Agenda item

Voluntary and Community Service - Support for Right Care Right Time Right Place

Steph Watt to present


Steph Watt, Head of Adult Commissioning at the NHS, presented an update on working with the voluntary and community Sector, Support for Right Care Right Time Right Place with the aid of the following PowerPoint presentation:



         Based on Rotherham’s commitment to supporting people to remain independent at home for as long as possible and home first ethos.

         Built on the strong tradition of partnership working and Voluntary Action Rotherham’s early pioneering of social prescribing.

         Highlighted three services which supported admission avoidance and discharge, to ensure people would receive the right level of care according to their needs.


Rotherham Urgent and Emergency Care, Social Prescribing Service-

         The role:

?    To work with health and social care professionals to support patients experiencing social, emotional and/or practical barriers to better health and wellbeing.

?    For admission avoidance and discharge.

?    Would provide holistic, wrap-around support for patients.

?    Would utilise wider voluntary and community sector services.

?    Would help to ensure a safe home environment and build independence, confidence and resilience.

         The Service:

?    Ran Monday to Friday for age eighteen plus.

?    Received referrals and assessed discharged for patients.

?    Developed a support plan.

?    Onward referrals.

?    Ongoing, short-term support.

?    Follow-up and closure of case.


UEC Social Prescribing in practise, Paul’s case study:

         About Paul:

?    Admitted with Critical Pneumonia.

?    Unable to walk or mobilise.

?    Poor mental and physical health following 9 months in hospital and a huge life change and lost his job and home.

         Paul’s experience:

?    Spent nine months in hospital and step-down beds.

?    Referred to befriending and enabling, advocacy and benefits support.

?    Since discharge, Paul had progressed from a bed space to independent living within supported housing.

?    Paul was feeling positive, and the aim was to walk independently and return to work in the future.

         The impact for Paul:

?    Improved wellbeing (outcomes measures).

?    Improved mental health and physical health.

?    Improved social connections.

?    Maximised finances.

?    Greater independence and resilience.

         The impact for the system:

?    Bridged a gap from acute back into the community.

?    Linked in with ED high intensity user group.

?    Improved co-ordination of care between health, social care and voluntary sectors

?    Reduced likelihood of readmissions.


YAWR Services Personal Health Budget (PHB)-

         The Need:

?    Removed barriers to allow early and safe discharge, in order to reduce delayed discharges.

?    Assessment and award of PHB (up to £500, with escalation process for exceptions) used to buy a service or goods for discharge home from the acute or community bed base.

         YAWR Services Offer:

?    The service visits patients on the ward prior to discharge to discuss and assess their needs to facilitate discharge from hospital.

?    Pre-discharge was included an initial assessment to discuss support needs and action plan.

?    Post discharge was included a visit the patient to address additional needs including benefits support.

         Barriers to Discharge:

?    Housing, equipment and adaptations, property, and referral pathways.


Personal Health Budgets (PHB) in practise-

         Marcia’s Story:

?    Patient was aged 59 years and admitted to Rotherham Hospital in June 2022, following a stroke, loss of sight and her property was no longer suitable.

?    Support with priority housing application, liaison with eye clinic and Rotherham Sight and Sound, a referral for wheelchair access and a review of a care package for double handling.

?    PHB used to pay for a removal company, purchased microwave and fridge freezer.

?    Successful discharge into the community, improved independence, confidence and quality of life.


Impact of the Personal Health Budget Pilot-

         For Patients and Families:

?    Increased independence and quality of life for individuals.

?    PHB had been utilised for household items, cleaning services enabling individuals to return to a safe and secure environment.

?    Reduced carer stress.

?    Improved financial outcomes for individuals through benefits claimed.

?    Informed choice through a holistic needs assessment.


AGE UK Hospital Aftercare Services-

         Our Offer:

?    Monday to Friday, for sixty plus.

?    Transport home from an acute or community bed, within three hours.

?    Settling in service with safe and well check.

?    Onward referrals and signposting.

?    Small aids and adaptations.

?    Short term non-personal enablement support for up to 30 days.

?    Service was also for avoidance of unnecessary admissions.

         The added value:

?    Over 5200 referrals, including safety netting.

?    Over 300 onward referrals and/or signposts to other agencies.

?    Approximately £150,000 in unclaimed monies released through benefit referrals.

?    Over one hundred people received further enabling support.

?    Four Trusted Assessor trained staff.

         Aftercare Service in Practise Case Study:

?    Carol was referred by a frailty nurse due to concerns for patient’s safety once home.

?    There was no answer when staff visited following day so permission was obtained from the next of kin to enter the house.

?    Patient was found lying on hall-way floor after falling four hours earlier and could not get up.

?    Made patient comfortable and provided reassurance whilst the emergency services were called.

?    The ambulance arrived within forty-five to sixty minutes and Carol was checked over.

?    In consultation with her GP, an agreement was made to send the district nursing team for an assessment.

?    The decision reassured the ambulance crew that suitable care was in place and avoided an ambulance conveyance, attendance at A&E and potential admission.

?    The emergency crew and staff member spent four hours with the patient.

?    The worker made the patient a drink of tea and prepared the following day’s breakfast and lunch before leaving.


The Next Steps-

         Embed in multi-disciplinary Transfer of Care Hub, right care, time and place.

         Evaluate pilots.

         Consolidate social prescribing, including investment in wider voluntary community sector.


Discussion ensued on the presentation with the following issues raised and/or clarified:


         There would be a discussion with the national team regarding evaluation of the pilots, to examine whether the scale of required impact could be analysed in comparison to the scale of impact achieved.



Resolved: - That the Health and Wellbeing Board:

1)    Noted the update provided.

Supporting documents: