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.

How does it work?

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.

Care Navigating success

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

Is there a difference between Care Navigators and Social Prescribers?

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.

Why have Care Navigators as part of our MSK service?

• Help and support with barriers to appointments.
• Liaise with clinicians/admin teams/clinical teams.
• A chance for patients to unpack, reflect and think about their next steps.
• Help people in multiple pathways within MSK and help make sense of their treatment plans.
• Help stop people falling through the cracks and bouncing in and out of the service.
• There are incredible resources out in the community – directing people more quickly to these can benefit the person.

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 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. 

A new era of integrated 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).

Key highlights of our approach 

• Integrated care pathways: We connect primary, community, and secondary care, creating seamless experiences for orthopaedics, pain management, and rheumatology. 

• Patient-first design: Our care begins with meaningful “what matters to you” conversations, empowering people to make informed decisions about their health. 

• Equitable access: From digital self-management tools to flexible in-person and virtual appointments, our service adapts to meet diverse needs. 

• Improving outcomes: Focusing on reducing health inequalities, we ensure timely, high-quality care for all. 

What sets us apart 

• 10+ Years of quality: Building on a decade of pioneering MSK care, we have consistently delivered high-quality, patient-centred outcomes. 

• Collaborative innovation: Our partnership with SCFT exemplifies integrated working across the NHS and beyond. 

• Ambitious vision: This service is part of a five-year transformation programme, aligning with Sussex’s health strategy, Improving Lives Together.

Why it matters 

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

New Musculoskeletal service set to transform care for patients in Sussex

“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.

Health and care partners across Sussex are delighted to announce that an innovative new Musculoskeletal (MSK) service is set to start for local people in December 2024.  

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.   

Other planned improvements to Sussex MSK services, under this new contract, are: 

• Better communication and information for patients to empower them to be in-charge of their own care and make informed choices about treatment options 

• A more joined-up and coordinated care offering which breaks-down traditional barriers between organisations 

• Streamlining access to care and advice: providing much more choice about how people can access care, and that services are available in their community when they need them 

• Helping people to live and work well for longer and offer more personalised care, including supported self-management when they need it, via digital platforms   

• A more concerted and systematic approach to reducing health inequalities and addressing variation in terms of access, waiting times and service provision.   

• Offering a personalised model of delivery for outpatient appointments, including virtual appointments where clinically and personally appropriate (considering other factors relevant to the individual) and face-to-face appointments. 

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.

World Stroke Day 2024

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.

Delivering care to stroke survivors

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

Our work at Here focusses on bringing together service improvement, lived experience and data.

Last June we joined the Sussex Health Equity Fellowship, a brand new programme created by Sussex Health and Care and partnered with Kent Surrey Sussex Academic Health Science Network.

We were extremely keen to be involved and were thrilled that of the eight places offered two of our team were accepted onto the programme.

Fern Bolwell, Learning Lead and Tom Golden, Business Intelligence Analyst at Here both took part in the programme. We felt that having people from both an operational and data and a analytics perspective would of huge benefit due to how equity learning could be used by these different skills areas.

In this blog, Fern shares her more about the Fellowship and reflects on what both she personally and us as an organisation have learned from the experience.

What is the Health Equity Fellowship? 

The Health Equity Fellowship is a nine-month programme delivered by NHS Sussex and Health Innovation Kent Surrey Sussex. The programme aims to equip participants with the skills and knowledge to become key change agents within their organisations, promoting a focus on equity and reducing health inequalities. 

The Fellowship is delivered through a mixture of lectures, webinars, action learning sets, mentoring and connection to each other’s knowledge and experience. Alongside this, Fellows complete a work-based project with a goal of improving health equity.

‘We know that our society is not fair and equitable, and many people face

 

 

 

systematised and institutional discrimination and cannot thrive in the conditions in which they live. We recognise the structural and cultural inequalities that are embedded in our wider society, and that this impacts our work in health and care. We recognise the inequities in the healthcare system and we want to work to address those.’ 

I have always been passionate about justice and fairness in society and ensuring everyone’s voices are heard and acted on. My professional goal is to realise this mission through the work that I am doing with Sussex MSK Partnership and ensure that health equity is always considered in each decision for the patients who need it most.  

For me the opportunity to be a part of the Fellowship came at a key moment of change for the Sussex MSK Partnership as we looked to the future and worked on how to deliver healthcare differently.

What skills did we bring?

Sussex MSK Partnership had already set aside dedicated project groups to focus on health equity. This work has been divided into 3 workstreams – Data, Staff Support and Community.

I work across each project group and was able to see where each intersected and supported the other. We first focused on an evidence-based approach through both community outreach and data gathering to ensure the changes we make, make a difference where it is most needed.

The way we work at Here meant we were able to be agile and encouraged to be innovative and forward thinking in approaches to delivering healthcare. 

What have been the results? 

The Health Equity Fellowship gave me the opportunity to grow my capability in population health, innovation and evaluation. My understanding increased in applying an equity lens to change initiatives. As well as expanding my network and connecting me to experts in a wide range of relevant areas.

Following the fellowship, I presented at Sussex Partnership Foundation Trust and Sussex Medical School’s Anti Racism event to showcase our work at Sussex MSK Partnership. 

I felt truly inspired by the dedication of the team leading the Fellowship and emboldened by their hope, even when honestly discussing the real challenge and shocking impact of inequity and prejudice.  

During the 9 months of the Fellowship I was able to work on: 

• Community Appointment Days (a patient journey offered in the community alongside VSOs).  

• Improving our data capture and reporting to be able to see, at a glance, differences between access, experience and journey of different groups of patients.

• Used our data to inform where we should be supporting our community, through this evidence, we connected with Crawley Asian networks. 

• Shared the learning from the fellowship and delivered training for all Here colleagues on health equity. 

• Simplified the interpreter booking process to address inequity.

• Created a new process to ensure patients with adjustments were flagged on our systems so that we can proactively support their needs.

What is our learning and what are we taking forward from this? 

The Fellowship experience has extended my confidence, competency and language to challenge and advocate for health equity in projects, process, the workplace and the wider world. 

I actively seek out to surface where there are challenges for patients and colleagues based on protected characteristics.  focused on fixing, improving and most importantly sharing the learning and awareness for future prevention of inequity.

I am grateful to those who speak up and teach me. It has shifted my vision to a world where I am no longer blind to inequity. 

Earlier this month Sussex Health and Care Fellowship held a webinar to share more information about the programme, Fern was invited to talk and share her experience – you can watch it in full below.

How can you get involved?  

The Sussex Health Equity Fellowship is now recruiting for a new cohort of Fellows – details on how to apply are below. 

1. Health Innovation KSS website: https://healthinnovation-kss.com/news/sussex-health-equity-fellowship-opens-for-applications/ 
2. LinkedIn: https://www.linkedin.com/feed/update/urn:li:activity:7224325761082552320
3. Twitter: https://x.com/HealthInnov_KSS/status/1818563477654417445
   
4. Applications close on 2nd September 2024, 11:59pm