New outdoor course commissioned to improve “mental toughness” of HIU clients

Natasha, Vicky and Ami were all referred to the HIU project due to their high hospital admissions and 999 call outs. Each one of them had their own mental health issues that they were trying to work through. They always discussed how they felt they had low confidence and low self esteem and this impacted negatively on their mental health on a daily basis.

They were all approached and asked if they would like to attend our new Challenge Academy social prescribing 5 week course. The course was designed to work on developing mental health awareness, building resilience, improving mental well-being, building confidence, developing self-esteem and positive self-image. Challenge Academy CIC have an excellent understanding of social determinants of mental health and through the course focus on goal-setting and personal achievement, changing unhealthy thinking and developing a positive mind-set.

They all said they would give it a try but were very apprehensive. On their first day they met with their course instructors Chris and Gregg who would deliver the course over the 5 weeks, they got to learn all about each other and what the course would entail over the coming weeks. As the weeks went by and they continued with the course activities they were able to learn and develop through participating in outdoor art sessions, orinteering, team building activities and much more.

Over the course of the weeks it was very easy to see the positive change in all of the participants. Their confidence increased, they felt better in themselves and were wanting to push themelves out of their individual comfort zones. They could easily identify the marked inprovement in their own mental wellbeing and were noticing changes.

Vicky (HIU client) said “it’s great fun and confidence boosting, it makes me feel good I don’t even realise im doing exercise! The staff are really friendly”

Natasha (HIU client) said “staff are really encouraging and push you out of your comfort zone. The team building exercises are fun and really help to build your trust and confidence.”

The three clients have formed a close knit friendship through attending the sessions and would always give each other encouragement in all their tasks and pick each other up when they were struggling. This friendship has continued outside of the course and on weekends they now meet up and go shopping, for a coffee or visit one another.

Speaking with the clients it is clear to see the improvements, not only through their admissions and ambulance call outs drastically reducing but also through their own personal wellbeing. They all advised that they didn’t find it easy but felt with each others support and the support from the course they could do anything that was asked of them, this even included completing activites in record time by working together as a team and solving the problems they were given.

Each individual is now looking forward to taking the skills they have learnt from this course and using them in their future.

Ami (HIU client) said “There is a great atmosphere, friendly staff who really challenge you but make you realise what you’re capable of when you put your mind to it.”

Danielle Giles – HIU Link Worker

Barbara helped to stay in her own home

Barbara was referred to Integrated Plus by her GP at Lion Health.  She had some household issues she wanted to resolve and suffering with depression.  When Barbara met Georgia, the Locality Link Officer for Stourbridge, Wollescote and Lye, she went into more detail as to how she was feeling.  Barbara said she was upset and depressed because there was some uncertainty about her having to move from her property due to access and safety issues.  One of the main issues was Barbara did not have a cooker and her social worker identified that her current set up in her kitchen was a safety risk.  Georgia discussed this with Barbara and her social worker and said we could support her with applying for a Grant for a cooker which would make her property safer and more accessible.  Barbara also said she would like support with her garden which had become overgrown and unmanageable.   

Barbara has osteoporosis, brittle bones, dry macular degeneration and glaucoma.  She is also a wheelchair user and has volunteered at Beacon Centre for many years.  Barbara is a real inspiration to everybody she meets and is always willing to help others, she travels to the Beacon Centre every day on her mobility scooter come rain or shine.  She volunteers with craft groups and is always there to welcome members and volunteers.  Georgia tasked Gary, the Link Support Worker to make contact with Barbara to look at possible grants for a cooker.  Gary discussed this with Barbara and it became apparent that she would need a cable fitted as well as an electric cooker.  He applied for a grant from The Reginald Unwin Charity and this was successful but only for the amount of a cooker and not for the cable and fitting.  Barbara could not afford to pay for the rest so Gary then applied to Badley Memorial Trust who work closely with Geoff Hill in Amblecote and they agreed to fund the electric cable and fitting.

Gary met Barbara a couple of weeks later to do a review and said she was delighted with her new cooker, she said: “The cooker has made a big difference to my life, I haven’t had a cooker for nine years, I use it regularly to cook healthy food.” 

This has also enabled her to stay at her property alleviating the stress of a potential move from the home she loves.  Barbara also mentioned to Gary when they first met that she would like support with her garden which had become overgrown and difficult to manage.  Unfortunately, this was difficult to accomplish due to the lockdown, however Barbara was able to get support with this from her circle of friends and other volunteers at Beacon Centre and they have supported her to regularly tend to and maintain her garden.  The Beacon Centre opens again soon and Barbara is eagerly awaiting to be reunited with her friends and fellow volunteers.  

Barbara with her new cooker

Emma helped out of poverty in order to focus on improving mental health

Emma was referred to the Integrated Plus service by her mental health nurse who had indicated that Emma had a long-standing history of poor mental health. An appointment was arranged for the Link Officer to meet with Emma and her husband Patrick, at their home.

During the assessment Emma shared that she had suffered many traumas and losses during both childhood and adulthood. Emma has since received a diagnosis of emotionally unstable personality disorder, anxiety and low mood and was awaiting further support.

It was also identified that Emma and Patrick were really struggling financially. Emma was unable to work due to her mental health and very rarely left the house. She did not feel able to mix with other people. Patrick was her full-time carer and only source of support.

Emma revealed that their bed was broken and they dragged an old mattress into the lounge to sleep on at night. They could not afford to put the heating on, the piece of carpet they had in the living area was frayed and worn and there was no carpet in the bedroom. The fridge/freezer was broken and only worked intermittently leaving food spoiled and inedible. Emma needed support to apply for Personal Independence Payment to help support her daily living costs.

The Link Officer and Link Support Worker acted quickly and arranged for a new bed and mattress to be delivered by Loaves and Fishes with help from Leslie’s Care Packages who covered the cost of delivery. They were successful in securing grants for new carpets and a fridge freezer from The Badley Memorial Trust and Reginald Unwin Dudley Charity. Vouchers were provided for clothing and bedding from Helping Hands and for food from Black Country Foodbank. Emma was helped to complete her application for Personal Independence Payment. Ongoing support was provided to Emma via telephone.

Emma’s application for the Personal Independence Payment was successful and she was awarded high rate daily living and mobility. This has relieved Emma of so much worry and has alleviated the pressures of living in a poverty stricken environment. Emma spends the majority of her time in her home and being able to make their living environment more comfortable, and have a few nice things, has helped Emma with her mental health. Emma is now able to focus on getting the treatment she needs to improve her mental health.

Emma said: “My mental health nurse referred me to Integrated Plus. The Integrated Plus Link Officer, Jason, got in touch really quickly to offer us the support which we desperately needed. So many things were sorted out straight away eg carpets, fridge freezer, bed and food parcels also vouchers for clothes bedding etc. The support shown has been excellent very much appreciated, also throughout the coronavirus. We cannot praise enough for these workers. Without them I think our lives would still be a struggle it has been eased greatly thank you Jill & Jason x It’s nice to have someone – not just for items but for advice and to talk to. Thank you”

Emma’s living room now

Dee supported through bereavement and reconnects with old friends

Dee was referred to Integrated Plus, due to experiencing feelings of loneliness and isolation. She had also experienced the recent bereavements of her son and husband, who both passed away within 6 weeks of each other. Soon after these bereavements, the UK went into a national lockdown, further exacerbating Dee’s feelings of isolation.

When the Link Officer first made contact with Dee, it was the first opportunity Dee had to freely express how she was feeling and how difficult things had been for her. Dee stated that she had received one counselling session arranged through the GP, but these had stopped suddenly when the national lock down took place, and Dee had not spoken to anyone else since about what had happened in her life and how it was impacting her.

The Link Officer identified that some bereavement counselling could possibly support Dee to explore her emotions and hopefully, in turn, find some peace. Dee was referred to Arts of Change, who provide therapeutic counselling to support individuals to deal with a wide range of issues and life experiences. Dee was initially reluctant to engage with Arts of Change due to being let down by other services in the past, but after some encouragement from the Link Officer, Dee agreed she would give it a go. Due to Dee’s vulnerabilities at this time, the Link Officer agreed to bi-weekly calls for a short period of time to support Dee to feel less isolated, until she found her feet with the counselling.

The Link Officer then asked a Link Support Worker to call Dee to check how she was getting on. At this point, Dee had been engaging with sessions from Arts of Change. Dee reported that she felt uplifted after one of these sessions, so decided to go on the bus and into Dudley Town Centre, where she happened to meet some old friends on the journey. This small, but significant, outing seemed to breathe a breath of fresh air into Dee.

During another call to Dee, she reported that she had been struggling with the nights and feeling lonely. The Link Support Worker reassured Dee and provided her with the number for Silver Line, who she could contact any time of the day or night if she was feeling low and wanted to talk.

Dee mentioned in a later call that she had started going to Dudley Town Centre twice weekly and had been going shopping with her cousin on a weekly basis. Dee also reported that she had connected with a neighbour, with whom she was meeting for walks and general catch ups.   

At this point, the Link Officer discussed ongoing support with Dee, and Dee said that she felt things were going a lot better than they had and she was moving forward.

Dee said “I was so grateful when Integrated Plus started calling me. I looked forward to their regular calls each week, as I was in such a dark place. I am more than thankful for the support they have given to me”

Integrated Plus share excellent outcomes from year 6 of social prescribing delivery in Dudley

The Integrated Plus social prescribing service is now into its 7th year with an experienced team continuing to provide 1-2-1 social prescribing support to vulnerable patients in the Dudley Borough aged 16 and over. The team continue to provide a valuable link to the voluntary and community sector and champion the non-clinical and social needs of patients within their GP lead multidisciplinary team meetings.

Dudley CVS are delighted to have witnessed the momentum that social prescribing is gaining. We’re proud to have been part of helping to gather valuable evidence to demonstrate the effectiveness of social prescribing interventions and to have contributed towards the roll out of social prescribing roles nationally.

Our annual evaluation report for year 6 shows that support provided by the service is continuing to result in significant reductions in A&E attendances and inpatient admissions, generating strong cost avoidance figures:

  • 731 patients accepted the service
  • Inpatient admissions reduced by 45% after 12 months – cost avoidance of £450,500
  • Attendances at A&E reduced by 32% after 12 months – cost avoidance of £22,885
  • Total cost avoidance of £473,385 resulting in a net saving to the borough of £28.30 per patient

More importantly, the support continues to result in positive social outcomes for patients. After receiving support the following reductions were made in the number of patients “not managing:”

  • Finance, 87% less patients
  • Physical Health, 91% less patients
  • Mental Health, 83% less patients
  • Social Contact, 88% less patients
  • Housing, 80% less patients
  • Safety, 83% less patients
  • Learning, 88% less patients

For more information about the service, including patient stories and reflections from members of the team, you can read the full report here:

Dudley High Intensity User Social Prescribing Service continues to achieve excellent results

Vulnerable patients are continuing to benefit from the High Intensity User (HIU) project in Dudley, which is now entering its third year.

Year one saw a 33% reduction in A&E attendance and a 41% reduction in inpatient admissions saving the NHS over £492,995. Our second annual evaluation report for year two has seen a 75% reduction in A&E attendances and a 78% reduction in inpatient admissions saving the NHS over £546,540. New data has shown a 66% reduction in West Midlands Ambulance Service call outs with an additional saving of £230,193.

Delivered by the Dudley CVS Integrated Plus social prescribing team and match-funded by Dudley CCG and the Department of Health, the service offers a robust way of reducing avoidable frequent user activity to 999, A&E, and hospital admissions, freeing up front line resources to improve care for all patients and reduce costs.

The two Link Workers have continued to work in a flexible non-clinical way providing tailored support to frequent users of emergency services. The service has benefitted from being able to spot purchase groups, activities and services from our Voluntary Sector Fluid Floating Fund. So far we have been able to commission five different organisations to deliver creative activities, counselling, peer support groups, outdoor learning and housing and benefits support.

In addition to this we have been able to allocate personal health budgets up to the value of £100 per client. This has been a really positive intervention enabling Link Workers to work in a person centred way. Personal health budgets have been used to pay for transport to peer support groups which was previously a barrier and also items such as tablet computers to enable isolated clients to connect with the outside world.

A local service user said, “I needed more than a worker, I needed a friend, someone who could help me get in touch with the outside world, I felt so lonely and isolated. When I first met Kelly I had been in hospital several times, I was suicidal, and had given up, whereas now I enjoy life and am reconnected with friends.”

Another said,“This service has been extremely helpful, from the first visit from Danielle I was put at ease, she listened to me and I truly felt my issues were understood, which in turn enabled her to help me identify new avenues to explore. I am looking forward to starting my new volunteering role and giving something back”

Dudley CVS are delighted with the positive outcomes that the project is achieving. You can read the full evaluation report below:

High Intensity User Social Prescribing Service helps reduce demand on emergency services in Dudley

Vulnerable patients are benefitting from a new High Intensity User (HIU) project in Dudley.

A one year evaluation of the project commissioned by Dudley CCG and Dudley CVS has shown a 33% reduction in A&E attendance and a 41% reduction in inpatient admissions saving the NHS over £492,995.

Delivered by the Dudley CVS Integrated Plus social prescribing team and match-funded by Dudley CCG and the Department of Health, the service offers a robust way of reducing avoidable frequent user activity to 999, A&E, and hospital admissions, freeing up front line resources to improve care for all patients and reduce costs.

Working together with partners, the HIU team uses a flexible and innovative non-clinical approach with the voluntary sector, to target high users of services and support the most vulnerable people within the community to flourish and find purpose in their lives.

This is in line with the Right Care Programme, which is part of the NHS Long Term Plan’s focus to better understand the needs of patients who are frequent users of emergency departments. Both will work to improve waiting times and response in emergency departments for those patients with the highest care needs is a priority.

Kelly Rea, (Urgent Care Link Worker), HIU Team said: “It all starts with a phone call, from which I am able to actively listen to understand the needs of patients accessing A&E departments. I like to arrange a face-to-face appointment as soon as possible to gain a better understanding of their situation. On the first visit, I try my best to make it very relaxed to allow them to tell their story.

It’s surprising how many people say after the visit it’s the first time they have been really listened to.

A local service user said, “This service, in my opinion, is vital to help other people from utter despair, I cannot explain in words what this service has done for me.

After another attempt to end it all, I was given a lifeline, introduced to my link worker from Integrated Plus, always at the end of the phone, caring and understanding, non-judgmental who listens to my every need in my recovery. My link worker takes me out for coffee and shopping and has enabled me to laugh again and understand a future without pain. I look forward to her visits helping me to feel normal again”.

Sarah Knight, Commissioning Manager, Dudley CCG, “We are really happy that the service is benefiting people in Dudley, we are always looking at new and innovative ways to meet the needs of our local population, and this is one way we are doing this”.

The programme initiated by NHS Blackpool CCG has also been rolled out in a number of other CCGs across the country.

The full impact report is available to read below:

Integrated Plus delivers a successful peer learning programme for staff delivering social prescribing schemes around the East and West Midlands

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During January – April 2019, Dudley CVS’s Integrated Plus service delivered a social prescribing peer learning programme for link workers around the country. The programme enabled existing link workers from across the East and West Midlands to connect with each other, share learning, successes, challenges and access training in areas such as motivational interviewing, mentoring and solution focused therapy.

25 staff from 9 organisations delivering social prescribing projects around the country attended the 10 day programme delivered over 3 months.

Participants shared that they had learnt:

  • More about what social prescribing is
  • Each other’s social prescribing models
  • Different approaches to supporting people
  • New techniques and coping strategies when working with vulnerable people

“Brilliant, invaluable, interesting and overall a fantastic and worthwhile training package” (participant who attended the programme)

“Spending time offering each other peer support has been incredibly invaluable” (participant who attended the programme)

For more information about the Integrated Plus service, please contact Kate Green on 01384 573381.

For National information and updates on social prescribing visit: