AN EVALUATION OF SOCIAL PRESCRIBING HEALTH TRAINERS IN SOUTH AND WEST BRADFORD

Judy White Karina Kinsella Jane South

December 2010

2

CONTENTS

Page Executive Summary and Key Findings

3

1.

Introduction

6

2.

Background

7

3.

Evaluation aims and methods

10

4.

The patients accessing Social Prescribing Health Trainers and what they think of it

12

The changes patients are making with the support of Social Prescribing Health Trainers

17

6.

GP practices and Social Prescribing Health Trainers

24

7.

Are Social Prescribing Health Trainers offering something distinctive?

28

8.

Organisational and Service Issues

30

9.

The future potential of the service

34

10.

Conclusions and recommendations

36

5.

3 EXECUTIVE SUMMARY „it‟s somewhere to send patients that I don‟t have the skills to deal with, things like housing benefit, loneliness, all those social problems that as a GP, I don‟t want to be prescribing anti depressants for‟ (GP talking about the Health Trainer and Social Prescribing Service) „….although they give you depression pills, they can keep giving them and giving them, but unless you get to the root of the problem….I think over the years, I think it‟s the best thing that I‟ve ever been given.‟ (patient talking about the social prescribing health trainer))

This report reviews the Bradford Health Trainer and Social Prescribing Service over nine months from January to September 2010. Health trainers work in a variety of settings to support people to change their behaviour to improve their health. Social prescribing is a relatively new approach in primary care which promotes the use of the voluntary and community sector to support patients who have health, well being and social needs. In South West Bradford, the two models have been brought together and six social prescribing health trainers (4.5 whole time equivalents) funded through practice based commissioning to work across 21 GP practices.

In the period under review social prescribing health trainers saw 484 patients who had largely been referred to them because they had low level mental health problems, social problems which were affecting their health or were isolated and lonely. The social prescribing health trainers have time (up to an hour) to listen and use problem solving methods to help patients to find ways forward. 51% of patients were referred to an agency in the community which could provide the support they needed and were accompanied on a first visit where necessary. Just under half of patients seen by the service developed a personal health action plan in which they decided on what goals they needed to achieve to move forward and 87% had made progress on these in the period under review.

For this service evaluation, 22 people were interviewed, 12 of whom were patients who had seen a social prescribing health trainer. They were all very positive about the experience and had made changes as a result which had improved their health, and for some people having someone to talk to and help them address their problems, had enabled them to turn their lives around. The GPs and other practice staff interviewed were also positive about the service and felt it enhanced the package of services that the practice had to offer patients. There is a significant amount of anecdotal evidence from patients and staff that many patients see their GP less when they are addressing their social issues with the help of a social prescribing health trainer.

The achievements and changes the patients interviewed had made with the support of a social prescribing health trainer included:

4 Going back to work after illness or accident repairing relationships or coping better with separation, joining activities and getting out more following bereavement making time for relaxation and physical activity losing over three stone in weight taking up swimming with her husband getting a wheelchair for her disabled child joining a support group for people with their condition doing home exercises regularly to offset arthritis taking steps to deal with their anxiety

The benefits practices are accruing from the Health Trainer and Social Prescribing Service can be summarised as:

A non clinical service for the practice to offer as part of a holistic package, particularly to patients with mental health and social issues A service that can respond to the myriad of social issues which patients bring, particularly in areas of high deprivation Staff with time to spend with patients over a number of weeks Reduction on use of GP time with patients whose problems are at least in part, social A means of building links with and making use of the wide range of community based services and activities offered by other agencies in the locality. An effective way of supporting people who want to make lifestyle changes High patient satisfaction with the service which is likely to extend to higher satisfaction with the practice as a whole A large part of the reason for the popularity of the service with patients is the supportive, problem solving model social prescribing health trainers use which puts patients in control of how they address the issues they want to tackle. This together with being non clinical personnel with time to spend with patients means that they bring a distinctive approach which is proving successful and achieving positive outcomes. The approach tackles the root cause of many of the psycho social problems that lead to poor mental health and well being and provides a sustainable solution to support people to self manage their health and well being.

The report recommends that the Health Trainer and Social Prescribing Service is recommissioned and that consideration is given to expanding the service. This would enable social prescribing health trainers to spend more time in each practice, become fully integrated into the practice team and extend their role to for example, meet practice needs to engage patients more, develop health improvement activities or enable patients with long term conditions to self manage better.

5 The evidence from this evaluation is that social prescribing health trainers are offering a service which is making a positive difference for patients and practices at a relatively low cost. Investing in the service has the promise of not only saving money but improving the range and quality of what primary care can offer to patients – in other words providing ‘better for less’.

KEY FINDINGS

484 patients were supported to cope better and improve their health – an impressive number (when compared with national baseline data for health trainer services) for a small service in just 9 months 51% of patients seen were referred to a community based service for support 48% made a personal action plan setting out how they were going to tackle their problems and by when 87% of those who had been signed off had made changes which were enabling them to cope better and improve their health The patients seen were some of the most vulnerable and disadvantaged, had mild mental health problems, relationship difficulties or were socially isolated. Patients value this service very highly – they like the friendly, informal approach, having someone who has time to listen and being supported to come up with their own solutions GPs and other practice staff like having somewhere to refer patients who have problems which are primarily social rather than medical. There is some evidence that patients are coming to their GP less with social problems having seen a social prescribing health trainer.

6

1. INTRODUCTION Health trainers are a relatively new public health workforce and the Department of Health (DH) has been actively supporting the roll out of the programme across the country.

This evaluation of the Social Prescribing Health Trainer Service in Bradford is one of a series of small scale evaluations undertaken by the Centre for Health Promotion Research at Leeds Met University and commissioned by the Yorkshire and Humber Health Trainer Hub. It focuses on one aspect of the service - the social prescribing health trainers based with GP practices in the South and West Alliance, one of four practice based commissioning groups in Bradford.

The report is divided into sections which describe the background to the health trainer service in the district; what the evaluation aimed to do and how it was set up; what patients think about the service; what difference the service is making for patients; how it is working with GP practices; whether social prescribing health trainers offer something distinctive; organisational and service issues, and finally what conclusions can be drawn and recommendations made for the future.

The report is intended to help inform future commissioning, but also to be of value to the service and its partner agencies as they strive to continually improve and develop health trainer provision in the district.

7

2. BACKGROUND 2.1 Choosing Health and Health Trainers Health trainers originated in 2004 in the white paper ‘Choosing Health’. From the outset they were intended to offer ‘support from next door’ rather than ‘advice from on high’ and to: • • • •

Target ‘hard to reach’ and disadvantaged groups Increase healthy behaviour and uptake of preventative services Provide opportunities for people from disadvantaged backgrounds to gain skills and employment Reduce health inequalities

Funding was made available for 12 ‘early adopter’ programmes commissioned by Primary Care Trusts (PCTs). These got underway in 2005/6 and other PCTs started to set up programmes soon after. 88% of PCTs nationally now have a health trainer service, and 100% in Yorkshire and Humber.

2.2 Social Prescribing Social prescribing is a relatively new approach in primary care which promotes the use of the voluntary and community sector to support patients who have social needs. Many people, particularly in disadvantaged areas, who go to see their GP, or other practice staff, have social rather than medical needs. They may be lonely or sad: have financial, housing, immigration or employment problems: be finding it difficult to come to terms with bereavement: having difficulties with a relationship: or struggling with parental or caring responsibilities or the impact of a disability. According to the commissioning plan of Bradford South and West Alliance:

„Research indicates that 75% of service users presenting in general practice have at least one psychosocial problem. Given the deprivation levels in the Alliance and the current economic climate demand for psychosocial support is increasing exponentially. Practices are seeing increasing numbers of patients with stress and anxiety and an increasing need for support, advice and signposting to appropriate services.‟1

1

Bradford South and West Commissioning Alliance, Commissioning Plan 2009-2012 NHS, Bradford and Airedale

8 Generally, GPs and practice staff do not have the time to spend listening to people’s social problems, but unless these are addressed, as the Alliance recognises, the same ‘revolving door’ patients keep returning to GP practices with needs which are more social than medical.

Numerous voluntary and community organisations exist, large and small, and offer support with a very varied and wide range of issues. Practices offering social prescribing have one or more staff in the practice with knowledge of what’s available so that patients can be put in touch with, or ‘sign posted’, to an appropriate support agency – ie offered a ‘social prescription’. Some evidence exists to suggest that social prescribing works well, ‘extending the boundaries of mainstream primary care for the benefit of patients and professionals’. 2

2.3 The Health Trainer and Social Prescribing Service in South and West Bradford Bradford was one of the health trainer early adopter sites and thus one of the very first districts to train and deploy health trainers from early 2006. A pilot social prescribing service then known as CHAT (Community Health Advice Team) was set up in 2004 and an evaluation undertaken in 20053 found that it had been well received by both patients and practice staff.

In its pilot phase CHAT only operated in three GP practices, but based on positive feedback, the decision was taken by the South and West GP Alliance to invest further in the service and extend it to cover 21 out of 22 practices in the area (one practice did not have the space). As the health trainer and social prescribing models were very similar the decision was taken to incorporate the CHAT service into a renamed Health Trainer and Social Prescribing Service. The Alliance invested £131k of practice based commissioning monies to fund the service until May 2011. Six social prescribing health trainers are employed (4.5 whole time equivalents) by the PCT and are based in practices for half to one day per week, depending on the size of the practice.

The social prescribing health trainers (SPHTs) work in the following way: Patients who meet the referral criteria set out in Box 1, can be referred to the SPHT using System One. (see Appendix 1 for referral pathway.) Patients can also self refer. The SPHT sees the patient at the surgery. First appointments are for around one hour and patients are usually seen one – six times. The SPHT spends time listening to the patient and then helps them to work out coping strategies, or ways of dealing with their problems, using a personal health action plan where appropriate. 2

South J et al Can social prescribing provide the missing link? Primary Health Care Research and Development 2008; 9: 310-318 3 Woodhall J and South J (2005) The Evaluation of the CHAT Social Prescribing Scheme in Bradford South and West PCT, Centre for Health Promotion Research

9 Where needed patients are sign posted (and can be accompanied on a first visit) to a local activity, social group, or support agency. SPHT take time to get to know the voluntary and community groups in the local area and to establish which patients could benefit from their services. They also do promotional events in the community and within the practice to try and ensure that patients and practice staff know about their service. Where patients want to work on a lifestyle issue (eg being more physically active or eating a better diet) the SPHT can help them to develop a personal health action plan and support them to achieve their goals.

Box 1 Patients can be referred to the SPHTS if they fulfil any of the following criteria: They have mild mental health problems (such as anxiety, stress, mild depression) are socially isolated, have relationship difficulties, are facing problems with finance, housing, employment, etc, are a carer or parent in need of support, are struggling to come to terms with a disability or long term illness are trying to come to terms with bereavement wish to adopt a healthier lifestyle

10 3. EVALUATION AIMS AND METHODS

This evaluation set out to assess how far the aims for the combined and expanded Health Trainer and Social Prescribing Service have been achieved. The evaluation sought the views of both patients and practitioners on the service and importantly has endeavoured to determine whether there is anything distinctive about social prescribing health trainers (SPHT) that enables them to successfully reach and support people. A full list of the questions the evaluation sought to answer is given in Box 2. These reflect the objectives for the service as detailed in the Bradford South and West Alliance Commissioning Plan for 2009-2011.

Box 2: The evaluation aims to provide answers to the following questions 1. Do social prescribing health trainers enable practices to offer a better quality service to patients as part of the mental health care pathway? 2. Do patients who are ‘frequent practice attenders’ make more appropriate use of the GP practice after referral to a health trainer? 3. Do social prescribing health trainers enable practices to more effectively signpost patients who need social support? 4. Are referral systems between the practice and social prescribing health trainers working well? 5. Have social prescribing health trainers been successful in supporting patients to make the healthy lifestyle changes of their choice? 6. How do patients view the service? 7. Is there anything distinctive about social prescribing health trainers and the way they work which enables them to successfully support patients? 8. What factors have been important to determining any achievements and failings of the Health Trainer and Social Prescribing Service?

The information sources used were the monitoring data and case stories routinely collected by the service, together with data collected from patients who had used the service and practice staff, including GPs, plus key personnel within the service. The latter was gathered through face to face and telephone interviews with 22 people (two SPHT service managers, one commissioning manager, one nurse practitioner, three practice/business managers, three GPs and twelve patients) and a focus group with the six social prescribing health trainers. Both interviews and the focus group were conducted during the Autumn of 2010, recorded and transcribed and then analysed using a simple thematic coding method. All interviewees were sent an information sheet prior to being contacted and consent to take part was obtained prior to the commencement of the face to face interviews and focus group.

11 Health trainers are encouraged to collect case stories in which they describe a particular client’s story. These case stories have been used, together with quotes from the interviews and focus group, to ‘bring the text alive’ throughout this report.

Monitoring data is collected by health trainers in paper form and entered into a national computer system called the Data Collection Recording System from which reports can be drawn. SPHTs also collect additional data to feedback to commissioners. This evaluation is based on monitoring data for the period January – September 2010.

12 4. THE PATIENTS ACCESSING SOCIAL PRESCRIBING HEALTH TRAINERS AND WHAT THEY THINK OF IT

4.1 Profile of patients using the Social Prescribing Health Trainer Service A total of 484 patients were seen by SPHTs in the nine month period under review. A breakdown of the social composition of this group is presented in Table 1. This shows that the service is reaching a wide age range of people from the most deprived sections of the population with a total of 68% coming from the two most deprived quintiles and (According to their Commissioning Plan, 67% of the population of the Alliance area is from quintiles 1 and 2). The significant proportion of patients seen who are unemployed (37%) also reflects that SPHTs are reaching people who are disadvantaged. The percentage of non white patients seen (22%) is greater than in the area covered by the GP Alliance, and again demonstrates that the service is reaching patients who are likely to be relatively disadvantaged. The gender split (66% women, 34% men) is typical of health trainer services across the country and may reflect a reluctance on the part of men to seek help and/or that women often take on the lion’s share of caring and coping within families.

Table 1: A profile of the 484 patients referred to the Social Prescribing Health Trainer Service January – September 2010

Age

Gender

Deprivation

Ethnicity

Employment status

Under 35

36-65

Over 65

Not recorded/declined

33%

48%

15%

4%

Female

Male

66%

34%

Q1 lowest Q2 second Q3 third Other 20% lowest 20% lowest 20% 46%

22%

21%

11%

White British

Pakistani

Indian/other Asian

Other

78%

9%

3%

10%

Employed unemployed full and part time

retired

Long term Other sick/disabled

27%

19%

9%

37%

8%

13

4.2 Patients views on the service 19 patients who had recently seen a social prescribing health trainer were randomly selected and sent a letter inviting them to take part in a telephone interview. Six could not be contacted, one worked night shifts and was not available to interview in the day. In total twelve patients were interviewed about their views of the service and what they had gained from it.

The responses were extremely positive – clients had found the service hugely helpful and it had enabled all of them to cope much better with the difficult circumstances they were in A summary of some of the key findings is presented in Table 2 below.

Table 2 – Client Views of the Health Trainer and Social Prescribing Service

Question

Yes

No

Was the place you saw the health trainer convenient?

12

0

Was the appointment time convenient?

12

0

12

0

6

6

Clients appreciated the flexibility offered and one commented that given her low mood and forgetfulness, text reminders were welcome Were you able to achieve what you’d hoped?

All very positive but one person said ‘to a degree’ – she would have liked to have seen the health trainer for more sessions. Were you signposted to another service or activity?

Could you have achieved what you did without the support of a 0 health trainer?

12

Would you say that your health trainer helpful and supportive?

0

12

14

10 ‘Strongly agreed’ and 2 ‘agreed’ Would you recommend the health trainer service to family or friends?

Very pleased How do you feel about 8 what you’ve achieved having seen a health trainer?

12

0

pleased

OK

disappointed

3

0

0

Note: One patient was not asked this question. Excellent How would you rate the 10 HT service overall?

Very good

good

fair

poor

2

0

0

0

The vast majority of the 484 patients were referred to the service by a GP or another member of the primary health care team (93%) with only a very small percentage referring themselves having seen a poster or other publicity. GPs are the main referrers (66%), nurses average 13% of referrals and Gateway workers 7%.

The main referral reasons are set out in table 3 and as would be expected, these reflect the referral criteria (see Box 1). Most patients referred also had a long term condition, most commonly depression (38%).

Table 3 Reasons for referral to the SPHT Service Mental issues 36%

health Social isolation

16%

Lifestyle

Family

other

21%

11%

16%

NB these percentages are based on the cumulative total of patients seen since the projects inception.

The patients interviewed for this evaluation were all referred by their GP apart from one who had seen a poster in the pharmacy and self referred. They were all going through very

15 difficult times in their personal lives when they saw the SPHT – either to do with employment and financial difficulties, bereavement, dealing with the aftermath of an accident or ongoing disability, family and relationship problems, loss of self esteem and weight problems, social isolation, anxiety or depression. Many felt overwhelmed by the extent and complexity of their problems and coping with bureaucracy and form filling. Some were at the end of their tether and did not know what to do to address their problems:

„…(due to family illness and other pressures)…my life totally spiralled out of control, silly things like filling in forms……I just couldn‟t focus on anything…. I‟d seen my doctor because my weight was also spiralling out of control and I knew I was endangering myself… I was feeling pretty naff about myself really and pretty useless.‟ (patient no. 8)

Patients self confidence was invariably low, and all found the chance to talk to someone outside of their situation invaluable – SPHTs can spend up to an hour with someone and for many patients this was the first time anyone had ever listened to them for that long:

„..because I‟ve got disabilities I‟ve kind of shut myself away a bit and it‟s like I don‟t really see anybody unless it‟s me family so I‟ve no like friends or anybody that you can offload on apart from me husband and sometimes it‟s not fair offloading everything on to him so to have somebody outside of that circle that were independent meant that I could actually open up more than I would with those people, you know wi‟ me family and me husband. You know I could say things that I really wanted to say you know.‟ (patient no. 10)

Patients also appreciated the way SPHTs helped them to think through their situation and come up with a way forward. They liked the hands on, practical approach taken – for example help with filling in forms, sign posting to an agency which could give information and support and working out and monitoring a weight reduction plan. Patients’ self confidence grew and they felt more motivated to make changes to address their problems:

„I‟ve gained a little bit more confidence where I‟ve applied for jobs what I know I‟d be able to do because of my disability. I‟m limited to what I can do but she‟s given me the encouragement and the courage to do it.‟ (patient no. 5)

16 Taking back some control over their lives was very important to the people interviewed. They all felt pleased with what they had achieved and had gained the confidence to carry on dealing better with the difficulties they faced. The changes clients have made as a result of seeing a SPHT are discussed in Section 5.

Patients reported seeing their GP less and taking less (or no) medication – these issues are addressed in section 6. They were also hugely complementary about the SPHTs and their qualities and skills – this is explored further in section 7. One person commented that she wished she could have had more sessions with the SPHT, but all the others felt that the time given had been enough to help them turn their lives around, although they did like to know that the SPHT was there if they needed to get in touch and appreciated follow up calls to check on their progress.

17 5. THE CHANGES PATIENTS ARE MAKING WITH THE SUPPORT OF SOCIAL PRESCRIBING HEALTH TRAINERS

This section has drawn on the monitoring data, interviews with clients and practice staff and the focus group with SPHTs to summarise the changes patients are making with the support of a SPHT. Some patients primarily need space to talk to someone about their troubles and some can be signposted to another agency after only one or two sessions with the SPHT; however where patients are seen for three or more sessions they are encouraged to develop a personal health action plan. This enables them to make some goals and decide on what they are going to do to achieve them. 48% of the 484 patients seen by a SPHT in the nine month period under review made a personal health action plan – 231 patients in total.

The SPHT helps patients develop and monitor their action plan, provides information and suggests techniques which might help. Patients are encouraged to focus on one issue at a time and this is recorded as their ‘primary issue’. Not surprisingly, given the referral criteria, the majority of patients (84%) decide to focus on their mental health and wellbeing as can be seen from table 4 below. The SPHT records what aspect of their mental health and well being is of greatest concern to them – general stress/anxiety/depression is the largest category, followed by low self confidence and social isolation.

Table 4 The primary issue patients focussed on Mental health and well being

194

84%

Diet

21

9%

Exercise

8

3%

Alcohol

5

2%

Smoking

3

1%

Total

231

When patients are ‘signed off’ having finished their sessions with the SPHT, how far they have achieved the goal they set themselves is recorded. For the 231 patients who made a health action plan, a record of what they achieved was available for 159 (69%) at the time of writing. 19 % were still seeing a SPHT and for 12% the final outcome was unknown. Overall 87% of patients made progress having seen a SPHT which is an excellent result.

18 Table 5 How far patients made progress on their goals Fully achieved their goals

84 out of 159 patients who 53% had completed their health action plan.

Part achieved their goals

54 out of 159 patients

34%

Did not achieve their goals

21 out of 159 patients

13%

Total who made progress

138 out of 159 patients

87%

The achievements and changes the patients interviewed talked about included: Going back to work after illness or accident repairing relationships or coping better with separation, joining activities and getting out more following bereavement making time for relaxation and physical activity losing over three stone in weight taking up swimming with her husband getting a wheelchair for her disabled child joining a support group for people with their condition doing home exercises regularly to offset arthritis taking steps to deal with their anxiety The changes made are examined in more detail below.

5.1 Improvements in mental health and reductions in social isolation Poor mental health, low self esteem and social isolation are key reasons why patients are referred to the service and the main primary issues they work on (see Tables 3 and 4). The patients interviewed were very clear that they had improved in relation to all of these as the quotes below illustrate. In some cases the changes they had made were really transformative.

„I‟ve never really opened up deeply about my disability but I actually went right back to the root with (the health trainer). I talked about when I did some work, how I got severely bullied, how I was bullied at school, I was bullied in my first marriage….we actually got into depth about things that had happened in childhood and all the way through me life which got a lot off me chest….although they give you depression pills, they can keep giving them and giving „em, but unless you get to the root of the problem….I think over the years, I think it‟s the best thing that I‟ve ever been given.‟ (Patient 10 who is continuing to go the swimming group she was introduced to by the SPHT,

19 where she has made new friends)

„‟I‟ve been going through a difficult time for the past few years with regards to (family relationships) and I just basically felt with that and other things everything was just getting a bit on top of me really. So rather than take tablets I felt it better to see if I could talk to somebody about it…‟ (Patient 7 who went on to say seeing a SPHT had been helpful and reduced her anxiety, the only downside being she‟d have liked more sessions)

In the nine months under review SPHTs had sign posted 51 % of the patients seen to a service or activity outside of the practice and made 130 accompanied visits to support patients who lacked the confidence to go on their own. Patients have been signposted to over 100 different agencies and activities, ranging from literacy courses at college, volunteering at a community allotment, learning how to line dance, Citizen’s Advice Bureau to Samaritans. SPHTs commented very positively on the difference getting involved in activities outside of the home had made to the patients they had seen, some of whom became volunteers themselves:

„I think like getting people into voluntary work is a fantastic way of building their confidence, „cos it makes them feel like they‟re making a difference…..it gives them as sense of self worth..‟ (SPHT)

In addition to signposting patients to other agencies, SPHTs work with them to find ways of coping with the issues they are facing. For example, one SPHT talked about how she had helped a male patient deal with the anger he felt towards the perpetrators following a car accident and got himself back to work:

„at the end of our sessions X felt much happier and also appeared to be dealing with his anxiety and (anger towards XX) very well. His anger subsided, he felt ready to face going back to work…he felt the service was there to listen to him without being judgemental. He felt that by talking and setting himself personal targets he has progressed very well.‟ (SPHT)

The intervention of a SPHT can not only help patients deal with existing problems, but reduce the chance that they will escalate, as the case story in Box 3, illustrates.

20

Box 3 Helping a patient cope with stress and avoid depression ‘The patient was a white British female, in the 26-35 age range, who was referred by her GP. She was feeling stressed and finding it difficult to cope at work and was worried that she was heading for a bout of depression, which she had previously experienced. We discussed what was going on in her life, how she was feeling, what coping strategies she was using, what had worked well for her in the past, what the current barriers were for her and what she could do to improve things by looking at where she wanted to be. She had so many different things going on at the time (she was getting married, worried about redundancies at work and concerned about the health of a close family member), it was important that she separated them off and looked to deal with them one step at a time. The patient was very aware of what was triggering her stress, although we did need to look at different coping mechanisms….it was very important to allow her to tell me everything she felt was relevant, as this helped to build up a rapport and encouraged her to be open. (With my help) she realised that if she became more organised she would feel more in control and one of the things she did was to start using a diary to help her plan her life. She also decided she needed more time to look after herself, which in turn, meant that she felt more able to look after others. For example, she planned time for herself to get her nails done, which led her to feel more confident about herself. This led on to her feeling able to visit the relative in hospital, which in turn made her realise that that problem was not such an issue etc etc.’

Case story recorded by the Social Prescribing Health Trainer

5.2 Patients who made behavioural changes to improve their lifestyle A minority of the patients seen by SPHTs want support to make a change to improve their lifestyle (see Table 3), which is the core role of generic health trainers. As described above, patients are supported to develop a personal action plan in order to reach a behavioural goal which they decide on. Most often this is about changing to a healthier diet, losing weight or becoming more physically active. All patients interviewed talked about improvements they had made to their mental health and half talked about improvements to physical health as well, even where their primary issue had been mental and social: „..I needed someone to motivate me basically and she did it, which is fantastic and I‟ve lost 3 stone….she‟s just been wonderful and she‟s got my head straight. It‟s not just losing the weight it „s the mental side as well.‟ (patient 8) „..I lost over 3 stone, but not only did I lose 3 stone. I gained in confidence. „ (Patient 9 who also, with the encouragement of the SPHT went to the nurse to get treatment for a skin condition which was stopping her going swimming (walking was difficult because of joint problems) – when it had healed she started swimming regularly)

21 The SPHTs recognised that mental and physical (especially weight) issues are often entwined and that underlying mental health issues need to be addressed:

It‟s not a question of just knowing what to eat….we start talking about why they‟re comfort eating and then gets into all many, many other things…‟ (SPHT)

SPHTs reported that often patients gain a lot from attending a cook and eat group and this can benefit the whole family:

„(the patient) didn‟t know a lot about healthy eating and cooking and preparing food and I sent her to a cook n‟ eat programme and now she‟s obviously, she‟s cooking more at home instead of getting frozen meals and obviously that‟s having an effect on her children as well….and exercising as well, they go out regularly at the weekends and do things …‟ (SPHT)

SPHTs talked about encouraging patients to become more physically active (especially to go walking) as this can have significant mental and well as physical benefits. One SPHT is able to signpost patients to activities in the healthy living centre where she is based where patients meet people in similar situations and gain social support.

Several patients reported that the benefits gained had spread to their families as well:

„from the discussions I‟ve had with my wife (after seeing the SPHT) we go for walks and that kind of stuff and have some relaxation time for ourselves and we‟ll probably go on holiday which I haven‟t been able to…..‟ (patient no. 3)

22 5.3 Support with work, benefits and other entitlements

Some patients are supported into work or to get benefits or other help they are entitled to, either directly by the SPHT or more often by referral to an appropriate agency.

One lady who does not speak much English found the support of a bilingual SPHT invaluable. A family member translated so that she could give feedback:

„she wanted advice and help filling in forms, her youngest daughter has got a disability and (the SPHT) was telling her…what services she can access…she referred her to the people who give you wheelchairs and to (an agency) that does short break and outings for the children…she says „I wouldn‟t have been able to do half the things I‟m doing now without (the SPHT)‟ (family member speaking for patient 4)

Another found the confidence to apply for jobs:

„I‟ve gained a little more confidence when I‟ve applied for jobs….I was bad with my nerves and I couldn‟t even think about how to..I‟m not into CVs and all that…I don‟t think I‟d have done it (apply for jobs) to be honest because I think I tend to look on the negative side of things…but she sort of kept me, you know she says just don‟t let these things knock you back…..‟ (Patient 5)

And a woman caring for her adult son was able to sort out his benefits:

„when I went to see her (SPHT) I didn‟t recognise what was going on with the form filling because I was constantly ignoring things. I have a son with learning disabilities and he had had forms coming in about his benefits and they‟d actually stopped his invalid care allowance because the forms weren‟t sent back but as a direct result of working with (the SPHT) … I was ready to tackle that again so I picked up the phone and told the benefits agency what had happened and told them it was my fault not theirs and they started putting things in place then to sort out his benefits.‟ (patient 8)

From the data gathered, the support SPHTs can give seems to be particularly valuable to people who are either coping with a disability themselves or supporting someone who is. The value this and other aspects of the SPHT Service add to general practice is covered in the next section.

23

For some patients the changes they had made with the support of a health trainer impacted on all aspects of their health - mental, physical and social and had really helped them make major changes in their lives:

„A patient came to see me in a desperate state. He had made two suicide attempts by taking overdoses, disliked his job, was having relationship problems, had been chucked out of his marital home by his wife and was now homeless and 'sofa surfing' with friends. However….after our sessions together I believe that some of my support, signposting and encouraging helped him get his life back in order. He is now living with his wife and little child again, …. has been accepted onto an apprenticeship which will lead to a better paid job with more sociable hours, is back exercising and has given up alcohol for the duration of his apprenticeship. The change I see before my eyes has been miraculous and I feel so privileged to have played a part in this transformation. „ (SPHT case story)

24 6. GP PRACTICES AND SOCIAL PRESCRIBING HEALTH TRAINERS

6.1 Referrals As discussed above (in 4.2) GPs are the main referrers to SPHTs, accounting for 66% of referrals on average over the nine month period under review; nurses averaged 13% of referrals and Gateway workers only 7%. 3% of patients referred themselves and the remaining 11% were referred by a variety of other staff. SPHTs reported that they generally had plenty of referrals and in one practice a waiting list of around 8 weeks had built up, in another a hold had been put on referrals until the backlog was cleared. This would indicate that practice staff do value the service and this is confirmed by the comments made in interviews.

The relatively small number of referrals from Gateway Workers4 is perhaps surprising given that health trainers are operating as part of the mental health care pathway. The number of nurse and Gateway worker referrals as a proportion of total referrals, have also declined slightly over the period under review. One of the GPs interviewed had talked to the Gateway worker in her practice who was very positive about SPHTs and found it very useful to be able to refer patients who needed help with accessing services and activities outside the practice, so clearly the referral pathway was working well in this practice.

Several interviewees commented that it can take GPs some time to get into the habit of referring to a relatively new service. SPHTs were concerned about the number of referrals they received which they felt were inappropriate (usually because of the severity of their mental health problems) and resulted in the patient being referred on to another member of staff. In their view, some patients were being referred to them because the waiting times to see mental health staff were so long.

6.2 Addressing social problems All practice staff interviewed recognised that clinicians do not have the time to address the social problems that often lie beneath the issues that patients present with in the surgery:

„I think it‟s somewhere to send patients that I don‟t have the skills to deal with, things like housing benefit, loneliness, all those social problems that as a GP, I don‟t want to be prescribing anti depressants for..I want an alternative approach that‟s more appropriate and it‟s that that it gives us‟ (BR19)

4

Gateway workers are members of the mental health services clinical team.

25

„they‟ll come to the GP asking various questions, when you dig deep, you find out it‟s not really a health issue but if we‟re not careful could become a health issue..‟ (BR17)

„it‟s really good as a clinician to be able to have somebody else that you can refer on to rather than just having to give them a prescription or something….(the SPHTs) need to have a good understanding of what is available out there you know, to be able to refer patients to other services.‟ (BR18)

The clinician quoted above recognised that SPHTs are able to provide a link to community based services which the practice might not otherwise know about. – this was echoed by others:

„Their contacts that they‟ve got are far better and they‟re far more experienced at that than our GPs are and they can give them the time that they need.‟ (BR20)

6.3 Reducing ‘frequent attendance’ One of the aims of the service is to reduce the amount that patients with predominantly social problems attend the surgery and there is qualitative data from patients, SPHTs, and practice staff that some patients are reducing attendance after having see the SPHT, and in some cases reducing their medication. Below is what some of the patients interviewed had to say:

„at times if I wasn‟t feeling so good I would go (to see her GP) once a week and if I wasn‟t feeling good I would make another appointment so at times I could visit more that twice a week but now I only go once a month for reviews or to discuss with my GP so it has reduced the number of visits that I‟m having.‟ (patient 6)

„I think it has (reduced the amount I see my GP) „cos I mean with depression you do tend to..run to your GP more. Whereas if you‟re not depressed you tend to get on with things and just go when you actually need summat.‟ (patient 10)

One SPHT commented that:

26 „ a few GPs have said that they haven‟t seen a certain person that was a very frequent attender. Sometimes people just want interaction and unfortunately GPs have got less than 10 minutes, some have 5 minute appointments with people and it‟s not enough…‟ (SPHT)

The GPs and practice staff interviewed, also felt that it was likely that for some patients attendance would be reduced, although they lacked hard evidence:

„ if the social problems aren‟t sorted then you know worry, anxiety, depression… then they end up seeing the doctor ‟….(BR22)

Several patients commented that they did not want to have to take medication like anti depressants and saw seeing the SPHT and getting back some control over the social issues they were facing as a way of cutting down on, or avoiding going onto, medication (see case study in Box 3)

Gathering quantitative data on whether attendance has been reduced is hard as this interviewee articulated:

„you‟d like to think so (that inappropriate frequent attendance dropped) but whether you can measure…you‟d have to really track that patient through the whole journey and say well how many times did they visit the practice for non medical reasons….then signpost them to SPHT and see if there was a reduction in non medical appointments….very difficult..‟ (BR17)

The Service Manager on behalf of the evaluation team did approach several practices to see if it was possible to look at patient attendance data pre and post seeing a SPHT, but for reasons of data security and time this was not possible for this evaluation.

6.4 Summary of benefits for GP practices

The benefits practices are accruing from SPHTs where the service is working well can be summarised as:

A non clinical service for the practice to offer as part of a holistic package, particularly to patients with mental health and social issues A service that can respond to the myriad of social issues which patients bring, particularly in areas of high deprivation

27 Staff with time to spend with patients over a number of weeks Reduction on use of GP time with patients whose problems are at least in part, social A means of building links with and making use of the wide range of community based services and activities offered by other agencies in the locality. An effective way of supporting people who want to make lifestyle changes High patient satisfaction with the service which is likely to extend to higher satisfaction with the practice as a whole

A number of issues around how the service is operating in practices were also raised by the SPHTs, service managers, GPs and practice staff interviewed – these are discussed in section 8 and some recommendations made in section 9.

28 7. ARE SOCIAL PRESCRIBING HEALTH TRAINERS OFFERING SOMETHING DISTINCTIVE?

One of the evaluation aims was to seek to answer the question: ‘Is there anything distinctive about social prescribing health trainers and the way they work which enables them to successfully reach and support people?’

Evidence from all sources in this evaluation is that SPHTs are a valued service that offers something different. Key to what is distinctive about SPHTs is that they are mostly local people, not clinically trained but skilled in communicating with the public, empowering people to come up with their own solutions and supporting them to make the changes they have decided on. Unlike most health professionals they can spend more than 5-10 minutes with patients (first appointments were for one hour), visit them at home if need be, can accompany them to activities and can see them several times over a number of weeks (usually up to six times per client). The patients they are supporting have generally got a range of problems and are greatly in need of help to deal with the issues they face. None of the patients interviewed thought they would have made the progress they did without the support of the SPHT.

Patients, practice and service staff all broadly agreed on the essential qualities that a SPHT needs and these are summarised in Box 4 below. All the patients interviewed were extremely positive about the SPHT who had worked with them and very grateful for the support they had received. They particularly liked being given control over what they did about the issues they wanted to address: Asked what they liked about the service, these are some typical quotes:

„I just felt relaxed. There‟s no pressure and it‟s up to me, they‟re not pushing me to do anything I don‟t want to do. There‟s never „no I think we should do this now‟ or any of that, that would make me feel pressurised, she seems understanding.‟ (Patient 1)

„I think it was the way (the SPHT) came across. She came across friendly, like someone you‟d meet like a friend to have a chat with. She was talking to me at my own level and she wasn‟t talking to me on a clinical way or in a doctor way if you know what I mean and I just found that easier. I found that I had a rapport with her and that I could tell her things and that I wasn‟t worried about telling her anything and I felt that she were easy to talk to.‟ (Patient 5)

29 Box 4

The qualities social prescribing health trainers have: Able to relate to people Non judgemental, caring and empathetic Approachable, friendly and trustworthy Flexible and adaptable Good communication skills Counselling and motivational skills Well organised, good time management Knowledgeable but know their limits Knowledge and understanding of the area/group they are working with ‘normal’ people

The SPHTs themselves and the service and practice staff also recognised the essential caring and communication qualities a SHPT needed but in addition saw that they needed to have organisational and networking skills and to be good team players:

„I think you need very good consultation…communication skills. I think you also need a quality that‟s sort of harder to come by which is the ability to keep going in your work but working from maybe three or four different bases in a week so sort of self reliance that requires. And organisational skills and networking skills, I would have thought.‟ (BR21)

The SPHTs commented that they needed an element of detachment as well:

„I think you‟ve got to be able to detach yourself in a sense as well. You‟ve got to look after your own mental health as well and not let things affect you to a degree where you‟re taking your work home and it‟s affecting your ability to be support to people..‟ (SPHT)

Overall from all the data collected, it appears that it is the combination of having time to spend with people plus empathy and a simple, common sense approach which made the way SPHTs work distinctive.

30

8. ORGANISATIONAL AND SERVICE ISSUES

As has been described above, Social Prescribing Health Trainers are clearly providing a service which is appreciated by GP practices and greatly liked by patients. Overall the service appears to be working very well. The SPHTs reported enjoying the interesting and varied challenges the job presents and getting a lot of on going motivation from seeing the positive changes in patients they work with. One SPHT shared a text she was sent by a patient she had worked with which she said was what gave her job satisfaction and motivation:

„You‟ve really helped to turn my way of thinking around which has had a great impact on my life. I‟ve learned to love myself more for my personality rather than how I look and my confidence gained. I finally got a job as a teaching assistant which I start on Monday. I am going to keep working on my self confidence as I still do have things to work at but the more I work at it the more my self confidence grows and the better a person I am becoming. Thanks again you are the nicest person I‟ve ever met. Thanks for helping me become a better person, a better mum and a better partner to my boyfriend. Good luck helping other patients and good luck with your career.” (SPHT sharing a patient‟s own words)

Service Managers and SPHTs reported that becoming a SPHT can be an important stepping stone into a career in health and social care, which fits with one of the original aims of the National Health Trainer Programme – to develop lay people and provide opportunities for them to progress.

Within this overall positive picture, some organisational issues emerged which are summarised below.

8.1 The Social Prescribing Health Trainer role SPHTs have a well defined approach to working with patients which is described in 2.3 above. However their role is not always clearly understood within GP practices and there appears to be potential for overlap with other roles. One GP interviewed commented that GPs not being clear about what the role was, in her view limiting the number of referrals and possibly patients taking up the offer of seeing a SPHT:

„many GPs are more conservative in their approach to things so they will only refer people when they think they know what they‟re referring to really…….. (patients) are already

31 anxious, coming to the doctor and if you offer something you can‟t really explain very well, they‟re less likely to take it up…‟ BR21

The SPHTs service manager recognised that it can take time for GPs and other practice staff to feel familiar with the SPHT role, but once they had experience of working with SPHTs and saw the impact on patients in this view, they were generally very positive:

„from a staff point of view, I think they‟re very sceptical to start off with……but over time it‟s shown that they have fewer consultations……so they actually love that. They get less people attending, less frequently and it also allows them, it frees up their consultations to consult.‟ BR14

This comment was echoed by a number of the practice staff interviewed – in most practices the SPHT Service is popular because it is something positive that can be offered to some of the most vulnerable patients and it saves GPs and other practice staff time.

One aspect of the SPHT role which appears to be underdeveloped is support for people to make behavioural changes to benefit their health. Some SPHTs reported that they saw virtually no patients for ‘lifestyle support’. This could be because the original service was social prescribing only, but that was only in three practices, so it seems likely that either SPHTs are not promoting that element of what they can offer and/or GPs and practice staff are not making much use of the opportunity to refer patients for support to change unhealthy behaviours. The SPHT is part of the mental health care pathway which may explain the perception that what they do is just around support for people with low level mental or social health issues.

8.2 Working as part of the mental health care pathway SPHTs work as part of the mental health care pathway and can be referred to by any of the other practitioners who also support patients within this pathway mainly GPs, nurses, Gateway workers, and Psychological Well Being Workers. SPHTs can also refer patients to other practitioners.

There was a general sense from all interviewees (except for patients who made no reference to the pathway) that this is not working as well as it could. SPHTs and the service managers felt that some referrals were inappropriate – usually because the patients had mental health issues which were too severe for SPHTs to deal with (see 6.1). Inappropriate referrals were also recognised as an issue by some practice staff. SPHTs, service managers and some practice staff also felt that there was some overlap between the role of the SPHT and the Psychological Well Being Worker. This raised the issue of pay banding for SPHTs who are

32 on a lower band than PWBs. SPHTs were concerned that they did not work beyond their competencies as set out in the Health Trainer Handbook5 .This was touched on in the quote in 6.1 above and is raised again here:

„I think that‟s like when I said before it‟s about…sending inappropriate referrals back as well…and being aware of what you can do because sometimes it is very easy to take on patients and you see them a couple of times and you think “I can handle this” but actually it‟s not what we‟re supposed to do and do we actually get paid enough to do that for a start you know and – but I think the mental health team, there‟s such a massive waiting list it becomes difficult, you say you‟ll refer to them but then you‟re left with this patient that‟s sort of dangling and having to wait, so sometimes you end up seeing that patient for more sessions than maybe you should „cos you‟re waiting for them to go into the mental health service‟ (SPHT)

Both those commissioning and providing the service recognise the issues outlined above and are considering how to address them.

8.3 Social prescribing health trainers working as part of the practice team All the SPHTs work in at least two practices and one of them works in five (she is the only full time SPHT). They do not have desks in the practices, (or within in the PCT – they just have a base where they can collect mail and have meetings). This presents challenges to being able to be, and being seen to be, part of the practice team. From the interviewees undertaken, it would seem that some are very much part of the practice team but some less so. This quote provides an overview:

„where they're part of the team and they're visual and they're part of the team meetings, they fit in very well; they're integral to the team so they work with the full practice team……. personalities do come into it, whereby they you know, they're not making themselves visual, they're not joining it as such, you know, they're a bit remote, well then that‟s where the issues come because then its two ways, because the practices need to make them feel welcome and vice versa. You know social prescribing health trainers need to be pro-active in their role as well so it‟s two ways. So we‟ve got mixed you know we've got it where it works excellent and we've got it where we need to see them a bit more. But unfortunately due to the nature of them flitting between practices…they can‟t always be around when the team meeting‟s on….they might be in another practice doing a session..‟ (BR16)

5

British Psychological Society (2008) Improving Health, Changing Behaviour, NHS Health Trainer Handbook, Department of Health

33 This overview of how SPHTs are working as part of the practice team was born out by the other interviewees – some practice staff felt that the SPHT was not around enough and did not really feel like a full team member, others could not praise them enough:

„it would be nice for her to be more integrated in the team. I know she likes it here and the staff you know, but in terms of….because she‟s only here a little bit of the time….it‟s a bit fly by night…it‟d be nice if they were more integrated into the team so that you know they gave us feedback and came to the clinical meetings and gave us feedback about patients…‟ (BR22) „ she fits in very well, she‟s liked and people know her and recognise her around the place. ….she comes to our, we have a GP meeting on a Friday lunchtime, so when she can, every so often, if referrals are dropping off in particular, she‟ll come and do a reminder to people…we do it via email as well….the staff at the practice think it‟s an excellent thing, because it gives them somewhere to refer these people who keep coming back to see them again and again who they can‟t really do much for but all of a sudden there‟s someone, there‟s somewhere we can send these people.‟ (BR20) As a small service with only 4.5 wte staff covering 21 practices, it is clearly going to be a challenge for SPHTs to fully integrate into every practice team. SPHTs also need to engage with community groups in order to keep up to date with activities and services which they can signpost patients to, which is another demand on their limited time. Where SPHTs are working well as part of a team, all the staff concerned deserve credit for making it happen, where it is working less well, all parties need to work at finding ways of trying to integrate better, but in large practices in particular, this is likely to continue to be difficult with a small service which is only able to over limited sessions to each practice. 8.4 Other service issues SPHTs spent some time in their focus group interview talking about support and supervision. Some felt strongly that whilst the support of their team leader was appreciated, they would like to have clinical supervision in the same way as PWB workers. SPHTs work alone and whilst many felt well supported by the practice staff where they were based, and by other SPHTs as well as their team leader, the fact that they do not have a base where they could interact with other health trainers on a regular basis, was perceived as a short coming by some. Home visits which are made alone after initial assessment visit was also raised as an issue of concern, in terms of safety. Covering long term sickness was raised by one practice that felt the loss of continuity when its SPHT was off for a long period and could not be replaced. Some SPHTs also voiced a desire to have more flexibility to see patients more than six times if they needed that time to deal with complex or multiple problems, and to work with some of the ‘hardest to reach’ groups in the community who might not even be registered with a GP.

34 9. THE FUTURE POTENTIAL OF THE SERVICE All the practices interviewed valued the service and wanted to see it continue, and several talked about wanting to expand the service in their practice: „just more of them would be great…before she came we really didn‟t know what to do with some patients..if we could have her every day that would be great.‟ (BR23) „obviously if we could have more (sessions) that would be better still…we‟re a bit limited as to how many people we can refer on..‟ (BR18) „we‟re happy with the way it‟s running…I still think there‟s more we could do…we‟re a large practice, we‟ve 22,000 patients and six appointments a week…I‟m sure we could fill twice as many.‟ (BR20) Three practice staff interviewed talked about wanting to see the SPHT more integrated into the team in the future, as discussed in 8.3 above. Three others had ideas about developing as well as expanding the service: „I'm conscious that she‟s working across three practices at least.. if she were more part of our team, we do have...a development aspect of our practice that's about more patient and public involvement and getting more things that have maybe health promotion activities like Walking for Health or healthy eating going in the practice and it strikes me that she might ...generate more referrals for herself but also become more embedded in the practice if she were to get involved in that work stream in our practice, do you know what I mean...We actually do need somebody, we've actually identified it as an area that we do want to develop and the PCT wants us to...but we haven‟t really found a body who would do it and it strikes me that she might be the right person cos she has her networks and her contacts really....‟ (BR21) „I suppose it‟s about building on what they do well now and looking out for other opportunities and networking. Linking it into a lot of the other local agencies..‟ (BR19) „we value the service and it just needs to be developed more in line with...my thoughts are about this central triage and that, not only are the social prescribers and the gateway workers working together but also the counsellors, GP, like a one-stop shop that does a bit of everything in one place so……..even through the pathways are there I think it‟s still needs to be a bit more…you know encompassing the whole of primary care.‟ (BR16)

The service managers were, not surprisingly, very committed to the model and saw potential for it to be expanded:

‘it‟s such a simple idea that is really valuable. It‟s very cost-effective. ….the only places where you'd struggle to get social prescribing off the ground, is somewhere that‟s got a weak voluntary/community sector or they haven‟t got very many voluntary organisations around cos it does rely totally on what's available in an area. But yeah it should work in most places

35 and you look at the cost of anti-depressants and things like that and you look at the cost of our service and I think it‟s a very relatively, cheap, effective way of supporting people to have a better lifestyle.‟ (BR14)

The SPHTs themselves look forward to the day when they are so well established, that other professionals immediately recognise the role:

„it‟s just about helping it grow….and hopefully that‟ll mean more people getting into the role and obviously that will provide us with additional support as well……..when you go on training courses for instance a lot of people.. in different roles, nurses for instance, they haven‟t heard of the role before, so I suppose it would be nice one day to go „ oh, the social prescribing health trainer,‟ oh right, OK.‟ (SPHT)

36 10. CONCLUSION AND RECOMMENDATIONS

This conclusion reflects back on the evaluation questions listed in section 3.

1. Do social prescribing health trainers enable practices to offer a better quality service to patients as part of the mental health care pathway? The findings from this evaluation are that the addition of a SPHT in a GP practice enhances the package of services that the practice has to offer patients, thereby improving the overall quality of provision. Patients with stress, mild mental health problems, or who are socially isolated are greatly benefiting from the service and GPs and other practice staff appreciate being able to have something to offer patients whose problems are predominantly social. The need for some review of how SPHTs are working as part of the mental health care pathway was touched on by most professionals interviewed

2. Do patients who are ‘frequent practice attenders’ make more appropriate use of the GP practice after referral to a social prescribing health trainer? There is a significant amount of anecdotal evidence from patients and staff that many patients see their GP less when they are addressing their social issues with the help of a SPHT. Primary care teams could explore ways of enabling access to quantitative data on how often patients see GPs and other practice staff with social issues. Analysis of this material from a health economics perspective would make it possible to assess the costs and benefits to practices of employing SPHTs.

3. Do social prescribing health trainers enable practices to more effectively signpost patients who need social support? Over 50 % of the patients seen by SPHTs are signposted to voluntary or community groups or other services which can help meet their needs. Without a SPHT with the time to make and maintain contacts with over 100 external agencies it is hard to see how practices could effectively signpost those patients in need of social support. So without the presence of a SPHT or someone in a similar role, this would be a largely untapped resource for practices.

4. Are referral systems between the practice and social prescribing health trainers working well? SPHTs are busy, and at times backlogs of patients build up so clearly many professionals are aware of the service and are using it. However although GPs make by far the biggest proportion of referrals, a number of interviewees (including GPs) felt that many were still unsure of what the service has to offer and were not making as much use of it as they could. Nurses, gateway workers and other practice staff are making relatively small numbers of referrals and this is an area, together with patient self referral where there appears to be room for improvement.

37 5. Have social prescribing health trainers been successful in supporting patients to make the healthy lifestyle changes of their choice? There is good evidence from the monitoring data collected that patients are being effectively signposted to other agencies and/or are being supported to make changes by developing a personal action plan. Patients are reporting significant improvements in their mental, social and physical health with high numbers (87%) making progress on their action plan goals. Given that the patients referred are usually from disadvantaged backgrounds and have mental health and social issues, the progress being made is particularly striking and positive.

6. How do patients view the service? The patients interviewed were extremely positive about the service and feedback from other interviewees and the case stories all confirmed this positive picture. The service is clearly meeting a need and has developed an approach which is greatly appreciated by patients.

7. Is there anything distinctive about social prescribing health trainers and the way they work which enables them to successfully support patients? A large part of the reason for the popularity of the service with patients is the supportive, problem solving model SPHTs use which puts patients in control of how they address the issues they want to tackle. This together with being non clinical personnel with time to spend with patients means that SPHT do bring a distinctive approach which is proving successful and achieving positive outcomes.

8. What factors have been important to determining any achievements and failings of the Health Trainer and Social Prescribing Service? The approach used by SPHTs seems to be the key to the success of the service, together with a dedicated and motivated team. Working effectively within practice teams is also important to the smooth and effective running of the service. Any short comings in terms of referral systems or other organisational issues, whilst important appear to be relatively minor, and do not detract from the positive achievements of the service overall.

Recommendations

The following recommendations are made for consideration by both those who commission and provide the service.

1. The Health Trainer and Social Prescribing Service continues to be commissioned by the current GP Commissioning Alliance or the GP consortia of the future. 2. Consideration is given to expanding the service to enable social prescribing health trainers to spend more time in each practice thereby becoming more fully integrated

38 into the practice team and to potentially expand their role to include more patient and public involvement and development of health improvement activities. 3. Whilst the focus on supporting patients with social and mild mental health problems is clearly working well, there is potential for social prescribing health trainers to provide more in the way of support to patients who need help to change to healthier behaviours, drawing on the experience of generic health trainers in Bradford and elsewhere who are achieving positive results. 4. There is potential for social prescribing health trainers to support patients with long term conditions such as diabetes which could be explored ( a pilot funded by the Regional Innovation Fund, is underway in Bradford and Sheffield). 5. The service continues to strive to improve quality and in particular to explore how is can capture more in the way of patient outcomes using existing monitoring systems and undertaking occasional patient surveys. The work of social prescribing health trainers fits with the approach of the Coalition Government as described in its White Paper on Public Health 6 which emphasises the need to ‘build people’s self esteem and confidence’ in order to bring about changes in behaviour. It also fits with the Marmot Review’s7 recommendation on tackling the social problems that undermine health and with the Coalition Government’s approach to behaviour change as outlined in recent publications such as MINDSPACE.8

In times when finances are under pressure and the NHS is charged with achieving ‘better for less’, primary care needs to be looking at how to do things differently. The evidence from this evaluation is that social prescribing health trainers are offering a service which is making a positive difference for patients and practices at a relatively low cost. Investing in the service has the promise of not only saving money but improving the range and quality of what primary care can offer to patients – in other words providing ‘better for less’.

6

Department of Health (2010) Healthy Lives, Healthy People: Our Strategy for Public Health in England, Marmot M, (2010) Fair Society, Healthy Lives: A Strategic Review of Health Inequalities in England post 2010 University of Central London 8 Institute of Government and Cabinet Office (2010) MINDSPACE: influencing behaviour through public policy 7

39

For more details about Social Prescribing Health Trainers in Yorkshire and Humber contact the Health Trainer Strategic Lead, Judy White: [email protected] 0113 8124479 / 07515334250

The regional Health Trainer website also offers lots of information and updates about Health Trainer services in Yorkshire and Humber:

www.yhtphn.co.uk/health-trainers