Steps towards implementation

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Identifying target population and local needs

Social prescribing can potentially benefit a whole range of people. When setting it up or expanding it however, commissioners might want to actively offer it to targeted populations based on their specific locality or GP practice, or by their health condition, patterns of service uptake, or other criteria, including where it might prevent health conditions developing or worsening. The following are commonly identified target populations (Kinsella S 2015)[1]:

  • People with mental health conditions (from mild through to more severe and enduring)
  • People who are socially excluded, disadvantaged, isolated and vulnerable
  • People who frequently attend primary and secondary care
  • People with one or more long term conditions
  • People whose conditions are not necessarily well served by existing health and care services e.g. People with Asperger’s Syndrome.
  • People who require additional support to promote lifestyle changes for better health

Local areas can determine their target population by using existing knowledge such as their Joint Strategic Needs Assessment, STPs, other planning processes and through risk stratification. Some NHS commissioners see benefits from social prescribing for ‘mainstream’ populations to meet the needs of people with lower level health needs across the whole life course. Some have used social prescribing to target patients with lower health self-efficacy who traditional health service approaches may have failed to engage.

Agreement needs to be reached between local commissioners and providers about which population to target. This could be defined in relation to, for example:

  • Those who have one or more long term conditions
  • Those at specific activation levels on the Patient Activation Measure (PAM) scale or similar
  • Those who use >£x of medication per week
  • Those who attend >x number of clinical contacts per month
  • Those presenting with a social problem/social isolation, or presenting frequently to primary care with a range of diffuse issues
  • Those presenting with mild to moderate mental health conditions
  • Those known to have health conditions, but don’t currently use health services.
  • Those who live alone
  • Those at risk of developing or worsening health conditions (e.g. pre-diabetic)

Data needs to be sourced to assist this decision, and then to help identify individuals who might benefit from a social prescription. The section on identifying target populations in the Healthy London Partnership’s self-care resource makes further suggestions, and information from other schemes can help to get a sense of the different target groups and the benefits being delivered locally.

Identifying local partners and assets

It is very likely that relevant voluntary and community resources exist in all boroughs, but they may not be referred to as social prescribing or be easily visible to those in the NHS. It is important to understand what currently exists to maximise the benefits of any new investment.

  • Borough based voluntary sector councils: Commissioners can work with them to draw out existing community capacity, provide opportunities for all providers to get to know each other and therefore work more effectively together. The London Voluntary Service Council (LVSC) has a London social prescribing map [2] which gives information on some of the services which currently exist in London. This is a useful starting place to begin your mapping. As well as describing what exists, this also provides links to information about the individual schemes, providing useful detail about the range of social prescribing services, and new schemes are invited to add their details to the map to keep it current.
  • Social housing providers: They have tenancy support teams, who will work with tenants to understand what their problems are and signpost them to potential sources of help (e.g. Family Mosaic who provide housing in London and the South East[3]).
  • Statutory provision: Some statutory services may be signposting people, e.g.
    • Health Champions[4]
    • Health Trainers[5]
    • Expert Patient Programmes[6]
    • Community pharmacies[7]
    • Care coordinators[8]

The National Social Prescribing Network has found that many existing schemes are initially shaped around local assets in the voluntary and community sectors and, over time, they build partnerships and capacity more widely across local communities. To help social prescribing develop further, local leadership then needs to be built across organisational boundaries and include CCGs, local authorities, voluntary sectors, GPs and local patient and carer groups. Without GP buy in social prescribing will struggle to develop locally – so leadership in this group is crucial.

Funding and resources

Voluntary sector partnerships are an essential feature of social prescribing, but many voluntary and community groups do not have the existing capacity and resources to be seeing more people directed through social prescribing. Commissioners and local providers will need to engage the sector to identify ways of making additional capacity available and identify what extra support or funding will be needed. Funding for longer periods is likely to be most effective when strategic partnerships and formalised working relationships have been established with local voluntary sector organisations. This should create the right environment for new systems which includes outcomes reporting, measurement and evaluation to be co-designed and implemented with partners and users.

By fostering an agile approach and collaborative learning environment, this will provide a platform to support mobilisation, delivery and gives time for return on investment to be realised.

Potential funding sources for social prescribing- New Care Model contracts e.g. Multispecialty Community Provider (MCP)

Outcomes can be included in the commissioning of MCPs which promote the use of social prescribing (to deliver those commissioned outcomes). Payment for Performance models are being developed by NHS England which could contribute towards this.

Best Practice Tariffs

Designed to encourage delivery of best practice. They are currently being developed and not likely to be ready until 2018-19 commissioning round. Subject to development they may be a good vehicle for supporting implementation of social prescribing and self-care.

CQUINs

They are not applicable to primary care, but could be used with community and secondary care providers. The planning guidance for 2017-19 (NHS England & NHS improvement 2016)[9] includes a CQUIN (no 11) to incentivise secondary care providers to use the PAM and train their staff in the use of personal care planning.

QOF/Local Incentive Scheme

Outcomes relating to social prescribing might be included, but QOF is under review and may come to an end (possibly replaced by New Care Models contracts). A more likely option to influence primary care activity is to include it in the core contract or any locally agreed service contracts with federations/ care networks.

New service specification

  • Commissioners could develop and commission a new service specification to improve support for social prescribing and self-management.
  • They could draw on the Year of Care model developed originally for diabetes, but now being applied more generally to implementation of social prescribing and self-care [10] [11]
  • A range of provider models may be used, including newer types of organisation (e.g. MCP), new joint venture or lead (VCS) provider arrangements. These may be quicker to set up than other models.
  • Service contracts could include provision for the provider to receive a share of any savings which might accrue from the delivery of the service acting as a financial incentive for performance.

Personal Health & Care Budgets

Where individuals have agreement for a personal budget (for health and/or social care), they could use that budget to purchase social interventions. This would be independent of commissioners.

Capitated Budgets

  • Capitated budgets allocate funds according to population numbers fitting certain criteria. They focus care on the individual, not on budget lines, and on outcomes rather than activity.
  • They can support joint investment from the commissioner side, and can be structured so that prevention and productivity are incentivised, by allowing for savings to be retained by providers, who also take on more risk.
  • Using capitated budgets to fund more integrated care (to which social prescribing contributes) in Valencia in Spain found (Oldham J et al (2012); Primary Care - the Central Function and Main Focus. Report of the Primary Care Working Group. Global Health Policy Summit):
    • reduced costs by up to 26%
    • increase in hospital productivity of 76%
    • patient satisfaction rates of 91%

Social Impact Bonds

  • Social Impact Bonds (SIBs) draw in additional investment, where the return on investment is

dependent upon the achievement of social outcomes, which may not be realised for a few years[13] [14].

  • They can therefore attract extra finance into the establishment and development of social prescribing, with a sharing of risk with others.
  • A SIB has been used to develop social prescribing in Newcastle[15].
  • The Regional Voices website has useful information and further resources about using SIBs[16]

Grant and project funding

  • New initiatives could be funded through the allocation of existing local grant funding (e.g. from the LA or CCG).
  • Grants tend to be easier to award than contracts and are sometimes less bureaucratic to performance manage – which may be quicker and beneficial to the grantor and grantee. However, grant funding is increasingly in short supply.
  • The NHS Five Year Forward View (p14) commits the NHS to developing alternatives to complex NHS contracts for the charitable and voluntary sector, and an increased use of grants. Guidance for the NHS and sample agreements for grants is available[17].
  • Grants from CCGs have been used to fund voluntary sector developments[18]. There are examples of money being allocated to a local VCS organisation which then awarded this as grants to other, usually smaller, VCS organisations to help deliver the CCG’s goals.
  • There is a government Social Outcomes Fund, which aims to “top up” funding for services which

are commissioned to achieve outcomes[19].

Commercial sponsorship.

This might take the form of:

  • funding in cash or support in kind – possibly aligned to Corporate Social Responsibility programmes.
  • loans at preferable rates
  • underwriting of a service

It would need work with business organisations/local area enterprise teams. A business will want to be clear about what it will get in return for any contributions it might make.

Donations/crowdfunding

Funds can be sought from local people and philanthropists.

  • Fitzrovia Neighbourhood Association is funded by grants and seeks voluntary donations [20].
  • Kentish Town Neighbourhood Fund is funded by voluntary donation.
  • The Lambeth GP Food Coop[21] are seeking investors to develop their scheme through “community

shares” which are a sort of localised crowdfunding [22].

The Bromley by Bow Centre draws on a range of funding sources, statutory, corporate, charitable and from generating income themselves. Their approach has enabled them to succeed for over 30 years, and their diversity of income source has perhaps contributed to this.

Things to consider when developing local operating models

Factors associated with successful social prescribing schemes. (National Social Prescribing Network, 2016)
Operating model for social prescribing & access to community based resources

Different models for social prescribing exist. But there are emerging factors that are associated with successful schemes. The national Social Prescribing Network has identified those which are common to many. Existing and emerging NHS models may be relevant, notably the six principles developed by NHS England for New Care Models. The key feature for social prescribing is that a system is in place which actively supports people to find out about and access a range of resources which can help them with a variety of social issues which can affect their health and their ability to manage illness. Social prescribing should develop and transform relationships between patients and providers, and between the NHS and other sectors. Systems can build on exiting provision or commission anew.