1. The Rotherham model Patients in Control of their Care
Social Prescribing
The Rotherham model
Patients in Control of their Care

2. Background The NHS Challenge
Increasing numbers with long term conditions
Above average unplanned hospital admissions
Unable to fund prevention without freeing up money from the acute sector
How can VCS help?
Development of Rotherham Social Prescribing
Co-production workshops – agreement of model linked to integrated case management pilot
Business case submitted to Rotherham CCG
Initial pilot proposal – 10 GP practices, but 26 signed up!
6 months to recruit staff team, set up systems and join first GP meetings
Pilot funded by Rotherham CCG from non-recurrent funding

3. What is Social Prescribing
What is Social Prescribing? Strengthening individuals, strengthening communities
Social prescribing (sometimes called community referral) is a framework for linking patients with non-medical needs affecting their health, well-being and ability to self-manage to sources of support within the community.
PRESCRIPTION
Exercise / healthy lifestyles
Self-management programmes
Social and leisure
Arts and crafts
Befriending/mentoring
Confidence building
Learning/training
Money – benefits, debt, fuel poverty
Housing/adaptations
Carers support
Dementia support
Transport/mobility
Advocacy
LTC Social Worker
It’s been excellent for the patients, in having access to such a medley of support services where you can interlink
An recent article in Primary Care Today on social prescribing points out that the NHS focus has always been on the Acute Sector, but 90% of care happens in primary care. It suggests that at a time when everyone in the NHS is struggling for resources, General Practice needs to look out there at the resources we have in the community and find ways to use them more effectively, and this pilot provides the infrastructure to enable this.

4. Rotherham Social Prescribing Model Key Features
LTC Matron
One-stop shop – there are numerous possible agencies to refer to so makes it easier referring to one
Social prescribing integral to integrated case management teams
Patient selection by GPs - using risk stratification
Single infrastructure organisation (VAR) manages contract ( 26 partners)
VAR employs and manages 5 link workers
Co-produced action plan and menu
of support activities
Funding to expand VCS capacity
and fill gaps in provision
VAR Advisors attend GP MDT meetings, visit patients and refer on to appropriate VCS services
Only patients referred to VAR Advisors by participating GP Practices are eligible for social prescribing

5. Rotherham Social Prescribing Model
Integrated LTC Case Management Team
Voluntary and Community Sector Advisor (VCSA)
Funded VCS Service
Community Activity
(non-funded)
Assessment
Patient is on risk tool
Patient has non-medical needs
Menu of options
Feedback
Feedback

6. SPS funding Sustainable funding Social Prescribing Patient Journey
Month 0
Month 1
Month 2
Month 3
Month 4
X weeks
X hours
X sessions
Patient Outcome
Towards Independence
Maintaining Independence
Patient continues to access service (patient self funds)
VCS provider Service 1
Patient continues to access service (external funding sustains service)
SPS Funded
Patient referred on to sustainable activities / service
VCS provider Service 2 GP
VCSA
SPS Referral in
Referral Out
VCSA FOLLOW UP
Patient attends peer-led group
SPS Funded
SPS funded Provider Service
VCS provider Service 3
No sustainable outcome for patient
SPS funding
Sustainable funding

7. The Story So Far……… 1974 referrals in to SPS since Sep 2012
Key Statistics
1974 referrals in to SPS since Sep 2012
referrals on to VCS Services
700 referrals on to non-VCS Services
65% referrals aged 75+
42% live alone
37% have an informal carer
5% BME
GP Quote:
Gives them a focus/purpose and goal to achieve. Integrates back into the community, especially the socially isolated. Supports and educates patients
Outcomes
55% - fewer outpatients appointments
48% - fewer hospital admissions
43% - fewer A&E Attendances
83% - progress on at least one outcome area
76% - financial benefits (£275,000 in additional benefits since Sep 2012)
69% - less isolated
54% - more active

8. Social prescribing - Success factors
VCS is integral to case management in primary care
CCG champion / streamlined and effective Steering Group
Simple referral processes for GPs
GP ‘buy in’ to social prescribing
Adequate resourcing of VCS services
VAR’s ability to support groups
Patient Quote:
I was on my own, I was totally on my own… Each day I’m getting better and better….before I could hardly walk…I’m feeling very positive, each day I get up and I just can’t believe how much I’ve come on
Social prescribing funded services as pathways to independence
Robust (and secure) patient data management to demonstrate impact
Link workers recognised by GPs as professional and an equal player in integrated care teams
Quality VCS staff – particularly Link Workers
GPs recognise the importance of social relationships as an alternative to medication
Development of community hubs and local community services
Pathways to independence, not an end in themselves

9. NHS National Award for Social Prescribing

10. Case Study Patient V Patient is registered blind and has angina
High anxiety levels – rings 999 frequently when support workers aren’t there
Limited friends and rarely goes anywhere independently, no confidence
Referred to SENSE art and craft group, disabled swimming session and befriending services.
Re-arranged his support worker hours to cover weekends by doing other activities in the week.
He has now met lady that attends the same group, they have fallen in love, are moving in together and getting married
Outcome: patient is more confident, more independent, much happier and less isolated
Outcome: patients rarely rings 999, more satisfied with support package and will be reducing the hours of support needed
Outcome: patients value SENSE group so much they are to continue it themselves by self-funding and applying for grants

11. Patient feedback

12. Thank You
Questions?
Janet Wheatley on or
Linda Jarrold on or
External evaluation interim report (December 2013) 
Voluntary Action Rotherham, The Spectrum, Coke Hill, Rotherham, S60 2HX; Tel: , Fax:
VAR is a company limited by guarantee, Registered Charity Number: , Registered Company Number: