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The notes form part of these financial statements
This report was approved by the board of directors on
and signed on behalf of the board by:
Name:
Status: Director
The notes form part of these financial statements
for the Period Ended 25 January 2023
Basis of measurement and preparation
for the Period Ended 25 January 2023
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Section 3 Community development and outreachA key element of the work is to develop partnerships with agencies seeking to work in the Thornton Heath area. This also involves working closely with Social P Community Co-ordinators to identify gaps in need and services to meet the especially local based provision.Through my work with the Community Co-ordinators, we continue to address gaps in provision which can be remedied by connecting to strengths within communities or changing the way in which services are offered.The Social Prescribers are also supported to develop and connect with community-based initiatives This work has been encouraged by referrals from Social Prescriber LW’s, surgeries, other activities, statutory services to free virtually and place-based activities. Social P has continued to support several communities led projects to access resources be it funding or partnerships with external agencies. As a part of this work, we have also developed strategic and service delivery partnerships with several services to meet need identified by Social Prescribers patients and the wider community. This work involves the followingOn the working task group to support to implement in the local system Joy the Social Prescribing Case Management Tool. It enables health and social care professionals to link clients to local services and demonstrate outcomes. Joy promotes a holistic approach to health and empowers care providers to address health inequalities and gaps in service provision. Further details are included in the attached presentation. I would like to draw your attention to the last slide which provides weblinks to Joy, summary of the system, a short webinar and link to Simply Connect Croydon.Video between myself and SWL DWP has been completed for internal use at SWL DWP, the video will be played across SWL job centres. DWP comms team are trying to work a way of allowing it to be shared externally to show great partnership working between DWP and SPLW.A range of VCS organisations are still in contact with my work to inform of all the changes they have made to provide support online e.g. CDI, Mencap, GIG buddies, FJC, S.L.A.M, Age UK, and Croydon Voluntary Action.Continued referrals and follow ups being made to Community Hub. Referral route currently being reviewed and adapted.Working with Access Social Care who provide free legal support to residents in Croydon to get the care they are entitled to. Continued partnership with BME Forum.Presented on APPG evidence session, to show parliament members how social prescribing is led in 1THN PCN. Please see link Developing systems with PCN care coordinator, need to discuss how all PCN staff work collectively around patient care.Case study25-year-old female, mental health disorder, lived with family, however due to being physically abusive to family members and trying to commit suicide, is now in supported living accommodation.Previously had 25 hours of carer support, and a social worker.Family overwhelmed, feel tare not kept in the loop, no carer support, no social worker.Outcome and Support -Family receiving support from CAB for Power of attorney. -Family referred to Access social care, legal support with social care and assessment for daughter.-Patient in contact with housing officer, and with adult social services. To have a new social worker appointed to patient, and also the correct living accommodation.-Family have also been referred for counselling.SPLW liaising with all organisations involved and ongoing support with both patient and family.Purley North Main challenge is around housing, for example patients being evicted from private rentals, unable to afford increase in rents or are on benefits, find they are unable to rent privately as landlords tend to discriminate.Patients living in temporary accommodation for long periods of time in unsuitable environments, impacting on wellbeing and mental health. Unfortunately, there is limited support I can offer, many patients report that the housing teams, including Housing associations ignore emails, phone calls etc.Cost of living support offered and referred to these can range from a2.Benefits checks via DWP and CAB3.Gov - Help for Households4.Application to the Household support fund, 5.Referral to a Debt agency e.g.Step Change or CAP , CAP also provide emotional support.6.Arrange emergency food parcels via the Purley Food Hub or referral on to the Food Stop at Old Lodge Lane Baptist Church Community supermarket7.Referrals to Employment programmes e.g.ReedSection 4 Growing challenges faced by patients facing across PCNs- OT referrals are extremely long now, some over 8months, so the pressure is being put on SPs to cover and they don’t have the expertise or capacity. Also, they are receiving more Mental Health Pick referrals coming back to them and again it’s outside of their expertise, as they only work with patients for 12 weeks and then close cases. So, GPs are then referring patients with high mental health needs back to SPs who can no longer help them.-ICN Plus MDT does not deal with patients needing access to children and social services does not manage the case if the children are based out of the borough. -Difficulty accessing the Child Immunisation patients and Weight Management patients due to number of new referrals and follow ups of current referrals.-Social Services – for many patients there is long wait. For those with Learning Disabilities and moving into adulthood, there does not seem to be smooth transition and some fall through the net. -Extremely long waiting list for Occupational Therapy. Patients who were referred to OT in Jan are not going to be assessed till Nov this year. -Cost of living crisis and increasing debt.-Rise in emotional and mental health illness among children and young people.-Housing issues people in unsuitable conditions, increase in homeless and lack of support available especially refugee/asylum seekers. -Long waiting time over 10 months for services that provide diagnosis for patients with Autism, ADHD which affects community services tailored to support only those with a diagnosis. Many children miss out on early intervention. Some families who can afford chose to pay privately.Section 5 Development of strategic plan for Social Prescribing programme in Croydon-Focus on prevention and proactive care provision.-Developing services in the heart of the community-Playing an active role in the implementation of the ICN Plus rollout-Participation in locally based activity -Community Building - contribution to community led health and well-being. This work has been encouraged by referrals from Social Prescriber LW’s, surgeries, other activities, statutory services to free virtually and place-based activities. The Social Prescribers are also supported to develop and connect with community-based initiatives. work is also supported by Community Co-ordinators.As a result, Social P has continued to support several community led projects to access resources be it funding or partnerships with external agencies.Access Social CareThrough a partnership with, Croydon Social P launched a social care legal advice hub which has so far enabled patients to get the support they have a legal right to under the Social Care Act. The charity will provide social care legal training to ensure communities are getting the social care they are legally entitled to, allowing individuals in need to live their lives in a way that is fulfilling. Social P has supported the running of legal training sessions with local organisations (with a specific focus on BAME communities who seldomly access such services) to teach and encourage the use of Access Social Care’s free legal social care advice portal or Chatbot called Alice. This portal will help individuals understand their rights, answer any questions they might have about going forward with social care legal challenges and to assist with correspondence to MPs and local authorities. We have now secure free legal caseworkers for Croydon patients around social care rights, benefit appeals, some employment and housing issues due to the growing need identified by social prescribers.Over the last 6 months the Advice Coordinator via Social P has supported and trained Social Prescriber Link Workers across SWL and in 7 Primary Care Networks within Croydon. In addition, they have engaged with and trained local advocates such as the BME Forum and Carers Centre.Key outcomes to date:-Twenty-one training sessions in 2022-23 on the Care Act and Legal Chatbot-Chatbot promoted to 209 people.-Chatbot conversations and letter downloads 43-Engaged with hundred and eighty people. -Offered one-off advice/conversations. -From March we have held fortnightly legal surgery involving Access Charity’s legal team and Social Prescribers. We have now held sixteen sessions with 4 to 6 attendees at each session.-Forty-eight people passported through the clinics for legal advice.-Conducted post training/workshop surveys with participants which: show an increased awareness of rights after training and knowledge of the Care Act, highlighted key issues such as low confidence, no trust with institutions due to experience of being let down and not listened to and that there is no other free legal support they have access to or are aware ofdemonstrated that the training has increased their hopes of getting the right support for either themselves, family, or people they support.Saw a trend around assessments not being carried out, packages of care not meeting needs and charging issues these are also are evidenced via the clinic case themes, one off conversations, feedback at training and events and chatbot themes.The strategic issues we are seeing include:Access to assessments is difficult due to LA not responding to request for assessments.The quality of assessments is often poor due for example to BAME communities cultural needs not being considered, independent advocates not being offered or after long waiting periods assessments being carried out over the phone.Charging issues include:LA starting the process with charging instead of following the Care Act guidelines with carrying out assessments first.Disability related expenditure not being explained or considered. Difficulties with the financial assessment including individuals not understanding how their charges have been calculated, due to the LA trying to balance books and saying they do not have the funds.Barriers to benefits No response for months, helpdesk discouraging people from appealing.ChatbotAll Social prescribers are facing capacity issues due to fully booked patient clinics, not enough time to go through the chatbot with patients as they are only given 20 minute slots and pressure from GP practice to increase numbers of patients they see due to targets set by NSH funding. Access co-designed a solution with the SPs to create and refer into a volunteer pro bono letter completion clinic. This has increased the number of referrals from SP and therefore the number of patients benefitting from ASC services. Access is learning that if this provision were not in place then patients wouldn’t have access to the free legal support as a result and this would disproportionately effect BAME communities the most.RengageA national body Rengage which offers a range of service including-Tea parties Our tea parties are free monthly social groups open to people aged seventy-five and over.They are a chance for a change of scenery and regular afternoons of conversation and laughter with friends of all ages.-Call companions Would you like a regular friendly chat over the phone with your very own call companionCall companions is available to anyone aged seventy-five and over who would benefit from a regular chat over the phone with a friendly volunteer.-Rainbow call companions Are you lesbian, gay, bisexual, transgender or otherwise part of the LGBT Plus communityAre you aged over seventy-fiveWould you like a regular friendly chat over the phone with your very own call companion-Rainbow call companions is a free service for older LGBT Plus people who live alone and feel they would enjoy a friendly phone call every week or two with a volunteer who is also LGBT Plus.Rengage approach is to connect a service/project with local initiatives and the Social Prescriber Link Workers and allow a bespoke offer to evolve that fits the requirement of the area in which we work.DWPCommunity groups and Social Prescribers also fed back that there was a need to provide individuals with support in relation to access to benefits and employment opportunities. Social P has continued to develop a relationship with the DWP to increase the capacity of Social Prescribers who feedback that they were constantly full of patients sometimes having to wait 3 weeks for an appointment. DWP staff will be based in practices were possible or work remotely in partnership with Social Prescribers offering patients more support around:1.Access to Work, Work Psychologists, Employment Advisors, Providers and payments team on Universal Credit, PIP, ESA and JSA.2.A point of contact for GPs, NHS, Local Authorities. 3.Liaising with Social Workers, Mental Health Support Workers, Homeless-ness4.Organisations and charities including Armed Forces and Salvation Army. 5.Local knowledge and can signpost to services on Health & Disability within your area and nationally.London SportsSocial P is seeking to build on its existing successful partnership with London Sports through the following proposal. To work with London Sport, One Croydon, PCN’s and others to develop a pilot programme that looks at the following1.A partnership and practical collaboration with PCN’s, SocialP, London Sport, other organisations, and keys PCN staff to develop a programme that works cohesively to tackle health inequalities, health, and well-being and healthily lifestyles and address the barriers to physical activity.2.To aide and assist the PCN’s in developing a partnership approach to the long-term benefit of patients and the community around preventive care and non-clinical support .3.To develop a programme and way of working that emboldens the support and understanding of the key role that the voluntary sector play in community touchpoints, impacts and sustainability.4.To enable the monitoring and impact of supporting patients through a holistic list of life issues developing intervention and support and guidance to healthier lifestyle’s 5.Facilitate a way of working that is cost effective, joined up and utilising the vast array of NHS funded ARRS staff and others, to protect future funding and to show effective outcomes both in Primary care and the community.There are several gaps in provision that the project will look to meet and through support of current provision. For example, the following programmes have been developed through work between Social P, Social Prescribing Link Workers, and local providers. 1.Nature walking Group 2.Online outdoor meditation - Using senses in mindfulness meditations in the outdoors.3.Park based exercise class for Over 50’s.4.Art Workshops5.Food growing and healthy eating workshops.Community Hub Through the work of Social Prescribers and Community Co-ordinators we continue to be able to identify strength in local communities and gaps in provision which can be remedied by connecting to strengths within communities or changing the way in which services are offered.To this end we have begun discussions within the Thornton Heath PCN and the Primary Care Development Funding to develop an action plan linked to enhancing integrated working, including:1.building relationships between PCNs and community providers, and between PCNs and other organisations – including local authorities and the voluntary sector. 2.development of integrated multidisciplinary teams across practices and organisations, between PCNs and community providers. 3.support for the development of clinical directors and of primary care provider place and system leadership. 4.enhancing understanding of and links with the local population, supporting a reduction in health inequalities, including: 5.developing approaches to the use of data and taking action to reduce inequalities, developing links with local communities and community organisations. 6.building on the COVID 19 vaccination programme to reach the whole PCN population. It is the aim to develop this through partnership work with both the PCN and additional NHS funded staff such as Care Co-ordinators, Health and Well-being coordinators and others including:1.Age UK Over 50’s Personal Independence Coordinator PIC2.Adult Social Care over sixty-five’s team3.District Nurse4.Domiciliary Physiotherapist5.Falls service.6.IAPT Talking Therapist7.ICN Plus Pharmacist8.Mental Health PIC9.Occupational TherapistThrough the care planning process, we will roll out the feasibility of the relevance, and method of obtaining and monitoring the following clinical parameters: anxiety, depression scores, pain, wellbeing, health confidence, weight , number of medications, falls concern, loneliness.Whilst Social P has had a presence at the Collaborative meetings, reduced capacity has meant that we have yet to fully engage with the strategic contributions to ICN Plus roll out. It is our intention to build this process in the coming quarter as we believe the necessary elements are in place.Through the work of Social Prescribing Link Workers and Community Co-ordinators we continue to be able to identify strength in local communities and gaps in provision which can be remedied by connecting to strengths within communities or changing the way in which services are offered.It is the aim to develop this through partnership work via The Hub with both the PCN and additional NHS funded staff such as Care Co-ordinators, Health and Well-being coordinators and other services.
Meetings are held every 6 weeks with stakeholders / directors and the team.
No remuneration was received
No transfer of assets other than for full consideration
This report was approved by the board of directors on
5 October 2023
And signed on behalf of the board by:
Name: Alex Maxwell
Status: Director