A key component of the NHS Long Term Plan is personalised care.
This involves taking a holistic approach that understands the often complex needs of individuals, and proactively supports them to find solutions.
What we do
The Social and Wellbeing Team started out with the Social Prescribing Link Workers (SPLW) as a requirement of the Primary Care Network Directed Enhanced Specification Contract (PCN DES) in 2019 for all PCN’s to have one of these roles employed within their PCN.
While Social Prescribing may have been new to many areas when introduced in 2019, for DDHF it was a natural continuation of one of our existing services.
Our Health Care Coordinator team was developed because of an unmet, non-clinical need for the more elderly and vulnerable in the community.
In 2019 with the introduction of the Social Prescribing services Personalised Care is available to anyone aged 18 or older who needs support for issues such as housing, finances, family and social networks, emotional wellbeing and physical health and fill the age gaps left.
Since 2019 other Personalised Care specific roles have been introduced as part of an Additional Roles Reimbursement Scheme (ARRS) within the subsequent DES contracts and these roles support the patients as illustrated on the diagram below:
Social Prescribing Link Worker (SPLW)
Each of the roles brings a varied and diverse skill set to the role with a clear vision to improve patient wellbeing.
Connecting patients to community-based support, including activities and services that support practical, social, and emotional needs that affect their health and wellbeing.
Support & empower patients to improve their own health & wellbeing by focusing on what matters to them – signposting/referral for support with: social anxiety/isolation debt benefits housing education employment substance/alcohol misuse.
Health and Wellbeing Coaches in Wear Valley & Teesdale PCNs
Skills and Qualifications for the coaches are a mixture of health coaching, nutrition, structured education on specific health conditions such as Type 2 Diabetes.
Receive a high volume of referrals from each practice and the roles deliver a variety of educational groups / 1-1 sessions for Pre-diabetes, Type 2 Diabetes, Weight Management etc.
Care Coordinator (CC)
Care Coordinators work across Bishop Auckland & Teesdale PCNs predominantly based in the GP surgeries, each providing a wide range of skills to carry out the role working within a healthcare setting, collaborating with other healthcare professionals to help support patients.
Some of the tasks they carry out are:
- Follow up appointments
- SPLW referrals
- arrange healthcare screening
- QOF reporting
- 2 week wait (2ww) journey
- arrange vaccinations
- ward rounds
- arrange annual reviews
- GP tasks re patient care
Armed Forces Community Social Prescribing Link Worker
This role was part of a 2-year ‘Test and Learn’ Demonstrator funded by NHSE Armed Forces Team to scope out how social prescribing can support the specific needs of the Armed Forces Community (AFC). The funding was due to expire in August 2023. However DDHF have been successful in securing funding for this post for a further year.
The AFC Social Prescribing Link Worker (SPLW) acts as a conduit for advice and education to the wider SPLW community in order to increase capacity and better support the AFC.
They also act as a resource for receiving referrals and supporting more complex cases.
Social prescribing empowers people to take control of their health and wellbeing through referral to ‘link workers’ who give time, focus on ‘what matters to me’ and take a holistic approach to an individual’s health and wellbeing, connecting people to community groups and statutory services for practical and emotional support.
Social prescribing link workers will work as a key part of as to strengthen community and personal resilience and reduce health and wellbeing inequalities by addressing the wider determinants of health, such as debt, poor housing and physical inactivity, by increasing people’s active involvement with their local communities. It particularly works for people with long term conditions (including support for mental health), for people who are lonely or isolated, or have complex social needs which affect their wellbeing.
Our AFC SPLW was instrumental in creating and delivering training and upskilling sessions for SPLWs and other nominated Health and Wellbeing staff to raise awareness and understanding of the Armed Forces Community across County Durham.
Early Cancer Diagnosis Facilitator
We have been asked to host a Primary Care Network Cancer Early Diagnosis Facilitator to cover County Durham on behalf of the Integrated Care Board (ICB) and have now recruited to this post commencing in April 2023.
The purpose of the role is to support PCN’s and practices throughout County Durham with activities which support early cancer diagnosis.
The role has many avenues including:
- Providing early diagnosis and screening stats data to practices
- Supporting PCN’s / practices to identify areas of focus for improvement
- Assist practices to implement activities to improve early diagnosis rates
- Share best practice relating to early diagnosis activities
- Providing cancer awareness training to practice staff
- Supporting whole system collaboration in relation to cancer and early diagnosis work
This is a fixed term post of 2 years and we are hopeful that the facilitator can achieve the above successfully.