East Staffordshire social prescribing

The neighbourhood

The model is based around football club charity Burton Albion Community Trust in partnership with East Staffordshire PCN. The PCN has a population of 150,000 people across 18 practices.

The proxy used for a neighbourhood in this example is the GP surgery size which varies within the geography from approximately 2,000 to 18,000 people.

Local assets that support the model include a technology platform for social prescribing called 'Joy', a local football club providing outreach and multiple local groups and activities that individuals can be referred to for non-medical support.

East Staffordshire covers an area that is both rural and urban. 26 per cent of the population live in rural areas, which is a higher proportion than the national average.

The health of people in East Staffordshire is varied compared with the England average. About 13.6 per cent (3,055) of children live in low-income families. Life expectancy for men is lower than the England average.

Over 23 languages are spoken across the geography. There is a transient population and high levels of deprivation in some areas, particularly central Burton.

Two-thirds of the population are overweight or obese, which is higher than the national comparator.

The context

Reducing the local footfall in GP practices and reducing levels of inequality is the focus of the model, to ensure primary care can provide the service that residents needed.

The collaboration is aiming to achieve health creation that responds to neighbourhood needs and harnesses the power of a community to generate health.

A founding principle is to build services for neighbourhoods rather than building services for GP practices, responding to the demands and needs of the community and harnessing communities themselves to address health and wellbeing issues.

The model

The model is a partnership between a Football Club Charity (Burton Albion Community Trust), East Staffordshire PCN, the 'Joy' app and various local organisations that provide activities for residents. The Football Club Charity helps the service to be perceived as a part of the community, rather than a part of healthcare infrastructure, that may present barriers for some potential users.

The model is a social prescribing model that is based in the community rather than in GP practices. GPs can refer to the service but do not need to be involved in the referral process.

The service employs six social prescribers and two form fillers who help residents to navigate statutory systems for accessing funding and support for their health and wellbeing. The model is funded through East Staffordshire PCN and the governance involves a partnership with East Staffordshire PCN and Burton Albion Community Trust that reports to the local ICB on impact and progress.

The social prescribing experience is based upon 'what is the most important thing for them' and aims to connect residents to their neighbourhood to achieve these goals and support other members of their neighbourhood at the same time through the formation of neighbourhood level groups to address shared challenges.

The model is responsive to local needs. If a similar issue is identified across a neighbourhood population, the model will support the creation of a self-help group for neighbourhood members. This supports the clients of the service becoming part of the solution to the problems that they identify.

Social prescribers pre-screen people before they signpost to other services, which helps to get the right fit.

The model is also data driven; it responds to demands in the neighbourhood by collecting this information through an online platform called Joy. This information can be used on a neighbourhood level by GPs to identify trends and at an individual level to send notifications on potential support that might be relevant to an individual's specific needs.

What makes this effective and resilient

Listening to the needs of a community and responding with services that address specific needs. This is exemplified by the employment of the two form fillers to help residents navigate statutory services and access the help, support and funding they need to improve their health and wellbeing.

Relationship with Burton Albion, and their willingness and enthusiasm to create change, has been vital to the model and provides a reach that GP surgeries could not achieve alone.

A data-driven community approach to social prescribing allows the model to establish the real time priority determinants of health in a neighbourhood. This enables the agile development of targeted programmes of support based on actual and not estimated locality need.

The local council is showing an increasing interest in the model and have provided funding through a Local Development Fund for the employment of an additional social prescriber. Increasing partnership may provide a route to further resilience and sustainability as well as build the size and scope of the partnership.

The social prescribing platform Joy allows for tracking of social prescribing, and it integrates with SystemOne, meaning GPs can monitor the pre- and post- intervention usage of primary care services.

Building on Joy, the model is now starting to respond flexibly to needs at a neighbourhood level, such as the formation of a dementia group, a breast screening group, fibromyalgia and opioid use groups.

Joy allows for two-way communication so GPs can send alerts to individuals they believe would benefit from specific services and support.

The data and insights offered through the Joy system support both effectiveness and resilience, through providing a conduit of information directly to GP practices but also through the suite of information it provides to support impact and justify the model.

What makes this challenging

Lack of service provision to meet community needs is an ongoing issue. Particularly local mental health services where the demands from the neighbourhood exceed the supply of available support.

The service is currently provided to 1.4 per cednt of the PCN population but has the potential to provide benefits far beyond this if greater adoption can be achieved.

The service has been funded on a pilot basis for 12 months at a time, which creates some uncertainty on the future of the model, but the impact that is able to be demonstrated makes a strong case for continuation.

Impact and outcomes

• Deployment of Joy has been key to supporting the tracking and quantification of impact at an individual and neighbourhood level. The information provided by Joy is becoming a key asset in responding to community needs and demonstrating impact.
• 40+ organisations are referring into the service, including statutory and non-statutory organisations, reaching far beyond what GP practices could achieve alone.
• East Staffordshire PCN has observed a 37 per cent uplift in clinical wellbeing for those using the service.
• Users of the service report a 98 per cent satisfaction score.
• £500,000 of benefits have been accessed by residents via form filler support in a four-month time window.
• East Staffordshire PCN has observed a 26 per cent reduction in clinical interventions for those supported through the service, equating to tens of thousands of avoided clinical interventions in the PCN every year.
• 73 per cent of the service clients live in postcodes identified by the GP practices as having high support needs and a greater burden of ill health.

“We have seen massive changes in people’s lives through the power of social prescribing, working with our community and Burton Albion Community Trust. Joy has given us proof of the return on investment to now take this to next level.”
Steve Rimmer, Health and Wellbeing Manager, Burton Albion Community Trust