Delivering Community Nursing in Neighbourhoods

Over the past two years, The Adult Community Nursing Team has undergone remodelling work to deliver their service through eight Neighbourhood Nursing Teams alongside a new Single Point of Access (SPA). Moving from larger cluster localities to eight Neighbourhood Teams has been beneficial in providing smaller and more multiple teams, able to focus on the needs of their local populations.

There is now one central point for triaging referrals to the SPA clinical staff who can carry out initial assessments for patients new to the service and manage short episodes of care; like blood tests and post-operative wound care. This means that those patients requiring longer term care can be triaged or transferred to their relevant Neighbourhood team so the nursing team can really get to know their local patients and their holistic needs. They also have a good understanding of local services & practitioners who can support them in their care.

Key Leads:

Dr Shaine Mehta -Quality Improvement Clinical Lead GP Confederation & Diabetes Lead in City & Hackney

Shanaz Begum – Health & Wellbeing Coach, Shoreditch Trust

Outcomes

Although it was challenging to support the team through changes in roles, teams and processes, restructuring has meant managers can better identify specific Neighbourhoods with high demand and can distribute work evenly across the borough to prevent staff burnout.
The new Single Point of Access has made it easier for management to collect data from one central place on the nature of their referrals (who they’re coming from and what for) meaning they can better plan the service.
Having smaller teams with dedicated budgets works well both for GPs who now have a few local named contacts who they know and can easily contact.
Neighbourhood Multi-disciplinary meetings have been great spaces for nurses who cover that patch to get the expert advice they need from other professionals involved in a patient’s care, as well as pulling in specialist advice quickly where necessary.

“Working in Neighbourhoods we’ve noticed the difference that the community navigation roles employed by our local GP networks (known as PCN’s) can make. They allow us to focus on clinical healthcare knowing that another professional such as a social prescriber can take the time to support residents with their social issues.”

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Health & Wellbeing Coach Improves take up of Weight Management Programme at local GP practice

Southgate Road Medical Centre in Shoreditch Park and City Neighbourhood saw the pandemic significantly impact patient’s levels of physical activity and ability to manage their weight. In response the GP Practice aimed to increase the amount of referrals to North East London NHS’s Digital Weight Management programme.

In order to make sure as many referrals as possible were successfully taken up, additional wraparound support for patients was brought in. The GP Practice trialled the use of a local Health & Wellbeing (H&W) Coach to initiate contact with patients at the surgery who had diabetes or hypertension who were identified as being overweight. The intention was that having a professional H&W coach start a conversation about weight management with a target group of known patients, would mean the individuals may feel more informed and confident about accessing weight management support.

Key Leads:

Dr Shaine Mehta -Quality Improvement Clinical Lead GP Confederation & Diabetes Lead in City & Hackney

Shanaz Begum – Health & Wellbeing Coach, Shoreditch Trust

Outcomes

The practice has the highest referrals to Digital Weight Management (March 2022) and accounts for 25.9% of all practice referrals from City & Hackney (October 2021).
40% of patients accepted referral to a weight management programme following a consultation with a H&W Coach
For patients, being informed that somebody will call them about weight management helps them to feel prepared and gives the coach a better opportunity to spend more time on talking about the programme in-depth if asked.
Calling at a time not too early or late in the day and sending a text with a link to the Digital Weight Management Programme information in advance was useful for patients to think about before a call

' It has been rewarding learning that there was a high uptake of the Digital Weight Management service since I called clients. This shows that there is a demand for the service. I enjoyed talking to people about their health and how they would like to make it better. Patients were much more likely to show interest in the programme having had it suggested by a GP or other health professional and being offered a call back. It made them feel prepared to spend some time discussing and asking questions about the programme" - Shanaz Begum - Health & Wellbeing coach, Shoreditch Trust

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Neighbourhoods Mental Health Teams

Whole person approach to mental health

Neighbourhoods Mental Health Team was developed to support people who have serious mental health care needs, as well as wider social factors that may be impacting their life. The 8 Neighbourhood teams take a multi-disciplinary and trauma-informed approach, involving a broad range of support and expertise so that they can consider all the health and social care factors and complexities impacting on someone’s mental health.

Outcomes

Previously referrals would have come through a central assessment team on a weekly basis. Now each Neighbourhood team looks at their specific area’s referrals and follow up at a daily meeting.
The range of groups and activities in each Neighbourhood are specially curated, working with the local voluntary sector. This includes social activities, trauma-informed and psycho-educational groups, and sports.
Working on an open access basis means once you are successfully referred you become a ‘member’ of the service and can access support for up to 2 years without having to be re-referred. This means you can quickly get support if your mental health starts to deteriorate.
More partnership working is happening between mental health teams and local support services.

"You never rushed me when I spoke to you on the phone and you were always so supportive, kind and understanding. You helped me get into my Tai Chi classes by helping to get my lessons funded. I was able to gain the strength to help my son through his special needs issues and depression also". - Resident

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Hackney Playbus in Neighbourhood Forums

Hackney Playbus run stay and play sessions for families with children under five. The charity regularly attends Neighbourhood Conversations in all eight Neighbourhoods to link up with local services and people and learn about new opportunities for them to collaborate with other services to bring families’ support to their doorstep.

Outcomes

Neighbourhood conversations have provided a dedicated space to learn about what other activities and events are going on in the Neighbourhoods.
Accessing services can be difficult. By linking in with new services at Neighbourhood Conversations and bringing them to the community in the bus makes them more accessible.
Grant funding from Neighbourhoods to renovate the bus has improved its exterior and created an even more interactive space for the children.

"The Neighbourhoods programme is about bringing people together. Neighbourhood conversations are great for making connections, it's so good to hear about what work is going on in the local Neighbourhoods we deliver in and see how we can work together!"

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Children's Social Prescribing pilot

Accessible services for children and young people

Well Street Common Primary Care Network appointed a Social Prescriber role to support children and young people (age 0-25) and families as a whole to access local services and support.

The experienced Social Prescriber can create personalised action plans for individuals, and has begun working with local schools to better connect them with local health, social care and voluntary sector support, and act as a link between the schools and GPs as necessary.

Outcomes

Families appreciate direct access to support rather than navigating a range of local services alone
Some families feel more comfortable accessing this support since the role has no affiliation with social services
Families working with the Social Prescriber in the medium term experience increase in self-confidence, motivation and general wellbeing
Parents and carers report being listened to, and supported to engage with services including social care where necessary
Children and young people are made aware of the local activities available which are relevant to their interests

“The Social Prescriber helped me with a grant application and I am now also going to the gym three times a week. I also found out about local holiday clubs for my children which they love.” - Client

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Unity Festival

Bringing communities together after isolation

Working with the local authorities, donations and funding from the Neighbourhoods grant, the Newington Green Alliance in collaboration with Minis Kardes organised the ‘Unity Festival’ to bring their community together after pandemic restrictions eased.

The festival celebrated the diverse area by hosting music and food from the different cultures in Newington Green, and brought a great sense of community cohesion.

Outcomes

Neighbourhoods funding provided budget towards the stage, and advertising
The Neighbourhoods Conversation provided a forum to advertise and collaborate with other organisations and residents
The event provided an opportunity to bring local people together in celebration and mourning following the first 18 months of the pandemic
New connections have been fostered to support further collaboration and sharing of cultures and resources in the area

"It was a wonderful day. Even the weather participated! I was especially moved to hear local residents say "this really feels like community" and others asking to have the event annually, monthly or even weekly!"

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Multi-Disciplinary Meetings

Together as a team

Ada is a 43 year old mother of 2 teenagers with a history of substance misuse and on probation following prison release. Ada lives on her own and suffers from diabetes which is poorly managed and has led to hospital admissions.

Although Ada already accesses multiple support services she is getting overwhelmed trying to keep them all up to date with her life while attempting to manage her diabetes.

It was suggested to Ada whether all the professionals she works with, including her mental health support worker, the local housing charity, probation officer and GP could meet and discuss how they can support her in a coordinated way.

Ada agreed and the professionals decided to refer her for a social care assessment. By establishing a lead professional to coordinate support and lead the multi disciplinary meetings, the professionals have a rounded understanding of her situation, and Ada is supported in a more effective way.

How did this make a difference?

Ada received a social care assessment and had professionals look into further financial support for her to ease her mental health issues

Ada felt less overwhelmed trying to communicate her health issues with probation when the professionals themselves knew each other and communicated on how they could work as a team to support her

Professionals gained a more well rounded understanding of what was going on in Ada’s life improving their ability to work in a way that suited her

Professionals learnt more about local services and referral pathways improving their knowledge of local support offers & local contacts

“I have seen wonderful examples where the resident has been at the centre of intervention, and their desired outcomes have been achieved.”

Adult Social Worker in Hackney

Multidisciplinary Meetings (MDMs)

MDM's bring together everyone who might be supporting an individual to better address that person’s needs.

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