Welcome to our new blog series, 'Connecting Conversations'.   For our first instalment, Tim Anfilogoff shares his reflections with us this month as he retires from his local health role.  He has been a member of the Social Prescribing Network committee since its inception and has worked nationally and regionally in supporting the development of the English model of social prescribing. You may be aware of his infamous saying "there's no point having lots of travel agents (aka Link Workers) if you have no holidays to send people to (funded VCFSE opportunities).

Taking the long view

NHS becoming more carer aware – and needs to be

In 1999, for example, I worked on the first National Carers Strategy for the Department of Health. That document was a watershed but it contained no serious commitments from the NHS at all. Since then, thanks to VCFSE campaigning and, more recently NHS England championing, significant culture change has taken place. We are now identifying in primary care about 30% of the carers the census indicates exist. The agenda is starting to catch up in acute care with carers' lead nurses. We can show – to our alarm - that 13% of carers registered in primary care in Herts are on opioids, significantly higher than the general population (5%) probably because of inappropriate moving and handling or levels of stress - and we know carers are more likely to have multiple long-term conditions. We can also identify overprescribing of anti-depressants to them.

How is this relevant to social prescribing? Carers are the classic whole system issue. One where joined up, humane, preventive services which are non-clinical can truly prevent ill health and crisis. If you're caring alone for someone with dementia, you may well be lonely, stressed, probably suffering financially, and almost certainly carrying out physical and administrative tasks other 75-year-olds wouldn't dream of doing. Women in this age group are those most likely to be caring 50 hours plus per week (associated both with deprivation and with 18 additional days of ill health per year -37 in the most deprived communities. If we want to prevent sickness, shouldn't we be more curious about how these people are coping? 

Policy not matched by resource

The Care Act (2014) promised carers parity of esteem with 'service-users', but research has shown resource restraints mean carers access less formal social care support than they did in 2014. It's not surprising caring issues are the fifth commonest reason for link workers to support people in Herts. Link workers help people find carers' voluntary organisations, navigate the complexities of health, social care, housing and the benefits system and build a network to support them. 'It's still a challenge,' carers often say, 'but I no longer feel totally alone.' 

Getting more imaginative

When I worked at the Department of Health, Local Authorities routinely told carers they could help with personal care (which the person they cared for often refused), but not with cleaning or laundry or practical help (which the family would have really valued and would have been cheaper). So, we put in place 'carers services' under the Carers and Disabled Children Act, 2000 (focused on what the carer thought would help them carry on caring). One carer in 2001 chose to use her direct payment to have belly-dancing lessons as a break. Some senior social care managers took some persuading - but we got there.

As these more varied and imaginative responses developed, it was easy to see the impact of listening to what the person valued, rather than automatically making the 'bog standard' offer. It built trust. Carers felt listened to, valued. Social workers felt liberated. Resources were still limited, but the focus on what carers wanted was transformational. 

What matters to me

My commitment to SP is because it's the one bit of the system that doesn't start with a menu of what we have, our specialisms or our statutory obligations. It looks at what may be possible - with a willingness to make it possible. I have a bitter memory of a carer who approached social care for help to be told she was not eligible; far from building her resilience, this left her humiliated and rejected. She told me she'd never go near social services again. I was furious. All they'd needed to do was link her to the VCFSE, who'd have time to get to know her. She would have been better prepared for the future and could have been helped to make a formal referral if needed. 

No Wrong Door

I often tell a story about a carer I met in 1989 in Kent. Beattie was seeing her GP regularly. Neither of them had any concept of a 'carer'. Both just thought she was a wife doing her duty. The GP knew nothing about what the local voluntary sector might have to offer (or any social care other than residential). Beattie was one of many people I've met who said: 'I wish someone had told me about this five years ago, Tim!' I persuaded her to apply for support. She had been caring for her husband for six years when she received her first Carers Allowance cheque (then known as Invalid Care Allowance). It arrived on the morning of her husband's funeral.

SP is a crucial element within the No Wrong Door strand of our ICS's Health Creation Strategy. We've made a lot of progress locally in getting agencies (statutory and voluntary) working together, so that people get help as easily and early as possible. We set up HertsHelp in 2011, a single point of contact for the VCFSE. Any professional, any member of the public, can contact if they're not sure where to look for help. (This service was a Godsend during Covid). Back in 2014 we developed our first SP project, to ensure HertsHelp's offer was equally available to those who needed face to face support. SP is crucial in supporting those who find it all baffling, demotivating or terrifying.

Meanwhile, the NHS is often too busy to do what's in its own interest. Evidence from the US is that identifying and engaging the carer of an older person properly at discharge reduces readmission rates by 25%. So why are carers so often treated as 'blockers' instead of a key partner in keeping the person well (and away from hospital)? The NHS often doesn't even have to do more work. What the carer needs is unlikely to be about clinical interventions; their resilience can be enhanced by local carers' groups, reducing isolation, helping them access timely advice. 

Room for some optimism?

As I put myself out to pasture (green social prescribing will be part of my retirement!) I'm confident SP is every day responding to Marmot's famous challenge: 'Why treat people and send them back to the conditions that made them sick?' So why does the NHS still treat your COPD flare up and send you home to a damp cold home without linking you into support that could make all the difference? Evidence is growing that being able to afford heating is better at preventing the next flare up than drugs. There are great examples of SP at discharge, and with high intensity users to reduce 'inappropriate' use of A&E. How many falls are linked to older people's malnutrition, cold homes, loneliness and poverty? How often are ICB's frailty programmes too focused on the clinical and not enough on the wider determinants (i.e. people's real lives – like whether they understand the drugs they're taking)? How many carers with heart disease have much worse outcomes than their peers because their carer stress is unseen and unmanaged through lack of support, money worries or just the inability to leave the person to take exercise?

We await the ten-year plan with interest. Darzi didn't mention SP but he did focus on the need to support carers better, and on the shift to prevention. As someone (for a couple of days longer) sitting in an ICB, watching colleagues dealing with the lack of clarity from the centre about the next months, I wonder if we can keep the momentum of SP going. I am hopeful. The movement is strong. The evidence is clear. Clinical medicine doesn't prevent that much disease. Addressing the challenges people face through helping them work on what matters to them, really can. 

About Tim

Name: Tim Anfilogoff

Part of the world I live: Suffolk, England

Occupation: ICB Head of Community Resilience, retired on May 1.

What makes You well? Walking the dog, cycling, sea-swimming, music, writing, friends and family

Why is social prescribing important? It's the only mechanism I've come across that focuses on what matters to the person and works across systems to help them improve their quality of life.

Your favourite nature based space? Delphi in Greece; Cove Hithe beach

Your favourite music? Too many to pick one

Your favourite pastime? Depends on the weather. Playing with my granddaughter is up there

If you had one wish for social prescribing what would it be? It continues to expand and help more people but without being institutionalised by the powers that be

What are your leadership tips for others who want to set up social prescribing projects? You can't train people to have the right personality – pick the right people – listeners, collaborators, problem-solvers who won't take over and who are interested in the community

Which one person has most influenced you and why? Really hard to pick, but professionally possibly a carer I met in Kent in the 80's – so many of her issues could have been managed so much better if the system focused on the right things and worked together effectively and I've never forgotten who she and people like her are regularly failed

Any advice for others when working in this space with communities? Never lose the simple clarity of SP. It's about helping people work on what matters to them. And that is usually in some way about connection 

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