Pockets of success

18 December 2020

As medicine advances, health needs change and society develops, the NHS has to continually move forward to ensure we always have a service fit for purpose. The NHS Long Term Plan sets out how this can be achieved, with a focus on providing high quality, lifesaving treatment and care for patients and their families, reducing pressure on NHS staff and investing in new technologies.

Across the NHS there is recognition of the need for change, and that there are multiple elements both driving and supporting its iterative development. These include a strong focus on digital intervention, self-care and responsibility, new ways of interacting with the clinical workforce, and prevention.

The All Party Parliamentary Group (APPG) on Longevity also identifies prevention as a fundamental concept around which to develop care in the future, by building on Marmot and offering recommendations about keeping people well so that they do not become ‘patients’. The APPG recognises people can become vulnerable by ‘context’ as well as by ‘condition’; for people to flourish they need sufficient regular income, safe and warm housing, good nutrition and to choose healthy behaviours (such as social interaction and exercise, rather than tobacco, alcohol and other drugs).

Where to begin?

Vulnerability is a complex concept, defying simple definitions and presenting a shifting set of challenges; as such it is an enduring issue that extends well beyond the treatment and illness prevention project of the NHS. Neither can social care provide the breadth or speed of interventions that are required. The changing context and conditions of individual lives make it all too easy for them to either become vulnerable or be unable to escape from its impact. Often, at these life changing moments, the most impactful support is sourced at a very local, individual level at a depth beyond the scope of site based services.

People who live with physical illness recognise a national health service with standards that apply across the land. People whose context and lives are precarious, who live with and are vulnerable to mental and social health challenges, recognise their support has to be delivered locally. Social enterprises and others active in this space refer to this as ‘place-based community assets’.

What can we learn from them and how can we apply that learning to benefit more people?

Ingredients of success

John Hitchen, CEO of Renaisi, believes that work to address vulnerability challenges blossoms when done at place level and that the most effective interventions stem from keeping things local and involving the right partners. In the case study from One Northern Devon, we will see how interventions based at place level have become the foundations for support networks to evolve across, streets, towns and, eventually, the north of the county.

Dan Lyus, the South West AHSN’s Director of Partnerships, highlights the role that social prescribing plays in the construction of a strong social infrastructure. While benefiting individuals. It also helps to build relationships across a community and can be a key element in a thriving place.

With the case studies that follow, we attempt to draw out some of the common characteristics for these projects succeeding, identifying some of their key components to inform new projects and the further development of existing work.

This is very much work in progress; we hope it will contribute to describing and developing a model of support that is based on real world, lived experience and which will be useful to anyone working with vulnerable individuals or communities.

Case study: “One Northern Devon”

“One Northern Devon” (1ND) grew out of the “One Ilfracombe” project which was originally created by Ilfracombe Town Council and other public services in 2013. As we write in the time of COVID-19, when vulnerability has been recognised as a key problem for society to address, we can see how the structures built before COVID-19 have been crucial to seeing these communities through the pandemic.

1ND was able to adapt and evolve to respond to the new needs created during COVID-19, including the needs of the newly vulnerable. The pillars that sustained the existing structure also enabled it to build outwards. These included six years of working relationships between individuals and organisations; charismatic leadership; compelling stories that showed past success; and a track record of growth that meant it had a tried and tested approach to developing its response to new challenges.


By the time COVID-19 hit, 1ND had become a trusted structure that encompassed four Primary Care Networks (PCNs). In order to ensure its ongoing ability to meet community and citizen need, 1ND had strengthened its sustainability and resilience. As part of this, it had appointed social prescribing link workers covering all the PCNs and supported by their own network.

The original model for 1ND grew out of work in Ilfracombe in 2013, when the town council was joined by the other public services in creating One Ilfracombe. It was established as a not for-profit company, with a social and community vision of improving the health, economy and living conditions of the people of Ilfracombe. One Ilfracombe organised into three work teams:

  • the Living Well Team
  • the Ilfracombe Works Team, and
  • the Town Team.

The work of each team was brought into an overall One Ilfracombe programme. It developed an approach that is community driven, meaning residents know where they can go for help and support should they need it

Outcomes based growth

Hannah McDonald, Partnerships Development Manager for One Northern Devon, talked to us about the growth and endurance of the 1ND model and building out from its initial Ilfracombe base.

“We were able to use outcomes and, more importantly, people’s stories as a currency to grow investment as the project grew beyond Ilfracombe and across north Devon.

“It was all about ensuring the involvement of the various partners who had something to offer for the benefit of the community. This included emergency services (police and fire) and business, as well as other players.”

Work to describe the return on investment was done in both in 2017 and 2018, but Hannah believes it’s difficult for ROI models to capture the full impact of the work, given the challenges of following savings through:

“In the end investment and support was leveraged through the depth and breadth of case studies and, crucially, through the stories of individual people who had benefitted – and, locally, this was enough,” she said. 

Ensuring inclusivity has been central to the project, and it has taken care to develop in ways which don’t marginalise some people and their needs and asks.

“You can never be 100% sure but there is no evidence that marginalisation has happened. It’s something we continue to look at periodically to check that needs and requests for help are being met. There is plenty of publicity about the project within the community and ways in which anyone who felt actively excluded could come forward,” Hannah explained. 

One Northern Devon COVID-19 response: building up and out from the streets

Starting at street level, in parishes and towns, the social infrastructure and relationships built by 1ND enabled rapid community-led volunteer support to build on its established relationships and extend support to those affected by COVID-19.

The social prescribing managers, link workers and community builders that know their communities best have been central to coordinating the effort. To support them these local teams are offered tools – like a template workplan – and opportunities to connect at a daily operations meeting with 1ND. A process for cascading cases up and across the district – including if local volunteers cannot be found – aims to ensure that no one in North Devon needing support during the COVID-19 crisis is missed.

The seven communities that comprise 1ND now have a combined volunteer workforce of more than 1,000 people carrying out essential tasks. By July 2020, more than 2,000 requests for help have been answered, including 600 shopping deliveries, 940 prescription deliveries, 300 befriending check-in calls and 160 other acts of kindness such as dog walking and letter posting.

Lessons learnt include:

A sustainable staffing model

1ND employed a System Support Coordinator, funded by the Devon Integrated Care System, for a five-month period to cover the initial COVID-19 response. The post covers the whole 1ND patch with the purpose of developing greater understanding of the needs and gaps in different areas.

A more resilient system of volunteering

To plan for scenarios in which demand rapidly escalates due to a local outbreak, the System Support Coordinator explores solutions with other local partners including businesses to see if they would be willing to fill gaps, such as supporting community shops that face running out of supplies or shopping for large numbers of newly isolating members of the community.

Identifying vulnerabilities and people in ongoing need of support

There are also concerns about people falling through the gaps where communities are not aware of their needs. Working to try and identify people that may not already be known to 1ND, potentially with a high level of need, is a key priority going forward.

Sharing with others

One Ilfracombe continues to be supported by the Institute for Social Prescribing and, together with the South West Academic Health Science Network (SW AHSN), they are sharing information about how social prescribing has helped support the community response to COVID-19. SW AHSN also helped with spread methodologies, supporting the scaling from One Ilfracombe and into other parts of the county.

Strong social infrastructure

The project has a strong social infrastructure stemming from work previously done that focused first and foremost on building relationships across and within the community. Taking a bottom-up approach and being confident in their community relationships and knowledge enables the project to respond quickly to a fast moving situation, rather than needing to wait for offers of county-wide, regional or national support.

By July 2020, more than 2,000 requests for help have been answered, including 600 shopping deliveries, 940 prescription deliveries, 300 befriending check-in calls and 160 other acts of kindness such as dog walking and letter posting.

Case study two: The importance of relationships when building a place-based response

Becca Randall joined KSS AHSN to work as the Implementation Lead on the Applied Research Collaboration Kent Surrey Sussex (ARC KSS) core theme of Starting Well: early detection and intervention of mental health problems in children and young people at the point that COVID-19 was changing the way that we were all working.

In this short interview she outlines her experience in supporting two groups of people made vulnerable by COVID-19: care leavers and young people with mental health needs. She highlights the importance of relationships in developing a place-based approach, and reflects on how COVID-19 shaped the approach of ARC KSS.

“I joined KSS AHSN, which has a strong reputation for delivering innovation, with relationships with many key stakeholders already in place. However, working with young people and addressing mental health challenges were new areas for the AHSN, meaning many relationships were in their infancy, especially relating to the Children and Young People’s (CYP) mental health agenda.

“As a commissioner with over 20 years’ experience of working across the region, I was able to bring in a number of existing relationships, networks and knowledge on how the CYP mental health system works.”

Using these pre-existing relationships, Becca was able to connect key players, enabling the COVID-19 response to develop much more quickly.

“I already had the trust of key stakeholders, so one challenge was being in a new role (I was previously in commissioning) and introducing the role to partners I had previously worked with. It’s been key to focus on both formal and informal relationships within the system to build that understanding of my work, and use that opportunity to do things quickly during the COVID-19 crisis.”

Reacting to COVID-19

Becca believes that COVID-19 allowed us to reframe and reiterate our approach to targeting inequalities in the seldom heard group of CYP and their families, according to their presenting issue, their life experience, their vulnerability or where they live.

“The YMCA was already working with young people to coproduce a website that contained information on COVID-19 and CYP mental health services across Sussex,” she said. 

“By working with key voluntary and community sector providers to further understand their challenges and the challenges of their service users, KSS AHSN and ARC KSS were able to link their insight to inform system recovery planning to identify priorities and gaps in service delivery.”

ARC KSS funded a rapid review of the psychological impact of COVID-19 on care leavers, leading to a guidance document being co-produced with care leavers and Leaving Care Teams within local authorities. One output of this work has seen care leavers themselves recognised as an important resource for other care leavers with problems.

Another output is the pledges made by service leads that will support better care for this seldom heard group. The process by which the Community of Practice was brought together and listened to, and actions were taken, was made possible not just by the small amount of research funding, but also by the more general way organisations worked at speed and on trust, working together in partnership. This mirrors the way that many physical health services have also talked about collaborating during the COVID-19 response. 

A rapid response

The nature of COVID-19 meant that this work had to happen quickly, so having strong, pre-existing relationships within the CYP mental health field across the region was fundamental to the work’s success.

Contact Becca Randell – becca.randell@nhs.net

Case study three: Hepatitis C eradication

Another example of work that has been able to persist during COVID-19 and which seeks to address the needs of a particular group of vulnerable people is the Hepatitis C eradication programme in Greater Manchester, whose in-scope population groups include street sleepers (where the prevalence of Hep C in a recent study was one third) and prisoners.

Again it highlights the importance of relationships between individuals, organisations and within communities when it comes to delivering support for vulnerable people.

The local NHS, Health Innovation Manchester (the AHSN for Greater Manchester), local authorities, the Mayor’s office, and the voluntary sector have learned that referral of people to hospital out-patients after a traditional positive test sees almost no one complete the 10-week therapeutic course necessary for viral eradication.

Past learnings

Working together on rapid testing and learning from the first winter of A Bed Every Night, (where no additional interventions were agreed in case it put people off seeking refuge), changed or evolved the mindset to support intervention in health issues.

This, and devolving delivery of the project to a more local area approach, from a central single project, is now seeing far more street sleepers completing their course of treatment and becoming virus-free.

Supporting prisoners

Work in HMP Styal, a women’s prison, was hampered before the development and implementation of rapid testing allowed treatment to begin while an individual is within the custody service.

Prior to this, women were being discharged from custody before their results were available. The project’s extension into the male prison system was possible not because of rapid testing, but through learning, success and publicity within the women’s sector.

This project shares features with the other projects described here: multiple partners with learned and earned trust, passionate leadership, understanding needs and motivations in hard to reach groups, and defined local geographies.

Case study four: The role of innovation in place-based approaches

Tony Davis, Director of Innovation & Economic Growth at West Midlands AHSN, reflects on how COVID-19 has highlighted the importance of place-based approaches in tackling health inequalities.

Our Digital Health and AI team works across a range of NHS organisations, including innovators in primary and secondary care and mental health, Tony writes. 

Back in 2018 we started to explore opportunities of working with local authority, Public Health and directors of Adult Social Services. By taking the data from remote monitoring devices and feeding that into a whole range of data sets, we could start to map health and care data.

That approach has now morphed into work across our ICS and STPs footprints, and the integration between health and social care has greatly accelerated during COVID-19, where we’ve seen good collaboration between social care and Adult Social Services and Public Health in trying to support population- and place-based approaches.

Two-pronged approach

Through our Innovation Exchange, Meridian, we’ve been helping innovators understand what the regional and national NHS challenges are, and connecting them to the help they need to transform patient care and deliver economic growth.

And then from a grassroots level we work with the Institute for Social Entrepreneurs’ FUSE Social Enterprise, which is a start-up business incubator for social enterprises looking to gain contracts and deliver services in the health, social care and well-being sectors.

We find that the majority of the social enterprises we work with come from BAME communities or are led by women. Their approaches generally fill gaps in service provision that hasn’t been directly commissioned by health or Local Authorities by taking either a place- or issue-based approach.

Learning from COVID-19

Technology can sometimes draw us into the trap of thinking that we need to make every new idea as big and as widespread as possible. Our collective experience of COVID-19 will, I hope, help to challenge that thinking.

During COVID-19 we’ve all seen local support networks spring up. As well as realising the importance of the ‘big’ technological approach, we shouldn’t forget the identity and needs of the people within those places, especially when it comes to health inequalities. This is a massive issue and should not be forgotten in a post-COVID-19 world. 

More from this issue of Innovate

Taking a place based

The urgency of the vulnerability challenge