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

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.

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.

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

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