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‘Social Prescribing’ and Carers in West Herts
Tim Anfilogoff Integration Lead
Herts Valleys CCG
Caring and reduced wellbeing • High levels of care - 23% higher risk of stroke • Older carers reporting ‘strain’ - 63% higher risk of death in a year
than non-carers/carers not reporting strain* • 58% have reduced exercise, 69% can’t get a good night’s sleep, 73%
feel more anxious, 82% more stressed, 45% eat less healthily while 50% describe themselves as depressed**
• Carers miss own health appointments and 39% postpone treatments because can’t leave person they care for ***
• 40% experience significant distress/depression; risk of distress increases with amount of time devoted to caring, while adverse effects of caring are evident beyond the end of caring****
*Haley, W et al (2010), ‘Caregiving Strain and Estimated Risk for Stroke and Coronary Heart Disease Among Spouse Caregivers’. Stroke, 41:331-336. **Carers UK, State of Caring Survey 2014 (n= 4,924 current carers) ***In Sickness and In Health, Carers UK, 2012 **** Supporting Carers: An action guide GPs, Royal College of General Practitioners
Social Determinants of Health (Robert Wood Johnson Foundation and University of Wisconsin Population
Health Institute)
• Health behaviours 30% (smoking 10%, diet/exercise 10%, alcohol 5%, poor sexual health 5%) • Socio-Economic factors 40% (education 10%, employment 10%, income 10%, family/social support 5%, community safety 5%) • Built Environment 10% (environmental quality 5%, built environment 5%)
• Clinical interventions 20% (access to care 10%, quality of care 10%)
Loneliness is bad for you • Age UK & Campaign to End Loneliness highlight lack of good
evidence on what services make a difference (Jopling, K. 2015)
• But feeling lonely is linked to risk of an earlier death, (Penninx, B., van Tilburg, T., Kriegsman, D. Deeg, D., Boeke, J. and van Eijk, J. 1997. Effects of Social Support and Personal Coping Resources on Mortality in Older Age: The Longitudinal Aging Study Amsterdam. American Journal of Epidemiology. 146(6) pp. 510-519) depression (Green B. H, Copeland J. R, Dewey M. E, Shamra V, Saunders P. A, Davidson I. A, Sullivan C, McWilliam C. 1992. Risk factors for depression in elderly people: A prospective study. Acta Psychiatrica Scandinavica 86(3) pp.213–7) dementia, (Holwerda, T. J. Deeg, D., Beekman, A. van Tilburg, T.G., Stek, M.L., Jonker, C., and Schoevers, R. 2012. Research paper: Feelings of loneliness, but not social isolation, predict dementia onset: results from the Amsterdam Study of the Elderly (AMSTEL) Journal of Neurology, Neurosurgery and Psychiatry) and poor self-rated health (Stickley, A., Koyanagi, A., Roberts, B., Richardson, E., Abbott, P., Tumanov, S. and McKee, M. 2013. Loneliness: Its Correlates and Association with Health Behaviours and Outcomes in Nine Countries of the Former Soviet Union. PLOS One)
• We need to know more about ‘what works’ to prevent or alleviate it
Everyone has a GP
• Obvious place to promote social interventions to support clinical outcomes
• But they need help to find non-clinical solutions!
• And they only have ten minutes!
Why is SP needed?
• 20% GP face to face time spent on non-medical issues (CAB/CommRes 2015) and 15% on welfare issues (Low Commission)
• There is social support out there in the voluntary sector (12,000 groups on www.hertsdirect.org )
• HertsHelp provides expert triage: referred on to 140 DIFFERENT organisations in May 2017
• Many clinicians don’t know how to refer (or don’t anyway – confidence?)
Carers in Herts: State of Caring Survey 2015 If you ever felt, as a carer, that you had reached breaking point, what happened next? N = 437/1222 Responses (carers could pick more than one) No. % of carers
I fell ill but was unable to take time off caring 167 38 I needed medical treatment 104 24 Family or friends had to take over the care 70 16 I had to take extra time off work 67 15 I left my job 67 15 I had a breakdown 61 14 I stopped providing care temporarily 46 11 The person I care for went into residential care 48 11 Social care services had to be provided to the person 42 10 Emergency care services had to be provided 31 7 The person I care for had to go into hospital 25 6 I stopped providing care permanently 10 2 Other comments 143 33
NHS needs to be more aware
• 66% of carers said NHS staff didn’t know how to signpost (consultation Dec 2013)
‘The five and a half million carers in England make a critical and underappreciated contribution not only to loved ones, neighbours and friends, but to the very sustainability of the NHS itself’ FYFV
Carers: a suitable case for SP?
• Get patients to people who can help them (think outside clinical ‘box’)
• Carers often not ill yet, but depression, muscular-skeletal etc are real risks
• Focus on what matters to people not just what is the matter with them (prevention)
• SP offers patients the time to talk in an informal non-clinical setting
• Are carers queuing up to be identified?
Can’t help carers if not identified
Contact with
‘system’
Crisis or routine contact
Carer not identified
Carer identified
Opportunity to identify
Carer and professional
receptive
1. Positive intervention
Carer not receptive
Professional receptive
intervention possible (with skill and time)
Professional not receptive
3. Carer not receptive.
Intervention blocked
Carers can be resistant too…
Role for social prescribing
Making it easier • Carers’ Champion (trained receptionist usually) in
every practice in West Herts • Local Incentive Scheme increases consistency • Surveying carers (891 returned 2016) and action
planning rewarded (Gold standard) • Primary care now biggest referrer to Carers in
Hertfordshire • Identifying opportunities to intervene…
What’s in it for the carer? • Carers’ health checks • The offer of a flu jab • Referral to Carers In Herts (Quality Metric SF12
evidence: 24% reduction in risk of depression) • Access to HertsHelp (triage service) and
community navigator (don’t need ‘carer’ label) • Carers’ champions and HertsHelp trained to
promote CinH even if carers do not want label • Referral to Adult Care for assessment if needed
Carers in Herts’ key role
• Welcome pack templates for carers: http://www.carersinherts.org.uk/help-us-help-carers/carers-health-information-for-gps/downloads
• Training for Carers’ Champions • Provision of wide range of support including:
– Information and Carers Planning Service – Make a Difference for Carers scheme – Carers Learning and Development – Involvement Service – Carers’ Passport – Discount Card
Feedback on Carers’ Champions
• “This really felt like a first rate service - particularly the flexible appointments as it is often so difficult to find time to get to the doctor's in between caring and working.
• ‘’It made me feel as if I really mattered. When I replied… I received a telephone call almost immediately offering an appointment for the health check. I really couldn't ask for a more supportive service.”
Identification and Support HVCCG Practices
2016-7
Carers on GP registers as at 31 March 2017 9,626
As % of 55,000 carers in West Hertfordshire 17.5%
Practices a) having a carers’ champion and b) keeping an up to date carers’ register and c) offering Autumn flu jabs
100% (77% in 2015)
Practices offering health checks to carers 94% (up 8%)
Carers who took up health check (NB some carers have health-checks for other reasons)
2,023 (up 10%)
Carers who took up flu jab last year 5,900 (up 11%)
Practice has flexible appointments for carers 82% (last year 77%)
Building an SP System
• GP referrals on-line to HertsHelp and CinH (both have nhs.net addresses)
• On-line registration also helps workers without formal referral processes (eg hospital and community nurses)
• A quality network supports professionals (I may not know but I know someone who does)
Making it easier: integrated registration
The Herts model
Package of support
Community Navigators
Package of support
Package of support
Carers Champions in primary
care
Carer
Friendly Hospital
Elements of developing ‘system’
STP’s direction of travel
Peer Mentoring (Carers in Herts)
From 17 completed relationships: How confident do you feel in your caring role? • Pre: Average: 4.4/10 • Post: Average: 6.6/10 Do you know where to go to find information and support? • Pre: Average 4.4/10 • Post: Average 7.7/10
Impact
• “GPs are now the biggest referrers of carers to Carers in Hertfordshire (CiH) for advice and support - last year they identified 379 people.’’ Carers in Hertfordshire
• “This really felt like a first rate service - particularly the flexible appointments as it is often so difficult to find time to get to the doctor's in between caring and working.’’ A carer
• It made me feel as if I really mattered. When I replied… I received a telephone call almost immediately offering an appointment for the health check. I really couldn't ask for a more supportive service.” A carer
2009-2015
Importance of ‘respite’ • Respite is not just a compassionate gesture. It
has immediate, measurable health benefits for carers
• Adult day care is a sustainable intervention for chronic conditions such as dementia
• The importance of building bridges of understanding about respite with carers
Steven H. Zarit, Ph.D. Penn State University 6th International Carers Conference Gothenburg, Sweden September, 2015 [email protected] www.anhoriga.se
Meet Doris & Donald… • Donald: Dementia & diabetes • Doris struggling cope with his
care and behaviour • Lots of people involved - Doris
too stressed to make sense of it all
• Professionals only engaging with Donald!
• Dietician (!) made referral to Community Navigator
What happened… • Now Donald uses Age UK day
centre and a lunch club • Doris linked in to Carers in
Hertfordshire & Alzheimer's • Doris self refers to IAPT
service, undertaking CBT • Doris diagnosed with
depression - professionals till then focused on Donald
• All supported by Community Navigator
View from Doris
“Previously I felt I had to tell people that I was coping OK, and had to put a brave face on things. It felt like I now had permission to start thinking about myself and my situation, without feeling guilty. The Community Navigator said that she would make sure that people from the various organisations would contact me. This is just what I needed as at this time, as I really couldn’t be bothered to contact anyone, it had all got too much. I now feel that I can cope and I now feel like I have a reason to live. Before I met the Community Navigator I was in an awful place. I feel so much better now I am getting a break, knowing that he [husband] is getting the support and stimulation that he needs as well.”
Sustainability and transformation plans (STPs)
• STPs = five year plans for the future of health and care services in 44 local areas
• STPs represent a very significant change to the planning of health and care services in England (Kings Fund)
• Herts and W Essex plan: – Social Prescribing in Prevention Workstream – Carers in Place Based Care Workstream – Both need to work across whole system
People need organised networks!
• Can’t rely on one gatekeeper (especially if not expert on community)
• All about networks (people talking to each other across boundaries)
• Must be shared vision of how resources link
[email protected] 07900 161673
EoE Regional Co-Chair, SP Network
Carers’ Lead on National SP Steering Group
How can we embed social prescribing across
the NHS?
July 2017 Bev Taylor
“ We will work collaboratively with the voluntary sector and primary care to design a common approach to self-care and social prescribing, including how to make it systematic and equitable”
(p.45 Next Steps for the Five Year Forward View)
NHS England Commitment:
34
• What matters to you? • ‘Co-produced’ – meeting people, getting
active, support
Introduction to Social Prescribing
Referral Agency: GP, Integrated Care
team, Library staff
Connectors: Community
Navigator or ‘link worker’
Prescribed: ‘Health Creating’ Community Groups - gardening, singing, dance, peer
support
Different Models: Not one size fits all but here’s the Rotherham Model
IMPACT (Independent evaluation by Sheffield Hallam University) • In-patient spells reduced by 11% and 17% drop A&E attendance for all patients • For U80’s, receiving long term support from VCSE groups, 51% drop in-patient stays, 35% fall in
A&E attendances.
Rotherham CCG, every GP involved,
standard NHS Contract
Voluntary Action Rotherham, team of
health advisors
Community Groups, 23 funded to
provide a menu of 33 services and spot
purchasing
• An asset-based approach – what do you already have ?
• No one size fits all – different models
• Shared local leadership – don’t worry about hierarchies
• Build it together, all partners important
• Can’t expect the voluntary sector to do everything for free!
• Collaboration and generosity, in spades – what offer can you make?
• Willingness to learn and share with others
Key Ingredients
37
• Older couple, wife caring, husband with early stages of dementia
• Stopped going out, with each other all the time – difficult
• The man had been a cyclist – could still cycle, but not safe, got lost
• Navigators contacted a cycling club, who picked the
man up on a Sunday morning, took him for a cycle and delivered back home after a few hours
Case Study – Halton CCG
38
What have we done so far?
• We’re building a ‘social prescribing
movement’
• Support for local commissioners
• Working across government – broader than NHS
• We’ve got lots of support, from
different places
• We’re starting to work on developing a Common
Framework to build the evidence base – measure impact on people, system and communities
• Quality Assurance Framework
• Develop the national and regional support networks
• Support to CCGs, STPs and Accountable Care Organisations
Priorities for the future:
40
Join the National Network and get on the
mailing list – [email protected] Attend regional social prescribing network
events
Contact me for connections to others: [email protected]
About the Social Prescribing Network
