Executive Summary: May 2015
Background: The Sources of Support Service (SOS) was established by the Equally Well programme in Dundee to address the socio-economic and personal circumstances that affect patients' health and well-being, which GPs have neither the time, nor sometimes the necessary skills, to address. Three Link Workers with backgrounds in mental health and community development were appointed to work across four practices identified as having considerable numbers of deprived patients. The Link Workers used structured conversations of 40-50 mins duration to establish a rapport with patients and tease out the issues the patient wished to address. A plan of action would be created and the patient supported to access local services/activities to fulfill the plan. The Link Worker role sits within an asset based approach, working with people to develop their capacity and skills, and give them the confidence to act in a positive way to protect their well-being within the context in which they live.
Method: a case-based approach was used to provide an in-depth analysis of the work of the service and achievements thus far. There have been 656 referrals to the Sources of Support Service from its operational start at March 2011 to 31st Dec 2014. A purposive sample of 100 cases was chosen. The sample was structured to reflect patients that had completed their involvement with the service, and referral patterns across the four practices and each Link Worker. Three case based telephone interviews were held with each Link Worker who was provided with a pro-forma beforehand to facilitate the data collection. Each Link Worker had the relevant case files to hand to enable them to consult their notes and refresh their knowledge.
Sample Characteristics: 60% of cases were female and 40% male, almost identical to the gender balance within the TOTAL referrals to the SOS service as at end 2014. 71% of cases were aged 30-59 yrs (71), which was a higher percentage than the same range in ALL referrals (57%, 116). Thus, the age range of those who engaged and completed was narrower than the TOTAL of those referred to the service.
- Link Workers averaged 3.1 consultations with each patient. 87% (86) of patients were moved through the service within the initial target of 4 consultations.
- Link Workers undertook supported visits to services/activities in 59 cases (156 supported visits in total); the average number of supported visits was 2.6 and the range 1-8.
- 272 goals were set by patients in concert with the Link Worker and of these 72% (195) were fully met, 13% (37) were partially met and 15% (40) were unmet. Forty five per cent (43) of patients had ALL their goals met. The main reasons patients did not meet their goals were: not turning up at the service/activity; deteriorating mental health; being overwhelmed by problems in their life at that moment.
- a wide variety of goal themes were addressed; the highest success rates (i.e. Yes, goal met) related to: finance (86% 34); housing (81% 22); work issues (79% 11); activities (76% 27) and mental health (72% 34).
- 55% (50) of cases had their goals addressed using 2 or 3 services and a further 27% (25) of cases by 4 or 5 services. The main services utilised within the SOS 100 cases were: Insight Counselling, Making Money Work, Listening Service, Penumbra, Dundee Association for Mental Health (DAMH), Positive Steps, Connect and Remploy (See Glossary in Full Report).
- The most common combination of goal themes were: mental health and activities; mental health and finance; mental health, activities and health; mental health, finance and social isolation; housing, finance and health/mental health. The most common issues encompassed by the goals were: the effects of anxiety on day-to-day functioning, the effects of poor physical health (e.g. pain, mobility), lack of finance, lack of structure to the day, lack of ability/opportunities to socialise, and unsatisfactory housing for patient's needs.
- The main Link Worker roles within the goals were: facilitating (referrals; appointments) (73%, 204); information giving/research (43% 108); liaising (39%, 108) and support (including supported visits) (37%, 104). Just over three quarters (76%, 212) of all goals required between one and three Link Worker roles, the most common being a combination of facilitation, research/information, and support.
Barriers and Facilitators to Progress:
The barriers to addressing identified needs and the facilitators towards achieving positive patient outcomes were identified as follows:
- Barriers: anxiety (e.g. meeting new people, going out); low mood and lack of motivation; poor mobility and other physical limitations (especially pain as a result of physical issues); lack of money and resources (e.g. for travel, daily living); the lack of encouragement of those around the patient; lack of basic social skills (e.g. to deal with services); lack of time due to family/work commitments. Patients usually had multiple barriers e.g. a lack of money, poor mobility, ongoing pain and a lack of self-confidence/low mood.
- Facilitators: a supportive family; patient's own determination and motivation; the ability to listen and process information; an understanding employer; being able to drive and having a car. As with the barriers, the facilitators tended to work in tandem (e.g. the ability to take things on board, alongside the patient being determined and motivated, and having good family support).
Working on the Front-line: The Emerging Themes
There were five emergent themes relevant to implementation and achievement of patient outcomes within the SOS service: patient typologies; impact of family and friends; working with external services; the role of the Link Worker; 'some you win, some you don't'. Taking each in turn:
- Patient Typologies: six types of patient were identified through the evaluation:
The 'Resistant' - not turning up at the external service/activity; declining services/activities as not meeting their expectations, not bringing themselves to accept external help.
The 'Challenging' - underlying clinical issues (e.g. alcohol/drugs; notable memory issues; anger issues affecting their ability to interact with others in a reasonable manner; lack of social and negotiating skills).
The 'Vacillator' - once the process reached a point where they had to act, they used delaying tactics or did not turn up; the 'vacillators' would ask to stay with the service and promise the next time they would attend the external service/activity.
The 'Dependent' - clinging to the service as much for the psychological benefits (i.e. being listened to), as the practical benefits; dependency as an excuse to do nothing unless the Link Worker took charge.
The 'Focused' - strong notion of what they would like to get from the service; a strong focus within their lives that pushed them into taking action.
The 'Determined and Motivated' - may not have had an agenda but had an underlying 'can do' attitude; once pointed in the right direction, these patients acted independently, picking up and adapting ideas to suit their own circumstances.
- Impact of Family and Friends: acting as facilitators (accompanying the patient to services/activities; finding new things to do together; joining in with groups); acting as impediments (over protective parents/partners; unforeseen consequences of them attending service meetings); family as the focus (wanting to open up opportunities for the family/individual members; lowering family member's dependency on the patient; reconnecting/strengthening family relationships).
- Working with External Services: flexible service response (the value of services who could make home visits and/or meet with patients in their own locality); the service cascade (whereby the initial receiving service referred on to other appropriate services for the patient); one-stop shop (services with multiple components, capable of dealing with a broad range of issues, creating a pathway that moved the patient through their various specialty groups to a positive outcome); access issues (timing of available places; requirement to charge for a service; being with one type of service blocking access to other services; waiting lists; lack of provision per se); first impressions of the service (style of communication; not returning phone calls; not knowing/understanding the full story; staff with whom the patient made a connection leaving).
- Role of the Link Worker: tailored approach (ensuring that patients go to the right service for them, not just any service with a place available); joint working (e.g. carrying out joint visits with other services as appropriate; jointly working on finance/college applications, etc.; working together to facilitate discharging patients from SOS); making connections (between services and families; facilitating communication and information between services; clarity around respective roles); breaking the impasse (finding out what happened to applications; brokering communication and understanding between patients and services); plugging gaps and holding the fort (supporting the patient until the required service/professional became available); keeping it local (understanding what could be delivered where in relation to a patient's practical circumstance and using their liaison and negotiating skills to put together the best local response as well as the best service fit); therapeutic underpinning (to gain trust by creating a safe environment; addressing behavioural issues that might prevent patients taking full advantage of SOS; using therapeutic techniques to calm patients when visiting services/activities).
- A Reality Check: the right service, the wrong moment (patients could experience a decline in their mental health that could act as a barrier to engagement just as opportunities opened up; a step back to go forward (e.g. addressing a basic skills gap/particular fears, might be the only way forward to achieving stated goals); you are never too old (the issues, solutions and potential benefits were similar across age groups).
Patient Asset/Skills Gains
Internal Assets/Skills Gains
- A greater awareness of services and how to access them
- A broader knowledge of what services are available
- The ability to access services for family members
- Sharing knowledge and skills with others
- Increased confidence and self-esteem (happier and taking charge of life)
- Developing a 'can do' attitude
- Seeing a future
- Ability to take/maximise opportunities
- More insight into their issues
- Knowing how to discuss issues calmly and positively
- Making their own decisions
- Wanting to go out and join in
- Specific self-help techniques (e.g. re pain control; SAD; Stress)
Practical External Gains
- Housing points
- Being rehoused (includes homeless)
- Internal house adaptations
- Improved employment conditions
- Change of employment/first job
- Volunteering training
- Volunteering post
- College course
- Literacy skills (including being able to draft a CV; fill in forms)
- More social contacts/new social networks
- Services for family members
- Opportunities to share own skills with others
- New interests/reconnect to previous interests
- Family activities
- Involvement in local community regeneration group
The analysis of the SOS 100 cases highlighted the range and complexity of the work being undertaken. Even those patients who engaged and worked with the Link Workers were variously committed and provided a challenge to the Link Workers to keep them on board and moving forward. The Link Workers have gained a breadth and depth of knowledge of mainstream and community based services and activities that might well be unique within the service environment. Patients were not just setting goals but achieving them. In no small measure, this was due to a combination of the tenacity of the Link Workers and the developing good communication and joint working between the SOS service and other services.
Email: Naureen Ahmad