Call for evidence - inclusion health

Case Studies

• Doctors of the World's Safe Surgeries initiative: supporting GP practices to improve access to primary care

  by DOTWUK, almost 3 years ago
  

  Developing integrated and accessible services for inclusion health

  Primary care is open to all, but often many people in inclusion health groups, including people without a fixed address, people seeking asylum and refugees, are wrongly refused access to the primary services they are entitled to. NHS England guidance on GP registration is clear: regardless of nationality or immigration status, everyone living in England can register and consult with a GP without charge. There is no regulatory requirement to prove identity or address in order to register and an NHS number is not required (1).

  An investigation by the Bureau of... Continue reading

  Developing integrated and accessible services for inclusion health

  Primary care is open to all, but often many people in inclusion health groups, including people without a fixed address, people seeking asylum and refugees, are wrongly refused access to the primary services they are entitled to. NHS England guidance on GP registration is clear: regardless of nationality or immigration status, everyone living in England can register and consult with a GP without charge. There is no regulatory requirement to prove identity or address in order to register and an NHS number is not required (1).

  An investigation by the Bureau of Investigative Journalism in 2021 found that almost two thirds (63%) of GP practices surveyed in 10 locations across the UK would refuse to register someone without proof of address, proof of ID or legal immigration status. 14% of practices surveyed were unsure and only 24% of practices were willing to register the hypothetical patient without documents (2). Evidence from the Doctors of the World clinic also highlights similar issues of registration refusal for those who cannot provide proof of ID or address, despite NHS England guidance (3).

  Doctors of the World's Safe Surgeries initiative was launched in 2018 and is a network of GP practices committed to tackling barriers preventing access to primary care and promoting the health of everyone in their community – regardless of their nationality or immigration status. Member practices receive free training for frontline staff, resources and access to a supportive national network to enhance the accessibility of their services and ensure that nobody in their community is turned away from primary care services. This includes guidance to support GP practices to adapt their registration policy and align with NHS England guidance (4), a toolkit for commissioners on promoting Safe Surgeries in their local area (5), posters for patient awareness (6) and resources for social prescribers (7).

  Safe Surgeries aligns with other NHS initiatives, including CORE20Plus5 and the emphasis on identifying inclusion health groups locally to combat health inequalities, and is endorsed by Integrated Care Boards (ICBs) across the country. Implementing Safe Surgeries recommendations and inclusive registration processes also helps practices to demonstrate practice that is 'responsive' to the needs of their practice population during CQC inspections, by ensuring that anyone can access GP services.

  A growing network of almost 1,500 practices across England have made commitment sas Safe Surgeries and are working towards making their services accessible for everyone in their communities. We will continue to work with primary care and ICBs across the country to expand the network and support frontline staff to welcome all patients, regardless of their circumstances.

  Feedback from Safe Surgery member practices and primary care staff:

  "It was important for us to become a Safe Surgery because we wanted to offer a safe place for the diverse populations in our community to access healthcare services without the worry of being asked for ID or proof of address. This was particularly important to us because of the large number of vulnerable patients living in our area and the need for them to feel safe and supported when visiting our practice. It is quick and easy to register patients, which had the added effect of reducing the reception and administration workload around registrations"

  "We were delighted that Doctors of the World hosted a ‘Safe Surgeries’ session for our colleagues and partners recently. The training is unequivocally excellent,informative and enlightening and was a key component in our organisation becoming the first ‘System of Sanctuary’ in the country. A number of colleagues have advised that, since they did the training, they feel much more informed,in terms of supporting refugees and asylum seekers within their practices"
  

  More information is available at https://www.doctorsoftheworld.org.uk/safesurgeries/
  

  
  

  References
  (1) Primary Medical Care Policy and Guidance Manual (PGM) https://www.england.nhs.uk/publication/primary-medical-care-policy-and-guidance-manual-pgm/

  (2) Bureau of Investigative Journalism (2021) Most GP surgeries refuse to register undocumented migrants despite NHS policy https://www.thebureauinvestigates.com/stories/2021-07-15/most-gp-surgeries-refuse-to-register-undocumented-migrants
  (3) Registration Refused: A study on access to GP registration in England (2018) https://www.doctorsoftheworld.org.uk/wp-content/uploads/2019/08/Registration-Refused-final.pdf

  (4) Safe Surgeries toolkit https://www.doctorsoftheworld.org.uk/wp-content/uploads/2021/10/Safe-Surgeries-Toolkit-2021.pdf
  (5) Toolkit for commissioners https://www.doctorsoftheworld.org.uk/wp-content/uploads/2019/05/CCG_safe_surgeries_toolkit_2019.pdf

  (6) Poster for patient awareness https://www.doctorsoftheworld.org.uk/safesurgeries/safe-surgeries-toolkit/#:~:text=Posters%20for%20patient%20awareness

  (7) Social prescribing resources https://www.doctorsoftheworld.org.uk/safesurgeries/safe-surgeries-toolkit/#:~:text=RESOURCES%20FOR%20FRONT%20LINE%20STAFF

  Permission: Do you give permission from the individual/group to share this case study? Yes

  Permission: Do you have permission from your organisation to share this case study? Do you have permission from any partner organisations also named to share this case study? Yes

  Permission: Do you give permission for NHSE to share this case study and publish it as part of the framework? Yes

  Logo: Would you like to share your logo for use? If yes, do you give permission for it to be published with your case study in the framework? Yes

• Homeless Health Service Westminster: Severe and multiple disadvantage caseload

  by Rebeccah Clews, almost 3 years ago

  This pilot will test a trauma informed relational service working intensively with a small cohort of people experiencing severe and multiple disadvantage (SMD) and with unmet health needs that puts them at a high risk of avoidable harm

  The pilot is delivered by the Homeless Health Team delivered by Central London Community Healthcare NHS Trust. The nursing team had identified a cohort of people experiencing SMD who were not engaging with the existing service and were at high risk of avoidable harm and, as a result call an ambulance or attend A&E frequently and funding to pilot this approach was... Continue reading

  This pilot will test a trauma informed relational service working intensively with a small cohort of people experiencing severe and multiple disadvantage (SMD) and with unmet health needs that puts them at a high risk of avoidable harm

  The pilot is delivered by the Homeless Health Team delivered by Central London Community Healthcare NHS Trust. The nursing team had identified a cohort of people experiencing SMD who were not engaging with the existing service and were at high risk of avoidable harm and, as a result call an ambulance or attend A&E frequently and funding to pilot this approach was identified from Public Health and Rough Sleeping Initiative (RSI) grants secured by the local authority over a two-year period.

  The pilot team consists of two Band 7 nurses working intensively with small caseloads (10-15 people) to deliver advanced nursing care as well as to plan and coordinate multi-disciplinary working to achieve these outcomes. The role is not intervention focussed, but trauma informed and relational, delivered at a pace suitable for the person to develop self-care and confidence in engaging with health and with the nurse following the patient on their journey. The caseload will include people sleeping rough, in supported or temporary accommodation, and permanently housed with the nurses providing in-reach and outreach.

  The pilot will be delivered within a multi-disciplinary framework with access to the caseload being determined through existing multi-disciplinary forums.

  The aims of the service are:

  • Improved health outcomes and engagement to meet identified physical health need(s)
  • Reduction in use of unplanned A&E and ambulance care for community and primary care needs
  • Engagement with specialist primary and other care services
  • Improved wellbeing
  • Wider savings to the public purse

  
  

• NWL ICS Asylum Seeker Volunteering

  by Aran Porter, almost 3 years ago

  We have developed a standardised and consistent process to support refugees and asylum seekers into volunteering roles in the NHS across NWL ICS. Participation in volunteering will improve their opportunities for integration, skills development and widening their routes to careers. The refugee and asylum seekers volunteering project is part of a larger recruitment programme aimed at recruiting refugees into paid employment with partner organisations in the NHS across NWL.

  A number of Asylum Seekers have been successful in securing volunteering roles within our health trusts and we have developed case studies reflecting their experiences.

  Charles’ Story

  Charles was born in... Continue reading

  We have developed a standardised and consistent process to support refugees and asylum seekers into volunteering roles in the NHS across NWL ICS. Participation in volunteering will improve their opportunities for integration, skills development and widening their routes to careers. The refugee and asylum seekers volunteering project is part of a larger recruitment programme aimed at recruiting refugees into paid employment with partner organisations in the NHS across NWL.

  A number of Asylum Seekers have been successful in securing volunteering roles within our health trusts and we have developed case studies reflecting their experiences.

  Charles’ Story

  Charles was born in Namibia and has a background in the IT sector for the past 7 years. He arrived in the UK in September 2022 with his wife.

  Charles currently volunteers his time for West London Health Trust and decided to volunteer as he enjoys helping other people, he wanted to develop his social skills in the UK, get to know the working environment and to get out and see new places.

  Charles applied online which presented him with some issues in regards to providing hotel details as a home address but overall he found the process easy. He was then contacted by the Volunteer Service Manager who talked through the roles available.

  Charles is currently providing a meet and greet role but would also like to increase his volunteer hours and expand his role to support patients through working with Health Care Assistants.

  Before his volunteer shifts he is really excited the night before and finds it hard to sleep. He always gets up really early so he can arrive before his shift starts.

  Charles reflected on how he is made to feel like one of the team and it makes him want to volunteer again. On one volunteering day he completed a morning shift and there was a gap in volunteers for the afternoon shift and so he agreed cover as he was enjoying the day so much.

  Charles’ dream is to be a successful employee in the NHS and is excited about developing new skills.

  Bryony’s Story

  Bryony’s was born in Uganda and arrived in the UK in 2022. She has a background in commerce and studied logistics at University.

  Bryony wanted to volunteer in the NHS to give back to the community and help people. She also wanted to learn new skills and occupy her mind.

  Bryony volunteers for Central London Community Healthcare and is a Meet and Greet Volunteer, which includes welcoming people and supporting patients with directions to their appointments.

  Bryony applied through an engagement event and applied using her mobile which she found easy and was able to volunteer in two weeks. She had to do a lot of online training which she completed in the local library.

  Bryony finds the volunteer experience to be really positive and feels part of the NHS family and has made a lot of friends.

  Bryony wants to continue volunteering for the NHS and would love to volunteer in the finance and accounting departments which would also help her develop her skills further. She sees her future working in accounting for the NHS.

• A holistic approach to wellbeing: Greener on the Outside for Prisons (GOOP)

  by Amy_Spectrum, almost 3 years ago
  

  Greener on the Outside of Prisons (GOOP)

  Spectrum Community Health CIC is proud to support the development and implementation of GOOP (Greener on the Outside for Prisons) projects across several prison sites where we currently provide healthcare services.
  
  

  What is GOOP?

  GOOP is a health and wellbeing programme which runs in several prisons across the UK and is designed to improve the health and wellbeing of patients by involving them with a range of environmental activities, including gardening. Research has shown that gardening, horticulture and outdoor activities have real therapeutic benefits for mental health.

  Working with HMPPS and raft of... Continue reading

  Greener on the Outside of Prisons (GOOP)

  Spectrum Community Health CIC is proud to support the development and implementation of GOOP (Greener on the Outside for Prisons) projects across several prison sites where we currently provide healthcare services.
  
  

  What is GOOP?

  GOOP is a health and wellbeing programme which runs in several prisons across the UK and is designed to improve the health and wellbeing of patients by involving them with a range of environmental activities, including gardening. Research has shown that gardening, horticulture and outdoor activities have real therapeutic benefits for mental health.

  Working with HMPPS and raft of fantastic mental health specialist providers (including GMMH, TEWV, Rethink and Mersey Care) Spectrum’s thriving healthcare partnerships are complemented by an equally thriving connection to nature. As part of this work, we want to showcase just a few of the GOOP projects our service users have been involved with over the past few years.

  
  

  HMP Kirkham

  Since 2021, men involved with GOOP in Kirkham have managed to boost habitats for wildlife by planting a new hedges of hawthorn, blackthorn, dog rose, guelder-rose and hazel as well as beech, oak, ash and birch trees. The prison’s Horticulture Enterprise has continued, with greenhouses filled with produce ready to harvest for the kitchens, farm shop and wholesale market.

  The men on the new temporary accommodation have also made their own garden area outside their building, planting flowers in a flower bed and painting old planters.

  HMP Styal

  In summer 2022, HMP Styal won the Silver Gilt award of the Community Borders category at the RHS Tatton Show. Their entry, entitled ‘Weeders and Bloomers’, was a celebration of plants inspired by the history of women workers on prison farms, the impact women weeders had on estates in the 18th century, and their role as bloomers in 1900. The garden was created by inmates who had no prior experience of gardening, alongside the dedicated Farms and Gardens team. Following the RHS show, the garden has been incorporated into the prison grounds.

  Sharon Loving, who runs the Crops & Produce department at Styal, said, “We have some women who have been in the prison system for a long time and are quite involved in the garden – they are the backbone of what we do. Then we have other women who have never been involved in gardening, or have probably never even had a garden, or seen fresh fruit and veg. They get involved and realise that they are quite good at something that they would have never experienced.”

  HMP Lancaster Farms

  In HMP Lancaster Farms, gardening and GOOP projects have taken on an even greater importance since the COVID-19 pandemic. Prisoners have grown over 8,000 bedding plants to enhance the grounds and planters around the prison, along with fruit and veg for the kitchen. All of the greenhouses have been repaired, and grown from seed so far are herbs, tomatoes, courgettes, green beans, peas, cabbages and peppers for the prison kitchen. Eight gardens outside each wing were revamped with full landscaping.

  HMP Haverigg

  • Prisoners at HMP Haverigg have been kept extremely busy over the past few years, thanks to GOOP. Since December 2019, Parkfield (a 12 acre field within the outer fence of the prison) has seen the following work and developments implemented by the men involved with GOOP;
  • Sunflower walk - a nature trail, lined with sunflower plants, taking you through the area of the field designated as a nature reserve.
  • A pond - dug out by hand and using funding from the 'Pond in Every Prison' project.
  • An orchard using local apple, pear and Meddlar varieties, which also includes native trees to produce a hedge surround.
  • Bird Watchers Hide (Twitchers Retreat) - halfway through the nature trail is a bird hide made from a recycled cattle carriage, adapted and fitted with seating and fixed binocular points. The trailer has numerous books and posters relevant to bird watching.
  • Trees - As well as the established and newly planted wild flowers, saplings of the endangered Aspen tree have been planted.
  • Feeding tables - to encourage more variety of birds, numerous tall-roofed bird tables have been erected. There are also smaller bird baths located across the area to enable ground dwellers access to water.
  • Wild flowers
  • Beehives - two sets of bee hives have been constructed in the field; these are thriving thanks to the plethora of flowers nearby.

  
  

  HMP Hull

  Back in 2018, HMP Hull triumphed for having the best-kept garden in a prison in the country, beating 15 others to win the prestigious RHS Windlesham Trophy.

  The outdoor space, tended to by 20 prisoners, has helped develop not only self-worth but also key transferable skills which can be used outside in the community. RHS judges said Hull stood out because of its production of fruit and vegetable, which are used in the prison's kitchens as well as donated to local foodbanks. The Windlesham Trophy award was set up by the RHS in 1983 by the former chairman of the Parole Board Lord Windlesham, to develop prisoners' sense of worth and "encourage garden excellence within the prison community".

• WY-FI+ Inclusive Health Service: supporting inclusion for homeless adults

  by Amy_Spectrum, almost 3 years ago
  

  
  

  Service context

  The Inclusive Healthcare Service was introduced in Wakefield in 2021 to provide urgent support for homeless adults and rough sleepers during the COVID-19 pandemic. At that time, homelessness in Wakefield had surged by a third and the local authority needed a nurse-led outreach project to engage with homeless people in safe areas (eg. in hostels, churches) guiding them to health and housing support and reducing pressure on A & E departments.

  In October 2022, this provision was incorporated into WY-FI+ - a new service funded through the NHS Core20PLUS5 initiative to improve outcomes for vulnerable adults.

  A need... Continue reading

  
  

  Service context

  The Inclusive Healthcare Service was introduced in Wakefield in 2021 to provide urgent support for homeless adults and rough sleepers during the COVID-19 pandemic. At that time, homelessness in Wakefield had surged by a third and the local authority needed a nurse-led outreach project to engage with homeless people in safe areas (eg. in hostels, churches) guiding them to health and housing support and reducing pressure on A & E departments.

  In October 2022, this provision was incorporated into WY-FI+ - a new service funded through the NHS Core20PLUS5 initiative to improve outcomes for vulnerable adults.

  A need for inclusion

  Homeless adults are one of the most marginalised populations in society, facing multiple barriers to healthcare, financial support and other public services. They are:

  • 50 times more likely to have blood borne viruses
  • 34 times more likely to have Respiratory health needs including TB, Asthma, COPD
  • 6 times more likely to have heart disease
  • 5 times more likely to have a stroke.
  • 20 times more likely to die from illicit drug use

  Despite these risks, homeless populations face many barriers to accessing health services and frequently do not appear ‘on the radar’ until they are at crisis point

  Our primary aim is to reduce health inequalities faced by homeless people, help them to access health interventions and engage them with support services.

  As part of this, a nurse-led team of two carries out community outreach and conducts drop-in sessions in hostels, hotels, day centres and community kitchens, as well as receiving direct referrals. Our nurse offers basic health checks like blood pressure and BMI, then takes a clinical history – looking at a person’s physical and emotional health, vaccination status, financial needs, and so on, before directing them to appropriate follow-up care. Clients experiencing severe need or health risks are allocated onto the IHS caseload for intensive 1:1 intervention.

  Our results

  
  

  The Inclusive Health Service has supported over 100 homeless people, helping them to improve their health and make vital links with community services. Our nurse, Faith, has a caseload of around 20 people who have consistent 1:1 engagement. Faith’s work is also supported by a non-clinical Navigator, who supports liaison with partner agencies.

  Case Study: Sindy

  Sindy* attended a weekly drop-in session that our nurse holds at the Community Awareness Programme centre in Wakefield. She was in tears and in pain due to extensive leg ulceration, which she had tried to bandage on the street using sanitary towels from a supermarket. She was not registered with a GP and was under the impression that she would not be able to access health services due to homelessness and drug misuse problems.

  The IHS Nurse assessed Sindy and drove her to an emergency walk-in centre for wound dressings and antibiotics. After this, she was assigned to Faith’s caseload, assessed, supported to register with a GP and to make links with District Nurses for ongoing wound care. Faith suspected correctly that the client had signs of peripheral neuropathy and discussed this with a GP to support a diagnosis.

  For more information about the Inclusive Healthcare Service and WY-FI+, please email wyfiplus@spectrum-cic.nhs.uk

• RECONNECT North East: working in partnership to reduce reoffending and improve outcomes for prison-leavers

  by Amy_Spectrum, almost 3 years ago
  

  Context

  Introduced in 2019, RECONNECT is a Care Navigation service which provides support for adults with health and wellbeing needs both before and after their release from prison. RECONNECT supports service users for up to three months pre-release and up to six months post release, helping them plan for release and make links with important services such as GP practices, mental health services, drug and alcohol services and probation.

  Across the North East Prisons, RECONNECT is led by the Reconnected to Health partnership of four organisations:

  • Spectrum Community Health CIC
  • Rethink Mental Illness
  • Tees, Esk and Wear Valley (TEWV) NHS... Continue reading

  Context

  Introduced in 2019, RECONNECT is a Care Navigation service which provides support for adults with health and wellbeing needs both before and after their release from prison. RECONNECT supports service users for up to three months pre-release and up to six months post release, helping them plan for release and make links with important services such as GP practices, mental health services, drug and alcohol services and probation.

  Across the North East Prisons, RECONNECT is led by the Reconnected to Health partnership of four organisations:

  • Spectrum Community Health CIC
  • Rethink Mental Illness
  • Tees, Esk and Wear Valley (TEWV) NHS Foundation Trust
  • Humankind

  RECONNECT staff work with prison and healthcare teams to identify people with health and wellbeing needs who will benefit from extra support in the community. Our aim is to reconnect people with the community and services, to reduce health inequalities often faced by people leaving prison and ultimately support a reduction in reoffending.

  Referrals to RECONNECT can be made by anyone or service users can self refer. We offer

  • 1:1 support from a Care Navigator, who works to understand their health needs and any potential concerns about release
  • Support to identify key priorities (eg. mental health support, continuing on methadone treatment, accessing a GP) and set goals for the future
  • Wrap around support, to help to make links with support services
  • Opportunities to gain skills after release by becoming a RECONNECT volunteer
  • Help to access benefits, financial support and inclusive work programmes
  • Practical support through our hub (eg. Referral into RECONNECT, access to a phone to make calls, clothing, information about food banks)

  When RECONNECT began, it focused on three key cohorts: under-25s, women, and those serving short sentences. It was recognised that these cohorts were at greater risk of poorer outcomes after release. Each year, we expanded Reconnect to include more vulnerabilities. In 2022, we opened the service to anyone being released with a health or wellbeing vulnerability
  
  

  Key Results
  
  

  • Since 2019, Reconnect has supported 1,292 prison-leavers across the North East. Referrals into the service soared 176% between 2020-22, from 276 to 488 per year
    
    
  • In 2021, Reconnect was granted £150,000 of additional funding to develop a new community hub for prison-leavers in Durham. This hub collects together resources and support from a wide network of partners including HMP Durham, Durham Constabulary, Durham County Council, JobcentrePlus and others.
    
    
  • The project expanded via Enhanced Reconnect, a linked service which targets the most complex and high-risk service users who are not ready to be discharged after six months in the main programme
    
    
  • In 2023, Reconnect achieved the Gold standard of the NHS Lived Experience Charter for its work improving opportunities for staff with lived experience of the care or justice system. Many former service users now work for Reconnect as Health and Wellbeing Coaches
    
    
  • The North East is now the top-performing region for wellbeing outcomes in prisoners with drug or alcohol issues - 59% of prison-leavers successfully engage with services within three weeks, compared to only 34% nationally
    
    
  • After engaging with Reconnect, prison-leavers scored an average of 6 points higher in the Warwick-Edinburgh Mental Wellbeing Scale than they had before the project

  Service User Testimonials
  

  “I’ve been out of prison a year now. Life still has its ups and downs, especially in that first six months when your anxiety is at its highest. I’ve had to leave some people behind but I have been abstinent from drugs since 2016, six years and counting!

  I reconnected with my family. I have a new career. I even work with some of the people that I've been inside with, supporting them when they come out of prison. Sometimes I feel like an imposter, I feel unworthy of everything I have. But I keep trying, I will never give up.”
  
  Kevin, Care Navigator, Reconnect

• Michelle's story

  by J Elliott, almost 3 years ago

  Michelle’s story

  “Growing up, I experienced abuse at home, and have struggled with physical health problems as a result, which are still ongoing. Over the years, this has made me vulnerable, and I have experienced a number of abusive relationships where my finances and freedom have been restricted.

  “For years, I struggled to get the help I needed – my physical health got worse, and out of desperation I turned to illegal substances to self-medicate. I was forced into homelessness and was sleeping rough or in temporary hostels, where I experienced further assaults.

  “I really needed help, but I was... Continue reading

  Michelle’s story

  “Growing up, I experienced abuse at home, and have struggled with physical health problems as a result, which are still ongoing. Over the years, this has made me vulnerable, and I have experienced a number of abusive relationships where my finances and freedom have been restricted.

  “For years, I struggled to get the help I needed – my physical health got worse, and out of desperation I turned to illegal substances to self-medicate. I was forced into homelessness and was sleeping rough or in temporary hostels, where I experienced further assaults.

  “I really needed help, but I was labelled as ‘intentionally homeless’, meaning I didn’t qualify for permanent housing. But this wasn’t right at all – I would be no safer at home. My physical health problems also weren’t taken seriously by my GP - they just saw me as a ‘junkie’.

  “Just as I was ready to give up, I was referred to Housing First by Manchester Action on Street Health (MASH), and this is where my story really started to change. My Housing First Support Worker, Natalie, was amazing. She really took the time to get to know me, to understand what I have been through, and help me access the support I need – including finally finding a place of my own to live.

  “I also received support from GMMH Housing First Dual Diagnosis Practitioner, Jade. She spoke to me about my physical and mental health needs, and then made sure the proper support was put in place. She liaised with my GP on my behalf, and made sure that they were doing the right tests, treatments and referring me on to the right specialists.

  “She also provided a range of support and resources for my mental health – I’ve learned about Post-Traumatic Stress Disorder (PTSD), grounded and mindful breathing, managing flashbacks and managing pain and fatigue – which has been so useful.

  “Without Housing First, I would be in a doorway or dead. But life now is so good now! I now have the proper medication I need and no longer use illegal substances. I have my own home – my own private space – where I can do the things I love to do. I grow plants, learn Korean, do yoga, play the piano, read, and watch films. I pay my bills, and do my weekly shop. I don’t have to worry about how I am going to be able to access things like clean water, toilets and washing facilities like I did when I was homeless. This I will never take for granted.

  “My daughter lives with me which is amazing. She has passed her A-levels with flying colours, and will be off to university soon. I’m so proud of her, and so happy to be her mum. I am in the process of fighting for access rights to have contact with my younger son. My Dual Diagnosis Practitioner, Jade, is supporting me throughout this process, and is by my side at every Family Court session. My Housing First Worker Natalie has also been instrumental in this process - she’s been there every step of the way from completing the court application to supervising contact.

  “Natalie still visits me regularly, and she’s only ever a phone call or text message away. She helps with anything from little admin tasks like reading over emails and letters, to advocating for my rights as a tenant, and providing moral support when I’m sad or frustrated or when I have exciting news to celebrate. Everyone should have a Natalie.

  “I now volunteer at MASH and a local foodbank, and recently I visited the Houses of Parliament, to share my story and talk about how Housing First helped me. This felt like a real full circle moment.

  “I am passionate about advocating for the rights of people experiencing homelessness – there are still so many who are struggling. The people I have seen and spent time with on the streets are resilient, brave and tenacious – they have had to be. They just need a chance for someone to believe in them, give them a helping hand, and provide that foundation of stability, and there is so much value they could contribute. This is what Housing First gave to me.”

• Principle 4: A flexible and integrated approach to engaging multi-stressed families at Safeguarding Support Unit Psychology (a specialist CAMHS Team)

  by KatSSUPsych, almost 3 years ago

  
  

  As a specialist CAMHS team embedded within the Safeguarding Support Unit at Sheffield Children’s Hospital, we accept referrals from Consultant Paediatricians who have seen children for a Child Protection Medical or Forensic SARC assessment following concerns about child abuse or neglect. We have very inclusive referral criteria and support any child who is experiencing mental health difficulties in relation to the child protection concern, up to 18 years. If families are struggling to engage, we work with multiagency partners to understand this and facilitate attendance at appointments. Once families have met us and understand how we can support them, they... Continue reading

  
  

  As a specialist CAMHS team embedded within the Safeguarding Support Unit at Sheffield Children’s Hospital, we accept referrals from Consultant Paediatricians who have seen children for a Child Protection Medical or Forensic SARC assessment following concerns about child abuse or neglect. We have very inclusive referral criteria and support any child who is experiencing mental health difficulties in relation to the child protection concern, up to 18 years. If families are struggling to engage, we work with multiagency partners to understand this and facilitate attendance at appointments. Once families have met us and understand how we can support them, they tend to engage well. We provide trauma informed care and work hard to overcome intergenerational mistrust of services. Children have one consistent professional throughout their care episode, to reduce the need for them to tell their trauma story repeatedly to new people. We know in advance if a translator is needed and book face to face translators, preferably who have worked well with the family before. Longer appointment times (90 minutes) are afforded to enable the child and family to feel secure and regulated enough to talk about difficult topics, and to allow space for the complexity of a systemic approach. Travel fairs to and from sessions can be reclaimed for families receiving Benefits. Our entire service is designed and delivered around the needs and preferences of inclusion health groups and safeguarding is integrated in everything we do.

  
  

  Molly is a 14 year old female, who has experienced intrafamilial sexual abuse. She is the middle child of three siblings and lives with her mother. Her father is in prison. Molly has been out of education for a year. She has been vulnerable to online sexual exploitation and is very isolated due to agoraphobia and removal of electronic devices due to concerns about her safety online. Her mental health has deteriorated in relation to the developmental trauma she has experienced, multiple house and school moves, sibling and parental mental health and behavioural concerns and parental physical health concerns. Family life is chaotic and, due to living in poverty, finances also present a barrier to attendance. Multiple initial sessions were missed, necessitating a multiagency approach, pulling together involved agencies/professionals and requesting a Social Care assessment to fully understand the needs of the whole family. Psychological assessment and formulation informed the multiagency plan for this family. Reintegrating the older two siblings into education was felt to be a priority in enabling this family to stabilise. We referred Molly to a specialist school providing interim provision for children experiencing mental health difficulties which prevent them from attending mainstream school. It was hoped that this would increase age-appropriate structure and stimulation to overcome the risks associated with isolation from healthy peer relationships combined with vulnerability to online exploitation. Once stabilised, Molly will be better able to benefit from psychological therapies in relation to the ongoing impacts of complex trauma experiences. We provide evidence based, NICE recommended therapies appropriate to the presenting problem and try to offer a choice so that service user preference is accounted for. The family may also benefit from family therapy within Community CAMHS services, which we can link to through internal referral systems.

  
  

  
  

  
  

  
  

  
  

  
  

  
  

• Reducing health inequalities for those with severe mental illness and complex mental health- looking at the bigger picture

  by Jodie Hall, almost 3 years ago

  A proactive, outreaching, and engaging holistic trauma-informed approach to reducing the health inequalities of those living with severe mental illness (SMI).

  The Team:

  Jodie Hall Clinical Lead OT & Physical health pathway lead

  Health Coaches

  Linked in with the wider Primary Care Community Mental Health MDT.

  Ambition:

  Adults with SMI are statistically significantly more likely to die prematurely than adults who do not have SMI; from often preventable illnesses and diseases. 5x more likely to die before the age of 75- up to 20 years younger. 4 times as many adults with SMI in the most deprived IMD quintile die... Continue reading

  A proactive, outreaching, and engaging holistic trauma-informed approach to reducing the health inequalities of those living with severe mental illness (SMI).

  The Team:

  Jodie Hall Clinical Lead OT & Physical health pathway lead

  Health Coaches

  Linked in with the wider Primary Care Community Mental Health MDT.

  Ambition:

  Adults with SMI are statistically significantly more likely to die prematurely than adults who do not have SMI; from often preventable illnesses and diseases. 5x more likely to die before the age of 75- up to 20 years younger. 4 times as many adults with SMI in the most deprived IMD quintile die prematurely than adults with SMI in the least deprived quintile, 37 % of the population of Sheffield live in the most deprived decile. The data shows that people with SMI are more likely to die prematurely than people who do not have SMI, and the gap between these 2 groups has continued to increase in recent years.
  
  In Sheffield the uptake of the SMI APHC as of the end of March 2018/19 we were at 18.5%, with only 1,102 people on Sheffield GP SMI registers having had all core 6 elements. With ongoing work on the accuracy of the SMI register, Sheffield now at 3,367 people on Sheffield GP SMI registers, with 60.8% at the end of Q4 2023 having received their SMI check: this is 2,265 more people from 203 checks in 2019 a 1015.76% increase in completion of all core 6 completed. The work that the team has engaged in has influenced change in practice.
  
  Created an evidence-based tool to find and support those living with potentially poor physical or mental health, poor well-being, or isolation With the tool gives a clinical rationale as to who we most need to assert the service offer too- and how we identify them.
  Find those not "furthest aware from accessing care", for example not responding to appointment letters, not contactable and not attending other appointments/ screenings etc to make contact with them and explore how their needs could be best supported.
  
  The service is developed with experts by experience, and real-time individuals that the service is being created for. Developed a service that offers tailored support to meet the individual and local needs of the population-which may vary from one group to another.
  
  There was appreciation given that patients often live with other long-term conditions (LTCs) and multi-morbidity, therefore aimed to make every contact count through reasonable adjustments for access, but also emphasised on booking in LTC reviews, cancer screening and any other appointment that the patient may require with the practice/ relevant service.
  
  To support with the "bigger picture" for the population group the service has developed pathways into smoking cessation service, benefit and finance support, employment support and vocational rehab, local organisations for socialisation, peer support, physical activity etc.

  Outcome:

  The team has directly worked with over 1000 patients. Those who have been engaged with the service are over 40% non-white British ethnicity and the service demonstrates a true ageless service with the eldest individual 103 years old.

  Improved accessibility and demonstrated on both a local and national level the need for proactive outreach for this population group.
  
  The SMI APHC appointment outcomes:
  - Health appointments with GP for unmedicated/managed hypertension, patients subsequently have commenced hypertension medications.
  - Appointments with GPs for out-of-range blood results and have engaged with follow up actioned accordingly
  - Linked individuals in with VCSE organisiations- health, activities, and socialisation
  - Facilitated health and well-being group- with the aim of sustained behavior change to live a healthier life. Individuals have gone on to join gyms and lost weight by healthier eating and increasing activity levels. Reporting significant improvement in Reqol scores and quality of life.
  -Identified safeguarding concerns and linked individuals in with relevant services
  - Acutely unwell patients linked in with acute secondary care mental health services
  - Identified needs of the individuals that could be supported with wider clinical MDT- opened up to 1:1 support from OT, Mental health practitioners etc.
  
  Wider Service Outcome:
  - The health inequalities risk identifier tool shared on NHS Futures
  - The team showcased the serious mental illness health inequalities tool at the national Community Mental Health Team transformation celebration event in London last week.
  Claire Murdock, national director for mental health, was keen to share the innovative work which has prompted the promotion of the new tool and the sharing of it to services across the country. The aim is for general practices and mental health services to be more aware of the patients with the greatest barriers to accessing healthcare and act to break down these barriers.
  -Development of systmone and EMIS clinical system templates to improve the experience for both clinicians and patients
  - New templates developed have also improved the ability for information sharing, running reports, and increasing accuracy of audits.

  - Health Inequality risk matrix tool has been made available on NHS Futures for other services nationally to download.
  - Aim to develop a systmone and Emis template for the health inequalities tool which will also be shared on NHS futures and free of charge.
  
  Patient feedback:
  " you have really changed my life", "it feels like you really care", "thankyou for your support and caring about me", "thankyou for all of your support", "I don't ever have my bloods taken, but you made me feel so comfortable and I trusted you to do so", "I wasnt aware that I was able to have this check, thank you for telling me about it and doing it, I'll come again in future". "thankyou for your support, I dont know what you did but youve changed the way I think about things and changed my life. I have lost 4 stone and go to the local boxing gym 3 x a week and cook healthy meals at home with my family now, my sons enjoy this and prefer it to the takeaways".

  
  

  GP Practice Feedback:

  "Thank you so much for all your help, you have been amazing working with us, it was really a pleasure"
  "Patients were able to be seen much sooner given current/ongoing access constraints. We would welcome the service back if it was offered again in the future. "

  "impressed that the team go above and beyond for the patients."

  "Thank you for helping with our SMI register, all SMI figures have decreased, your team saw a lot of complex patients in a short space of time. Your support is very much appreciated. Ambah has been talking with colleagues at different points which was great as it showed a consideration for how our practice does things. "

  "Excellent service manged to complete most of our SMI patients including a very complex patient who will not engage with the practice"

  "I think it's great - having dedicated clinics for the SMI checks helps us and reception organise the check much better and for patients I think it's working well that they have a dedicated slot with a health coach for the PH Health Check. Health Coach has been great too and even noticed a BT a patient had the day after her appointment which was no longer needed so prevented the patient from having a double appointment/wasted trip!”

  "you have been able to reach patients who wouldn’t normally engage with the surgery or DNA"

  "Always found the health coaches to go above and beyond to ensure all patients were contacted and seen"

  "The practice has benefited greatly from this service as we don’t have the capacity to provide the level of support to these patients as you have"

  "The support to both patients and practice has fantastic. You have been able to provide focused care to a cohort of patients that we are not always able to reach."

  "patients have attended who are difficult to engage with."

  "From start to finish, this has been a brilliant service. So helpful and useful to the practice"

  " Excellent service, Health Coach went above and beyond to contact patients and try and book them in"

  
  https://www.shsc.nhs.uk/news/new-tool-developed-break-down-barriers-mental-health

• Preventing avoidable admissions

  by Rebeccah Clews, almost 3 years ago

  Background

  Westminster has the highest number of rough sleepers in England and, in response to this there are a number of specialist health interventions including two, specialist GP practices. GPs provide regular outreach sessions alongside the rough sleeping outreach team taking healthcare to those who are not accessing it. The ICB and local authority commission a number of health beds within the supported accommodation pathway with accompanying nursing in-reach and clinical supervision to prevent avoidable admissions and discharge to the street.

  Case study

  Towards the end of a joint street outreach session the team came across H, being escorted from... Continue reading

  Background

  Westminster has the highest number of rough sleepers in England and, in response to this there are a number of specialist health interventions including two, specialist GP practices. GPs provide regular outreach sessions alongside the rough sleeping outreach team taking healthcare to those who are not accessing it. The ICB and local authority commission a number of health beds within the supported accommodation pathway with accompanying nursing in-reach and clinical supervision to prevent avoidable admissions and discharge to the street.

  Case study

  Towards the end of a joint street outreach session the team came across H, being escorted from Victoria Train Station departure hall by security.

  He appeared profoundly unwell, extremely pale and unable to stand The GP and street engagement team member introduced themselves and had a conversation about health and housing. Like most initial encounters he wasn’t giving much away, however he knew he was unwell not having taken his medication for some time.

  He was found to have capacity and refused hospital admission at this time. He was taken by taxi to an emergency hotel bed space where he was met in the morning by a street engagement worker, had a cooked breakfast and escorted to the surgery.

  Later the next day he presented at the surgery five minutes before closing. He looked very unwell, had no shoes on and was not appropriately dressed for the season. The reception team brought him in from the cold and started the registration process. He was initially very reluctant to provide his details; with a bit of encouragement and explaining, he provided his details, enabling the GP to access to his medical history. He had been rough sleeping for the past 3 months, had been seen in A&E a few days before, receiving IV antibiotics and then discharged back on the streets with oral antibiotics, which he had yet to start. The GP noted there was considerably swelling on both his lower legs, cracked skin likely to be dependent oedema, which would worsen on the street. It was agreed that he was suitable for a local authority commissioned health bed and one was found 3 minutes’ walk from the surgery.

  He returned the next day and had a thorough health check and reviewed on GP in-reach visit at the hostel two weeks later. Further bloods were taken and a diagnosis of myxoedema, severe hypothyroidism, with significantly raised TSH levels. To avoid admission duty GP spoke with a consultant at Guys and he was commenced on medication.

  He improved over the next few weeks and the joined up work avoided an acute admission.

  However, during his stay his past caught up with him and he was taken into custody for an offence that he had been avoiding for almost 8 years. He served a short time on remand and received a suspended sentence. Since that time he has turned his life around, he no longer worries about his past catching up with him, he is in good health and his social needs are currently being met and he is looking for employment.