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Social Prescribing Strategy
Governing Body meeting C 6 April 2017
Author(s) Joe Fowler, Programme Director for Neighbourhood Delivery and Mental Health Transformation
Sponsor Nicki Doherty, Interim Director – Care Outside of Hospital Is your report for Approval / Consideration / Noting
Consideration and Approval
Are there any Resource Implications (including Financial, Staffing etc)?
Yes
Audit Requirement
CCG Objectives
Which of the CCG’s objectives does this paper support? This paper relates to a number of objectives but in particular provides assurance against the following:
1. To improve patient experience and access to care
2. 2. To improve the quality and equality of healthcare in Sheffield
4. To ensure there is a sustainable, affordable healthcare system in Sheffield.
Risks: 1.2 System wide or specific provider capacity problems in secondary and/or primary care emerge to prevent delivery of NHS Constitution and/or NHSE required pledges including seven day access
2.4 Insufficient resources across health and social care to be able to prioritise and implement the key developments required to achieve our goal of giving every child and young person the best start in life, potentially increasing demand for health and care services.
The current challenge the health and wellbeing system faces is to adapt and become more sustainable for the 21st Century, enabling people to adapt, change and self-manage in the face of growing social, physical and psychological challenges. Social prescribing is one approach that will enable the health and wellbeing community across the CCG to bring services together around patient need to meet some of these challenges.
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Equality impact assessment
Have you carried out an Equality Impact Assessment and is it attached? No
PPE Activity
How does your paper support involving patients, carers and the public? As alternative and complimentary means of support to vulnerable communities, patients and carers.
Recommendations
The Governing Body is asked to: Agree the social prescribing model advocated in this paper Agree the plan for making social prescribing a more impactful and integral part of the
health system and seek an update on the implementation of the plan in July 2017. Commit to the commercial strategy – i.e. the routing of any funding for community
based wellbeing activities through the formally established Community Partnerships. Commit to the financial strategy for social prescribing – i.e. the allocation of the
earmarked social prescribing (CSW) budgets so that we secure the infrastructure for 2017/18.
Recognise social prescribing as a priority for investment of any new / invest to save funding for 2017/18.
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SSoocciaal PPrressccribbinngg
1 Introodducttioon / BBaacckggroouunnd
1.1 TThis ppapperr seeekks Gooveerniingg Boodyy ccommmitmmennt to ssoccial prrescribbinng aandd aa plan annd
iinvvestment sttratteggy ffor maakiingg soociaal ppreesccribingg a mooree innteggraal aandd immpaacttful paart
oof oourr heealth annd ccarre ssysstem.
1.2 TThee ppapper deefinness soociaal ppreesccribbingg inn thhe SShefffieldd cconntexxt; proovides aa suummmaaryy
oof wwheree wwe aree wwithh soociaal ppreesccribbingg; ssetss oout thee isssuuess wwe nneeed to sort to
aachhieeve immproveed ouutcoommess froomm soociaal ppreesccribingg inn Sheffieeld;; annd,, seets ouut aa
pplaan ffor mooving forwaardd soo thatt wwe ccann delivverr immprrovved ouutcommess att paacee.
1.3 TThee rrecoommmeenddattionns in thiss ppapper woould mmean eaarmmarrked CCCCG funndinng forr soocial
ppreesccribbingg beinng ffullly ccommmmitteed forr 20177/118. It wwoouldd alsoo mmeaan tthaat thhe CCCGG
wwoouldd fuundd thhe maajorrityy off thhe ccurrrennt ccosst oof CCommmmunnityy SSupppoort WWoorkeerss foor
22017//188. TThiss wwouuld bee onn thhe baasiss off thhe CCoounncil inccreeassingg fuunddingg foor tthee
ccommmmunnityy activvities annd ssupppoort thaat CCommmunityy SSupppoort Woorkker (annd othherr
ssimmilaar rrolees) linnk ppeoople to in thheiir ccommmmunnitiees.
1.4 AA ffull revvieew of socciaal presscribinng haas bbeeen hit byy siignnificcannt ddelaayss reesuultinng froom
iinfoormmattionn ggovvernnanncee isssuues. HHowwevverr, thhe revvieww wwilll bee reeaddy in July, whhichh wwill
eenaablle iits conncllusionns tto iinfoormm CCCGG ccommmmisssiooninng inteenttionns annd bbuddgeet ssettingg
ffor 200188/199.
2 WWWhaat iss SSocial PPreesccrribbinng??
2.1 SSociaal ppresscrribing is ofttenn deefinnedd inn reelattiveely medicaal teermms, e.g.
““Soociaal PPreesccribbingg iss a waay of linkinng ppattiennts in pririmaaryy caaree wwith soourcess oof
ssupppoort withinn thhe coommmuunitty. It pprooviddess GGPss with a nnonn-mmeddiccal refferrral opptioon
tthaat ccann opperratee aalonngssidee eexisstinng treatmmentss too immprrovve hheaalthh aandd weell--beeingg.”
YYork Unniveerssity 200155
2.2 BBeforre ccritiquuingg thhis deefinnitioon,, it is wwoorthh reemeemmbeerinng tthaat thhe vast maajorrityy off
ppeooplle iin SSheeffiieldd do ssommetthinng evveryy day to immprovee thheiir hheaalthh annd weellbbeinng.
PPeople wwaalk to wwoork annd ggattheer thheiir thhouughhtss; sit ddowwn forr a meeal wiith fammily aandd
ffrieendds; goo too a ‘weeigght waatcherrs’ or daancce cclass;; accceesss finnanncial aadvvicce; stoop ffor a
ffeww secoondds to takke nooticee oof ssommetthinng beeautifuul oor innteeresstinng;; puurssuee a hoobbby oor
1
interest; learn something new; see some live music; help someone to achieve
something they couldn’t have done alone; and, so on (and on).
2.3 People in family, social and other networks (e.g. workplace) also support each
other. Offering encouragement and information on exercise, giving up smoking,
healthy relationships and so on.
2.4 The point being made here is that most people are “social prescribing” for
themselves and others already; identifying things and doing things that they need to
do to stay healthy and well, and helping others to do the same.
2.5 However, some people, some of the time, need a bit of extra support. For example,
they might face a range of challenges that have got on top of them and have
support needs that exceed the capabilities of their family or social networks.
Examples might include people who have:
o experienced a recent bereavement or relationship breakdown, which has led to
them withdrawing from social networks and becoming depressed and isolated;
o had a deterioration in their physical or mental health that is affecting their ability
to do the things they used to do to stay well;
o just moved into a community where they have no support network – perhaps
being unaware that there are things going on in the community that would be
right up their street (literally and figuratively); or,
o be struggling to find the time or the money to do things they used to do because
they are spending more time looking after a partner or loved one.
2.6 Without support, the health and wellbeing of some people in situations like these
deteriorates and they increasingly depend on public services – e.g. by turning up at
the GP frequently, falling behind on their rent, struggling to get the kids to school,
being referred for a social care assessment, or, being admitted to hospital with
medical issues resulting from self-neglect or an unchecked health issue.
2.7 The challenge for Sheffield is (a) how the city effectively supports more people to
connect with and do things that reduce
their risk of ill health and improve
overall wellbeing; and, (b) how we
make sure that this translates into
reduced demand for formal public
services (so that we better live within
our means and protect / prioritise
public resources). A logic model for
Figure 1 - Wider definition of social prescribing
2
f
ssoccial presscriibinng beeneefitss iss prrovvideed at Annneex AA.
2.8 T
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3
3 Are we benefiting from social prescribing in Sheffield?
3.1 The ‘social prescribing’ model is alive and well across much of Sheffield. It is not
necessarily described as ‘social prescribing’, but there is plenty of it going on.
3.2 Initiatives that use the social prescribing model include Community Support
Workers, Age UK outreach work, MCDT Advocates, SOAR social prescribing,
Darnall GURU, Floating Support (lower-level short-term engagements), Health
Trainers / Champions, and the Council’s Community Reablement Services.
3.3 Over the last year, we know that at least 7,000 people were identified and referred
for a ‘linking’ conversation1. And, we know that these conversations led to people
doing things that are known to have a significant benefit on their wellbeing.
3.4 Data collected from thousands of social prescriptions in Sheffield shows that for
every 100 people referred, there is the following resultant activity:
o 86 of the people will get information and advice on a range of issues from
managing debts to local activities
o 24 are supported to claim benefits like attendance allowance and carers
allowance that they didn’t know they were eligible for
o 28 are supported to access local voluntary / community activities
o 14 get medium-term support to help them manage a tenancy or avoid eviction
(e.g. from Shelter, Age UK, SYHA)
o 12 are helped with transport issues
o 6 are connected to specific medical services
o 6 are linked to equipment retailers / providers
o 5 are referred for a formal social care assessment
o 6 refuse help
3.5 We have literally hundreds of case studies showing the positive impact of these
activities on the lives of individuals in Sheffield2, and lots of positive feedback from
health and care staff about the benefits of having social prescribing in place.
3.6 Whilst issues with information governance have thus far hindered the completion of
the service evaluation of whether social prescribing has conclusively reduced
demand on the health and care system, we can demonstrate clearly that referrers
are proving adept at identifying people who are at risk of declining health and
wellbeing. And, link workers are proving highly effective at improving peoples’
capabilities to support themselves.
1 This is just data from Community Support Workers, which is routinely collated and analysed. 2 A booklet of case studies is available from [email protected] on request
4
3.7 TThis is eeviddennt iin tthee nuumbeer oof successsfful claaimms ffor beeneefitss likke atttendancee
aalloowaancce annd ccarrerss aallowaancce tthaat link woorkkerss are heelping peeopple to claaimm foor the
ffirsst timee. TTheesee benefitts aaree knnowwn to heelp peeopple remmaain inddeppenndeentt ass thheyy arre
ttyppicaallyy ussedd too pay for cleaaneers,, peerssonnal care, traansspoort to apppointmeentss,
hheaatinng,, hooussing rrepairrs, aandd sso oon..
3.8 TThee immppacct oof thhe exxpansionn off thhe ssoccial prresscriibinng infrasstruuctuuree inn 200155 ccann bee
ccleearly sseeen iin tthee inncreeassedd taakee-up oof aa raangge of ttheesee tyypee off beeneefitts inn
SShefffieldd. FFigguree 33 beeloow shoowws tthiss cleaarly for CCarerss AAllowwaancce aandd FFiguuree 4 forr
AAtttendancee AAlloowaancce.
Figgurre 33 - CCarrerss Alllowwanncee Claimms ((as % of poppulatioon))
5
Figure 4 - Attendance Allowance Lower Rate Claims (% of 65+ Population)
8.0%
7.0%
6.0%
5.0%
£0.7m
Sheffield Lower 4.0%
Comparator Lower
3.0% Low Rate Top Claimer
2.0%
1.0%
0.0% May 13 May 14 May 15 May 16
3.9 A typical link worker will support people to access around £150,000 of benefits per
year3 - although one of our Community Support Workers (who has a welfare
background) is on track to support people to claim £310,000 in 2016/17. On
average a referral to a link worker costs around £100 but has a direct financial
benefit to people at risk of poor health and wellbeing (and the local economy) of
around £500 (assuming claims last on average one year).
3.10 Social prescribing is available city-wide. However, referrals are focused in
neighbourhoods where health inequalities are most pronounced because this is
where the most people identified as being at rksk live. Analysis of 6,000 referrals
(mostly over 65s) shows clearly that referrals are heavily weighted towards areas
with high health deprivation scores. This analysis is based on referral and
deprivation data for areas of around 1,500 people (LSOAs).
0 10 20 30 40 50 60 70 80 90
100
1 2 3 4 5 6 7 8 9 10
Referals per 1,000 Population by IMD Health Decile
Referals per 1,000 O65 Pop.
Referals per 1,000 Adult Pop.
3 Based on claims lasting one year – many are longer
6
A
r
r
f
4 WWWhaat iss sstooppingg uuss aachhieevvinng mmooree?
4.1 T
s
The
soc
ere
cia
e a
l p
re
res
a n
scri
num
ibin
mb
ng
er
mo
of
ode
kn
el.
owwn iissuess wwithh SSheeffieeld’s ccurrrennt iimpplemeenttatioon of thee
4.2 T
b
m
w
The
ba
me
wh
ere
rel
edic
here
e a
y u
cal
e th
re
use
su
hey
so
ed
upp
y liv
me
me
port
ve
e a
ean
t to
an
rea
nin
o re
nd w
as o
ng t
edu
wh
of t
tha
uce
ich
the
at w
e th
h G
e ci
whe
heir
GP o
ity
ethe
r ris
or
an
er
sk
oth
d s
a p
of
her
som
per
de
r pu
me
so
eclin
ubl
se
n h
nin
ic s
ervi
has
ng h
ser
ice
s th
hea
rvic
s w
he o
alth
ces
whe
opt
h a
s th
ere
tion
nd
hey
e so
n o
we
y ar
oc
or c
ellb
re i
ial
cho
bei
in c
pr
oice
ng
con
res
e of
de
nta
scri
f no
epe
ct w
ibi
on-
end
wit
ng
-
ds o
h.
is
on
4.3 T
p
l
Th
pre
lev
is v
esc
vels
var
crib
s of
riab
bing
f he
bilit
g is
eal
ty i
s a
lth
n id
pa
de
de
artic
epri
ntif
cul
iva
fica
ar
atio
atio
co
n.
on
onc
An
an
ern
nne
d r
n in
ex E
refe
n a
E p
erra
rea
prov
al o
as w
vid
of p
wh
es
peo
here
m
opl
e w
ore
e w
we
e d
who
kno
eta
o w
ow
ail o
wou
w th
on
uld
hat
are
be
the
eas
ene
ere
s o
efit
e ar
of c
fro
re s
con
om
sig
nce
so
nif
rn.
ocia
ica
al
ant
Noote: CSSWss onnly parrt o f thhe ppicturee – ssomme ppracticces witth loow CSWW rrefeerraals hhavve ootheer s ociaal ppx r outtes
4.4 TTheeree are diffferrennt aappprooacchees to soociaal ppresscrribing accross thee ccity annd eeveen
wwitthinn thhe ssammee neeigghbbourhooodds. Thhis meeans thaat iideentificaatioon of peeopple whho
wwoouldd benefitt fromm soocial preesccribbingg iss not alwwayys connsisteent; reeferraal roouttess arre
uunccleear to pootenntiaal rrefeerreerss (mmeaaniingg they arre lesss likely tto bbe used); aandd, ssomme
rrolees caan ooveerlaap if thheyy aare noot mmannaggedd wwelll loocally..
4.5 NNoot eevery areea or sociaal ppresscrribi ng sccheemee ssysstemmaaticcally mmaanaagees refferrralls;
rreccorrdss thhe ouutcoommess frromm linnkiingg coonvversattionns; orr, pprovvides accceesssible
ffeeedbbacck to the rrefeerrrer.. Thhe lacck of consooliddatted daata alsso meeanns thaat
ccommmmissiooneers doo noot hhavve thee eviddenncee thheyy neeedd too seecuuree coonttinuuedd oor
iinccreaaseed invvesstmmennt. TThee laackk off feeeddbaackk also reducess thhe likkelihhoood of peeopple
cconntinnuing to referr.
4.6 SSociaal ppresscrribing is noot inteegrrattedd inn too thhe wider ssocciall caaree acceesss mmoodeel
((maainnly due tto tthe rissk oof llinkk wworkkerrs // CSWWs beecooming ovverloaadeed wwitth ssoccial
7
care casework). This means that people with existing social care support are not
benefiting routinely from social prescribing.
4.7 There is a lack of activities and support in some communities – so there is
sometimes a shortage of things for link workers to connect people to. As the use of
social prescribing increases, the city will need to increase the availability of
community activities and local support services. Some of these activities will be no
or low-cost, but we need to avoid assuming that voluntary sector services are
cooked up in a magic porridge pot – they cost money and increased use of social
prescribing will need to be accompanied by some investment in things to refer to.
4.8 We also need community development activity to focus on the things that
communities and people need to maintain / improve their wellbeing, which will
require us, in turn, to get smarter at analysing the intelligence gathered from
conversations with people at risk of declining health and wellbeing.
4.9 A high impact social prescribing infrastructure is not ‘free’ – there are
infrastructure costs, and the link workers that connect people to activities generally
need to be paid, well-trained and managed, able to access and be trusted by health
and care, and supported with phones, technology, and transport.
4.10 There are currently only just enough known link workers to deal with known
demand. However, if social prescribing takes off, as is the intention, then we will
need more link workers and this will require investment. A typical link worker will
deal with around 8 new referrals per working week (circa 350 per year) – a cost of
around £100 per referral.
5 What is the plan for addressing these issues?
5.1 There is a strong consensus about what needs to happen to make social
prescribing a more impactful and integral part of public service in Sheffield.
5.2 People at key touch points need to be trained to recognise and refer people at
risk of declining health and wellbeing who would benefit from being linked to
activities and support services. Wider data from housing and other services also
needs to be systematically reviewed to identify people at risk who are not
presenting at service touch points.
5.3 We need neighbourhood and city-wide referral points that facilitate very quick and
easy referral – this means creating well sign-posted, consolidated referral hubs in
neighbourhoods, and a ‘back-up’ central hub for people who do not know the
referral arrangements in the neighbourhood.
8
City Referral Hub
Neighbourhood 1 Referral Hub
Neighbourhood 2 Referral Hub
Neighbourhood 3 Referral Hub
Neighbourhood 4 Referral Hub
Neighbourhood 5 Referral Hub
Neighbourhood 5 Referral Hub
Neighbourhood 6 Referral Hub
Neighbourhood 7 Referral Hub
Neighbourhood X... Referral
Hub
Local GP
Local Nurse
Local Housing
Officer
Hospital Staff?
Carer?
5.4 Learning from existing good practice in Sheffield would suggest that each referral
hub needs to have processes in place to make sure referrals are met with a
proportionate, effective and efficient response, which could range from a
safeguarding alert (high risk), to an outreach visit from a link worker (med risk), to a
referral to published self-help info or an advice café (low risk).
5.5 This ‘triage’ process needs to ‘hide the wiring’ from the referrer and the person
referred, and facilitate the effective use of resources in the neighbourhood. This
means, for example, matching the right worker to the individual depending on their
presenting issues.
5.6 The referral, triage and referral outcome / intelligence data needs to be recorded
securely and consistently, so that data can be used to:
o inform city-wide commissioning (including external funding bids)
o influence the development of local community assets so that they are tuned to
the needs of people at risk; and,
o ensure good quality feedback to referrers.
5.7 This strong consensus view has been translated into a ‘maturity index’ for a high-
impact social prescribing approach, which is provided at Annex C. This index has
been used to assess the readiness of neighbourhoods to implement a high-impact
social prescribing approach, which has in turn informed the plan outlined later in
this paper.
5.8 Alongside this assessment of readiness, we need to model demand for social
prescribing and analyse referrals so that we can estimate the required investment
9
over the next 2 – 3 years in social prescribing infrastructure (central /
neighbourhood), link workers, and community activities and support services. This
modelling needs to factor in planned developments including:
o The impact of increased primary care use of social prescribing as more GPs are
made aware of referral routes and simple one-stop shop referral hubs are put in
place in each neighbourhood (could add 2,000 – 3,000 referrals in the next two
years)
o The impact of re-routing hundreds of referrals per year from GPs to social care.
We know that around 4 out of 5 referrals from primary care to social care are
subsequently assessed as requiring no further social care action. This is likely to
add 1,000 referrals (in addition to the referrals above)
o It is expected that thousands of social care referrals from the Council’s contact
centres and new locality teams will be re-routed to social prescribing – likely to
add around 2,000 referrals
o Social prescribing is likely to become the default primary and social care
response to people presenting or being assessed as having low-level mental
health and care needs – adding around 1,000 referrals
o There could be a step change in referrals for mental wellbeing if initiatives to
reduce the prescription of anti-depressants involve referrals to social
prescribing. This change could add thousands of referrals during 2018/19, and,
critically, would change the social prescribing cohort considerably (e.g. lots
more working age / working residents)4
5.9 This assessment of future demand, the resources required to meet it, and an
assessment of the city and neighbourhood readiness to implement a high impact
approach to social prescribing (summary at Annex E), are informing the
development of an action plan for the next two years (summary at Annex G).
6 Financial Strategy
Prioritisation and Focus
6.1 Funding to support social prescribing at the neighbourhood level will be allocated in
line with the priorities for development in each neighbourhood and the level of need
in each neighbourhood.
6.2 For example, it is clear that Gleadless and Broomhall (amongst others) have high
levels of need (high health deprivation) but are not currently able to deliver the high
impact social prescribing model because there is a lack of routine identification of
need (low referral rates) and no infrastructure to run a functional neighbourhood
4 Note that the evidence base for social prescribing appears to be stronger for mental health and wellbeing
10
referrals hub. We are therefore proposing that these neighbourhoods are prioritised
for investment in referral management infrastructure and link workers, and that we
do focused work with primary care (in its widest sense) to increase identification
and referral rates.
6.3 Funding for the development of community assets (things to link people to) will also
be based on assessed need. For example, the allocation of the £400k funding for
community-based dementia activities will be based on an assessment of existing
activities, dementia prevalence, and levels of health deprivation in the area.
6.4 Prioritisation inevitably means inequitable distribution of funding. This will be
mitigated in part by making sure that developments in one area can be used to help
other areas make more rapid progress.
Commercial Approach
6.5 Where there are formally established and recognised Community Partnerships –
these will be the default investment route for implementing the social prescribing
action plan. Investment in social prescribing is already being made in many
neighbourhoods via this route and there are framework contracts and monitoring
arrangements in place with each partnership.
6.6 Our intention is to increasingly use the framework contracts to support community
support services and activities – and encourage collaboration between voluntary
and charitable organisations so that less of our precious community resources are
spent on competitive tenders and individual grant funding bids. We also intend to
allocate funding on a 3-year basis wherever possible to give some sustainability to
services. The Community Partnership locations and members are listed at Annex
D.
6.7 The Social Prescribing model and the Community Partnerships contracts also offer
significant potential to help the city leverage external funding – e.g. applying for
funding for community activities to support people to be more physically active.
There are also new potential funding streams coming on stream – e.g. there are
already strong rumours about new primary care funding for social prescribing and a
growing expectation that STPs will invest in social prescribing.
6.8 In the handful of areas with no formally established Community Partnerships in
place, work will be done with local groups to support their development – with ad
hoc arrangements used to fund activity where necessary. It is highly likely that in
some areas of the city that the Council will need to continue to provide a local hub
function.
11
2017/18 Funding
6.9 The city’s investment in social prescribing can be split across the components of
the model, funding organisation, and by direct and indirect investment as shown in
the table below.
Part of Model DIRECT 2017/18 INDIRECT 2017/18
Social £300k from SCC for Community £m mainstream staff
Prescribing Infrastructure Partnerships to develop neighbourhood referral hubs and support systems etc
resources across
Investment in identifying £70k from CCG to create central hub public sector –
people at risk and for referrals identifying people at
managing referral / triage £862k support for localities (paid direct risk who would benefit
process and data to GPs as part of locally commissioned from referral and
£1,232k services money)
support
Community Link Workers £178k from SCC for Community Range of frontline
People that have Support Workers
£493k from CCG for Community staff providing advice
conversations with people Support Workers – but not taking social
that have been referred £60k for Age UK Workers (funded by prescribing referrals
and link them to support / CCG) specifically
activities £? VCF Workers taking social px
£1,258 referrals
£327k Health Trainers (SCC) £200k Health Trainers (CCG)
Community Support and £492k Public Health Funded Range of other
Activities Community Wellbeing Activities
£110k SCC Health Champions (develop publicly / charitably
Local activities and support and deliver activities) funded activities - e.g.
that people are commonly £40k SCC MH Social Cafes (new parks, walking groups,
linked to recurrent funding for 2017/18) library activities
£2,251k £400k SCC dementia support in
(not inc Ageing Better) communities (new recurrent funding for 2017/18)
£80k carer support activities (new recurrent funding for 2017/18)
£189k SCC lunch clubs (funding protected 2017/18)
£875k SCC Community Based Advice (Sheffield Advice)
£65k SCC Innovation Fund (new funding for 2017/18
£1m Ageing Better - Lottery Funding in target areas
6.10 The key funding issues relating to the table above are set out below:
12
6.11 The Council has invested additional funding (£585k) in community based activities
for 2017/18 through the retendering and reshaping of contracts. For example, the
Council has reduced funding for central building based services and, next year, will
be investing more in community-based activities that link workers can support
people to access.
6.12 However, the Council has not been able to replace non-recurrent national funding
for Council-funded, primary care-based link workers (Community Support Workers)
who currently play the key ‘linking role’ for primary care in many areas of the city.
This is because the funding released from changes to services has had to be
redirected to fund activities in the community.
6.13 Note that there is a natural split emerging in the investment. The CCG are
predominantly funding (a) the primary care infrastructure to identify people at risk,
and (b) the primary-care based link workers that people at risk are referred to.
Whereas the Council investment is increasingly weighted towards (a) development
of VCF infrastructure to support social prescribing; and, (b) community activities
and support services that people can be linked to. This may provide a useful
delineation in the future.
6.14 The costs of maintaining the current cohort of Community Support Workers (without
filling several vacancies) is estimated at £758k for 2017/18. The budget secured5
for 2017/18 – subject to Governing Body agreement – is £741k (£563k from CCG,
£178k from the Council). The CCG funding includes £70k for the central referral
hub, which is generally staffed by a Community Support Worker. Given the
likelihood of staff turnover, we have reasonable confidence that the current budget
will cover the current cohort of Community Support workers.
6.15 Given the likely increase in the use of social prescribing in 2017/18, it is
recommended that we protect the social prescribing infrastructure we have
built.
6.16 In practice this means:
o extending the contracts of the current cohort of Community Support Workers for
one year (to avoid losing any more talented, well-trained, and locally-connected
staff)
o protecting the new Council investment in community based activities
o looking to secure external funding to support the social prescribing model at a
city and neighbourhood level (including from STP where stakeholders identified
social prescribing as a top priority)
5 Half of the CCG funding is dependent on agreement to this plan
13
o bringing together stakeholders involved in initiatives related to or dependent on
neighbourhood social prescribing approaches (as discussed above) to ensure
we understand dependencies and planning timelines
Investment required in the future
6.17 Based on the anticipated developments discussed in paragraph 5.8, referrals could
potentially double during 2017/18 to around 1,750 per month – with further
increases likely during 2018/19.
6.18 To manage this level of demand, would require us to have (a) around 25 more link
workers (circa £750k including costs); (b) robust shared systems in place to
manage referrals and management information; and, (c) a significant expansion in
community activities and city / neighbourhood support services that people can be
linked to.
6.19 Clearly this modelling is crude – but it illustrates that planned initiatives will quickly
over-load our social prescribing infrastructure. Given this, we need a strategy for
dealing with increased demand.
6.20 There are three main options for dealing with the cost of increases in demand.
6.21 Firstly, we could set aside a reserve each year (around £500k in 2017/18) to fund
an expansion of our social prescribing infrastructure as measured demand
increases throughout the year. This option is strongly favoured. However,
organisational budgets are already committed for 2017/18 so this option is only
really feasible if new recurrent funding can be found.
6.22 Secondly, we could require any new initiative or service that is going to refer into
the social prescribing infrastructure to fund the cost of expected referrals. For
example, if Community Mental Health Teams were looking to make 1,000 referrals,
then SHSC would need to commit £100,000 to cover the costs (£100 per referral).
This option has some obvious difficulties – not least that the costs associated with
services currently using our social prescribing infrastructure (mainly primary care)
are met centrally by CCG / SCC.
6.23 A middle ground option could be to secure invest to save funding to sustain the
social prescribing infrastructure for the next 1 – 2 years, before moving to a
recharge model in 2018/19 with organisations and services committing a level of
budget in proportion to their reliance on / benefits achieved from the social
prescribing infrastructure.
6.24 Given the above, it is recommended that we (a) track referral rates carefully so we
can identify areas of growth and put in place mitigating strategies (e.g. seeking
14
funding); (b) put social prescribing at the front of the queue for new funding / invest
to save initiatives – to create a reserve to cope with increase demand; and (c) seek
advance contributions from any organisation or service looking to place demand on
the social prescribing infrastructure.
6.25 It is recommended that Governing Body ask Council and CCG officers to work on
funding models and report back alongside the results of the review in July 2017 in
time to inform commissioning intentions for 2018/19.
7 Recommendations
7.1 CCG Governing Body is asked to:
7.2 Agree the social prescribing model set out in this paper
7.3 Protect the social prescribing infrastructure we have built.
7.4 Commit to the financial strategy for social prescribing – i.e. the allocation of the
earmarked social prescribing budgets for 12 months so that we can secure the
existing infrastructure for 2017/18.
7.5 Agree the plan for making social prescribing a more impactful and integral part of
the health system and seek an update in July 2017 on: (a) the implementation of
the plan; (b) the proposed future funding model for social prescribing; and, (c) the
evaluation of CSWs / social prescribing.
7.6 Commit to the commercial strategy – i.e. the routing of any funding for community
based wellbeing activities through established Community Partnerships where they
exist.
7.7 Commit to focusing social prescribing investment in areas of greatest need and on
the development required to support neighbourhoods to achieve a high impact
social prescribing infrastructure.
7.8 Recognise social prescribing as a priority for investment of any new / invest to save
funding for 2017/18.
15
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16
AAnneex BB – CCommmuunityy Supppoort WWorkker RRefeerralls (220166)
17
Annex C - Social Prescribing – Draft Maturity Index
Infrastructure and Access Intelligence and Feedback Knowledge and Skills
5. E
mb
edd
ed a
nd
Su
cces
sfu
l
It is hard to find a frontline health / care / voluntary
sector worker in our neighbourhood who doesn’t know
how to refer to social px and / or handle a referral
themselves
Social px is the default neighbourhood response to
lower‐level social issues and health risk – and is also
routinely used to make sure people with high needs can
access social support to supplement care / support
Each neighbourhood (and / or practice) has a single
referral hub for social prescribing and it takes less than
a minute to make a referral – and less than 24 hours to
make contact
Referral numbers in the neighbourhood are running at
around 5% of the population per annum.
There is granular data and info about every referral,
presenting issues, and outcomes. This is linked to
peoples medical / care records and fed back
proactively to referrers and funders.
Referrals are triaged to make sure the right person
with the right skills has a conversation with the person
referred
The data is routinely analysed to identify gaps in local
services and activities, and to assess impact
Community assets and services are developed
specifically to meet the needs identified during
hundreds of social px conversations.
People dealing with social px referrals are
recognised as highly knowledgeable about the
offer in the community and what city‐wide
services can offer to supplement this.
People dealing with referrals are trained and
supported to coach people to set and achieve
their wellbeing goals
Other frontline workers are trained and are
now performing this role too
43
21.
Sta
rtin
g O
ut
Some GPs in some practices know how to engage with
social prescribing.
People in the neighbourhood / practices recognise the
need to rationalise social px‐like referral routes and
initiatives – it’s a bit of a spaghetti junction.
Recorded referrals from the few practices using social
px are around 100 per annum per practice.
Systems are put in place to record, track and report on
referrals but they are not well used and the data is not
great.
Referrers get occasional feedback that their referral is
being dealt with and they occasionally find out what
has happened.
There is anecdotal evidence about community needs
from social px conversations but it is not yet informing
the development of assets and services in the
community, which are still commissioned centrally.
There are a few people in the community that
are knowledgeable about local assets and
activities but it is ‘pot luck’ whether the person
handling a referral has the local knowledge to
help someone improve their outcomes.
Some people having ‘social prescribing’ type
conversations are not well‐trained or
supported enough so they are actually
increasing demand on health, care and other
support services.
18
________________________________________________________________________________
Annex D – Community Partnerships (locations and member organisationsrevised 18 Jan 2017
People Keeping Well (PKW) Framework Partnerships
Area 1: Stocksbridge, Grenoside, Rural, Bradfield, Oughtibridge, Wharncliffe Side, Worrall – (South Yorkshire Housing Association) Oughtibridge Surgery
Valley Medical Centre
Deepcar Medical Centre
Stocksbridge Health Forum
Stocksbridge Community Care Group
STEP Development Trust
4SLC
Stocksbridge Community Forum
Woodthorpe Development Trust
Dransfield Properties Limited
Main Contact: Claire Matthews - [email protected] - 0114 2900 218 – South Yorkshire Housing Association, 43-47 Wellington Street, Sheffield, S1 4HF
Page 1 of 9
19
_____________________________________________________________________________
_____________________________________________________________________________
revised 18 Jan 2017
Area 2: Chapel Green, Ecclesfield, Burncross, Chapeltown – (SOAR) Age UK
PACES
Sheffield Citizen’s !dvice High Green Development Trust
Chapelgreen Practice
St Saviour’s Church Sheffield Carers’ Centre Ecclesfield Parish Council
Sheffield 50+
!lzheimer’s Society
Main Contact: Ian Drayton - [email protected] - 0114 213 4066 – or Guy Weston - [email protected] - 0114 213 4065 - SOAR Works, 14 Knutton Road, Sheffield, S5 9NU
Area 3: Middlewood, Wadsley, Hillsborough, Walkley Bank, Wisewood, Woodland – (ZEST) Age UK Sheffield
Burton Street Foundation
Dykes Hall Medical Centre
Places for People Leisure
St John’s Church Owlerton
Main Contact: Isobel Thomas - [email protected] - 0114 270 2041 - Zest, 18 Upperthorpe, Sheffield, S6 3NA
Area 4: Fox Hill, New Parson Cross, Old Parson Cross, Southey Green, Longley, Shirecliffe, Colley –
(SOAR) The Healthcare Surgery Foxhill Forum LEAF Parson Cross Initiative (PXI) Parson Cross Forum Shirecliffe Forum Southey Development Forum Friends of Ecclesfield Library Sheffield North Live at Home
Main Contact: Ian Drayton - [email protected] - 0114 213 4066 – or Guy Weston - [email protected] - 0114 213 4065 - SOAR Works, 14 Knutton Road, Sheffield, S5 9NU
Page 2 of 9
20
________________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
________________________________________________________________________________
revised 18 Jan 2017
Area 5: Shiregreen, Wincobank, Brightside, Flower, Stubbin, Brushes, Firth Park – (SOAR) Shiregreen Medical Centre
Concord Sports Centre (SIV)
Firth Park Active (Centre for Life)
Flower Estate Family Action
Flower Estate TARA
St Mary’s Timebuilders
Friends of Wincobank Hill
PACA
Sanctuary Housing
Brushes TARA
Main Contact: Ian Drayton - [email protected] - 0114 213 4066 – or Guy Weston - [email protected] - 0114 213 4065 - SOAR Works, 14 Knutton Road, Sheffield, S5 9NU
Area 6: Upperthorpe, Netherthorpe, Walkley, Langsett, Crookesmoor – (ZEST) Upperthorpe Medical Centre
Age UK
The Vine
Main Contact: Isobel Thomas - [email protected] - 0114 270 2041 - Zest, 18 Upperthorpe, Sheffield, S6 3NA
Area 7: Burngreave, Abbeyfield, Firvale, Firshill, Spital Hill, Woodside and Darnall – (Creative Pathways) Aspiring Communities Together (ACT)
PACA
Main Contact: Freda Cotterell - [email protected] - 0114 2701066 - Creative Pathways, Offices 1 – 5, Spartan House, 20 Carlisle Street, Sheffield, S4 7LJ
Area 8: Firvale, Abbeyfield, Firshill, Burngreave, Woodside – (SOAR) Page Hall Medical Practice
PACA
MAAN
Aspiring Communities Together (ACT)
Arches Housing
Burngreave TARA
SAGE Greenfingers
SACHMA
Page 3 of 9
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________________________________________________________________________________
________________________________________________________________________________
revised 18 Jan 2017
Main Contact: Ian Drayton - [email protected] - 0114 213 4066 – or Guy Weston - [email protected] - 0114 213 4065 - SOAR Works, 14 Knutton Road, Sheffield, S5 9NU
Area 9: Darnall, Tinsley, Acres Hill (some partnership work with other Clover Group Practices -
Jordanthorpe, Mulberry etc.) – (Darnall Wellbeing)
The Family Development Project
Darnall Forum
Tinsley Forum
Darnall Dementia Group
Heeley City Farm – South Yorkshire Energy Centre
Sheffield Carers’ Centre
The Clover Group Practice (Darnall and Tinsley)
York Road Surgery
Main Contact: Lucy Melleney - [email protected] or Natalie Shaw [email protected] - 0114 249 6315 - Darnall Wellbeing, Darnall Primary Care Centre, 290 Main Road, Darnall, Sheffield, S9 4QH
Area 10: Broomhill, Crosspool, Crookes – (Heeley Development Trust)
Manchester Road Surgery
Crookes Practice
Crosspool Forum
Crookes Forum
Recovery Enterprise
Wesley Hall Lunch Club
St Timothy’s Lunch Club
Crosspool Lunch Club
Crookes TARA
Westminster TARA
St Columba’s Church
The Beacon St Stephen Hill Methodist Church
Tapton Hill Congregational Church
St Francis Roman Catholic Church
Care in Crosspool
Main Contact: Andy Jackson - [email protected] - 0114 2500613 - or Maxine Bowler [email protected] - 0114 2500 613 - Heeley Development Trust, Ash Tree Yard, 62-68 Thirlwell Road, Sheffield, S8 9TF
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________________________________________________________________________________
________________________________________________________________________________
______________________________________________________________________________
revised 18 Jan 2017
Area 11: City Centre, Broomhall, Sharrow – (ShipShape) Ignite Imaginations
Broomhall Centre
Together Women
Devonshire Green Medical Centre
Porterbrook Medical Centre
SIV
Ben’s Centre
U-Night
MAAN
Main Contact: Tanya Basharat - [email protected] - 0114 2500222 - Shipshape Health and Wellbeing Centre, Sharrow Lane, Sheffield, S11 8AE
Area 12: Manor, Wybourn, Park Hill, Granville – (Manor & Castle Development Trust One) Dovercourt Surgery
Whitehouse GP Practice
Manor Park Medical Centre
S2 Foodbank
Green Estate
Manor Park Post Office
Manor Assembly
Victoria Centre (Victoria Community Enterprises)
MASKK
Main Contact: Lucy Andrews - [email protected] - 07957 465523 - Manor & Castle Development Trust, The Quadrant, 99 Parkway Avenue, Sheffield, S9 4WG
Area 13: Highfield, Heeley, Woodseats, Gleadless Valley (parts of Meersbrook) – (Heeley Development Trust) Sloan Medical Practice
Shipshape
Roshni
FURD
Page 5 of 9
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______________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
revised 18 Jan 2017
Heeley Asian Women’s Group
Main Contact: Andy Jackson - [email protected] - 0114 2500613 - or Maxine Bowler [email protected] - 0114 2500 613 - Heeley Development Trust, Ash Tree Yard, 62-68 Thirlwell Road, Sheffield, S8 9TF
Area 14: Gleadless Valley, Gleadless, Heeley (and older people in Hemsworth, Meersbrook,
Arbourthorne, Highfield – (Heeley City Farm)
Reach South Sheffield
Heeley Green Surgery
St Wilfrid’s Centre Church of Nazarene
Sheffield Mind
Heeley Rise TARA
Shelter
Freedom Therapies
Gleadless Medical Centre
Waggon and Horses Community Pub
Main Contact: Shelly McDonald - [email protected] - 0114 3039981 ext 2 - Heeley
City Farm, Richards Road, Sheffield, S2 3DT
Area 15: Gleadless, Arbourthorne, Norfolk Park – (Manor & Castle Development Trust) East Bank Medical Centre
The Arbourthorne Centre
Norfolk Park Medical Centre
Arbourthorne TARA
Nolfolk Park TARA
Tiddlywinks
Arbourthorne Antics and Arbourthorne Strong & Steady
The Spires Centre
S2 Food Bank
Main Contact: Lucy Andrews - [email protected] - 07957 465523 - Manor & Castle Development Trust, The Quadrant, 99 Parkway Avenue, Sheffield, S9 4WG
Page 6 of 9
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________________________________________________________________________________
________________________________________________________________________________
revised 18 Jan 2017
Area 16: Gleadless Valley, Gleadless, Heeley (and older people in Hemsworth, Meersbrook,
Arbourthorne, Highfield) – (Heeley City Farm)
Reach South Sheffield
Heeley Green Surgery
St Wilfrid’s Centre Church of Nazarene
Sheffield Mind
Heeley Rise TARA
Shelter
Freedom Therapies
Gleadless Medical Centre
Waggon and Horses Community Pub
Main Contact: Shelly McDonald - [email protected] - 0114 3039981 ext 2 - Heeley
City Farm, Richards Road, Sheffield, S2 3DT
Area 17: Dore and Totley – (Age UK) Royal Voluntary Service
Sheffield Citizen’s !dvice Totley Community Resource & Information Centre
Totley Pharmacy
Sheffield 50+
Sheffield Carers’ Centre Voluntary Action Sheffield
!lzheimer’s Society Sheffield Health & Social Care
Main Contact: Andy Callard – [email protected] – 0114 250 2850 – Age UK Sheffield, 44 Castle Square, Sheffield, S1 2GF
Area 18: Batemoor, Jordanthorpe, Lowedges, Bradway, Greenhill, Beauchief – (Reach South Sheffield) The Terminus
Shelter
VAS
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_____________________________________________________________________________
revised 18 Jan 2017
CAB
Jordanthorpe Library
Heeley City Farm
Main Contact: Steve Rundell - [email protected] - 07939 411221 - Reach South Sheffield, 187 Blackstock Road, Sheffield, S14 1FX
Area 19: Woodhouse, Beighton, Hackenthorpe, Westfield – (Woodhouse and District Community Forum) Westfield Big Local
St !nne’s Community Services
Sheffield City Council Housing and Neighbourhoods
Woodhouse Health Centre
Sheffield DACT (Drugs and Alcohol / Domestic Abuse Co-ordination Team)
South Yorkshire Police
Woodhouse West Primary School
The Salvation Army Westfield
Activity Sheffield
Breast Cancer Care volunteer
East MAST (Multi-Agency Support Team)
Hackenthorpe Medical Centre
Owlthorpe Surgery
Crystal Peals Medical Centre
!lzheimer’s Society
Workers’ Education !ssociation
Main Contact: Kathryn Taylor – [email protected] – 0114 2690222 – 2 Goathland Place, Woodhouse, Sheffield, S13 7TE
Area 20: Beighton, Waterthorpe, Sothall, Mosborough – (ShipShape) Mosborough Health Centre
Sothall & Beighton Medical Practice
Woodhouse and District Community Forum
Heeley Development Trust
Dawn Young – Independent Training Consultant
Main Contact: Tanya Basharat - [email protected] - 0114 2500222 - Shipshape Health and Wellbeing Centre, Sharrow Lane, Sheffield, S11 8AE
Page 8 of 9
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revised 18 Jan 2017
Page 9 of 9
27
Annex E – Initial Assessment of Maturity of Local Area Social Prescribing Models
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Knowledge and Skills
Community Assets
Intelligence and Feedback
Infrastructure and Access
Central : Hills, Broomhil, Sharrow vale, City
North: Stannington, Stocks, Ecclesfield
North East: Southey, Firth Park, Shiregreen, Burngreave
East: Darnall, Manor, Richmond, Park and Arbourthorne
South: Netheredge and Sharrow, Gleadless Valley, Graves Park, Beauchief and Greenhill
South West: Fulwood, Crookes, Ecclesall, Dore and Totley
South East: Woodhouse, Beighton, Mosborough, Birley
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Annex F – Social Px Referral Rates by Neighbourhood vs Health IMD (CSWs only)
IMD Health Rank Top 25% 25 ‐ 50 50 ‐ 75 Bottom 25% 1 Fulwood 2 Ecclesall 3 Millhouses 4 Endcliffe 5 Bents Green 5 Whirlow / Abbeydale 7 Worrall 8 Dore 9 Lodge Moor 10 Greystones 11 Bradway 12 Crosspool 13 Ranmoor 14 Sothall 15 Halfway 16 Grenoside 17 Mosborough 18 Broomhill 19 Oughtibridge 20 Beauchief 21 Stannington 21 Crookes 23 Owlthorpe 23 Burncross 25 Norton 26 Greenhill 27 Totley 28 Chapeltown 29 Deepcar 30 Brincliffe 31 Loxley 32 Wharncliffe Side 33 Nether Edge 34 Woodseats 35 Middlewood 36 Walkley Bank 37 Wadsley 38 Hillsborough 38 Charnock 40 Meersbrook 41 Gleadless 42 High Green 43 Handsworth 44 Birley 45 Wisewood 45 Beighton 47 Base Green 48 Waterthorpe 49 Highfield 49 Tinsley 51 Fox Hill 51 Housteads 53 Granville 54 Stocksbridge 54 Walkley 54 Westfield 57 Hollins End 58 Langsett 59 Ecclesfield 60 Woodland View 61 Hackenthorpe 61 Heeley 63 Wincobank 63 Sharrow 65 Richmond 66 Woodhouse 66 City Centre 68 Colley 68 Firth Park 68 Hemsworth 71 Crookesmoor 72 Woodthorpe 72 Abbeyfield 74 Fir Vale 75 Acres Hill 76 Southey Green 77 Firshill 78 Shiregreen 79 Lowedges 80 Gleadless Valley 81 New Parson Cross 81 Brightside 81 Netherthorpe 84 Shirecliffe 85 Broomhall 86 Wybourn 87 Park Hill 88 Old Parson Cross 88 Upperthorpe 90 Longley 90 Darnall 92 Norfolk Park 93 Stubbin / Brushes 93 Woodside 95 Arbourthorne 96 Burngreave 97 Batemoor / Jordanthorpe 98 Flower 99 Manor
MCDT Social PX Area SOAR Social PX Area
REFERRAL RATE (adjusted for population)
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Annex G – Social Prescribing Outline Plan
Project Plan ‐Social Prescribing
Number Milestone/Task Planned Start Planned Finish Actual Finish RAG
M1 Clear and transparent governance in place
M1a SCC Governance process agreed 01/03/2017 31st March A
M1b CCG Governance process agreed 01/03/2017 31st March A
M2 Project plan is agreed and signed off
M2a Agreed by SCC 17/03/2017 31st March A
M2b Agreed by CCG 17/03/2017 31st March A
M3 Central Referral Hub in place and live G
M3a IT system in place 01/03/2017 03/03/2017 03/03/2017 G
M3b Referral form designed 01/03/2017 03/03/2017 03/03/2017 G
M3c Icon/link on GP desktop 01/03/2017 03/03/2017 03/03/2017 G
M3d Staff in place to manage referrrals 01/03/2017 03/03/2017 03/03/2017 G
M3e CP's aware of process 06/03/2017 16/03/2017 G
M3f GP's aware of process 09/03/2017 31/03/2017 G
M3g CSW's aware of process 05/03/2017 05/03/2017 05/03/2017 G
M4 Maturity Index analysis complete
M4a Initial city level desktop analysis 24/02/2017 03/03/2017 03/03/2017 G
M4b Practice level analysis 21/02/2017 03/03/2017 10/03/2017 G
M4c Community Partnership/VCF sector analysis 03/03/2017 10/03/2017 10/03/2017 G
M4d Neighbourhood "Spider Diagram" produced 03/03/2017 10/02/2017 14/03/2017 G
M4e Citywide "Current State" identified 03/03/2017 10/03/2017 14/03/2017 G
M5 Citywide Delivery Plan complete 24/02/2017 21/04/2017
Draft complete 24/02/2017 17/03/2017
Consult on draft with stakeholders 20/03/2017 14/04/2017
Amend draft in light of consultation 14/04/2017 21/04/2017
M6 Risks, Issues and Challenges Log in place 03/03/2017 10/03/2017 14/03/2017 G
M6a Feed into AS&R 06/03/2017 16/03/2017 G
M7 SP Model reflects and encompasses needs of CYPF
M7a Id key stakeholders
M7b Preliminary discussion with key stakeholders
M7c Workshop with CYPF stakeholders to align protocols etc
M8 Communications Plan in place 14/03/2017 28/04/2017
M8a Carryout a Stakeholder Analysis 14/03/2017 14/04/2017
M9 Resources for life of plan in place 14/03/2017 07/04/2017 A
M9a Identify existing resources 03/03/2017 10/03/2017 14/03/2017 G
M9b Identify resources required 03/03/2017 10/03/2017 14/03/2017 G
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M9c Commissioning Route agreed 17/03/2017 31/03/2017
M10 Social Prescribing Task and Finish group established 14/03/2017 10/04/2017
M10a First meeting and TOR produced 14/04/2017 28/04/2017
M11 Neighbourhood Delivery Plans co‐produced and agreed 21/04/2017 16/06/2017
M11a Draft outline plan produced for each neighbourhood
M11b Neighbourhood workshops to develop into delivery plan
Data Management System in place
Assess current systems in place
Asses alternative systems
Options appraisal
Recommendation in year one evaluation report
Year one evaluation complete 30/04/2017 31/03/2018
Data collection methodology in place 16/03/2017 01/04/2017
Montly Data collection from SP Hubs
Montly Data collection from SP Hubs
M All GP practices are making good use of SP
SP Model Connected to other referral systems Residents know how to access their local SP hub
Social Workers making appropriate use of SP
Housing+ officers connected to SP Hubs
MAST teams connected to SP hubs
Community Partnerships supported by VAS
Community groups supported by
A single Risk Modelling Tool is in place and being used
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