Call for evidence - inclusion health

Case Studies

• North East London Integrated Community Pathway

  by Loretta Cox @OxleasNHS, almost 3 years ago

  The London Offender Personality Disorder (OPD) Partnership is consortium of London NHS trusts that work with the Probation Service and other third sector organisations to deliver psychological treatment to complex high-risk offenders in the community and prisons.

  Challenges faced by people in contact with the justice system can include disruption to the continuity of care and treatment and exclusion from access to treatment. This case study describes the challenge and solution for one young man in our services.

  Kenneth is 29-year-old black British gentleman born and raised in East London. He experienced a chaotic childhood; his mother struggled with substance... Continue reading

  The London Offender Personality Disorder (OPD) Partnership is consortium of London NHS trusts that work with the Probation Service and other third sector organisations to deliver psychological treatment to complex high-risk offenders in the community and prisons.

  Challenges faced by people in contact with the justice system can include disruption to the continuity of care and treatment and exclusion from access to treatment. This case study describes the challenge and solution for one young man in our services.

  Kenneth is 29-year-old black British gentleman born and raised in East London. He experienced a chaotic childhood; his mother struggled with substance misuse and was a victim of intimate partner violence from multiple partners. Kenneth’s mother was unable to offer him or his siblings emotional support or physical protection. Kenneth recalled memories of being in his room as a child and hearing his mother being assaulted in another room; he reports a strong threat response to banging sounds to this day.

  As an adolescent, Kenneth found a sense of belonging and safety after joining a local gang. His participation in serious group offending (SGO) also provided him with financial independence, at the cost of regular exposure to extreme violence. He began carrying weapons, initially to threaten and engage in SGO, but later as a safety behaviour. He has convictions for robbery, possession and distribution of illicit substances, and carrying weapons.

  Whilst involved in SGO, Kenneth’s sense of threat and vulnerability increased. He was the victim of and witness to multiple acts of gang violence, and his local area was rife with SGO rivalries and conflicts. In 2019, he witnessed the death of a close friend. Kenneth was present and charged with the possession of offensive weapons in public. The investigation is on-going, but it is understood that the murder was committed by members of a rival SGO organisation. Following his friend’s death, Kenneth’s weapon carrying increased and has remained an on-going concern; weapon carrying become a primary means of managing feelings of anxiety and vulnerability when in public. Kenneth has also reported vivid flashbacks and other symptoms consistent with PTSD following his friend’s death.

  Positively, Kenneth appears to have distanced himself from SGO associations in recent years. He was first referred to Changing Lanes (NE Integrated Community Pathway Service) in 2020, where he engaged in psychological assessment and worked with a Clinical Practitioner to address housing issues and develop a daily structure (as best as possible during the COVID-19 lockdown). Noting his history of complex trauma and active PTSD symptoms, Kenneth was also referred to EMDR (eye movement desensitisation and reprocessing) therapy with an ICPS psychologist in late 2021.

  Kenneth readily engaged with the ICPS from 2020 to 2022. During his EMDR treatment, he was recalled to custody following arrest and conviction for a historical violence disorder (pre-ICPS). This unfortunately disrupted his community Pathways plan.

  In December 2022, his probation practitioner requested consultation with the local Probation Delivery Unit (PDU) OPD psychologist and queried a re-referral to the NE ICPS. Kenneth had also expressed a desire to return to the service and continue with his EMDR treatment on release. It was agreed this would be beneficial to his risk management plan and overall psychological wellbeing. In Q4, he was released and promptly reopened to the NE ICPS. He has recommenced EMDR with his previous EMDR therapist and ICPS psychologist, ensuring a continuity of care.

  As Kenneth is excluded from several East London boroughs, he was unable to attend NE ICPS premises. Changing Lanes staff helpfully formed a positive working relationship with his GP clinic. They have generously provided us with a therapy clinic room in North London for our weekly EMDR sessions.

  
  

• Development of a refugee health assessment toolkit for specific populations to support primary care

  by Talia Boshari, almost 3 years ago

  In autumn 2021, approximately 4000 refugees arrived from Afghanistan into London. GPs identified a need for readily accessible and comprehensive guidance to support them in conducting health assessments for the new arrivals with a complex range of needs.[1] The rapid pace of the influx meant that additional infrastructure was required to enrol and support the health of this cohort, many of whom were in temporary accommodation. Primary care provision was also recovering from COVID-19-related pressures, and routine expertise in migrant health was not widespread. This led to concerns about the access to, and quality of, initial health assessments for newly... Continue reading

  In autumn 2021, approximately 4000 refugees arrived from Afghanistan into London. GPs identified a need for readily accessible and comprehensive guidance to support them in conducting health assessments for the new arrivals with a complex range of needs.[1] The rapid pace of the influx meant that additional infrastructure was required to enrol and support the health of this cohort, many of whom were in temporary accommodation. Primary care provision was also recovering from COVID-19-related pressures, and routine expertise in migrant health was not widespread. This led to concerns about the access to, and quality of, initial health assessments for newly arrived refugees.[2]

  A London Health community of practice (CoP) had been established in September 2021 to respond to the arrival of the Afghan refugees. The CoP provided a structure in which the NHS, the Association of Directors of Public Health, local public health teams, the Office for Health Improvement and Disparities, the United Kingdom Health Security Agency London Region and Greater London Authority could facilitate multiagency conversations, identify issues and pragmatic solutions, escalate operational challenges, share practices and advocate for the health of refugees. The CoP connected into other national governmental structures (including the Home Office) coordinating support for Afghan arrivals. NGOs, such as Doctors of the World, were also closely involved.

  The CoP outlined a need to develop a bespoke initial assessment toolkit for Afghan migrants, to support capacity-building in primary care and a standardized London-wide approach. The CoP facilitated the development of the toolkit and the compilation of a pan-London perspective on local challenges and initiatives. The CoP enabled both problem identification – insufficient infrastructure, capacity and guidance to meet the needs of refugees at this pace and scale – and suggested a solution (the toolkit), and brought together the partners necessary to realize this work.

  The toolkit consolidated guidance and expertise across several sources:

  - CoP expertise and advice;

  - United Kingdom Afghan migrant health guide; and

  - Clinicians with humanitarian experience, front-line practitioners, NGOs and those leading the health and public health response.

  Interviews with stakeholders across the patient pathway from GP registration to specialist and routine care were interviewed, with a focus on mental health screening/presentation, health protection, immunization and safeguarding. This advice was complemented by suggestions from real-world experience to facilitate triaging of needs, for example on wound management, dental triage and malnutrition, while applying public health approaches to long-term condition prevention and management.

  The final toolkit ensured greater consistency in assessments, considered primary needs alongside broader well-being and was responsive to both anticipated and known health priorities.

  The initial health assessment toolkit for Afghan migrants demonstrated partnership working towards holistic initial health assessments for new migrants in the context of primary care. The toolkit and associated supporting information were made available nationally for the wider system and have formed a template that can be rapidly adapted to suit emerging needs, for example for further waves of migrants. This work is applicable to asylum seeker health, and these partnership structures and outputs have implications internationally for other countries experiencing similar trends in migration and providing health care to an increasing number of refugees. In London, the CoP has evolved into a new regional workstream to produce a core London offer of best practice in support for primary care capacity and access.

  The central role of public health within the CoP allowed for the successful championing of broader well-being needs and patient voice – an asset when supporting new arrivals to rebuild their lives. Capturing the voices of migrants to drive and inform the content of the toolkit was anticipated. Unfortunately, this was delayed, highlighting a need for appropriate structures through which to engage with vulnerable communities around their health and care needs in a timely manner. Based on this learning, a targeted, co-produced piece of work is now underway to collect and incorporate their lived experience.

  Organizational bureaucracy led to delays in publishing the toolkit. To overcome this, it was circulated in draft among health partners to ensure that the critical window of opportunity for assessments was not missed. This enabled the toolkit to be refined based on feedback prior to publication. Feedback from frontline staff using the draft toolkit suggest that it was well received; however, usage was not formally monitored because of its online format. Additional capacity is needed to evaluate its overall impact.

  References:

  [1] Office for Health Improvements and Disparities (2022). Afghan refugees and newly displaced populations: individual health assessment. London: Office for Health Improvements and Disparities (https://www.gov.uk/government/publications/individual-health-assessments-for-afghan-refugees/afghan-refugees-and-newly-displaced-populations-individual-health-assessment, accessed 10 December 2022).

  [2] Boshari T, Hassan S, Hussain K, Billett J, Garry S, Weil L. (2022). Development of a refugee health assessment toolkit for specific populations to support primary care. Eur J Public Health. 32(suppl 3):ckac131.243. doi: 10.1093/eurpub/ckac131.243

  
  

  
  

• Actioning System Change in services for Health Inclusion Cohorts in Wakefield District

  by Pat McCusker, almost 3 years ago

  Actioning System Change in services for Health Inclusion Cohorts in Wakefield District

  Introduction:

  The COVID-19 pandemic presented opportunities for new ways of working to meet the needs of Health Inclusion cohorts at scale across Wakefield’s Health and Social Care economy. In particular, the COVID-19 vaccination programme meant that services collectively had to make adaptations to ensure equity of access through the development of assertive outreach and roving vaccination to community settings where Health Inclusions cohorts live, socialise, or seek support.

  The learning from this experience saw partners develop a population level approach to meet the needs of Health Inclusion cohorts... Continue reading

  Actioning System Change in services for Health Inclusion Cohorts in Wakefield District

  Introduction:

  The COVID-19 pandemic presented opportunities for new ways of working to meet the needs of Health Inclusion cohorts at scale across Wakefield’s Health and Social Care economy. In particular, the COVID-19 vaccination programme meant that services collectively had to make adaptations to ensure equity of access through the development of assertive outreach and roving vaccination to community settings where Health Inclusions cohorts live, socialise, or seek support.

  The learning from this experience saw partners develop a population level approach to meet the needs of Health Inclusion cohorts and went on to serve as the basis for the development of health needs assessments, service specifications, and the commissioning of services to meet the need of Health Inclusion cohorts locally.

  How we achieved this:

  In February 2021 “Vaccine Inequalities Delivery Plan” was published for Wakefield District. It identified homeless people, Gypsy, and Traveller communities, and Refugees/Asylum Seekers as initial target groups. The programme’s partnership response to foster a problem-solving and “build and learn” approach was a key enabler of the success of the programme. This resulted in local innovation in terms of delivering vaccines to the target communities. A key element was the recognition of the importance of taking vaccines into community settings rather than asking the target group to come to healthcare settings, which many in Health Inclusion cohorts either saw as a barrier or had no pre-existing relationship with.

  The delivery of a bespoke roving vaccination programme changed the perceptions of delivery staff and strategic decision makers to recognise that those generally deemed to be ‘hard to reach’ by health professionals were best served by a model designed with their access needs in mind. The provision of this support means there is now a greater reach into communities previously deemed to be ‘hard to reach'. This work helped to provide an evidence base about the extent and nature of Health Inclusion cohorts in Wakefield District, as well as their needs.

  The Roving Vaccination Team was externally evaluated with a summary report published in September 2022. Gathering the perceptions of strategic decision makers, front line delivery professionals, and Health Inclusion cohorts themselves it recommended that amongst possible commissioning options for the future could include:

  “A more ambitious roving health service would involve a dedicated team of staff working with marginalised groups on a rolling programme of specific health awareness campaigns, delivering specific health interventions and undertaking action research with the most marginalised communities”

  Alongside this evaluation in between 2022-2023 a Homelessness health needs assessment, and a Gypsy and Traveller health needs assessment were undertaken by Groundswell and by Leeds GATE in partnership with Wakefield Council’s Public Health Team. Both health needs assessments made recommendations around the commissioning of outreach services to better meet the needs of these Health Inclusion cohorts.

  Core20+5 funds became available both at ICB region and at place. Place based decisions were taken for the development of a service specification for a Roving Health Inclusion service who would complement Primary Care by providing a peripatetic Primary Care service providing health assessments, vaccinations, mental health support, and social prescribing for Health Inclusion cohorts across the district. This service was awarded to Bevan Healthcare and went live in May 2023.

  Spectrum Community Health CIC were awarded Core20+5 funding to continue and consolidate WYFI+, an existing team of staff who support people with complex social needs such as homelessness, mental health, and substance use. This also included the continuation of a post developed during COVID-19, to carry out health needs assessments for homeless people and support them to access appropriate health services.

  Core20+5 monies were also awarded at region for Leeds GATE to improve health outcomes for Gypsy and Travellers across West Yorkshire regions, and to Maternity Stream of Sanctuary to improve the health and social outcomes of pregnant asylum seekers in Wakefield’s Initial Accommodation Centre.

  The Gypsy and Traveller health needs assessment and Homelessness health needs assessments both have active strategic and operational action plans, facilitated by Public Health and with senior strategic commitment to progress, and with a commitment to co-produce solutions and value the voices of those with lived experience.

  Other key achievements:

  There is improved knowledge, skills, resource, and services dedicated to the improvement of outcomes for Health Inclusion cohorts in Wakefield District. Working practices when meeting the needs of these cohorts have improved as they have become more embedded into the culture of the local Health and Social Care economy.

  Having a suitably skilled and culturally aware workforce with an interest in working with Health Inclusion cohorts was important in planning and providing quality and consistent care. The model has facilitated wider partnership working and more education, skills development, and working experience regarding Health Inclusion cohorts within Primary Care, VCSE and Mental Health services. There is overall a greater and more co-ordinated ambition in decision makers to meet Health Inclusion needs through targeted work; a vision which includes partnership working, especially with those with lived experience, learning from best practice both regionally and nationally.

  The commissioning of specialist services and projects to address the needs of Health Inclusion cohorts is evidence of system change in response to the needs of these groups. This system change will be embedded into future practice and commissioning considerations. Further developments continue in the undertaking of a migrant health needs assessment for all migrant communities living within the Wakefield district.

  Authors:

  Pat McCusker, COVID Response Manager Vulnerability and Health Inequality, Wakefield Council

  Emma Smith, Head of Health Protection, Wakefield Council

  Kerry Murphy, Public Health Manager (Health Inequalities and Poverty), Wakefield Council

  Natalie Knowles, Primary Care Development Manager, Wakefield District Health & Care Partnership

• NHSE Southwest Screening and Immunisation Team (SIT) response to National recommendations of Diphtheria Vaccinations and Treatment for Refugees and Asylum Seekers in Hotels

  by Lisa Harrison, almost 3 years ago

  Background

  In November 2022 UKHSA noted a marked increase in the number of cases caused by toxigenic Corynebacterium diphtheriae reported amongst asylum seekers in England.

  The majority of the cases were identified in new arrivals to the two large initial reception centres for asylum seekers in Kent (Manston and the Kent unit for unaccompanied minors).

  Further cases have also been identified further along the asylum seeker (AS) pathway in individuals who have been relocated into hotel accommodations settings across England, including in the South West.

  Most cases will have likely acquired the infection in their country of origin or during... Continue reading

  Background

  In November 2022 UKHSA noted a marked increase in the number of cases caused by toxigenic Corynebacterium diphtheriae reported amongst asylum seekers in England.

  The majority of the cases were identified in new arrivals to the two large initial reception centres for asylum seekers in Kent (Manston and the Kent unit for unaccompanied minors).

  Further cases have also been identified further along the asylum seeker (AS) pathway in individuals who have been relocated into hotel accommodations settings across England, including in the South West.

  Most cases will have likely acquired the infection in their country of origin or during their journey to the UK but due to the extended stays in the initial reception centres in late October – early November, it cannot be ruled out that transmission occurred in these settings as well.

  From the 11^th November UKHSA recommended that a course of Diphtheria antibiotic prophylaxis and a single dose of diphtheria containing vaccine was recommended for the following groups for Asylum seekers who arrive to the Manston and Kent intake units from after the 31^st October 2022 until October 2023.

  As recommended by UKHSA, these patients should have a clinical assessment once arrived at their hotel accommodation and be supported in registering with a GP so that through primary care, all residents can be immunised to be in line with the routine UK immunisation schedule.

  NHSE South West Screening and Immunisation Team (SIT) Response

  The South West NHSE SIT responded to the preliminary UKHSA recommendations on the 9^th November by directly contacting the regional systems with hotels which had been quickly stood up for newly arrived asylum seekers. We supported them with any initial queries and concerns.

  By the 10^th November, the SIT created and distributed Operational Plans for the delivery of Diphtheria Vaccination and Treatment in first two SW regions, Cornwall and Devon.

  On the 10^th November, the SIT ensured that we had a rapid response workplan to support various SW regions once they were notified by the Home Office of a hotel being stood up in the region for newly arrived Asylum Seekers.

  As a result of this rapid and collaborative response from both the South West regional systems and the South West SIT, the South West had one of the earliest responses in the UK to the management of this national incident with the first asylum seekers being offered vaccinations and treatment on the 15^th November 2022.

  In the ongoing response since November 2022, the South West SIT have supported the seven South West regions in the following ways:

  
  1. Support and Co-ordination

  • Bringing together or ensuring all appropriate stakeholders were a part of operational meetings to discuss the ongoing response to the diphtheria vaccination and prophylaxis response through our already established links with the systems, local authorities, hotel management and GPs
  • Ensuring our wider team understood the added workforce issues for the relevant teams / GPs and how this may impact upon other immunisation programmes such as winter vaccinations like Flu and COVID.
  • Regularly engaged with systems to support in their planning for their response and answering or addressing any immunisation queries or concerns
  • Sharing best practice from the local SW Migrant Health Network, the gov.uk Migrant Health Guide and any translated materials available from the 11^th November
  • Shared translated information leaflets, consent forms and updated UKHSA publication summaries.
  • Escalating any concerns from the regions to the national team.
  • Later on in November we shared best practice / lessons learned between the regions and supported the networking of the clinicians and programme managers in the South West to support a co-ordinated response
    
    2. Public Health Advice and Emergency Support
  • Advised other vaccines which could be co-administered with a view of mitigating the risk of any other outbreaks, for example, Measles.
  • As a result of people being brought together into one setting there were outbreaks of other communicable diseases / infections such as scabies whereby UKSHA chaired and ran health protection meetings.
  • Our team would support in these meetings by ensuring all appropriate meeting members were present through our established links with the systems, local authorities, hotel management and GPs on the diphtheria response.
  • We would also support with any issues raised in relation to routine immunisation and screening programmes.
  • Signposted to services to support with any other health concerns raised in the hotels including;
  • Sharing the contact details for the SW Health Protection Team for any notified health protection outbreaks
  • Advising best contacts for dental concerns
  • Sharing known local authority contacts for food banks and clothing
  • On the behalf of the regions, we have supported in ordering emergency stocks of vaccines from Immform and ensuring the delivery was made with a short turnaround of 48 hours to meet the 10-day timeline.
    
    3. Monitoring and Evaluation
  • As part of the national ask, we collated the data from the South West regions to measure the uptake of the people offered the diphtheria vaccinations and treatment.
  • We also collated lessons learned from the regions which included:
  • Try to gain as much demographic information as possible about the population in the hotel – mainly people’s age and spoken language. This should be shared by Clearsprings (Home Office) or through the introductory visit (if there is the time permitting).
  • Record treatment/antibiotics given with a person’s hotel number to be assured have the details of the correct person as DOB’s or people’s names may be unreliable. This was advised before the development of the UKHSA diphtheria vaccinations and treatment card which is now given to all vaccinated in relation to this incident.
  • For translation – if no formal resources are available to consider identifying any residents who are able to translate for others as they can be seen as a trusted champion for vaccination/antibiotics in the hotel to support uptake, as well as supporting in the translation of information.

• Specialist Health Visitor for Vulnerable Families in Temporary Accommodation in Hounslow

  by Lisa Gordon, almost 3 years ago

  Background

  Health visitors are registered nurses or midwives who have additional specialist training in public health. They work with families from pregnancy to starting school. They are in a unique position as the ‘eyes and ears’ of the community, with contacts carried out in the family home.

  During the Covid 19 pandemic, the number of asylum seeker families staying in temporary accommodation in hotels in Hounslow increased. This increase was recognised by members of the health visiting team and created an unmet health need.

  We took steps to improve access to healthcare for these vulnerable families and this culminated in... Continue reading

  Background

  Health visitors are registered nurses or midwives who have additional specialist training in public health. They work with families from pregnancy to starting school. They are in a unique position as the ‘eyes and ears’ of the community, with contacts carried out in the family home.

  During the Covid 19 pandemic, the number of asylum seeker families staying in temporary accommodation in hotels in Hounslow increased. This increase was recognised by members of the health visiting team and created an unmet health need.

  We took steps to improve access to healthcare for these vulnerable families and this culminated in the creation of a Specialist Health Visitor role for Vulnerable Families in Temporary Accommodation in the Hounslow health visiting team in November 2022.

  The increase in asylum seekers and the increase in health needs related to this community inspired us to create this role. We felt that it was more beneficial for the families to have one person they could build a relationship with and trust rather than having different health visitors.

  We also had a vision of having a lead person who would advocate for the families and influence decision making while working with other partners.

  The number of asylum seekers living in hotels in Hounslow fluctuates, but currently there are circa 100 mothers/expectant mothers and 200 children aged under 5 housed in seven hotels. The families come from countries such as Albania, Afghanistan, Iran, Iraq and Syria and face a life of uncertainty. Parents and children have experienced trauma in their home countries and on their journeys to England and mental health support is a priority.

  Improving access to our service

  Telephone language interpreters are used for face-to-face contacts when needed and information leaflets are provided in the home language of the family.

  Text messaging and communication via email is preferred by clients rather than telephone calls as they are able to use technology to translate communications. This population rely on hotel wifi as they frequently do not have credit on their phones. The specialist health visitor has therefore adjusted her methods of communicating with this group accordingly.

  The specialist health visitor spends days and half days at the hotels thus increasing visibility and access to the health visiting service.

  Meeting the needs of individual service users

  This role adds value by collaborating across disciplines and stakeholder groups to meet healthcare needs. On the occasion of a planned closure of one the hotels, the specialist health visitor wrote supporting letters for two of the most vulnerable families living there. The letters outlined the reasons why the families needed to be re-housed in the local area so they could continue to access vital health and wellbeing services.

  The post-holder works collaboratively with hotels and other services such as midwifery, dietitians, and primary health care to suggest improvements to the food provided at the hotels.

  The specialist health visitor has met with local MPs and councillors to share her concerns for this vulnerable population. She has also liaised with senior colleagues in primary care, Hounslow Borough Council and safeguarding. In addition, relationships have been built with the hotel staff supporting the families and local charities and voluntary organisations. All with the same aim – to support the health and wellbeing of this vulnerable group who can find it difficult to navigate systems and who do not always have a voice.

  Outcomes

  • Keeping children free from harm – this new role has enabled focused attention on the health needs of this vulnerable group
  • Ensuring that children live in safe and appropriate accommodation - the specialist health visitor identified security concerns at one of the hotels. The concerns were shared with the relevant safeguarding teams and the company that manages the hotels on behalf of the Home Office. As a result of sharing this information, security was increased the next day and within two weeks all the service users were moved to alternative accommodation.
  • Early identification of health needs and prompt referral to services - the residents at the same hotel had not registered with local GPs and their health needs were not being met. Within 24 hours a team of welfare officers were at the site assisting the families to access the care they needed.
  • Funding for free vitamins for this cohort has been secured.

  Feedback

  Feedback from one of the charities working at the hotel since the creation of this specialist service:

  “Since health visiting created a specialist role for this community there has been a dramatic change. I have seen a marked difference in how supported families are feeling.

  For example:

  - I am able to signpost or refer families to the post holder and give them her name, which I can see immediately reduces the anxiety for the family.

  - The post holder has worked tirelessly to advocate for the families including meeting with the hotel staff to campaign for better food, and she has secured funding from the local public health team to ensure pregnant women and small children get the vitamins they need.

  - Families supported by the post holder feel more able to trust in local services and are therefore more likely to access local community groups.”

  The role has helped to keep vulnerable children in Hounslow safe from harm, health needs have been identified and referrals made to relevant services.

  Next steps

  We would like to apply for funding to expand the team to broaden the skill mix and improve access and health outcomes for these vulnerable children.

• RESET Project

  by Alex Leeder, almost 3 years ago

  Following Shropshire Council being awarded £1.4 million following a successful bid for funding to support rough sleepers and those at risk of rough sleeping via the Rough Sleepers Drug and Alcohol Treatment Grant provided by the Office of Health Improvement and Disparities (OHID) commissioned partners have worked together to establish the RESET project.

  The project will support the county in meeting the intended outcomes of the national drug strategy by helping to reduce drug-related deaths, reducing alcohol-related hospital admissions and increasing the number of successful individuals in treatment.

  RESET is a multi-agency team (MDT) that provides holistic wrap-around support and... Continue reading

  Following Shropshire Council being awarded £1.4 million following a successful bid for funding to support rough sleepers and those at risk of rough sleeping via the Rough Sleepers Drug and Alcohol Treatment Grant provided by the Office of Health Improvement and Disparities (OHID) commissioned partners have worked together to establish the RESET project.

  The project will support the county in meeting the intended outcomes of the national drug strategy by helping to reduce drug-related deaths, reducing alcohol-related hospital admissions and increasing the number of successful individuals in treatment.

  RESET is a multi-agency team (MDT) that provides holistic wrap-around support and drug and alcohol treatment for rough sleepers and those at risk of rough sleeping across the county. Partners of the project are Shropshire Council, Shropshire Recovery Partnership, the Midlands Partnership Foundation Trust (MPFT), Shropshire Domestic Abuse Service (SDAS), The Shrewsbury Ark and Intuitive Thinking Skills.
  
  

  The RESET Project design and implementation has required close working between partners and key stakeholders to ensure that a robust service is available to those in need of support. RESET have been operational as a team since February and have been able to provide wrap around support to those engaged with the project.

  The project has the resource of a harm reduction outreach van that will ensure that the project has a county wide focus and will serve as a tool to connect potential service users with a wide range of support from across the RESET partnership.

  The following case study provide an overview of the partnership work that has been undertaken by the RESET project.

  Case Study 1: R's RESET TREATMENT AND RECOVERY JOURNEY.

  R is a 35-year-old male who struggles with opiate, crack cocaine and alcohol addiction. He injects daily into the groin, which puts him at risk of overdose with continued use of illicit substances. He is also at risk of blood-borne viruses with injecting, sepsis and endocarditis due to self-neglect of physical health. R has engaged with services in the past but has struggled to maintain consistent engagement.

  Since RESET engaged with R he has been prescribed a supervised Methadone treatment of 60ml daily at the pharmacy. He has begun to regularly engage with the wider RESET team and medical reviews where he is looking to titrate further.

  R is known to self-neglect his physical health and has missed hospital appointments in the past. He sleeps on the streets with his brother or occasionally sofa surfs. R can access the Ark where the wider RESET team can engage regularly.

  The main effort is to provide ongoing support, through specifically the Recovery Worker, ITS and housing on his long-term recovery plan. The focus remains on detox/rehab and mental health treatment.

  R has made significant progress since RESET started to engage with him. Whilst there is a long path of treatment ahead, the RESET model of trust building, extensive, detailed and co-ordinated wrap-around care plans and regular engagement has allowed RL to take ownership of his life and his treatment.

• Haref: Cultural Competency Training and Haref Allies Membership

  by Haref-Connected Voice, almost 3 years ago
  

  Draft Principle: Develop the Workforce for inclusion Health

  Organisations involved:

  Haref strives for health equity for ethnically marginalised communities in Newcastle and Gateshead.

  Our Haref Network is made up of over 80 community organisations working with ethnically marginalised communities in Newcastle and Gateshead. As a network we identify barriers to good health, come together to be a stronger voice and work in collaboration, identify ways to be involved in research, and work with local health services.

  Information from the Network feeds into the work we do with our Haref Allies, health and wellbeing service providers working in Newcastle and... Continue reading

  Draft Principle: Develop the Workforce for inclusion Health

  Organisations involved:

  Haref strives for health equity for ethnically marginalised communities in Newcastle and Gateshead.

  Our Haref Network is made up of over 80 community organisations working with ethnically marginalised communities in Newcastle and Gateshead. As a network we identify barriers to good health, come together to be a stronger voice and work in collaboration, identify ways to be involved in research, and work with local health services.

  Information from the Network feeds into the work we do with our Haref Allies, health and wellbeing service providers working in Newcastle and Gateshead. We work with our Haref Allies to improve their understanding and confidence to work with diverse communities, supported by our Cultural Competency Training. We share good practice and information about health, research, and local events through our monthly Haref Bulletin, which has over 850 subscribers.

  Haref is a service area of Connected Voice, the infrastructure organisation for the VCSE sector across Newcastle and Gateshead.

  The challenge:

  Our focus at Haref is on health equity for ethnically marginalised communities and refugees and people seeking asylum. We know members of these groups often face inequalities in health from accessing health services, receiving accessible health information, registering at GPs, receiving culturally competent care, and experience inequalities in the wider social determinants of health.

  We look at the issue of health equity from many perspectives but in this case study we are focussing on the challenges of cultural competency in health services, providing training for health and wellbeing services to improve service delivery for diverse communities, and connecting health services and community groups together to build stronger relationships.

  We try to influence change across many levels, from individual practitioners to changes in policy.

  The approach/solution:

  Cultural Competency training:

  We deliver Cultural Competency – working with ethnically marginalised people in health settings to increase cultural sensitivity in the workforce and raise understanding for practitioners of the barriers to achieving equitable outcomes.

  This is funded by Newcastle Public Health and we are able to deliver this training to health and wellbeing service providers (both statutory and VCSE) for free in Newcastle. We also deliver our Cultural Competency training on a paid-for basis both regionally and nationally.

  Connected Voice’s Haref Network provide lived experience of barriers to achieving health equity in the training both in the form of short videos incorporated into the training and generally informing the content. This brings the training to life as it is relevant, local and in real time.

  Haref Allies:

  In 2022, we developed the Haref Allies membership in consultation with health services to strengthen our current work, engage better with health services, and forge stronger links between the Allies and the Haref Network. Our annual membership fee is kept deliberately low to ensure cost is not a barrier, but increases commitment to the issues we are tackling.

  Between May 1 2022 and April 30 2023, 111 Allies from 60 organisations joined. From May 2023 we already have had 28 Allies renew their membership.

  Allies meet throughout the year. At Allies meetings we bring information from the network and invite network speakers to share information about communities and their health needs. Allies meetings are themed around the network’s health priorities and we ask the Allies to work together to develop solutions and ideas.

  By becoming members, our Allies pledge to:

  • Support the Haref Network, and respond with solutions to the experiences of ethnically marginalised communities accessing health services
  • Commit to improve health and wellbeing services for ethnically marginalised communities in Newcastle and Gateshead
  • Support other Haref Allies to improve their service provision and share good practice for service delivery

  Examples of these pledges in action are:

  • Setting up and facilitating health information sessions on topics requested by the Network and delivered by the Allies (i.e. mental health support, navigating the NHS for new arrivals, providing health checks) along with running good practice sessions with Allies on how best to run health information sessions.
  • Working with the Allies and the Network to develop a public leaflet on peoples’ rights to an interpreter in health settings.
  • Facilitating external partner training for the Haref Allies on issues such as how to work better with interpreters in a work setting.

  Required Cultural Competency Training

  Allies are required to complete Cultural Competency training within 6 months of signing up for membership to encourage health and wellbeing services to deliver their service information in culturally sensitive ways.

  We offer additional internal training such as: ‘Best practice on delivering health information’, ‘Understanding the Causes of Health Inequalities’, and direct them to external training from our partners.

  Insights and Impacts:

  Date range (membership)	Allies	Trained in Cultural competency	Unable to complete training
  May 2022 to April 30 2023	111	82	29
  May 2023 to April 2024	28	Sessions offered from June 2023

  Total number of health and wellbeing practitioners delivering services in Newcastle who received cultural competency – working with ethnically marginalised people in health settings as part of the public health contract:

  1 Aug 2021 to 31 July 2022: 301

  1 Aug 2022 to 5 June 2023: 211

  94.6% of participants feel their confidence has increased following the course.

  What People Said:

  Quotes from Allies

  • ‘Being a part of that network brings integrity and quality to our work. It makes our involvement work meaningful. We have been able to do outreach. Haref is brilliant at introducing people. They speed up the process. They are like a trusted bridge. They help organisations think about how they work with communities in a meaningful and accessible way’
  • ‘The Allies and Network, that makes so much sense. The building up of the network and Allies is useful, and can be built on as an organic progress. Things can spin off from communication between organisations.’

  Quotes from Cultural Competency Training Evaluation

  • ‘The course was great, a good mix of information as well as discussion. I feel this has prompted myself, and in turn our organisation to consider and take action on ways we can improve our work with ethnically minoritised communities and in removing barriers to using our service. I appreciated the experiences that were shared as well. Thank you for the course.’
  • ‘The video clip in particular highlighted the sheer number of issues which people face any one of which can lead to them having a poor experience’.

  Tips for Success:

  The facilitator attends all Network meetings and incorporates the key concerns of the Network into the session delivery. This makes this Cultural Competency unique as it is local, relevant and continually evolving. Participants really appreciate this and can connect it directly to their service provision. We work collaboratively so there is a feedback loop from the Allies and Network officer, research that we are involved with, and key health information from the Health Equity and Inclusion Lead.

  The training facilitator brings over 12 years’ experience working in Newcastle through health-funded third sector projects. This has enabled quality service-specific facilitated discussions and a problem-solving focus when delivering directly to organisations, enhanced by knowledge of services in the Locality.

  The learning outcomes are measurable through the evaluation process and consistently achieved:

  • Explore what do we mean by culture?
  • Understand the diverse and intersecting characteristics of local communities
  • Develop skills to identify barriers to accessing services
  • Recognise good practice
  • Feel more confident in working with different communities

  The Allies membership is promoted through the training and our social media and website. Frequently, a participant will attend the session, enquire about Allies membership post course and request session delivery to their whole organisation. This has led to a wait list for delivery and regular signups for Allies membership as the model is gaining traction.

  What’s Next?

  This year we will start offering skills-building sessions outside of regular meetings, focussing on a key area for concern for the Network. The first session will be on best practice in health services for access to interpreters and translators. We hope this will encourage services to work together to build capacity to offer a holistic approach to tackling health inequalities locally.

  We will continue to expand the Haref Allies to other health services in Newcastle and Gateshead. We do this by attending conferences and events, delivering presentations in order to raise the profile of the Haref Allies membership, as well as following up on all new leads and introductions presented to the Allies officer. We actively look out for new services and organisations to sign up and directly approach them.

  We have permission from our organisation to share this case study. We give permission for NHSE to share this case study and publish it as part of the frame work. We give permission for our logo to be used.

  
  

• South West Migrant Health Network

  by Mina Fatemi, almost 3 years ago

  The South West Migrant Health Network is a multiagency forum with membership from the NHS, OHID, public health, local authorities, third sector, frontline staff and people with lived experience.

  The network’s objectives include sharing best practice, sources of data and information and provision of support to professionals working with vulnerable migrants. Tackling health inequalities, with a focus on Core20Plus5 and wider determinants of health, is a core focus of the group.

  This network aims to address the ongoing problems that have been identified in the workstreams related to vulnerable migrants, including:

  • limited shared resources/information and single points of reference for... Continue reading

  The South West Migrant Health Network is a multiagency forum with membership from the NHS, OHID, public health, local authorities, third sector, frontline staff and people with lived experience.

  The network’s objectives include sharing best practice, sources of data and information and provision of support to professionals working with vulnerable migrants. Tackling health inequalities, with a focus on Core20Plus5 and wider determinants of health, is a core focus of the group.

  This network aims to address the ongoing problems that have been identified in the workstreams related to vulnerable migrants, including:

  • limited shared resources/information and single points of reference for sharing of experiences and good practices for those working with migrants;
  • lack of multiagency forum for shared discussion, raising of current and future challenges and resource sharing;
  • lack of a forum for escalation of reported challenges to migrant health in the region; and
  • no website or other one-stop online location for information and resources accessible to NHS staff and external stakeholders.

  The Migrant Health Networks provides an opportunity for professionals working with migrants to raise concerns and receive support and advice in tackling challenges in improving the health and well-being of migrants. Some of the examples of work are:

  • Improving oral health and dentistry provision for asylum seekers living in contingency accommodations.
  • Sharing of multilingual resources for vaccination, immunology guidelines and the guide to the NHS. Some of the non-English languages include Arabic (for the Syrian re-settlement programme), Chinese (for the Hong Kong programme), Farsi (for Afghan refugees) and most recently Russian and Ukrainian (for those fleeing Ukraine)
  • Sharing resources and examples of good practice for delivering MECC (Making Every Contact Count) interventions for asylum seekers and resettled communities both in asylum seeker accommodations and community-based health clinics.
  • Research, practice and policy collaborations have been nurtured and examples have been included in research funding bids (for example a successful bid to the National Institute for Health and Care Research under the Health and Social Care Delivery research awards has enabled the co-design of a peer-led community approach to support mental health in refugees.[1]
  • Creating a Future NHS workspace, where a wealth of resources to support migrant health are available.

  
  

  [1] National Institute for Health and Care Research (2022). Forced to flee. Co-designing a peer-led community approach to support the mental health of refugees. London: National Institute for Health and Care Research (https://fundingawards.nihr.ac.uk/award/NIHR134589, accessed 9 December 2022).

  
  

  
  

• North Central London Inclusion Health Needs Assessment

  by Priyal Shah, almost 3 years ago

  People in Inclusion Health groups face the most significant health inequalities of any group in our population – often compounded by the impact of intersectionality/multiple disadvantage. Addressing health inequalities faced by inclusion health groups is a key component of the NCL Population Health and Integration Strategy and one of our locally identified PLUS populations from the CORE20PLUS5 framework, because the needs of these populations can only be solved by working together with our partners.

  Tackling inclusion health inequalities requires integrated service approaches and partnership working at system, place and neighbourhood level to address the complex set of needs these populations... Continue reading

  People in Inclusion Health groups face the most significant health inequalities of any group in our population – often compounded by the impact of intersectionality/multiple disadvantage. Addressing health inequalities faced by inclusion health groups is a key component of the NCL Population Health and Integration Strategy and one of our locally identified PLUS populations from the CORE20PLUS5 framework, because the needs of these populations can only be solved by working together with our partners.

  Tackling inclusion health inequalities requires integrated service approaches and partnership working at system, place and neighbourhood level to address the complex set of needs these populations experience. Integrating care around these underserved groups is fundamentally linked to improving how we use our resources most effectively. The annual cost of unplanned care for patients experiencing homelessness is eight times that of the housed population. The estimated annual cost across all agencies for people who sleep rough in North Central London (NCL) is £149m.

  North Central London comprises the Boroughs of Barnet, Camden, Enfield, Haringey and Islington. Within North Central London, there are a number of excellent borough-based services providing care and support for various inclusion health groups such as outreach sexual health services and specialist homeless health services. However there was a real gap in systematic evidence and information for these population groups, in terms of demographics, health needs, service provision and gaps to inform strategic commissioning and wider integrated partnership working. Each borough had limited and varied information about inclusion health groups.

  North Central London ICB working in partnership with Directors of Public Health for the five boroughs and borough leads for homeless and inclusion health developed plans for an Inclusion Health Needs Assessment (HNA). The aim was to better understand the demographics, health needs and barriers to healthcare for people in inclusion groups, with a focus on people experiencing homelessness, Gypsy, Roma and Traveller communities, sex workers, vulnerable migrants and those with a history of imprisonment. It made sense to work at a system level to collate the HNA as it enabled us to draw on the expertise, experience and relationships certain boroughs had developed with particular inclusion groups.

  Conducting the Inclusion HNA

  The Inclusion HNA was conducted in two phases. The first phase was a collation of available evidence and information on the inclusion health groups from a range of sources, including national databases, service data and Council-held data. Phase one Rapid Evidence Review identified the size and demographic profile, health needs, services and gaps for inclusion health groups. Phase two comprised extensive engagement with senior stakeholders and individuals with lived experience as well as a staff survey. The aim was to complement demographic data with lived and staff experiences. A total of 24 senior stakeholders from across health, Councils, housing and the voluntary sector were interviewed to get a broad strategic view on inclusion health across the system. Over 140 staff from health, housing, social care and voluntary sector completed the survey to share their experiences of delivering care and support to inclusion health groups. Twenty-four people with lived experience of inclusion health were interviewed by Groundswell (a charity supporting people experiencing homelessness) from across the five broughs and with varied lived experience of multiple disadvantage and social exclusion.

  The Inclusion HNA highlighted a number of factors:

  Across the five groups, evidence on people experiencing homelessness is the most recent, local and comprehensive, while there is limited local evidence on people with a history of imprisonment, undocumented migrants, sex workers and Roma communities.

  There are overlaps among inclusion health groups, with many individuals facing severe multiple disadvantage and common drivers of social exclusion that push people into homelessness, sex work and prison.

  Within the 5 broad inclusion health categories, there is also substantial diversity: people with a history of imprisonment; those engaged in direct (on and off-street), survival and indirect sex work; Romany Gypsies, Irish travellers, Roma people, travelling show people, new travellers and liveaboard boaters; asylum seekers, refugees and undocumented migrants; rough sleepers, statutory, single and hidden homelessness.

  Inclusion health groups often have many similar health needs, particularly related to mental health, substance abuse, TB and STIs and untreated long-term conditions, leading to higher mortality.

  Common barriers in accessing healthcare across groups include: fear of stigma and discrimination, lack of identification or proof of permanent address, lack of awareness of the healthcare system and entitlements, trauma triggers, language and digital exclusion. Sex workers and undocumented migrants face additional fears of prosecution.

  Insights and impacts

  The Inclusion HNA has received enormous support and input from stakeholders across the system, including the Borough Partnerships, Health and Wellbeing Boards and the NCL Population Health Integration Committee. The Inclusion HNA has enabled us to improve cross-borough equity of service provision within NCL and has provided the evidence for system-wide opportunities related to particular inclusion health groups. The findings from the Inclusion HNA has encourage place-based discussions to identify Borough Partnership priorities for inclusion health groups.

  • Based on the evidence and insight from the Inclusion HNA, one of the boroughs will be hosting an Inclusion Health Summit for later in 2023 with the aim of raising awareness on inclusion health, sharing information and facilitating collaboration across services.
  • NCL ICB has commissioned a project on participation for individuals with lived experience of homelessness, multiple disadvantage and inclusion health to enable them to contribute to service design as equal partners.
  • A pan-NCL Homeless Health and Care Community of Practice was launched in May 2023 to enable sharing of good practice, collaboration and partnerships across the system as this was a gap highlighted in the Inclusion HNA. The aspiration is to extend these to cover other inclusion health groups over time.
  • A focus on inclusion health has ensured equity of primary care provision for people experiencing homelessness across the five boroughs through the commissioning of additional specialist homeless GP services in two boroughs.

  Feedback on the Inclusion HNA

  NCL director of Public Health, “Well done to the team for this excellent piece of work. Look forward to continuing to work on this including through the health inclusion summit we have planned.”

  In relation to the case studies and lived experience within the Inclusion HNA, NCL joint commissioning lead, “This is a sobering read”.

  Key NCL ICB stakeholder, “Inclusion health has to be embedded in the clinical strategy and reviewed in the context of the system and its governance. That brings in financial conversations and resource conversations; for example, the Health Inequalities Fund which can support key programs of work.”

  Tips for success and lessons to take forward

  The combination of demographic and published data alongside lived experience and staff experience provides valuable insight and opportunities for the system to focus on. The addition of journey-maps and case studies of individuals with lived experience within the Inclusion HNA portrays the complexity of inclusion health and multiple disadvantage, highlighting the different factors, services and interactions that impact on a person.

  There were a number of limitations and lessons to take forward.

  For lived experience interviews:

  • It is important to work with charities and experts with lived experience of specific inclusion groups when conducting peer research, as these experiences may not be translatable across the groups.
  • Engaging with sex workers and GRT communities was particularly difficult, requiring more time and resource which was not available. For example, to properly engage with the Roma community, researchers who speak Bulgarian are needed.
  • Additional resource and capacity for translation should be factored in.

  For demographic profiles:

  • Demographic profile data for inclusion groups is challenging to collate, varies according to source and coding methodology and, fluctuates over time as inclusion health groups are often transient. Consistency in coding and data collection across services and organisations is important for service planning, delivery and evaluation.

  Next steps

  There are a number of additional plans in development based on the findings of the Inclusion HNA:

  • A focussed piece of work on improving access and experience for sex workers and vulnerable women in inclusion health groups is planned. This will include experts from the voluntary sectors as well as services that support women with a history of offending and violence against women and girls (VAWG) to ensure a relatively broad scope.
  • Build on the pan-London co-occurring conditions programme to improve service provision for individuals in inclusion health groups.
  • Improve coordination of care and support for prison leavers (e.g. GP registration, access to substance use and mental health and wider support services) to reduce risk of re-offending.
  • Develop plans to improve access to dental care for inclusion health groups.
  • Focussed, culturally and linguistically appropriate engagement with asylum seekers and Gypsy, Roma and Traveller communities.

  There are planned regional workshops around Primary Care and Homeless and Inclusion Health that NCL will be co-producing. These include reviewing Locally Commissioned Services (LCS) for homeless and inclusion health currently in practice across London. There is considerable crossover in terms of unmet need between multiple inclusion health groups and the Inclusion HNA report provides valuable contextual background that can help shape conversations in terms of what should be included within the context of LCSs going forward, in the interest of formulating a framework for best practice.

  This links to framework principle 2
  
  We have permission to share this, happy for it to be published by NHSE and for NHS NCL ICB and ICS logos to be used

• Homeless Step Down Pathway Case Study 10

  by Teri Milewska, almost 3 years ago

  CASE STUDY

  By Kattya Mayre-Chilton

  Specialist Dietitian B7 DT25287

  Mildmay Hospital

  This is a case study I would like to bring to everyone's attention given the special circumstances in which it took place. It not common for the therapist to key work the patients on the homeless pathway but I felt compelled to do so given the patient's predicament and complex dietetic intervention. He is not recognised as a resident in this country, nor his home country due to a lack of paperwork and a passport.

  He had no traceable next of kin, and even if he were to return... Continue reading

  CASE STUDY

  By Kattya Mayre-Chilton

  Specialist Dietitian B7 DT25287

  Mildmay Hospital

  This is a case study I would like to bring to everyone's attention given the special circumstances in which it took place. It not common for the therapist to key work the patients on the homeless pathway but I felt compelled to do so given the patient's predicament and complex dietetic intervention. He is not recognised as a resident in this country, nor his home country due to a lack of paperwork and a passport.

  He had no traceable next of kin, and even if he were to return home we would not how it would be possible to maintain the necessary level of care given the perilous situation in his native country.

  This gentleman, 55 years old from the Union of Soviet Socialist Republics (USSR) era, entered the UK before 1992, as an immigrant smuggled in the back of a truck. He was originally from the Ukraine area of the USSR and had no documents. This was his third admission to Mildmay since 2020. He was referred to dietetic intervention on his third admission when he was transferred after he had a Stroke (left middle cerebral artery (MCA) infarct) with complicating expressive and receptive dysphasia (receptive dysphasia is difficulty in comprehension and expressive dysphasia is difficulty in putting words together to make meaning). He was being fed via a percutaneous endoscopic gastrostomy (PEG) feeding tube (to prevent aspiration pneumonia) due to unsafe swallowing. PEG feed and care and discharge planning requires extensive monitoring and handover from the dietitian, for this reason I volunteered to help the homeless team and key work on his behalf.

  This gentleman was always referred through the homeless pathway as he had no immigration status in UK but cannot go back to the dissolution of the Soviet Union, Ukraine zone, as he has no passport or identification to get travel pass. Our housing officer explore this during his admission over 2020 and 2021, where the Ukraine embassy would not recognise him as a citizen because he has no passport. She also identified that he had a daughter but all ways to contact her failed. During his third admission in 2022 and with his complex clinical needs it was even less likely to be returned to the Ukraine war zone and harder for us to locate his daughter.

  This gentleman required long term enteral feeding via a PEG due to unsafe swallowing, and being unlikely to be able to meet his nutritional requirements without this support. The PEG was also used to maintain his hydration and delivery of medication such as his medication to treat seizures (Levetiracetam) twice a day; dispersible aspirin daily; to treat ulcers by slowing down the food transition (Propantheline) three times a day; for elevated cholesterol (Atorvastatin) daily; to help with sleeping hormone Melatonin was given daily and 'when required'.

  His weight on admission (Aug 2022) was 77.9kg, height 1.86m with a body mass index (BMI) of 22.5kg/m2 classified in the healthy weight range, malnutrition universal screening tool (MUST) score >2. The following graph shows an upward trend for weight gain. He did have a few troughs when he increased his activity levels or when he had episodes of diarrhoea. On discharge (Feb 2023) his weight was 83.1kg with a BMI of 24.0kg/m2 in the healthy range, MUST >2 because he needed PEG support. He gained 5.2kg (6.25%) during this admission.

  His estimated requirements targets were calculated, based on his weight, for energy to be 2337kcal,with protein 78-116g and fluids to meet 2.7L per day.

  He was nil by mouth (NBM) with regular mouth care. All his nutrition and hydration was delivered directly to the stomach via the PEG, this is known as Enteral Nutrition using a tube feeding. The PEG tube insertion was on the 14 July 2022. It was a 15FG Freka in diameter with a skin gastric lumen distance of 4cm. There were no reported complications. This is important information to handover in case the PEG needs replacing at any point.

  At the acute hospital he was started on an overnight feeding regime and this was continued on transfer to Mildmay. This overnight feeding method is advisable to encourage patients to engage with rehabilitation care during the day. However, night staff found him frequently touching the tube which raised concerns of the tube getting dislodged (pulling the tube out or displacing).

  His feed was changed to a bolus feed regime, which allowed administration of 200–400 ml of feed down the PEG over 15–60 minutes at regular intervals. Bolus feeding can be similar to a normal feeding pattern, more convenient, and allows freedom of movement for the patient. He tolerated the bolus feed concentration and ingredient content.

  The established bolus regime feed volume was seven 200ml bottles of Fresubin Energy Fibre 200ml per day (total vol 1400ml/24hrs); with 50ml water flushes (to prevent the tube getting blocked) per and post each bolus delivery (total of 700ml/24hrs). Total provided by the feed was, for: Energy 2100kcal; Protein 78.4g and Fluids 2625ml/day.

  Any additional water to meet his requirements was given with his medication dilution and flushes. He had seven medication events per day. According to our Tube Feeding Procedure and Drugs - Management Administration of Medicines Procedure, all medication needed to be reviewed to enable them to be delivered via an enteral tube to the stomach and checked they did not react to the feed. Each separate medication was recommended to be dissolve or suspend use 15ml of sterile water. Administration involved the use of 30ml of sterile water for flushes (to prevent the tube getting blocked) pre and post each medication (total of 525ml/24hrs).

  The staff were trained (Hospital standards) and advised to ensure the patient was always positioned at >40 degrees during feeding and for 30 minutes after feeding stops. Using the appropriate feeding syringe (purple in colour), they feed slowly and gently through the tube, e.g. 250ml over 20 minutes. The prescribed water (50ml) was poured into the syringe and allow to flow through to flush the feeding tube appropriately.

  The PEG stoma site care required daily cleaning by nurses, during this cleaning any changes to appearance, colour or discharge were noted, to indicate any possible infection, and the medical team and the dietitian would be informed if any concerns were raised. We were more vigilant in monitoring this as due to the expressive and receptive dysphasia he was unable to tell us if he was in pain or discomfort. We used the communication tool developed by our Speech and language therapist (SLT) to help with understanding if he was in pain or not. He could point at pictures to indicate if he was happy or not. We used this to guide us on his possible preferences. Prior to him being discharged (2/3/23) the PEG stoma site looked clean, clear and slight pink colour, indicating no infection with the established track.

  Other stoma site care involved the PEG being advanced and rotated, at Mildmay this takes place every week on Thursdays. This weekly procedure is to prevent Buried Bumper syndrome, whereby holding the visible end of the tube and rotating it 360° (a complete circle) and advanced (push) the tube approximately 2 - 3cm into the stomach and pulling it back to the original position. Prior to him being discharged (2/3/23) there were no issues, and his PEG care was conducted appropriately.

  During his admission he had a couple for episodes of diarrhoea, samples were checked and they were not infectious. We hand to closely monitor his tolerance to the feed concentration, fibre content and rate of delivery until we found a feed and rate which he tolerated. Bowels were opening on average twice per day and loose ~200g, this was normal for him. We started to use the validated King's stool chart for enteral feeding to better monitor his bowel habits.

  SLTs worked intensively with him to help with communication, capacity and trialled oral options to improve his quality of life. Some of the challenges with oral trials with yogurt or teaspoons of water included coughing and hypersalivation. The nursing team reported that he was not managing oral secretions and he was not swallowing when given teaspoons of water. This was reviewed by SLT with close liaison with the allocated Independent Mental Capacity Advocate (IMCA) to determine if it was in his best interest to remain NBM.

  The physiotherapy team worked intensively with him and he was able to leave his room and sit by the nurses desk. There he could interact with everyone on the ward and he was engaged in looking at the newspaper, magazines as well as playing games with staff. On occasion we got to see a smile.

  In coordination with our social worker lead a referral was completed for an IMCA to be allocated to represent him because he had no family or contact available. Under the Mental Capacity Act 2005 the role of the IMCA is to legally safeguard his interests with regards to making decisions about where he wanted to be discharged to and about eating options risks and quality of life. The IMCA could not see any reasons why it was not in the patient's best interest given the current situation that he shouldn’t have a nursing care placement. The social worker lead completed a referral for the community social worker allocation. Once one was allocated we organised a discharge planning meeting, she attended and also conducted a capacity review with him. The team with the for the community social worker completed a full discharge decision tool form and the overall agreement was that the best place for him was a nursing care environment, ideally with some neuro-rehabilitation to help him continue to improve. The forms were submitted and the funding borough approved this.

  He was reviewed by 4 nursing homes, one specialised in Neurorehabilitation and the others offering more general care. The funding borough referred and selected the nursing home. Once we received the final approval we could proceed with planning for discharge and his transfer. This included calls to the nursing home by various members of staff to see what they had in the facility, what they required for us to send over for a safe discharge.

  From a dietetic viewpoint this included the regime, and they requested a month's feed supply (nine boxes were provided). They were supplied by a different feeding company so to prevent delay I wrote to their GP with appropriate prescription for using Nutricia Fortisip Multi-fibre 200ml bottles which were nutritionally complete, high energy (1.5kcal/ml) with fibre, 7 per day, and recommended that on review that the dietitian may want to reduce bolus to 6 per day as his weight was steadily increasing.

  I referred to their community enteral nutrition team, nurses sent any additional equipment and information, doctors completed the discharge summary and medication on discharge and all other therapies involved completed their ongoing referrals. The transfer was booked and a member of staff accompanied him.

  The staff reported that he looked happy with he arrived at the nursing home and was smiling. We conducted a few follow-up calls to ensure all was going well and the funding borough also requested paperwork to support their funding allocation. The nursing home manager reported that he looked happy, had settled and there were no issues raised, we had a safe discharge.