Community Asset Navigator Programme Information Pack. Enhancing population health and prevention in Bolton.

Transcription

1 Community Asset Navigator Programme Information Pack Enhancing population health and prevention in Bolton. Bolton CVS September 2017

2 Introduction This summary provides an outline of the Community Asset Navigator programme, which aims to effectively connect the primary care, and broader public sector workforce in Bolton to non-clinical interventions funded through Bolton s Transformation Fund allocated through the Greater Manchester Health and Social Care Partnership. Overview Bolton is home to 1,561 voluntary and community sector (VCS) groups and organisations that offer a rich and diverse offer of social interventions that span everything from knit and natter to supporting people with complex lifestyles through drug and alcohol provision to domestic violence support. These Bolton based groups and organisations provide a vast array volunteering opportunities for more than 36,300 people that enables Bolton residents to give over 113,000 hours of their time each week. Evidence indicates that 1 in 5 GP s actively refer patients to non-clinical services and this can vary significantly across localities dependent on the strength of relationship, resources and the local voluntary and community sector. The Citizen s Advice Bureau report A very general practice highlighted that GPs in England report spending almost a fifth (19 per cent) of their time on social issues that are not principally about health. The implied cost to the health service of this time is almost 400 million a year. The focus of the local VCS offer in Bolton is person-centred; enabling self-care and self-management; building, fostering and adopting approaches that consider the individual and their strengths and assets; ensuring continuous and effective prevention at every stage of the life course and promoting the value and potential of people in communities. In the ever-developing health and social care landscape, the VCS is positioned effectively not just as an early prevention option, but as a continuum, from early intervention to being part of the end of life pathway. There is a clear opportunity for community groups and organisations to support the public sector in better meeting the needs of people in communities, to ensure that the best people for the job offer the right interventions at the right time. Through the development of Bolton s Locality Plan Transformation Fund bid, a role for the voluntary and community sector was clearly identified in order to achieve the ambitious change required in communities through a comprehensive social prescribing programme. In Bolton, we have adopted a common definition of social prescribing to be; the connection of people, services and support to the non-clinical assets in our communities that will improve the health, wellbeing and happiness of residents. The Community Asset Navigator model for Bolton has been developed in partnership to connect the VCS offer to the public sector health and social care economy and improve the health and wellbeing of people in communities, building the strong and

3 effective foundations for effective connectivity to non-medical, community based interventions and activities in Bolton. Current position Bolton already has a vast array of social interventions that individual organisations and support workers connect to across the health and social care economy. The aim is to ensure that the pathways are clear and understood, navigation is simple for all and that improved patient and system outcomes are measured effectively. Public sector partners recognise the need to strengthen knowledge around the impact, reach and access to voluntary and community sector services. The support available across the voluntary, community and social enterprise sector and the interdependencies across the health and social care economy also need to be clear. Bolton has established a firm commitment towards understanding and realising the assets of people and communities, fostering person-centred approaches and achieving improved outcomes in communities is fully agreed system-wide through its Locality Plan. Creating the environment for people to manage their own care and promoting self-care and self-management at every stage is a priority in Bolton. The VCS faces increased expectation and demand, which means there s a need for increased capacity and we have to work collaboratively to build that capacity in Bolton. The opportunity presented To achieve the ambitions that have been agreed in Bolton, to put people in control and to ensure that we are able to maximise the potential of our community assets, we believe that connecting the health and social care workforce to non-medical interventions forms an essential part of our transformation plans. We recognise that for our health and social care workforce, the only way that we can start to reduce the demand on the time of the specialists in our health and social care economy is to connect people to new models of support that consider their individual needs and aspirations, what they like and what they enjoy in order to activate people. At the heart of our intention is a shift to person centred approaches across the health and social care workforce, making sure that we listen to individuals, better understand what motivates them and then use that to enable positive and lasting change and this will connect with the Bolton offer. In order to ensure a smooth journey for individuals, we need to ensure that when we ve listened and understood people, that we re able to build the right journey for them and connect them to a broader offer. We believe that our local approach to social prescribing, through the introduction and development of Community Asset Navigators who will work with the existing health and social care workforce to maximise our assets in Bolton, better connecting people to what s on offer, will transform the connectivity of existing provision to communities, from where the true potential and ambition of our local transformation plans will be realised.

4 Bolton s transformation proposals recognise that the diversity and quantity of voluntary sector organisations is both a strength and an asset and that we must find solutions to working with it. Procurement that focuses on large single providers can work against this and our intention is to strengthen our local market and offer through supporting the local providers who hold expert knowledge and reach into communities, building on their expertise, reach and specialism. Bolton recognised that there s significant work to do to connect the amazing activities of the public sector health and social care services to the infinite and positive potential of the voluntary and community sector; testing non-clinical interventions and approaches that are truly person-centred and accessible. There needs to be a clear offer that could support a Bolton approach to social prescribing across the borough and in a meaningful way. Partners understand the essential need to invest in the voluntary and community sector if we expect it to deliver as part of a system and support the shift of demand from acute and public sector services and support. The Locality Plan and Vision 2030 Through the development of the Locality Plan, Bolton agreed that we needed to introduce a function that would shape, guide and influence the existing and emerging health and care workforce to connect with the voluntary and community sector (and wider offer) and make that connectivity clear, simple and accessible.

5 System partners agreed that we d ensure that we d measure and evaluate proportionately; better understanding and focusing on social value and not on a purely cost and benefit basis. Bolton agreed we would test and develop the model and develop into a sustainable approach through the life of the Locality Plan. Furthermore, partners agreed that we would develop this model in addition to existing prevention approaches, services and commissions and connect the offer and pathways to enhance and further develop what exists. Bolton agreed that innovation and transformation were incredibly important, however that as a system, we hadn t capitalised on what exists in the VCS, therefore time and attention would be allocated to understanding what s treasured and not purely what s measured in line with the asset narrative that s been fostered through the development and implementation of Bolton s Vision Co-design in practice The Community Asset Navigator model has been designed using the borough-wide agreed and championed principles of co-design and the co-design toolkit. The specification has been developed with people in communities, volunteers across sectors, patients from services, voluntary and community sector staff, private sector, housing staff, CCG staff, CCG clinical leads, Bolton Council Staff, Bolton Council Public Health, Foundation Trust Staff, General Practitioners and academics. The programme has been designed to be phased and developed, this is an evolutionary model that will be continuously improved. The Community Asset Navigator Model for Bolton Bolton Community Asset Navigators will connect residents and the health and social care workforce in Bolton to the vast array of community assets available, broadening and promoting the choice available to residents across the borough to improve their health and wellbeing outcomes. Built around a champion model, the skills of the Community Asset Navigators will be focussed on knowledge and interaction across the voluntary and community sector, connecting to what is known, understood and considering the skills and capacity of services and organisations. Where gaps are identified, this will be escalated and addressed to identify appropriate provision or the need for investment. This will be aligned to understanding the wider community offer and also where cultural offer, existing statutory provision and private sector interventions are also considered, with the focus on achieving the best outcomes for individuals. The Community Asset Navigators will enable communities of practice to thrive; supporting the development of networks where practitioners can learn and share, ensuring that traditional sector and knowledge boundaries can be overcome, refreshing and enhancing the skills and knowledge of others regardless of who employs them or where they deliver.

6 The Community Asset Navigators will act as an access point for individuals, together with working one to one with individuals where needed, although generally the focus will be to connect individuals to a VCS organisation or activity and will focus on patient activation, taking a proactive approach to connecting people to relevant options. The options will involve supporting people directly to attend initial sessions through existing resource or through volunteers and it may mean formally referring or informally arranging initial meetings with relevant groups, as well as the option of simply sign-posting an individual. The Community Asset Navigators will follow up with individuals after a defined period of time to see if they have achieved their original goals as agreed at referral. Through connecting specialists to the amazing and diverse non-clinical offer available through the voluntary, community, faith and social enterprise sector, the wider independent sector and the broader public sector offer; the primary purpose of this team is to prevent, reduce and delay demand on primary and secondary health and social care services and other public sector services, whilst promoting the potential and opportunity of people taking charge of their individual health and care needs. As experts in communities who understand the diversity of offer and routes in to interventions that are available through existing community activities and initiatives, commissioned services that sit outside of the public sector, fee based activities and through a core framework designed as part of the this social prescribing pilot, Bolton CAN will provide navigation support to service professionals, as well as residents, aiming to truly transform the journey for the individual and achieve positive outcomes. Bolton Community Asset Navigators will be made up of; A Programme Co-ordinator responsible for managing the framework and holding a relationship management role with identified leads across Primary Care, Secondary Care and the Social Care workforce. There will be an equipped group of 5 x Community Asset Navigators that will work borough wide, whilst actively participating in existing multi-disciplinary team activities and connecting with all aspects of the system. There will be specific allocated Community Asset Information post that will ensure that data collection and outcomes monitoring information is collected across the programme. In addition, a Community Investments support post that will support capacity building through access to the Community Investments Programme. Bolton Community Asset Navigators will be physically and strategically positioned to connect with all existing initiatives on rotation. They will have access to existing and emerging team Hubs and communication networks across the borough. Individuals within the team will have direct responsibility for a specified geographic area, as well as building in connectivity to communities of identity who often don t span traditional geographies, and where specific support that improves their lives may not be available within a defined neighbourhood.

7 Community Asset Navigators will be portable, with access to cloud based system that isn t connected to the health or social care IT system, ensuring that access can be achieved wherever they are, and all work can be undertaken remotely in any setting. Bolton s Community Asset Navigators will engage, enable and co-ordinate a group of volunteers from across the borough, recruited, supported and managed through Bolton CVS s existing Volunteer Centre and existing volunteer support activities. The role of Bolton Community Asset Navigator is that of a catalyst and connector, building on and embracing the principles of asset based community development. Where activities don t exist, they will connect groups and individuals to the infrastructure and development support that is available in order to kick start new activities and initiatives, as well as connecting to other borough wide positive initiatives such as the Community Empowerment Fund and small grants programmes. As well as connecting people to resources, information and support, Bolton Community Asset Navigators will enable individuals and groups to build capacity through the existing broader voluntary and community sector offer borough wide. Through connecting groups and organisations to the comprehensive infrastructure support offer from Bolton CVS, we will also be able to continuously developing the local market for the future. The Bolton Community Asset Navigator model has been built and developed on the principles of other social prescribing approaches nationally. A person-centred, asset focused approach that promotes and enables self-care and self-management. A team of people to connect what exists in Bolton to existing pathways and support ensuring we know what s out there and escalating the gaps. The specialist knowledge will be gained through thematic secondments from VCS organisation s from across Bolton across the following specialisms: (1) emotional wellbeing, (2) physical activity, (3) ageing, (4) young people; and (5) social inclusion. Secondments will spend time with their original employing organisation as well as being active and engaging across the borough, building capacity in the sector and individual organisations joining dots, strengthening assets and sharing knowledge.

8 The Community Asset Navigator Model on a page

9 Connectivity to other services The guiding principle of developing the Bolton Community Asset Navigators is to ensure that the existing workforce, through programmes such as Staying Well and Health Improvement Practitioners, have a clear access route in to the programme, ensuring smooth and efficient access to the voluntary and community sector and liberating the specialist public sector workforce to focus on high intensity cases. The focus will be on connecting the existing workforce and statutory aspects with the wider offer; which is built around, but not limited to, voluntary and community sector provision. This collaborative approach will build and engage with other programmes such as Families First and Complex Dependencies to ensure that unnecessary duplication is eliminated in the system, delivering a greater return on investment thanks to the added value this connectivity will achieve. Initial focus would be developing and connecting the VCS offer to GP s/primary Care and the broader health and social care workforce. The specialist knowledge and approach needs to be from the voluntary and community sector it s time to see, think and do things differently. The learning from this programme will influence workforce development across the system for the future. Building capacity in Bolton s voluntary and community sector The connectivity to capacity, innovation and assets will be created through a framework of investment priorities through the Population Health and Prevention Programme through the Community Investments Programme. The Community Investments Programme will provide investment for the voluntary and community sector to create defined packages that are designed to address specific need, an innovation fund that will provide the opportunity for the voluntary and community sector to develop new solutions, access to existing and emerging provision through the voluntary and community sector and a fund that will provide access to paid for provision where someone may be excluded due to their financial situation. Referral pathways to service

10 The referral pathway into the Community Asset Navigator will be continuously developed with people at the heart. Recognising time and other constraints of individuals and teams across the system, the identified preferred option is to have a referral system that works for individuals, staff members and volunteers that requires minimum data transfer at this initial stage. The focus of the referral pathway to enable people to self-serve (through a digital platform), but also providing the opportunity to telephone and pop-in. There is the recognition that people who require a little more support to self-refer, will have the opportunity to speak to a Community Asset Navigator. Outcomes and measurement For this programme, the whole focus is on prevention in communities, people being in control, maximising assets and person-centred approaches. The model is led through the voluntary and community sector and connecting to services that are offered and funded through existing commissioning models, including Primary Care, statutory, acute services and VCS services. To ensure that the programme is working, we will effectively measure, monitor and evaluate against individual outcomes, programme outcomes and use these measurements so that we can flex and develop our local offer, providing the information that will help to inform the development of where and when support is needed. We are currently in the process of co-designing the person-centred metrics for outcomes measurement for the Community Asset Navigators. The first individual assessment would be done either by phone or online at point of referral and followed up with a secondary assessment after six months, to evaluate impact and behaviour change. The outcomes all track back to the Locality Plan and in particular the two high level outcomes: 1. Increase in healthy life expectancy and reduction of the internal life expectancy gap across Bolton. 2. Achievement of financial and clinical sustainability across Bolton. Rigorous data collection principles will enable us to develop the evidence base and the benefits of individual activities, enabling us to promote the benefits of social options to clinicians and patients and quantifying the benefits of the Bolton approach. An outcomes star approach will be tailored and adopted that can be used by individuals and community asset navigators, this information will be collected at three stages; At point of referral. At 6 months following initial referral to an intervention. In order to better understand the workforce response, we will assess the understanding and perception of people making the referrals whether they recognise that having the Community Asset Navigators has made an impact on what they do or the people they have referred.

11 Case studies will be collected as standard from individuals accessing support, the Community Asset Navigators themselves and referral points in order to be able to highlight the cumulative story of the programme as well as qualitative data that shows the impact of the interventions. We will work with system partners to develop information collection processes to establish if the impact of new programmes, activities or procedures affect the Community Asset Navigator programme in any way. This will be when appropriate and the process will be co-designed in partnership with the VCS organisations providing interventions and be proportionate to the investment and activities provided. All monitoring will be supported by agreed formats (quality, outcomes and demographics) enabling analysis of the population in line with health inequalities information. This should be standardised and consistent for Bolton, whilst made accessible, practical and proportionate for the voluntary and community sector and the individual. Key considerations for data include; It will be contained in a database that is accessible to a range of stakeholders. Information can be extracted easily for analysis by a range of stakeholders. It will be through the existing Bolton CVS system database and should be web-based. Continuous development The Community Asset Navigator model is not intended to be a permanent workforce. The intention of this model is through the life of the Locality Plan (to 31 March 2021), Bolton will re-engineer its relationship across health and social care to fully embrace the potential of the talents, skills, resources and investment in communities and develop an effective community investment model that will resource the VCS to form pathways and deliver in partnership with the public sector, and offer added value through a range of community based interventions that people can access. Through exploring and liberating community assets across the borough, the health and social care economy will benefit from reduced demand on services through a range of social interventions. Social interventions will be adequately resourced through health, social care and prevention investment from across partners across the borough. Through the implementation of this model in Bolton, health and social care commissioners will realise the intrinsic value and potential of the voluntary and community sector and explore more sophisticated relationships and alliances through developing their own neighbourhood delivery and funding models, developing person-centred, person-led models of care within local communities. We must see the development of social value as a key aspect of commissioning and voluntary and community sector investment.

12 Further information and detail: Louise McDade Policy and Engagement Manager Bolton CVS Bolton Community and Voluntary Services (CVS) Registered Charity No: Registered Company No: The Bolton Hub Bold Street Bolton Greater Manchester BL1 1LS