Connect North: Our co-designed, integrated, person-centred and needs led social prescribing service
A pilot of a community Navigator role was piloted and rolled out in the NHSCT area in 2017. Following the success of this role various condition/area specific navigation and signposting services were developed. Services had differing referral criteria and the landscape to access the right help and support was ironically becoming challenging to navigate – clients could be known to multiple services offering similar supports where others in need may be entirely unsupported. Trust senior management determined that a review of NHSCT navigation-type services be undertaken as the existing profile was confusing, inefficient and unsustainable.
Aim
Review NHSCT social prescribing related services to determine a more cost-effective, efficient and sustainable model of service provision for people requiring support with their practical, social or emotional needs impacting their wellbeing.
Objectives
- Review and map existing services and offerings exploring how a more collaborative approach and technology can support effective service provision
- Engage with all stakeholders to determine “what matters to you?”
- Co-design a collaborative model that delivers on “what matters to you?”
- Operationalise the service to deliver a person-centred and positive user experience with measurable outcomes, utilising all reportable data to inform service improvements”
Plans and planning were fluid and guided by the outcomes of the engagement process (diagram 1) to enable appropriate co-design and co-production.
- Mapping existing services highlighting areas of duplication and gaps in services
- Bringing together, facilitating and engaging stakeholders to work together to achieve improved outcomes for our population
- Learning from the user experience, highlighting their needs and expectations of our services
A software system was procured to best meet the needs identified and a steering group was established with relevant stakeholders including service users and carers to oversee progress and accountability.
Service users and carers co-designed all client facing resources including the service name and branding. They critiqued and selected an appropriate assessment tool to monitor outcomes and build evidence of impact. We continually invite and welcome learning from the user experience to improve service delivery.
We mapped existing services, gaps and needs by engaging and facilitating engagement workshops with stakeholders including service providers, users and carers. The need for a single shared online directory of services was a common outcome of the engagement sessions as was the need for a single point of access, effective first point of contact, direct access to information without referral, integration, accessibility, responsiveness and consistency, clients and carers did not want to be passed from pillar to post having to retell their story and there was a clear call for services to look at the whole person and not to focus on a single condition or factor.
We reviewed software and systems which could fulfil the needs identified throughout the engagement process and procured the best fit. We developed and tested an online directory of services before publishing and making publicly available to all services, organisations and individuals in the NHSCT area and beyond (diagram 2).
Our online directory of services enables universal access to information and supports without onward referral. It provides accurate information to those supporting clients to address health or wellbeing concerns without unnecessarily passing the client from pillar to post. Link worker time and capacity is protected for those who need the specific and tailored 1:1 support of a link worker to address their wellbeing concerns to meaningfully connect to beneficial services. Our model has evolved – we have developed and continue to grow our network of community connectors who can promote and direct people to the Connect North directory and we are further establishing community information points which are accessible venues within our local communities where people can go and access or be supported to access the Connect North Directory and connect with information and supports (diagram 3
We have co-created and delivered an integrated, needs-led and person-centred model for social prescribing in the NHSCT area. Since receiving our first referral in December 2022 our Connect North link workers have supported over 2,000 clients and their carers to assess, identify and meaningfully connect with beneficial services and supports in their area.
Our single online directory of services for the NHSCT area is publicly available for all and contains more than 1,100 interventions to benefit our people. In the last year over 8,000 people have used the directory. Our service meets all stakeholder needs identified throughout the extensive engagement programme and we have robust data collection and data reporting systems in place to ensure quality, consistency and fairness irrespective of a client’s postcode, age, medical condition(s) or living circumstances.
We are able to effectively capture data highlighting gaps in services and common areas of needs for our people. 85% of clients report an improvement in their health and wellbeing following link worker intervention with 68% reporting an improvement in their primary wellbeing concern. Taken in the context that over 70% of referrals to our service are for clients living with a degenerative and progressive disease this improvement in wellbeing is astounding. The vast majority of clients and carers also report significantly greater peace of mind and reduced stress through being involved with the Connect North service.
Connect North were Runners up in 2 categories at the Patient Experience Network National Awards in 2024. The Patient Experience Network recognises best practice in all aspects of patient care in health and social care across the whole of the United Kingdom.
PHA PPI Human Library Engage website piece Model
PHA PPI Human Library Engage website piece Engagement Journey
