Presentation by Clare Mahoney, Senior Transformation Manager, NHS Liverpool CCG: Can social prescribing help tackle the inverse care law? at the Health, wellbeing and the environment event on Monday 28 January 2019 at The Isla Gladstone Conservatory, Liverpool

1. Can social prescribing help
tackle the inverse care law?
Health Wellbeing & the Environment
28th January 2019
Clare.mahoney@liverpoolccg.nhs.uk

2. Communities are good for health

3. Poverty is not

4. Is social prescribing part of the
solution?
“A greater focus on psycho-social factors is
part of a wider acknowledgement of the
non- material dimensions of deprivation,
perhaps most famously in Amartya Sen’s
call for ‘the ability to go about without
shame’ to be recognised as a basic human
freedom (Zaveleta 2007)”

5. Why should social prescribing focus on
wider determinants?
• Link between deprivation and health
• Inverse care law – those who need support and care most are
furthest away
• Presentations relating to social and economic needs in primary
care
• Welfare reforms – in Liverpool 55,000 households are poorer;
Pronounced effects on the long-term sick, mentally distressed,
disabled, women, younger people, and people aged 40-59 in
social housing.**
• A ‘practical offer’ of advice and advocacy should be integral to a
medical, well-being and psychological offers
** Taken from Liverpool City Council Welfare Reform Cumulative Impact Assessment

6. Advice on prescription….Plus
+

7. Non-medical presentations –
who makes them and why?
Local GP…
“these are the patients that keep coming back to surgery, and every
experienced GP knows who they are…the woman who asks for sleeping
tablets - because worrying about her debts keeps her awake at night, the
carers who can’t cope with the financial stresses that caring places upon them,
the young mothers who are making choices about whether to eat a meal or
heat their homes, they are the patients who we cannot treat with medicine”.
• Increasingly, people found ‘fit for work’ by DWP, sanctioned and so with little
or no money for food or fuel.
• people go to their GPs when they feel that they have nowhere else to turn
(Taken from independent evaluation of Advice On Prescription)
1/30/2019

8. Activity and outputs 2017 – 2018
• > 8,500 referrals
• £2.7 million debt managed
• >£6.7 million in benefit income for the lowest income households in the city –
ongoing welfare reform that has taken £157 million in welfare income from
Liverpool – a figure set to rise to £292 million by 2020
• Key enquiry areas, debt management, bailiff action, evictions, benefits reviews and
appeals, tribunal preparation and representation, budgeting and fincap support
• 20% have a household income of less than £320 pcm
• Majority in social or rented housing
1/30/2019

9. We wanted to know more so we linked four years of
person-level data
Primary Care Data
• Health Conditions
• Health
• Prescribing
• Consultations
Secondary Care Data
• Emergency and elective admissions
• Outpatient attendances
• Accident & Emergency Department
attendances
Social Care Data
• Contacts by package
• Assessments
• Social care need
Mental Health Data
• Contacts by service
• Mental health conditions
• Mental health need
Patient
Level data
link on
common
identifier in
a secure
environment
Patient level,
but not
identifiable.
Output
available for
analysis
Community Care Data
• Contacts by Service
• Referral Source
• Discharge outcome
Advice on
Prescription
Data
• Cases opened
• Case issues &
activity
• Self reported
health
outcomes

10. APP users - demographics
• 55.5% women, 44.5% men
• Majority 40-65 yrs
• 47% single person households
• 14% single parent
• 45% with an income of <£800,
(dropping to 24% after CAB
intervention)

11. APP users - health
Significantly higher prevalence of:
– Multiple long-term conditions
– COPD & other respiratory conditions
– Anxiety
– Depression
– Bi-polar
– Psychosis
– Poisoning
– Smokers

12. Long-term conditions in the
Advice on Prescription cohort

13. Dr Foster report of high intensity use
patients -shared characteristics
• Deprivation
• Working age adults
• Smoking/respiratory
• Drugs and alcohol,
• Mental distress
(Dr Foster Analysis of A&E attendances
2017 - 18)

14. Service utilisaton

15. Usage of Advice on Prescription
by ward and deprivation

16. Conclusions
• Material deprivation is so intrinsically
connected to ill-health, that when used
as a social prescribing criterion, it is
effective as a risk stratification tool.
• This creates an opportunity to relieve
financial and social hardship…
• ..and be proactive in providing
preventative care and promoting well-
being.

17. Next stage priorities
• In depth analysis of acute services
utilisation –start in Jan 2019
• Dig into nature of relationship with adult
social care
• Potential to control for variables of interest
eg respiratory conditions, single parents
• Develop algorithm to support risk
stratification as well as a targeted &
proportionate prevention approach
• Sustainability & growth funding for our new
health and wellbeing link-workers

18. Activity: e.g. green therapies,
gardening, allotments, city
farms, falconry, bowling,
angling, bicycling for beginners,
bicycling with a disability, yoga,
tai chi, walking groups –
different levels, active ageing
Resilience: building
personal & economic
resilence, e.g. financial
management skills,
confidence-building,
adult skills and lifelong
learning, pathways to
employment,
volunteering, Enterprise
Hub.
Creativity: e.g. arts &
crafts, music, orchestra,
pottery, knit & natter,
Made –Up-To-Meet,
acting, cookery classes,
woodwork
Volunteering & connecting: eg
Liverpool Re-connect, community
development, community groups,
befriending, lunch clubs, circles of
support, drama, local history clubs,
cookery, intergenerational groups,
walk and talk groups, bereavement
support, peer support, Back to Life,
WAYS TO WELL-BEING GATEWAY MODEL
Simple referral,
initial assessment
via phone call
within 2 working
days
TRUSTED PARTNERS
GPs
Mersey Care
PSS Wellbeing Centres
Liverpool Re-connect
WHISC
Live Well
Healthwatch
Carers
Cancer services
Macmillan/Wellbeing
Stroke Association
Respiratory
Liverpool Domestic
Abuse Services
YPAS
Barnardos Young
Carers
Age UK
And more….
Practical: e.g. income
maximisation, welfare
benefits, debt
management, help with
prescription, fuel, food
poverty, housing,
employment, tribunals,
bereavement, relationship
breakdown