The document evaluates social prescribing projects in West Hampshire aimed at transforming care for older people through different networks, focusing on care navigators and proactive care teams. Key findings indicate significant reductions in emergency care usage and potential cost savings, with varying approaches taken across different groups. The evaluations highlight both quantitative and qualitative metrics to assess the impact of these initiatives on patient care and service efficiency.

1. Social Prescribing Evaluations

2. • In 2015/16 West Hampshire CCG used its
Transformation Funding with its four GP
Federations to design and deliver transformation
projects for older people:
• Eastleigh Southern Parishes Network – Care
Navigators
• Mid Hampshire Healthcare – Proactive Care
Teams
• New Forest Healthcare – Care Navigators
• Tri-Locality Care - Practice Based Outreach Teams
Transformation Fund Projects

3. AHSN Evaluation
The CCG commissioned Wessex AHSN to evaluate
each of these. Evaluations included:
• Implementation and organisation
• Service statistics
• Surveys of stakeholders and referrers
• Patient Reported Outcome Measures
• Case studies
• Impact on emergency secondary care activity
• Economic evaluation

4. Case study
See Eastleigh Southern Parishes Care Navigator
case study handout.

5. Comparison
Issues
• Different patient groups
• Different length of time support/ care
provided
• Assumptions about how long the benefits last
and how these might differ

6. Transformation Fund Evaluation Summaries
Eastleigh Southern Parishes Network Care
Navigators
Mid Hampshire Healthcare Proactive Care
Teams
New Forest Healthcare Limited Care
Navigators
Population · 49,000 people
· 5 general practices
· 205,000 people
· 19 general practices
· 189,000 people
· 17 general practices
Service The service started seeing patients in August
2015.
5 fte Care Navigators (CNs) (band 4
equivalent) attached to practices and
providing cross cover and a 7 day service.
Service primarily for older vulnerable patients
- who are contacted within 24 hours of
referral; visited at home and a holistic plan
developed covering care coordination and
connection with voluntary sector. CN
implements plan with patient/ carer. Patients
are supported as long as is required and
average is 6.5 weeks.
45% of referrals come from GPs and 45%
from reviewing hospital discharges for over
70’s.
The service started seeing patients in October
2015.
12.4 fte Proactive Care Nurses (PCNs) (band 6
equivalent) and 6.7 fte Care Coordinators
(CCs) (band 4 equivalent) appointed to provide
a 5 day service to people aged over 70 who are
identified as being at risk of deterioration or
crisis
PCNs undertake an initial 40 minute home visit
and holistic assessment from which they
develop a plan that will involve social
prescribing and referral to health and care
services. They can also provide direct clinical
care such as phlebotomy and falls
assessments. Patients typically receive 2 visits.
CC’s are based in the practice and work in
partnership with the PCNs to maintain contact
with patients and to take the actions to deliver
the plan.
The service started seeing patients in October
2015.
9.4 fte Care Navigators (CNs) (band 4
equivalent) attached to practices providing a 5
day service to people aged over 70 requiring
support and signposting.
The CNs provide a short period of active support
these patients typically over a 2-4 week period.
Half will receive a phonecall and half will be
visited at home – to establish which social,
voluntary and health services might help them
and to signpost them to these.
60% of referrals from GPs with the remainder
coming from a wide range of sources within the
practice and from other services.
Patient numbers Receive an average of 62 new referrals
per month – approx. 12 per CN.
Estimate annual activity 744 patients.
See 391 new patients per month –
approx.. 31 per PCN.
Estimate annual activity 4692 patients
Receive an average of 238 new referrals per
month – approx. 25 per CN.
Estimate annual activity 1500 patients.
Activity impact1
Analysis of 183 patients showed:
· A&E attendances reduced by 50%
· NEL admissions reduced by 32%
Analysis of 1757 patients showed:
· A&E attendances reduced by 31%
· NEL admissions reduced by 32%
· Ambulance activity reduced by 12%
Analysis of 1018 patients showed:
· A&E attendances reduced by 46%
· NEL admissions reduced by 20%
Economic
evaluation
(In development)
· Extrapolating the activity reductions to
all patients and over a year identified
potential tariff savings of £627,000.
· Potential Return on Investment 225%
· Extrapolating the activity reductions to
all patients and over a year identified
potential tariff savings of £2,715,000
· Potential Return on Investment 222%.
1
The analysis for Eastleigh and New Forest compared activity for the 120 days before referral with the 120 days afterwards. For Mid Hampshire it compared 90 days.

7. R-Outcomes scores from Eastleigh Southern Parishes and Mid Hampshire Healthcare
The higher the score –
the more positive the
response from patients

8. Discussion