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Care Navigation/Social Prescribing is a model that enables health and social care professionals to refer people to a range of non-medical services within their community to improve and support social, mental and physical health and wellbeing.
Recognising that people’s health and wellbeing is affected by a range of social, economic, and environmental factors.
Care Navigation takes a holistic approach that enables people to take control of their own health. With the practical and emotional support of a Care Navigator this allows people to identify ways to improve how they are feeling.
Our Care Navigators spend time helping people to focus on ‘what matters’ to them. They assess the needs of each individual and together create a personalised care and support plan. This may involve connecting them to community groups, classes, workshops, or even advisory bodies for legal advice or debt counselling.
There is increasing evidence in the success of Care Navigating/Social Prescribing and the impact it has on both individuals and communities.
“In one evaluation, six care navigators from voluntary care organisations worked in integrated health and social care teams across and county. They carried out up to six face to face interviews with an older person, with a unit cost of £42 (compared to £213 per visit for adult social worker). Health related quality of life measures improved by 17%, people needed to use fewer health services and the project was overall cost effective.” ~ Care Navigation: A Competency Framework
“Thank you so much, you’ve helped me to realise there are resources out there for me” – Patient was experiencing homelessness
There is no universal definition of care navigation a variety of titles are used, including ‘care navigator (CN)’, ‘social prescriber (SP)’ and ‘link worker’. All these roles provide effective navigation and is a key element of delivering coordinated, person-centred care and support.
Care Navigators are often existing members of staff within Community Services and GP practices. At Sussex MSK Health, our Care Navigators work closely with clinicians, which helps to free up valuable clinical time for addressing physical health needs, while Care Navigators can focusing on non-medical and wellbeing concerns. By providing this additional support patients receive holistic care that extends beyond clinical treatment.
Many things affect our health and wellbeing. We can all sometimes feel isolated, lonely, or stressed out by work or money. It can also be very difficult dealing with the stress of managing a long-term condition.
We now have a team of 8 people who are helping patients deal with similar concerns every day, creating personalised support plans for our patients giving them access the support and resources they need to help them feel better.
Read more about Personalised Care/ Social Prescribing on the NHS website: NHS England » Social prescribing
Or if you’d like to learn more about our MSK service you can find out more here: Community MSK Services in Sussex – Here
We’ve been asking communities what really matters when they’re living with pain. In this update, we share what we heard, what surprised us, and how this learning is shaping a new three-part support offer for MSK pain that starts locally, builds on existing strengths, and is designed together.
What if pain wasn’t just something to manage, but a signal for change? The Kings Fund and Here explore how a “do with” approach can transform pain services – focusing on prevention, connection, and holistic support.
Introducing Rethinking Our Health – a new way of working with communities to support people living with long-term conditions.
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]]>The post Congratulations Aaron Salter: Hospice UK’s Digital Champion Award winner 2024 appeared first on Here.
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We are delighted to share the inspiring story of Aaron Salter from Pilgrims Hospices in East Kent, winner of the Digital Champion Award at the Hospice UK Conference 2024. His remarkable work exemplifies the power of digital innovation in transforming healthcare delivery.
As a social enterprise dedicated to supporting other healthcare organisations use data and analytics, we were proud to sponsor an award that celebrates individuals driving meaningful change in hospice care. Aaron’s recognition is not just a personal achievement but an inspiration for how technology can revolutionise patient care.
In 2022, Pilgrims Hospices faced a real challenge: inconsistent data collection and reporting across their three Inpatient Units (IPUs). This variability created significant obstacles:
Recognising the transformative potential of data, Aaron embarked on a mission to standardise and enhance data management. The Digital Champion Award criteria perfectly captured his journey:
In the realm of hospice and palliative care, every piece of data represents someone’s life and story. Aaron’s work goes beyond numbers, it’s about ensuring that every patient receives personalised, high-quality care that respects their unique journey.
His achievement reinforces our belief that technology, when thoughtfully applied, can be a powerful tool for compassionate healthcare. Congratulations, Aaron Salter – a true Digital Champion who is redefining what’s possible in hospice care.
The conference highlighted a critical challenge facing hospices: the pressing need to demonstrate their value within the healthcare ecosystem to secure sustainable NHS funding. With direct cost pressures mounting, it’s becoming increasingly clear that traditional charitable funding may not be sufficient to support hospices in the long term without innovative strategies.
In the current constrained commissioning landscape, data has emerged as a powerful tool for validation. As one presenter succinctly noted, “commissioners will pay for what they can measure.” This insight has prompted a promising collaborative approach among hospices, who are now pooling their data—often aligned with Integrated Care Board (ICB) geographical boundaries—to illustrate their collective impact.
This collaborative data-sharing represents an exciting and progressive development for the hospice sector. By aggregating and presenting comprehensive evidence of their contributions, hospices are positioning themselves to make a compelling case for continued and potentially expanded NHS support. In an era of increasing financial scrutiny, robust and meaningful data will be more crucial than ever in securing the resources necessary to maintain and enhance hospice services.
This award is about celebrating the people who make technology happen. Digital innovation in any healthcare environment is really hard, and it doesn’t matter how brilliant the technology is; it will only work when you have amazing people to make it work. That is why ‘Here’ are delighted to sponsor this award.
Hospices provide vital care and support to children and adults living with long-term illnesses or approaching the end of their lives.
In 2022-23, hospices across the UK provided palliative and end of life care to 300,000 and provided direct support services to 60,000 family members, friends and carers.
It costs £1.6 billion each year to run the hospices in the UK.
Hospices raise over £1.1 billion of this through fundraising, and less than £0.5 billion comes from government funding.
Hospices do incredible work but they can’t do it without support. To find out about the different ways you could support Hospice UK you can find details on their website.
How can Here help hospices enhance their impact with data? – Here
Why do we want to work with hospices? – Here
To get in touch email: matthew.riley@nhs.net
Like many of us delivering healthcare in collaboration with the NHS, hospices are experiencing the dilemma of not being an NHS organisation but needing to know our way around the landscape of data as if they are.
Like many of us delivering healthcare in collaboration with the NHS, hospices are experiencing the dilemma of not being an NHS organisation but needing to know our way around the landscape of data as if they are.
As a social enterprise dedicated to transforming healthcare through data analytics, we are thrilled to share the inspiring story of Aaron Salter, winner of the Digital Champion Award at the Hospice UK Conference 2024.
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We are delighted to announce the launch of Sussex MSK Health Brighton & Hove and West Sussex, our brand-new Musculoskeletal (MSK) service, which officially begins today – 2nd December 2024.
This launch marks a new chapter in delivering joined-up, person-centred care. Together with our partners Sussex Community NHS Foundation Trust (SCFT), we’re building on over 10 years of expertise in designing and delivering innovative long-term conditions services, including CQC outstanding MSK care.
The new community service covers Brighton & Hove and West Sussex, replacing Sussex MSK Partnership Central (SMSKPC), University Hospitals Sussex (UHSussex) and Coastal Sussex Integrated MSK Service (CSIMS).
Musculoskeletal conditions are one of the most common long-term conditions in the UK. Affecting one in three people and significantly impacting their quality of life and independence.
As specialists in long-term condition care, we understand the importance of creating services that are easy to navigate, responsive, and effective at supporting people to live well.
We’re proud to be shaping the future of MSK care, ensuring that everyone in Brighton & Hove and West Sussex has access to exceptional, personalised support.
To learn more about our approach and the impact we’re making, visit Community MSK Services in Sussex – Here
We’ve been asking communities what really matters when they’re living with pain. In this update, we share what we heard, what surprised us, and how this learning is shaping a new three-part support offer for MSK pain that starts locally, builds on existing strengths, and is designed together.
What if pain wasn’t just something to manage, but a signal for change? The Kings Fund and Here explore how a “do with” approach can transform pain services – focusing on prevention, connection, and holistic support.
Introducing Rethinking Our Health – a new way of working with communities to support people living with long-term conditions.
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]]>The post Reflecting on a decade of impact: A farewell to Sussex MSK Partnership Central appeared first on Here.
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Over the past decade, this partnership has been more than a service – it’s been a community, a purpose, and a shared commitment to making a real difference in people’s lives.
To mark this special occasion, we’ve created a series of videos that highlight the many achievements of SMSKPC and the incredible people who’ve made it all possible. Each focuses on a key aspect of our journey, showcasing the impact and the values that have defined our partnership.
Our first video takes us back to May 2024, when we celebrated ten years of SMSKPC at our annual conference. This event marked a special moment for us – a chance to look back on all that’s been achieved, and to recognise the people who’ve made it possible.
Over the past decade, it’s been our team’s commitment and shared purpose that have shaped our success, and May’s celebration was a reminder of just how much we’ve accomplished together.
This video shines a light on the tangible difference our service has made to people and our communities – it’s the personal connections that have been at the heart of everything we do.
Showcasing the positive feedback and gratitude of those who’ve benefited from our service, these stories of care and support truly bring our partnership’s impact to life.
It’s the culture that has defined our service – a culture built on strong relationships, shared values, and a deep commitment to patient care. The camaraderie, teamwork, and dedication of our team highlight the connections that have shaped our partnership and made it more than just a service, but a community.
From the kindness shown in small gestures and moments of support to the collaborative efforts that have made a big difference – and the friendships formed along the way – this video is a chance to honour everyone who has contributed to delivering SMSKPC.
Each individual’s hard work, passion, and care have made this service possible.
As SMSKPC comes to a close, this series is our way of looking back with pride and gratitude. We’ve come so far over the last 10 years, and it’s all thanks to the incredible individuals hard work, passion, and care have made our service possible. Together, we’ve built something truly special.
We hope our work inspires others to see the power of community, the importance of shared purpose, and the enduring impact of truly personalised care.
Thank you to everyone involved in being part of this incredible story.
Stay tuned as we celebrate this final chapter of the Sussex MSK Partnership Central journey and say hello to MSK Health.
Journey through our memorable moments and key innovations from the past ten years to find out more about the development and transformation of SMSKP.
Partnership forms
Here created a delivery partnership with Sussex Community Foundation Trust as prime contract holder for MSK
Collaboration
Drawing on strengths of expertise from across the system. Building networks across primary, secondary care the voluntary sector
Culture
Bringing teams together to create their own shared values – together we strive for human and unhurried care.
We were the first organisation to recruit a Patient Director, putting the lived experience voice front and centre of the service. This has now evolved into our Health Builders Programme.
Personalisation
As one of the first services to create Personalised Care Leads we can evidence that seeing truly personalised care leads to better outcomes, better use of resources and saves the health system money
Started addressing letters to patients rather than clinicians to ensure information is understandable, jargon free and supporting the “no decision about me, without me” approach
Reached 7% reduction in referrals to secondary care, whilst ensuring quick access times within the community and supporting people to self manage
Quality
Safe, high standard care for patients is enshrined in all we do. We deliver at scale, a complex service, over 10 locations alongside over 200 colleagues
Rated CQC outstanding
Won HSJ Partnership award
Proactively redirected MSK resource to support the urgent and non-elective COVID-19 response
Publish The CASE For Change, Creating and Sustaining Excellence in MSK Care
Data
Our decisions are data led. Using our award winning suite of data analytics for optimal resource management and meaningful future planning
Community
We work alongside communities, using our data systems to find underserved groups, we proactively seek to understand how we can meet their needs
Co-creation
Our network of paid and volunteer Health Builders – people with lived experience – work with us at every level of our governance structure and in service design and delivery
Vision
We see a future where community powered, personalised MSK care is standard, where seeing the whole person means we provide human and unhurried care for everyone and by doing so, facilitate better outcomes for patients, staff and our community
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It is our great pleasure to be sponsoring the Digital Champion Award!
The award recognises the work of an individual who has passionately promoted the use of technology or digital ways of working in a hospice or palliative care organisation.
Entries were of a high standard and Matthew Riley will be presenting the award on Day 2 of their Annual Conference held in Glasgow this November.
This award celebrates individuals that have encouraged and supported others to use technology or digital tools and techniques to:
The technology or digital tools and techniques they have used don’t need to be cutting edge, but how they were used may be innovative for your organisation.
Hospices provide vital care and support to children and adults living with long-term illnesses or approaching the end of their lives.
In 2022-23, hospices across the UK provided palliative and end of life care to 300,000 and provided direct support services to 60,000 family members, friends and carers.
It costs £1.6 billion each year to run the hospices in the UK.
Hospices raise over £1.1 billion of this through fundraising, and less than £0.5 billion comes from government funding.
Hospices do incredible work but they can’t do it without support. To find out about the different ways you could support Hospice UK you can find details on their website.
How can Here help hospices enhance their impact with data? – Here
Why do we want to work with hospices? – Here
Email: collab@hereweare.org.uk
Like many of us delivering healthcare in collaboration with the NHS, hospices are experiencing the dilemma of not being an NHS organisation but needing to know our way around the landscape of data as if they are.
Like many of us delivering healthcare in collaboration with the NHS, hospices are experiencing the dilemma of not being an NHS organisation but needing to know our way around the landscape of data as if they are.
As a social enterprise dedicated to transforming healthcare through data analytics, we are thrilled to share the inspiring story of Aaron Salter, winner of the Digital Champion Award at the Hospice UK Conference 2024.
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]]>The post New Musculoskeletal service set to transform care for patients in Sussex appeared first on Here.
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“We are delighted to be awarded this contract along with SCFT as part of an innovative new Sussex MSK collaborative. Working closely with partners, professionals, patients, and our communities, this collaboration builds on our long-standing set of innovations that are leading the way nationally in how MSK healthcare is delivered. This marks another significant step on our journey to deliver exceptional care for those we serve.
Our vision is to deliver the highest standards of patient care by providing equitable, personalised, and seamless services across the entire MSK pathway.” ~ Helen Curr, chief executive officer at Here.
This is the culmination of four years of work and engagement with many stakeholders across the Sussex health and care system to design a transformed, integrated, MSK service for patients in Sussex.
Following a robust procurement process, Sussex Community NHS Foundation Trust, working alongside University Hospitals Sussex NHS Foundation Trust and Here, have been awarded a new contract to deliver MSK services in West Sussex and Brighton and Hove; and East Sussex Healthcare NHS Trust, working alongside Horder Healthcare will cover East Sussex.
The approach taken across Sussex is considered national best practice and is clear in its ambition to improve care and experience for local people.
The new service will see a fully integrated MSK pathway across primary, community and secondary care for orthopaedics, pain and rheumatology, and include services such as physiotherapy, diagnostics, and surgical treatment.
The new service will focus on improving access, experience, and outcomes for patients, with providers working together to ensure patients receive a consistent experience, feel supported throughout the whole pathway, and get the best treatment first time.
The new service’s specification is fully aligned to Sussex’s five year health and care strategy, Improving Lives Together, by working to a new, joined-up, community-based approach to MSK care, by growing and developing the Sussex health and care workforce, by improving the use digital technology and information, and by maximising the power of partnership working across health and care organisations in Sussex.
The specification and awarding of the successful bid were developed with a range of different partners, including patient representatives and Healthwatch. The service contract is worth around £41m per year of the contract – which is for five years, with the option of two additional years after the initial five.
MSK conditions can affect joints, bones and muscles and sometimes associated tissues such as nerves. They can range from minor injuries to long-term conditions.
Over 20 million people in the UK, almost one third of the population, have a MSK condition such as arthritis or back pain.
Symptoms can include pain, stiffness, limited movement, and disability which affect quality of life and independence.
In Sussex, MSK services are in high demand, so the new service is an important step for providing quality services for local people. For example, in 2019-20, over 172,000 referrals were made to MSK services, which resulted in 225,000 community appointments and 67,000 referrals on to secondary care.
Work is taking place at pace to implement changes which are required to develop the new service, which is due to go live on 1 December 2024.
We’ve been asking communities what really matters when they’re living with pain. In this update, we share what we heard, what surprised us, and how this learning is shaping a new three-part support offer for MSK pain that starts locally, builds on existing strengths, and is designed together.
What if pain wasn’t just something to manage, but a signal for change? The Kings Fund and Here explore how a “do with” approach can transform pain services – focusing on prevention, connection, and holistic support.
Introducing Rethinking Our Health – a new way of working with communities to support people living with long-term conditions.
The post New Musculoskeletal service set to transform care for patients in Sussex appeared first on Here.
]]>The post World Stroke Day 2024: Alasdair’s story of recovery appeared first on Here.
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This World Stroke Day we wanted to share Alasdair’s story. In this video stroke survivor Alasdair and his wife Emma talk about their experience of what it was like to be invited to be a part of the Stroke Health and Wellbeing Service, and the difference this support has had on Alasdair’s recovery to date.
The Stroke Health and Wellbeing Service was a pilot project set up as part of the National Stroke Service Model to test new, innovative ways of delivering care to stroke survivors. Working in partnership with NHS Sussex, Sussex Community NHS Foundation Trust, University Hospitals Sussex NHS Foundation Trust, NHS England, Stroke Association, Headway Sussex, Kent Surrey Sussex Academic Health Science Network.
You can learn more about the project on our service page – Stroke Care Pathway Design – Here
The project has now come to an end, but over the coming months we will be sharing more about this transformative pilot and its impact, showing what can be achieved through building strong, collaborative partnerships across the system, the role of Health Builders and the importance of including people with lived experience as a part of service design.
In the video above you’ll hear Alasdair talk about how much of an inspiration Shreddie, one of our Lead Health Builders was to him and his recovery. You can learn about Shreddie’s story in our case study – Health Builders, improving stroke services – Here
We’ve been asking communities what really matters when they’re living with pain. In this update, we share what we heard, what surprised us, and how this learning is shaping a new three-part support offer for MSK pain that starts locally, builds on existing strengths, and is designed together.
Introducing Rethinking Our Health – a new way of working with communities to support people living with long-term conditions.
Introducing Rethinking Our Health – a new way of working with communities to support people living with long-term conditions.
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Laura Finucane, Clinical Director at Sussex MSK Partnership Central shares her reflections on the evaluation.
When we commissioned this evaluation, our main goal was to get an independent and fresh perspective on what we had already observed. We needed an objective review to validate our findings and to dig deeper into the data – helping us to see what might have been overlooked.
Most importantly, we wanted to assess it all through the lens of health inequality, ensuring our work is truly making an impact where it’s needed most.
One of the key purposes of this evaluation was to keep evolving. We wanted the data not only to validate what we were doing, but to inform and improve future Community Appointment Days (CADs), strengthening the overall offer.
This has been an invaluable process, continually shaping how we support our community.
A significant shift we’ve made is moving our health hub to the front of the patient journey. This simple change led to a dramatic increase in screening for blood pressure and diabetes – a real success in terms of uptake. But the evaluation also revealed some gaps, like the fact that many people weren’t engaging with the information provided. So, we’ve now placed extra resources on stewarding, helping guide people right from the front door.
Data has become a powerful tool for us, highlighting areas that need further attention and helping us plan the next steps. We’re seeing the importance of exploring longitudinal data to understand long-term outcomes. And one key takeaway? Both people attending and staff have really valued the service, with many staff members appreciating the chance to step outside their usual routine and connect more deeply with people and colleagues.
Importantly, this evaluation has paved the way for new initiatives, particularly in tackling health inequalities. We’re now focusing on reaching those who don’t typically engage with services, ensuring that our approach is as inclusive as possible.
Looking ahead, we’re keen to build on what we’ve learned. Our current model was developed with patients on waiting lists in mind, but our future plans aim to offer CADs as the first touchpoint in a person’s health journey with us. We believe this early intervention will help people understand what to expect and get the support they need sooner.
We’re also strengthening our collaboration with the voluntary and community sector, ensuring our offer truly reflects the needs of our local population – and we’re using data to guide us every step of the way.
This project started with a bold vision in 2022, alongside Natalie Blunt, Managing Director of Sussex MSK Partnership Central.
We took a risk in trying something different, but with the focus on what matters most to people who access the service– staff thought we were a bit mad at first – but gradually, they came on board. Initially, there was a temptation to simply ‘lift and shift’ hospital services to the community, but we knew that wasn’t the right approach.
What we needed was a more radical change, and our staff fully embraced that challenge.
The CAD continues to evolve, change and works because of the enthusiasm and dedication of the team. This has only been possible because of that commitment and the team effort.
It was the culture of the organisation that allowed us to take those risks and pushed us to think outside the box. We were supported every step of the way.
For me, one of the biggest takeaways has been the sheer joy of working with our staff in such an engaging and inspiring way.
This journey has been full of learning, growth, and joy, and it’s something we’re all proud of.
Thank you to Kate Cheema, part of Kaleidoscope Health & Care, who undertook the analysis and evaluation of the data.
For us the report confirms that for many, this is a powerful way of linking the physical and social sides of health and gives us clear recommendations on how to develop both the CAD events and our data and evaluation work in the future.
We hope it is useful to you too, feel free to get in touch with us at collab@hereweare.org.uk if you’d like to discuss collaborating with us.
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]]>The post Community Appointment Days – Evaluation proves impact on MSK care appeared first on Here.
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As a not-for-profit, we’re always focused on learning from our work and pushing to improve our services, ensuring exceptional care reaches everyone. This review highlights the tangible impact CADs are having on MSK care delivery and reveals key insights that will help us build on this progress.
One of the standout successes of the initiative has been the rise in Patient-Initiated Follow-Up (PIFU) rates. More than 50% of CAD attendees opted for this approach, a significant increase compared to the 12% seen in other services. Although national evidence on PIFU’s effectiveness is still emerging, these figures suggest that CADs are making a real difference in promoting long-term self-management.
Although CADs weren’t specifically designed to reduce waiting times, we’ve seen another benefit: they’ve helped us keep waiting lists stable, a big achievement given national trends of increasing backlogs.
We’re excited to share these findings with you. You can download the complete Evaluation Review and Report and dive into all the details.
If you’re thinking of starting your own Community Appointment Days, check out our Essential Ingredients guide for tips on how to get started.
Curious about how CADs work? Read more in our blog series:
Stable waiting times: The CAD initiative was not specifically designed to reduce waiting lists, but has shown a potential positive impact. From January to May 2024, the waiting list for Sussex MSK Partnership remained stable, while national trends show increasing volumes. Sussex MSK has also reduced the number of patients waiting over 18 weeks, outperforming the national average. Although a direct causal link between CAD and waiting list reductions cannot be confirmed, timing correlations and qualitative findings suggest a positive influence.
Potential long-term effect: Further analysis is required to determine CAD’s long-term impact on waiting times, but current patterns, combined with low Patient Initiated Follow-Up (PIFU) rates, indicate that CAD may contribute to sustained reductions if the initiative continues.
The CAD initiative has achieved its goals of improving patient self-management and staff engagement. There are opportunities for further operational improvements and more comprehensive data collection to enhance future evaluations.
If you’ve looked at our work at Here and you think we’d make a good partner for your next project or you’d like to share ideas, we’d love to hear from you.
To get in touch email: collab@hereweare.org.uk
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]]>The post Announcing our new partnership with St Gemma’s Hospice appeared first on Here.
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This collaboration represents an important step towards achieving our shared commitment to delivering exceptional care, for everyone.
As a purpose-driven organisation, we are dedicated to empowering organisations with data-driven insights. Our expertise in health analytics, cloud-based data warehousing, and system configuration helps organisations make informed decisions that improve the services they offer to their communities.
As part of this partnership, we will utilise our established infrastructure to provide St Gemma’s with a flexible and scalable data platform.
Our system will integrate seamlessly with St Gemma’s existing tools, enabling real-time insights to support better, data-driven decision-making for patient care. From securely managing data storage, and transformation to delivering advanced data dashboard, we aim to create a robust, transparent, and efficient data environment.
Tony Deighton, Information Manager/Data Protection Officer at St Gemma’s Hospice, said:
“We are delighted to collaborate with Here as we transition to a new data warehouse model for all our data. This partnership marks an exciting step forward for St Gemma’s, and we are confident that together, we will generate comprehensive data insights that drive informed decision-making.”
Matthew Riley, Head of Informatics at Here, said:
“St. Gemma’s Hospice exemplifies the critical role that hospices play in our healthcare system. By embracing this work, St. Gemma’s will be able to use data to truly understand the value they bring and work more efficiently and effectively. We are proud to collaborate with such a forward-thinking organisation and look forward to working with the team.”
What sets this partnership apart is our shared values. As a social enterprise, Here focuses on building partnerships that create direct, meaningful benefits for the people seeking care.
Our collaboration with St Gemma’s will also prioritise knowledge sharing, allowing their team to upskill and grow their in-house analytics capability, ensuring the long-term success of their data-driven initiatives.
Helen Curr, CEO of Here, said:
“When we work in partnership, we seek like-minded organisations, and it is no surprise that we have started to find these in the hospice sector. We feel privileged to support the work of St Gemma’s and to share our learning in this new partnership.”
Learn more about our award-winning healthcare data and analytics.
Email: collab@hereweare.org.uk
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