Social Prescribing case study

Glenda is a 77-year-old lady who regularly attended her GP surgery. She has had to deal with several health conditions including cancer, diabetes, angina and back pain after surgery. Glenda had been feeling isolated and depressed and just needed human contact to help her with these feelings. So her GP referred her to a local Social Prescribing Link Worker.

Support given by the Link worker

The Link worker helped Glenda, by forwarding her to a local befriending project in the area. The project aims to connect people to reduce loneliness and isolation by hosting walk and talk sessions. Glenda now attends these sessions once a week and really enjoys them.

Outcomes

Glenda is a lot happier now, has reduced her social isolation, gained greater confidence and a wider social network. She also feels fitter, evidenced through lower blood sugar levels. Glenda now attends fewer GP appointments.

Health and social care providers unite to get patients home from hospital as Covid rates rise

The local health system across Nottingham and Nottinghamshire is working together and calling on families to help them get patients home safely once they are well enough to leave hospital.

As we see a rise in the Omicron variant of Covid-19, teams are working together to help protect elderly and vulnerable patients to get them home and safe as the surge in cases results in a spike in hospital admissions.

The new variant has also led to some care providers and health and care settings managing the additional demands and staff shortages.

Although the healthcare system is under pressure, discharge teams across Nottingham and Nottinghamshire health and social care are working together to help patients leave hospital sooner once they are well enough to help protect them and get them into a safer environment. Hospital is the best place for patients who are very unwell, but being at home in their own environment once they are well enough enables them to recover more quickly.

Melanie Brooks, Corporate Director, Adult Social Care and Health at Nottinghamshire County Council explains: “Despite the challenges, we are working with the NHS to support people out of hospital and into safe and appropriate care settings, to get the help they need during the holiday period and over the next couple of months.

“But our social care services are under pressure due to staff shortages and we are asking people to do what they can – while being safe – to help neighbours, family members and friends who may need some support. Every small effort to look out for one another could help.”

There are a number of things friends and families can do to support their loved one to come out of hospital quicker when they are ready. These include checking their home is set up for their return – or a spare room if they are moving in with family. Other key actions include arranging to pick them up from hospital and, if they are frail or needing support, checking that their fridge is stocked, their heating is on and they are checked on regularly.

Sara Storey, Director for Adult Health and Social Care in Nottingham City, said: “Thank you to everyone in Nottingham and Nottinghamshire who is looking out for a relative or friend, providing informal care and support, or being a good neighbour, and joining our health and social care staff in their efforts to help people to get home from hospital as soon as they can. All of your support is greatly appreciated – being a carer can often be very hard work – you are all an essential part of our team.”

Michelle Rhodes, Chief Nurse at Nottingham University Hospitals NHS Trust said: “Increasingly we are seeing patients in our hospitals every day who no longer need our acute specialist care and who are safe to be discharged back home or to their normal place of residence to continue their recovery. We know it is in the best interest of these patients to leave hospital as soon as possible – not least with Christmas almost upon us. We also have many patients in our Emergency Department needing our acute specialist care who need to be admitted and many patients awaiting surgery who desperately need a bed.

“Before a patient leaves hospital, their care team will talk with them and their family and carers if appropriate, about going home or going to another place for care. We will always ensure that everything is in place, including visiting them at home and signposting them to further sources of support if needed.

“We are working hard with colleagues in social care and we know families are doing everything they can to support their loved ones. Ahead of Christmas we are asking everyone to join together for a push to support people currently in hospital to get back home or their place of residence as soon as they are ready”

Michelle Rhodes added: “We know many patients have a preference for where they want to go when they leave hospital, but if a patient is offered a bed in a place that is not their first choice, we would urge them to take it whilst their care package is arranged and an alternative arrangement can be made. Our teams are doing everything they can to ensure that our hospitals are as Covid-safe as they can be, but if you no longer need to be in hospital we know that it is not the best place for you to be.”

Chief Nurse for Sherwood Forest Hospitals, Julie Hogg added: “At Sherwood, we always strive to give the same care to our patients as we would want for our own friends and family, but we know that once patients are well enough to go home that is the best place to recover with the right support in place. We are working hard with our social care partners to ensure where needed, packages of care are provided for our patients so that they can return home to a safe and well managed environment. Where possible we work closely with family members to ensure that this can happen and that their loved ones have all they need to return home.

“At this time of year especially, we are keen to see patients return home so that they can be with their family. Over the last month we have seen our average length of hospital stay increase by 1 day. This extended stay significantly increases the chance of patients experiencing delays in their care when they seek emergency care via the Emergency Department or by ambulance. We know that once well enough a hospital bed is not the best place to recover, so we are encouraging families to support us to get loved one’s home where they can.”

Brian Woodward went into Woodthorpe Hospital for a hip operation but ran into health problems afterwards and was transferred to Nottingham City Hospital. He was on very strong painkillers and had issues with his memory, as well as urinary problems which meant he couldn’t get up and about straight away. He spent a total of nine days in hospital.

When Brian was medically fit to be discharged from hospital, the social care team at the hospital worked with him to help him return home safely.

His wife Sandra said: “I couldn’t fault the support we’ve had. It was through the hospital discharge team that he’s got all this help. A senior reablement worker got all the equipment we needed to get Brian back on his feet.

“Carers came in the morning and at night for five weeks to help Brian with showering and dressing. An occupational therapist got all sorts of equipment to help around the house. Our chairs were quite low, so we got some things to raise those. We also had a perching stool, commode and a shower seat.

“Once Brian had come out, it was so amazing the difference in 4 or 5 weeks, he was up and walking about. It’s a success story during Covid. If I didn’t have the help, I couldn’t have coped.”

A heartfelt thank you

Our leaders across health and care in Nottingham, Nottinghamshire and Bassetlaw want to share this video message to say thank you.

We know the festive season will be incredibly challenging, but we hope you manage to get some rest and enjoy some time with loved ones. In whatever shape it comes, we wish you all a safe and peaceful Christmas and New Year.

Kathy’s Blog – end of year message

I am writing to you in mid-December – so given the speed at which events are progressing in the country’s response to the pandemic and in particular the Omicron variant I am hoping not to be left behind by any changes in circumstances by the time that you read this!

But one thing that is fixed is Christmas – like it or not, it is coming on 25^th December and whilst I know that not everyone might celebrate this particular festival, I think it’s relevant to everyone in our City and County as a time for family, a time for rest and reflection and a time to think about the year ahead. The health and social care system often feels like a family and this year (like last year) we have tested and strengthened those family bonds in our pandemic response and also in our preparation for next year’s legal and structural changes as we become a statutory Integrated Care System.

At the end of what has been quite a year, I want to say clearly and loudly that you all have my enormous and heartfelt thanks for all that you have done. Whether you’ve worked in an acute setting in Worksop, as part of a community team in Mansfield, been involved in homecare in Nottingham or general practice in West Bridgford – and all points and all services inbetween – thank you.

There are too many specifics to be able to mention them all but I did just want to highlight a few real high points of our year together serving the people of Nottingham and Nottinghamshire. We saw the one year anniversary of the Covid-19 vaccination programme the other week and in our area the fact that we have delivered over 1.7m vaccinations is nothing short of extraordinary. Recognition must go to the front-line colleagues who have been injecting but also to everyone else who has been involved in the operational and back-office support for what will go down as a national triumph.

During the last twelve months (to end of October) General Practice teams in our patch have carried out 4.9m appointments – 57% of them face-to-face and 51% of them the same day or the next day. That’s 4.9m conversations, vaccinations, test results, consultations, diagnoses, prescriptions and reassurance. General Practice has gone through a revolution in the last 18 months and I expect that this period of change will continue into 2022. There is some exciting thinking being done locally about the future of General Practice which I am looking forward to seeing more of – but even in a world of change, the fact will remain that long-term patient relationships of General Practice will remain the bedrock of our health and care system.

The collaborative working between health and care in terms of supporting patients to leave hospital when it’s time to do so and return to their home or other care location has also been a highlight for me this year. The care and professionalism of our social workers, discharge teams and community care teams is first rate. And all delivered in a person-centred way – thank you.

During the various waves of the pandemic this year and despite the pressures on staffing due to self-isolation and sickness, as a system we have managed to remain focussed on delivering elective care and tackling the backlog of procedures. As a system, thanks to our collective efforts to deliver the ‘Accelerator’ programme, an additional 24,768 patients were seen or diagnosed. The additional equipment and learnings from this programme means that whilst we still have waiting lists to tackle, we are in a good place to go faster in 2022.

Please do have a read of our new-look ICS newsletter which has lots more to celebrate about what we’ve achieved and are up to: https://healthandcarenotts.co.uk/news-from-notts-ics-november-2021/ .

And going faster in 2022 is the second thing that I want to talk about in this update. Due to a huge amount of hard work from a lot of colleagues from the CCG, NHS providers and Local Authorities, we are in a very good place going into 2022 to be ready for our establishment as a statutory ICS comprising of: an Integrated Care Board (ICB, the successor body to the CCG), an Integrated Care Partnership (ICP, the ‘guiding mind of the system’) and our four Place Based Partnerships (Bassetlaw, Mid Notts, South Notts and Nottingham City). We now have a proposed membership of our ICB Board, a draft constitution for the ICB, some emerging clarity on how our committees and structures will work, a good plan for how we will work with people and communities to understand their thoughts on our health and care services – and so much more.

We know from feedback from the Regional NHSE/I team that our plans and progress so far are strong and that we have the building blocks in place to launch forward successfully in 2022 and specifically to be ready for the start of our new organisation and structures in April. But there is still a fair bit to do – not least confirming how our ICP will work. As a joint committee between the ICB and the Local Authorities this is a critical part of our ICS and there are still some elements to be confirmed in terms of membership and chairing. We will also need to firm up how the four Places will operate and interact with the ICB as well as the detail of the role of our Provider Collaborative.

Finally, I do want to wish you a very merry and happy Christmas break. I know lots of people will be working hard on the vaccination programme as well as supporting our citizens with their other health and care needs but I truly hope everyone does get a chance to have a break. Look after yourselves and your families and friends, keep safe from the new variant by following the guidance and the rules and I look forward to catching up with all of you in the new year.

You can see our system-wide video of thanks and festive wishes.

Best wishes,

Kathy McLean

Retired rugby player tackles Diabetes

Alex, 56 from Nuthall, has tackled diabetes after a scrum with inactivity following his retirement from playing rugby – all with the help from a brand-new type of Coach. Starting in Spring 2021, Alex worked with Gareth, a Health and Wellbeing Coach from his local GP Surgery. Alex lost 11 pounds after one month and he pushed his Diabetes into remission by the third month.

A lover of sport, Alex used to play Rugby but he had to retire from the sport and couldn’t find an team-based activity that he enjoyed as much. Sadly, his dog passed away and so he also stopped going for walks every day. Alex started to find it difficult to motivate himself to be active and once his weight and blood sugars started to increase, he developed Type 2 Diabetes.

Alex says: “I couldn’t believe it when I found out. I was a bit angry with myself that I allowed it to happen. So all I’ve done since then is really really try hard to exercise and try and lose weight, but it’s always been a bit of a cycle. I tried to recover, but then the thing was, Covid happened. We’re all sent home, other things changed.”

Alex developed more conditions. He started going to the hospital every week for treatment which he describes as exhausting, and he was off work for 10 months with sickness.

Alex tried loads of ways to get back into an active lifestyle but things kept getting in the way. When his community Diabetic Specialist Nurse, Karen Richardson, suggested he talk with Gareth from the new Health and Wellbeing Service, Alex was ready to try something different.

Gareth Dixon works in a new type of role recruited and managed by Primary Integrated Community Services (PICS) on behalf of Nottingham West Primary Care Network.

Dr Emma Shapiro, Clinical Director for the PCN explains: “Health Coaching is a Supported Self-Management intervention which fits with the NHS Long Term Plan’s commitment to provide personalised care. Initially providing one to one coaching, the vision for the role is broader with developing a network of peer support groups, group consultations, expert patients and also train the trainers courses.”

In April 2021, Alex and Gareth started working together, they met every two or three weeks to check progress and to talk about any challenges and to identify any behaviour changes he needed to make.

Gareth explains how he met Alex and what his goals were: “I get lots of referrals from PICS Diabetes and Respiratory Services, Social Prescribers, GPs and Practice Nurses from all the surgeries in Nottingham West. I provide guidance and support so patients can take more of an active role in their own health care by setting realistic health related goals.

We provide six to eight sessions to help them work towards their goals.

“Alex needed the right support to turn things around for himself. I listened to his worries about lacking motivation to increase activity and change his diet. After talking through what was happening and what is possible, Alex identified some health-related goals, including a long-term aim to lose 3-4 stone. He decided that walking twice a day would be a good lifestyle and activity change, as well as to stop eating desserts, to reduce how much bread he ate and to eat more salads. He also said he would be healthier at the weekend.

“The conversations helped Alex realise he needed to do something and having the regular sessions really helped him. Off the back of our conversations he set some actions to start a meal planner, start walking every day and record his food on My Fitness Pal.

“Alex has done a really good job for himself and as well as achieving his short-term goals, he’s reduced the chance of further complications from Diabetes.”

Watch Alex explain how he’s changed his lifestyle and what the service has done for him. https://youtu.be/-XlnmOEDLTI

Befriending service is a lifeline for vulnerable people across South Notts

The South Notts Telephone Befriending service, managed by Rushcliffe CVS, began in response to the Coronavirus pandemic. At the time demand was high and the befriending service rapidly grew and the service was soon supporting people in Broxtowe, Gedling as well as Rushcliffe. The service has quickly grown to become a precious lifeline for many who would otherwise be lonely and isolated across south Nottinghamshire.

Covid-19 has presented so many challenges but the fantastic befriending volunteers have made a huge different to the lonely people they speak to.

But don’t just take our word for it…Mary is 74 and lives alone. She was feeling very isolated and was unable to go outside. She couldn’t read or watch TV because of deteriorating eyesight, and her hospital treatment was put on hold as a result of the pandemic. Helen, calls her once a week for a friendly chat. Helen helped Mary to join the library service and another volunteer, Lesley, now delivers a regular supply of talking books to Mary’s home.

Mary says: “The befriending service has made a real difference to me. I so enjoy the books that Lesley brings and look forward to chatting to Helen every week”

Vulnerable and isolated people are referred to Rushcliffe CVS by friends and family, GPs and social services. But if you’re not going out and feel you’d benefit from a comforting chat, call the CVS on 0115 969 9060 or fill out the contact form. Rushcliffe Community and Voluntary Service also offers help with shopping and transport to COVID, vaccinations, and essential medical appointments. The befriending service has received funding from NHS Charities Together which will allow it to expand. For more on the befriending service, please visit the Rushcliffe CVS website.

If you’re interested in volunteering to become a befriender, all you have to do is commit to an hour once a week or once a fortnight and you really could make a difference to someone like Mary. Please get in touch with using this contact form.

Community Days of Action

Community Days of Action – Local Health Input

Introduction

The Nottingham City Integrated Care Partnership (ICP) was invited to support Community Days of Actions throughout the Nottingham City Wards. These events have already been held throughout June and July, and the specific involvement of the ICP began in July. These events are scheduled throughout each month running through to March 2022.

The aim of the Days of Action include:

Reduce crime and anti-social behaviour
Increase community engagement and empowerment
Improve the perception of an area
Enable citizens to take ownership in improving neighbourhoods
To create and strengthen networks and partnerships

The days of action will involve both City Council services (such as Street Cleansing, Safer Housing, NDOs and CPOs) and a range of other partners, such as Nottinghamshire Police and Fire and Rescue Service, the voluntary and community sector, Nottingham Trent University, the University of Nottingham and Nottingham City ICP health services Different partners will be involved in the days of action, depending on the makeup of the ward.

The days of action will be an important tool for agencies to continue to strengthen partnerships and to work effectively together. They will also provide a mechanism for agencies to demonstrate their commitment to the communities they serve and will be a means for the community to engage with agencies who can support them.

The Nottingham City ICP Vision

The Council were keen to have the Clinical Commissioning Group involved with these days, linking into the health networks for the local areas. The ICP will focus on local health needs of the citizens to be promoted on the various days/events.

Population Health Management Approach

In addition to networking, providing resource on the Day of Actions will benefit the local community as it will allow PCNs the platform to showcase the local health needs of the population, and use the events to improve said health needs of the populations.

Showcase of September events

Day of Action in Bestwood – PCN 1 and 5

Councillors, partner agencies and local community and voluntary groups all joined together in September to undertake a Day of Action in Bestwood. An array of activities were undertaken including parking enforcement outside local schools, checks for untaxed vehicles, a deep clean of the Peary Close and surrounding area partners door knocked and spoke to local residents in part of Top Valley, whilst the Fire Service fitted smoke alarms. The PCN team had chance to engage with the community promoting healthy lifestyles.

Councillors regularly support the Nottingham Clean Champions who help to keep Bestwood, Bestwood Park and Top Valley clean. Local Bestwood councillors Audra, Georgia and Jay were recently also joined by MP Alex Norris on a litter pick around the Bala Drive area.

Day of Action success in Bulwell Forest and Top Valley – PCN 1

day — *The group photo prior to the big litter pick around Colston Flats, Bestwood Road*

The Bulwell Forest Day of Action, was held at Tesco, Top Valley in September, where there was space for the community providers to set up stalls on the day. The event went really well, there was a lot of footfall and public interaction with service providers.

In attendance was our Stub it! service, PCN pharmacist, social prescriber, clinical nurse, PCN physiotherapist, members of the City Locality Team, Royal British Legion, Nottinghamshire Police and Fire Services. Also, colleagues from Nottingham City homes, Housing 21, Neighbourhood Development Officers, dog wardens, employability advisors and childcare information.

Local Councillors spent the day getting involved in all the activities and meeting people of all ages.
Children from Stanstead School litter picked around the walkway on Hucknall Road
Heathfield School asked their parents about any issues which they thought needed addressing in the local community
The parking enforcement team visited Heathfield School to tackle problems with irresponsible parking at school drop off times
Heathfield school children litter picked around the Brooklyn park area, checks were made on private rented properties and much more
Bulwell Forest Bowls Club opened their doors to anyone who wanted to learn how to play bowls
Bulwell Forest Community Garden and Nottingham City Homes arranged a litter pick around the Bestwood Road area
The police, fire and Nottingham City Council officers door knocked in an area to talk to residents and fit free smoke alarms where needed

A member of the public on the day received a health check, which resulted in a referral being made to their GP for weight management.

Day of Action success in Bulwell Market – PCN 1

Some of the health team at Bulwell Market

The event held in the Bulwell market square in September was very successful.

Organisations that attended included the Stub it! service, social prescriber, PCN physiotherapist, members of the City Locality Team, Royal British Legion, Nottinghamshire Police and Fire Service. And, Neighbourhood Development Officers, dog wardens, This Girl Can, Cats Protection and employment advisors.

Quite a few members of the public received a health check from one of the PCN physiotherapists who referred them to their GPs. The public were very engaging and were happy to be able to talk to a healthcare professional.

The Stub it! service was promoted on the My Bulwell Facebook page prior to the event, and this ensured the team spoke to many members of the public and handed out a lot of information about the service.

The fire service gave helpful advice and support to a concerned resident. And the employment advisors took referrals from the public looking for work. Any other local issues were raised with the Council – and these will get followed up after the event

Future Events

The plans highlight what can be achieved by partaking in these events. The ICP should continue supporting these events, with PCNs working with their PCN Development Managers to work on events suitable to each of the local populations. The ICP has provided dedicated resource for these events to support in the planning of them, and the Council have dedicated resource for promotion and engagement with the communities.

Whilst stalls have been the most utilised option for events so far, there are so many activities and events undertaken on these days which PCNs could utilise. Most events have door knocking activities which the PCNs could engage with, and discuss health priorities on the door. The networking capabilities of these events allows for PCNs to have two meetings with councillors, housing providers, neighbourhood development managers, fire services, and police colleagues amongst others where they can collaborate on what matters most for their local population.

Dates for the 21/22 Days of Action

Ward	Date
Bestwood	8 September 21
Bulwell	22 September 21
Bulwell Forest	15 September 21
Bilborough	10 November 21
Leen Valley	17 November 21
Radford	14 October 21
Hyson Green & Arboretum	12 October 21
Castle	12 October 21
Lenton and Wollaton East	13 October 21
Wollaton West	24 November 21
Meadows	23 March 22
Clifton East	16 March 22
Clifton West	9 March 22

Ward/PCN Overlap

Each ward has an allocated day and each PCN on average covers approximately 3 wards. Below we have mapped out each ward and which PCN sits within them. From this we have invited each PCN development manager to support these days linking into the local health priorities, and develop a unique health offer at every event.

Ward	PCNs Covered
Bestwood	PCN 1 + 5
Bulwell	PCN 1
Bulwell Forest	PCN 1
Basford	PCN 3 + 5
Berridge	PCN 4 + 5
Sherwood	PCN 5
Aspley	PCN 3
Bilborough	PCN 3 + 7
Leen Valley	PCN 3, 4, + 7
Radford	PCN 7 + 4
Hyson Green & Arboretum	PCN 4
Castle	PCN U, 4, 6 + 8
Lenton and Wollaton East	PCN U + 7
Wollaton West	PCN 7
Dales	PCN 6
St Anns	PCN 6
Mapperley	PCN 6
Meadows	PCN 8+6
Clifton East	PCN 8 + U
Clifton West	PCN 8 + U

Wanted – Expressions of Interest

Do you have the passion and time to represent the Mental Health Collaborative members at the Nottingham City Integrated Care Partnership (ICP) Mental Health Group?

ICP partners in this group will design and deliver services to improve mental health and wellbeing outcomes of Nottingham citizens of all ages in line with the Integrated Care System (ICS) Mental Health Strategy.

The role of the group includes: Create a culture of shared responsibility around mental health

Foster closer working between ICP partners (including Primary Care Networks)
Identify opportunities for integration and support implementation of integrated care models
Develop and deliver the Nottingham City Mental Health Prevention Concordat
Identify opportunities and build business cases for delegated programme budgets from the ICS and Local Authority.

What the group needs from you

To gather the views of the collaborative members and represent their views at the ICP Mental Health Group
Have confidence to offer your ideas, suggestions, and comments in a group with multiple partner representatives
Respect group members but challenge decisions where you feel necessary
Keep sensitive information confidential
Read the meeting papers in advance
Provide feedback to the Collaborative

What to expect from the group

Support to participate in the meeting and have regular catch ups with the Chair
An opportunity to ask questions and participate in discussion and decisions
An opportunity to innovate and improve current and future service offers
Up-to-date information on service transformation and mental health prevention projects

When and Where?

The meetings run for 90 minutes at 11am on the Third Wednesday of every month and are held online on Microsoft Teams.

To discuss the role please contact Ciara Stuart, Chair on ciara.stuart@nhs.net

To register your interest in taking up this role please e-mail Daniel.Biggin@nhs.net with your name and a short description of your role and/or interest in supporting Mental Health in Nottingham City.

A Thank you, from Cllr Georgia Power NCC Health and Adult Social Care Committee Chair

Dear all,

I wanted to write on behalf of the Nottingham City Council Health and Adult Social Care Committee to thank you for your work caring for Nottingham residents throughout covid and presently.

As a Committee we are aware that there have been a number of reports in the media talking about patients’ experience of access to their GP. Whilst we know that there are issues – and these are not isolated to Nottingham – we are clear that this is not an issue caused by GPs and that putting the blame on GPs and practice staff is not helpful and does nothing to tackle the root cause of depleted resources, a decade of austerity and increased need.

At yesterday’s Committee meeting we heard from the CCG who set out some of the excellent work you’ve been doing on the frontline serving our residents. We are extremely grateful for this and are keen to work with you to tackle some of the real issues you and your patients are facing.

Please be assured that we are first and foremost grateful for you work, and that we will be firm in ensuring good scrutiny of the all services and areas needed to provide support to Primary Care, and above all to support Nottingham City residents.

I understand through the many conversations I have with GPs in my capacity as Committee Chair morale is low and the onslaught of media reports placing the blame on you is unhelpful. I do not ascribe the so called “GP crisis” to GPs or GP practices and your staff, and we as a Committee have, and will continue to state this publicly whenever asked.

If you would like to discuss any issues facing your practice or Primary Care in general with me, any of the Committee or your ward councillors please do let me know and I am more than happy to try and facilitate these conversations.

Thank you once again for your commitment to Nottingham and to our residents.

Best wishes,

Councillor Georgia Power

Chair of the Health and Adult Social Care Scrutiny Committee, Nottingham City Council