The housing association connecting patients and local services

The housing association had an existing well-being team providing “wraparound holistic support for any tenant who has a need”, explains Toria Buzza, who leads the work at ForHousing’s Ellesmere Port office. That need could be to do with financial or relationship problems, or help with social issues or housing.

The new scheme has made the whole process more effective and brought those in need to the attention of the service providers who could help them.

Dr Rajesh Rajan, clinical director at the nearby Westminster GP Surgery, is often people’s route into the scheme.

“Being able to put people in contact with these other services gives me an extra choice, another route for the patients” – Dr Rajesh Rajan

He works in one of the area’s most deprived boroughs, and had been struck by the number of ForHousing’s tenants who were visiting him on a regular basis with needs that he believed could be treated through non-medical methods.

“The ForHousing project was particularly appropriate for us,” says Dr Rajan. “This is one of the poorest areas in Cheshire and nationally it has high rates of poverty-related factors, like depression and social isolation.

“Being able to put people in contact with these other services gives me an extra choice, another route for the patients.” His options before had been “rigid”, he adds. “It was, ‘Is this person bad enough to go to hospital?’ And if not, it was really the council that needed to help.”

Now, using software called Elemental, Dr Rajan can ‘prescribe’ social activities in the same way he would medicine.

When he sees a patient who he thinks could benefit from referral to the Passport to Wellbeing programme, he is able to send that person to outside services using the software on his existing system.

“It is formalising the referral process,” Ms Buzza says. “And it’s also helping us to test how we use outside referral bodies for our tenants.”

The services available through the pilot include relaxation programmes, Nordic walking, healthy eating sessions, counselling and Wednesday’s lunch club, which for some people is their only social interaction during the week.

One of the companies ForHousing is working with is Healthbox, which is running a three-year, Lottery-funded scheme called Wellbeing High Street. Nicola Taylor, the project’s volunteer co-ordinator, explains how patients have been successfully referred for activities including confidence-building sessions or yoga.

“We’ve had a lady going along to [yoga] and she came from quite a dark place,” Ms Taylor says. But she enjoyed the sessions so much that she decided she wanted to volunteer with Healthbox, which has given her a reason to go out.

“Her confidence has grown, and that has been so nice to see – and that all came from her initial involvement in this,” Ms Taylor says.

“What is core in this is keeping the person at the centre,” adds Jenny Chapman, group director of innovation and excellence at ForViva. “It is about putting people in control of what their pathways are.”

Over the project’s first eight months, there has been a drop-out rate from referrals of around 50% as people struggle to trust the new system. “But what we found was that people who had dropped out ended up coming back in because they saw other people benefiting from it,” explains Ms Buzza.

“We are not about displacing clinical or medical services,” Ms Chapman stresses, “but there are some people who will continually present themselves to a GP and that GP feels that it isn’t a clinical problem.”

The programme is not targeting people with long-term conditions, she explains, but rather those who a GP suspects have issues related to debt, managing their home, or social interactions.

“What GPs have is a very limited time to be able to spend with someone who is presenting as a patient,” Ms Chapman points out. Now, with a single click, Dr Rajan can send the patient’s details to the housing association, which then follows up with the tenant.

“That information then automatically goes into the system to the other providers on the platform,” continues Ms Chapman. “Perhaps it is Mr Jones who goes to his GP and says, ‘Actually I don’t get out very much and I think it is making me feel a bit depressed’. We can give Mr Jones a number of options for engaging with different agencies; he agrees and that agency will then contact him. All of that information stays in one area, so if Mr Jones goes back to the GP, the doctor can see he’s gone to the lunch club and ask how he’s feeling about it.”

The services are already out there, she explains, but people are just not linked up to them. A housing association has a natural role as a co-ordinator in the local area and can access people’s homes, allowing an insight into their lives that other services may not get.

“What is core in this is keeping the person at the centre. It is about putting people in control of what their pathways are” – Jenny Chapman, group director of innovation and excellence, ForViva

“As public services are being squeezed tighter and tighter, the need isn’t going away, and housing associations have a key preventative role,” says Ms Chapman.

One of the major aims of Passport to Wellbeing is to avoid high-cost public service intervention such as an acute hospital admission, which costs around £450 a day.

“Things are moving towards community-based care instead of sending people to hospital, which can be very expensive,” says Dr Rajan, adding that the key for him is that the process is very simple – involving little more than one click.

“When we talk about services in the community it is shocking to me how many services are out there and you don’t even know about them. The NHS says we need more money. We don’t need more money, we need what is already there to be utilised properly.”

Treating symptoms medically often only has a limited effect, he says, if the underlying problems are not being dealt with.

Back at Trinity Church, a roast lunch is being served at one end of the hall while at the other, guests sift through donations of clothes and household goods from the local Aldi supermarket.