You are here: Agenda item

Agenda item

Scrutiny Topic - Witness Evidence - GP Surgeries


Imogen Bloor and Rebecca Kingsnorth, Islington CCG, were present for discussion of this item.


During consideration of the report the following main points were made –


·         Social prescribing is the process of linking people with a range of non-medical community based services, which can support wellbeing and develop skills, knowledge and confidence to self- manage (activation)

·         Patient activation refers to the extent to which people feel engaged and confident in taking care of their health conditions

·         Patients who are more activated are better able to self-manage and use traditional services less frequently

·         Patient activation measure is a validated tool that measures levels of patient activation – skills, knowledge and confidence

·         An evaluation of the use of Patient Activation measures in Islington in 2014/15 found that 13% of patients reported the highest level of ability in managing their health conditions and 25% reported the lowest level and may feel overwhelmed by their conditions

·         Patients most able to manage their health conditions had 38% fewer emergency admissions than the patients who were least able to

·         If patients with low levels of activation were better supported to manage their conditions, as well as the most able, emergency admissions and attendances at A&E could be prevented

·         Evidence supports that social prescribing builds capacity into the health and social care system, offering an alternative to traditional health care interventions

·         A pilot in East Merton showed a reduction in GP consultations for patients referred to social prescribing by 33%. Patients identified were frequent attenders at this practice

·         Social Prescribing Islington Navigation service – Age UK is the Islington provider of the Islington Navigation Service the principal social prescribing connector service in the borough. There are 7 care navigators and support patients/service users to identify ways of achieving individual health aims

·         The navigators also connect service users to appropriate health/care services and other non-traditional providers to make best use of community resources for the delivery of these goals. There is enhanced signposting through up to date knowledge of available local services

·         There is also promotion of patients/service users independence through improved availability of information and support linked to personal goals. It is not simply a signposting service and the navigators are highly skilled professionals with backgrounds in a range of social and community care services – for example mental health, drug and alcohol services

·         The Islington Navigation service is open to all adults with an identified need. There are onward referrals to over 130 different organisations per year and service users are 81% likely or highly likely to reduce use of primary and secondary care services, due to navigation service interventions

·         There were 1088 referrals in 2017/18 and there were 350 referrals from GP practices

·         The new 2018 contract requires the service to develop and build links with primary care to raise the profile across all sites and to increase referrals

·         There is a focus on an integrated care and health integrated network model, which is focused on building resilience through collaboration – a team around the practice connecting primary care to a network of support

·         In response to a question it was stated that NHS England had granted licences for social prescribing until 2021

·         GP’s from each practice meet regularly with a team of health and social care practitioners to discuss the care needs of patients who have the most complex needs

·         Each meeting is centred on patients from a small group of GP practices. Health and Care issues are discussed and the team creates a coordinated plan to make the best use of local services

·         An external evaluation of the networks in 2017 identified over a12 month period, that patients were less likely to have visited hospital

·         Services wrapped around primary care – identifying moderately frail patient include – the North Care Closer to Home Integrated Network (CHIN), a partnership between GP’s, Whittington Health (Islington Community Ageing Team), Age UK, Islington GP Federation has established a service for moderately frail patients. Each practice has clinically verified those patients identified as moderately frail by EFI (electronic frailty index), to confirm a provisional assessment of moderate frailty

·         458 patients across 9 practices were identified as moderately frail and a further 217 whose frailty status was unclear

·         The next steps include prioritising the list, to have clinically led telephone triage, subsequent face to face assessment, and interventions as indicated

·         These contacts resulted in a regrading of frailty status in half of the cohort, severe, mild, or not frail

·         There are a broad range of interventions (either by the service or other agencies), for those confirmed with moderate frailty difficulties including medication review, therapy intervention, and social prescribing approaches

·         In response to a question it was stated that in the new 2018 contract it required the service to develop and build links with primary care and to build the profile and increase referrals from GP’s

·         Reference was made to the wide skill set in Age UK that could assist clients

·         A Member referred to the issue of frequent callers and whether there was any information on this, and whether the service were aware if information from the LAS and hospitals was available. Reference was made to the fact that work was going on with Whittington A&E around this and information would be supplied to Members when available


The Chair thanked Imogen Bloor and Rebecca Kingsnorth for their presentation