Dr Genevieve Dingle, University of Queensland - 12 November 2021 - 2
Community Support and Services Committee
29 Nov 2021
Correspondence

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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.