In a guest blog this week, Sheinaz Stansfield, a Practice Manager from Gateshead, gives an insight into how community engagement and social prescribing is making a real difference in her practice. If you want to read more about Sheinaz’s practice they appear as a case study in our new book “The Future of General Practice; Real Life Case Studies in Innovation and New Ways of Working”. The book can be purchased here

It was snowing in Gateshead at 9am on the Friday before the bank holiday. On leaving the surgery I bumped into Jez, a homeless patient, recently released from prison. I was late for a meeting and he followed me out, cold wet and hungry, when he burst into tears. I gave him some money for breakfast and asked him to wait for me in a local café. By this time, I was also cold, wet and very late – but I had a warm car to escape to.

Working jointly with the 3^rd sector, the practice had just won some funding to manage people with complex need; those who were too complex for us to manage in primary care, but not complex enough to fit the criteria for other local services. We have many such patients; those who have GP appointments several times a week, because of social issues impacting on their health and cannot possibly be addressed through the health system alone. People who have nowhere else to go.

At Oxford Terrace and Rawling Road Medical Group in Gateshead, our social prescribing is led by two Primary Care Navigators (HCA’S). Having developed an extensive “dynamic” directory of services, they are well respected and known to all of the statutory and non-statutory services within our GP catchment area. Jez and others like him are also known to them and we have worked with a local charity Fulfilling Lives, and won transformation funding (from the local Authority) to test a new model of care. We were meeting that morning to develop a mobilisation plan.

The meeting was attended by our practice based complex care team, who take a patient-centred approach to case management. The team consists of our frailty nurse, care navigators, occupational therapist and community matron. Between us we were able to identify the first half dozen patients for Alex, the co-ordinator. Jez fitted the bill perfectly. I introduced Alex to him as her first patient!

A core component of this service will be to identify peer mentors as volunteers for befriending and support. Fortuitously, my next engagement was a training session for Practice Health Champions. We have 39, who work with us as volunteers leading various groups including knit ‘n’ natter, reading, walking and others. They also host events for patients including a flu fair, summer health fair and an annual Christmas dinner on Christmas day. A new event for this year will be a veteran’s engagement event and a full WW2 re-enactment on 11^th November! Such is the power of unleashing energy to connect patients’ skills and passion with staff commitment.

This morning we were welcoming 10 new volunteers into the fold. The training was developed and led by other champions, facilitated by the practice, hosted by a local charity. Therefore, there was no additional cost to the health and wellbeing system. We were connecting local resources, building alliances around patient need and supporting each other to help the most vulnerable and dispossessed people in our community. There is no funding in the GP contracting mechanism for us to do this work, we do it because we care, it adds value and we are passionate about our people.

We have many Practice Health Champions with enduring mental health problems running these groups. Two champions, recovering alcoholics, run the men’s group and the Practice Facebook page. With training and support, they will become our first two peer mentors, for this new service.

My afternoon was spent back at the desk, trying to navigate my way through the tangled bureaucratic mess that is the transformation fund (GP Premises). I was interrupted by a phone call from a neighbouring Practice Manager, wondering how she was going to manage demand with two partners retiring and no applicants for the vacancies. We talked about social prescribing and the complex care team.

At this point I decided to call it a day. At 6pm as I left the practice, one patient was waiting in the waiting room, the sun was shining. Reflecting on my day, I smiled at the patient on my way out, looking forward to the long weekend ahead. My day job as a Practice Manager is full of “bad” NHS rules that block and frustrate most of our attempts to care for people the way they need to be taken care of. Today though, we had made a difference to at least one person, who might have otherwise spent the long weekend on a park bench, tired, cold and hungry.

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