Category: Social Prescribing

Social Prescribing case study: changing circumstances

Every so often, we highlight case studies from our Social Prescribing Link Workers.

Our Link Workers work with GPs across Birmingham and Solihull to provide social and non-medical support for patients. Their role is that of connector: working with people to help them identify their own needs, and then putting them in touch with support services that can help them in the longer term.

Because a Link Worker can spend weeks talking, listening and building a relationship with a patient, they sometimes find that people’s needs go beyond what was disclosed to their GP. This was the case when Link Worker Abeda took on a case referred by a Balsall Heath GP, which mentioned only that the patient needed help with a benefits application.

Changing support for changing circumstances: Yasmin’s story

When Yasmin (not her real name) was referred to the Social Prescribing Link Worker service, she was allocated to Abeda (pictured). Yasmin’s referral, which came from her GP surgery, mentioned that she would like some general advice on benefits, so Abeda gave her a call to find out more.

During their first conversation, Abeda asked Yasmin to tell her as much as possible about her situation, to make sure she could give her all-round support. Often, things come up in these initial chats that might not have been mentioned in the referral – and sometimes, it can help the person just to know they have someone to talk to.

Yasmin, who’s in her 30s, told Abeda that she was having some difficulties with her benefit claims, because there had been some changes in her circumstances.

Until recently, she explained, she had been the sole carer for her mum, who had cancer. Sadly, her mum passed away last year, so Yasmin now lives alone. She also has some physical health problems of her own – issues with her legs that mean she is now unable to work. So, she wanted to make sure she was claiming the correct benefits, and asked Abeda to help her with applications for employment support allowance and universal credit.

They made the claim together, making sure the authorities had all the correct information, and that Yasmin understood all the related evidence that would need to be submitted.

Over the few weeks that Abeda supported Yasmin, she could see that her health was deteriorating, and that she was finding it more and more difficult to care for herself. When Yasmin told Abeda that she had slipped and fallen trying to have a bath, Abeda asked if she would think about getting a carer of her own to help her around the house. She agreed, so together they applied to Occupational Therapy for an assessment, and also looked at local care agencies to see if there was one that might be able to help.

Within a few weeks, she had had an assessment, and together they had found a care service Yasmin was happy with. Now, carers from Sevacare visit her three times a week to help her at home and, depending on the outcome of the Occupational Therapy assessment, she may also be able to get additional support and equipment.

Yasmin has continued to submit sick notes to support her benefits claim, but she is still waiting to hear the results of the application. Because she has less money coming in than before, she’s finding it harder to pay bills, so Abeda helped her to get a discount from Severn Trent, as part of their scheme for people with a low household income.

Abeda hopes that Yasmin’s benefit claim will be accepted soon, but until then she’s continuing to chase it on her behalf, and to support Yasmin while she waits. Yasmin has said she would have been lost without the service, especially during such a difficult time, and tells Abeda she is very grateful for giving her so many options.

Social Prescribing case study: Kurdish connections

Throughout the pandemic, our Social Prescribing Link Workers have continued to support people – usually patients referred by their GP – with social or other non-medical issues. This is the latest in a series of blog posts highlighting their work; you can read more Link Worker case studies here.

The job of the Link Workers is to help people make connections: to help them navigate the city’s statutory services, to put them in touch with specialist advice and support, and to suggest groups and other activities that might help them improve their health and wellbeing. If a Link Worker can’t help, they will know someone who can!

Osman (not his real name), a Kurdish man living in Birmingham, knew what he needed – but had so far been unable to navigate the system, or even communicate his needs to his GP fully, due to the language barrier.

Creating confidence and connections: Osman’s story

“Osman” was referred to the Social Prescribing service by his GP surgery. However, although he had multiple needs, he doesn’t speak English, so wasn’t able to communicate them in detail.

He was allocated to Sadaf (pictured), a Link Worker based in Small Heath. The first thing Sadaf did was to contact a local interpreting agency that specialises in patient liaison.

During a three-way call with Sadaf, Osman and a Kurdish interpreter, Osman told Sadaf he had three main issues.

Firstly, problems with his physical health mean that Osman has difficulty with steps and using the bathroom at home. He asked how to access equipment to help him get around the house. This was clearly Osman’s most urgent issue. He said that his physical problems affect his mental health, which impacts his day-to-day life, and described feeling stripped of his independence.

Sadaf explained that Osman would need to be assessed by the Council’s Occupational Therapy department to find out if he was eligible for equipment. For this to happen, he would need to be referred, and he readily agreed to this.

Next, he said he was struggling to keep up gas and electricity payments. He told Sadaf he would like to change to a pre-paid meter but, because of the language barrier, he felt unable to call the utilities company to arrange it. This, too, was causing him a lot of concern.

Sadaf assured Osman that all the utilities companies have interpreters, and that they would be pleased to help him. He was reassured and said he felt a lot more confident about calling them.

Finally, Osman said he wanted to find a solicitor to help him with a medical negligence case. He reiterated that his physical health was at the core of his problems, and explained that it had deteriorated during a hospital admission. He felt he had not been medicated correctly during his stay, and that this had left him immobile. PALS (Patient Advice and Liaison Service) had recommended seeking legal advice, but he had been unable to find a solicitor himself.

Sadaf explained that Link Workers cannot give legal advice or recommendations, but said she would try and connect him to a Kurdish community service that can.

After the phonecall, Sadaf made the referral to Occupational Therapy, and then began the search for more specific help. However, after hours of online research and phonecalls, she found that support for the Kurdish community in Birmingham is limited. Instead, a Community Connector at Family Action, which works with hundreds of groups and services, said they would work with Osman in the longer term to arrange further support that would help with his claim.

Occupational Therapy have since contacted Osman and, although his referral has been received, there is a backlog due to the pandemic. He will be assessed, but it could take a while.

Despite the setbacks, Osman has told Sadaf he is already feeling happier because someone reached out to him and offered to work through issues together. Although he understands that it will be a lengthy process, and that this is just the start of his journey, the reassurance and guidance that Sadaf was able to give him has already helped a lot.

Services working hand in hand

The job of Social Prescribing Link Workers is to listen to what people want and need, and then to direct them to local groups and services that can help them achieve their goals.

Sometimes, those services are also delivered by Gateway!

Glenn is a Social Prescribing Link Worker who works in the North Solihull area. So when she met a patient who needed some help with her physical activity and eating habits, who better to direct her to than the Solihull Lifestyle Service?

Social Prescribing Case Study: Pam

Glenn, a Link Worker in North Solihull
Pam* was referred to the Social Prescribing Link Workers service in January 2021, because her GP felt that she would benefit from someone listening and giving her support.

Link Worker Glenn contacted Pam straight away and they arranged a time to talk over the phone.

The following week, Glenn called Pam and they spoke for quite some time. Pam explained she has a long term health condition, and also suffers from arthritis which causes her a lot of pain. Her follow up appointments at the hospital had been pushed back due to Covid, which was causing her to feel very low. Although Pam lives with her husband, he works during the day and she told Glenn she gets very anxious on her own.

Feeling down

As they chatted, it was clear the pain Pam was enduring really got her down, and this had caused her to stop doing the things she enjoyed. She said her eating habits were poor as she didn’t have an appetite and, although her husband often tried to encourage her to go out for a little walk or sit in the garden, she hadn’t been out of the house for a year.

Glenn told Pam about the Solihull Lifestyle Service, explaining that they could offer her support and advice about diet and exercise, and she agreed to be referred to them. She was allocated a Wellbeing Advisor called April, who would be able to start working with her in a couple of weeks’ time. In the meantime, Glenn and Pam talked about exercises Pam might be able to do. She mentioned that she had a treadmill at home but didn’t use it.

Glenn shared her own experiences of arthritis. She explained how she had forced herself to try and walk each day, and had found this boosted her mental health. Pam said she felt better having someone to talk to and said she would start using her treadmill.

April, a Wellbeing Advisor with the Solihull Lifestyle Service
The next time they spoke, Pam had started using the treadmill every couple of days for 15 minutes at a time, and had started eating small, regular meals, thanks to April’s encouragement. However, she told Glenn she wanted to stop taking anti-depressants. Glenn advised her to continue until she spoke to her GP, but also told her about St Germain’s, a service that uses a cognitive behaviour approach to depression and anxiety. Pam said she was willing to give it a go and consented to a referral.

Feeling the benefits

The next time they spoke, there had been a complete turnaround. Pam was eating regular meals and exercising nearly every day. Her GP had lowered her anti-depressant dosage so she could gradually stop taking them. John from St Germain’s had sent information about CBT and exercises for her to follow, and Pam was feeling the benefits already.

In their last conversation, Pam told Glenn that both her husband and son had noticed a difference in her wellbeing. In her own words, she had “stopped feeling sorry for herself”, and said she was even looking forward to doing some gardening!

She told Glenn she would always be grateful for the support she received from all three services.

*Pam’s name has been changed

Hand in hand

As you can see, Gateway’s approach is not about duplicating support, it’s about working hand in hand. Social Prescribing is about listening, finding out what someone needs, and linking them to it. The Solihull Lifestyle advisers are the experts in helping people to eat and exercise healthily.

As well as our own services, we are constantly making new contacts with others, widening our network so that we can direct people to the most suitable local support, and “plugging people in” to their community in the most effective way.

If you run a service in Birmingham or Solihull that would like to take referrals from Link Workers, get in touch to make sure we have your details.

Social Prescribing case study: Confidence, boundaries and a place to call home

This is the fourth blog post in a series highlighting the inspiring work of our Social Prescribing Link Workers. Previously, Wayne, Becky and Glenn highlighted some of the ways our Link Workers listen and support their patients, helping them to improve their confidence and develop their independence.

To support the UN’s #16days of activism against gender-based violence this blog will look at the support given to Ellie* by Link Worker Liana after Ellie separated from her husband. Much like all our Link Workers, Liana was able to listen and offer guidance to help Ellie deal with the practical problems she was facing after her life changed. This allowed her to have better control over her finances, set boundaries with her ex’s family as well as find more permanent housing.

Ellie’s Story:

Ellie was referred to a Link Worker by her GP because it was felt she needed additional support. A mother of three, Ellie had recently separated from her husband because of domestic abuse.

Link Worker Liana called Ellie as soon as possible to find out more about her situation and to talk through how she may be able to help.

Ellie told Liana that, although she was working, she was struggling – both financially and emotionally. After moving out and living with a friend for a while, she and her children were now living in a property rented from a private landlord, but it wasn’t ideal and she was finding it hard to budget. She was also finding the new family situation very hard; she wanted her children to be able to see her ex-partner’s family, but was finding the management of these relationships difficult and it was causing her a great deal of anxiety.

Liana realised that Ellie’s confidence was very low and that she would need help to rebuild it after such big changes. Between them, they established that Ellie’s priorities were to get a handle on her finances, to feel more confident about setting boundaries with her ex’s family, and to secure a more permanent housing solution.

The first referral Liana made was to Gingerbread, the charity for single parent families, which would be able to provide expert advice and help Ellie to make the necessary arrangements for child support.

Then she helped Ellie to make some benefits calculations, putting her in touch with the benefits agency and helping her to research and claim for the benefits she was entitled to.

Liana also helped Ellie to budget and find more suitable ways to manage her day-to-day finances. She showed her how to apply for the Severn Trent Trust fund and their Big Difference Scheme, which is for people on a low income, to see if she would be eligible to make non-standard payment arrangement for water bills.

The housing situation was very important to Ellie, so Liana and Ellie looked at all the options available to her. They contacted Birmingham City Council to find out current waiting times, and talked about applying to local housing associations – for which Liana was able to give Ellie all the information and contact details she needed.

This practical help, together with the amount of time Liana has been able to give Ellie to talk things through and decide for herself what she and her family need, has been a great help to Ellie. She’s found ways to allow her children to see their dad’s family in a way that causes her much less stress, and is feeling much more confident about her future.

* Ellie’s name has been changed

Social Prescribing case study: “Head in the sand”

This is the third blog post in a series highlighting some of the real life cases our Social Prescribing Link Workers have worked on this year.

The first two stories we published were from Birmingham Link Workers:

Social Prescribing case study: “Help me to sort this out!”
Social Prescribing case study: “I just want to know my son is OK”

Now it’s the turn of our Solihull team. Glenn is one of four Social Prescribing Link Workers who are based at North Solihull GP practices and, like all our Link Workers, she has been working with patients who have been referred by their GP or other practice staff for social, non-clinical needs. Since Covid hit in March, most of the work has been done via video and phone calls, with occasional visits to foodbanks, shops and pharmacies to help patients out, and the occasional distanced meet-up in parks and open areas.

Glenn told us about “Lorraine” (not her real name), who was referred for general advice and befriending, and explained how she encouraged her to deal with things one step at a time.

“No longer burying her head in the sand”: Lorraine’s story

Link Worker Glenn works in North Solihull

In June, Lorraine’s* GP referred her to the surgery’s Social Prescribing Link Worker, Glenn, for some extra support. The referral form mentioned that she may potentially need befriending, general advice and signposting (directing her to other organisations and agencies she might not have known about before).

Glenn called Lorraine shortly after receiving the referral. She asked her what had been happening in her life recently, and how she might be able to help.

Lorraine, who’s in her late 60s, told Glenn that she felt her health was suffering because of stress. So they had a long chat about it. Lorraine explained she had recently moved to Solihull from the other side of the city, and didn’t know anyone nearby, but that the main issue on her mind was debt. She told Glenn that this was causing her the biggest worry and was the source of most of her feelings of stress.

Lorraine explained that she had debts with a number of companies, including her own bank, with whom she had gone overdrawn. It had got to the stage where she admitted she now didn’t know where to start sorting it out. She was feeling overwhelmed.

The first thing Glenn did was to give her the details of Step Change, an organisation that would give her free debt advice. Then they wrote everything down to see where they could make a start. Lorraine said she didn’t have the confidence to ring the bank to talk to them about the overdraft, but Glenn gave her the encouragement she needed to make the call.

In fact, the bank were really helpful on the phone, and sent Lorraine an income and outgoings form to fill in. Lorraine and Glenn filled it in together, and this has allowed the bank to give Lorraine a repayment plan that feels positive and achievable.

The next step will be to use this information to fill in some forms for Step Change. Then Glenn will call the other places where Lorraine has debts and tell them that she is working on a budget plan with the organisation. By working methodically and making achievable plans with the help of debt specialists, Lorraine is already starting to feel more in control.

“[Lorraine] definitely feels better now that she has started to sort her debts out,” says Glenn. “She feels like she’s no longer burying her head in the sand.”

Now that Lorraine has tackled her biggest worry, she is starting to think about some of the other things she’d like to improve. She has mentioned that she’d like some help to lose weight and stop smoking, so Glenn has also referred her to the Solihull Lifestyle Service, where she will be able to work with an advisor to make more positive lifestyle changes.

*Lorraine’s name has been changed

Social Prescribing case study: “I just want to know my son is OK”

This is the second blog post in a series highlighting some of the real life cases our Social Prescribing Link Workers have worked on since they started in February.

You can read the first one, about Wayne and his patient ‘Linda’, here: Social Prescribing case study: “Help me to sort this out!”

“I just want to know my son is OK”: Chloe’s story

Becky, Link Worker

Chloe* was referred to Link Worker Becky (pictured, right) by her GP, who reported that Chloe was struggling with her mental health and a lack of routine.

When Becky contacted Chloe a few days later, it was obvious why. She said, “my baby son has been taken into care and is being adopted. I haven’t seen him for months. I just want to know if he’s OK but I’ve called and the social worker isn’t answering.”

At first, Becky simply listened.

In supported housing because of her learning difficulties and mental health needs, Chloe also told Becky she was unhappy sharing a house with people who, she felt, didn’t care about her son. She had previously lived with her son’s dad but now they were in separate houses and, because of Covid-19, they couldn’t see each other. She felt sad and isolated.

Having established that finding out about the baby was Chloe’s priority, Becky offered to call the social worker, and the next day was able to reassure her that her son was doing well. She explained that she would be sent a “settling in” letter, and helped her understand that, although she couldn’t see him, she would be able to write a letter to him every year.

Giving Chloe the space to talk about her son was vital. They discussed writing letters, or keeping a journal, and Becky has suggested setting aside a time each week to think about him and express her feelings. She’s reassured Chloe that what she’s going through is a very significant and difficult thing, and put her in touch with Karis Neighbourhood Scheme’s Listening and Guidance Service, which supports people going through loss.

Chloe really wants to move house, so Becky contacted her support worker, who told her that Chloe is in arrears and on a very low level of benefit. Clearly, budgeting isn’t easy –Chloe had already run out of food for the month – so Becky put her in touch with Ladywood Money Advice to find out if she’s on the right benefits, and what her housing options are. In the meantime, she also arranged for a one-off food parcel to be delivered.

Becky also pointed Chloe to an online social prescribing art group, which has turned out to be beneficial to both of them. Becky says, “it’s great because she enjoys the activities and it’s something for us to talk about. But the group leader has also shared a lot of Housing Association knowledge with us. We can communicate about Chloe and keep her GP in the loop too. It’s a great network.”

Chloe continues to lead her own support, but Becky expects she’ll help her with housing, budgeting support, and perhaps finding some volunteer work over the next few weeks. In the long term, she hopes Chloe will be able to make sense of the loss of her son.

Becky says, “when someone has multiple issues, it’s natural to want to do everything at once, but it’s important to focus on a person’s priorities. It’s not about rushing in with a magic wand or a sledge hammer. As Link Workers, we are able to spend time getting to know someone, understanding their needs and supporting them one step at a time.”

*Chloe’s name has been changed

Social Prescribing Link Workers and lockdown

Some of the Social Prescribing Link Workers team, pictured in February

Based at GP practices, Link Workers take referrals directly from GPs and other practice staff for Social Prescribing: offering one-to-one “whole person” support for non-medical and social issues, and helping people to access local activities and services.

We started putting together our Birmingham Social Prescribing Link Workers team in February; however, they had only been working with their local surgeries for a few weeks when Covid-19 hit and the country went into lockdown.

As more and more people started to need help, the referrals came flooding in and our Link Workers went into overdrive. As well as continuing to build relationships with their local GPs and care staff, they also continued to build their networks of local organisations and agencies, including making contact with the hundreds of new volunteer organisations and foodbanks that were popping up. And of course they were still getting to know each other as a team, albeit remotely. All work was done via video and phone calls, with occasional visits to foodbanks, shops and pharmacies to help patients out.

It has been tough, but they have done (and continue to do!) a tremendous job. In the five months they have been in their roles, our Social Prescribing Link Workers have already supported more than 400 people.

Social Prescribing case study: “Help me to sort this out!”

We thought it would be interesting to highlight some of the real life cases our Social Prescribing Link Workers have worked on since they started in February. We’ll be publishing a selection of these over the next few weeks and you can read the first one, about Wayne and his patient Linda*, below.

But first, a little note about the last few months…

Social Prescribing Link Workers and lockdown

Some of the Social Prescribing Link Workers team, pictured in February

Based at GP practices, Link Workers take referrals directly from GPs and other practice staff for Social Prescribing: offering one-to-one “whole person” support for non-medical and social issues, and helping people to access local activities and services.

We started putting together our Birmingham Social Prescribing Link Workers team in February; however, they had only been working with their local surgeries for a few weeks when Covid-19 hit and the country went into lockdown.

As more and more people started to need help, the referrals came flooding in and our Link Workers went into overdrive. As well as continuing to build relationships with their local GPs and care staff, they also continued to build their networks of local organisations and agencies, including making contact with the hundreds of new volunteer organisations and foodbanks that were popping up. And of course they were still getting to know each other as a team, albeit remotely. All work was done via video and phone calls, with occasional visits to foodbanks, shops and pharmacies to help patients out.

It has been tough, but they have done (and continue to do!) a tremendous job. In the five months they have been in their roles, our Social Prescribing Link Workers have already supported more than 400 people.

“Help me to sort this out”: Linda’s story

In February, Linda’s* GP referred her to the surgery’s Link Worker, Wayne (pictured), because of her issues with hoarding.

“A hoarding disorder is where someone acquires an excessive number of items and stores them in a chaotic manner, usually resulting in unmanageable amounts of clutter. The items can be of little or no monetary value.” (source: www.nhs.uk)

When he received the referral, Wayne contacted Linda straight away and they arranged to meet up at the surgery for a chat.

They spoke for over an hour. Linda, who’s in her fifties, explained that her relationship with her parents was at the heart of her hoarding problems, and that although she was getting help from the Mental Health team, it was only short term. She told Wayne she felt alone and helpless, saying “there’s not much anyone can do to help me. I don’t know how to solve this.”

Wayne asked Linda to talk about what she really wanted. How could they work together to make her feel happier? She said, simply, “help me to sort this out.”

Wayne went online and spoke to his network of contacts to find out what was available. He quickly discovered that West Midlands Fire Service hold regular meetings run by Clouds End, a specialist organisation that helps people with hoarding behaviours.

Wayne encouraged Linda to attend, and even offered to accompany her if she wanted some support. She decided to go on her own and found the meetings to be a positive experience. The other attendees were people like her and the group sessions had a non-judgemental atmosphere. She told Wayne she felt encouraged by the support.

In the meantime, Wayne found out more about what the Fire Service could offer. The priority was Linda’s safety; because no-one had been able to get into the house for a while, there was no way of knowing if it was safe. They arranged a home visit where WMFS carried out a fire safety check and installed a new smoke alarm. Wayne also found out that WMFS have a Specialist Team who support people just like Linda. When he told her, she was over the moon and started planning for them to visit.

The next step was for Linda to start reducing the clutter in her home. She started selling items online, which has been going well; she is happy to see some cash coming her way.

Unfortunately, at the time of writing, the Fire Service Specialist Team hadn’t yet been able to visit due to the Covid-19 isolation measures, but Wayne is in regular contact with them and they will start working with her as soon as it’s safe.

Wayne continues to contact Linda every week for a chat about her wellbeing. She remains pleased with her progress and tells him she feels positive about her future.

* Linda’s name has been changed