Social Prescribing Innovators Programme in London
"The Social Prescribing Innovators Programme in London aims to support frontline problem solvers in developing and implementing innovative solutions to address healthcare challenges through social prescribing. With a focus on holistic approaches to enhance health and wellbeing while relieving pressure on the NHS, this program provides funding and support to test new ideas and practices. Successful applicants will participate in a 6-month program to tackle various challenges in social prescribing, with results shared nationally in March 2023."
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PERSONALISED CARE FOR LONDON Social Prescribing Innovators Programme Investing in London s frontline problem solvers. Projects @SP_LDN hlp.socialprescribing@nhs.net 1
Social Prescribing Innovators Programme HLP s Social Prescribing Innovators Programme will unleash powerful ideas from London s vibrant social prescribing workforce to tackle some of the biggest issues we face across London s health and care system. This programme will give talented individuals and teams the opportunity to have the support they need to test out new ideas for making sure we can rollout social prescribing right across London, taking a holistic approach to even more people s health and wellbeing while easing the pressure on the NHS. Dr Jagan John North East London CCG Chair, Clinical Chair Barking and Dagenham @SP_LDN 2 hlp.socialprescribing@nhs.net
Social Prescribing Innovators Programme The Programme aims to support Social Prescribing services and individual Social Prescribing Link Workers across London to mitigate challenges they face in delivering social prescribing in primary care by testing and sharing innovative ways of working. Successful applicants will benefit from a 6-month programme of support between Oct 22 - Mar 23 to help deliver projects against their specified challenge , as well as up to 10k funding Results of the pilot programme will be shared across London and Nationally in March 2023 Programme offer Session timings 40 applications > 20 shortlisted > 12 successful 4x monthly QI training sessions Half day The projects will each work on different challenges, including: Supporting the recruitment and retention of social prescribing link 3x bi-monthly skills share 1.5 hours workers 3x bi-monthly Co consulting peer groups 2 hours Improving mental health supports and services 3x bi-monthly 1:1 coaching sessions 45 minutes Improving access to social prescribing for target cohorts, including Fortnightly drop-in support sessions 1.5 hours asylum seekers or refugees, pre-diabetics as well as people experiencing social and material deprivation @SP_LDN 3 hlp.socialprescribing@nhs.net
Programme Participants Project number Borough ICS Organisation Project Lead Project Team Name A2Dominion Community Link Worker (Social Prescribing) 23 Ealing NWL Ealing PCN 10 Caroline O'Leary Rianna Breen and Samar Battikh 28 Hillingdon NWL The Confederation, Hillingdon CIC The Confederation, Hillingdon CIC 33 Lambeth SEL Age UK Lambeth Alexandra Norman My Community Camden Care Navigation and Social Prescribing Service. AgeUK Camden and Voluntary Action Camden Barking and Dagenham Social prescribing and Care coordinator group Donna Turnbull and Katalin Swann Camden Care Navigation and Social Prescribing Service 13 Camden Barking and Dagenham NCL 12 NEL Lucy Walsh and Emma Gillan Stuart Cox, Sahdia Warraich and Ceri Durham Barking and Dagenham SP Innovators 16 Tower Hamlets NEL St Margaret's House and Tower Hamlets GPCG Men s Project WCPCN Wellbeing Partnership 25 Waltham Forest NEL Walthamstow Central Primary Care Network Sue Kofi 31 Hounslow NWL Groundwork London Cheryl Chin and Khadijah Arije Hounslow Social Prescribing 7 Waltham Forest NEL Walthamstow West Primary Care network Farah Ahmed Walthamstow West PCN 26 Camden NCL West and Central Camden Primary Care Network City and Hackney Social Prescribing Service, Family Action Denise Marsh Brondesbury Medical Centre 10 City and Hackney NEL Miranda Cook Feel Good Now CIC 40 Lambeth SEL Hills, Brook & Dale Primary Care Network Ruth Marie Vidal-Tunkara HBD Women s Health Network @SP_LDN 4 hlp.socialprescribing@nhs.net
A2Dominion Community Link Worker (Social Prescribing) (SPIP 23) Challenge: Participant response in application Project Summary: Aims to tackle isolation and loneliness among Black and Minority Ethnic (BAME) backgrounds through community outreach. Isolation and loneliness, particularly among older black and minority ethic people, has reached epic proportions over the last two years, with the Covid-19 pandemic forcing the more clinically vulnerable to seek safety behind closed doors. Project Team Ealing PCN10 currently employs two social prescribers to engage with almost 800 patients. A key challenge for us is ensuring those older (aged 65+) lonely and isolated people from Black and Minority Ethnic (BAME) backgrounds - of whom there is a high concentration in this area - can access support to attend medical appointments or social groups. Many, particularly Asian and Irish customers fall through the gap, missing appointments due to language difficulties, limited family support and significant financial pressures. Importantly, our experience, supported by the data, highlights that many older Asian and Irish customers either lack the confidence to come forward or are simply reluctant seek professional help, thereby putting their health at great risk and further increasing their sense of isolation. Name Organisation Job role Project role Dele Ryder A2Dominion Housing Group Partnership Manager Strategic oversight Caroline O-leary A2Dominion Housing Group Community Link Worker - SP Project Lead Joseph McCarthy A2Dominion Housing Group Community Link Worker - SP Project Support Caroline Wolff A2Dominion Housing Group Partnership and Fundraising Project Manager Strategic oversight / support @SP_LDN 5 hlp.socialprescribing@nhs.net
The Confederation, Hillingdon CIC (SPIP 28) Challenge: Participant response in application Project Summary: Evidence shows that patients with Severe Mental Health (SMI), and people with challenging behaviours, are more likely to experience physical health inequalities. This cohort have a higher prevalence of obesity, asthma, diabetes and cardiovascular disease. Social prescribers can play a pivot role to improve health outcomes of people with SMI by connecting mental health with physical health. On average, this cohort dies 15 to 20 years earlier than the general population, have 3.7 times higher death rate for ages under 75 than the general population and are more than likely to have comorbidities. We wish to address these challenges through our neighbourhood data analysis of a sample of 219 people between the ages of 30 and 44 from the most deprived communities. As part of the evidence gathering exercise, social prescribers have shared their views, opinions and experiences about working with people with SMI and people with challenging behaviours. Social prescribers reported that they are more than likely to leave the role if the appropriate infrastructure is not in place. In Hillingdon, over 90% of referrals have an element of mental health. Aims to build a specialised SPLW model to ensure Social Prescribing is tackling inequality and targeting a specific cohort of patients with Severe Mental Illness (SMI). Project Team Name Organisation Job role Project role Rianna Breen The Confederation Social Prescriber Link Worker Lead Social Prescribing Project Lead Natasha England The Confederation Head of Workforce, Training & Education Designing and delivering the curriculum Project Support Abdullah Al-Ahmad The Confederation Head of PCN (ARRS) Additional Roles Offering senior leadership ensuring appraisals and supervision is in place Oversight Frank Hamilton The Confederation Head of Transformation Oversight of programme Samar Battikh The Confederation Associate Transformation Manager Managerial Project Lead Noreen Groves The Confederation Associate Director of Transformation Oversight of programme @SP_LDN 6 hlp.socialprescribing@nhs.net
My Community (SPIP 33) Challenge: Participant response in application Project Summary: Aims to design a process to evaluate services with SPLWs at the core in order to support recruitment & retention and demonstrate impact. Our challenge is that Social Prescribing Link Workers (SPLWs) aren't consulted for service development. Our service has been running for 3 years. It has evolved, but the PCNs, and NHS data requirements, drive changes. While this is important, this leads to issues: Project Team Name Organisation Job role Project role - We miss a wealth of knowledge and relevant experience from our SPLWs. - Lack of consultation is having an impact on their wellbeing and job satisfaction. - They feel that issues they raise are not acted upon, thus feeling they are not listened to. - Some SPLWs have left or feel disenfranchised with the model. Age UK Lambeth My Community Services Manager Alexandra Norman Project lead Ollie Shotton Age UK Lambeth My Community Social Prescribing Lead Project support @SP_LDN 7 hlp.socialprescribing@nhs.net
Camden Care Navigation and Social Prescribing Service (SPIP 13) Challenge: Participant response in application Project Summary: Aims to tackle recruitment and retention through the development of a voluntary role to support SPLWs with admin & transactions around referrals. One of the challenges Social Prescribers face is burn out which results in taking prolonged sick leave or intermittent sick leave, which can be 15+ days within a financial year or can result in leaving the profession altogether. GP practices in Camden such as West Hampstead Medical Centre, James Wigg and Queens Crescent Medical Centres and Camden South PCN as well as the Care Navigation and Social Prescribing Service have experienced this phenomenon in the past couple of years where social prescribers become overwhelmed by the demands of the role. The overload is a result of time taken with fire-fighting , for example, challenges presented by service failures within areas of housing and welfare support, or organising transport and finding chaperones to attend appointments. Project Team Name Organisation Job role Project role Donna Turnbull VAC Community Development Manager Project lead (Community Links) Katalin Swann AUC Service Manager Project lead (Care Navigation) Mandira Manandhar VAC Volunteer coordinator Volunteer development support A related challenge faced is recruitment, such as finding job applicants and deploying new staff quickly. Emma Worthington AUC Care Navigator / SPLW Social prescriber development support Jamie Aldridge AUC Care Navigation Service Administrator Project and admin support @SP_LDN 8 hlp.socialprescribing@nhs.net
Barking and Dagenham SP Innovators (SPIP 12) Project Team Challenge: Participant response in application Working as a group of 5 different PCN's and Local Social Prescribing, we have collectively discussed the issues we face with regards to embedding the SP service within GP practices and local community. We want to ensure the right people are contacted and that we are taking positive steps to tackle health and social inequalities within Barking and Dagenham. Areas of concern: - Accessing residents with complex needs that do not attend GP surgeries / also other vulnerable groups that are not registered with GP practices. - SP referral are sent via GP practice, this creates a shortage of GP appointments for those who require appointments with a Dr for medical reasons. This also means its only those who are willing and able to go to the GP will be referred. - Referrals can only be done Monday - Friday 9 to 5 during GP opening hrs, if appointments are available! - Lack of knowledge of SP service within the community and patient referral journey - Local bough residents who are registered with GP practice out side the area, are not able to make the same referrals. Name Organisation Job role Project role Emma Gillan London Borough of Barking & Dagenham Barking & Dagenham NHS Relationship Manager and Link Worker East One Care Coordinator East One Project Lead Lucy Walsh Project Lead Naziha Rahman London Borough of Barking & Dagenham Frontline Officer and Link Worker East One and East Project Support Adele Famurewa London Borough of Barking & Dagenham Relationship Manager and Link Worker New West Project Support Uzma Ali London Borough of Barking & Dagenham Frontline Officer and Link Worker New West Project Support Shumina Begum Barking & Dagenham NHS Care Coordinator New West Project Support Dani Alder London Borough of Barking & Dagenham Relationship Manager and Link Worker North Project Support Britishe Karakusi London Borough of Barking & Dagenham Frontline Officer and Link Worker North Project Support Mehrunisa Cheema Barking & Dagenham NHS Care Coordinator North Project Support Jessie Nicholson London Borough of Barking & Dagenham Relationship Manager and Link Worker East Project Support Hakim Cheema Barking & Dagenham NHS Care Coordinator East Project Support Jacquie Hutchinson London Borough of Barking & Dagenham Service Manager and SP Lead Project Oversight Dimitri Bakanov Barking & Dagenham NHS PCN Business Manager (East One and West One) Project Oversight Project Summary: Aims to improve access to SP services for those in the community who aren t able to access via the GP referral pathway. Brandon Delisser- Lee (TBC) Robyn Winnett Together First Barking & Dagenham West One PCN Business Manager Project Support (Data) Project Support Care Coordinator @SP_LDN 9 hlp.socialprescribing@nhs.net
Mens Project (SPIP 16) Challenge: Participant response in application Project Summary: Aims to support men s mental health through a series of training, workshops, events, engagement and coproduction. How can more men benefit from social prescribing? We know from previous experience delivering a Thriving Communities project The Health Tree , less men benefit from social prescribing. We found that only 16% of our participants identified as male. One of the elements of The Health Tree was a woodwork group that proved very popular with men with mental health conditions and this was most of the 16%. We want to explore what it is about the woodwork sessions that worked and how we apply the learning of this to other projects. We ll explore in partnership with the local social prescribing service, the barriers to accessing social prescribing with local men and what a more holistic programme looks like for them. We know from data provided by our partners Tower Hamlets GP Care Group that less men are benefitting from Social Prescribing in Tower Hamlets: Data shows from last year the percentage of men accessing social prescribing services were Quarter One: 37.3% Quarter Two: 40.7% Quarter Three: 38.1% and Quarter Four: 39.7%. Project Team Name Organisation Job role Project role Stuart Cox St Margaret s House Arts and Wellbeing Director/Deputy CEO Project Lead and Oversight Sahdia Warraich Tower Hamlets GP Care Group Social Prescribing Manager Project Lead and Oversight Laura Furner St Margaret s House Wellbeing Manager Project Support Farrah Idris Tower Hamlets GP Care Group Social Prescriber Project Support Jessica Connolly- Black Tower Hamlets GP Care Group Social Prescriber Project Support Ceri Durham Social Action for Health CEO Project Lead Fredi Beard VoiceBox Finance and Administration Director Project Support Andy Hill Voicebox Managing Director Project Support Sally Ramsden St Margaret s House Freelance practitioner @SP_LDN 10 hlp.socialprescribing@nhs.net
WCPCN Wellbeing Partnership (SPIP 25) Challenge: Participant response in application Project Summary: Being in regular discussion with both Clinical staff and other colleagues, we are aware of the upturn in patients needing support with their mental health. The causes of this upturn lie rooted in the pandemic; the isolation, the loss of work, bereavement, a fear of mixing again as well as coping with the ongoing possibility of further pandemics and lockdowns. It is unprecedented state of affairs which, we believe, needs a different mechanism to help patients. Aims to tackle the challenge of inadequate services for patients with mental health issues through designing more specialised support for these patients. Project Team Name Organisation Job role Project role Sue Kofi Walthamstow Central PCN Social Prescriber Project Leader I receive a large number of referrals for patients with mental health, anxiety and bereavement. The big issue is that there are long waiting lists for counselling (free/low cost) so that there are large gaps where patients are not receiving support, which can badly affect their mental health. There are various activities, walking groups etc, however these are often not what patients want (some do, of course). Working with a voluntary sector partner, we plan to offer a variety of activities as tasters but with an emphasis on community. Shahid Mahmood Blossom/MTC Learning Director at Blossom Workshop Leader Amira Louati Blossom/MTC Learning Workshop Leader (for MTC Learning) Workshop Co-Leader Tali Noor Walthamstow Central PCN Care Co-ordinator Workshop Assistant Alex Kyriakidis Walthamstow Central PCN Health and Wellbeing Coach Wellbeing session Co-ordinator @SP_LDN 11 hlp.socialprescribing@nhs.net
Hounslow Social Prescribing (SPIP 31) Challenge: Participant response in application Project Summary: There is no effective referral pathway into Social Prescribing in Hounslow for vulnerable individuals not registered with a GP and there s a lack of local networks to provide essential support. Hounslow with its proximity to Heathrow is a gateway for new UK arrivals and welcomes migrants, refugees and asylum seekers fleeing conflict. As some of our most vulnerable groups, they face multiple barriers to accessing health services and are disproportionately affected by health inequalities. Aims to engage unregistered populations in Hounslow, specifically migrant, asylum seekers and refugees using an outreach SPLW. Project Team Name Organisation Job role Project role Cheryl Chin Groundwork London Social Prescribing Team Lead Project Lead Newly arrived refugees and asylum seekers have limited ways to access Hounslow Prescriber Service (HPS), until they have signed up with GP Practice meaning a delay in essential early health intervention. Currently, when HPS receive referrals, they are made at point of crisis, and the health and social needs of the patient have become complex and multi-faceted. Khadijah Arije Groundwork London Social Prescribing Team Lead Project Lead Katrina Baker Groundwork London Director, Communities and Environmental Services Oversight TBC Groundwork London Social Prescribing Link Worker Project Support TBC Groundwork London Social Prescribing Link Worker Project Support TBC Groundwork London Outreach Officer, Integration Project Support @SP_LDN 12 hlp.socialprescribing@nhs.net
Walthamstow West PCN (SPIP 7) Challenge: Participant response in application Project Summary: Diabetes is a Long-Term condition highly prevalent in Waltham Forest and is associated with other conditions including; Cardiovascular Disease, heart attack, stroke and kidney disease. The prevalence of diabetes is higher in Waltham Forest than the London average at 10.2% (Annual Public Health Report 2020- Waltham Forest). Many patients referred to Social Prescribers (SP s) for pre-diabetic support are unsuitable for referral to the NHS online pre-diabetic program available in our PCN as they face many barriers including; Language and cultural barriers and digital exclusion/poverty. In many instances patients have reported these barriers and cannot access a service to meet their needs. South Asian s and those from black backgrounds are most at risk of Diabetes and its complications. Our PCN is perfectly placed in wards in Waltham Forest that are affected adversely by inequalities in health compared to other parts of the borough. We aim to tackle access to appropriate Pre-diabetic support for our patients by formulating a new service suitable to those who face inequalities in health which takes into account their barriers and needs. Aims to tackle health inequalities and improve access to appropriate Pre-diabetic support for those facing barriers in access. Project Team Name Organisation Job role Project role Dr Naheed Khan Lodhi Queens Road Surgery Clinical Director Oversight Samiha Ahmed PCN Walthamstow West PCN manager and PA Oversight Saiba Salam Walthamstow West PCN Social Prescriber Project Support Nashrin Akthar Queens Road Surgery Care coordinator Project Support Bibi Sheikh Chand St James Surgery Care coordinator Project Support Humza Shaikh Grove Road Medical Practice Care coordinator Project Support Gemma Segust Seymour Medical Practice Care coordinator Project Support Farah Ahmed Walthamstow West PCN Social Prescriber Project Lead @SP_LDN 13 hlp.socialprescribing@nhs.net
Brondesbury Medical Centre (SPIP 26) (SPIP 26) Challenge: Participant response in application Project Summary: Aims to improve access to social prescribing for Somali and Arabic speaking patients through proactive outreach within these communities. Kilburn is a relatively deprived mixed inner city area with a high ethnic minority patient population (approximately 30%). The largest ethnic minorities are from Somali and Arabic speaking communities. Project Team Reaching these communities and providing them with Help, advice and support remains a significant challenge, particularly with language and cultural barriers. Brondesbury Medical Centre, where the project will be predominantly based has a 21,300 list size, including approximately 1000 Somali speaking patients. Name Organisation Job role Project role Denise Marsh Brondesbury Medical Centre Social Prescriber Project Lead Dr. Richard Mendall Brondesbury Medical Centre GP Parner Project Oversight Michelle Mullins Brondesbury Medical Centre Operations Manager Project Support Vikram Kumar Brondesbury Medical Centre IT Lead IT Support @SP_LDN 14 hlp.socialprescribing@nhs.net
Feel Good Now CIC (SPIP 10) (SPIP 10) Challenge: Participant response in application Project Summary: Aims to host holistic wellness events and promotions in multiple PCNs, bringing together statutory, health and VCSE organisations to evolve the SP offer in City and Hackney. Regularly, social prescribing clients do not have their identified goals met by the service because their needs are complex; also there are huge waiting lists for example for mental health/housing. Project Team I would like to show a tangible benefit from a social prescribing service in that my project will enable participants to improve their physical and mental wellbeing by attending. I also hope to meet the goals of retention difficulties because seeing a positive result from these events has supported me to stay in my role when I was feeling burnt out. Name Organisation Job role Project role Miranda Cook Feel Good Now CIC Director Project lead It also meets the challenge of reaching the right people because this event can be targeted to engage those hardest to reach and who would benefit most; homeless population, refugees, those with SMI etc. @SP_LDN 15 hlp.socialprescribing@nhs.net
HBD Womens Health Network (SPIP 40) Project Summary: Challenge: Participant response in application Aims to proactively support cohorts to access SP, specifically patients with material/social issues & wellbeing/mental issues, enabling SP services to be more holistic. To create a more holistic and unified approach to proactively supporting cohorts of patients to access a range of social prescribing and health interventions. Some of the current barriers to offering a more transformative Social Prescribing service within primary care: -Complex cases; referrals to SPLWs for multiple issues at a time that can t be addressed in the allocated timeframe. -Wider social & health inequalities lead to referrals for primarily crisis issues & not on-going personal development or life enriching activities . -Helping patients make the necessary connection between their social needs and their wellbeing issues to be able to prioritise both. -Growing dependency on SPLWs can create a revolving door dynamic which directly impacts referral waiting times and access to support. -Dependency on SPLWs does not nurture resilience, problem solving skills or encourage patients to meaningfully build relationships with the relevant community based projects and appropriate health services . Project Team Name Organisation Job role Project role Ruth Vidal-Tunkara HBD PCN SPLW Project Lead & Budget oversight Cheryl Alfred HBD PCN PCN Project Support Assistant Project Support Budget oversight Dr Sadru Kheraj HBD PCN Clinical Director Project Oversight and PCN Director Michele Izzo HBD PCN PCN business manager Financial oversight Natalie Senior HBD PCN SPLW Project team member Malika HBD PCN SLPW Project team member @SP_LDN 16 hlp.socialprescribing@nhs.net
What would you most like to get out of the programme? "To see volunteering alongside social prescribers recognised as an effective route into employment (and a way to aid retention of existing SP workforce)." To get a real understanding of what activities local men want and also how best to deliver them. We hope this will influence future projects of all kinds and help local partners too. "To make good use of the support and leadership training offered by the programme, increase my project management experience and widen my knowledge of effective evaluation methods." To explore and test new ways of working for the SP team, to reach our most vulnerable residents. And to develop the innovation side of our programme, increase learning and team skills. "To learn new skills which will help me to improve my practice as a social prescriber and in innovating new services which would directly improve the health outcomes for my target group of patients." Being part of a London- wide team testing service improvement ideas and the chance to share ideas/knowledge and support each other along the way. "To be able to develop and create practical and workable solutions to issues that social prescribers face, in collaboration with colleagues from HLP and from other voluntary organisations." "To bring about creative solutions that support frontline workers to do their job and make our work more sustainable over the long term. I am excited by the possibility that we can improve our service to patients and offer more support to GP surgeries." @SP_LDN 17 hlp.socialprescribing@nhs.net
