Community referrals can relieve burden on primary care

Photo by Rémi Walle on Unsplash

The pandemic has worsened health and wellbeing for many and widened inequalities further. Link workers can improve outcomes for people whom GPs may struggle to support and help achieve better results, writes Julie Bass.

Primary care is once again at the forefront of vaccination efforts, this time in the race to booster-jab the nation against Omicron.

GP resources were already stretched to the limit long before this latest crisis, and before the pandemic itself. What covid has done is to shine a spotlight on the need for better long-term solutions to lighten the ever-increasing load carried by practices.

Social prescribing is an approach that could make working life easier for a greater number of primary health care professionals. It could improve patients’ quality of life by tackling unmet non-medical need and delivering the right support.

A key part of NHS long-term plan goals, this form of community referral delivers help and advice through link workers or wellbeing coordinators. Although many schemes are relatively new, findings suggest they can improve wellbeing and encourage positive thinking. The NHS aim is to have 900,000 people referred to link workers by 2023-24.

So far, the focus has been on putting people with low-level health and wellbeing issues, such as anxiety and loneliness, in touch with befriending services, debt advice and bereavement groups. What these social prescribing schemes haven’t been able to do is take on (in a way that is effective) particularly vulnerable patients where there are high levels of risk.

However, Turning Point is well-placed to manage risk because of our established clinical governance structures overseen by a senior clinical team. The result has been a new approach that targets patients with complex needs who take up considerable GP time.

In the first service of its kind in the UK, we have joined forces with six primary care networks across 29 surgeries serving over 200,000 patients in and around Birmingham. This specialist social prescribing scheme is commissioned by Our Health Partnership which is one of the largest GP partnerships in England. Also involved are agencies including Age Concern, Shelter and local pharmacies.

Drug problems, domestic abuse, dementia. These are just some of the issues supported by our multidisciplinary team of staff who have the expertise and training to identify the right help in the community. To access a programme of support, the individual must be judged as having complex social needs: they could for example be homeless, a sex worker, abuse drugs and alcohol, engage in offending behaviour, or come from a traveller community.

The approach provides a space to tackle the social and economic inequalities that can impact on an individual’s health. The benefit of locating this type of service in primary care is that patients – whose social circumstances pose a major risk to their health – can be more accurately identified and supported, and GP time is freed up. Before, a significant part of a GP’s workload would have involved understanding a patient’s particular situation and liaising with other agencies to ensure they were getting the right support.

A social prescribing programme for non-complex needs is already delivered across Birmingham by The Active Wellbeing Society (TAWS). To create a smooth pathway, Turning Point and TAWS have created a joint referral form and single point of access for the forms to be submitted. This approach means GP practice staff do not have to triage in relation to the “complex” criteria – this is instead done after the referral has been put forward for consideration.

Since the specialist social prescribing service went live in August, there have been several success stories including that of Johnny (name has been changed) who was referred by his GP to a link worker. The former prisoner was known to drug and alcohol services but not engaging with them, and was also experiencing memory issues which put him in contravention of his probation terms (he hadn’t attended appointments).

What Turning Point’s link workers did was to liaise with probation who agreed to reconsider his breach while Johnny was being investigated for dementia. The (dementia) diagnosis was confirmed after our link workers supported him to access the GP for a capacity assessment.

This in turn meant he was eligible for social care support and additional help from his probation team in order for him to remain compliant with his probation order conditions.

Read the full blog post here.

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This content was created by Turning Point

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