Dudley multispecialty community provider vanguard aims to improve health and wellbeing for local people through more closely linked health and care services, based around GP practices, which allow easier access to care that is consistent and better co-ordinated. In October 2014 they created Integrated Plus, a service based on a social prescribing model that supports people who frequently visit their GP and who are at high risk of hospital admission. Kate Green manages the service and discusses the important role that Link Officers play in the supporting patients.
The aim of the Integrated Plus service is to look at the whole needs of a person, regardless of what those needs might be and jointly find solutions to problems faced and identify opportunities for people to become more involved and active in their community. We help to ensure people are accessing services and activities appropriate to their needs.
The Locality Link Officer roles were new and were created specifically to complement Dudley’s vanguard. Locality Link Officers attend the 46 multi-disciplinary team meetings in their locality (held at GP practices) to ensure the non-medical needs of people are being met. What we have found from supporting patients referred to the service is that often people frequently visit their GP because they face a wider range of issues than just a medical condition. Over 70% of the people we have supported over the age of 35 reported feelings of loneliness and isolation, 60% reported feeling depressed, stressed and having severe anxiety, 50% have a long term condition. Many of the presenting issues were being exacerbated by family relationship breakdowns, housing issues, poverty and debt.
What was important to us when we established the service was to not provide a purely signposting service but to offer people a holistic approach and support them to share with us their issues, challenges, opportunities and support needs. What we found was that people needed support in a much wider variety of areas than expected. These have included:
- Helping people to navigate the health and social care system
- Ensuring people are getting the right care and support they need and are entitled to
- Ensuring people have adequate heating and food
- Resolving household issues
- Support people with family issues
- Reconnecting people with family and friends
- Connecting people with each other to offer peer support
Focusing on building individual resilience and identifying how people could use their own skills, experience and knowledge to help themselves better and other people facing similar issues or conditions was also important to us. Once given the opportunity, we found that people are willing to reach out to others, share their experiences and reconnect. To date, we have supported over 100 people into peer to peer led activities and helped 22 people into volunteering.
Why the Locality Link Officer approach seems to be working?
People we have supported have told us that they like our approach because it is independent from any sector, its flexible, we have a ‘can do’ attitude as we are not tied by organisational boundaries and cultures. We do whatever we can to help whatever the support needs are, we spend time with people, actively listening to their needs and aspirations.
Data captured on the people we have supported, has shown that GP visits have reduced by 29% and GP home visits by 30%, a cost saving of £13,604. Through data collected on our IT system, PSIAMS, has also shown a cost saving to the wider health and social care economy of £575,000 based on 98 people supported.
Integrated Plus would not be as successful as it has been without the vital services and activities provided by the voluntary and community sector. Over 70% of our referrals have been to voluntary sector organisations (including social enterprises and faith based organisations). The sector has also helped us to utilise community physical assets to develop new social activities and peer to peer led support based on new needs. National Government expectations for the voluntary sector to play an active and bigger role in delivering preventative services, helping to divert demand from frontline medical services is only leading to increased demand on the voluntary sector. New ways of financing voluntary sector services in times of austerity needs to be thought through.
A personal reflection from a Locality Link Officer
I see the role of a Link Officer as a strange privilege, and one that I’m only beginning to properly understand. Sitting in the living room of an individual’s house you are invited into their world. Avoiding the temptation to hastily fix problems as they are disclosed and giving time for the person to talk you can begin to understand. The picture is painted before you and you realise that the passing of a child in 1987 led to the depression which caused the marriage breakdown which brought about the ’isolation’ on the ticked box of the referral form. Of course it’s not always as melancholy as that but what you begin to learn when you genuinely give someone your time is that there are many layers and complexities behind every door you pass through. The stories range from absurd to hilarious, sad to devastating, but they are rarely dull. There are common themes that can be learned and all reflect the human condition. Sometimes there is little we can do but listen, and try to show that we genuinely care. Other times we have an abundance of potential solutions and it is wonderful to see a glimmer of hope on a face that seemingly had given up expressing feelings of happiness.
To sit with someone, to be empathetic, to see how lives are so different and yet so similar is, I think, a privilege. A privilege with an opportunity and that opportunity depends on how quickly we can forge a relationship and build trust. Not to push outcomes or to shoehorn people into services but to listen and attempt to understand. The thing I most like about this job is the thing I find most difficult; the people themselves. It’s challenging because, as so many of the people I work with put it; ‘that’s life isn’t it?’ But it’s also hopeful, as we witness resilience and the desire to improve the cards these people have been dealt.
(Jason Griffiths, Locality Link Officer, Sedgely, Coseley and Gornal)