08/03/2024 Waiting Well: perioperative social prescribing in North East and North Cumbria

Simon Bromhead, Development Lead at Ways to Wellness, tells us about a pilot programme that offers social prescribing support to people on the waiting list for hip and knee surgery, using targeted data to identify and reach those in the most deprived communities.

• Using NHS data can be challenging but can ultimately help services to reach those patients that need help the most.
• By engaging with patients in the community, social prescribing link workers can identify non-clinical issues affecting the patients’ wellbeing, and have the knowledge and networks to help tackle them.
• Giving link workers a small ‘client support budget’ has allowed them to easily make small purchases that make a big difference. A common example is ‘sock putter-oners’, which help clients who have poor mobility to have a little bit more independence.

The North East and North Cumbria (NENC) region has some of the starkest health inequalities in the country, a situation that has been being exacerbated by the pandemic and the cost-of-living crisis which is having the greatest impact on those living in its most deprived communities.

There is lots of evidence to show that taking some simple steps before surgery or treatment to improve fitness, diet and mental health, helps patients make a better and quicker recovery. It also reduces the risk of their treatment being cancelled because of them not being well or fit enough to have the operation.

A key facet of this is the use of pain medication. Many people waiting for surgery are put on pain medication to manage their symptoms. However, this can result in complex postoperative interventions, worse pain control (resulting in slower rehabilitation), delayed wound healing and increased risk of post-operative complications. The result is poorer outcomes for the patient and additional cost (hospital bed days, medication, staff time) for the NHS.

NENC Integrated Care Board (ICB) developed the Waiting Well programme which is targeted to the approximately 30,000 people who are classed as 'Priority 4' patients, many of whom have been waiting for their treatment for a considerable amount of time. Around 9,500 of those people live in deciles 1 and 2 – the 20% most deprived communities in the country. People living in these areas are known to have greater co-morbidities such as heart and respiratory disease, diabetes, high blood pressure, mental health issues and dementia. This increases the risk of complications during and after surgery.

Ways to Wellness was commissioned to deliver a pilot social prescribing service for people identified through the Waiting Well programme, which is known as Perioperative Social Prescribing or PROSPeR. The pilot employs 1.5 Full Time Equivalent social prescribing link workers. It started in January 2023 and is expected to run to the end of 2025.

To be eligible for PROSPeR, patients must:

• Be on the P4 waiting list for hip or knee replacement surgery.
• Be taking pain medication (e.g. opioids, gabapentinoids), and not currently receiving support from the acute or chronic pain service
• Have a minimum of 12 weeks until surgery is due to take place
• Be resident in the geographical area of the project (Newcastle upon Tyne, Gateshead, North Tyneside and Northumberland).

The ICB team use RAIDR, a population health management digital dashboard which merges elective surgery waiting lists and primary care data, to help identify patients who may need support. Identified patients are contacted by a central hub, who explain the programme and invite them take up the offer of support.

If the patient agrees to engage with PROSPeR, there are three phases of support:

• 12-week preoperative intensive phase, in which the link worker assesses the person’s needs, establishes their goals, and links them to support
• Waiting well phase, in which the person will continue to receive community-based support, and have regular contact with the link worker until surgery takes place
• 12-week postoperative phase, in which the link worker is again more closely involved, to provide consistency of support, maintain behaviour change and promote engagement with rehabilitation, as well as planning for ongoing support.

Common goals set with clients include:

• Housing - getting adaptations, big and small
• Benefits, in particular attendance allowance and personal independence payments
• Emotional support - this can involve support in preparation for the operation itself, but some people just want someone to talk to
• Weight loss - several people have joined Slimming World and ‘low impact’ exercise groups like fall prevention
• Small ‘gadgets’ that make a big difference, such as sock putter-oners and grabbers

Using data for referrals: while this was a significant innovation for the Waiting Well programme, it has also had its challenges. In particular, the RAIDR digital dashboard does not currently include information about use of pain drugs. It therefore requires additional staff time to cross reference RAIDR data with other data, to identify eligible patients, and led to slow referrals at the start. It is hoped that use of pain drugs can be integrated into RAIDR in the near future. The project is also exploring stronger links with primary care.

Numbers of referrals: when referrals came through, there was a large number to deal with. This made it difficult to see everyone promptly: most people were contacted briefly and informed there would be a proper follow-up soon. Steps are being taken to ensure referrals are more staggered in future.

Getting people to engage in group activities was more difficult than anticipated. This was particularly difficult with clients that lived further away from services. Ways to Wellness is looking at possible solutions, such as a taxi contract.

In the first year of delivery:

• 81 people have been supported, 89% of whom lived in the 20% most deprived communities
• 71 Wellbeing Stars™ were completed. The average improvement between the first and most recent Stars was 2.95, representing significant improvements in wellbeing for the clients that have been supported
• 74 goals were set of which 20 have been achieved so far
• 545 contacts completed, including indirect link work, 11 DNAs

We are using validated tools to track progress, including the Wellbeing Star™.

We will also undertake qualitative interviews with pain nurses who have been involved with patients during the pilot.

The pilot is expected to continue delivery until December 2025.

As more patients reach the end of support, the team will continue to evaluate impact and adapt delivery accordingly. For example, in order to measure financial savings, they hope to undertake a comparison between the cohort who are offered support through the pilot with a matched cohort. This cohort includes a group of people whose data was collected up to a maximum of 3 years ago, matched by: operation type; length of stay; Index of Multiple Deprivation scores; and morphine equivalent pain drug use.They will compare patient outcomes on measures such as length of hospital stay, readmission rates within 28 days and number of times the patient has been seen by the pain nurse.

They are also incorporating a new piece of work that aims to link this support with primary care provision. Funded by the Deep End Network North East and North Cumbria, GP practices will be supported to identify patients on their records that are eligible for support. An Acute Pain Nurse will work in tandem with patients, and the GP practice and social prescribing link workers will work to support patients to improve their wellbeing and reduce their use of pain drugs.

The wider voluntary, community and social enterprise sector will be further integrated into delivery over the next few months. The ICB has commissioned a number of specific services that are frequently required by patients so that all Waiting Well services can signpost patients directly to them.

You can read more about the PROSPeR project and NENC ICB’s Waiting Well programme, while Get Set for Surgery has information for patients.