Swindon have piloted a social prescribing scheme to support individuals being discharged from secondary mental health services. This presentation was given as part of an action learning day on social prescribing hosted by Swindon Building Health Partnerships group. For more information about the Building Health Partnerships programme www.socialenterprise.org.uk/buildinghealthpartnerships

1. Adult Demand Programme
- Wellbeing Co-ordination Project
14th
March 2014

2. What is Wellbeing Co-ordination?
A new approach to help people:
• Take control of their situation
• Manage their health & wellbeing more effectively
• Build their personal resilience & ability to cope
• Build their personal independence
• Engage the help they need early in order to avoid reaching crisis points
People are often able to cope far better if their needs can be met in a holistic, joined-up way – this
approach is about how we can help them achieve that

3. Why Do We Need It?
Recent studies & surveys have highlighted a number of reasons people in Swindon often don’t
engage help until they reach crisis point:
•Lack of knowledge about the services available
•Difficulty in engaging services
•Weariness at having to “tell their story” repeatedly
•Lack of co-ordination between services & organisations
•Carers not being able to leave loved-ones for long enough to get help
•People get lost in “grey areas” between services
We also know that people need additional help when they reach certain key points in their lives –
bereavement, job loss, changes in health, etc.

4. Wellbeing Co-ordination Approach
The approach was developed to:
• Build on current best practices
• Develop use of person-centred planning
• Ensure people own plans about themselves
• Help people to find support for themselves
• Enable people to be as independent as possible
• Improve joined-up working between organisations
• Build support within local communities
The approach & processes are based around Solution Focus - complements Children’s Services work
The intention is that this new way of working will be introduced across all relevant organisations
involved in health, wellbeing and social care in Swindon

5. Wellbeing Continuum Perspectives…
Primary Care
(GP)
Secondary
Care
General Public
GP involved, but need additional
support
“Stuck” between Primary
and Secondary Care
In Secondary Care
Discharged & recovering – may be under
GP care

6. Piloting The Approach
• Commissioners agreed to pilot wellbeing co-ordination approach with Service Users being
stepped-down from secondary mental health services
• Much of the focus within the “system” is currently on meeting clinical needs, but the reasons
people struggle to cope are far wider (financial issues, social isolation, loss of benefits, etc.)
• Wellbeing co-ordination gives us a way to change this and be more joined-up - it is about working
differently, not creating new roles
• The approach is supported by:
­ GP leads for mental health
­ Mental Health Care Forum
­ Mental Health Providers Forum
• Pilot started using staff and organisations who understood the concepts and already worked in
similar ways, now starting to broaden out to involve others

7. How Does The Pilot Work?
Phased
Transition
AWP Care
Co-ordination
Wellbeing
Co-ordination
Care plan Step-down &
wellbeing plans
developed together
Ongoing
review of wellbeing plans
Secondary Care Primary Care (GP)
Step-down
(Discharge)

8. The wellbeing co-ordination approach is designed to support the person’s journey of recovery &
independence:
•The person is involved at all stages of the process
•The person identifies their priorities, needs and strengths
•The person owns their plan and is key to its delivery
•The Wellbeing Co-ordinator acts as a coach/mentor, but does not replace the role of the statutory
Mental Health Care Co-ordinator
•Plans are developed around the needs of the person, which may well need services from several
organisations
•The person is supported at each stage of their journey, so don’t get “lost” in the system
•The plan establishes a baseline on which the person can build & measure success
Principles of Wellbeing Co-ordination Plans

9. Supporting People’s Journey to Recovery & Independence
Community Based
Groups & Activities
Supported Activities
In Wider Social Setting
Specialist Support
Groups & Activities
Wellbeing Co-ordination Support

10. Progress So Far…
• Pilot launched in November 2013
• Aim was to work with 12 individuals - currently working with 28 to allow for setbacks in recovery
and some not wishing / being able to become part of the pilot
• Strong engagement from both statutory and third sector staff
• Feedback from staff is that pilot is progressing far more smoothly and effectively than they had
hoped given the nature of the target client group
• Additional benefits being realised in terms of working relationships and shared learning
• Feedback from users around significant reductions in step-down anxiety and that a “hole in
services” is being addressed
• Governance & supervision through Case Analysis Workshops – reflective team approach used to
highlight learning and develop approach
• Links being identified into other areas of need

11. Learning So Far…
• Having a phased transition is a major step forward in managing people’s anxiety levels
• The coaching / mentoring approach helps people look at their needs & requirements differently
• People know themselves well – most already have goals in mind
• People don’t ask for the earth – plans are realistic
• The areas of help people need are very diverse
• One fairly common theme is around wanting a regular “check-up” to reflect on things every few
months before they become overwhelming and trigger points are reached
• Building in capability for Wellbeing Co-ordinators to link to GPs and Primary Care Liaison Service
is welcomed by users, but hasn’t been needed yet
• Cross-sector approach is working well – discussions build richer plans and address disconnects

12. Monitoring Progress
• Each person’s wellbeing during the pilot is tracked using the Warwick-Edinburgh Wellness Scale
• In addition, each person’s identified outcomes are also tracked on a regular basis and clustered
into key groups:
­ Coping at home
­ Welfare rights, benefits & debt
­ Support networks & social isolation
­ Employment, training & volunteering
­ Supportive activities
­ Relationships & social integration
• Other tools, such as the Recovery Star model, are used for more in-depth support work
dependant on individual needs

13. Three Questions For The Group
• How do we collectively design our services to bring together the best that the statutory and third
sector can offer at each stage so that we best meet the needs of the individual?
• How do we support our teams to build better cross-sector and cross-organisational working
relationships?
• How do we design our services so that we ensure that people don’t get lost at transition points –
concept of “passing the baton”?
Many thanks for listening.
Dave Potts
pottsdg@btinternet.com
dpotts2@swindon.gov.uk
07704 472600