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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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What we've been up to in Neighbourhoods

August 2022

Dr Aimee Henderson,
GP Sandringham Practice & Neighbourhoods Programme,
MDM Chair for London Fields PCN

An update on the Neighbourhoods Programme from Dr Aimee Henderson

In light of the recent Fuller report, City & Hackney health and care partners have been doing some stock-taking around the achievements of the Neighbourhoods Programme. The Fuller Report presents a vision around three key objectives:

  • Streamlining access to care and advice for people who get ill but only use health services infrequently: providing them with much more choice about how they access care and ensuring care is always available in their community when they need it
  • Providing more proactive, personalised care with support from a multidisciplinary team of professionals to people with more complex needs, including, but not limited to, those with multiple long-term conditions
  • Helping people to stay well for longer as part of a more ambitious and joined-up approach to prevention.

In City and Hackney this vision was kick-started through a transformation programme in 2018. This has laid a really solid foundation to take forward the Fuller recommendations and drive our Neighbourhoods model of health and care delivery. We also have the benefit of working in a place that has a strong sense of community, a robust voluntary sector and a network of services driven by the goal of improving the lives of all the residents and addressing health inequalities.

For a resident with complex needs, Neighbourhoods means that care can be delivered closer to home, in a more timely manner, that takes their views into consideration. Bringing care professionals together in Neighbourhoods aims to prevent people (especially those with complex needs) having to repeat their story many times or being lost between gaps in services.

The Neighbourhoods Programme has delivered the reorganisation of a core group of services that now work in 8 Neighbourhoods together through multidisciplinary teams. These include community mental health services, social workers, community nurses and community pharmacy. Through the creation of the Primary Care Networks that are also structured around the 8 neighbourhoods we have gained the support of GPs and a wealth of additional roles such as Clinical Pharmacists, First Contact Practitioners, and Physician’s Associates. These practitioners are working together to meet the needs of local people by sharing expertise in local ‘multidisciplinary meetings.

Other services have also been moving towards the Neighbourhoods model of delivering services together. These include children’s services and adult home care. In addition, Long Term Conditions staff have successfully piloted virtual group consultations in Gynaecology to be rolled out to all Neighbourhoods and are initiating new pilot work in Nephrology in the coming months. We hope work here will provide a model of Neighbourhoods delivery for secondary care services too.

Supporting all of this work is the development of a City & Hackney Community Navigation system, comprising many roles (e.g. Social Prescribers and Wellbeing Practitioners) that play a crucial role in linking residents, local health/social care, and wider services that support wellbeing. This year also welcomes the introduction of a new way of bringing residents into conversations with all services through new Neighbourhood Forums (see this newsletter’s write up on our newly recruited Neighbourhood Forum Facilitators).

Neighbourhoods has also started to pilot a new programme of organisational support for staff working in this new way. This includes embedding personalisation, inclusive recruitment, coproduction, anti-racism and skills in working across and between organisations.

We are working this year to understand the impact of all this work and what needs to be done next. An external evaluator will support us to track the progress of the neighbourhoods programme and its contribution to the health & wellbeing outcomes we are working to deliver through our work.

I hope you enjoy reading more detail on some of these areas of work in this and future newsletters. If there is anything you cannot find please get in touch with us at huh-tr.neighbourhoods.admin@nhs.net and someone from the Central Neighbourhood Team will get in touch.

Best wishes,

Dr Aimée Henderson,

Clinical Lead for Neighbourhoods C&H GP Clinical Lead Sandringham Practice & MDM Chair for London Fields PCN