthHouseMedicalCentreandWideWayMedical
Centre,wereselectedtohostthepilotprogrammeastheywereideallylocatedwithinthe
eastofMerton.TheSPCworkedatbothpracticesfortwodaysaweekeachandwasvisible
asafullyintegratedmemberofthepracticeteams.
Thepilotaimedtopromoteself-help,socialengagementandresiliencetoitspopulationin
EastMertonby:
• Providingamodelofservicedeliverythatconnectsmedicalcarewithlocalresources;
and
• Establishingacollaborativepathwaybetweentheprimarycareandvoluntaryand
communityservices.
Theoverarchingaimsofthepilotwereto:
• Improvethehealthandwellbeingofpatientsbyprovidingaccesstonon-medical
support.
• Reducegeneralpracticeclinicalworkloadwhileincreasingskill-mixwithinprimarycare.
• ReduceavoidablecostsincludingA&Eattendancesandhospitaladmissions.
ThePilot:AnOverview
10
Typically,GPswouldreferpatientstotheprogrammeiftheypresentedwiththefollowing
criteria:
• FrequentattendancetoGPservices
• Socialisolation
• Mild/moderatementalhealthissues
• Socialneeds
• Recenthospitaladmissions
TheSPCwouldbookaone-hourinitialconsultationappointmentandofferthepatienta
needsassessmentthatisstructuredaroundtheWellbeingSTAR(Figure5,page18).The
SPCandpatientwouldthenagreeaplanofactionbasedonthatneedsassessmentthat
mayincludemakingareferralorsignpostingtoactivitiesprovidedbythelocalvoluntary
andcommunitysector,basicassistancewithformfilling,benefitseligibilitychecksor
engagementwithmentalhealthservices.WhereneededtheSPCwouldofferafollow-up
appointmentatthree-monthlyintervals.
FromApril2018theprogrammehasbeguntoberolledoutacrossallninepracticesinEast
Merton,withtwoadditionalSPCs.
11
Thisevaluationemployedamixed-methodsapproachtoreviewhoweffectivetheSocial
PrescribingpilotisinimprovingthehealthandwellbeingofpatientsandreducingGP
practiceclinicalworkload.Theevaluationlookedattheprocessesinvolvedinthe
developmentoftheSocialPrescribingpilot,itsimpactandpotentialbyexploringallthe
differentfacetswithintheSocialPrescribingPilotLogicModel(Figure1).
PatientdatawascollectedfromtheGPdatabaseEMISandtheOutcomesSTAR-ahealth
andwellbeingquestionnairethatpatientscompletedateachvisit(figure5,page18).The
researchersspokewitharangeofpeopleinvolvedintheprogrammeabouttheir
experiencesofthepilotandviewsonthefollowing:pathway,accesstoengagement,
communicationanddatatransferandscalability.
Thefollowingpeopleparticipatedininterviewsorfocusgroupsforthisevaluation:
• GPpracticestaff
• Patients
• SocialPrescribingCoordinator
• ImplementationGroupmembersandstakeholders
• Voluntaryandcommunityserviceproviders
Additionally,theevaluatorsobservedtheSocialPrescribinginterventionsatthebeginning
ofthepilotandtowardstheendofthepilottofeedbackonthebehaviourchange
conversations.Eachofthequalitativeanalysesaresummarisedintheappendices.
Evaluation:WhatWeDid
12
Figure1:EastMertonSocialPrescribingPilotLogicModel.
13
Theresultsinthisreportarepresentedasananalysisofpatientdemographics,reasonsfor
referralandoutcomes.Additionally,theinterviewsandfocusgroupshaveprovidedinsight
astothekeyfactorsofsuccess,howthepilotpathwayworksandrecommendationsfor
upscalingin2018.
TheresearchersundertookananalysisofthepatientsthathavebeenreferredtotheSocial
Prescribingprogrammeinthefirstyearofthepilot(1stFebruary2017to31stJanuary
2018).Theanalysisthatfollowsprovidesanoverviewofthosereferred,theirwellbeing,GP
appointmentsandA&Eattendances.
Patientdemographics
Inthe12monthpilotperiodbetweenthe1stofFebruary2017to31stJanuary2018316
patientswerereferredtotheEastMertonSocialPrescribingprogramme,250ofwhom
werefromtheWideWayMedicalCentreand66fromTamworthHouseMedicalCentre
(seefigure2).Whatfollowsisabreakdownofthesereferralsbyage,genderandethnicity.
Ageandgender
ThereisgenerallygoodengagementwithallagegroupsfortheSocialPrescribing
programme.Thelargestproportionofpatients(15%)arebetween40and49yearsofage
andmorewomen(71%)havebeenreferredtotheprogrammethanmen(29%).
Results
14
Figure2.NumberofSocialPrescribingpatientsbyage-group,genderandpractice
Ethnicity
Overhalf(55%)ofpatientsreferredwerewhite,followedbyblack(24%)andAsian(10%).
Theethnicityreachoftheprogrammegenerallyreflectstheethnicmake-upofthelocal
area(Dent,2014).
15
Figure3.NumberofSocialPrescribingpatientsbyethnicity,genderandpractice
Reasonsforreferral
Theresearcherslookedatthereasonsforreferraltoreviewwhichpatientswerebeing
referredtotheserviceandwhethertheagreedeligibilitycriteriawasappropriateforthe
needsofthepatientsandtheprogramme.
OuranalysisofthereasonforreferraltotheSocialPrescribingprogrammewasbasedon
theSPCdataratherthanGPpracticedata.Thismeansthatthereasonsasdeterminedby
theSPCmaydifferfromtheGP’soriginalreasons.Theresearchersadaptedthisapproach
becausetheSPCdatawasmorecomplete.
ThemajorityofthepatientsreferredtotheSocialPrescribingprogrammewerereferred
formorethanonereason.Themostcommonreasoncitedwasmild/moderatemental
healthissues(seefigure4).Thenextmostcommonreasonscitedwasforlong-term
physicalcondition(s)whichwasnotwithintheagreedreferralcriteriafortheintervention.
16
Theseresultsareindicativeofwhichpatientsareeligiblefortheprogrammeandfuture
evaluationscanreviewtheeligibilitycriteriamoreclearlyonceallGPsareroutinely
followinganagreedreferralprocess.
Figure4.Reasonsforreferral
Outcomes
Wellbeing
AteachSocialPrescribingappointment,theSPCasksthepatientstofillintheWellbeing
Star.Therearesomeoccasionswhenthepatientdoesnotcompletethequestionnaire,this
istypicallyduetolanguagebarriers,learningdisabilityoremotionaldistressatthetimeof
theappointment.
TheWellbeingStarisareliableandvalidtool(Mackeithetal,2010andMackeith,2011),
thatlooksateighthealthandwell-beingsub-categoriesthatpatientsrateonascale
rangingfrom1(notthinkingaboutit)to5(asgoodasitcanbe).
Theresultsaredisplayedinastardiagramthatthepatientscanseeandcomparewith
previousresultsateachappointment(Mackeith,2014).TheStaranditssub-categoriesare
showninFigure5.
17
Figure5:TheWellbeingStar
Figure6:TheNumberofStarreadingsperpatient.
DuringthepilottheSPCsaw206
patients,187ofwhomhadaStar
assessment.100patientshadonlyhad
oneassessmentbytheendofthe
pilotperiod.Seventy-fivepatients
completedtwoStarassessmentsand
12completedthree.
18
Figure7.DistributionofoverallWellbeingscoresduringfirstandlatestSPCsession
Analysisshowsthataltogether,
patientswhoattendedSocial
Prescribingexperiencedan
improvementintheiroverallwellbeing
score(seefigure7).
Thepatient’saveragescoreatthefirst
appointmentwas2.8(SD=0.80).This
increasedto3.5(SD=0.83)bytheir
lastappointment.
Pairsamplest-testanalysisshowsthat
thisisasignificantincrease(t(86)=1.99;
p=0.00).
AlleightdomainsoftheSTARmeasureimprovedatthreemonthfollowup,withthegreatestin
the‘lifestyle’domainandtheleastinthe‘whereyoulive’domain(Figure8).Astatistically
significantincreasewasfoundacrosseachdomain.Figure8.WellbeingscoresduringfirstandlatestSPCsession
19
GPappointmentsThenumberofGPappointmentsapatientattendsbeforeandafterengagingwiththe
programmecanindicatewhetherthereisanyimpactonclinicaloutcomes.
Toimprovetheaccuracyoftheassessment,thedaythepatientwasfirstseenbytheSPC
andaStarassessmentcarriedoutwasusedasthebaselinedate.Theresearcherslookedat
thenumberofGPappointmentsatthreeandsixmonthspre-andpostSocialPrescribing
intervention.
ThreemonthchangeinGPappointments
Atthepointofdatacollection,therewere138patientsseenbytheSPCatleast3months
beforethedatacollectionpoint.ThisallowedthestudytoexaminetheirGPappointment
ratesthreesmonthsbeforeandthreeafterfirstseeingtheSPC.Inall,theytookup1,641
appointmentsbeforetheSocialPrescribinginterventionand1,098afterwards,
representingareductionof543appointments(33%)inthepilotyear.
Figure9:DistributionofGPappointments,threemonthspre-andpostSocialPrescribing
Theaveragenumberof
appointmentsperpatient
reducedfrom11.9(SD=9.48)
to8(SD=6.85).
Pairedsamplest-testanalysis
showsthatthisisastatistically
significantreductioninthe
numberofappointments
(t(137)=1.98;p=0.00).
20
SixmonthchangeinGPappointments
Atthepointofdatacollection,therewere101patientsseenbytheSPCforwhomthere
wassixmonthspre-andpostGPappointmentfigures.Altogethertheytookup2,013
appointmentsbeforetheSocialPrescribinginterventionand1,790afterwards,thisisa
reductionof233appointments.
Figure10:DistributionofGPappointments,sixmonthspre-andpostSocialPrescribing
Theaveragenumber
ofappointmentsper
patientreducedfrom
20(SD=14.08)to18
(SD=13.18).
Howeverthis
reductionisnot
statistically
significant
(t(100)=1.98;p=
0.08).
A&Eattendances
ThepilotalsoexaminedtheeffectofSocialPrescribingonA&Eattendancestoascertain
howitmayimpactonthewiderhealthcaresystem.
ThreemonthchangeinA&Eattendances
Duringthepilot,60patientsattendedA&E39timesinthethreemonthsbeforetheSP
interventionand20timesafterwards(areductionof19overall).Theaveragenumber
21
ofappointmentsperpatientdroppedfrom0.65(SD=1.31)to0.33(SD=0.73).Thisisnotastatisticallysignificantdecrease(t(59)=2.00;p=0.11).
SixmonthchangeinA&EattendancesThepilotsaw43patientswhoattendedA&EinthesixmonthsbeforetheSocialPrescribingintervention.IntotaltheyvisitedA&E60timesbeforeand31timesafterwards,leadingtoareductionof29visitsoverall.
Figure11:DistributionofA&Eattendances,sixmonthspre-andpostSocialPrescribing
Theaveragenumberofappointmentsperpatientdroppedfrom1.4(SD=1.65)to0.7(SD=0.93)(seeFigure11).Thisisastatisticallysignificantdecrease(t(59)=2.01;p=0.04).
22
Overall,thoseinterviewedspokeverypositivelyabouttheprogramme.Theyfeltthatthe
pilothadbeensetupsuccessfully,isrunningsmoothlyandprovidingstronghealthand
wellbeingoutcomesforpatientsbyconnectingthemtoresourcesavailabletothemin
theirowncommunity.
Thekeyfactorsforsuccesshavebeendrawnfromtheinterviewsandfocusgroupsandare
outlinedbelow.
Mobilisation
• StrongengagementwithintheImplementationGroupensuredthatallkey
stakeholdershadagreedonwhattheSocialPrescribingmodellookedlikeandwhatthe
referralcriteriawas.
• ByusingtheexistingsystemswithinthepracticestheSocialPrescribingprogramme
andSPCwaseasilyembeddedwithintheGPPractices.
• WheretherewasstrongengagementandvisibilityoftheSPCwithinthepractice,
morereferralstotheprogrammewereseen.
• ByensuringtheearlysetupofITsystemstheSPChadaccesstopatient’scase
managementsystemsandcouldbookpatientappointmentsstraightawayand
understandthecircumstancesaroundwhytheywerereferred.
• TheGPChampionwaskeyintranslatingthe‘blue-sky’ideasinthepilotstrategyinto
practicalsolutionsfortheprojectplanandpathway.Hehadalsobeenkeytoraisingthe
profileoftheprogrammeandchampioningtheprogrammeinhisownpractice.
KeyFactorsforSuccess
23
SocialPrescribingappointments
• Patientsareseenwithintwoweeksofreferralwhichenabledthemtoaddresstheir
issuesorconcernsquicklythroughvoluntaryandcommunitychannels.
• TheWellbeingToolsurveyaddedstructuretotheSocialPrescribingappointments.This
helpedpatientstothinkabouttheirsituationmorethoroughlyandallowedthe
evaluatorstoseetheimpactofSocialPrescribingonthepatient’shealthandwellbeing
overtime.
• TherelaxedpersonalapproachoftheSPChelpedbuildgoodrapportandatrusting
relationshipwiththepatients.AdditionallytheSPCsabilitytoaddresssomeissues
‘thereandthen’helpedpatientstotakethatfirststeptowardssupportingtheir
recoverywhichwasvaluedhighlybypatients.
• TheSPC’sstronglinkstothecommunityandbreadthofknowledgeofsupport
availableenabledpatientstoaccesstheavailableappropriatesupportrightaway.
24
ThisfinalpartofthisreportisaqualitativereviewoftheSocialPrescribingPilotPathwayanditskeyfeatures,asdescribedbythepatientsandprofessionalswespokewith.
Thekeyfeaturesinclude:referralprocessesanddatacollection,theSPCappointmentsystemandreferralsandsignpostingtothevoluntaryandcommunityserviceSector.Thesearesummarisedinthefollowingpages.
Figure12representsthepilotSocialPrescribingpathwayasoutlinedbythepeopleinterviewedthroughouttheyear.
Figure12:EastMertonSocialPrescribingPilotPathway
SocialPrescribingPilotPathwayReview
25
GP
SPC
Voluntaryand
CommunityServices
AdhocFeedback
VariedFeedback
• AllreferralsarebyGP• Onepracticedescribesathree-step
approachtomakingareferral
• SPCreviewsreferralformorEMISdataandcallspatienttoarrangefirstappointment
• SPCwillseepatienteverythreemonthsuntildischarge
• SPCrecommendsvoluntaryandcommunityservicesandsignpostsorsupportspatient’sfirstcontactwiththeservice.
• SPCmaycalltheservicetofollow-uppatient
Referralprocessesanddatacollection
AtthebeginningofthepathwaytheGPscreenspatientsandthenrefersthoseeligiblefor
theprogrammetotheSPC.
ThereferralprocessisdescribedbythetwoGPpracticesindifferentways.Whilst
WidewayMedicalCentreGPsfinditaquickandeasyprocess,TamworthHouseMedical
CentreGPsdescribeathree-stepprocessthattheybelievecouldbesimplified(see
AppendixB).Futureprogrammeswouldbenefitfromco-designingthereferralprocesses
sothatitfitswellwithinthepracticesexistingsystemsandGPswillfindquickandeasyto
do.
CurrentlynotallGPscompletetheagreedreferralformandinsteaduseothermeanssuch
asemailstomakeareferral.ThissometimesmadeitdifficultfortheSPCtohaveafull
understandingofthecontextofthereferralasdetailsthatwereintheagreedreferralform
werefrequentlymissing.Additionally,theassessorsfoundthatthereasonsforreferralas
recordedbytheSPCwereoftendifferentfromthereasonsstatedbytheGP.Clear
guidelinesonthereferralcriteriawillhelpalignthediscrepanciesbetweenGPsandthe
SPConwhyapatientisreferred.
Thetwopracticesalsodescribethedifferentlevelsoffeedbacktheyreceiveregardingthe
patientinterventiononcetheGPhasreferredtotheSocialPrescribingprogramme.Some
GPsfeelthattheyreceivedgoodfeedbackonthepatientfollowingtheirfirstSocial
Prescribingappointment,whereasothersfeeltheywouldbenefitfromamoresystematic
approachtoreceivingfeedback.Astandardisedcomprehensiveapproachtoproviding
feedbackonreferralsagreedbyallpartieswillpreventanygapsincommunication
betweentheSocialPrescribingprogrammeandthecliniciansreferringtothem.
26
27
Finally,bothpracticestaffandpatientshaverecommendedtoallowreferralsfromthe
practice’swiderclinicalteamwithaviewthatthiswillspeedupreferralsforpatientsand
preventunnecessaryGPappointments.
TheSocialPrescribingintervention
AstheSocialPrescribingprogrammeprogressedthroughitspilotyeartheSPChastried
andtesteddifferentwaystoapproachsessionswiththepatients.Additionally,the
evaluatorobservedappointmentsatthebeginningoftheyearusingtheBehaviourChange
CounsellingIndex(Laneetal,2005)andmadesomesmallrecommendationsregardingthe
intervention.TheserecommendationsweretakenonboardbytheSPCandeffective
improvementswereseenwhentheappointmentswereobservedforasecondtime
towardstheendofthepilotyear.
SPCappointmentsystem
OnceapatienthasbeenreferredtotheprogrammetheSPCwillseethemface-to-facefor
45minutesatthree-monthlyintervals.Thiswasmodeledonbestpracticegleamedfrom
othersuccessfulSocialPrescribingmodelsacrossthecountry.Thepatients,SPCand
practiceclinicalteamhaveeachhighlightedthatthereisroomforflexibilityinthis
approachsothatthereareoptionsforpatientswhocannotattendfacetoface
appointmentsduringworkhoursandtheSPCstimecanbeusedmoreefficiently.
Currently,thereisnodischargeguidelineorpolicythattheprogrammefollows,ratherthe
patientwillseetheSPCuntiltheynolongerneedtheserviceortheystopattending.This
hasnotposedanyissuesfortheprogrammeinthisoneyearpilot.However,awelldefined
setofguidelinesondischargingpatientswillempowertheSPCtosupportclientsto
transitionawayfromtheserviceoncetheycompletetheintervention.
28
Referralsandsignpostingtothevoluntaryandcommunity
servicesector
TheroutefromtheSocialPrescribingprogrammetothevoluntaryandcommunitysector
variesfromservicetoserviceanddependingontheneedsofthepatient.Forexample,
someservicesrequirepatientstoself-referwhichtheSPCwillsignpostthepatientto,
whereastheSPCcanrefertootherservicesdirectly.Incaseswherepatientswould
benefitfromsupporttotakethatfirststeptheSPCwillmakeaphonecalltotheserviceto
initiatetheprocess.
QuiteoftenserviceswillbeunawarethattheSocialPrescribingProgrammehassignposted
tothemorbecauseofpatientconfidentialityareunabletoreportifapatienthasbeenin
contactwiththem.Asaresult,thefeedbackregardingtheoutcomesofthesereferralsis
oftennotpossibleorisinconsistent.Itisthereforenotpossibletoevaluatewhatreferrals
orsignpostsareworkingwellandforwhom.
Thefindingswithinthisreportwerepresentedanddiscussedwithrepresentativesofthe
ImplementationGroupandthefollowingrecommendationswereagreed.
ReferralProcessesandDataCollection
1. ThereferralprocessfromGPtoSPCbeco-designedwitharepresentativefromeach
practiceandtheSPCduringthemobilisationphaseorassoonaspossible,andthe
referralcriteriabereviewedaspartofthisprocess.Thiswillensurethatthereferral
processfitswellwithinthepractice’sexistingsystemsandclinicianshavean
opportunitytoinputtoitsdesigntoensurethatit’sfeasibleforthemtouse.
2. TheSPCtoacceptreferralsfromthepractices’widerclinicalteamtospeedupreferrals
timesandfreeupGPappointments.
3. AsystematicapproachfortheSPCtofeedbacktotheclinicianontheoutcomesofthe
SocialPrescribingintervention.Thiscouldbeasimpleprocesssuchasprovidingverbal
feedbackatteammeetingsoremails.
SocialPrescribingIntervention
4. SPCshaveexperienceortrainingonbehaviourchangeconversationssotheyhavethe
skillstobuildrapportwithpatients,supportthemtobuildtheirself-efficacyand
navigatearoundbarrierstochange.
5. FutureprogrammesbuildonbestpracticeastriedandtestedbytheSPC.
6. Appointmentsfollowaclearstructurethatwillincludecollaborativeagendasetting,a
needsassessmentincludingusingSTAROutcomesandreferring/signposting.Where
patientsareunabletocompletetheSTAROutcomessurvey,thisshouldberecorded.
7. TheSPCsignposttoamaximumoftwovoluntaryandcommunityservicesatatime
(wherepossible)soastonotoverwhelmthepatientandcausethemtodisengage.
8. Theinterventionconcludewithawrittenagreementofstepstobetakensothatthey
canberecordedandreviewedatfurtherappointments.
Recommendations
29
SPCAppointmentSystem
9. TheSocialPrescribingprogrammeshouldexploreandtesttheoptionofaflexible
appointmentsystemwherebyoncetheSPChasmadeinitialcontactwiththepatient,
incaseswherea45minuteface-to-faceappointmentisnotrequiredtheoptionofa
telephoneappointmentorreferraltoapracticehealthchampionisavailable.Thiswill
freeupappointmentspacesforadditionalpatients.
10. AsetofpatientdischargeguidelinesbeagreedbetweentheSPCsandclinicalteamso
thatpatientswhohavecompletedtheprogrammecanhaveasmoothtransitionaway
fromtheservice.
ReferralsandSignpostingtotheVoluntaryandCommunity
ServiceSector
11. TheSocialPrescribingprogrammeengageswiththeservicestheyreferintomost
frequentlytoco-designaprocessforprovidingfeedbackontheresultsofthereferral,
includinganypatientoutcomes.
12. Theprogrammeimplementsasystematicapproachtoobtainingfeedbackfrom
patients.IdeallytheSPCascertainswhetherthepatientfollowed-uponthereferralor
signposting,howtheyratedtheserviceandverbalfeedbackontheirviewsonthe
service.ThiswouldberecordedbytheSPCsforanalysis.
TheresultingrecommendedpathwayforEastMertonSocialPrescribingprogrammeis
presentedinFigure13.
30
Figure13:EastMertonSocialPrescribingFuturePathwayProposal
31
GPPracticeClinicalTeam
SPC
Voluntaryand
CommunityServices
SystematicfeedbacktoGP
Feedbackfromkeyservicesand
patients
• ReferralsbyGPs,practicenursesandpracticepharmacist
• Co-designreferralsystem
• Flexibleappointmentsystem• StructuredSocialPrescribing
Interventionsusingbehaviourchangeconversationalskills
• Signposts/referralstonomorethantwoservicesatatime.
• Co-designfeedbacklooptoSPCwithkeyservices
MertonCCGandMertonCouncilPublicHealthteamsetouttoimplementanewmodelof
caretoaddresshealthinequalitiesinEastMerton.ThisSocialPrescribingpilotmodel
wouldprovideGPswithanoptiontorefertheirpatientstonon-medicalsupportforthe
widerdeterminantsofhealthandconnectthemtotheircommunityandtheresources
withinit.
Thisevaluationreviewedtheprocessesandoutcomesofthemodel,specificallythepilot
pathwayandwhethertheprogrammewouldimpactonthehealthandwellbeingof
patients,GPclinicalworkloadandavoidablecostssuchasA&Eattendances.
MertonVoluntaryServiceCouncildeliveredthepilotthroughtwoGPPractices,Wideway
MedicalCentreandTamworthHouseMedicalCentre.Thepathwayandprocesseswere
modeledonbestpracticefromotherprogrammesinthecountry.
Overallthepilotwasasuccess.Theprogrammewaseffectivelysetupandembedded
withintheGPpracticesandgeneratedahighnumberofreferrals.
Positiveoutcomeswereseeninpatient’shealthandwellbeingandthepatients
interviewedreportedstronghealthoutcomesandbetterself-managementasaresultof
visitingtheSPC.AdditionallyGPappointmentsandA&Eattendancessignificantlyreduced
inthosereferredtotheprogrammewhichcanbringhugecostsavingsforbothGP
practicesandCCGs.
Interviewee’sattributethesuccessoftheprogrammetogoodplanning,thedriveand
expertiseoftheGPleadsandtheskillsandbreadthoflocalknowledgeoftheSPC,GPLead
andImplementationGroup.
Conclusion
32
NextSteps
Duetothesuccessseeninthispilotyeartheprogrammewillbeextendedandexpanded
acrossEastMertonwithinninepracticesfromApril2018.Recommendationsoutlinedin
thisreporthighlightareaswheretheSocialPrescribingpathwaycanbeperfectedforthe
comingyears.
33
Bairdetal.(2016)Understandingpressuresingeneralpractice.TheKing’sFund.
Braun,V.andClarke,V.(2006)Usingthematicanalysisinpsychology.QualitativeResearch
inPsychology[online].3(2),pp.77-101.
Burd,H.&Hallsworth,M.(2016).Makingthechange:Behaviouralfactorsinperson-and
communitycentredapproachesforhealthandwellbeing.Accessedat:
https://www.nesta.org.uk/sites/default/files/making_the_change.rtv_.pdf
CareAct(2014),Chapter23,accessedat:
http://www.legislation.gov.uk/ukpga/2014/23/pdfs/ukpga_20140023_en.pdf
Citizen’sAdvice(2016)Averygeneralpractice:HowmuchtimedoGPsspendonissues
otherthanhealth?
https://www.citizensadvice.org.uk/Global/CitizensAdvice/
Public%20services%20publications/CitizensAdvice_AVeryGeneralPractice_May2015.pdf
Dayson,C.,Bennet,E(2016)EvaluationofDoncasterSocialPrescribingService:
understandingoutcomesandimpact.SheffieldHallamUniversity.Accessedat:
http://www4.shu.ac.uk/research/cresr/sites/shu.ac.uk/files/eval-doncaster-social-
prescribing-service.pdf
DepartmentofHealth(2015)Policypaper:2010to2015governmentpolicy:longterm
healthconditions,availableat:
www.gov.uk/government/publications/2010-to-2015-government-policy-long-term-
health-conditions/2010-to-2015-government-policy-long-term-health-conditions
References
34
Dent(2014).TheHealthNeedsofEastMerton.PHAST.Accessedat:
https://www2.merton.gov.uk/merton_the_health_needs_of_east_merton.pdf
Frieldli,L.etal(2012).EvaluationofDundeeEquallyWellSourcesofSupport:Social
PrescribinginMaryfield.EvaluationReportFour.
Hogarth,S.etal(2013)SocialPrescriberPilotProjectEvaluation,January–June2013.The
BromleybyBowCentre.
LaneC,Huws-ThomasM,HoodK,RollnickS,EdwardsK,RoblingM.(2005)Measuring
adaptationsofmotivationalinterviewing:thedevelopmentandvalidationofthebehavior
changecounselingindex(BECCI).PatientEducationandCounseling2005;56:166-173.
MacKeith,J.andBurns,S.(2010)TheWellbeingStar:UserGuide,Brighton:Triangle
ConsultingSocialEnterprise
MacKeith,J.(2011).ThedevelopmentoftheOutcomesStar:aparticipatoryapproachto
assessmentandoutcomemeasurement.Housing,CareandSupport,14(3),98-106.
Mackeith,J.(2014).AssessingthereliabilityoftheOutcomesStarinresearchand
practice.Housing,CareandSupport,17(4),188-197.
NHSEngland,(2014)FiveYearForwardView.Accessedat:
https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
35
ParsfieldM.etal(eds)(2015):CommunityCapital-Thevalueofconnectedcommunities.
RSA.
PolleyMetal(2017).Reviewofevidenceassessingimpactofsocialprescribingon
healthcaredemandandcostimplications.Report.
https://www.westminster.ac.uk/file/107671/download
SouthwestLondonCollaborativeCommissioningGroup(2016)SouthwestLondon
SustainabilityPlan.Accessedat:
https://www.swlondon.nhs.uk/our-plan/our-plan-for-south-west-london/
WHO(2018)Aboutsocialdeterminantsofhealth.Accessedat:
http://www.who.int/social_determinants/sdh_definition/en/
36
AppendixA:PatientexperiencesofSocialPrescribing
AppendixB:GPPracticeFocusGroups
AppendixC:InterviewswithStakeholdersandSPC
AppendixD:InterviewswiththeVoluntaryandCommunityServices
AppendixE:SocialPrescribingInterventionObservations
Appendices
37
ThisevaluationsoughttoattaintheviewsofthepatientswhoattendedtheEastMerton
SocialPrescribingpilotonhowtheyfoundtheprogramme.Theresearchersspokewitha
totaloftwelvepatientsthroughtelephoneinterviewsandonefocusgroup(seeTable1).
Table1:Patientparticipantgroup.
Inordertorecruitpatientstoparticipateinthisevaluationwecontactedparticipantsfrom
arandomlistofpatientswhohadvisitedtheSocialPrescribingprogrammeoneormore
times.Twenty-threepatientsweretelephonedbytheresearch.Ofthosethatcouldbe
reached,threedeclinedtobeinterviewed,twocouldnotbecontactedattheagreedtime
andsixprovidedatelephoneinterview.Theresearchersstoppedcontactingpatients
whentheyreacheddatasaturation.Additionally,sixpatientswhowerecontactedbythe
SPCagreedtoparticipateinafocusgroup.
Thefocusgroupwasheldatthelocalcommunitycentre.Participantsweregiven£10
vouchersfortheirparticipation.
PatientsExperiencesofSocialPrescribing
FocusGroupPatients InterviewPatients
- Female–carer(age40-49)
- Female(age-40-49)
- Male(age70+)
- Female(age60-69)
- Female(age40-49)
- Female(age-30-39)
- Male(age50-59)
- Female(age-50-59)
- Female(age-40-49)
- Female-carer(age-30-39)
- Female(age-40-49)
- Male(50-59)
AppendixA
38
Theresearchersusedopen-endquestionedinboththetelephoneinterviewsandfocus
groups.Thisallowedustoexploretherangeoftopicswhileencouragingparticipantsto
expresstheirownperspectiveindetail.
Thefocusgrouplastedforonehourwhilethetelephoneinterviewslastedbetweenfive
and30minutes.Theywererecorded,transcribedandanalysedusingtheoreticalthematic
analysis.Thekeythemesarepresentedbelow.
GettingthatfirstappointmentAllparticipantstheresearchersspokewithhadnotheardoftheSocialPrescribing
programmeuntiltheirGPtoldthemaboutitandmadetheirreferral.InmostcasestheGP
gaveadescriptionoftheprogrammeandofferedtomakeareferral.Inthreecasesthe
patientsweregivenaleaflettotakeawayandreadmore.InallbutonecasestheSPC
calledthepatientwithinaweekofreferralandanappointmentwassetupwithintwo
weeks.
“Weweredealingwithmydepressionandtimeoffworkandthenextissuewasproblems
withdebtfrombeingoffwork.TheGPtoldmeabouttheservicesandhowtheywereright
thereinthepractice.”
Mostpatientswerecomplimentaryaboutthespeedatwhichtheywereabletoseethe
SPCaftertheywerereferred;usuallybetweenoneandthreeweeks.However,two
patientsdidnotfeelthattheywereabletoseetheSPCasquicklyasneeded.Onepatient
experiencedalongdelayasaresultofanerrorinthereferralprocess.
Fivepatientsfeltthattheywouldbenefitfromamoreflexibleapproachtothe
appointmentsystem.Thisincludedmoreregularappointmentsforthosepatientswho
needitandtheoptionofdrop-insessions.
AppendixA
39
Twopatientsmentionedthattheywouldhavepreferredtohavemoreflexibilityinhowto
reachtheirSPC.Currently,patientshavetocallthroughtotheirpracticereception,leavea
messageandwaitfortheirSPCtocallthemback.AlthoughtheSPChasalwaysresponded
totheminatimelyfashion,theyfeltthattheservicewouldbealittlebitmorehelpifthey
wereabletocallorevenemailtheSPCdirectlywhentheyneededto.
“Itwouldbebetterifhecouldbethereeveryday,orifthereisanyotherwayofcontacting
him.Idon’thavehisnumber,soIhavetocallthesurgeryandafterafewdayshecallsme
backandgivesmeatimeIcancomeintothesurgery.Ifwouldbegreatifwecouldgeta
contactnumbertogetstraighttohim.”
Thefocusgroupdiscussedhowtheywouldhavebenefitedmorehadtheybeenreferredto
theSPprogrammemuchsooner.Theyfeltthattheservicecouldbebetteradvertisedso
thatitcanreachthosepatientswhoneeditbeforetheirsituationbecomesmuchworse.
“Whenyouareinastate,therearesomanyotherthingsgoingon,anyhelpissomething…
oneofthemainthingsisthatIfoundreallyhardisthatIhadtohitrockbottombefore
knowingabouttheSocialPrescribing.YousitintheGPsallthetimeandthere’sthewall
withtheleaflets,andthereisnothingthereaboutSocialPrescribing.Ihadneverheardofit
before.IhadneverheardofthecontactsthattheSPCgaveme.”
“IhadhitthepointwhereIfeltsooverwhelmedthatIdidn’tknowwheretoturnto,I
literallylivedowntheroadandIdidn’tknowtheserviceswerejustthere.”
“ItwasnotuntilIsawhim(theSPC)didIfindoutaboutthingsthatcouldhavehelpedmy
parents10yearsago.Itmademeverysad.”
AppendixA
40
TheWellbeingtoolFouroftheintervieweestalkedabouttheWellbeingtoolasausefulwayofexaminingtheircurrent
situation.
TheydescribedhowtheSPCwouldworkthroughtheWellbeingStarquestionnaireatthebeginning
oftheirappointment.EachtopicintheOutcomesSTARactsasaprompttotalkabouttheirsituation
andhighlightanyissuesthattheycouldworkontogetherwittheSPC.
“TheSTARmakesyouthinkaboutthings,insteadofsaying“everythingisfine”itmakesyourealise
youaren’tbeingtrulyhonestwithyourself”
Thequestionnairealsoservesasareminderofwhattheytalkedaboutattheirlastmeetingand
whathaschangedsincethen.
“Itgivessomeperspectiveonhowyouarefeelingandrememberwhathasimprovedandwhatis
good”
FlexibilityofapproachAllthepatientswespokewithappreciatedtherelaxedandflexibleapproachoftheSPCduringtheir
appointmentsforanumberofreasons.Forexample,theSPCgavethetimetoexploretheir
situation;patientshaduptoonehourtotalkintheirinitialmeetings.ParticipantsstatedtheSPC
usesthattimetolistenwithoutrushing,jumpingtosolutionsormakingjudgements.
“Heisthepersonthatmakesyoufeelthatwhatyouaredoingisok,andeverythingthatyouare
doingisjustwhatyoushouldbedoing.”
“Heisveryopen,verygoodonhowheleadstheconversation,heopensthingsupandmakesyou
thinkaboutyoursituation.”
“Itismorenurturing,whereastheGPhasonlygot10minutes.”
AppendixA
41
AdditionallyahugevaluetothepatientswastheSPC’sabilityto‘simplypickupthephone
thereandthen’tocontactservices,especiallyattimeswhenpatientsweregoingthrougha
crisisandfeelunabletotakethatfirststep.
“[TheSPC]isabletositwithyou.Youarefrightenedtopickupthephone,oryoudon’t
remember,butheskipsthatandsays:rightwearegoingtofilloutyourformsnow,wecan
phonethemforyounow….Youareatthispointwhereyouarefeelingthat‘thereisnohelp
forme,Ican’tcope’.It’sareliefthatthereissomeoneinthecommunitythatwasworking
almostonourside.Tohelpustakethatstepaheadandtoalmostkeepaneyeonyou.It
hasbeenamazing.”
Patientsdidsaythattheywouldbenefitfrommoreregularappointments.Currently,
patientswhoseetheSPCregularlyhaveappointmentsatsix-weekintervals.Forsomeof
thepatients,thisistoolongagap.
“Thereisnooutsideappointmenttoseehowthereferralwentandifitworked.”
LinkswiththecommunityMostintervieweesdescribedthewealthofinformationthattheSPChastohandand
providestothem.TheyappreciatetheknowledgeandconnectionstheSPChaswiththe
serviceswithinthecommunity.
“HegotmeintouchwithplacesIdidn’teventhinkabout,Ididn’tknowthatwasthere,yet
itwasacrosstheroad”
“IhadtohittothepointwhereIfeltsooverwhelmedthatIdidn’tknowwheretoturnto,I
literallylivedowntheroadandIdidn’tknowtheserviceswerejustthere.”
AppendixA
42
Theydescribedthesimpleprocessbywhichtheyareprovidedinformationabouttheir
community.SometimestheSPCwouldprintoutinformationforthem,orgivethema
leaflet.SometimestheySPCwouldmakethatfirstphonecalltotheservicetogettheball
rolling.
“[TheSPC]calledthecommunitycentrerightawayandtoldmewhenIcouldgothereand
gavemeatimetable.‘Thesearetheirdetails’.”
Oftheservicesbroughtup,theCommonsideCommunityCentrewasmentionedmost
oftenandmostfavourably.Manyofthepatientswespoketowerereferredtothe
communitynavigatoremployedatthecentrewhowasabletotalkthroughtheirproblems
withthemandprovidearangeofpracticalsupporttothem.
Mostpatientsfeltthattheygotthesupporttheyneededinthecommunity.However,two
patientsdidmentionthattheywouldhavelikedtohavegonetosomesupportservicesfor
carers.Thesepatientscarefortheirelderlyparentswhileworkingfulltime,andtherefore
areunabletoattendduringtheopeninghoursoftheseservices.Positively,theywereable
togetthesupporttheyneededthroughtheCommonsidecommunitynavigatorinstead.
Fourpatientstalkedaboutthementalhealthsupporttheywerereferredto.Oncetheyhad
receivedthementalhealthsupporttheywereverypleasedwiththeservice.Theydid
howeverdiscusslongwaitingtimesbeforegettingtheirfirstappointment.
WhattheservicehasdoneforthemMostpatientstalkedfavourablyabouttheserviceandhowithelpedconnectthemtothe
resourcestheyneededorhelpedthemtryoutnewthingsthatwouldbenefitthem,suchas
volunteeringorsocialactivities.Otherscredittheprogrammeforhelpingbringthemback
torecovery.
AppendixA
43
“Igotinvolvedinvolunteering,itkeepingmeoccupiedandfocusedonwhatwasgoodand
offthedepressionitself.Thatwasgood.”
“HeaskedmewhatIlikedoing,ItoldhimthatIenjoyedmakingcardsandheputmein
touchwiththelocalcardmakinggroupwhichIwentto.”
OnepatientfeltthatalthoughtheSPCwasabletoconnecttoactivitiesthatshewouldnot
haveotherwiseused,shedidnotgetthehelpshespecificallyneededtohelphermanage
herdebtissues.
“Thebasicswerethere,whenImentionedmyfinancialproblems;hegavemeinformation
onhousingbenefitsandtaxcredits,buttheyweren’trelevanttomysituation.Ineeded
helpwithsortingoutmydebt.”
EightofthepatientscreditedtheSPservicetohelpingbringthembacktorecovery.For
example,onepatientsaidshewouldnothavebeenbacktoworkifitwerenotforthe
service.Anothersaidsheiscopingalotbetterandismanagingherdepressionalotbetter
becauseofvisitingtheservice.Yetanothersaidsheisabletohelpherselfandotherswith
thesimpleyetreallyhelpfulinformationshegotfromtheservice.
“Iwouldnothavebeenbacktoworkifitwasn’tforthehelpIgot,andIwouldprobablybe
onanti-depressants”
ThelocationoftheserviceTheconsensusamongthefocusgroupwasthattheroomoftheirSocialPrescribing
appointmentwasnotideal.Theydiscussedhowthedeskfeltlikeabarrierandtheroom
wasveryclinicalanduncomfortable.Theysuggestedremovingthedeskandhaving
comfortablechairs.Theyalsosuggestedusingadifferentlocationsothattheyareless
exposedwhengoingtotheSPCforhelp.
AppendixA
44
“Itwasatthedoctorssurgerysoitfeltabitformal.Itfeltverymedical,Idon’tknow
whetheritwastherightplaceforit.”
“Youareinyourcommunity,andtherearepeoplethatknowyou.Iwasinthissituation
whereIcouldn’tcope,andIdidn’twantpeopletoknowIcouldn’tcopeanditwasgoingto
thedoctor,itwasjustanotherthing.Ifitwaslikeacommunitycentrewhereyoujustwalk
inthedoorandpeoplearealwayscominginandout…orevenupstairs,thatwouldbe
better”
Overall,patientswerepleasedwiththeservicetheyreceivedfromtheirSPCandthrough
theservicestheyweresignpostedtointhecommunity.Elevenofthe12patientswespoke
towouldrecommendSocialPrescribingtoothers.
AppendixA
45
ToexploretheSocialPrescribingprogrammefromaclinician’spointofviewwehelda
focusgroupateachpilotpractice.ParticipantsincludedGPs,GPRegistrars,PracticeNurses
andaCCGPrescribingPharmacist.
WeaskedtheClinicalTeamateachpracticetomapoutapatient’sSocialPrescribing
pathwayfromtheGPs’viewpoint.
TheydescribedtheprocessestowhichpatientsareidentifiedandreferredtotheSocial
Prescribingappointmentandwhathappensnext.Ateachstagetheywereaskedto
describewhatworkedwellandwhatcouldbeimproved.Keythemesareoutlinedbelow.
ThePatientJourneyEachpatientjourneycanvarydependingonhowtheyareidentified,whattheirneedsare
andhowtheyrespondtotheservice.Figure1outlineswhatatypicalpatientjourneycan
looklikefromtheeyesofaclinician.
Figure1:Patientjourneyfromclinicianperspective
GPPracticeFocusGroups
1 PatientisidentifiedbyapracticestaffmemberandisgivenaSocialPrescribingbooklet.
2 TheGPwillseethepatientandifthepatientiswillingtheGPwillmakeareferraltotheSPC
3 ThepracticeadministratorreceivesthereferralformandforwardsittotheSPC
4 TheSPCreviewsthepatient’snotes,makesaTriagecallandbooksanappointment
5 TheSPCseesthepatientandupdatesthepatientnotesonEMIS
AppendixB
46
IdentifyingPatientsPatientsareidentifiedthroughanumberofmeans,forexample,throughGP
appointments,lunchtimediscussionsbetweencliniciansandduringpatientdressings.
Additionally,WidewayMedicalCentrediscussedhowthereceptionteamhavebeengreat
atidentifyingpatientswhentheycomeinforfrequentappointments,orwhenapatients
expressesaneedthatcannotbeaddressedbythemedicalteam.TamworthHouseMedical
Centrehavenotyetinvolvedtheirreceptionteaminidentifyingpatients.
Therearevastdifferencesbetweenthepracticesinthenumbersofpatientsbeing
referred.WidewayMedicalCentrearereferringsomanythattheSPChasbuiltawaiting
list,whereasTamworthHouseMedicalCentredonotfillalltheSPCappointments.
TamworthHouseMedicalCentrediscussedhowtheywouldlikemoreinformationfrom
WidewayMedicalCentreonwhotheyarereferringthroughandhowtheyareidentifying
them.
MakingthereferralTheteamatTamworthHouseMedicalCentredescribea“three-step”processtomaking
thereferral(seefigure2):
1. Codingthereferraltype
2. FillinginthereferralformforadministrationteamtoemailtotheSPC
3. Givingthepatienttheleaflet
Theyfeltthatthiscouldbesimplifiedbychangingthereferraltoa1-2lineemailsent
directlytotheSPC.TheSPCcanlookupadditionalinformationthroughthepatientnotes
heldontheEMIS.
Conversely,WidewayMedicalCentrefeltthereferralprocesswasrelativelysimpleastheir
referralformsareautomaticallypopulatedbytheEMISsystem.Theydidnotfeelany
valuablechangescouldbemade.
AppendixB
47
Figure2:TamworthHouseMedicalCentre’sFocusGroupFeedback
ThenumberofpatientsseenbytheSPCTherewassomediscussioninbothmeetingsregardinghowmanypatientstheSPCbooks
foreachday.CurrentlytheSPCreserves45minutesforeachpatient.Healsoallowsfor15
minutesbeforeandaftereachappointmenttoreviewandupdatepatientnotes,make
referralsandplanning.Althoughbothpracticeswouldlikemorepatientsseeninaday,
theybothrecognisedthevalueofallowingthepatienttohavethattimewiththeSPC.
Bothpracticesidentifiedtheopportunitytointroducesomeflexibilitytotheappointments,
forexample,sometimecouldbeallocatedfordrop-insessions.Internet,telephoneand
videoappointmentswerealsodiscussedasanoptiontoexplorefurtherwiththeideathat
itcanfreeupsomeappointmenttimeandbeflexibletothepatientsneeds(seefigure3as
example).
AppendixB
48
Figure3:WidewayMedicalCentre’sFocusGroupFeedback
WhomakesthereferralsAtpresent,referralstotheSPCarebythepracticeGPsonly.Bothpracticesdiscussedhow
thiscouldbeopenedupsomewhattobroadenthereachoftheSPCandtolessenthe
workloadoftheGP.Currently,ifthepracticenurseorreceptionistidentifiesapatientwho
maybenefittheSPC,theyhavetoinformtheGPwhothenmakesthereferral.
Practicenurses,pharmacistsandperhapsevenreceptionswerediscussedasoptions.
FeedbackfollowingareferralTheTamworthHouseMedicalCentreteamexpressedthattheywouldlikemoreupdates
fromtheSPContheirpatients’progress.Thiscouldbeintheformofregularverbal
feedback,forexampleatteammeetings,orviaanemailedsummary.
AppendixB
49
Theyfeltthatthiswouldhelpthemseemoreofthevalueoftheserviceforthepatient.
Thesummaryshouldinclude:
• Howmanypatientsarereferred
• Howmanypatientsareseen
• Whatfurtherfollow-upsorplanshavebeenmade
TheteamwelcomedtheSPCtoattendtheirteammeetingsandjointhemintheir
discussionsregardingeligiblepatientsandtheprogressoftheirpatients.
ImpactWidewayMedicalCentrehavebeguntoseetheimpactoftheSocialPrescribing
programmeontheirpatients.Theyhavefoundthatoneortwofrequentattendershave
beenattendinglessfrequently.
“Patientswhocomeinfordepressionandareprescribedanti-depressantsoftencomeback
lessdepressedandnolongerneedingtheirmedicationbecausetheyhavebeenreferredto
thesocialprescriberforarelatedissuelikehousingorloneliness”
BothpracticesfeltthatthepresenceoftheSPCinthepracticewasverypositiveasthereis
aneedfortheserviceandtheSPChasmoretimetobeabletospendwithpatients.
“Weoftenseepatientsthatwecan’tdoanythingforbecausetheirissuesareabouttheir
housing,financesorisolation,itisreallyvaluabletohavethatoptionwithinthesurgeryfor
thepatient.”
AppendixB
50
SevenstakeholdersidentifiedfromtheImplementationGroupwereinterviewedtoelicittheirviewsontheSPpilot,mobilisationprocessandexpectationsforthisevaluation.Thestakeholderswere:
• RayHautot,SocialPrescribingCoordinator
• KhadiruMahdi,ChiefExecutiveoftheMVSC
• DrAmandaKilloran,FormerPublicHealthConsultantatLondonBoroughofMerton
• DrMohanSekeram,GPLeadforSocialPrescribingfromWideWayMedicalCentre.
• JohnDimmer,HeadofPolicy,StrategyandPartnershipsforLondonBoroughofMerton.
• Anne-MarieLiew,formerCommunityDevelopmentCoordinatorforLondonBoroughofMerton
• DrDouglasHing,GPandMertonCCGClinicalDirector
Semi-structuredinterviewsusingopen-endedquestionswereconductedtoallowthesestakeholderstoexpresstheirownperspectiveindetail.Thequestionsweredeveloped
basedontheprocessesoutlinedinthelogicmodel.Eachinterviewlastedbetween20-60minutes.Theywererecordedandanalysedusingtheoreticalthematicanalysis.Thekeythemesaroundhopes,challengesandsuccessareoutlined.
HopesforSocialPrescribingPilot“WewantGPsrecognisingthattheyareacommunityorganisation”
-KhadiruMahdi
“Givingpeopleanotheroutletbyshowingthemotherwaysofsustainingtheirwellbeing.”
-KhadiruMahdi
InterviewswithStakeholdersandSPC
AppendixC
51
StakeholdersareverypositiveabouttheSocialPrescribingpilotandfeelthatitfitswell
withinthestrategiccontextofEastMerton.Stakeholderexpectations/hopesinclude:
• Demonstrationofasuccessfulmodelofdeliverythatconnectsbio-medicalcareto
communityresourcesandfitswiththeEastMertoncontext
• Healthandwellbeingimprovementinresidentsbyprovidingaccesstonon-medical
supportthataddressestheirwiderneeds
• Demonstrationthatitisasustainablemodel
• Establishacollaborativepathwaybetweenprimarycarevoluntary,communityand
statutoryservicesandutilisecommunityresourcesmoreeffectively
• EstablishapracticelearningnetworkaspartofwidertransformationworkforEast
Merton
HopesforthisEvaluation“WewanttounderstandwhatthemosteffectiveSocialPrescribingpathwayis,particularly
asembeddedinGeneralPractice,ifrobustcanbeplannedtobetakenupinpracticesin
EastMerton”
-DrAmandaKilloran
ThereareseveralkeyresearchquestionsthestakeholdershopetoexploreintheSocial
Prescribingpilot.Theseinclude:
• Communityresources:Arewemakingbestuseofexistingcommunityresourcesand
offeringthingslikeaccesstoreadingandgardeningclubs?Whatdoestheevaluation
recommendforthevolunteeringstrategy?
• Patientoutcomes:AreweseeingimprovedwellbeingofpatientsasaresultoftheSocial
Prescribingintervention?Arewedemonstratinggoodoutcomesforpatientswhoare
notbenefitingfrommedicalinterventions?
• GPworkload:IstheSPpilotresultinginfewerGPappointmentsforthesepatients?Orif
patientsareengagingintheirownhealthmore,willitleadtomoreGPappointments?
AppendixC
52
• Aformativeevaluation:Thereisageneralconsensusamongthestakeholdergroupthat
theywanttounderstandthe‘nutsandbolts’ofhowthepathwayisworking.
• Strengthsandweaknesses:Overallthestakeholdergroupwouldliketoknowwhatis
workingwellandwhatcanbeimprovedtoensurecost-effectivenessand
embeddednessoftheSocialPrescribingprogramme.
• SharingLearning:Providetheevidencethatthisisworking,notjustaboutthepatients,
toensurethatwehavesomelearningfortheGPs,sotheycanseethatthisismakinga
differenceforthepatients.
Barrierstomobilisation/ConcernsaboutSPpilot Weaskedthestakeholdersquestionsaroundthechallengesandbarrierstosettingupthis
SocialPrescribingPilot.Thegeneralconsensusfromthegroupswasthatanypotential
challengeswereanticipatedandaddressedearlyonduringmobilisation.
“Iamveryproudthattheprogrammeisupandrunningsosuccessfullyandthiscanbeseen
highnumberpatientsarealreadygoingthrough.”
-DrAmandaKilloran
ThesteeringgroupwasabletodrawfromlearningfromapreviousCommunityNavigator
programmeinMertonthatsomemembershadbeenleadingon.Keylearningpointsfrom
thisprogrammeshowedthatgoodvisibilityandengagementwiththeGPswaskeyto
ensuringtheprogrammeiswelcomeandconnectedtothesystemswithinthepractice.
SettingupITsystemssuchasEMISandestablishingwheretheSocialPrescribing
Coordinatorwillbebasedwithinthepracticetakestimetoagreeandarrange.TheEast
MertonPilotteamensuredthatthesesystemsweresetuppriortotheSPCcominginto
postandsomeoftheengagementwithinthepracticeshadbegin.Thisenabledhimtostart
seeingpatientsrightattheoutset.
AppendixC
53
Onestakeholderreportedthatthesetupdidtakesometimeandrecommendedthatmore
timeandresourcesshouldbeallowedtopreparefortheimplementationphaseaheadof
thegolivedate.
“Fleshingoutthefinerdetailsoflogisticsisjustasimportantastheoverallvisiontoputting
itintopractice”
-AnneMarieLiew
Sherecommendedprovidingabriefingtoeverystaffmemberatthepractices,including
receptionstaff,sothateveryoneknowswhatisgoingon,hasanopportunitytoask
questionsandfeelsthattheirparttoplayisvalued.
“Everypracticememberisanimportantpartofthecogintheprocessandshouldfeelpart
ofthewiderdialogue”
-AnneMarieLiew
ShehighlightedtheimportanceofenablingtheSPCandpracticestafftofeedbacktoeach
otheroncetheprogrammeisupandrunning,onhowitisworkingandhowthepatients
arerespondingtoit.Shealsorecommendedthatco-designoftheprogrammewithacross-
sectionofthepracticestafffromtheonsetwillencouragegenuinebuy-inatalllevels
ratherthansimplyinname.
TheSPCalsohighlightedthatthereissubstantialtrainingthatisrequiredbeforeanSPCis
readytousethesystemswithinthepracticeandseepatientsandthisneedstobe
accountedforwithintheimplementationphase.
Allstakeholdersraisedconcernsaroundthecapacityofcommunityandvoluntaryservices
inEastMertonandtheirabilitytodealwiththeincreasedvolumeofreferralsgenerated
viatheSPserviceonceitgainedmomentum.Therewasalsoaconcernwhetherexisting
servicescateredtotheneedsofethnicminoritypopulations.Insomecasesthepatientsdo
notmeetthecriteriafortheendservicesastheyresideoutsideoftheborough;inthese
casestheSPClookstoservicesbeyondEastMerton.
AppendixC
54
WithregardstodeliveringSocialPrescribing,themethodformeasuringpatients’wellbeing
isthroughuseoftheWellbeingStar.TheSPChighlightedthatthisisnotalways
appropriateforpatients,particularlyiftherearecommunicationissuessuchasalanguage
barrierorliteracyissue,oriftherethepatientisdistressed.Additionally,thereferral
formsarenotalwayscompletedinfullbytheGPswhichcanleavetheSPCfeelingnotfully
preparedforhispatient,althoughtheinformationcanoftenbefoundwithinthepatient’s
records.
Successes/EnablersOverallthestakeholdergroupspokeverypositivelyaboutthepilotprogrammeand
attributeditssuccessfulsetuptoseveralfactorsincluding:
• CommitmentandsharedexpertiseoftheImplementationGroup
• UsinglearningfromSPpilotsacrossthecountryandcarefullyplanningmobilisationof
theprogramme
• FlexibilityandsimplicityoftheserviceandEndServicestomeetthediverseandoften
complexneedsofthepatients
SuccessfulPlanningThestakeholdersdiscussedanumberoffactorsthattheyaddressedinthemobilisation
phasetoensurethatitisembeddedwithintheGPpracticesfromtheoutset.Thesewere
anticipatedbybuildingonlearningfromotherprogrammesandincluded:
• StrongengagementwithintheImplementationGrouptoensureallkeystakeholders
agreedonwhattheSocialPrescribingmodellookedlikeandwhatthereferralcriteria
was.
• UsingtheexistingsystemswithinthepracticestoensurethatSPCiseasilyembedded
withinGPPractices
• StrongengagementandvisibilitywithallPracticestaffandpatients
• EnsuringearlysetupofITsystemsensuringSPChadaccesstopatient’scase
managementsystemsandcouldbookpatientappointmentsstraightaway
AppendixC
55
ChampionsofthePilotOneofthestakeholdersdiscussedthestrongsenseofcommitmenttothepilotandtheadvantageofhavingupfrontfundingfromtheCCGandtheLocalAuthoritytostrengthenstrategiccommitment.
TheleadGPswerekeyintranslatingthe‘blue-sky’ideaswithinthepilotstrategyintopracticalsolutions,draftingtheprojectplan,andvisualisingthepathway.Theyalsoledand
championedtheprogrammewithintheirPractices.
TheSPCisalsoseenasakeycontributortothesuccessofthepilotsofar.Hisexperienceandbackgroundgiveshimskillsandcompetencetodelivereffectively.Hislocalknowledge
andnetworksenablesanunderstandingofwhatwidersupportisavailableforpatientsinthecommunity.Hisgoodlisteningskillsenableseffectiveconsultations.
“Fortunately,wehadsomebodywhounderstandstheboroughverywellandunderstandsthecommunitysectorverywell.Healsoengagedwiththestaffinthepracticesverywell.”
- KhadiruMahdi
Additionally,thecommunityorganisationshavebeenwillinglytakingonthereferralsfromthepatientsandthepatientshavebeenutilisingthisresource.
“Wehave10minutesappointmentsandwearecurrentlygeareduptowardsamedicalmodelwherewegivesomethingtothepatientstotakeawaywiththem…whenpatientsraisesocialissues…wecannowcapturethatandreallymakeadifferenceandsayIknow
someonewhocanhelpwiththat.”
-DrMohanSekeram
“The[SPC]isabletodealwithconcernsthatwerebeyondremitofthe[SPC]…andtheGPcanseestraightawaytheinterventionandwhathashappenedinthefollowup.”
-KhadiruMahdi
AppendixC
56
TounderstandhowtheSocialPrescribingprogrammeworksalongsidethecommunityand
voluntaryservices,wespoketofourservicesthattheSocialPrescribingCoordinatorhas
beenreferringpatientsinto,theseare:
• CommonsideCommunityDevelopmentTrust
• AgeUKMerton
• MertonIAPTservice
• MertonVoluntaryServiceCouncil’svolunteeringservice(MVSC).
Themainaimwastounderstandreferralpathways,communicationbetweentheSPCand
endservices,whattheythoughtabouttheinterventioningeneralandanythoughtsthey
hadaboutscalabilityandfactorswewouldneedtoconsider.
“Ithinkit’sgoodtohavethatkindofholisticviewofpeople'swellbeing,thatisnotjust
medical;itcanbemuchwiderthanthat-socialandcommunityconnections.Ithinkit’sa
positivesignthatthathasbeenrecognised”
Overalltheserviceswerequitepositiveabouttheeffectivenessoftheinterventionandfelt
thatitwasneededinEastMerton.Theconversationshighlightedtheneedtodevelop
robustreferralpathwaysandsystemstocapturenumbersandfeedback.
Thekeythemesareoutlined.
FirstContactwithSocialPrescribingPilotServiceswespoketoknewabouttheSPpilotbeforeitstartedorintheinitialmonths.
SomeknewthepilotwascomingtoMertonastheyhadbeenworkingcloselywith
WidewayMedicalCentreandtheleadGP.OthersestablishedlinkswiththeSPCandthe
pilotatmeetingssuchastheMentalHealthForum.
InterviewswiththeVoluntaryandCommunitySectorServices
AppendixD
57
TheSPChimselfwasafamiliarfiguretomostservicesashehasworkedintheBorough
previouslyandisawareofalotoflocalorganisations.
“He(SPC)hadafairlygoodgraspoftheworkwedohereandIhadamemoryofhimand
howheworks.Sofairlyeasytoestablishaworkingrelationship”
ReferralPathwayandCommunication
“TheSPChasgivenalotofhisclientsourdetails,whetherthat’sactuallyresultedinthem
comingtoaccessourservicesIdon'tknow.Itdoesn'tmeantheyhaven't,butit’scertainly
notbeensomethingthathasbeenobviousfromoursideofthings”
Acleardistinctionbetween‘Referral’and‘Signposting’wasmadebyoneoftheservices
andtheconsensuswasthattheprocessbywhichindividualsmaketheirwayfromtheSPC
totheirserviceswassignposting.
ThereisnoreferralformandnouniformwayinwhichtheSPCcommunicatesinformation
aboutpatientswhoaresignpostedtoendservices.Twooutoffourservicessaidthatthey
knewtheSPCwasgivingoutinformationabouttheirservices,butaswithotherself-
referralstheywerenotabletosayhowmanypeopleaccessedtheirserviceasaresultof
theintervention.
OneservicereceivesthecontactdetailsofpatientssignpostedtothembytheSPCviaan
emailandthen,basedonthedetailstheyaregiven,theyeitherpostoutaletter,
telephoneoremailtheseindividuals.Otherservicesrequirepatientstoself-refer.Dueto
thedifferencesinapproach,feedbackfromservicesiseithernotavailableoriscollected
andgiventotheSPCindifferentways.
AppendixD
58
“Welethimleadonthis.Ifheisn’tgettingtheinformationhewouldletusknow.Herings/
popsinwithalistofpeople.Welethismonitoringneedsleadusratherthaninventsome
monitoringforourselves”
ThefrequencyofinteractionwiththeSPCvaries;insomecases,theSPCdropsinweekly,is
inregularcommunicationoveremails,orjustmeetsservicesatcommoneventsand
meetings.TheSPCisbasedinthesameofficeastheMVSCvolunteeringservicewhich
makescommunicationeasier.
ServicesrecognisedtheimportanceoflettingtheSPCknowaboutanychangesthatwere
takingplaceintheirservicesandmakingsuretheinformationhehadforthemwasnotout
ofdate.ThepathwaydescribedbystakeholdersissummarisedinFigure4.
Figure4:SignpostingandfeedbackPathway
1 SPCspeakstopatientsandassessestheirneeds.
2 Patient is given leaflets/ information about service and encouraged to make
contactbySPC.InothercasestheSPCmakesareferral.
3 Patientcomestoserviceandmay/maynotidentifyasbeingsentbytheSPC
4 Patientmay/maynotaccessservicebasedonsuitabilityandinsomecasespatientmaybesignpostedtootherrelevantservices
5 Feedback toSPC is varied; there isno formalmechanismand is ledby theSPC.
SPCmightapproachservicesthemselvestocheckifpatientshavesignposted,orcheckwithpatientswhentheycomebackforsecondappointment
AppendixD
59
Numbersanddemographicsofpatientssignposted
OneservicerecordedasurgeinthenumberofpeoplecomingthroughbetweenMarchand
Mayandhad40extrapeopleaccessingtheirservices.Anotherservicehad10people
signpostedand8ofwhomtheycouldcontact.TherestcouldnottracktheirSocial
Prescribingreferralsandwerenotabletocomment.
Oneservicereportedthattherewasagreaterrepresentationofolder,whiteworking-class
individualssignpostedtothemfromthepilot.
OneservicementionedthattheywouldideallyliketohavemorereferralsfromBME
populations,men,olderadultsandthosewithlong-termconditionsandworkwiththeSPC
aroundthis.
CapacityofEndServices
Theservicesthatcouldcommentonthevolumeofreferralstheyreceivefeltthatthey
couldcopewiththedemandintheshortterm.Shouldtheprogrammebeexpandedor
extended,thiswouldneedtobediscussedwithcommissioners.Theyfeltthatneedsofthe
peoplebeingreferredisalsoanimportantpartoftheconsideration.
Theendservicesalsotalkedabouttheoptionofacceptingsignpostsintoservicesthey
chargedfororforservicesthatareunderutilised.Oneserviceistryingtoincreaseuptake
ratesandsaidtheywouldwelcomemorenumberofreferralscomingintotheservice
(targetgroupsmentionedabove).
ScalabilityConsiderations
Servicestalkedaboutseveralfactorsthatneedtobeconsiderediftheinterventionwereto
beupscaled.Theseinclude:
AppendixD
60
Robustreferralandfeedbackpathways-ServicesareopentoworkingwithSPCtolookat
howreferralpathwaysandsystemscanbesetuptoenablebetterdatacaptureand
feedbackbetweenservices.Forexample,datasharingagreementsorsimplyaskingthose
whoself-referwheretheyheardabouttheservice.
Understandingpatientneed-Toascertainwhetherpatientsneedareferralserviceora
signpostingservice.
“IfIgavealeaflettoaclient,didtheclientreallygototheagency?Wasthereany
hesitationinthere,wasthereanythingthatwasmissed.Ifthat'snotworking,thendoIfill
thereferralformordoIcalltheGPpractice”
DataProtection-Ifthepilotisup-scaled,dataprotectionandsharingagreementswill
havetoberevisited.Itisimportanttonotbecometooencumberedinprocessesand
maintainabalance.Organisationstakingpartwillneedtrainingaroundsharing
informationwithpeopleandthiscouldbesomethingthattheMVSCcouldsupportwith.
“IfitdoesgoBoroughwide,theproblemisthatitbecomesencumberedwithlotsofcontrol
andprotectionsystems-whicharegoodinthemselvesbutcanstymiesomeoftheenergy
thatwehavehadintheearlystages”
GPcommitment-TherewasrecognitionthattheleadGPinWideWayismassively
committedtothisandhasbeenchampioningthepilot.Ifthepilotweretoexpand,other
GPpracticesneedtoembracethisapproachandbefullycommittedtoitsdevelopment.
“Idon’tknowifotherGPsareasenthusiasticasthem.Theyhavetodoitiftheyhavetodo
it,notbecausetheylovetheirjob.SoifsomeGPsorotherprofessionalsinthepractice
werethinkingthat‘ohgoshthisisanotherthingthatIneedtofitinourdailyjobs’,that
wouldthenkillsomeofitseffectiveness.So,wehavetosellitassomethingthathelpstheir
effectivenessandnotsomethingthataddstotheirto-dolist”
AppendixD
61
BuildingCapacitywithintheVoluntarySector-Serviceswereclearthatiftheprojectwere
tobeupscaled,therewouldneedtobefundingputintothevoluntarysector.Therewere
somesuggestionsincludingpayingtheorganisationperpersonpervisit.Ifthiswasnot
possible,thentoworkinpartnershiptolookforfundingopportunitiesorreallocate
fundingfromdeadprojects.
“Asthevoluntarysectorisreliedonmoreandmoretofillingapsandpickupservices,on
theonehanditisgettinglessandlessfundingandontheotherhandmoreandmore
referrals.Atsomepoint,thatisnotgoingtowork.Youcanonlyscaleitupifyoucanfund
thevoluntarysectortoabsorbtheincreaseddemand”
GeographicalConsiderations-ExpandingtootherareasinEastMertonaswellaspossibly
havingaserviceinWestMertonsothatthereisabalanceacrosstheborough.
Considerothersimilarmodels-Stakeholderstalkedaboutothersimilarinterventionssuch
astheLivingWellprojectwithinAgeUK,carenavigators,communitynavigatorsbasedout
oftheNelsonHealthCentreandCommonsideTrustandtheFireSafeandWell
coordinators.Itwouldbeworthlookingatsynergiesandhowthesedifferentprojects
couldworktogether.
LinkinginwithFundingopportunities-HousingandregenerationpartnerslikeMerton
HousingandUnitedLivingarewillingtoworkwithlocalstakeholdersarounddesigning
servicesthatmeettheneedsofthelocalpopulation.Theyhaveexpressedaninterestin
workingwiththeSPCanddonotwanttoduplicateeffortsorsetupsomethingthatdoes
nothavesynergywiththeSPPilot.Thiscouldbeexploredwithotherorganisationslike
ClarionHousingaswell.
AppendixD
62
LimitationsofSPPilot
“Itishardtomanageboththecapacityofthatandknowwhatdifferencethesignposting
hasmade…Iknowtherearesomeamazingcasestudies,whereSPChasbeenabletorefer
someoneandthatpersonhasgonefromstrengthtostrength,butlikeIsaid,ifyoujust
signpostsomeone,it’squitehardtoreallytrackthatagainstanyimprovementthathave
beenmadeinthatperson'slife”
ServicesspokeaboutsomeofthelimitationsoftheSPPilot:
• Signpostingsystemthatmakesitdifficulttotrackuptakeandprovidefeedbackor
prepareforanyupscaling.
• Endservicesnotknowingwhattheactualinterventionis,howmanytimesdoesthe
patientgetseenetc.whichmakesitdifficultforthemtothinkaboutimpacts.
• Therewereconcernsthatforcertainvulnerablegroupsforexampleolderpeople,
signpostingwouldnotbeaseffectiveasareferral.
• TheSPinterventionisbasedonthepremisethattherearewiderservicesthatcanmeet
patientneeds.Thereisaconcernthattheremightnotbeenoughservicesorcapacity
withinthoseservicestoaddressneedsoracceptsignposts.
“Whereitfallsdownis,it’safantasticideareferringpeople/signpostingpeopletoservices,
butthereareincreasinglyfewerservices.Ifyoudon'thaveanywheretosignpostpeopleto,
thenthemodelfallsdown”
AppendixD
63
Observationmethodology
TheassessorsobservedfiveSocialPrescribingconsultationsinJuly2017,includingtwofirstappointmentsandthreefollow-upappointments.Thepurposeoftheobservationswasto
getanunderstandingofthestructureoftheconsultations,thecommunicationbetweentheSPCandpatientandreferralprocess.
ObservationswereratedontheBehaviourChangeCounsellingChecklistthatlooksatperson-centredmethodsforbehaviourchangecounselling(Laneetal,2005).Eachitemof
thechecklistisratedonaLikertscaleof0-4wherebyahigherscorereflectsstrongerbehaviourchangecounsellingskills.Notallitemsonthechecklistarerelevantforallconsultations,soanaveragescorefortherelevantitemsarerecordedforeachconsultation.Theobserversalsorecordedwhatwentwellandwhatcouldbeimproved.
TheSocialPrescribingconsultation
PatientsareseenbytheSPCbetweenonetofourtimesatthree-monthintervals,dependingontheirneedsandexpectations.Thetimefortheconsultationvariesbetween15minutesto1hour.Priortomeetingthepatient,theSPCgathersasmuchinformationas
theycanaboutthepatient’sbackgroundandreasonforreferralusingEMISandthereferralform.
TheSPCbeginstheconsultationbywelcomingthepatientandensuringtheyarecomfortable.Heexplainsthereasonforreferral,describeswhatSocialPrescribingisand
asksthepatienttofillintheSTARquestionnairewhereappropriate.Duringthistime,thepatientisabletodiscussin-depththeirpersonalcircumstancesandreasonforreferral.
SocialPrescribingInterventionObservations
64
AppendixE
TheSPCoffersreferraloptionsandsignpostingthroughoutthediscussionwhenthe
opportunityarises.Theconsultationendswithanagreementtomeetatalaterdateto
reviewthecontactwiththeendservices.
Whatwentwell
TheSPCratesverywellontheBehaviourChangeCounsellingChecklistwithanaverage
scoreof3.2outofapossible4;hisstrengthsinclude:encouragingthepatienttotalkabout
theirbehaviourandstatusquo,acknowledgingchallengesandbeingsensitiveand
understandingtothepatientsconcerns.
Overall,itisclearthattheSPCisfriendly,approachableandskilledatmakingthepatients
feelatease.Heisalsoflexibleinofferingappointmentsofvaryinglengthstomeet
individualneeds.Patientsareabletodiscusstheirpersonalcircumstancesin-depthand
cantalkaboutarangeofissueswithoutstricttimeconstraints.
TheSPCrecallsthepatient’sinformationfrompriormeetingsandfrommedicalrecords.
Heregularlyrecognises,acknowledgesandpraisesthepatient’sstrengths,intentionsand
behavioursthatlead
TheSPCalsohasawealthofknowledgeofthelocalservicesavailabletothepatientsand
providessupportandguidancetothepatientsastohowtheycanaccesstheseservices.
65
AppendixE
SuggestionsforimprovementsafterJuly2017observations
- Theconsultationscouldoftenbenefitfromhavingaclearerstructure.Attheoutset,
whentalkingaboutwhatwillbecoveredduringtheappointment,itwouldbebeneficial
toaskthepatientwhattheywouldliketodiscussandsettingajointagenda.
- Restrictthenumberofreferralopportunitiesofferedtothepatientasthiscanbe
overwhelming.Tonarrowthefocus,thepatientcanbeaskedwhattheyhopeto
achieve/whatsolutionwouldworkbestforthem.Alternatively,whenthereareseveral
options,theycanbeshowna‘menuofoptions’andaskedwhich1-2serviceswould
theyliketobeginwith.Thiswouldalsoensurethatadviceandsignpostingistailoredto
theneedsexpressedbythepatientsandthattheyhavemoreownershiponnextsteps.
- Insteadofaverbalagreement,itwouldbemorebeneficialtohaveawrittenplanof
actionwhichhasbeendiscussedandagreedwiththepatient’sactiveparticipation.
Evidenceshowsthatawrittenagreementofbehaviourchangeisastrongindicatorof
positivebehaviourchange.
FollowupdiscussionwiththeSocialPrescribing
CoordinatorinAugust2017
ThesesuggestionswerediscussedwiththeSPCwhoputthemintopracticefromAugust
2017.FeedbackfromtheSPConthechangeshasbeenpositive.Hefeltthatthechanges
haveallowedthepatienttohavemorecontroloverhissignpostingandthathehas
becomemoreflexibleinhisapproachtoallowingthepatienttosettheirownpriorities
withtheirconsultationwithhim.
66
AppendixE
DecemberObservations:
TheresearchersreturnedtoobservetwomoreconsultationsinDecember2017.We
observedtwo2ndsessionappointments.Duringthoseobservationsweratedthe
interactionusingtheBehaviourChangeCounsellingChecklist,theSPCscoredanaverageof
3.9outofapossible4,exhibitingthattheSPCwasstronginhisuseofbehaviourchange
counsellingskills.
DuringtheconsultationstheSPChadstructuredtheconsultationsinaclearway,allowing
thepatientstoco-createtheagenda.TheSPChadstrongrapportwiththepatientsanda
relaxedapproach.Thesignpostingandreferralswereinresponsetothepatients’
expressedneedandactionplanswereagreed.
67
AppendixE
68
EvaluationoftheEastMertonSocialPrescribingPilotbyHealthyDialoguesLtd,July2018.If
youwouldliketolearnmoreaboutthisevaluationpleasecontact:
TheEastMertonSocialPrescribingPilotwasdeliveredbyMertonCCG,MertonCounciland
MertonVoluntaryServiceCouncil.IfyouwouldliketoknowmoreabouttheMertonSocial
Prescribingprogrammeyoucancontact:[email protected].