Case study summary
People with Long Term Conditions (LTCs) and their carers benefit from access to additional, non-clinical support options via primary care. They experienced positive outcomes associated with their health and well-being and became less socially isolated and more independent.
The service helps people with LTCs to access a wide range of services and activities provided by voluntary organisations and community groups in Rotherham. Funded by the CCG (initially through non-recurrent funding), it is part of the wider case management initiative in Rotherham that brings together health, social care and voluntary sector professionals for people with LTCs.
Voluntary Action Rotherham (VAR) employs and manages five VCS link workers (known as VCS Advisors) – they attend GP Long Term Condition Multidisciplinary Team Meeting (MDT) meetings, visit patients and refer on to appropriate Voluntary Care Sector (VCS) services. Only patients referred to VCS advisors by anticipating GP Practices are eligible for social prescribing. GPs select patients for social prescribing using a risk stratification tool. A single VCS infrastructure organisation (VAR) manages the contract with CCG and multiple funding contracts with VCS providers. An independent funding panel decides grant/block funding allocations. A bespoke VCS database / Management Information (MI) system has been developed for the project.
People with LTCs and their carers benefit from access to additional, non-clinical support options via primary care – they experienced positive outcomes associated with their health and well-being (78% reported progress on at least one outcome area), and becoming less socially isolated and more independent (69% reported being less isolated and 54% more active). Other benefits include a reduction in costly hospital episodes (47% of referred patients attended fewer outpatients appointments, 38% had fewer A&E attendances and 40% had fewer hospital admissions), and the development of new and innovative community based services that complement traditional medical interventions.
Tips for adoption
- Explaining the model to GPs is important, so they readily recognise the importance of social support as an alternative to medication.
- Simple referral processes for GPs are very helpful, allowing this new service to fit into existing ways of working.
- Encourage providers of care and support to regard these services as a route to greater independence for users, rather than as an end in their own right.
- It is helpful to establish a local multi-agency coordination and oversight group, including voluntary sector providers, healthcare teams and local commissioners. This facilitates setup as well as sustainability of the new service.
- It may be necessary for the NHS to provide additional funds to support recruitment, training and coordination work being undertaken by voluntary sector groups.