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Joined up solution to patient care saved stroke survivor's life


For some, dealing with official bodies is a daunting prospect when they need help. A significant number of people either can’t, or don’t want to, engage with them.

Left unchecked, social issues such as poor housing, social isolation or money worries can lead to health and wellbeing problems. Often, when enduring such difficulties, an individual’s first contact with any official body begins when they become unwell.

While health services can treat physical or mental health symptoms, some people can often begin a cycle of repeat visits to their GP or hospital if the root causes of their problems aren’t addressed.

In a bid to break that cycle, public bodies and voluntary organisations in our region have led the way nationally on social prescribing, which tries to tackle underlying causes of health and wellbeing issues.

BCUHB project manager Julie Marsh said: “Social prescribing is not a new theory but it is often not high on people’s agendas, because all services are under severe pressure.

“It takes a little more work but, in the long-term, it reduces the burden on services like the Health Board and, more importantly, gives people a better quality of life through targeted support.”

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The approach also falls in with the Health Board’s aims of providing more preventative care within people’s communities and halting the escalation of health issues.

One of the project’s many success stories demonstrated how a stroke survivor overcame health and money issues with aid of his community navigator. To protect his anonymity, we have called him “Albert” (not his real name).

Albert was a proud individual and refused to accept support or advice from hospital staff. Consequently, his health deteriorated.

After having a What Matters conversation with a community navigator it became apparent he had isolated himself but for occasional visits from his daughter. He also revealed he was in financial difficulty.

Albert was in crisis and he further revealed he was struggling around the home and was socially isolated, hardly seeing anyone day to day. He had broken his ribs trying to get himself around and on another occasion burned himself while trying to cook a meal. He also had a chest infection.

In a further chat, with an invited social care practitioner and his community navigator, Albert became emotional and revealed he hadn’t eaten properly for months because most of his money went towards renting his flat. His mood was extremely low.

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With support from his community navigator he visited Citizen’s Advice, who found he was being underpaid benefits. They also directed him to a local food share scheme where he could access fresh fruit and vegetables.

Slowly, over a three-month period Albert’s confidence grew and he attended Talking Points meetings, where he built a rapport with his community navigator. He saw his GP, who treated his chest infection, and he revealed he was due to have heart bypass surgery and a pacemaker fitted - but kept failing the pro-operative check.

Because he had started eating properly, he passed the next pre-operative check and successfully underwent surgery.

He then received news his disability benefits had been increased in line with his entitlements along with sizeable back pay, which allowed him to clear his debts with an energy provider.

Albert said: “Going at my own pace, allowed me to build up trust with my community navigator. I found it hard to talk about what was going on in my life but I feel confident about life now.

“Walking into that library and having that first meeting with my community navigator saved my life.”

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Called Well North Wales, the scheme supports people with health issues and tries to unpick and address the problems which cause health and wellbeing concerns.

To celebrate National Social Prescribing Day on March 14, the Health Board is hosting a showcase of the work done by the partnership at Rhyl Rugby Club, for community groups, charities, housing and public sector organisations.

Julie Marsh hopes more organisations will sign up to the scheme, giving more people the chance to access the services they need.

“It is the case that some people don’t want to engage with services because they don’t see what benefit it will be to them,” she said. “Others just feel overwhelmed and don’t know where to turn to for help.

“Sometimes it can just be a chat with a GP or a health professional which unlocks the reasons behind someone’s health or wellbeing challenges. The GP can then refer their patient on to a specialist community navigator, who will work with the individual to try and remove their barriers to living a better quality of life.”

Once community navigators have had a “What Matters” conversation with someone, a fuller picture of their circumstances emerges. Partner organisations are then identified to help address the underlying issues, which may be affecting a person’s quality of life.

Brian Laing, BCUHB Strategic Partnership Manager for Public Health, added: “By working together with other public services and partners in the charity sector, we can actually address the underlying causes of poor health and wellbeing. It’s about listening to people and tackling their issues in a joined up way.”

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