Abstract
Background: Connect North is the Northern Health and Social Care Trust area wide integrated, needs led, person-centred social prescribing service. It is the result of a comprehensive lens co-design process with stakeholders, service users and carers. Uniquely delivered in partnership by 2 organisations across 2 sectors working as one team combining leadership, resources and expertise for maximum impact.
Approach: Our review of services delivering signposting, navigation or social prescribing functions found services to be disconnected; clients could be known to multiple providers for similar issues where others in need were unsupported. Directories offering helpful information were closed, targeted specific age or health condition and out of date. Support provided took the form of signposting relying on high levels of health literacy and client activation to take action.
We also held a series of stakeholder, public, service user and carer engagements (face-to-face, virtual workshops, interviews, phone calls and surveys). These highlighted shared needs and a collective call for change and integration.
We procured software enabling data collection and evidence based reporting to drive client, service and system level outcomes and created a publicly available online directory of services enabling more people to have more timely access to support along their care journey.
“Connect North – your pathway to wellbeing” was named by service users, our holistic needs assessment tool was selected by users and our resources are user led and co-produced.
Results: Our shared directory lists more than 900 services and activities with users accessing around 17,000 pages/month. 20% of users are returning users. Our directory enabled us to develop a stepped model of care to support more clients earlier, at the level they need and throughout their care journey.
Each month we support 74 new client referrals, conduct 913 client interactions and make 148 signposts and 52 social prescriptions/month. We have trained over 240 referral agents from 25 organisations. Our top referral reasons include: dementia, connecting to groups/activities, befriending and loneliness and isolation. 87% of referrals are for clients over 65years. 75% of clients report an improvement in their primary wellbeing concern and 89% of clients report an overall improvement or maintenance of their health and wellbeing, despite the majority living with a long-term and progressive illness. 100% of clients report a positive experience finding the service helpful and informative.
Implications: A health literate, needs led and true co-design process works. Pooling knowledge and skills from all partners including providers, communities, service users and carers has maximised impact beyond the sum of our respective parts. Digitalisation has released time to be directed to client care while simultaneously maximising care quality, value for money and the user experience.
Next steps include progression of a network of people within the community and information access points to direct more people to connect with local services encouraging earlier action to manage health and wellbeing. A further initiative to connect people directly with a range of supports linked to a common theme e.g. dementia, via a single appointment (community appointment days) are also in development.