Dudley CVS has been delivering a social prescribing service for the nearly 5 years. In early 2014, Dudley CVS with support from Dudley Clinical Commissioning Group (Dudley CCG), identified an opportunity to develop and deliver an innovative, flexible and complementary service called ‘Integrated Plus’.

The service was set up to trial a different approach to supporting people in their own homes to ensure the non-clinical needs of patients are taken into account at the GP-led Multi-Disciplinary Team meetings (MDTs) established in 2014. Integrated Plus offers 1-2-1 social prescribing support to patients aged 16 and over who are:

• At high risk of hospital admission
• Frequently visiting their GP
• Vulnerable and in need on non-clinical, social support

Our support is about enabling and facilitating connections with others, nurturing new friendships and helping people to find purpose in their lives. We focus on the whole person’s needs whatever they might be, to jointly find solutions to challenges faced. Our approach is about spending quality time with people, actively listening to their needs, goals and aspirations. We explore what is important to the person and help them to identify, amplify and reflect on their strengths, passions and skills. 99% of people we have connected with stated that spending quality time with them actively listening and exploring what they want to achieve as the most valuable component of our service.

Other key facts and stats

• 4,326 referrals from GPs and at the MDT meetings. Of 4,326 we have connected with 3,132 people.
• 81% reduction change in people that were not managing in the areas of finances but who are now getting appropriate support or now managing ok
• 82% reduction change in people that were not managing their physical health but who are now getting support or now managing ok
• 80% reduction change in people that were isolated and lonely but who are now accessing services/activities or no longer feel isolated or lonely
• 8,719 outward referrals to organisations, 60% to the voluntary sector
• Avoidable A&E attendances have reduced by 17% over a 12 month period after Integrated Plus interventions, cost avoidance totalling £58,305
• Avoidable hospital admissions have reduced by 15% over a 12 month period after Integrated Plus interventions, cost avoidance totalling £751,400
• Overall GP consultations have reduced by 15%, cost avoidance totalling £73,115

Karen supported to find time for herself and regain her confidence

Karen was referred to Integrated Plus by her GP. She was diagnosed with depression and finding life difficult to cope with.  Karen is selfless and spends most of her time caring for others.  She has caring responsibilities for her mother, an aunt and a son who is disabled.  Despite her busy schedule, Karen is regarded as being positive and upbeat about herself and her life but while looking after everybody else her own mental health was deteriorating and she became unwell.

When Karen met the Locality Link Officer for Stourbridge, Wollescote and Lye she said she felt “Lost and exhausted and didn’t know what to do.” The Link Officer listened to Karen and discussed options for her to have some time concentrating on herself, regaining her confidence and doing something she would find helpful and worthwhile.  The Link Officer asked Karen what hobbies and interests she had and if she would like to do some activities. Karen said yes and the Link Officer agreed to accompany her to her first activity until she felt comfortable with her surroundings.  They went to the University of the 3^rd Age in Stourbridge (U3A) and Karen enjoyed it and settled in a lot quicker than she thought she would.

Karen now has the confidence to attend on her own and has been to the U3A several times and is going to join the group as a member. She is looking forward to enrolling on a diverse programme of classes in the New Year, including, lace making, walking and tap dancing. She was surprised and pleased to find that the lace making course is taught by a neighbour and this has rekindled their friendship.

The Link Support Worker met Karen a couple of months later to do a follow up review and she said her mental health has significantly improved and that she is feeling much better. Karen has also grown in confidence and has attended some Carers Coffee Mornings and said this has been important in reducing the isolation and loneliness felt by many carers.

Karen has reconnected with neighbours and her wider community and has made new friends since being referred to Integrated Plus. She said she was very grateful for the “…impartial support from Integrated Plus.”  And without this support she said she would probably be “sat at home rocking back and forth in her chair not knowing what to do next.” With support from Integrated Plus and Karen’s desire to make changes she is looking forward to the future with renewed confidence and hope.

For more information contact: Kate Green. Email: buildingblocks@dudleycvs.org.uk