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Dr Moon Halder, Elizabeth Mair, Dr Juliet Wakefield, Dr Blerina Kellezi, Dr Niamh McNamara, Dr Mhairi Bowe, Dr Iain Wilson & Dr Clifford Stevenson
Department of Psychology, Nottingham Trent University March 2019
Evaluation of the Let’s Live Well in Rushcliffe Initiative: Final Report
SUMMARY DOCUMENT
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Executive Summary
1. The Let’s Live Well in Rushcliffe (LLWiR) pathway is a model of care provision which
allows people with complex social, mental, and physical health and social care needs to co-
identify their own goals and coproduce and implement a personalised wellbeing plan.
2. Uniquely, this pathway combines a health focus with more socially-focused support:
patients are referred by healthcare staff (or self-refer) to a Health Coach (HC) who initially
assesses their health needs before either providing self-care support or refers them on to
community-based Link Workers (LWs) to address their social needs.
3. By the end of February 2019 there have been 1483 referrals to the pathway. Of these, 1176
patients had a first face-to-face appointment by then. 655 patients have completed their
formal baseline assessment and of these 630 provided usable data for the evaluation. This
level of recruitment looks set to place LLWiR among the larger, more established pathways
of Social Prescribing in England.
4. The Nottingham Trent University (NTU) evaluation sets out to capture the degree to which
the LLWiR pathway impacts upon the health and service use of its beneficiaries.
Accordingly, it involves three studies: a patient survey study to establish the extent of the
effects, a survey of GP and practice nurse perceptions and experiences of the pathway and
an interview study with clients, providers and third sector organisations to understand how
it works.
5. The patient survey study resulted in 630 usable responses at baseline, 178 at a four month
follow-up and 63 at a final eight month follow-up. There were improvements in patient
wellbeing after the initial four month period which were maintained after eight months.
There was also a decrease in primary and secondary care usage over the evaluation period.
However, there were no improvements in participants’ sense of loneliness or their ‘patient
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activation’ and an initial improvement in group memberships declined at the second follow-
up.
6. The economic evaluation of the programme attached savings to the improvements in health
as well as the changes in health and social care usage, finding a saving of £0.34 over the
four month period. Projected over a year post-baseline assessment, this estimates a ROI of
£1.00. In other words, if the patient benefits recorded for the first four months after initial
assessment are continued for the rest of the year, the programme will recoup 100% of its
costs by January 2020. While bearing in mind the many caveats associated with the possible
accuracy of these estimates, this compares favourably with many other comparable
programmes in this area.
7. Our interviews with 7 GPs, 3 HCs, and 6 LWs indicated that they recognise both the
increasing importance of addressing social factors in patient care and the need for person-
centred care in addressing holistic needs. Their experiences of referring or delivering
treatment on the pathway point to the importance of improving social connectedness among
patients in the improvement of their health and wellbeing, even for those with a focus on
specific health concerns. These findings were supported by the GP/practice nurse survey,
which found substantial support for the programme and positive experiences of its
performance.
8. Interviews with 19 beneficiaries evidence a range of physical and social benefits which
patients had gained from their experience of engaging in the LLWiR programme. Of
particular importance to patients were their relationships with LLWiR staff and their ability
to connect effectively with activity groups, both of which contributed towards their
confidence in meeting their set goals.
9. Interviews with 8 members of the co-production group, 8 group leads, and 3 volunteers
pointed to the good work done by LLWiR in establishing supportive relationships across
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the voluntary sector, in setting up new groups to meet patients’ needs, and in drawing upon
the skills of those with lived experience to develop the programme and support patients.
Co-production members and group leads also highlighted the need to stimulate and
maintain community engagement with groups whilst supporting their sustainability.
10. Key challenges for the programme include refining and promoting a clear message as to
the purpose and focus of the pathway. Some GPs confessed to having only a basic grasp of
the content of the pathway and lack of programme clarity was reported as the main reason
for failing to refer to the programme. Lack of fit between expectations and service delivery
was a key reason for negative experiences among beneficiaries, who occasionally reported
that their groups were unfamiliar with their needs as LLWiR patients.
11. Future developments will include an expansion of the range of support provided by LLWiR
to community groups and organisations including the provision of volunteer training. If
successful, this will help offset the burden placed on community groups through the referral
of patients and increase the sustainability of their provision.
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Contents
Executive Summary ................................................................................................................. 2
SECTION ONE: Introduction .................................................................................................... 6
1.1 Background to the report .................................................................................................. 6
1.2 Overview of key policy initiatives .................................................................................... 7
1.3 Models of Self-Care.......................................................................................................... 7
1.4 Models of Social Prescribing ............................................................................................ 7
SECTION TWO: Programme and Evaluation ........................................................................... 9
2.1 The ‘Let’s Live Well in Rushcliffe’ Initiative .................................................................. 9
2.2 The Nottingham Trent University Evaluation ................................................................ 10
SECTION THREE: Evaluation Results ................................................................................... 11
3.1 Results of Patient Survey ................................................................................................ 11
3.2 Programme Costings....................................................................................................... 12
3.3 Beneficiary Interview Study ........................................................................................... 14
3.4 Staff Survey and Interview Study ................................................................................... 16
3.5 Community Group and Coproduction Member Interview Study ................................... 19
SECTION FOUR: Discussion ................................................................................................. 21
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SECTION ONE: Introduction
1.1 Background to the report
• The Let’s Live Well in Rushcliffe (LLWiR) programme is a preventative model of
healthcare delivery that aims to improve patient self-management of chronic illness
through a more effective coordination of primary health care, local authority and third
sector services.
• It allows patients with complex social, emotional and physical health needs to be
referred by their GPs to a Health Coach and, if appropriate, a Link Worker who then
engage with the patient to co-produce a personalised care plan that addresses their needs
in a holistic way.
• Against a substantial background of evidence which attests to the positive impacts of
similar models of ‘Self-Care’ and ‘Social Prescribing’ upon individuals’ health,
wellbeing and healthcare usage, the LLWiR pathway serves to link potential
beneficiaries to existing healthcare and community assets.
• This final report outlines the findings of the programme evaluation at the 18 month
mark. It reviews the preliminary evidence gathered from beneficiaries who have had
their initial appointment and their four month follow-up review and examines
beneficiaries’ overall change in wellbeing and healthcare use. From this, we can
calculate a provisional figure for the economic impact or ‘Return on Investment’ for
the programme.
• It also reports a summary of interviews with those charged with the delivery of the
programme including GPs, Health Coaches, Link Workers and community group
leaders as well as interviews with beneficiaries. It also reports the results of an online
survey with GPs and practice nurses.
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1.2 Overview of key policy initiatives
• The gap in health and social care funding, the increasing awareness of the role of social
factors in exacerbating chronic health conditions, and the need to harness community
resources to provide out of hospital care all encourage the development and evaluation of
initiatives that can address holistic needs of patients.
• This is reflected in the NHS Long Term Plan which aims to dissolve the divide between
primary care and community health services, provide more personalised and integrated care
and move to a more community-based and prevention-focussed approach to healthcare.
• This will be accomplished in part through the provision of dedicated staff: ‘physician
associates’ who will assist with the identification of individual healthcare needs and the
tailoring of personal support to promote self-care; and Social Prescribing Link Workers
who will address the social and well as health-related needs of patients through referral to
appropriate community-based supports.
• There is considerable consensus that these alternative modes of care delivery can help
reintegrate isolated patients and help them better manage their own conditions.
1.3 Models of Self-Care
• Proactive, behaviourally focussed self-management support which is designed to
increase self-efficacy can have a positive impact on people’s health and wellbeing and
on patterns of healthcare use.
• Self-care interventions have been associated with reduced symptomology, enhanced
Quality of Life (QoL) and reduced emergency treatment usage.
1.4 Models of Social Prescribing
• Patients’ health conditions are often exacerbated by loneliness and isolation and Social
Prescribing (SP) serves to connect marginalised individuals to community groups and
activities. Social needs are addressed by Link Workers who connect patients to
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community activity groups and support their engagement. Other pathways, with a focus
on self-management, can use Health Coaches instead of (or alongside) Link Workers.
• NHS England has provided a set of guidelines for the delivery of Social Prescribing
which details the expected impacts upon individuals, the community and the healthcare
system. These include guidance as to the caseload of LWs (up to 250 patients per year)
and number of contacts with individual patients (6-12).
• Previous evaluations of SP programmes have found a range of health, social and
economic benefits, with the full benefits usually only evident after 24 months post-
delivery.
• Evaluations of Social Prescribing pathways need to capture information on the impact
of the initiative on individuals, community groups and healthcare systems. This is best
done through the use of mixed-methodology, although previous evaluations have
typically captured only part of this range of impacts and neglected the impact on
community.
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SECTION TWO: Programme and Evaluation
2.1 The ‘Let’s Live Well in Rushcliffe’ Initiative
• The Let’s Live Well in Rushcliffe (LLWiR) initiative is a model of care provision which
allows NHS patients with complex social, mental, and physical health needs to co-produce
their personalised care plan.
• This initiative combines a health focus with more socially-focused support: GPs refer
patients to a Health Coach who initially assesses their health needs before either providing
self-care support or referring on to community-based Link Workers who more directly
address their social needs.
• As such, it can be considered a ‘blended pathway’ with both self-care and Social
Prescribing components.
• By the end of February 2019 there have been 1483 referrals to the pathway. Of these, 630
patients have completed their formal assessment and provided analysable data for
evaluation.
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2.2 The Nottingham Trent University Evaluation
• The Nottingham Trent University (NTU) evaluation set out to capture the degree to which
the LLWiR pathway impacts upon the health, wellbeing and service usage of its
beneficiaries.
• Accordingly, it involves three studies: a patient survey study to establish the extent of the
effects, an interview study with clients, providers and community groups to understand
how it has its effects and a third survey study to capture the range of perceptions and
experiences among referring staff.
• This is considered best practice in the area and constitutes one of the most rigorous
assessments of a Social Prescribing-style initiative to date.
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SECTION THREE: Evaluation Results
3.1 Results of Patient Survey
• The analysis of the baseline (point of referral) survey shows:
o Belonging to social groups and receiving social support from others is associated
with higher levels of health-related quality of life.
o Stronger feelings of ‘community belonging’ and lower levels of loneliness are
related to better levels of health.
o Loneliness is associated with greater primary, secondary, and social care usage.
o Lower self-reported QoL is linked with increased primary and secondary care use.
• The analysis of change from baseline to the first follow-up (T0 – T1) shows:
o Beneficiaries’ quality of life improved significantly between the time-points.
o At follow-up 1, beneficiaries were members of more groups.
o Beneficiaries used less primary and secondary healthcare at follow-up.
• The analysis of change from the first follow-up to the second follow-up (T1 – T2) shows:
o Beneficiaries’ QoL improvements at T1 were maintained at T2.
o Beneficiaries’ decreased primary and secondary care usage at T1 was maintained
at T2, indicating a longer-term impact on the healthcare system.
o At T2 beneficiaries belonged to fewer groups than at T1, suggesting a tail-off in
group involvement after treatment.
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3.2 Programme Costings
• In order to calculate the economic impact of Rushcliffe Programme we conducted an
analysis of the impact of the programme on the beneficiaries who completed our
longitudinal survey at time 1 (n=178) and multiplied the results by the total number of
beneficiaries involved in the initiative up to eight weeks by the end of the intervention, the
31st of March 2019. This is a very short time to indicate any benefits in this type of
programme and existing evaluations show actual benefits can be best observed in the
medium or long-term (12-24 months).
• The reduction in health and social care usage among the sample over the period between
the time points was substantial. The reduced usage equates to reduced costs of £97.8 per
person over a three month period which, if scaled up to 630 beneficiaries and were to last
over 1 year, could indicate a saving of £246,5601 due to reduced service use in the first year
from start of intervention.
• The change in the EQ5D measure of wellbeing allowed us to calculate the change in
‘Quality Adjusted Life Years’ over the course of the first four months in the intervention.
Using the n=630 beneficiary estimates, there is an estimated overall projected gain of 26.4
QALYs annually if benefits for participants are maintained over 12 months from the start
of the intervention. The overall benefits of the programme from the QALYs in monetary
terms are estimated at £483,569. This number is projected for n=630 maintaining the
benefits gained over 12 months from the start of the intervention.
• Projection however was based on calculations from only 178 participants followed up at
four months in the interventions so the results must be interpreted with caution. Since less
than 50% of existing beneficiaries in the intervention were included in this analysis it is not
1 This figure must be viewed with caution as it an actual additional cost of £50,452 if a high service user for nights in hospital were included in the analysis
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possible to establish if they are similar or different to those who did not participate at
follow-up.
• It is known that those taking part in the evaluation, compared to those who did not, had
significantly different levels of quality of life at start of the intervention. The estimation
also excludes one participant with unusually high cost in relation to nights in hospital.
• The overall cost of the Rushcliffe programme from 1.10.2017 to 31.03.2019 was £726,807,
so the savings associated with improved health and reduced care costs suggest an overall
saving of £243,666 or a return of £0.34 per £1 spent. The return of investment if the benefits
persist over one year is estimated at £1.00 per £1 spent, which would be accumulated by
31st of January 2020.
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3.3 Beneficiary Interview Study
• Semi-structured interviews were conducted with 19 LLWiR beneficiaries (12 female,
6 male, 1 prefer not to say; ranging in age from 29 to 85 years). 11 beneficiaries were
referred onto the LLWiR programme by their GP, 3 were referred by a nurse, and the
remaining 5 were self-referrals. Most were referred to LLWiR for help with weight loss
and for support with social isolation linked to living with multiple/complex needs.
• Interactions with staff and the relationship with HCs and LWs were viewed by
beneficiaries to be extremely positive, for the most part. Meetings were perceived to be
fundamentally different to consultations with other Healthcare Professionals as
beneficiaries reported they were provided the time and space to thoroughly discuss the
challenges they faced and to set goals to address these challenges. Support provided by
staff was experienced as empowering and supportive, which was particularly helpful if
beneficiaries were struggling to achieve their original goals.
• Forging social connections through groups also had a positive impact on those who
were socially isolated. In order to form successful connections, it was important to feel
supported by the Link Worker (e.g. by being accompanied to the first group meeting).
However, it was also essential that beneficiaries perceived a feeling of similarity with
others in the group, a sense of belonging to the group, and a positive initial meeting
with the group. Some beneficiaries had very negative group experiences which they
found to be very stressful and upsetting. A lack of communication between group
leaders and Link Workers was perceived to underlie these negative experiences.
• It is important when linking individuals to groups to ensure that groups are selected
taking into account individual circumstances which might act as a barrier to
participation (such as mobility issues or financial constraints). It is also essential to
ensure that groups that beneficiaries are referred to have the capacity to accept new
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members and that group leaders are sensitive to the particular issues faced by LLWiR
patients.
• Our data highlight the complexities involved in supporting those individuals who are
particularly socially isolated. Some beneficiaries in this category noted that they had to
feel ready before they could fully engage with the programme and some reported that
they would like an increase in programme duration.
• Overall, beneficiaries reported a range of psychological and physical changes following
their participation in the LLWiR programme. This included changes in diet and physical
activity, increased confidence, motivation to change, and new social connections.
Those who were referred for help with weight-loss felt that the programme was
somewhat unsuitable for them.
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3.4 Staff Survey and Interview Study
GP/Practice Nurse Survey
• 42 GPs and 23 PNs participated in an online survey about their understanding and
experiences of LLWiR. The survey was distributed to all GPs and PNs working in
medical surgeries involved in referring patients to LLWiR. 45% of GPs and 51% of
PNs responded to the survey.
• Most respondents had referred to LLWiR (89%), primarily to assist patients to set
personalised health goals. The least popular reasons for referring were to support
patients in building meaningful connections and broader community building. Lack of
programme clarity was the primary reason selected for not referring to the programme.
• The most popular criterion for referring to LLWiR was presence of a long-term
condition with low activation levels. Few respondents indicated that high service usage
or complex mental health issues were criteria used for referral.
• Referrers indicated that they would appreciate better feedback from the programme.
Respondents who received feedback indicated that this influenced their decision
whether to refer other patients to the programme in the future.
• Most respondents viewed LLWiR as a holistic health programme rather than a sing-
posting only service. Responses to open-ended comments indicated respondents felt
LLWiR was a valuable service, that positively impacted patients, and they would like
to see it continue.
• Finally, respondents reported high levels of confidence in the programme; the greater
their confidence in the effectiveness of the programme, the more likely they were to
refer patients.
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Staff Interview Study
• Semi-structured interviews were conducted with 7 GPs, 3 HCs, and 6 LWs. All GPs
interviewed referred patients to the LLWiR programme. GPs viewed the programme as
a means of supporting self-care in patients. It was perceived to be suitable for frequent
attenders at GP surgeries, those living with multiple, complex conditions, and/or who
were socially isolated.
• Across participants, there was a shared understanding of the need for initiatives such as
LLWiR in order to provide a holistic health service.
• Person-centred care was viewed as essential to improve patient health. In order to put
this model into practice, LLWiR staff stressed the importance of having time and space
to explore with patients the factors impacting on their health and well-being and
developing strategies to address these.
• The importance of building and enhancing social connections was perceived to be at
the heart of LLWiR’s potential to reduce social isolation. Connections were forged with
local community groups but also with LLWiR staff, particularly those with similar lived
experience to patients.
• Overall, referrers and LLWiR staff identified a range of physical and psychological
changes in patients following their participation in the LLWiR programme. These
included, weight loss, increased physical activity, increased confidence, and a greater
number of social connections. LLWiR staff reported that such changes needed to be
maintained through linking patients to community organisations, finding volunteering
opportunities, and fostering patient autonomy.
• There were some initial implementation issues reported by referrers and LLWiR staff.
These were: the lack of dedicated space for LLWiR staff to hold patient consultations,
poor referrer knowledge of the programme, and the absence of a clear and effective
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feedback loop to referrers. Participants noted that these issues were being addressed
within the lifetime of the pilot.
• In terms of future developments, participants noted that the longevity of the service
depended on creating greater awareness of the programme amongst potential referrers
and the general public. Some, however, were concerned that increases in referrals
needed to be matched by increases in resources, most notably, staff.
• Finally, participants highlighted factors impacting on the programme sustainability,
including the need for funding and buy-in from local organisations and GP practices.
LLWiR staff were working on those factors that were in their zone of influence, such
as connecting with GPs and other local organisations to promote awareness of the
service and encourage referrals. The programme’s long-term sustainability also
depends on the availability of local community resources and infrastructure.
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3.5 Community Group and Coproduction Member Interview Study
• Two interview studies with members of LLWiR’s Co-production group (n=8) and those
leading and volunteering in LLWiR groups in the community (n=11) evidenced their shared
view of the LLWiR pathway as being an effective programme to address multiple needs in
the community.
• These community needs are described as being related to physical, psychological, and
social determinants by co-production members and those involved in the running of linked
community groups. There was a shared view that mental health needs can relate to both
long term physical conditions and social issues such as loneliness and isolation.
• The LLWiR model was viewed as able to address gaps in current healthcare services and
to support community action and engagement where it might be currently lacking.
• Through its co-production methods and the building of strong and supportive relationships,
LLWiR has been successful in building relationships with local community groups and
working in partnership to create new community groups in response to identified needs,
whilst drawing on the skills of those with lived experience and professional knowledge.
• Relationships between community group leads and volunteers and the LLWiR staff have
been experienced as largely positive and helpful. They have been particularly strong when
groups are developed in partnership with LLWiR staff, but they are experienced as less
well developed at present with some pre-existing community groups.
• Both co-production members and those that run linked community groups recognise the
need to build sustainable community resources that can tackle multiple challenges linked
with funding and policy changes, marketing and accessibility needs, and changes in
community demand and engagement.
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• LLWiR staff and interviewees recognise the need to provide opportunities for volunteers
to support community groups and activities to promote their sustainability and LLWiR have
therefore taken steps to develop, train, and support volunteers.
• The co-production model employed by LLWiR has facilitated valuable working
relationships between community partner organisations and service providers within the
local area.
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SECTION FOUR: Discussion
• LLWiR falls on the larger end of the spectrum of similar initiatives being developed and
trialled across England in response to widespread calls for programmes that address non-
medical needs and the embedding of Social Prescribing and Self Care into the NHS Long
Term Plan. LLWiR has already reached a substantial number of the population living in
the Rushcliffe community over the period of its initial implementation.
• In terms of the structure of the model, the pathway is distinctive in employing both Health
Coaches and Link Workers. Both staff and beneficiaries respond well to this provision,
with the relationships with Health Coaches, Link Workers and community groups being
central to beneficiaries’ accounts of the social and physical benefits of the programme.
• The survey data bears out these indications, with significant improvement in the main
outcomes of health-related Quality of Life and primary healthcare usage (with one extreme
exception of increased usage) at the four month follow-up point. The occurrence of these
effects at the eight month follow-up timepoint are evidence of the longer-term impact on
health benefits of this programme.
• The calculation of ROI at £1.00 in 1 year post-treatment, gives a 100% return by January
2020. This initial ROI is comparable to other successful initiatives (see Kimberlee, 2016;
Dayson & Bashir, 2014). Though this does ignore the exceptional case of high healthcare
usage noted above, it is still likely to underestimate the true impact of the programme which
might reasonably be expected to endure beyond this timeframe.
• Challenges for the programme include communicating a clear and consistent rationale for
referral and ensuring that beneficiaries are supported to access appropriate activities and
groups. Given the range of needs among the target group, this is likely to be challenging,
but worthwhile for these more vulnerable patients.
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• Future developments will include an expansion of the range of support provided by LLWiR
to community groups and organisations including the provision of volunteer training. If
successful, this will help offset the burden placed on community groups through the referral
of patients and increase the sustainability of their provision.