Earlier this year, South Notts ICP News visited the Nottingham West and Rushcliffe Social Prescribing Teams to see how they were developing. This December, we revisit the Nottingham West team to see how things have progressed, especially during what has been a difficult year.
One year into the Social Prescribing team contract at PICS and the Nottingham West team has grown from the original two link workers to five, covering the three neighbourhoods, Stapleford, Beeston and Eastwood.
Louise Redhead, Social Prescribing Manager at PICS (Primary Integrated Community Services), offers an insight into how the team have explored solutions around non-medical issues that impact on the health and wellbeing of members of our communities.
“As well as mapping out and delivering additional covid-support for hundreds of the most vulnerable residents in Nottingham West, the team have maintained their case load work, while also supporting the development and set up of new community initiatives. Read on to find out more about their work with a friendship group in Beeston, a project to address the barriers to South Asian women accessing health care, the Broxtowe Health Partnership and the Eastwood Community Project. Louise also shares her excitement for their plans for 2021, including the set-up of a new local telephone befriending service, a community garden and a local community hub, and the roll out support from the PCN’s new Health and Wellbeing Coach.
“The teams have worked very hard in what has been a challenging year for everyone. They have established their roles, established themselves as part of the PCN workforce, made vital links with the community and voluntary sector and helped to get the message out there as to what social prescribing actually is and its benefits. They have also met the challenges of working through a pandemic, the first in our lifetimes, and the difficulties and uncertainty that brings, not only for the team, but their patients and communities too.
“Link Workers left the surgeries in March and adapted their way of working under Covid, as their roles became more important than ever. Working from home office, the sofa or dining room tables, they worked in partnership with the CCG and Nottinghamshire County Council Covid Hub to identify the most clinically vulnerable patients and they set about making contact with them. These included patients with dementia, those who were frail or housebound and those with learning difficulties. The Link Workers got to work identifying if they had any support networks, whether they were shielding and if they needed urgent food parcels and deliveries. Were they able to get their medication? Did they need support around loneliness and isolation? Were there any other identifiable needs for support? The team did a phenomenal job – between them they made contact with 351 patients between March and September on top of their caseload work.
“During this period, Link Workers communicated with GP practices and community and voluntary groups, and worked with local mutual aid groups. They mapped the local services prior to the Nottingham County Council Hub being available and ensured that all who needed this information had it to hand. They collated information for groups that provide mental health support and worked with local surgeries and pharmacies around medication delivery. This was all done while maintaining an active caseload and ensuring that the patients they were working with received any direct support that they needed, and they were busy delivering food parcels, connecting with befrienders, referring on for care and support needs, and communicating with families and carers to ensure everyone was supported.
“As shielding has eased, the Link Workers have been able to get back to something that reassembles their ‘normal’ role, and can start to look at the future – being able to focus more on community development and addressing health in equalities within the communities. This has included delivering walking groups, being successful in applying for funding to start a Friendship Group in Beeston, and working alongside GP’s to address the barriers to South Asian women accessing health care.
“The team have also created a quarterly newsletter to share positive stories and information with their surgeries. We’ve presented a re-launch campaign to forge new links with GPs who may not have been aware of the service and to share feedback on the types of referrals the team have supported so far. We have also been involved with Broxtowe Borough Council on a number of projects including the Broxtowe Health Partnership, looking at mental health gaps as well as facilitating conversations in the recent PCN ‘Community Voices’ event.
It has been a pleasure to be involved in the creation and development of the ‘Eastwood Community Project’. There have been exciting conversations involving community groups and statutory bodies around a number of areas that will benefit the whole of Eastwood and out into the NG16 area. These have included a new local telephone befriending service, a community garden and hopefully a Local Community Hub in the New Year. It is really exciting to see just how much Social Prescribing can do to support patients and connect them with their communities – because connection is the key to improving wellbeing.
“We are pleased to welcome on board our new ‘Health and Wellbeing Coach’ who will soon be working with patients from all over the PCN, looking at the many ways that they can improve their health and wellbeing, especially after a year like the one we have all just had.
Here’s looking to a brighter 2021!”
Case studies
Mrs H, Stapleford
A GP referred Mrs H, 77, who lived alone and had been recently diagnosed with breast cancer. She was struggling to come to terms with her diagnosis and had overwhelming bouts of anxiety. The link worker spent time talking with Mrs H to understand her preferred coping mechanisms, and could then suggest some relaxation techniques. At their next appointment, Mrs H described feeling overwhelmed by all her appointments, by all the phone calls she was getting about her health, and all the information from different professionals. Her pharmacy had also changed so it was also more difficult to collect her prescription. The link worker arranged for her prescriptions to be delivered, and on their next call, Mrs H spoke of the difference not having to worry about her medication had made to her at that point in time.
Mr T, Beeston
A GP referred Mr T, who lived alone and had recently lost his sight. His flat had been damaged, so he was living in a hotel while it was being fixed, but had to move back early when the Covid-19 crisis began. Most of his possessions had been damaged and he only had a microwave to cook with. He usually had help to do his shopping, but hadn’t been able to talk with his local shop to access their assisted shopping service since the pandemic started. He also couldn’t get hold of any shop to ask for deliveries and his food supplies were running very low.
The link worker spent some time on the phone with the patient, speaking about his difficulties and what support he would benefit from. Mr T agreed for his details to be shared, so the link worker approached a local community group who brought round a food parcel that same day, arranged for a hot meal to be delivered to him four times a week for free and they also found a volunteer to do his food shopping for him. His social worker was also brought up to date and agreed to continue their support for him.
Mr W, Eastwood
Mr. W was referred for low mood and isolation; he was having issues in his marriage, he had hardly left his house in years, had reduced mobility and put on weight. He felt unable to get back into any exercise.
The link worker worked with the patient to identify what mattered to him in his life. She arranged activities and trips for him to try that were based on his interests and took into account his anxieties. They set goals together and over the next couple of months, the patient managed to go around town with his wife shopping and worked with his pain team to reduce his pain medication. He attended a slimming club with his daughter and started to take regular exercise, with walks in nature and swimming.
Mr W said: “Thank you so much for your support and confidence. I couldn’t have done it without that”.