Untitled

COGs - Community Opportunities Gloucestershire
Social Prescription - A Better Value Pathway to Feeling Better? - When the pills dont work!
Date: Version: Presented to:
August 2013 Draft 2 Clinical Commissioning Group, Gloucestershire
Prepared By:
Rob Rees, MBE (The Wiggly Worm) Miranda Steel (People and Places in Gloucestershire CIC) Louise Carruthers (The Wiggly Worm)
Contact:
Rob Rees, MBE (info@robrees.com)
Disclaimer:
This study is funded by The Wiggly Worm, Stroud District Council, Public Health Gloucestershire and Job Centre Plus South West. The views expressed are those of the researchers and not necessarily those of the funding bodies.
Community Opportunity Gloucestershire
List of Abbreviations
CCG COGs DH GB H&WB LA PPGs PCT PHGlos SDC JC+ QIPP WW HCP GP PHCP
Clinical Commissioning Group Community Opportunities Gloucestershire Department of Health Governing Body Health and Wellbeing Board Local Authority People and Places Gloucestershire Primary Care Trust Public Health Gloucestershire Stroud District Council Job Centre Plus Quality, Innovation, Productivity and Prevention The Wiggly Worm Health Care Professional General Practitioner Primary Health Care Providers
Acknowledgements
We are particularly grateful to the Steering Group members who worked with the team. The professionalism and positive approach by those involved contributed greatly to the success of the project. We are particularly grateful for the support and commitment shown by Rob Rees, MBE, the Wiggly Worm and People and Places Gloucestershire teams who delivered the commissioned community opportunity, Kitchen Challenge, and were responsible for the data collection. To reference this report, please use the following citation: Community Opportunities Gloucestershire - WigWorm13 Community Opportunity Gloucestershire 2
Contents
List of Abbreviations ...................................................................................................................................................................2 Acknowledgements.....................................................................................................................................................................2 Contents.......................................................................................................................................................................................3 Introduction by Rob Rees, MBE. ................................................................................................................................................5 Executive Summary .....................................................................................................................................................................6 Social Prescription...................................................................................................................................................................6 Feasibility Study ......................................................................................................................................................................6 Conclusion ...............................................................................................................................................................................7 Recommendations ..................................................................................................................................................................7 Introduction .................................................................................................................................................................................9 Rationale..................................................................................................................................................................................9 Social Prescription...................................................................................................................................................................9 Community Opportunities Gloucestershire (COGs) ...........................................................................................................10 1.0 Background..........................................................................................................................................................................11 1.1 National Picture of Social Prescription ..........................................................................................................................11 1.2 Local strategic context within Gloucestershire for mental health and wellbeing .....................................................13 Asset-based Approaches ......................................................................................................................................................15 Co-operative Approaches within Gloucestershire..............................................................................................................16 2.0 Social Prescription Activities ..............................................................................................................................................19 2.1 Self Help and Computerised Therapy............................................................................................................................20 2.2 Books on Prescription.....................................................................................................................................................22 2.3 Exercise on Prescription .................................................................................................................................................22 2.4 Arts on Prescription ........................................................................................................................................................24 2.5 Green Activity/ Eco-therapy...........................................................................................................................................25 2.6 COGs and Social Prescription activities within Gloucestershire ................................... Error! Bookmark not defined. 2.7 Who can social prescribing benefit ...............................................................................................................................25 Community Opportunity Gloucestershire 3
Demographics - Gloucestershire..........................................................................................................................................26 3.0 Developing COGs - Testing the Local Approach................................................................................................................29 3.1 National search of practice ............................................................................................................................................29 3.2 What does it teach us? ...................................................................................................................................................31 3.3 Conversation with primary contacts .............................................................................................................................32 3.4 Creating COGs to include a referral pathway ...............................................................................................................33 3.5 Overview of proposed COGs referral pathway.............................................................................................................36 4.0 Delivering COGs ..................................................................................................................................................................37 4.1 Proposed COGs Engagement Pathway..........................................................................................................................37 5.0 Evaluating COGs ..................................................................................................................................................................42 5.1 Commissioned Community Opportunity ......................................................................................................................43 5.2 Case Studies ....................................................................................................................................................................46 5.3 Referrer Evaluation.........................................................................................................................................................47 5.4 Limitations .......................................................................................................................................................................48 5.6 Outcomes ........................................................................................................................................................................48 6.0 Developing COGs - A Proposed Way Forward ..................................................................................................................50 6.1 Building the Model .........................................................................................................................................................50 6.2 Increasing Referrals ........................................................................................................................................................50 6.3 Recommendations ..........................................................................................................................................................51 6.4 Expected Outcomes ........................................................................................................................................................52 7.0 Conclusion ...........................................................................................................................................................................54
Introduction by Rob Rees, MBE.

My skills are not clinical and my experiences are not entrenched in mental health. I stumbled into social prescription by chance by simply working with great partner organisations, treating people with respect, adapting to individual strengths and playing to their differences. I have taken time to listen to so many people, participants and organisations public, private and charitable. Over the last few years many people who I have worked with have come to me with huge challenges and chaos in their lives. Many have been working professionals, many from broken families and many with illness and sickness that they have juggled with for all or most of their lives. My organisation was lucky to receive a funding award to help it grow and develop as an organisation. In order for that to happen the subject of social prescription or, as we call it in this report, community opportunities needed to be better understood locally and a process for scaled up commissioning, referral, brokering, auditing and delivery established. I want our county to flourish and its most vulnerable to be an integrated and celebrated part of our society, with their value nurtured to make our economy strong, our environment better and quite simple our place better. For that reason I chose to invest that award into a match funding pot that allowed this report to happen and a small scale testing of a COGs process in Stroud District. At all stages I have been clear that this report and project was to offer potential for growth for all organisations that deliver solutions for those who need and have asked for help. I hope that commissioners of all kinds will now consider this report so that we can reflect and find a way to scale up a well informed but simple referral process, an energetic people focused broker system and a quality variety of options for those whom the system will be designed to help. There is real potential for change here that can show the value for money in non-medical interventions. Like all such things it requires huge cultural shifts by organisations and calculated risk taking and context to so many involved in delivering solutions. Most importantly though it takes nerves to simply do the right thing and apply common sense to a people centred opportunity.
Executive Summary
Social Prescription
Social prescribing is a mechanism for linking patients with non-medical sources of support within the community, providing alternative responses to psychosocial needs, forming part of the wider recognition of the influence of social and cultural factors, upon health and wellbeing. Social prescription is thought to have three main benefits (Friedli and Watson, 2004): Improving mental health outcomes; Improving community wellbeing; Reducing social exclusion.
Feasibility Study
A feasibility study for a social prescribing referral pathway, has been investigated within the Stroud and Berkeley Vale districts of Gloucestershire. The aims of the feasibility study was to investigate the possibility of a single referral pathway, called COGs (Community Opportunities Gloucestershire), as a service provision for individuals with nonclinical needs and to facilitate links between the primary health care providers and the voluntary sector. A primary health care provider (PHCP) would make a social prescription referral to COGs, and the COGs Broker would engage with the individual to determine the most appropriate community opportunities for them, for social engagement rather than medical treatment. The intention of COGs is to move the individual from complementation of change through to preparation and into action (Prochaska and Norcross, 1999). The feasibility study focused upon the development of a COGs service in the Stroud and Berkeley Vale districts and used a specifically commissioned community opportunity (CO) to initially examine the value of COGs from an individual (service user) and PHCP (referrer) perspective. For the purposes , timeframe and funding allowance of this project the commissioned CO was Kitchen Challenge and the CO provider The Wiggly Worm Charity Feedback from both individuals and referrers, give support to the value of a COGs service within Gloucestershire, as an alternative to traditional medical treatments. In particular, it is reported that COGs has helped to raise individuals self confidence and made them feel useful again, especially as someone was paying an interest into their wellbeing. All individuals could be responded to in a bespoke way. The feasibility study has been able to identify a number of existing community opportunities, within Gloucestershire, that are available for individuals to engage with, but also that there are potential local gaps. However, it is proposed that through additional funding and good relationships, opportunities could be commissioned on an ad hoc basis basis.
Conclusion
The focus of COGs is the accessibility to community opportunities, through social prescribing, specifically highlighting the importance of social engagement and support networks available to an individual. These positive connections can facilitate improvement in mental health and wellbeing, with outcomes including reduced social exclusion and despondency. It is clear from the feasibility study that a COGs service within Gloucestershire would be a valued service within the primary health care environment. It is highlighted that in order for COGs to have a supportive and motivational influence upon non-medical treatment of mental health and wellbeing issues, good relationships between all stakeholders, including patients, public,, referrers, brokers and provider, must be developed. In order to implement COGs within Gloucestershire, an initial 2 year development phase should be considered , incorporating the building of stakeholder relationships. As positive outcomes of engagement with community opportunities are often slow and halting, development should continue to explore the COGs process and its positive impact upon individuals in terms of: Mental health and wellbeing; Distance travelled - improvements made on issues brought to COGs; Service satisfaction.
By conducting this feasibility study, it has been possible to highlight the positive effects of COGs upon individuals and the benefits such a service can bring to primary healthcare, whilst illustrating a strong and robust collaboration between health, social care and the voluntary sector.
Recommendations
By strengthening of the provision of access to non-medical sources of support, through social prescription opportunities, via COGs; a positive contribution to the mental health and wellbeing of Gloucestershire will be observed. COGs will be a fully integrated gateway for primary care providers, but will also promote and furthermore strength links between primary care, communities, voluntary and third sector services, which influence mental wellbeing. Commission a development phase to create COGs as the local service that offers primary health care providers a referral pathway into non-medical interventions, within Gloucestershire.
To create a positive environment for the creation and development of COGs, the following recommendations are required: Commitment and investment of resources over a minimum 2 year period Sponsorship by Senior Leadership Community Opportunity Gloucestershire 7
Strategic approach to development Steering Group of key stakeholders forming a multi-agency partnership arrangement reporting into senior leadership Project management team lead by experienced Project Manager COGs delivery by professional, local VCS provider Bespoke measuring tool Opportunities development fund Marketing and promotional resourcesIncreasing PHCP and public awareness of COGs and the potential effectiveness for improving mental health and well being, and the promotion of the wider range of community opportunities. Implementation, investigation and evaluation report . Further evaluation and identification of the mental health and well being outcomes associated with COGs, following implementation.
Introduction
Rationale
This report, commissioned by The Wiggly Worm Charity, considers the case for a local referral service for the coordination of social prescribing or community referrals, for primary health care providers (PHCP) within Gloucestershire, to improve the mental health and well-being of the population served; to be known as Community Opportunities Gloucestershire (COGs).
Social Prescription
Social prescribing creates a formal means of enabling primary care services to refer patients with social, emotion or practical needs to a variety of holistic, local, non-clinical services. (Brandling and House, 2007) Social prescribing is a mechanism for linking patients with non-medical sources of support within the community, providing alternative responses to psychosocial needs, forming part of the wider recognition of the influence of social and cultural factors, upon health and wellbeing (Friedli and Watson, 2004). Community opportunities may include programmes and services within arts and creativity, physical activity, learning, volunteering, mutual aid, befriending and self-help; in addition support with, benefits, debt, legal advice and parenting problems, might also be made available. Social prescription for mental health and well-being provides a framework for: Developing alternative responses to mental distress; A wider recognition of the influence of social, economic and cultural factors on mental health outcomes across the whole spectrum of disorders; Improving access to mainstream services and opportunities for people with long-term health issues.
On an individual level, social prescription provides both psychosocial and practical support for those with long-term mental health and well being issues, and research suggests that outcomes may include emotional, cognitive and social benefits, such as reducing social exclusion (Friedli et al., 2009, Evans et al., 2011). Examples of social prescription, which PHCPs may be familiar with, include exercise on prescription, arts of prescription, and books on prescription. Social prescription encompasses a wide range of perspectives on the causes and treatment of mental health issues, taking a person-centred approach and a broader emphasis upon personal experiences, relationships and social conditions (Rogers and Pilgrim, 1997). In particular, social prescription gives opportunity to provide an earlier intervention than medication or psychological treatments and therapies. Community Opportunity Gloucestershire 9
Community Opportunities Gloucestershire (COGs)

Social prescribing opportunities would be brokered by a new service called Community Opportunities Gloucestershire (COGs) where PHCPs refer individuals to engage in support and activities available within the community (community opportunities, CO). A feasibility study for the potential development of COGs was recently conducted. Funding was provided over a six month period. Partnership funding from The Wiggly Worm, Public Health Gloucestershire, Job Centre Plus and Stroud District Council was received. In kind support from Public Health Gloucestershire, GPs and Disability Employment Service was received. People and Places in Gloucestershire CIC where commissioned for the expertise and input. The initial funding created an opportunity for a community opportunity (CO), Kitchen Challenge (KC) to be conducted; this funding was enhanced by further investment, enabling the exploration of the development of a local COGs service.
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1.0 Background
The importance of mental health and wellbeing is widely recognised, with the World Health Organisation (WHO) ranking mental health as the second global burden of disease (World Health Organisation, 2003). A report commissioned in Norway, showed that our 75% of individuals consulting their GP admitted to having at least one psychosocial problem, such as stress, loneliness, depression, and of those over 33% reported that this impacted upon their general health (Gulbrandsen, Hjortdahl and Fugelli, 1997). The financial and economic burden of mental health can be determined by the increase of the use of anti-depressants, with an associated expenditure. The Centre for Mental Health reports that the total financial cost of mental health in the UK, between 2009-2010, totaled 105.2billion (Centre for Mental Health, 2011), with an 9.1% increase in the number of anti-depressant prescriptions issued, over the same period. It has been observed that the emergence of a non-medical, holistic intervention, such as social prescribing, is an important area within primary health care practice, with key developments within the promotion and prevention of mental health and wellbeing, and is seen as a pathway to primary health care providers, building and strengthening links within local, social and community opportunities (South, Higgins, Woodall and White, 2008). The national picture of social prescription provides an evidence base for the inclusion and promotion of social prescribing within PHCP settings (Department of Health, 1999, however whilst such opportunities exist for GPs, it is argued that these services are generally underutilised (Graham, 1995). Research by the Mental Health Foundation noted that 78% of GPs, had in the previous three year, prescribed an anti-depressant, despite the belief that an alternative treatment may be more appropriate.
1.1 National Picture of Social Prescription

With long term conditions affecting more than 15 million people in England, and with this figure predicted to increas e by 23% over the next 25 years; the biggest challenge upon existing systems will be their ability to support these figures. With that in mind, the requirement to be able to manage conditions outside of hospitals and medical settings, within homes and communities is just as important to the healthcare on a national scale; and takes into consideration the impact social factors, such as isolation and class influence, can have upon health outcomes. In order to address this, a successful health care system must be able to effectively respond to the underlying causes of poor health as well as more familiar medical ones.
Our Health, Our Care, Our Say (Department of Health, 2006) Established in 2006, Our Health, Our Care, Our Say sets out government agenda for the movement of resources towards the prevention of ill health and wellbeing, through the increasing range of intervention available to individuals and the promotion of relationships between statutory health, social and voluntary services.
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In particular, Our Health, Our Care, Our Say identifies that social prescribing is a mechanism for the promotion of good health and wellbeing and independence; whilst ensuring that individuals have easy access to a wide range of services, facilities and activities. Furthermore, it aims to prioritise local provision of social prescribing services for the improvement in mental health. In support of the movement, from 2008, Our Health, Our Care, Our Say, proposed that individuals presenting with long-term conditions, or social care need, in consultation with PHCPs, will be given information prescriptions to guide them to relevant and reliable sources of information. It is suggested that information prescriptions will empower individuals to feel more in control of their mental health and wellbeing, and be better able to manage and maintain their independence.
No Health without Mental Health No health without mental health was introduced in 2011, setting a clear and compelling strategy vision for the improvement of mental health and wellbeing in England, through a wide range of local organisations to bring about real and measurable improvements. The proposed framework puts mental health on a par with physical health, aiming to ensure that all individuals have access to the support and treatment that they require, whilst reducing mental health stigma and improving attitudes across society. The framework further focuses on a shift towards local responsibility, local leadership and local decision-making, to in order to make best use of powers and resources to deliver the vision of improved mental health and wellbeing. National policy sets out six objectives for mental health and wellbeing, based upon evidence-based actions: More people will have good mental health; More people with mental health problems will recover; More people with mental health problems will have good physical health; More people will have a positive experience of care and support; Fewer people will suffer avoidable harm; Fewer people will experience stigma and discrimination.
Through the implementation of a framework, which underlines the importance of providing equal access for everyone, the strategy aims to bring about significant and tangible improvements in peoples lives, in the most effective way.
Five Ways to Wellbeing (New Economics Foundation, 2008) Following on from No Health without Mental Health programme, and the prominence of the notion that through the promotion of positive mental health and wellbeing, it is argued that impact can be made not only in mental health outcomes, but also across a wide range of non-health areas. Community Opportunity Gloucestershire 12
Five Ways to Wellbeing addresses the balance of the promotion and prevention of mental health and wellbeing at a population level, together with care and treatment. The model suggests that the presence of positive psychological states and strategies, such as contentment and fulfillment, enable individuals to shift from moderate mental health to flourishing. For example, individuals who report higher levels of wellbeing tend to be more involved in social and civic life (Helliwell and Putnam, 2006), are more likely to behave in environmentally responsible ways (Brown and Kasser, 2005), have better family and social relationships at home (Diener and Seligman, 2002) and be more productive at work (Losada and Heaphy, 2004). This supports the No Health without Mental Health approach and can be applied to social prescription and the importance of the benefits of such an approach to an individuals wellbeing: Connect with people Development of social relationships is critical for promoting wellbeing and act as a buffer against poor mental health. Be active Regular physical activity is associated with a greater sense of wellbeing and lower rates of depression and anxiety. Take notice Being aware of sensations, thoughts and feelings might enhance wellbeing and improve behaviours. Keep learning Lifelong learning can enhance self-esteem; encourage social interaction and a more active lifestyle. Give Social cooperation is intrinsically rewarding and can contribute to gains in cognitive and social functioning, critical for the development of mental capital and wellbeing.
1.2 Local strategic context within Gloucestershire for mental health and wellbeing
Within Gloucestershire, two key strategies have been developed specifically relating to mental health and wellbeing: Health and Wellbeing Strategy - Fit for the Future Your Heath, Your Care Strategy
A review of Gloucestershire against the proposed outcome measures, within the No health without mental health framework, shows that subjective wellbeing is higher than the national rates (ONS, 2012):
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Life satisfaction - 7.54 vs. 7.4 Life worthwhile - 7.74 vs. 7.66 Happy - 7.3 vs. 7.28 Anxious - 2.95 vs. 3.15
Additionally it is reported that more people will recover, with evidence-based support that the proportion of people in employment, with mental health illness, on CPA and receiving mental health services, is lower than the national average (7.8% vs. 8.9%, ASCOF 2011/2012). Attitudes to mental health in Gloucestershire are suggested to be more positive and supportive, with individuals reporting to have a better understanding and be better informed, than nationally (2FT Survey, 2008). Although available various wellbeing measures suggest that Gloucestershire has a higher level of wellbeing compared to the national average, there are significant variations across the county, which must be addressed. In particular, Gloucester and Cheltenham have relatively high rates of many of the risk factors for poor mental health, including deprivation, unemployment, substance misuse, low levels of physical activity, crime etc. In order to address mental health and wellbeing issues, Gloucestershire has taken a local approach to the six objectives set out within the No health without mental health implementation framework, with commitment to enabling everyone to have better mental health. Public Health Gloucestershire have developed a Public Mental Health Plan which aims to work in partnership with the public, private and voluntary sector to deliver a number of interventions that will improve peoples mental well being and prevent the incidence of mental ill health occurring. The establishment of new Health and Wellbeing groups and Board enables the development of the implementation plan, set out against national objectives. At a national level, the Health and Wellbeing Board has been established as an independent NHS board for the allocation of resources and providing commissioning guidance. The Board seeks to increase GP powers to commission services on behalf of their patients and establish Boards in all first-tier councils. Health and Wellbeing Boards are a key element of the reforms captured in the Health and Social Care Act 2012. Gloucestershires Health and Wellbeing Board was formed in the summer of 2011, the Board will sit in Shadow form until April 2013 when it becomes a statutory Executive Committee of the County Council.
Gloucestershire Health and Wellbeing Vision Gloucestershire developed and implemented a Joint Health and Wellbeing strategy - Fit for the Future, with a focus upon the improvement of the health of all Gloucestershire residents and to protect the most vulnerable. This will be achieved by working with communities to co-produce health and wellbeing and resilience. The aim of the strategy, highlights the desire for people to be free of ill health for as long as possible and lead active and independent lives, specifically focusing upon strengthening health and wellbeing, and preventing ill health in Gloucestershire. The strategy projects forward twenty years, in order to take into consideration that the full benefit of Community Opportunity Gloucestershire 14
such health improvement strategies, may not be observed in the short-term. The following principles, underpin the strategy and will help guide what we focus: Supporting communities to take an active role in improving health; Encouraging people to adopt healthy lifestyles to stop problems from developing; Taking early action to tackle symptoms or risks; Helping people to take more responsibility for their health; Helping people to recover quickly from illness and return home to their normal lives; Supporting individuals or communities where life expectancy is lower than the county average or where quality of life is poor.
Asset-based Approaches within Gloucestershire
Asset Based Community Development (ABCD) Asset based community development (ABCD) is a new approach to the development and empowerment of individuals and communities, using what local assets a community has got. Local assets are seen as primary building blocks for sustainable community development. Through the building on the local skills of individuals and communities, new relationships can be built continually strengthening the community as a whole for the future. Essentially, the main principle of ABCD is the intrinsic value of the process, which promotes inclusivity and the building of relationships and networks. At the core of ABCD, is the notion that an individuals health and wellbeing can be influenced by their community and social networks. Furthermore, it is suggested that the extent to which an individual contributes, will be critical to their emotional health and wellbeing. Through the engagement of agencies to drive community solutions for improved health, the ability of individuals and communities to act as co-producers of health rather than consumers, is strengthened. Within Gloucestershire, the development of ABCD service to focus on improving broader public heath outcomes, in particular well being, has been implemented. Funds have been pooled to ensure greater sustainability and to show have public funding from different sources can be used to achieve shared outcomes. Due to the nature of ABCD approaches, success is not quick and replication is difficult, however, the intrinsic value or a strength-based approach, means that the process of implementation is itself a pathway to increasing wellbeing and be viewed as being as beneficial as any of the long-term goals identified by individual and communities. This focus on an individual and matching and offer against a menu of solutions, developing strengths, overcoming challenges makes it intrinsic to COGs
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aspire aspire has been developed over the past 4 years and has successfully delivered a similar way of working to the proposed COGs model. aspire has also successfully developed a small-scale version of the proposed GP referral process. Since 2009, a small amount of funding was made available each year by NHS Gloucestershire to support the vocational progress of individuals who face significant barriers. Initially for individuals in long-term receipt of Incapacity Benefit, expanding to those who had experienced a stroke and then extending to people with a neurological condition or acquired brain injury. Recently, aspire was further developed to include people with a Long Term Condition. Although a very small budget limited capacity to deliver, aspire reached people from all areas of the County including the outer reaches of Gloucestershire. Restricted resources have prevented aspire being widely marketed, however, close working relationships have been successfully developed with a range of professionals across many different fields and at various levels of Health and Social Care in Gloucestershire. Strong links have been made with referrers from Primary and Secondary services, including GPs, Medical Consultants, Psychologists and Mental Health Teams. The clinicians and professionals who have regularly referred people have been fully aware of the limited capacity of aspire and for this reason have usually referred only those individuals with the most complex of problems. A simple and effective referral process was created, which offers a single point of access using flexible mechanisms that respond to the wishes of the different referrers. Some referrers choose to use specific paperwork, some select to write a referral letter, others prefer to make a verbal referral following discussion over the telephone. Ongoing feedback and updates are provided, again responding to the requirements of the individual referrers. aspire is the closest approach available, to that proposed by COGs. However, the difference remains the scale of service, the menu of community opportunities available, the brokering system, accountability development and the engagement process of all stakeholders.
Co-operative Approaches within Gloucestershire

In the movement towards improved health and wellbeing for local population, a number of co-operative strategies are in place across the county, which add value, support and have a wider determinant upon health and wellbeing. These person-centred approaches operate at ease with other strengths-based approach organisations across the county, working in harmony and adding value to their strategies.
Gloucestershire County Council Priorities Launched in 2011, Gloucestershire County Councils four-year strategy programme sets out priorities for the county. The programme recognises that the current economic climate is having a significant affect upon individuals and communities, and the wider role of local government within public health, putting the health and wellbeing of the local population at the heart of the programme.
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Protecting vulnerable people Ensuring that all individuals are safe from harm, the strategy enables individuals to have more choice about the support they receive; Taking a people-powered health approach to allow individual to make good choices about what support they receive; Better response to children and young people, by better targeting of preventative work, to make sure referrals are made only when appropriate and in the best interests of the child. Supporting active communities Communities are active, and are able to do more themselves, by giving them more control over local services; Resilient and able to prevent accidents, injury, crime and respond to emergency disaster with a more sustainable approach in the long-term, with ability to be more flexible to local needs; Access to education, training, work and essential services; Highways - Your Way, Life Skills Centre, Big Community Offer. Health and wellbeing Shifting resources away from traditional institutions and stimulating the market to provide innovative services and solutions that focus on integrating, community based activity; Movement towards the removal of artificial boundaries for service users; Creation of Health and Wellbeing Board, whose priority is the development of a Health and Wellbeing Strategy. People with long term support People with a disability or long term illness live as independently as possible;
Police and Crime Commissioner The aims and priorities of the Policing and Crime plan consider the role of communities for a safer, healthier and more just and inclusive Gloucestershire, with a better quality of life for all. Many of the determinants of poor health and wellbeing are the same as those that may lead to crime, with offending not only affecting the individual, but their families and the wider community. It is suggested that effective intervention to divert offenders to appropriate services including health services can make a real difference. Community safety Pursue the necessities of cultural, social and economic life;
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Receiving adequate services; Exercising skills; Experiencing wellbeing; Engaging in community life; Creating wealth in the widest sense. Vulnerable groups Visibility and proactive with all vulnerable groups; Older but not overlooked To ensure that older people feel and remain an active part of communities, where living independently or within residential care; Young people becoming adults System must work with them, not against them to ensure law -abiding and productive members of communities;
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2.0 Social Prescription Activities

COGs and Social Prescription activities within Gloucestershire There is a wealth of social prescription activities or community opportunities available within Gloucestershire, and COGs would work with those, to provide an inequitable distribution of opportunities. However, it is also suggested that COGs should have access to resources to allow the commissioning of new opportunities, which maybe more appropriate for an individual, at that specific stage in their journey to improved mental health and wellbeing. Furthermore, it is noted that many of the opportunities available are geographically and demographically disconnected, with this COGs aims to provide the link-pin between the individual and opportunities; providing coordination and the ongoing and stepped support that can be intensified and de-intensified for the individual, so it is as meaningful and purposeful as possible. National examples: The most common examples of social prescribing are primary care based, when at risk-individuals are referred to specific programmes, such as exercise on prescription or art on prescription. However, there is also a wide range of opportunities which individuals can be signposted to, that link to other sources of information and support within the community and voluntary sector. Activity Self Help or Computerised Therapy Overview Computers and internet-based programmes have potential to provide more cost-effective assessment and treatments. However whilst internet support groups may have a number of perceived advantages over face-to-face therapy, research into this area is limited (NICE, 2006). Books on Prescription Books on prescription is a widely operational opportunity with over half of public libraries in England participating in a bibliotherapy scheme (Hicks, 2006). Activities usually take the form of a prescription for a specific book, or list of books, which can be obtained, via an individuals local library; however referral may be made to reading groups. Exercise on Prescription Exercise is a widely supported as an opportunity for the improvement in mental health and wellbeing, quality of life and the prevention of the onset of mental health issues (Fox, 2000; Faulkner and Biddle, 1999; Killoran et al. 1994). Cycling Swimming & aquatherapy Team sports Exercise & dance classes Community Opportunity Gloucestershire 19 Gym-based activities Guided/ health walks Books on Prescription Books for Teenagers on Prescription Reading Groups Free CBT websites Examples Beating the Blues Fearfighter
Activity Green Activity Eco-therapy
Overview Green activities provide individuals with opportunities to improve their physical and mental wellbeing through the contact with nature; with associated increases in selfesteem, positive mood and self-efficacy (Pretty et al, 2003).
Examples Gardening & horticulture Growing food Park/countryside walks Nature conservation Community green space Writing Painting Sculpture Photography Music Poetry Performing Arts
Arts on Prescription
Creative activities provide opportunities to promote selfexpression, self-worth and identity, and self-esteem, whilst promoting social inclusion and reducing symptoms of poor mental health and wellbeing, such as anxiety, depression etc.
Community Learning & Supports
Education on prescription is based around referral into formal learning opportunities, which may include literacy and basic skills; that promotes an improvement in an individuals access to health services and information, problem solving, self-efficacy and esteem.
Learning advisors Days services Mental health terms Voluntary sector organisations to support access
Table 1: Examples of Community Opportunities
2.1 Self Help and Computerised Therapy

Nice (2006) found evidence to support the effectiveness of computerised cognitive behavioural therapy (CBT) as a treatment opportunity for individuals with mild or moderate depression. Beating the Blues is a self-help programme for individuals with no computer experience, run over a period of eight sessions. The programme includes interaction, animation and voice-overs to engage and motivate the individual; in particular the programme employs fictional case studies to replicate symptoms and demonstrate the effectiveness of CBT as a treatment. Within the UK, Beating the Blues is only accessible through a health care professional. It is available in over 300 local NHS primary care trusts, community mental health trusts and specialist CBT services.
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Other computerised therapy programmes, which provide evidence for the effectiveness of these opportunities, include FearFighter and several free-to-access CBT websites. Similar to Beating the Blue, FearFighter is a self-help computer programme, delivered online, over an 8 to 12 week period, to help treat phobias, panic and anxiety. FearFighter engages the individual through interviews to assess their fears and anxieties to provide a self-treatment, monitor progress and give feedback. The NHS has entered an agreement framework to deliver FearFighter. Powell and Clarke (2006) provide evidence that over 10% of the population turn to the internet, as a source of mental health information; and 20% of those have a history of mental health issues. The majority of users (90%) were 18- to 29 year olds, in employment and students. However, it is noted that due to the limited regulation of the information available, it is difficult to recommend free sites within a social prescribing model and ensure effectiveness, validity and appropriateness. The British Association for Behaviours and Cognitive Psychotherapies published a review of free CBT sites (Mood Gym, Living Life to the Full), but also included recommendations to PHCPs regarding the use of such sites (Gournay, 2006). Computerised cognitive behavioural therapy (CCBT), including free-to-access programmes, may provide individuals with substantial benefits; Although the free-to-access programmes may provide some benefit if used on their own, the benefits may increase if the user is encouraged to use the site by a professional; Information about the reviewed websites should be made freely available; Information about the reviewed websites should be made available to health care professionals who may have contact with people suffering from mental health and wellbeing issues; Health care professionals should be encouraged to access and navigate their way through the websites to understand what is available; CCCBT websites may be used as an secondary opportunity to any of the steps within a stepped care model, and health care professionals who provide support and intervention to individuals with mental health and wellbeing issues should be encouraged to offer access to CCCBT websites as supporting opportunity to evidence-based approaches. Potential users should be advised that the benefits of these websites generally come with increasing use. Primary care trusts should continue to monitor the development of internet-based programmes.
Self Help and Computerised Therapy in Gloucestershire With Gloucestershire, national computerised therapy schemes are available but it is noted that few GP surgeries within the county have decided to purchase licences, such as Fear Fighter. However, there are a significant number of self-help opportunities, in particular face-to-face talking therapies.
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In addition to more traditional counseling services, the 2gether Trust provides the Lets Talk service, th rough an Improving Access to Psychological Therapy service (IAPT). IAPT is a free service, accessed through an individuals GP, and provides information, guidance and support when an individual feels their mental health and well being is poor. The Lets Talk service works through a number of ways, including online computerised therapy through a Gaining Self Help Toolkit. The toolkit provides information to individuals about more common problem, and give ideas and suggestions on how best to tackle them. The service also incorporates the Books on Prescription opportunity and signposts book suggestions available within an individuals local library. For individuals without access to a computer, Lets Talk also provides the opportunity for face-to-face or telephone therapy
2.2 Books on Prescription

A review of research evidence for self-help interventions for people with mental health and wellbeing issues, reported that the majority of studies illustrated, through the use of self-help materials centred around CBT approaches, that individuals received significant positive benefits in terms of their mental health and wellbeing (Lewis and Anderson, 2003). However, as with CCBT, it is advised that self-help materials were most beneficial and safer to an individual, when they were supported by a health care professional, and integrated into a stepped care approach. In support of previous evidence, Frude (2004) demonstrated that books on prescription had a high acceptance, with a continued improvement overtime and low relapse rate. However, it should be considered that effectiveness can depend on the individuals motivation and literacy as well as the quality of the book (Hicks, 2006).
Books on Prescription in Gloucestershire Within Gloucestershire, the Books on Prescription scheme is coordinated by the 2gether Trust but available to everyone with access to a library, and is delivered through a national reading lists, by The Reading Agency and Society of Chief Librarians with funding from Arts Council England. Books on the list have been carefully selected and are designed to cover a range of mild to moderate mental health problems including stress, anxiety, anger, phobias and depression amongst others. Books on Prescription is easily accessible and can be provided eit her through a prescription from an individuals PHCP or by any individual who uses a library.
2.3 Exercise on Prescription

Faulkner and Biddle (1999) highlighted that exercise is an effective intervention for poor mental health and wellbeing, and may also provide a suitable coping strategy for other symptoms, such as hallucinations. In support of this, national consensus statements show that exercise is as effective as psychotherapeutic interventions for the treatment and prevention of clinical depression, whilst reducing anxiety, enhancing mood and improving self-esteem (Fox, 2000). Furthermore, it has been demonstrated that regular exercise can improve cognitive functioning and mental health (Etnier et al. 1997). An evaluation of PHCP exercise on prescription opportunities has shown that a prescribed 10 week exercise programme, can significantly reduce depression and anxiety, whilst increasing self-efficacy and quality of life; with
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68% of diagnosed clinically depressed individuals, achieving a non-clinical depression score within three months. (Darbishire and Glenister, 1998). However, whilst there is significant evidence in support of the positive benefits of exercise upon mental health and wellbeing; there is limited evidence to support the uptake of exercise and what works to promote such opportunities. NICE published a review of four common methods, which can be used to increase physical activity levels: Brief interventions in primary care; Exercise referral schemes; Pedometers and community-based walking; Cycling programmes.
It was concluded that there was limited evidence to support the effectiveness of any of theme, with the exception of brief interventions (advice and written information) in primary care (NICE 2006a). A review of 22 studies by Sorensen et al. (2006), identified most studies reported moderate improvements in physical activity for up to 6-12 months. For those individuals who were receiving intervention, 10% had improved their physical activity levels, when compared with controls, and mean aerobic fitness improved by 5-10%. There is little evidence in support of the view, that more intensive programmes are more effective.
Exercise on Prescription in Gloucestershire Whilst Exercise on Prescription is a national initiative, there are a number of appropriate and available opportunities within Gloucestershire. Exercise community opportunities are typically driven through the individuals district and target specific audiences. In additional to exercise on prescription, PHCPs within Gloucestershire can also refer individuals to Community Health Trainers (CHT). CHTs are community-based individual who have been trained with the skills to help individuals make a real difference to their health. Where exercise referrals are usually into a group based activity, Health Trainers are able to provide one-to-one advice and support to help individuals improve their health and well being. Health Trainers can provide help and support with: Health eating and weight management; Stopping smoking; Sensible drinking; Becoming more physically active Accessing other services or groups.
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2.4 Arts on Prescription

Studies have suggested that arts on prescription can have positive benefits to mental health and wellbeing, in particular relating to the development of self expression and self-esteem through opportunities for social contact and interaction (Huxley, 1997). In addition, it is highlighted that participation provides a sense of purpose and meaning, and subsequently may lead to an improvement in quality of life (Tyldeseley and Rigby, 2003). Reviews by the Health Education Authority (1999) and Matarasso (1997), have further demonstrated improvements to an individuals mental health and wellbeing through indications including: Enhanced motivation; Greater connectedness to others; More positive outlook; Reduced sense of fear, isolation or anxiety. It is proposed that these indicators were brought about by the opportunities for an individual to participate in, which sought to engage: Self-expression; Sense of value and attainment; Pride in achievement.
An evaluation of Stockport Arts on Prescription scheme demonstrated a moderate impact on self-esteem and social functioning. In particular, an increase in social activities, specifically participative activities, was statistically significant, and there was supporting evidence that the use of GPs, social works and other service was reduced (Huxley, 1997; Health Education Authority, 1998; Tyldesley and Rigby, 2003). Furthermore, case studies centred upon those individuals referred to an art activity by health and social services, gave evidence that those individuals used in-patient and other hospital service less often and the risk of relapse was reduced (Department for Culture, Media and Sport, 1999). However, despite evidence in support of the benefits of arts on prescription, evaluations are typically based upon short term or immediate outcomes, with evidence is based upon small scale anecdotal case studies, that lack a longitudinal dimension to provide long-term evidence (Coulter, 2001).
Arts on Prescription in Gloucestershire Art Lift in Gloucestershire is the countys long established arts and health programme, which seeks to improve individuals mental health and wellbeing through a multi -disciplinary programme of arts experiences. Evaluation of Art Lift supports and reinforces previous evidence that individuals experience positive benefits of such a programme; including greater social interaction, sharing and support. Furthermore, individuals reported to have acquired greater skills and knowledge, improved confidence and the ability to better manage their condition. Overall it is proposed, Community Opportunity Gloucestershire 24
that the support and benefits of Art Lift has enabled individuals to establish new behaviours which have a positive impact upon their mental health and wellbeing, including the ability to cope with their symptoms long term (Crone et al. 2013). However, it is noted that despite the success of the Art Lift programme, individuals may be restricted or excluded on a geographical and/or demographical basis.
2.5 Green Activity/ Eco-therapy

The review of social prescription opportunities within the United Kingdom, provides supporting evidence of their effectiveness and efficacy, in addressing mental health and wellbeing issues at a primary care level. Furthermore, evidence illustrates that activities such as arts on prescription, exercise on prescription, green activities etc have a positive impact upon mental health and wellbeing.
Green Activity/ Eco-therapy in Gloucestershire There is a wide variety of green activity opportunities within communities, in Gloucestershire; however these opportunities are often restricted by the commissioning district, and are small time limited projects. In addition to district commissioned opportunities, there are a variety of community garden opportunities available; although again these are limited by geographical area. Some communities have set up their own gardening groups, and these give individuals the choice to visit and become involved with activities in their local community, with a more relaxed and gentle approach to work 2.6 Community Learning and Supports NIACE (2003) found opportunities for learning may impact positively on health by improving an individuals socioeconomic position, access to health services and information, resilience and problem solving, self esteem and self efficacy. Feinstein et al (2003) found participation in learning plays an important role in contributing to the small shifts in attitudes and behaviours. Evaluation of prescription for learning in Nottingham (James 2001) found a range of benefits, including lifted mood, greater sense of control and increased activity. These were particularly significant for adults with no qualifications who had not accessed any form of learning since leaving school. Community Learning and Suppports in Gloucestershire Adult Education in Gloucestershire is one of the main providers of basic skills and foundation level learning, which take place at various community venues and local colleges. At times and in places, Voluntary and Community Sector organisations are commissioned through local district funding or charitable funding, to deliver informal learning opportunities for specified target groups. Opportunities are often restricted by geographic, demographics, time, or activitity.
Who can social prescribing benefit
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Social prescription has been widely used and found to be applicable for vulnerable and at-risk groups; in particular for individuals with mild to moderate mental health problems, including those with vague or unexplained symptoms or inconclusive diagnoses, frequent attenders to GP surgeries and those with poor social support mechanisms. Social prescription has been found to have a number of positive outcomes and benefits, specifically related to cognitive, social and emotional needs of an individual. Thus social prescribing may be seen as a route to reducing social exclusion, not only for people with enduring mental health issues, but all disadvantaged, isolated and vulnerable populations. (Bates, 2002). Social prescription can provide psychosocial and practical support for those who are (Frasure-Smith, 2000): Vulnerable, at risk groups; Individuals who are lonely, isolated or excluded; Individuals with mild to moderate depression and/or anxiety; Individuals with long-term and enduring mental health problems; Frequent attenders to PHCP.
Demographics - Gloucestershire
COGs would ultimately support the entire population of Gloucestershire, but in particular will benefit vulnerable and at risk groups.
General Population The population of Gloucestershire is currently growing at an annual rate of 0.57%, on average 3,200 per year. Mainly internal migrants, between 30-44 moving to the county with young families, drive growth. Natural growth accounts for an increasing proportion of the overall growth, since 2007 with a surge in births. The Office for National Statistics (ONS) estimates the population of Gloucestershire at around 593,500 (2010). ONS projections for the next 25 years, propos e that the countys population will continue to grow at an average rate of 0.51%, or 3,000 people per annum. Specifically noted in the growth is the sharp increase of older people (aged 65+), whilst the projected growth for children and young people is very small, and a projected decline in the population of working age (20-64 years).
Deprivation Between 2004/ 2007, as a county Gloucestershire moved towards greater deprivation. Lower Super Output Area (LSOA) levels cover small geographical units, covering between 1,000 and 3,000 people provide appreciation of deprivation at a low level. Within Gloucestershire there are 367 LSOAs, of which eight are Community Opportunity Gloucestershire 26
amongst the most deprived LSOAs in England, accounting for 12,700 individuals or 2% of the county population, and approximately 7.2% of the county population are considered within the 20% most deprived areas of England (Indices of Deprivation, 2010).
Statutory Homeless Rate Homelessness is considered a group that is amongst the most vulnerable in society, and is associated with severe poverty and is a social determinant of health. Homeless households are represent as all those registered homeless or living in temporary accommodation waiting on the housing list. Within Gloucestershire, statutory homeless households are estimated at a rate of 1.15 per 1,000 households (2010/2011).
Unemployment Effects of the current recession, locally within Gloucestershire, has seen a 132% rise in unemployment over a 12 month period (June 2008 - June 2009), with a total of 12,620 claimants, or 3.6% of the local population (gfirst). Further evidence support a continued increase over 2010/2011, to approximately 17.2 per 1,000 population of working age adults, registered as unemployed.
Mental Health As a county rates of serious mental health problems are lower than national averages, but specific wards within Gloucestershire, experience rates that are higher than nationally, specifically noted Westgate in Gloucester is reported to have 60% more mental health illness, than in the country as a whole. Rates of anxiety and depression are high countywide, with prevalence highest in Cheltenham and Gloucester. Generalised Any neurotic LA Name Cheltenham Cotswold Forest of Dean Gloucester Stroud Tewkesbury disorder 11858 11810 11970 22497 16264 11410 All phobias 2601 1354 1361 2608 1865 1310 Depressive episode 1802 948 965 1792 1318 919 anxiety disorder 5664 3088 3094 5699 4256 2964 Mixed anxiety disorder 13140 6666 6790 12857 9182 6472 Obsessive compulsive disorder 1171 592 602 1149 815 567 Panic disorder 856 448 446 827 614 423
Table 2: Rates of Mental Health across Gloucestershire
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Further reports, Gloucestershire has a higher prescribing rate of benzodiazepines at primary care level, compared to Gloucestershire PCT regional and national rates (2.03 vs. 1.69, over 2010/2011).
Learning Disability If applied to Gloucestershire, the national rates of prevalence of learning disability in the Projecting Adult Needs and Service Information (PANSI), developed by the Institute of Public Care, would give the total number of people with learning disability as nearly 11,000 with approximately 2,270 likely to be in touch with services locally. It is estimated that over the next 10 years, these figures are estimated to increase by approximately 8%. Additionally the number of people aged over 65, in touch with services is expected to grow by 30%, with a further 100 people over the age of 65, by 2020. Estimates from PANSI, regarding people who challenge services through their behaviour, are 86 people aged over 18; and it is suggested that this will remain stable for the next 15 years. PANSI estimates the number of people with Autistic Spectrum Disorders, to be 3,600, with this number remaining stable for the next 15 years.
Reports show that the numbers of people known to services in Gloucestershire, through the three large organisations that work with large numbers of people with learning disabilities are: 2Gether Number of people known to services: 1560 Social Care 1951 GPs 2145
Table 3: Cross-organisational patient numbers in Gloucestershire Other Indicators Percentage of the population with a limiting long term illness - 15.1% (2001) Emergency hospital admission rate for self harm - 252 (Directly standardised - 2011/2012) Mortality rate for suicide and undetermined injury - 150 (Indirectly standardised - 2010/2011) Rate of hospital admissions for alcohol attributable conditions - 23.6 per 1,000 population (2011/2012) Allocated average spend for mental health per head - 167 (2011/2012)
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3.0 Developing COGs Examples of Tested Local Approaches

3.1 National search of social prescription practice
The following section provides an overview of existing social prescription services that are in place within the UK. This review of services illustrates the scale of some existing projects and concepts, and values other work in the area conducted throughout the UK. It provides good examples of community opportunities and highlights some of the challenges as well as the positives encountered when developing such pathways. It is noted that there are many other examples of projects and process, on differing scales, but those referred to below, have been highlighted as the most pertinent. Stockton on Tees - Service Navigator Pilot Project A two-year project, running from 2010 to 2012, was commissioned to Catalyst, designed to provide support to GP surgeries to help patients with access to the large number of community opportunities available within the area, via a navigating service. The project specifically focused upon frequent attenders and those with long-term conditions. The evaluation identified a number of challenges, including the over-reliance of the individual upon the Navigator, which in turn proposed a danger of over-extended workloads. The findings show that clarity in terms of definition of the roles and professional boundaries of the navigator is a necessity. However, case studies have demonstrated the value of the engagement of a navigator, specifically the time that they spent with individuals to determine their needs and key opportunities, to ensure they are benefitting from the such a service. Furthermore, the report highlighted that a navigating service could provide a regular support network for vulnerable and isolated individuals.
Stockton on Tees - Social Prescribing Pathway Following a period of consultation, a social prescription pathway was developed and implemented focusing upon the four key elements: Individual making the referral; Individual referred; Administration of the service; Delivery partners. Operating on an inclusive, rather than exclusive referral system, the pathway has tackled the challenges of the integration of into primary care, and has employed a voluntary sector organisation, Hartlepool MIND to oversee referrals. Findings suggest that through the availability of such a service, 89% of those referred felt that they have been helped. Furthermore, there was evidence to suggest:
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Some individuals have their medication reduced, with some coming off their medication all together; Some individuals had taken up volunteering; Some individuals had entered education, returned to employment or found new employment; Some individuals had increased their uptake of healthy activities.
The Bromley Bow Centre Bromley PCT reported the most important aspects of social prescription, following the development of the Bromley Bow Centre, working in one of the most deprived wards of the UK, to help individuals learn new skills, improve their health and wellbeing, find employment and develop the confidence to achieve their goals and transform their lives, with a clear equity of access to services. Reviews of the implementation of Bromley Bow Centre, have identified a number of recommendations for the development of similar projects: Integration/ Interdisciplinary approach - overlapping services re more likely to address the needs of a community in a holistic way; Accessibility - informality and creativity enable engagement of at risk or vulnerable communities, and create more approachable relationships; Flexibility - more cohesive approach to delivery; Sustainability - imbedding knowledge within communities increases social capital, thus strengthening and empowering local neighbourhoods; Quality - high level of quality in delivery of services raises the aspiration levels within a community; Holistic - a whole-person approach to addressing individual needs Action - Seeing is believing - if able to witness positive change, more likely to engage in future opportunities; Collaboration - Appreciating the value of forming beneficial partnerships in order to share information; Participation - engage communities in both delivery and accessing services to foster empowerment and ownership; Empowerment - commit to deliver services that increase social and economic strength, thereby developing confidence and capacity within the community.
Bradford and South West PCT - CHAT Social Prescribing (2005) Bradford and South West Primary Care Trust (PCT) provided a report of the lessons learnt and feedback regarding a pilot implementation of a social prescribing service, CHAT (Community Health Advice Team). The evaluation suggested Community Opportunity Gloucestershire 30
that CHAT was a valued scheme within a primary health setting, with a steady flow of referrals across a diverse range of individuals. Findings show that the service is acceptable, relevant and appropriate from both the perspectives of PHCPs and individuals, using the service; with the perception that such a service bridges the gap between PHCPs, the community and the voluntary sector. In terms of personal outcomes, the report highlighted that individuals typically expressed some form of positive outcome from their engagement with the service, including: Reduced isolation; Increased confidence; Access to non-stigmatised support.
A strong indicator of the success of the service was the reported perception of users of CHAT being an individual, caring service, tailored to the own appropriate needs (Woodall and South, 2005). In further support of the strength of the service, and it value of as an extension to primary health care, PHCPs reported benefits including: Potential to reduce workload; Improve the quality of patient consultation; Personalised, caring service; Source of expert knowledge.
New Routes - Bath & Avon Findings suggest that through a strong and effective partnership between statutory and voluntary section organisations, alternative solutions can be found, to relieve the burden of mental health issues, placed upon primary care. However, it is highlighted that there is a need to be aware of the attachment of a medical diagnosis to socioeconomic problems.
3.2 What does it teach us?

Overall, there is over-whelming evidence to support for the inclusion of social prescribing services, based upon existing services and schemes. Although evidence is continually emerging, it is to learn from the approaches adopted. The Bromley Bow Centre has identified and illustrated through sustained integration, the recommendations for the successful inclusion of a social prescription service within communities, providing support to at risk and vulnerable groups; Community Opportunity Gloucestershire 31
The Service Navigator Pilot Scheme has demonstrated that there is value in cutting PHCP time allowing focus upon more complex issues; The Social Prescribing Pathway has been developed over four years, which has allowed time to improve services and outcomes, and remove potential obstacles; CHAT has shown that such a service bridges the gap between PHCPs, the community and the voluntary sector, strengthening its value of as an extension to primary health care.
There is sufficient evidence to suggest that an integrated social prescription service within primary health care, is a useful approach, and can benefit individuals by providing a holistic package of care. Furthermore, there is a growing amount of evidence to support the establishment and implementation of partnerships between PHCPs and social prescription opportunity providers.
3.3 Conversation with primary contacts
The primary focus of the feasibility study was the role of PHCPs, in particular GPs, as referrers into COGs. Interview data exploring the role and feasibility of COGs was collected so that a short snapshot of perception and process could be gathered.. Of the GPs interviewed, the majority demonstrated an understanding of social prescribing and awareness of community opportunities providing non-medical support within their practice district, which individuals could be linked to. However, it was argued that the term social prescribing might not be familiar to GPs. Whilst, GPs might not be familiar with the term, it was highlighted that they were often aware of community opportunities within their district, but their knowledge could be significantly affected by factors including the time to become familiar with a potentially large number of opportunities, and keeping up to date with them. Furthermore, their knowledge tended to be limited to a few opportunities that were well promoted, such as smoking cessation and weight management. Those GPs interviewed who actively referred or signposted patients to opportunities, were largely positive about the benefits of social prescription upon their patients mental health and wellbeing. However, they supported the need for a centralised service or Social Prescribing Guru that they could refer or signpost their patients to, who would be up to date with community opportunities, as it is unrealistic and inefficient for them to be knowledgeable of all opportunities. GP attitudes highlight the need for explicit and comprehensive information regarding social prescribing and a generalisation of terms. There is a preference for a centralised service to which they were able to refer to, which would determine the most appropriate opportunities available, overcoming perceived barriers to social prescription.
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3.4 Creating COGs
The COGs Model COGs is defined as a referral pathway for the delivery of social prescription, within Gloucestershire, addressing the determinants of mental health in order to improve health and wellbeing. It is envisaged that referrals to COGs would primarily by via an individuals GP, this is by no means exclusive, and COGs will embrace a wide range of approaches to social prescription: Self-referral; Signposting through the provision of information; Indirect referral via an advisor or link worker; Formal referral from a PHCP; COGs Broker based within primary care environments to facilitate referrals and joint working.
COGs is keen to work as a fully integrated referral mechanism for all adults presenting to PHCPs, with mental health and well being issues. Through the adoption of a hub model approach, COGs provides a single point of contact, which oversees promotion, administration, delivery and accountability for social prescription. This model of delivery addresses issues of ownership, flexible referral pathways, local responsiveness within a wider strategic approach, efficient management and clear protocols between all involved parties. COGs proposes that the referral pathway from the individuals point of contact with a PHCP, should be a simple and clear process. The hub model approach supports the notion of a continuous referral process, allowing for formal and informal feedback to referrers. Within the COGs hub model, a collaborative approach is introduced between the Broker and the community opportunities providers, to ensure the services are accessible and supportive of mental health and wellbeing. It is suggested that this collaboration is a key aspect to the success of COGs (White and Salamon, 2010). However, it is noted that the balance between the development of community opportunities and the need for monitoring to ensure good practice, is paramount to the success of opportunities.
COGs Elements Referral pathways for access to social prescription and community opportunities contain a number of core elements, with PHCPs being a central component, acting as a referrer and in some cases coordinator. In other models, voluntary or community service providers undertake coordination, whilst an information resource is available for up to date information on support available.
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Primary Health Care Providers Community/ Voluntary Sector Services Information Resources Service User Mechanisms for: Referral, Feedback, Quality, Review
Table 4: Core Elements of Social Prescription (Kennaghan, 2012)
COGs proposes that the following elements are core to the referral pathway and engagement:
The Individual In essence, anyone can be referred to COGs; yet it is noted that individuals who have been found to be particularly suitable to social prescription for those with mild to moderate mental health problems, those with vague and unexplained symptoms or inconclusive diagnoses, frequent attenders to GP surgeries, those with poor social support mechanisms or are experiencing psychological difficulties. Furthermore, it is reported that individual who expressed dissatisfaction with results, or those who have had poor results with mainstream treatments, recurrent evaluation and revision of prescriptions due to lack of effect, may find social prescription beneficial (Brandling and House, 2008). In order for COGs to be beneficial to the individual, it is imperative that they have a clear understanding of the model of treatment, which they are being offered, especially if their previous treatment has been focused upon a medical model of care. COGs employs a person-centred model of care providing social support in order to address their health issues. By ensuring the individual understands their engagement with COGs and the model of care employed, it is proposed that they are empowered to actively engage further with COGs and potential community opportunities. In particular, evidence suggests that ensuring an indivi duals knowledge of their model of care, mitigates against a fear of failure of the service; and further supports the need for individuals to be a key stakeholder within their own treatment, from the outset (Evans et al., 2011).
The Referrer It is proposed that the main source of referral to COGs will be through PHCPs, including GPS, nurses, health visitors, district nurses and receptionists, as a means of linking individuals with support within their community. Referral through PHCPs supports the perception of a safe and secure environment of a surgery. In particular, COGs envisages itself as a fifth option within the consultation room, providing a non -medical treatment response to an individuals mental health and wellbeing issues. It is further proposed that due to the nature of COGs, how an individual is Community Opportunity Gloucestershire 34
referred into the service, is at the discretion of the referrer. As community opportunities are not necessarily tangible, such as a medication prescription, it is suggested that the method of referral should responsd to the needs of the individual, their ability, motivation, needs and strengths. For example; a individual presenting to a GP may feel that a physical, hand -written prescription is required as that is what they associate with visiting the GP surgery. It may also be that other individuals are more receptive to signposting with the suggestion that they can take control of their treatment. However, it is important to emphasise, that although GPs will not determine the community opportunities the individuals engage with, they do need to know what to look for in individuals who might be suitable for referral to COGs. Furthermore, PHCPs need to be clear what is achievable from such an approach, and so training and support must be considered. In particular, PHCPs must have access to reliable information on the referral pathway and community opportunities.
The COGs Broker The role of the COGs Broker is to act as a link between PHCPs and the community opportunities, and is seen as the key to a successful service. It is suggested that the Broker will possess highly developed interpersonal, communication and networking skills, with a motivating and inspiring manner to encourage individuals to make brave decisions or take up new opportunities (Brandling and House, 2008). Through a process of comprehensive and continuing assessment the COGs Broker will work in partnership with the individual to plan a personalised pathway, identifying suitable community opportunities with personally tailored support. Further detail of this process is presented in the delivering COGS section..
The Community Opportunities Provider It has been highlighted that the relationship between primary care and communities and voluntary sector organisations, is a pivotal aspect of social prescribing (Edmonds, 2003;, Constantine, 2007, Friedli et al., 2009, White and Salamon, 2010). In particular, this relationship should be nurtured and supported to allow an understanding of each others work and expertise, with clarity on wha t is provided, and referral and feedback pathways. Evidence review and investigation has highlighted that social prescription was not as familiar to PHCPs, as previously thought, and furthermore referrals are less likely to be made by to a service which they have little or no information or knowledge. Therefore, with the integration of COGs, relationships can be developed through the link of the Broker, so as to not place excessive demands upon the PHCPs time, with also allow a basic knowledge and underst anding of the community opportunities available within their locality. The suite of menus or opportunities can be developed, tested and reviewed by this person based centred strengths based approach, developing steady innovation and value for money.
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3.5 Overview of proposed COGs referral pathway
REFERRER Examples: PHCP (GP, Practice Nurse, Mental Health) Other Health Professional (Physiotherapist) Community Support (CPN, Keyworker) Other Professional (Job Centre +) Personal (Self-referral, Family)
COGs BROKER Comprehensive consultation period and assessment with individual and COGs Broker to determine best community opportunities to engage for movement towards improved mental health and well being
COGs ENGAGEMENT Individual is engaged with COGs Broker and Community Opportunities
COGs DISENGAGEMENT Individual actively engages in community opportunities Independently from the COGs Broker
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4.0 Delivering COGs

4.1 Proposed COGs Engagement Pathway
The proposed engagement pathway is initiated following an individuals referral to the COGs Broker, via the preferred referral mechanism. The pathway is not exclusive and can be adapted to the needs of the individual and the support that they require. The COGs Broker acts a link pin, which connects the individual to community opportunities, facilitates the connection between them and community groups or courses, in addition to providing support during engagement. Following disengagement, the COGs Broker can still provide support to the individual as and when it is sought. A key benefit of COGs is that the Broker is able to spend as long is necessary with the individual, and therefore typically longer than the PHCPs are often able too. In particular, it is proposed that the period of assessment and evaluation is not constrained by timescales. This enables the COGs Broker to develop a good relationship with the individual, and therefore the ability to discuss any issues that they feel are or maybe affecting their health, and to explore a variety of community opportunities, which may benefit them.
Step 1 Point of Referral
COGs
Link Pin
Individual
Broker
At the point of referral, the individual is not currently engaged with the COGs service and Broker. The individual will have been referred through one of a number of pathways, including PHCPs, other health professional, community support services, other professional organisations or possibly through self-referral. Referral can be a direct referral to COGs or an indirect signposting, and the engagement of COGs is initiated.
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Step 2 COGs Functional Assessment
Individual engages with the
COGs Broker, who provides a link pin of support.
Following referral to the COGs service and the initiation of engagement, the COGs Broker works with the individual, over an undefined period of time, to comprehensively assess their abilities and limitations, in order to determine the most appropriate pathway and community opportunities. The COGs functional assessment comprehensively assesses the individuals abilities and limitation and covers every aspect of the their day-to-day life, which could include: Assessing the person individually Environment Physical Personal Interests Activities within their life How they lead their life Ability to do so independently Capacity to engage in activities The reasons why they engage in activities It is proposed that the functional assessment employs a person-centred approach whereby needs are assessed on an individual basis, and that the assessment process cannot be templated for universal use. Assessment will be organic in Community Opportunity Gloucestershire 38
nature, employing a wide range of assessments, on an informal basis, based upon theoretical models of human occupation, developed within occupational therapy systems. It is argued that a more traditional pen and paper, tick box approach to assessment is not conducive to forming a good relationship between the COGs Broker and the individual built upon trust and respect between both parties. Through organic, unstructured assessment, the natural dialogue between the COGs Broker and the individual can be established.
Step 3 Determining Community Opportunities
2 1 E
Community opportunities to which the individual may engage are identified.
3 2 2 1
During the assessment period, the community opportunities that may be of interest and beneficial to the individual and their mental health and well being are identified. The person centred nature of the functional assessment ensures that the determined community opportunities are fitted to the person rathe r than the person fitting them. Community opportunties can be classified as: 1. Naturally occurring Community opportunities such as those that are already established within the community or area, including exercise on prescription, books on prescription, self help therapy. 2. Already commissioned These are community opportunities which are not necessarily on-going but have previously been commissioned and are available for future commissioning, such as the Kitchen Challenge programme. 3. For Purchase Community opportunities that are not currently available, but would be suitable for referred individuals. Potential community opportunities would be determined and commissioned through the COGs service.
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Step 4 - Engagement with Community Opportunities
2 1 1 E 2 3 1 2 2
Referred individual engages with identified community opportunities with support
The referred individual is engaged with determined identified opportunities with support. Through the individuals engagement, they act as their own COG within the system, to drive movement towards an improved mental health and well-being. During the engagement process, the COGs Broker continues to act as a link pin for the individual, providing them with stability and support.
Step 5 Independent engagement of Community Opportunities
2 1 3 3
2 1 E
2
Individual initiates their engagement with community opportunities.
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As the individual engages with community opportunities, they will make movements towards the improvement of their mental health and well-being; in particular to those issues that they were originally referred to COGs regarding. As the individual continues to move forward, it is believed that they will take more control over the community opportunities that they engage with; making decisions and initiating contact, driving their own progression. As the individual travels further, The individual initiates disengagement from the COGs broker. At any time , the individual or referrer may initiate re-engagement with the COGs broker.
Step 6 Individual disengages from COGs Broker
1 2 2 1 2 3 3 D
Individual independently engages with opportunities, and disengages from COGs
The individual continues to travel forward within the improvement of their mental health and well-being, and interacts with opportunities independently, without the support of the COGs Broker. The individual takes control of their own pathway and ultimately creates opportunities for themselves, such as volunteering or employment. At this stage, the COGs Broker is disengaged from the individual. It should be noted that disengagement is by the individual; the COGs Broker will not initiate disengagement. In addition, the COGs Broker can be re-engaged by the individual or the original referrer at any stage.
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5.0 Evaluating COGs

Despite literature available, with supporting evidence of a social prescription service, such as COGs, there is limited information for the process involved in establishing partnerships with PCHPs and implementing a service. Therefore, this feasibility study was conducted, with the aims of COGs being to broaden the service provision for individuals with non-clinical needs and to facilitate the links between primary health care providers and the community and voluntary sector. The delivery of COGs, focused upon the individuals COGs would assist, the role of the COGs broker, and the impact COGs would have on individuals involved. This feasibility study was conducted within the environs of the Stroud and Berkeley Vale district (SBV), of Gloucestershire. People and Places Gloucestershire CIC, a Cheltenham based voluntary sector infrastructure organisation, brokered COGs.
StakeholdersPotential stakeholders of COGs, were identified as: Primary healthcare professionals referring into COGs; Statutory services referring into COGs, such as Job Centre Plus; Voluntary service providers referring into COGs, such as Open House; Individual referred into COGs; Voluntary sector organisations taking referrals from COGs, providing a non-medical intervention, such as The Wiggly Worm.
Delivery and Steering The delivery steering group consisted of commissioners, stakeholders and evaluators: Rob Rees MBE, The Wiggly Worm; Miranda Steele, People and Places in Gloucestershire CIC; Hannah Williams, Public Health, Gloucestershire; Dr. Claire Mould, Open House; Lynsdey Lukaszewicz, Job Centre Plus; Louise Carruthers, The Wiggly Worm. (Secretariat and Lead Project Officer)
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The study was lead by the steering group listed above. The collaboration was between GPs in the Stroud and Berkeley Vale district, Open House, Job Centre Plus, People and Places in Gloucestershire CIC and The Wiggly Worm. The feasibility study into COGs was commissioned with evaluation objectives: Investigate the acceptability, relevance and appropriateness of COGs for individuals and PHCPs; Investigate the effectiveness of community opportunities in addressing social, emotional or practical needs in a primary health care context; Investigate and identify factors influencing delivery and utilisation of community opportunities; To produce a feasibility report with the main findings and points of learning from the investigation Make and implement recommendations
The feasibility study focused upon the requirements for a second phase development study for COGs within a district of Gloucestershire, not yet identified. As part of the feasibility study a specific community opportunity was commissioned and used as a case study design to examine the potential for COGs from the perspective of users, individual and referrers.
5.1 A pilot Community Opportunity
Kitchen Challenge by The Wiggly Worm Charity As recognized many examples of COG activities exsist. As yet none had been trialed al COGS Broker model in mind hence the utilizing of this particular project for this trial purpose.
A 6-week Kitchen Challenge (KC) programme was specifically commissioned as a community opportunity as part of the feasibility study into the value and appropriateness of COGs to PHCPs. It should be noted that other community opportunities are available within Gloucestershire. With regards to feasibility study, the Kitchen Challenge programme was used as a case study for the evaluation of the referral process, with the full knowledge that other opportunities exist. The Kitchen Challenge programme uses cooking as a vehicle for communicating wider messages such as team work, improving confidence, daily organisational skills and being exposed to challenges that individuals havent experienced before. Kitchen Challenge is very demanding and requires full commitment from each individual involved. The opportunity takes a strengths-based approach enabling individuals to develop confidence, self esteem and self belief. The unique experience provides an opportunity for individuals to exceed their own and others expectations, stretching and testing themselves to their limits.
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A purposively selected sample of individuals were referred to COGs and the Kitchen Challenge programme through Job Centre Plus. The individuals selected were to reflect the diversity of COGs users in relation to gender, age, complex and less complex needs. Individuals were believed to be at a ready for movement position in terms of their mental health and wellbeing. Once individuals had been identified, they met with COGs Broker to outline the purpose of the Kitchen Challenge programme and also to discuss their needs and identify any appropriate sources of support that they may require. Individuals were in contact with the COGs Broker on several occasions prior to starting the Kitchen Challenge programme, either face-to-face, over the telephone or in their own home. Assessment of the individuals requirements was through a semi-structured, informal interview. It was emphasised to each individual that participation and outcomes of the programme would not affect any benefits claims that they were receiving. Most of the individuals valued the initial assessment carried out by the COGs Broker, and found it to be thorough and beneficial. The non-clinical and informal aspect of the assessment was appreciated and individuals reported that they felt at ease talking to a non-institution, such as Job Centre Plus, or non-medical worker. All individuals were aware that the Kitchen Challenge programme was being conducted as an evaluation process for COGs and that their participation was voluntary. Individuals who declined to participate in the Kitchen Challenge programme were referred back to their support worker at Job Centre Plus and advised that there was no penalty for not participating. Additional individuals were resampled and met with the COGs Broker. The Kitchen Challenge programme was run twice as a commissioned community opportunity for two purposively sampled groups of individuals. The programme aims for individuals to achieve a number of objectives relating to mental health and wellbeing, which fall in within the remit of social prescription. All Improved attitude and positive motivation Problem-solving Ability to break problem into smaller parts Identify key issues Identify possible solutions Apply knowledge to work to a solution Ability to use initiative and self motivation Team working to accomplish goal/task Improvement in self perception and worthiness Sense of happiness, achievement, positive outlook to life Improved mental health and wellbeing Movement towards Community Opportunity Gloucestershire Most Improved independence Develop long-term aspirations and short-term goals Reduction in psychological distress Adaptable - change in direction dependent upon situation Improvement in self-esteem and confidence Demonstrate strong personal drive Being considerate of others and value of diversity Take on board others feelings and express own in unemotional fashion to achieve win-win outcome Ability to tackle/face challenges with improved self-confidence and accomplish in a better way Some Reduction in dependency and improved independence Ability to challenge self Consideration of the larger things in life To be able to put self forward/ volunteer for tasks and make suggestions Breakdown barriers of unfamiliarity and sense of alienation
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employment - confidence to take the next step
Table 5: Personal Objectives within Kitchen Challenge Expectations of the Kitchen Challenge Programme Those individuals who were referred into the commissioned community opportunity, engaged as part of the feasibility study, had varying expectations of what COGs could do for them. Its so I can have contact with other people and not loose my benefits. Ive done an IT course and other courses Ive been offered, now I can say Ive done this one. The majority of the individuals believed that their experience was to help them get a job or learn how to cook; however several reported that they wanted to feel better about them self and be more confident, and that they expected COGs and KC to be the vehicle to provide them with the ability to do so. I want to feel better about myself and built my confidence, I think it will help me to get a job. It is suggested that individuals reasoning for their participation was influenced by the way in which the Kitchen Challenge programme was sold to them through their Job Centre Plus advisor. Furthermore, some of the individuals had no expectations of Kitchen Challenge and simply participated because it was Its something to do on a Wednesday It was suggested that I do it, because I might be good at it. It was noted that the individuals experience of the Kitchen Challenge programme and the opportunities it afforded them, were realistic to their expectations; so as to encourage positive growth during the 6 week period.
Post-Kitchen Challenge Programme Disengagement Whilst most individuals, continued to engage after the Kitchen Challenge, through the COGs Broker and Job Centre Plus, whether this maybe through other projects, community opportunities or just social interaction; there are individuals that disengage. It is suggested that disengagement may be due to a number of external factors; which COGs or the community opportunity, such as Kitchen Challenge is unable to mitigate against. The support of the Broker and the Provider during the period of time spend with the individual, challenges within their life may provide barriers to continuing this. In review of previously commissioned Kitchen Challenge programmes, outside of the feasibility study, it was observed that typically disengagement followed when an individual was not seen to be able to fully engage into the programme group. However, some individuals were observed to engage and move forward within the group and their development; yet choose to disengage. Longer projected disengagement was also observed following the individual gaining volunteering or employment or self employment.
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Warwick Edinburgh Mental Health and Well Being Scale Evidence from the commissioned Kitchen Challenge programme, illustrates a positive movement towards improved mental health and well being. In addition to discussion, individuals provided feedback through self-reporting using the Warwick-Edinburgh Mental Health and Well Being Scale (WEMWBS).
5.2 Case Studies
Stuart, late 50s Stuart is in his late fifties, who lost a limb in a motorcycle accident 25 years previously. Stuart has since suffered from depression and poor mental health. He has often managed his emotional issues by cutting himself off from the outside world. Stuart has become obese and has lost self-confidence. Stuart was referred to the 6 week Kitchen Challenge programme. Participating in Kitchen Challenge enabled Stuart to identify his skills and strengths and recognise his potential. This led to an increased feeling of self worth and confidence, which contributed to a sense of improved wellbeing. He felt better able to job search and has lost weight, he is more outgoing and self confidence.
John, late 20s John is a man in his late twenties who has been receiving support from Job Centre Plus and claiming employment and support allowance (ELA) for people who have a limited capability for work because of a health condition or disability. John has moderate learning difficulties, but has previously had employment. John was a quiet and shy person who preferred watch and listen, rather than be involved. John lived at home with his parents. John was referred to the 6 week Kitchen Challenge programme. Participating in Kitchen Challenge enabled John was able to step forward and take on roles he would not normally be comfortable with, such as Head Chef. This helped John to build his self-confidence and esteem, and push his own personal boundaries to recognise his potential to identify his skills and strengths, to recognise his potential. This led to John becoming the nominated leader of the group and a feeling an increase in self worth. John felt better able to manage environments and situations he would not normally feel comfort within, and more confident to find employment. John has been motivated to apply for a number of different roles during and after the programme, and has been supported by his Support Worker. John has been offered a position with a new food charity initiative on a part-time basis, and it has been suggested that a volunteering period in the run up would be beneficial for John.
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Peter, late 20s Peter is a man in his late twenties who has been receiving support from Job Centre Plus and claiming employment and support allowance (ELA) for people who have a limited capability for work because of a health condition or disability. He was disconnected from society, unable to make eye contact, unkempt and disheveled, and did not eat properly as he did not have an oven. Peter was referred to the 6 week Kitchen Challenge programme. Participating in Kitchen Challenge enabled Peter to identify his skills and strengths, to recognise his potential. This led to Peter feeling an increase in self worth and confidence to a sense of improved wellbeing. He felt better able to engage in with Job Centre Plus to find employment, and has taken on a job as a car valeter, 18 hours a week. Peter takes pride in his appearance and is bright eyed and clean-shaven. He has also given up smoking, and has been cigarette free for over two months. Peter has also brought an oven, which has allowed him to eat better. Joan, late 40.s Joan was referred to Kitchen Challenge by her GP with the aim of improving her wellbeing. Joan has a complex history of mental health problems, which are exacerbated by a multitude of social problems and long term alcohol dependency. This had resulted in her having very low self confidence and being unable to face social situations. Joan frequently feels stuck due to her complex social situation and her inability to plan and take decisions. Following comprehensive assessment it became clear that Joan would not yet be able to engage with the demands of a Kitchen Challenge. However, in discussion with Joan it was agreed that a longer term approach to providing support would be of benefit to her. This COGs style support has helped her with practicing strategies to allow her to explore a more independent lifestyle. She frequently voices a desire to find a flat in a nearby town and is being assisted in dealing with her anxieties to allow her to begin to think more clearly about planning for her future.
5.3 Referrer Evaluation
Following the commissioning of the Kitchen Challenge programme, as a community opportunity, referrers reported that referral to COGs could be integrated as part of suggestions which are signposted to individuals. Furthermore, this is supported through PHCP interview evidence, that social prescription could be adopted as a fifth referral option, within the consulting room. The importance of the COGs Broker was noted as being a fundamental aspect of the delivery of the Kitchen Challenge programme, and its success. The assessment of the claimants was conducted with a personnel approach, and their skill is the key to the service. Community Opportunity Gloucestershire 47
It was noted that the benefit of the COGs Broker being approachable, flexible, understanding and knowledgable of opportunities, would help elicit information from referred individuals. In addition, referrers of individuals to the Kitchen Challenge programme, reported that they felt comfortable and had a high level of trust and confidence in the Broker. They also believed that the Broker would be able to find the most appropriate community opportunity for referred individuals. I couldnt fault them [the Broker], they were approachable and knowledgeable and it made me feel con fident that the programme was the right pathway for the claimants I referred.
5.4 Limitations
Despite the positive aspects of the delivery of COGs, a number of challenges and barriers were identified during engagement. These issues highlight the need for a strong and robust service and a further development stage. Due to time constraints, the period of time allowed to the feasibility study was significantly reduced, thus having a significant effect upon relationship building between the Broker and both referrers and the referred individuals. The COGs Broker was unable to make significant contact with both referrers and individuals, in order to allow for comprehensive assessment of an individuals needs and issues. This affected the time it took for compl ementary working practices to be established, including decisions regarding referrals and the acceptance from referrers, such as PHCPs and GPs. In particular, the limitation of a lead-in period restricted the dissemination of knowledge of the feasibility study and its remit, and subsequently limiting the engagement of GPs and bringing social prescription to their attention. However, strong relationships were established with statutory organisations, such as Job Centre Plus who provided monies for the commissioning of a community opportunity, and provided access and referrals from other agencies, outside of PHCPs.
5.6 Outcomes of the pilot
As highlighted, the establishment of a central service for community opportunities, will require learning and subsequent development, using the information collected during the investigation period, in addition to the observations from other reports. This development will enable the understanding of the principal requirements for COGs, illustrating the trends and effects it has upon different individuals and stakeholders. The findings from the feasibility study provide confidence in the impact of COGs upon individuals and stakeholders, and therefore the usefulness and importance of such a service. The investigation benefited from the multi-agency partnership of voluntary services and statutory stakeholders. Of the general practices that agreed to be involved, no referrals were received. It is believed that the restricted time period to develop strong working relationships and a trusted referral pathway, may have had an effect on the commitment and focus of GP referrals, upon COGs.
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Due to time constraints upon the investigation, a lead -in period could not be fully implemented. The absence of a lead-in period was noted to have a significant effect upon the uptake of stakeholders to refer individuals to the investigation, and alas the assessment of referred individuals. It is therefore proposed, that for a second phase a sufficient time period is scheduled to allow ground work to be established, to build relationships with all stakeholders, in particular GPs, and define referral criteria. Second phase ground work should also include further definition of the referral and assessment criteria, a launch event and the development of working practices to ensure buy-in from all stakeholders, conveying a clear and explicit understanding of the mission and purse of COGs. In addition a menu of audited and tested community opportunities that are available for commissioning should be created. The stake-holding referrers within the investigation, were all potential referring and signposting individuals to COGs, however the extent was relatively limited. Referrers did acknowledge that COGs was beneficial for individuals, and it is suggested that there is scope for wider development of COGs, through wider referral mechanisms into a wider range of COGs providers. The perceived barriers to referral to COGs were primarily around the lack of appropriate information about COGs, workload, time to acquire up to date information, and the perceived lack of motivation in some individuals.
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6.0 Developing COGs - A Proposed Way Forward

The strengthening and provision of and access to community opportunities and non-medical sources of support via COGs, has considerable potential to contribute to an improvement in mental health and well being, within Gloucestershire. COGs can be developed to become a fully integrated referral pathway for PHCPs in Gloucestershire, and strengthen the links between PHCPs and communities, statutory and voluntary services, which may influence the wider determinants of mental health. Although the feasibility study into the understanding of social prescription and the integration of a COGs service, was small; the flexibility and personalised service that it provides has been highlighted. The overall recommendations are set out below and consider the key issues which need to be addressed to create a good environment to support and promote improved mental well being within Gloucestershire.
6.1 Building the Model

The proposed model of COGs has, in the initial stages of investigation, been shown to work well and be acceptable and relevant at a low level of input, with the key elements of the service being: Flexible and personalised service; Skilled COGs Broker with good knowledge of the local community and voluntary sector, and experience of support people;statuatory sector and PHCPs Time spent with individual allowing them opportunity to explore solutions; Ability to provide support for as long as the individual requires, both pre, during and post involvement with COGs. Supporting people using true person-centred strength based approaches If COGs was to be extended to a pilot stage and subsequently rolled out to other districts, it is imperative that the core elements of the model explored and developed within the feasibility study are maintained. However consistent and regular feedback, from referrers and individuals, must be achieved for the consideration of future development and practice.
6.2 Increasing Referrals

In order to continue the development COGs, the number of referrals onto the service from PHCPs must be increased. Although there are a number of PHCPs within the Gloucestershire area who are familiar with the concept of social prescription and the opportunities available, it has been highlighted that there is a significant proportion who are not. Therefore to enable a successful development of COGs, a rise in referrals must be gained. This maybe achieved in a number of ways including: Community Opportunity Gloucestershire 50
Hosted visits by COGs to general practices for both GPs, Practice Nurses, receptionists and patients; Monthly emails to PHCPs reminding them of COGs and the benefits it can provide; Making COGs a regular agenda item during Practice Meetings; Making COGs an agenda item at Public Health meetings. Developing a multipurpose and far reaching behavior change/ marketing campaign
6.3 Recommendations
Commission a development phase to create COGs as the local service that offers primary health care providers a referral pathway into non-medical interventions, within Gloucestershire. Consideration should be given to further development within the Stroud and Berkeley Vale district and scaling up to incorporate Gloucester and Cheltenham.
By strengthening of the provision of access to non-medical sources of support, through social prescription opportunities, via COGs; a positive contribution to the mental health and wellbeing of Gloucestershire should be observed. COGs would be a fully integrated gateway for primary care providers, but will also promote and furthermore strength links between primary care, communities, voluntary and third sector services, which influence mental wellbeing. To create a positive environment for the creation and development of COGs, the following recommendations are required: Implementation Requirements Commitment and investment of resources over a minimum 2 year period Sponsorship by Senior Leadership Strategic approach to development Steering Group of key stakeholders forming a multi-agency partnership arrangement reporting into senior leadership Project management team lead by experienced Project Manager COGs delivery by professional, local VCS provider Bespoke measuring tool Opportunities development fund Marketing and promotional resources Community Opportunity Gloucestershire 51
Increasing PHCP and public awareness and engagement of COGs and the potential effectiveness for improving mental health and well being, and the promotion of the wider range of community opportunities. Implementation, investigation and evaluation Further evaluation and identification of the mental health and well being outcomes associated with COGs, following implementation.
6.4 Expected Outcomes (Non weighted)

For the Individual Short- and Medium-term Outcomes o Improved mental health and well being Increased awareness of skills, activities and behaviours that improve and protect mental wellbeing; Increased uptake of arts, leisure, education, volunteering, sport and other activities by vulnerable and at-risk groups, including people using mental health services; Increased levels of social contact and social support among marginalised and isolated groups. Better Experience of Health System
Long-term Goal Reduced levels of inappropriate prescribing of anti-depressants for mild to moderate depression, in line with National Institute for Health and Clinical Excellence (NICE) guidelines (NICE, 2004); Reduced waiting-lists for counselors and psychological services; Reduced levels of frequent attendance - defined as more than 12 visits to GP per year; Better chance of employment or volunteering and retaining it.
For the Primary Health Care Provider Improved access to psychological therapies; Reduced level of frequent attendance; Reduced levels of inappropriate prescribing of anti-depressants for mild to moderate depression; Reduced waiting lists for counselors and psychological services; Community Opportunity Gloucestershire 52
Improved range, choice and availability of primary care provision; Improved relationships with wider community partners. For the Commissioner COGs successfully operating in one locality, within Gloucestershire; A recognised single point of access to non-medical interventions; A flexible and responsive referral pathway for primary health care providers; An established multi-agency partnership structure; A bespoke measuring tool; Evaluation report with analysis and recommendations for further development; Value added to County Council and Clinical Commissioning strategies. Better patient experiences
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7.0 Conclusion
The focus of access for all, to community opportunities, is central to COGs, and that social engagement and support networks can promote the improvement of an individuals mental health and well being, and subsequently reduce social isolation and despondency. It is clear from the feasibility study and literature review, that a successful community opportunity was facilitated through the creation of COGs which is proposed as a Gloucestershire model for local prescription; however good relationships between all stakeholders are necessary to ensure that COGs can provide, engage and sustain suitable opportunities for Gloucestershire. Positive outcomes are slow and halting and not immediately apparent, and therefore COGs should be able to provide a continuous support system for individuals. Evidence has suggested that the success of social prescription cannot be clearly defined as the complete recovery of an individual, i.e. the patient gets better. It is proposed that the outcomes of social prescribing can be classified as short- and medium-term, relating to contributing factors to the improvement in an individuals mental well being. Whilst outcomes can be applied to all, they are not uniform and each outcome must be considered in relation to a unique set of circumstances around the individual engaged in a social prescription programme. The feasibility study has provided a comprehensive overview of social prescription nationally and locally, and its value to individuals, with positive impact highlighted through: Mental wellbeing; Distance travelled - improvements made on issues brought to COGs; Service satisfaction. By conducting this feasibility study, it has been possible to outline the benefits of COGs to Gloucestershire, and illustrate the effects of the such a service on individuals/users; setting out that a robust collaboration between health, statutory and voluntary services is imperative to ensuring success.
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COGs - Community Opportunities Gloucestershire

Date: Version: Presented to:

August 2013 Draft 2 Clinical Commissioning Group, Gloucestershire

Rob Rees, MBE (info@robrees.com)

Community Opportunity Gloucestershire

Community Opportunity Gloucestershire

Introduction by Rob Rees, MBE.

Community Opportunity Gloucestershire

Community Opportunity Gloucestershire

Community Opportunity Gloucestershire

Community Opportunities Gloucestershire (COGs)

Community Opportunity Gloucestershire

1.1 National Picture of Social Prescription

Community Opportunity Gloucestershire

Community Opportunity Gloucestershire

Asset-based Approaches within Gloucestershire

Community Opportunity Gloucestershire

Co-operative Approaches within Gloucestershire

Community Opportunity Gloucestershire

Community Opportunity Gloucestershire

Community Opportunity Gloucestershire

2.0 Social Prescription Activities

Activity Green Activity Eco-therapy

Community Learning & Supports

Table 1: Examples of Community Opportunities

2.1 Self Help and Computerised Therapy

Community Opportunity Gloucestershire

Community Opportunity Gloucestershire

2.2 Books on Prescription

2.3 Exercise on Prescription

Community Opportunity Gloucestershire

Community Opportunity Gloucestershire

2.4 Arts on Prescription

2.5 Green Activity/ Eco-therapy

Who can social prescribing benefit

Community Opportunity Gloucestershire

Table 2: Rates of Mental Health across Gloucestershire

Community Opportunity Gloucestershire

Community Opportunity Gloucestershire

3.0 Developing COGs Examples of Tested Local Approaches

Community Opportunity Gloucestershire

3.2 What does it teach us?

3.3 Conversation with primary contacts

Community Opportunity Gloucestershire

3.4 Creating COGs

Community Opportunity Gloucestershire

Table 4: Core Elements of Social Prescription (Kennaghan, 2012)

Community Opportunity Gloucestershire

3.5 Overview of proposed COGs referral pathway

Community Opportunity Gloucestershire

4.0 Delivering COGs

Step 1 Point of Referral

Community Opportunity Gloucestershire

Step 2 COGs Functional Assessment

Individual engages with the

COGs Broker, who provides a link pin of support.

Step 3 Determining Community Opportunities

Community Opportunity Gloucestershire

Step 4 - Engagement with Community Opportunities

Step 5 Independent engagement of Community Opportunities

Community Opportunity Gloucestershire

Step 6 Individual disengages from COGs Broker

Community Opportunity Gloucestershire