Section A: The organisations and groups within the partnership Lead applicant Name of Organisation: Watford Community Housing Trust (WCHT)
Type of Organisation: Registered Charity, Housing Trust
Contact details: Contact - Amy Willcox-Smith
Email - [email protected]
Phone - 01923 209219 Address - 59 Clarendon Road, Watford, WD17 1LA
Summary of Purpose of organisation and role within the partnership (70 words max): organisation: Watford Community Housing Trust host the Watford Community Navigator, supporting the roll out of the scheme in the Watford Community and providing connections to local networks of community support in Watford, which can help the people that have been referred to the scheme. WCHT is a housing association providing around 5,000 affordable homes and additional services to over 20 local communities throughout Watford and parts of Three Rivers. Partner 1 Name of Organisation: Dacortium
Type of Organisation: Registered Charity
Contact details: Contact - Helen Mutio Email - [email protected]
Phone - 01442 253935 Address - 48 High Street, Hemel Hempstead, Herts, HP1 3AF Summary of Purpose of organisation and role within the partnership (70 words max): organisation: Dacortium is the host organisation for the Dacorum Community Navigator, the Scheme Relief Community Navigator and Support Officer. Dacortium provide the local connection to the Dacorum voluntary sector. Dacortium is a consortium of voluntary sector organisations based in Dacorum; it aims to improve the quality of life of local people, especially those who are disadvantaged or vulnerable by delivering high quality, cost- effective services in a consistent, co-ordinated and co-operative manner. Partner 2 Name of Organisation: Carers In Hertfordshire (CinH)
Type of Organisation: Registered Charity
Contact details: Contact - Carole Whittle Email - [email protected]
Phone - 07917 186 840 Address - The Red House, 119 Fore Street, Hertford , SG14 1AX Summary of CinH host the St Albans, Hertsmere and Parkfield Medical Centre Community Navigators. organisation: CinH bring expertise on the support available to Carers as well as providing links to local networks in St Albans and Hertsmere. CinH aim to ensure that all carers in Hertfordshire are recognised and valued; are informed and supported in their caring role; have an opportunity for a life outside caring and can exercise a collective voice.
Partner 3 Name of Organisation: POhWER
Type of Organisation: Registered Charity
Contact details: Contact - Riaz Khan Email - [email protected]
Phone - 07848 005727 Address - Hertlands House, Primett Road, Stevenage, Hertfordshire, SG13EE Summary of POhWER are the host organisation for the Three Rivers Community Navigator. They also organisation: deliver the Herts Help service, which the Community Navigator Scheme works closely with and builds on. POhWER bring the expertise of running Herts Help and the associated knowledge of the voluntary sector in West Herts. POhWER is a charity who provides information, advice, support and advocacy to people who experience disability, vulnerability, distress and social exclusion. Partner 4
Name of Organisation: Herts Valleys Clinical Commissioning Group (HVCCG)
Type of Organisation: NHS Clinical Commissioning Group
Contact details: Contact - Paul O’Hare Email - Paul.o’[email protected]
Phone - 07917 053713 Address - Hemel One, Boundary Way, Hemel Hempstead, Herts, HP2 7YU Summary of Purpose of organisation and role within the partnership (70 words max): organisation: HVCCG is the NHS organisation responsible for commissioning health services on behalf of people who live in Hertfordshire’s districts of Dacorum, Hertsmere, St Albans, Three Rivers and Watford. HVCCG is the lead commissioner of the Community Navigator Scheme and host the Scheme Manager. HVCCG have provided strategic direction for the scheme and enabled it to embed within Primary Care delivery within West Hertfordshire. Partner 5 Name of Organisation: Hertfordshire County Council – Community Wellbeing Team
Type of Organisation: Upper Tier Local Authority
Contact details: Contact - Kristy Thakur Email - [email protected]
Phone - 07812 323069 Address - Farnham House, Six Hills Way, Stevenage, SG1 2FQ Summary of Purpose of organisation and role within the partnership (70 words max): organisation: The Community Wellbeing Team commissions’ services on behalf of the County Council and Clinical Commissioning Groups to encourage independence, physical and mental wellbeing, reduce avoidable ill health and disability, support carers, encourage self- reliance, community cohesion, social enterprise and volunteering, and Reduce demand on formal social and health care services. The Community Wellbeing Team is the joint lead commissioners for the Community Navigator Scheme.
Section B: Partnerships & Stories What the partnership is achieving and learning 1. Your partnership’s project or initiative.
The Community Navigator Scheme operates across the areas of Dacorum, Three Rivers, Watford, St Albans and Hertsmere. The scheme receives referrals from health and social care professionals (GPs, Social Workers, etc.) that have people present to them with issues that need non-clinical or non-statutory solutions and the health and social care professionals are unsure of which voluntary sector or universal service is available to help. Health and Social care professionals then refer the person to Community Navigator Scheme (referrals triaged by Herts Help). The Community Navigator then works with the individual and establishes the relationships with all of the voluntary sector organisations and activities which will support the person with the issues they face; e.g. they may be a family carer, could be in debt, or are isolated; and need network of community support wrapped around them to ensure they stay well, independent and feel supported by their community.
2. How did your partnership come about and develop?
The Marmot Report ‘Fair Society, Healthy Lives’, found that 20% of someone’s health and well-being depends on clinical interventions. The rest is conditioned by social or environmental factors. Research carried out by the Citizens Advice Bureau found that one fifth of GP time is spent on non-clinical issues. Almost a half of GPs saw value in understanding local communities but many don’t have the time to do this. Herts Help already existed as the one-stop entry to the voluntary sector; however, it was a challenge for vulnerable people to contact Herts Help and act on the information provided. These people needed support to access all of the services available to them and needed someone to build the relationships between them and the organisations. In response to this HVCCG and HCC commissioned the Community Navigators (delivered by voluntary sector providers) to provide face to face support to vulnerable people, and build relationships with health and social care professionals and the voluntary sector. Through the commissioning of the scheme the partnership was born. The Scheme Manager, employed by HCC and hosted by HVCCG, ensured that the partnership had oversight and could be developed collectively and would support effective delivery of the project.
3. Impact. Please describe what outcomes you are achieving, your impact or how you are making a difference.
The Community Navigator Scheme receives 1,200 referrals a year and has: - Improved and supported people’s access to existing local community services, helping them to stay well and independent, while reducing the demand on primary and acute care services. - Reduced the amount of time that statutory professionals (GPs, Social Workers etc.) spend on supporting people to access informal services from the voluntary sector. Herts Help and Community Navigators are seen as the "one stop shop" for social prescribing; and anecdotal evidence has shown that clinicians are now having more constructive, two- way clinical engagement with people about their clinical health needs; all because the Community Navigators have connected people to the informal support available in the community in order to address their ‘wider determinants of health’. - Prevented acute admissions due to non-clinical reasons and delayed the need for people to access more formal Health & Social Care activities (see GP video for example: https://www.youtube.com/watch?v=LUoLM- bVaq8&list=PLxGLedelF6pnf2bwd4bjmA1E5iAzbjwG3&index=4) - Improved people’s emotional wellbeing and reduced their risk of developing depression (as measured by the SF12 Quality Metric tool). Those who have been supported are also demonstrating increased resilience. - Developed a preventative model of care that addresses the wider determinants of health at a community level, by successfully integrating existing voluntary and community sector provision with Health and Social Care providers.
“I don’t know what is available from the voluntary sector and I don’t always have the time to find out, but the Community Navigator does, and makes sure the support my patients get lasts.”
4. How partnership working is helping you to achieve more.
The ways in which working in partnership has achieved more include:
1. Provide better connections to the local voluntary sector. Each partner has a unique insight into the wide and varied range of support that is available from the voluntary sector in a specific locality. Each partner has been able to champion the Community Navigator Scheme within their local area, grow connections, increase referrals and solutions. Statutory partners, such as Herts Valleys CCG, provide access health care pathways increasing referrals from GPs. 2. Able to be agile to seize new opportunities. With a large number of partners, it has enabled the scheme to be agile and adaptable. When funding was available to recruit a Frequent Attenders Community Navigator, and test the concept with people who regularly attend A&E; having a range of partners meant that the most suited one (Watford Housing Trust) could ensure that this happened quickly. 3. Specific expertise and Knowledge. The expertise that each organisation brings to the scheme is available to all of the Community Navigators, regardless of locality or host. Watford Housing Trust can provide housing expertise, while Carers in Hertfordshire can provide their expertise and knowledge around supporting carers; as two examples. 4. Able to market the voluntary sector as one professional entity to frontline health and social care professionals. By working as a network of partners the voluntary sector is able to be marketed to statutory sector professionals as one, professionally run sector, which provides real, credible, solutions for challenges faced by people.
5. How you are making sure that the partnership is working effectively.
The governance of the partnership and the Community Navigator Scheme is through a steering group which includes all partner organisations, and both lead commissioning partners. The Steering Group also has representatives from Social care to ensure the project is supporting and complimenting social care delivery and strategy. The Steering group also has a GP representative to ensure the scheme is working effectively with Primary Care. There are also representatives from Hertfordshire Community NHS Trust and West Herts Hospital Trust and also Herts Help on the steering group. Together, the steering group members support the strategic direction of the Community Navigator Scheme and provide a critical voice to operational delivery of the scheme. Having the steering group has built excellent trust and relationships between all of the partners within this project.
The Community Navigator scheme manager is employed by Hertfordshire County Council and is hosted by Herts Valleys CCG. The scheme Manager manages the day to day operations of the Community Navigators, providing oversight of delivery across all of the hosts, as well as ensuring that the scheme links effectively into appropriate networks across health and social care. Open, regular, communication and dialogue between the scheme manager and all of the host organisations and the Community Navigators themselves, has been a critical element in building effective partnership working for the project. This has also enabled the Community Navigators to develop as a team working to a common goal, despite the fact that they are hosted by different organisations within the partnership.
6. What you are learning from each other.
1. Effective engagement with frontline health care providers. We better understand that one simple route from the Health and Social care sector to the voluntary sector is the easiest way to ensure people get the help they need. Primary Care is now the biggest single referrer to Carers in Hertfordshire. Moreover, Community Navigators have complimented the carers Champions and the Carer Support Advisors. 2. Wider determinants of health are being identified by frontline staff of all partners, regardless of their project area. Solutions to addressing these are being found through informal networking with the Community Navigators and other voluntary sector partners. All hosts are now part of the recently established West Herts Community Resilience Forum, which helps to develop the strategic direction of community support and social prescribing across West Hertfordshire. 3. Engagement with Multispecialty teams (MST). Through the scheme, each partner understands how MSTs (integrating social care / mental and community health) operate. Carers in Herts, Age UK Dacorum (Dacortium members), POhWER advocates have all attended MSTs to contribute solutions to shared care plans. 4. As external partners. We also now understand “the language of health” and in turn people are also aware of the language of housing and voluntary sector.