Edinburgh Integration
Joint Board

After supporting Mr G for a few weeks, it appeared that Mr G also suffered from very high anxiety when it comes to attending any appointments. Other than this Mr G came across as a very active man, out and about every day and enjoyed keeping on top of his housework.

Mr G had no immediate family apart from a niece living in the Borders who only kept in touch via telephone.

Generally, Mr G always answered his calls, was cheery and upbeat and plausible. However, CIC detected a change in his behaviour and reported this back to his GP who originally referred him. Unfortunately, the GP informed CIC unless he presented himself to the surgery there wasn’t much they could do as Mr G was regarded as an able man who attended his appointments when they were scheduled for him. Mr G continued to assure CIC he was fine.

CIC remained concerned and contacted his niece who was his specified emergency contact. Mr G refused to allow access to his relatives and police were called the next morning when he refused to answer CIC’s daily telephone call.

Mr G was found unconsciousness on his floor. Initially the Police thought he had been attacked in his home as he was so bruised and was taken to hospital where they managed to stabilise him. His house was found in a bad state with mice, dirt, uneaten food and boxes of medication that he hadn’t taken for some time. It also emerged that Mr G had become blind and was no longer able to manage but had not shared this deterioration in his sight with anyone.

The family were grateful for CIC pursuing their concerns and the family are now back in each other’s life and Mr G is getting the help and support he needs. His house was cleaned and decorated while he was in hospital giving him the motivation to return home and live safe and well with support.  Mr G now has the support of homecare and a befriender to get him out and about while being supported with his sight loss.

• Reduced social isolation
• Improved mental wellbeing
• Supported self-management of long-term conditions

• Received appropriate support for his sight loss.
• Reconnected with his extended family.
• Continues to be active despite his deteriorating health.
• Supported self-management of his long-term health conditions.
• Reduced loneliness and isolation through regular contact with his befriender.

• Reduced risk of crisis hospital admission due to re-engagement with health services and acceptance of appropriate support.

B has a mild learning disability which means that he can’t read or write. Before attending our sessions, he led a very sedentary and isolated lifestyle, staying indoors playing video games and watching films.  When the organisation first met B, he was keen to make lifestyle changes to improve his mood and help him to lose weight.  He had already begun his weight loss journey and was looking for ways to support this.

He first came along to Walking Adventures in Moredun just before COVID and continued with zoom catch ups and yoga sessions in lockdown following digital support to get him connected. When restrictions lifted and the outside exercise sessions to resumed, B benefitted from meeting new people and forming friendships with other participants.

Peer support encouraged him to attend other communities such as the Goodtrees Garden Get Togethers and Move n Groove sessions. This widened his circle of friends and consequently his support network. He learned about other sessions happening in the community such as cycling sessions at Bridgend Farmhouse and began attending activities provided by other projects. Through his new social network, he also struck up a friendship with a lady who had previously been a head teacher who began teaching him to read and write each week.

With structure and support in his week, B reach and maintain his target weight, he found a love of jogging and outdoor exercise and has become a real ambassador for the organisation’s Out & About programme. B completed the Couch to 5K jogging programme in 2021 and now regularly runs 10k distances on his own although he still runs with the jogging group, helping others in their fitness journey.

In 2022, B attended a programme of Social Cycling sessions with ELGT and joined the new Ambling Adventures walking group in Holyrood Park, which have helped him get to know new parts of the city and whole new groups of people.

• Promote healthy lifestyles including physical activity and healthy eating
• Improved mental wellbeing
• Reduced social isolation
• Reduced digital exclusion
• Building stronger, inclusive and resilient communities

• Became fitter and healthier, achieved new fitness goals.
• Created positive change in habits and lifestyle.
• Improved confidence and increased independence.
• Greater connection with community, formed friendships and social networks.

• Encouraging engagement in community activities.
• Building inclusive communities.

JJ was in extremely poor health and refusing to take necessary medications, he later explained he was angry with his GP whom he believed should have contacted him, he said he felt forgotten. JJ displayed poor communication skills and, despite the removal of Covid restrictions, JJ remained very scared of Covid and was shocked that people weren’t wearing masks or observing restrictions. JJ only left his home briefly to buy essentials provisions from a local shop.

It took a while to gain JJ’s trust, conversation was difficult to start but eventually conversations around the medical profession were instigated and offers to accompany him to appointments were made.

JJ was introduced to a volunteer in November 22 and with his volunteer’s encouragement, JJ started engaging with his GP and taking his medications, thus improving his overall health. the volunteer also encouraged JJ to get out of the house for short spells, initially to the local shop, then for regular visits to a local café and eventually to a museum which had been favourite for JJ in the past. Visits to museums and art galleries continued with his befriender whilst JJ built up his confidence. The next goal for JJ is to join one of the organisation’s regular groups at an Art gallery which will give him the opportunity to socialise with the wider CARDS community.

JJ had previously been in the music industry but a mental health break down had led to years of homelessness and problematic alcohol use. However, JJ is now writing music again which is helping him manage his thoughts and take his mind off his physical pain.

• Improved mental wellbeing
• Reduced social isolation
• Supported self-management of long-term conditions

• Improved physical & mental health – Taking prescribed medications & engaging with medical professionals.
• Increased trust and improved social skills – Engaging regularly with his volunteer and participating in meaningful activities.
• Self-management of health conditions – Writing music – to distract from intrusive thoughts and pain.
• Reduced loneliness and isolation – regular contact with volunteer, having someone who cares about his wellbeing, getting out of the house and being part of his local community.

• Reduced risk of crisis hospital admission due to re-engagement with health services.
• Reduced risk of repeat homelessness due to social interaction with volunteer and acceptance of support.
• Developed of self-management techniques through peer support.

After an initial discussion, it was agreed that Mrs B would start the 6-week Action for Pain course. At the beginning, she remained unsure about participating in the group but with encouragement she decided to give it a try. Mrs B attended all six sessions and engaged well. She felt that there was something within the Action for Pain group which just ‘clicked’ with her – a lot more than previous experiences of pain management groups / services – and that having a GP involved with the course was particularly useful. She felt really listened to by the GP on the course, which was something she had not felt for some time.

Whilst on the course Mrs B started making changes to her lifestyle, and soon began feeling better both physically and mentally. Her PAM (Patient Activation Measure) scores increased which is indicative of an increased sense of control over her own health and wellbeing. This improved confidence resulted in her not having to ‘rely’ on others so much and encouraged her to consider reducing her use of pain medication.

After the course, Mrs B went on to access other Health All Round services: counselling, art and the writing group and these became an important part of her self – management. Increasing physical activity also played a key role in Mrs B’s recovery and with support via the Active Steps service at HAR she was able to access a local pool for swimming. Mrs B received further support to enhance her activity levels through the organisation’s in home physio service which supported her to leave the house for short walks, increasing gradually in distance until she met her personal target.

• Supported self-management of long-term conditions
• Promote healthy lifestyles including physical activity and healthy eating
• Improved mental wellbeing
• Long term support at a local level

• Self-management of health conditions – reduce reliance on medication & engagement with alternative approaches.
• Improved physical & mental health – improved activity levels and engagement with the Heads Up Counselling Service.
• Developed of self-management techniques through peer support.
• Ability to leave the house.

• Reduced number of repeat GP presentations and GP appointments.
• Increased GP clinical time.
• Reduced need for prescribed medication.
• Recognition of an alternative pathway for chronic pain.
• Supported through the Modernising Patient Pathways Fund.

Client accessed the service after attending a CAB drop-in session with a support worker.

Client had been in long-term receipt of benefits, including ESA awarded due to his health conditions preventing him from working, housing benefit, and PIP. Client had his PIP revoked after a review, but due to client having significant learning difficulties client did not understand the letter giving the outcome of the review and was unaware that his PIP had stopped. Client’s other benefits – ESA and Housing Benefit had also been stopped due to client spending a short spell in prison on remand. As a result, client had accumulated around £1000 in rent arrears.

The adviser that dealt with the client made contact with the DWP to ascertain the situation regarding the client’s benefits, and with help from a support worker that was allocated by client’s landlord LINK Living, contact was made with Housing Benefit to ascertain the situation here as well. These actions were necessary as, due to client’s learning difficulties he was unable to advocate on his behalf and would have been unable to make this contact himself.

The outcome of these interventions was extremely positive for the client as the initial re-instatement of Housing Benefit prevented further debt accruing and cancelled out previously accrued debt. The client had been struggling and essentially living on no income, but this was rectified with the help of the CAE support worker who was successful in reinstating previous benefits and successfully making new benefit claims. The partnership working with the client’s LINK Living support worker proved invaluable in this case, in enabling the client to access CAE services initially, and providing a point of contact that could ably liaise with the client.

There were a number of initial obstacles to her learning. Her laptop was very old and next to unusable, there was no antivirus installed on it. She was also very anxious and lacked any IT skills which resulted in her struggling to understand and IT information that was given to her.

As a first step, ACE IT offered her a refurbished laptop from their partnership with Edinburgh Remakery as she did not have the funds to purchase a new device. They then assisted her with setting up, installing appropriate anti-virus software and educating her about scams and how to be vigilant online. They also helped to move her files from the old machine to the new one.

The learner was delighted with the help she received from ACE IT quoting “I definitely appreciated my new laptop. What a lovely thing to do to help people”.

Volunteers from the organisation continued to calmly and patiently help the learner to understand further functionality in her laptop, assisted her to setup a Facebook account and to navigate social media in general. Over time, it emerged that the learner was very artistic and produced a number of creative items. At her request, ACE IT volunteers investigated the best way for her to sell her artistic items online and eventually helped her to build an online shop which she now confidently uses.

• Reduced digital exclusion
• Reduced social isolation
• Improved mental wellbeing

• improved confidence in both her IT knowledge and IT skills.
• Selling her products online has given her a real focus which has improved her mental wellbeing.
• She continues to use ACE IT services where she benefits from social interaction whilst continuing to enhance her IT skills.
• Facebook has opened up her world, as she has joined local groups and communicates with many more people now.

• The learner has recently started volunteering with a local charity which has been in part due to the positive experience that she has had with ACE IT volunteers.

Mr JN had been referred to the Digital Inclusion service. The referrer requested help with reconnecting broadband, support in accessing a suitable device and coaching Mr JN on how to access online shopping. The community key worker called Mr JN to arrange a home visit, and agreed to visit the day Mr JN would be discharged from the care home because the client was keen on accessing online shopping asap.

Upon visiting Mr JN in his flat, it turned out that the gas central heating was not working, and the TV had been disconnected by the contractors who carried out the deep clean. Although Mr JN had a bed in his bedroom, he was unable to use it as it had also been disconnected by the cleaning company and was in a position that made it impossible for Mr JN to access it.

The community key worker consulted with Mr JN and established that the bed was his priority, then the heating and then the TV. They decided to address the client’s digital needs once the most urgent needs had been addressed.

The key worker managed to reconnect the electric operated bed and set the remote control to the required setting. He also phoned the City of Edinburgh Council out of hours emergency repairs and established that due to Mr JN’s age and health conditions he was a priority case and an urgent heating engineer visit was scheduled for the same night. The key worker also managed re-connected the TV set (Mr JN was unable to do this independently as he was at risk of falls and could not reach the sockets or work out all the different wires) and set the remote control so Mr JN could access the programmes he liked.

During subsequent visits the key worker managed to get Mr JN’s broadband reconnected and visit the local shopping centre jointly with Mr JN to support him to purchase a suitable device. Due to successful reconnections, Mr JN recently managed to place his first order online with Wiltshire meals and is now looking forward to his weekly deliveries by a friendly delivery driver.

• Improved digital connectiveness
• Improved sense of wellbeing
• More able to cope with everyday life
• Building stronger, inclusive and resilient communities

• The client accessed appropriate community support when it was needed.
• He has regained confidence in looking after his own affairs following his hospital visit.
• He is enjoying his regained independence.
• He has remained part of the local community.

• the role of key community worker the client no longer requires a place in a local authority’s care facility.
• the client’s digital connectiveness, he is able to access his own meals and does not require local authority provision.