Health and Social Care Partnership grant programme monitoring and evaluation 2020-21

This report provides an overveiw of the work carried out by organisations grant funded by the Edinburgh Integration Joint Board (EIJB) in 2020/21 – the second year of the 3 year grant programme (£4.7m).

The grant programme helps realise two key priorities of the EIJB’s Strategic Plan 2019-22:

  • Tackle inequalities:  take action to identify those experiencing poorer health outcomes and address the barriers they face which will in turn help manage the increasing demand for health and social care services.
  • Consolidate the approach to prevention and early intervention:  establish links with community resources and assets to ensure people have the opportunity to access preventative opportunities which will help them keep themselves as fit and healthy as possible.

The Programme was developed collaboratively in 2018 following extensive engagement with partners. An open invite was extended to organisations to apply for 3-year funding for 2019-22.

The fund was considerably over-subscribed and, following a robust assessment process, 3-year funding was awarded to 66 organisations to implement activities and services aligned to the seven funding priorities of the Programme.

Reducing social isolation, promoting healthy lifestyles including physical activity and healthy eating, improving mental wellbeing, supported self management of long term conditions, information and advice - income maximisation, reducing digital exclusion, building strong, inclusive and resilient communities

The conditions of grants require that organisations must complete annual monitoring returns using both quantitative and qualitative data. The information provided in these returns is compiled and used to complete this annual report.  The returns from organisations inlcude:

  • Self-Monitoring Annual Returns (SMARs) demonstrating Key Performance Indicators
  • Case Studies (a selection of which are contained within Appendix 2)

Organisations are normally also required to complete service user surveys using Standard Impact Assessment Questions (SIAQs). This year however, given the Covid restrictions, the requirement to complete SIAQs was removed.

2020/21 was an extremely difficult year for grant funded organisations. The Covid restrictions introduced in March 2021 meant that it would not always be possible to deliver on the targets set in their funding agreements.  Continuing fluctuations in government restrictions and guidance have meant that these difficulties have endured throughout the year.

The EIJB recognised these difficulties and gave a commitment to continue to support organisations financially. However, in order to ensure accountability and reflect the restrictions imposed by Covid-19, organisations were asked in October 2020 to set out revised  targets for the second half of the financial year (Oct 2020-March 2021).

The majority of grant funded activities were intended to be held in-person and often in group setttings, however due to the Covid restrictions, this was just not possible.

The returns from organisations show however that they were quick to respond and adapt their working practices and service delivery models to ensure continued service. In the initial period of lockdown, organisations worked hard to ensure that they kept in touch, in some way, with their service users, carers and volunteers. This was done whilst setting-up home working capacity for staff and volunteers and moving all possible services to online delivery.

In exceptional circumstance, it was essential that meetings with clients took place in person, even at the height of lockdown restrictions, and these continued in risk assessed, Covid safe environments with a range of precautionary measures in place.

Digital inclusion

The grant programme recognises the important role which digital connection can play in maintaining health and well-being and recognises that existing inequalities in our society mean that it is often those who are older and those with lower household incomes who are digitally excluded The programme therefore provides targeted support to help improve digital skills and knowledge and reduce digital exclusion.

The restrictions on our freedoms due to Covid led to an increased reliance on digital technology and the negative consequences of being digitally excluded are now greater than ever.

Throughout the pandemic, projects continued to work hard to help ensure digital inclusion for all and provided, for example, IT remote one to one coaching, IT Helpline, help sheets, phone calls; scam awareness workshops, equipment lending and newsletters. In addition organisations worked well to well to secure donations and additional funding for technology to enable the loan of tablets, ipads, chromebooks and to secure internet access to those who required it.

However, the lack of equipment, connectivity and technological skills, has undoubtedly been a challenge in many cases and it is recognised that not all people were able to, or wished to, access services remotely.

Social isolation

Social isolation was exacerbated, particularly for those in already marginalised populations, by the lockdown restrictions as interactions with anyone outside the home were severely limited. Organisations reported that the isolation had increased people’s anxiety, fear and confusion, particularly for people who are older and shielded alone.

The detrimental health impacts of social isolation are well documented and organisations worked hard to mitigate the impacts of the restrictions, especially for those most vulnerable. Organisations undertook a range of social activities throughout the pandemic and made regular phone calls to their members to check-in on their well-being and to offer support and a friendly voice to allay their fears.

Organisations also set up private social media groups eg WhatsApp, Zoom groups, Facebook, chat rooms. These provided a safe space for service users to stay connected and provided a forum for peer support.

Feedback from organisations showed that participants were very appreciative of these service and reported that for most people this helped allay their fears, reduce social isolation, alleviate boredom and gave them something to look forward to in the week.

Lunch clubs

A number of grant awards were to assist in the running of lunch clubs and community cafes and, for the majority of the year, these could not operate. The beneficial impacts of these services are clear – they not only provide healthy meals for vulnerable people but also an opportunity to socialise, share experiences and give and receive advice and support.  They provide a routine for those who attend, a break for carers as well as opportunity for informal welfare checks.  Organisations reported that the lunch clubs and cafes have been greatly missed during the pandemic and the decline in the physical and mental health of many of the participants was clear.

As an alternative to the clubs and cafes, organisations prepared and delivered meals. This not only ensured participants got a healthy meal but also provided the opportunity for one to one chats, helped maintain social connections, provided a routine and structure to people’s week and provided opportunity for welfare check-ins.

Healthy lifestyles, improved mental health

In the early stages of lockdown, activities to promote healthy lifestyles and improve mental well-being were quickly moved on-line where possible. For example cookery classes, exercise classes, counselling, rehabilitation sessions, peer group sessions etc were held online.

As lockdown restrictions were eased, temporarily as it turned out, organisations did manage to host some, face-to-face classes, for example exercise classes, although these had to be held outside with small group sizes.  To accommodate demand for these in-person classes and the restrictions on class sizes,  organisations reported that they hosted additional classes per week.

Organisations also continued their one to one support and counselling using online platforms such as Zoom, Skype or telephone, depending on the client’s preference. Face-to-face meetings for those at risk have also been provided outdoor or in cafes when permitted.  Organisations, in general, were able to offer a high level of flexibility to enable individuals to engage with the service.

In addition to the ongoing mental health support, organisations reported that the emotional strain of lockdown saw a rise in demand for support and crisis intervention from particularly vulnerable service users. Organisations supported service users experiencing a variety of challenges, including suicidal ideation and action, self-harm, excess alcohol advice consumption, financial fraud, emotional abuse from carers and lack of support from their usual support mechanisms.

Alternatives to online service provision

Technology proved to be a useful tool in the provision of services during lockdown, however, as restrictions continued, it became apparent that the provisions of physical resources to maintain wellbeing and mental stimulation would be useful, particularly for those that do not use technology. Throughout the period organisations continued to explore ways of engaging with people and worked together to devlop and share ideas.  Various physical resources were created and distributed and included, for example, a range of activity packs, newsletters, birthday cards and traditional events like Christmas and Easter were marked.

Provision of emergency and additional services

In addition to the provision of the programmed services, organisations also saw a shift in the needs of service users and, thanks to the flexibility of staff and volunteers and to the partnership working of organisations, undertook a variety of emergency and additional services including:

  • Ensuring those with low literacy/language barriers understood the changing Covid restrictions
  • Help to access the statutory food parcels and support
  • Set-up, preparation and delivery of emergency food parcels to people who were vulnerable, shielding or had been directly affected by the pandemic
  • Shopping on behalf of service users
  • Delivery of medication and other urgent items and prompts to take medication
  • Intensive well-being, practical and financial telephone support
  • Transport for those needing medical assistance
  • Social, emotional and well-being telephone check-ins
  • referrals to emergency food provision, welfare benefit advice and any other support where required
  • assistance to access on-line services e.g. shopping, prescriptions, doctor’s appointments, mental health needs etc
  • help for people with language barriers to access basic health care and communicate with health professionals (the introduction of answering machines in GP practices often made this difficult for some)

Community transport organisations continue to work in partnership with Edinburgh City Council, the NHS and other Community Transport providers, to provide minibuses and drivers to help with the covid19 vaccination programme.  This includes taking PPE supplies to care homes in advance of residents being vaccinated and taking vaccinators to the homes of the most vulnerable groups to administer vaccinations.

Number of service users

As part of their annual returns, organisations provided an indication of the number of people who use their services. From these it is estimated that approximately 54,000  people took part in activities/used services funded through the Programme.  (Some participants may have taken part in more than one activity and so will be double counted.)  The pie chart below provides a guide to the number of participants for each priority outcome.

Number of participants

  • Provide information and advice and and promote income maximisation – 16,549 – 31%
  • Build strong, inclusive and resilient communities – 10,798 – 20%
  • Promoting health lifestyles including physical activity and healthy eating – 9797 – 18%
  • Reducing social isolation – 8563 – 16%
  • Improving mental wellbeing – 4815 – 9%
  • Supporting self-management 0f long term conditions – 2718 – 5%
  • Reducing digital exclusion – 778 – 1%

Appendix 1 lists the projects funded for 2019-22 with a brief description of the proposed activities. This helps demonstrate the scale and diverse range of activities implemented.

The annual SMAR returns from individual organisations demonstrated variations, both up and down, in the number of people using their servies compared to previous years. Overall, the total number of people using the services is slightly up on last year and a number of reasons for this were indicated in the returns, including:

  • online classes/activities/sessions can be made available to a wider audience and can have a higher capacity than would be possible when delivering face-to-face sessions
  • the added convenience and flexibility of participating from home rather than making a trip meant that some people have been able to participate in sessions when otherwise they would not have been able to do so
  • additional funding was secured to carry out additional roles for example emergency food preparation and delivery; purchase and distribution of IT equipment and delivery of medication
  • there was a higher demand for help and support particularly in relation to anxiety caused by Covid-19
  • additional referrals due to reduced capacity within other health agencies which led to a need for alternative means of providing support eg telephone support instead of Care visits; assistance in getting to appointments for those anxious about using public transport and other concerns relating to Covid
  • additional referrals to carer support organisations as the pandemic continued and the additionial pressures on carers mounted
  • an increase in incidents of violence against women and girls led to an increase in referrals for support to victims of violence
  • an increase in client contact and one-to-one appointments as many clients who would have ordinarily have disengaged from appointments in person felt more confident to remain connected with the service online or by telephone
  • increased uptake as people who would not normally attend a traditional, face to face service, came to an on-line session.

In some areas of activity, the number of people using services decreased over the year. Reasons given include:

  • some activities which were normally held in person and often in group settings could not take place due to Covid restrictions and could not be moved to online delivery
  • disruption to referral routes – People were not attending their GP practices, unless for health emergencies, and and so referrals from GPs reduced considerably. Returns however note that referrals are slowly picking up
  • people were not going into council offices, community centres and other locations where referals were often made
  • lack of IT equipment, connectivity and technological skills, was a challenge in many cases and it is recognised that not all people were able to, or had the wish to, access services online.

Many organisations noted that they anticipate an influx of referrals once the referral agencies re-open and the full scale of the impacts on mental and physical health becomes known.

Targets

Despite the impact of Covid-19 in the first half of 2020/21, by the second half of the year organisations had responded flexibly to the restrictions imposed by the pandemic and were developing a blended approach to their service delivery. At this point organisations were asked in October 2020 to set out revised targets for the second half of the financial year (October 2020-March 2021) and the returns showed that 631 targets were set and 502 of these were met (80%).

Customer satisfaction

Because of the Covid restrictions this year, many organisations were unable to get a user satisfaction figure however from those which did, the average user satisfaction score was found to be 92%.

Volunteer numbers

Many of the organisations depend on volunteers to help deliver their programmes. In 2020/21, volunteer hours added a further 28% of hours worked by paid staff and without their involvement, the wide range of service provision would just not be possible.  The financial value of this volunteering is estimated at over £1.8m.  Equally important are the many benefits which volunteering brings to the individuals who volunteer such as improved confidence and well-being, increased skills and increased social connections.

The effect which the Covid restrictions had on volunteer numbers varied from organisation to organisation and service to service. Some organisations reported that their volunteer hours were down on the previous years for different reasons.   For some it was due to the nature of their activities e.g. going into people’s homes, indoor group sessions or face to face activities, which meant that volunteers were unable to continue in their roles due to the government restrictions imposed.  Some organisations reported numbers were down,  partly because many of their long term volunteers were older or shielding and so they themselves were required to isolate and could therefore not volunteer.

On the other hand, remote support increased over the period and this provided alternative opportunities for volunteering for example telephone befriending and welfare check-in calls. Some organisations reported that they were quick to provide support to enable their volunteers to provide their invaluable support remotely.   In addition, the seriousness of Covid-19 meant that there was a number of people coming forward who wished to give their time to help provide emergency support for those most vulnerable.

Additional funding

Funding Leverage was also reported. The returns show that for every pound awarded through the programme, organisations brought in a further £3.19 to the city. This equates to an additional benefit of funding leverage, estimated at over £13m. This figure compares favourably with last years figure of £2.97.  Some organisations noted that the EIJB grant funding and their community experience, knowledge and trust allowed them to successfully apply for emergency funding from various funds which allowed them to extend their service provision, provide additional emergency services, make adaptations and purchase PPE.

The unknown and fluctuating timescales for lifting restrictions and the changing safety measures required have made it difficult for services to plan returns to normal service. Most have continued to adopt a, carefully managed, cautious approach as restrictions have eased and subsequently been reimposed.

It is envisaged that the number of individuals who will be permitted to attend in-person activities at any one time will be reduced for the foreseeable future and, given the benefits and flexibilities of online services outlined above, organisations report that they will continue to offer online services where appropriate . Feedback however in many cases showed that face-to-face experience can be more beneficial in reducing feelings of isolation, making connections and improving confidence and so organisations report that a blended format of in-person and on-line services will be provided where possible which will help ensure services continue to to meet individual needs and help achieve the outcomes and agreed targets.

During the pandemic, organisations sought to maintain and expand their connections with other local organisations, locality officers, community link workers and businesses in order to ensure they worked efficiently, and often in partnership, to deliver Covid-19 collective responses.

Rapidly changing government guidance and restrictions meant that the management peer support which organisations provided for each other was more important than ever and provided a crucial support system during the pandemic.

National health and wellbeing outcomes

In addition to contributing to the 2 key priorities of the Strategic Plan – preventing poor health and wellbeing and reducing health inequalities – the services delivered through the grant programme also work directly to achieve the National Health and Wellbeing Outcomes, in particular, those noted in the table below.

National outcome Achievement
Outcome 1: People are able to look after and improve their own health and wellbeing and live in good health for longer Provision of services to encourage healthy lifestyles and self-management and wellbeing continued despite the Covid restrictions and included activities to reduce alcohol intake, improve diet, improve mental health, help to access technology and increase physical activity.

The programme also addresses the environmental and social factors that can act as barriers to health and wellbeing, for example, improving greenspace and maximising income.

Outcome 2: People, including those with disabilities, long term conditions or who are frail, are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community. Over the years, the Grant Programme has helped build and create community capacity and resilience so that people can receive the care and support they need locally to help them stay independent.  This strong community foundation was relied on more than ever during the pandemic and the support provided often proved to be a lifeline for many.  Services included, for example, telephone support and befriending, falls prevention activities, advice and support for carers, self-management programmes and one to one support.
Outcome 3: People who use health and social care services have positive experiences of those services, and have their dignity respected Due to the social distancing restrictions, the requirement for user surveys was removed this year however many organisations continued to gather feedback from their service users as part of their ongoing improvement plans.  From the feedback gathered it is clear that experiences were  positive and the average user satisfaction rate was found to be  92% .
Outcome 4: Health and social care services are centred on helping to maintain or improve the quality of life of people who use those services The grant criteria is built around the key components of a good quality of life including: social interactions, personal income, physical environment, personal confidence and health

Grants through the programme are awarded to trusted, experienced organisations who have continuous improvement plans in place which take a person centred approach.

Outcome 5: Health and social care services contribute to reducing health inequalities The coronavirus and the restrictions imposed have highlighted and exacerbated the existing inequalities in our society.  The Grant Programme began in 2019, with a key prioity of reducing health inequalities, and as such organisations and their activities were well established when Covid hit.  As demonstrated in their returns, organisations not only quickly adapted to ensure that they could continue to provide their services which reduce health inequalities but they also quickly set up emergency response actions to mitigate against the additional impacts which tended to hit the most vulnerable and disadvantaged the hardest.
Outcome 6: People who provide unpaid care are supported to look after their own health and wellbeing, including to reduce any negative impact of their caring role on their own health and well-being. A number of funded projects provide support for carers.  Now more than ever, this support is vital.

The impact of Covid on carers has been well documented and research3 has found that the coronavirus crisis is having a profound impact on carers’ lives.

The demands and stress on carers increased as day care activities were suspended, packages of care were often reduced and respite was limited.  The uncertainty of when normality would return added additional pressure.

Caring behind closed doors Forgotten families in the  coronavirus outbreak April 2020, Carers UK

A significant level of investment has been allocated to implement the duties of the Carers Act (2018) and to meet the 6 key priority areas of the joint strategy, details can be found here and on the EHSCP web page.

Outcome 9: Resources are used effectively and efficiently in the provision of health and social care services. To ensure effective use of the limited grant budget, the criteria for grant funding was co-produced with stakeholders and a stringent grants assessment process was followed.

In addition, grant funded organisations complete and return annual monitoring returns.  This year, because of Covid restrictions and the need to adapt services, organisations were also asked to provide revised service targets  for the second half of the financial year (Oct 2020-March 2021) which helps ensure accountability.

Poverty

The Edinburgh Poverty Commission final report A Just Capital: Actions to End Poverty in Edinburgh, identified that the single biggest transformation Edinburgh could achieve would be to make the experience of seeking help less painful, less complex, more humane, and more compassionate. This aspiration is a common thread which runs through the heart of the funded organisations.   The report also identified six broad areas for action, all of which the Grant Programme helps deliver on:

  • health and wellbeing
  • connections,
  • fair work,
  • a decent home
  • income security,
  • opportunities to progress.

Climate change/sustainability

The EIJB recognises the global climate change emergency and that everyone has a part to play if we are to reach Edinburgh’s ambitious net zero 2030 target.

A core aim of the Grant Programme –building strong, inclusive and resilient communities is in-step with the central aims of our partners’ emerging sustainability strategies and aspirations of creating sustainable, 20 minute neighbourhoods. For example, the income maximisation collaborative model developed as part of the Grants Programme is an exemplar of how we can ensure people have the opportunity to access the support they need in the place they live and work with welfare advice now provided in GP practices, drug and alcohol recovery hubs, mental health hubs, locally based offices and in schools.

Health outcomes are influenced by a combination of fundamental determinants including behaviour, environmental and physical influences and social factors which are often interconnected. Many of the funded projects which promote health and well-being also have positive effects for the environment and sustainability for example projects which increase and improve our greenspace; encourage active transport and improve energy efficiencies of our homes.

In addition, the shift to the delivery of services online during lockdown will be continued where appropriate and will help reduce carbon emissions.

Looking forward however, consideration should be given to what the Partnership can do to help organisations become more environmentally sustainable and influence and support the behavioural change required to help Edinburgh reach its ambitious net zero target for 2030.

2019/20 was a very different year than expected for everyone.  Organisations adapted quickly to lockdown restrictions and were able to continue to deliver their services, albeit in a different way.  The care and concern for the people continued.  The flexibility of the organisations allowed them to react quickly to the developing and changing needs of their communities and the trust, connections, partnerships and local knowledge which organisations have built over time, facilitated quick emergency responses

A handful of organisations found that they could not continue to operate due to the restrictions and closed their services although most maintained telephone contact with their service users.

Returns showed that over 54,000 participants took part in or received a service over the year

The returns demonstrate that the projects have continued to deliver on the 7 key priorities of the Programme, the 2 EIJB strategic outcomes – reducing Health inequalities and Prevention of ill health,  several of the National Health and Wellbeing Outcomes and have with strong links to the City’s anti-poverty and sustainability agendas.

The year saw a heightened reliance on digital technologies and the negative consequences of being digitally excluded were greater than ever. Funded organisations were quick to assist those that needed help in making the transition to the use of digital technology.  The restrcitions imposed have reinforced the continued need to reduce digital exclusion.

Going forward it is anticipated, that as physical restrictions are lifted, there will be an even greater need for the services as we deal with the devastating impact which these restrictions have had on both the physical and mental health of those most vulnerable.

Organisations are strengthened by their learnings through the pandemic and, as restrictions are lifted, will continue to offer more flexible options for service delivery where appropriate.

Appendix 2 provides case studies from projects funded through the EIJB grant programme and demonstrate how the organisations have not only continued to improve the health and well-being of individuals in-line with the 7 priorities of the programme but have, in some cases, been lifelines for many vulnerable individuals during this difficult time.

Organisation Project Activities Amount
ACE IT Digital Inclusion for Older People The project will enhance digital knowledge, skills and well being in older people with staff, volunteers and other organisations via four services.

  • Moose in the Hoose for residents in care homes
  • Office – based one to one training sessions
  • Scam workshops with Changeworks
  • Outreach for older workers and people in retirement establishments
£62,225
Art In Healthcare  – Room for Art Room for Art Room For Art is a series of visual arts workshops delivered by artists throughout Edinburgh using an ‘art on prescription’ approach and an occupational therapy supported model of 1:1s to support self-management. Participants will be referred by professionals in statutory and third sectors working in partnership with Art in Healthcare. £67,243
Autism Initiatives Diagnosis and support for autistic adults without a learning disability The Project will assist Mental Health Teams (MHTs), and the Lothian Adult ADHD and Autism Resource Team (LAAART), in Edinburgh by meeting those seeking an autism diagnosis; gathering information to support MHTs in their assessments; diagnosing those who do not meet their criteria for functional impairment, and providing post-diagnostic support. £82,626
Bethany Christian Trust Passing the Baton Project Through volunteer befriending and community groups for isolated and lonely individuals, the project aims to decrease social isolation and prevent homelessness in Edinburgh. £50,684
Bridgend Farmhouse Community kitchen Creating a community kitchen as an engagement tool to connect and engage a multi-generational, multi-cultural, multi-ability food community supporting each other to learn, gain confidence, reduce social isolation, and help each other become part of the wider community. Using local collaborations and food as the focus for building community capacity £24,978
Calton Welfare Services Welfare Services for Socially Isolated Older People The project will provide a Club for Socially Isolated Older People and a Day Care Service for Dementia sufferers, as well as providing Welfare Advice and Information for our service users and their carers and socially isolated older people in our area, and events throughout the year for older people. £16,183
Care for Carers Stepping Out Residential and Short Breaks for Carers To provide information, support and a range of organised, structured and supported short breaks (residential, day and evening breaks) to unpaid carers in Edinburgh. The short breaks aim to support and improve carers mental and physical wellbeing and enable them to feel able to maintain and sustain their caring role. £71,886
Caring In Craigmillar Phonelink We plan to extend “Phonelink”; our unique telephone support service, to all Edinburgh localities. CiC, currently offers reassuring & supportive phone calls, twice daily, 365 days, to vulnerable & elderly clients, living in their own homes with long term health conditions, additional support needs or at risk of social isolation. £88,481
Changeworks Heat Heroes Heat Heroes provides support to people vulnerable to health impacts of living in fuel poverty. A team of 12 volunteers will be trained to support 1650 people to be in control of their energy costs, helping them be affordably warm and prevent health issues caused by living in cold/damp homes. £54,736
Community One Stop Shop COSS The project will deliver our existing project and ancillary services. We provide advice and advocacy for clients living in poverty and challenging circumstances within the Broomhouse and South West area. Continued provision of our Food Bank and support services, and our outreach services. We currently receive two smalls grants but as suggested have amalgamated them both for the purpose of this application for the first time. £23,000
Community Renewal Trust Health Case Management (HCM) Continuation and improvement of Edinburgh’s HCM service: intensive support for GPs’ 2% most complex adult cases. Our open-ended long-term community-based one-to-one support assesses need, introduces people to services and reduces demand for Primary Care. Our staff are experts in compassionate-listening, coaching, self-management and recovery techniques to foster resilience and wellbeing. £49,063
Cruse Bereavement Care Scotland Edinburgh Bereavement Services Cruse Scotland will provide a community-based listening/counselling support for over 850 people who are bereaved across Edinburgh.  On average clients will receive six sessions, which will improve their mental well-being and reduce their visits to GPs services.  The service is delivered by highly trained volunteers at an accredited standard. £34,000
Currie Day Centre Day Centre for Older People To enable Currie Day Centre to continue to run every Friday as a crucial and unique service for frail and isolated older people living in Currie, Balerno and Juniper Green.  Transport is provided, with a programme of stimulating activities, social opportunities and a nutritious two-course lunch. £13,960
Cyrenians Golden Years Community Connecting Service A preventative service to reduce loneliness and social isolation in older people by connecting them with their community and in turn reduce the number of people who need support of statutory services and increase the number of people who can live at home for as long as possible. £78,457
Drake Music Scotland Musicspace We propose to deliver Musicspace – a programme giving 80 disabled young people and adults in the Craigmillar area access to group music making activities which have proven benefits to mental health and wellbeing, physical coordination and social inclusion. £18,000
Edinburgh & Lothians Greenspace Trust Healthy Lifestyles in South Edinburgh The project is to provide a programme of outdoor activities that promote  physical activity and healthy eating for those who face health inequalities. The work involves developing the successful programme that has been running since 2013. £112,157
Edinburgh Community Food Healthier Food, Healthier Lives, Healthier Futures

The project will promote healthy lifestyles by delivering community food and health work across Edinburgh. The key components will be a range of cooking courses, nutrition workshops, health promotion sessions, training and support. We will also provide greater access to affordable healthy food within communities.

£166,138
Edinburgh Community Health Forum Tackling health inequalities by building a stronger and more resilient 3rd sector To continue the work of the Forum which provides and coordinates tailored support, information and training to Forum members who are the managers of locally based community led health projects and to raise awareness strategically about the importance of addressing health inequalities. £52,296
Edinburgh Garden Partners Befriending Through Gardening EGP and Edinburgh and Lothians Regional Equality Council (ELREC) will jointly deliver a befriending model, creating relationships through shared gardening within the black and minority ethnic (BME) communities. Using EGP’s established and successful model, 15 befriending partnerships will be created annually between socially isolated, predominantly older garden owners and volunteers. £23,170
Edinburgh Headway Group Early Intervention ABI Rehabilitation Support Project To provide an early intervention rehabilitation project for 20 adults in total  with an Acquired Brain Injury to improve everyday functioning and encourage reintegration into the community. Our  preventative support includes: independent living skills, physical activities, social opportunities, therapeutic creative activities, advocacy, complementary therapies and 1:1 Community Outreach. £45,073
Edinburgh Leisure Steady Steps Edinburgh Leisure are seeking funding for Steady Steps, a 16-week group based physical activity and exercise falls prevention programme which focuses on improving strength and balance to deliver positive health and social outcomes for around 2,328 older adults over three years. £119,253
Edinburgh Rape Crisis Centre Rape Crisis support Service The project will support the provision of our specialist, trauma-informed rape crisis support service for women, non-binary and trans people who have experienced sexual violence, including rape, sexual assault and childhood sexual abuse/exploitation.  The proposed activities of the service include trauma support, counselling, advocacy and group support. £73,565
Eric Liddell Centre Caring for Carers Befriending Service An emotional, physical and practical programme to support unpaid carers across Edinburgh delivered by the Eric Liddell Centre (ELC). This proposal will build on established experience/service delivery and increase the level of support being offered to carers throughout Edinburgh.

Provide emotional support through linking, matching and ongoing support service in which volunteer befrienders offer a socially supportive relationship to befriendees.

£25,190
FAIR Ltd (Family Advice and Information Resource) FAIR – Information and advice for people with learning disabilities and their carers FAIR will:

  • Provide a welfare rights and financial capability advice service.
  • Produce an Easy Read Newsletter every 2 months that will include and share information from key stakeholders.
  • Work in co-production with the Health and Social Care Partnership to consult on the Strategic Commissioning Plan for People with Learning Disabilities.
£91,795
Feniks:  Counselling, Personal Development and Support Services Ltd “Reach Out, Help Within” Supporting Central Eastern European community in Edinburgh This project aims to tackle mental health inequalities and social isolation amongst Polish and Central Eastern European people in Edinburgh. We will employ two therapists/counsellors, a CEE Mental Health Service manager and a community development worker to improve the provision of the mental health services, integration and cultural-bridging within the city. £74,773
Fresh Start Fresh Start:  helping people make a home for themselves Working with partners across Edinburgh and with volunteer  teams, we will support people previously homeless to ‘make a home’ in new tenancies providing goods and practical support to 5,000+ households and 1000+ places on gardening, cooking, and employability activities.  Service-users develop key life skills and access ongoing social and emotional support. £87,525
Gowrie Care Ltd Futures Hub An accessible resource hub where vulnerable people who are, have been or are at risk of becoming homeless, can be supported to learn independent living  skills and experience social, recreational, employment and educational opportunities they would otherwise be excluded from. Promoting health & wellbeing, tenancy sustainment, recovery and social inclusion. £59,530
Harlaw Monday Group Harlaw Monday Group Day Care Centre The proposal is to continue to operate a day care centre on one day per week  for those elderly people living in the Balerno, Currie and Juniper Green areas who have been diagnosed with mild to moderate dementia or cognitive impairment. £6,704
Health All Round Health All Round Community Health Initiative HAR is a community health initiative covering the Sighthill/ Gorgie ward of Edinburgh. We deliver a range of services to improve the physical, emotional & social wellbeing of local people. We specifically target low income and other vulnerable groups. £195,169
Health In Mind Craigmillar Counselling 10 hours a week counselling offered to people with anxiety, depression and similar issues living in the Craigmillar /Portobello area.  Self-referrals, and referrals through GP’s, voluntary organisations, social work or other professionals accepted.  This proposal funds direct counselling costs, with other staffing, direct costs and overhead funded by NHS Lothian. £13,000
Home-Start Edinburgh West and South West (HSEW) Promoting positive perinatal mental health Access to family learning from a perinatal stage provides opportunities for parents/carers to gain confidence in their role and has a positive impact on mental health and children’s learning outcomes/resilience.  Promotion of attachment is offered through Baby Massage and Peep.  Home-based support is available where required. £24,910
LGBT Health and Wellbeing Core Funding and Community Programme The project will support LGBT Health’s work to promote the health, wellbeing and equality of lesbian, gay, bisexual and transgender (LGBT) adults, as well as funding to continue established social capital work through our Edinburgh LGBT Community Programme of social, community engagement and volunteering activities. £98,500
Libertus Services Positive Futures – The Volunteering Project The project is a collaboration of 2 well established projects with proven track records based within Libertus Services.  Using the 5 principles of community development we aim to reduce social isolation, promote healthy lifestyles/mental wellbeing and build strong and inclusive communities by running groups for older people and recruiting volunteers £123,019
Link Up Link Up Women’s Support Centre Women’s Mental Health & Wellbeing services including:

  • 2 weekly evening peer support groups
  • weekend healthy eating lunchtime drop-in
  • weekend one to one support and initial assessments
  • week day, evening and weekend counselling service

creche services for mothers attending the weekend drop-in and counselling service.

£45,321
Organisation Project Activities Amount
Lothian Centre for Inclusive Living (LCIL) Lothian Centre for Inclusive Living (LCIL) We will deliver comprehensive benefit checks and follow up support to physically disabled people.

We will extend our Grapevine Disability Information Service to cover Universal Credit claims and raise awareness of the support we can provide, through collaborative working, with this new extremely complex benefit across the 4 localities.

£19,872
MECOPP MECOPP Jump Start The project will deliver a ‘broad-based health literacy and health improvement service to Chinese people aged 40+ who are disadvantaged by age, disability or long-term health condition, economic or social circumstances through the provision of: health information sessions, educational workshops, physical activity programme and supporting civic engagement. £31,446
MECOPP MECOPP  BME Carer Support Carer support service for Black and Minority Ethnic carers (primarily South Asian and Chinese) to include casework support, telephone based multi-lingual advice and information and carer training. Training on ‘achieving cultural competency’ will also be provided to health and social care staff. £64,794
Multi-Cultural Family Base Multi-Cultural Family Base – Syrian Men’s Mental Health Group Group supporting Syrian men newly arrived to Edinburgh under the United Nations Scheme for Vulnerable Persons Relocation.

The group will support 15 men per week with issues including integration, employment and English language. The project will also offer outreach and befriending, including for men who cannot attend the weekly sessions.

£16,568
Murrayfield Dementia Project Murrayfield Dementia Project Day resource for those with dementia £54,815
Om Music Sanctuary Om Music Sanctuary Om offers opportunities to learn and play music, for the mental health community. This funding will be for a free programme of weekly individual/group lessons, band rehearsals, weekly/Saturday ‘Music Café’ and concerts in the Stafford Centre. Om opened Nov/17, and we already have 70+ registered members. £9,000
Pilmeny Development Project Pilmeny Development Project (PDP) – Older Peoples Services PDP will deliver activities, services and opportunities within Leith and North East Edinburgh, reducing social isolation, promoting participation and inclusion of socially isolated older people in need of community-based support, using low level, preventative, early intervention and self-help approaches, which improves their quality of life. £72,450
Pilton Equalities Project Mental Health The Mental Health & Wellbeing Support Service (Neighbourhood Group) The Service will provide support to older people with enduring mental health problems; who may have significant issues with substance dependencies; to remain and participate in the community.  The service aims to increase individual capacity; improve group co-operation and socialization; raise skills and confidence; encourage wellbeing preventing readmission to hospital. £87,859
Pilton Equalities Project Pilton Equalities Project  Day Care Services PEP will operate 5 daycare clubs, a weekend provision, a visiting/assessment service across North Edinburgh for vulnerable older adults; reducing isolation and enabling older people to stay in their homes longer, and enhancing a level of independence and socialisation. This supports CEC’s Reshaping Care for Older Peoples prevention strategy. £85,869
Portobello Monday Centre Portobello Monday Centre The project will provide informal day-care once a week for our members (10 to 12) who suffer from dementia, whilst at the same time giving some valued respite for their carers. The service is run entirely by volunteers for members resident in the Portobello area. £4,320
Portobello Older People’s Project Portobello Older People’s Project Portobello Older Peoples Project is a lunch/social club that gives older people the opportunity to have the company of others and enjoy a hot meal. It supports people who are isolated and the aims are to reduce loneliness and social isolation, increase social connectivity and improve health & wellbeing. £15,417
Positive Help Positive Help Positive Help will deliver needs-led services to vulnerable adults affected by HIV/AIDS and Hepatitis C. Supportive Transport and Home Support enables service users to live independently, positively engage with health services, thus improving wellbeing and quality of life. These services deliver best value and reduce pressures on NHS and Council services. £48,410
Queensferry Churches Care in the Community Queensferry Churches Care in the Community Develop a Community Hub for older people living in the rural areas of  South Queensferry, Dalmeny, Kirkliston, Newbridge, Ratho Village and Station.  To ensure that older people are well connected, have a variety of support services and volunteering opportunities, therefore enabling them to participate and remain active in their communities. £41,429
Rowan Alba Limited Rowan Alba Limited CARDS is a city-wide volunteer led service which supports people with Alcohol Related Brain Damage (ARBD), who are at risk of developing ARBD and people whose alcohol use puts them at risk. We require funding to continue to deliver this service across all localities and improve health outcomes for people who use this service. £49,519
Scottish Huntington’s Association Lothian Huntington’s Disease Service The Lothian Huntington’s Disease service will deliver an integrated Health & Social Care  model  of person-centred  care-management  to people impacted by Huntington’s disease across Edinburgh City. Providing specialist assessment, expert advice, information and one to one support to reduce social isolation, increased resilience, improved quality of life and well-being. £33,046
Sikh Sanjog Health and Wellbeing Group The Health and Wellbeing Group, partnering with health organisations, will deliver a programme focussing on preventative measures by providing a safe space for ethnic minority women to access bespoke activities, designed to support their mental and physical health and wellbeing, reduce isolation and loneliness, increase confidence and develop interpersonal skills. £24,392
South Edinburgh Amenities Group SEAG South Edinburgh Amenities Group SEAG Utilise our specially adapted minibuses to enable elderly, frail and other vulnerable groups of people in our communities to access a range of 30 voluntary sector, lunch clubs, day centres, and dementia services, which will contribute to the passengers’ mental and physical well-being and therefore reduce their social isolation. £70,902
South Edinburgh Day Centre Volunteer Forum South Edinburgh Day Centre Volunteer Forum (SEDCVF) The grant is to assist with the running costs of five local day groups for people aged 60+ who are socially isolated in the SE area of Edinburgh.  The grant will be to employ trained care staff, transport and volunteer expenses. £25,000
Support in Mind Scotland Support in Mind Scotland RAISE for Carers We will deliver an integrated support, information and education service for carers of people with mental health problems/mental illness

  • Reception:  open access;
  • Assessment: compassionate response and review;
  • Information:  rights and services;
  • Support: crisis, emotional and practical;
  • Empowerment:  rights, advocacy and resilience for the future
£23,309
The Broomhouse Centre The Beacon Club We are seeking funding to develop The Beacon Club: our services for older people with dementia in South West Edinburgh which prevents this long-term condition affecting their quality of life in old age. £53,734
The Broomhouse Centre on behalf of Vintage Vibes Consortium The Broomhouse Centre on behalf of Vintage Vibes Consortium A city-wide project to tackle isolation in Edinburgh’s loneliest over 60s through creating long term, locally based one-to-one friendships based on shared interests. This is a Vintage Vibes Consortium application for 2.5 Service Coordinators for 3-year period. The Consortium is a partnership between LifeCare and The Broomhouse Centre. £67,740
The Broomhouse Health Strategy Group Supporting Healthier Lifestyles To improve physical and mental health and wellbeing in SW Edinburgh, a recognised area of deprivation, we will deliver a programme of volunteering, healthy eating and exercise services.  Our comprehensive package of support will also help vulnerable people overcome barriers to effective parenting, build positive relationships and develop resilience. £56,958
The Dove Centre The Dove Centre The Dove Centre is a social day centre whose aims are to help older people remain as independent as they can be through a variety of socially inclusive activities, learning, volunteering, fresh meals and fully accessible transport. £129,846
The Health Agency The Health Agency The Health Agency is an organisation that aims to promote and develop a community led approach to health improvement in an area that experiences a high level of social and economic deprivation. £179,393
The Living Memory Association The Living Memory Association We will use reminiscence projects to decrease isolation and improve the health and quality of life of isolated older people and their carers. We will run groups, a ‘drop in ’facility, recruit older volunteers and work with those who are housebound offering a whole range of activities and ongoing support. £24,665
The Open Door Senior Men’s Group The Open Door Senior Men’s Group The group will continue to provide a safe and supportive space for men over the age of 60, who are at risk of social isolation, to meet, make friends and participate in a programme of shared activities one afternoon per week. £6,470
The Ripple Project The Ripple Project Using a community-led approach the Ripple aims to improve the quality of life for all ages living in our community by helping people to help themselves. £92,045
The Welcoming Association The Welcoming Association Welcoming Health is a programme of volunteer-led health and wellbeing activities for migrants and refugees in Edinburgh. It is designed to promote active lifestyles, improve wellbeing, reduce isolation and build community between locals and newcomers to the city. £15,169
Venture Scotland Venture Scotland We will deliver four weekend residential experiences, four extended 5-day residential experiences plus 32 x full-day outdoor activity sessions across Edinburgh’s four areas. The programme is designed to build physical, emotional and mental wellbeing, resilience, development of problem-solving skills, building positive relationships and the opportunity to experience meaning and accomplishment. £47,252
VOCAL VOCAL This application seeks funding to allow an additional 100+ carers a year to access and benefit from professional counselling, to respond to a growing need for counselling support and help carers manage the severe emotional impacts of many caring situation arising from changing relationships and the effects guilt, anger and social isolation. £51,075
Waverley Care Waverley Care This project will support populations affected by HIV and Hepatitis C to live healthy positive lives and to achieve their full potential. Through outreach, self-management programmes, peer mentoring, befriending and volunteer opportunities, we will address the health and social inequalities that impact on people affected by these conditions.   £191,753
SUB TOTAL £3,867.126
CHAI, Citizens Advice Edinburgh, Granton Information Centre, NHS Lothian Income Maximisation – Welfare and Debt Advice £845,024
TOTAL £4,712,150.00

Case Study: Edinburgh Leisure and the delivery of Steady Steps 

Gwen and Arnold both 91 were attending Steady Steps at our Craiglockhart Leisure Centre prior to lockdown March 2020. Both were referred to Steady Steps by their physio after having serious falls around the home, Arnold broke his hip and Gwen, from a separate fall broke her elbow. Prior to attending Steady Steps, the couple worried about falling constantly and how their independence might be affected if they could not manage to improve their balance and confidence.  Their daughter encouraged them to take part in an exercise class together to help improve their mobility and confidence. The couple describe loving their time together at Steady Steps and attending their class with Michael (Steady Steps instructor).

“It is the comradery and getting out and seeing people, we loved a structure in place. The atmosphere of the class was brilliant we really enjoyed the instructor’s stories and having a good discussion and sharing our own stories during the social session after class. We also liked exercising together with people who had similar problems’’

During lockdown, the couple could continue with their classes via shared, pre-recorded classes and live zoom sessions

We absolutely adore our sessions on zoom with Michael. It is given us more structure to our week and discipline to keep on exercising. We both feel we have improved physically and mentally from having a live class. Michael’s feedback and his good manner keeps us all in high spirits and we find ourselves not wanting to say good-bye to everyone at the end of the session. The social element has been the biggest surprise, we have met people we never would have seen in our neighbourhood. Our strength has improved, we feel energised to do more around the house and we have both noted our upbeat moods after a zoom session. Getting to know people through a social chat after the exercise has been very interesting, it allows us to share stories and knowledge with others which we both love’’

Strategic outcomes:

  • Reducing Social Isolation
  • Promoting healthy lifestyles
  • Supported self-management
  • Improved mental wellbeing.

Personal outcomes:

  • Improved Confidence
  • Increased Strength
  • More active
  • Increased energy and motivation to do things around the house.

‘’Without Steady Steps and Michaels support over this long year, we do not know where we would be health wise. We feel so lucky to be a part of this programme and having the support and encouragement to keep improving. We look forward to our online sessions and seeing our new friends and knowing we have also improved our balance and regained our confidence after a fall, something we thought we would never have again. We cannot speak more highly of the programme and we know other participants feel the same way’’

Wider impacts:

As a result of Steady Steps online support (pre-recorded content and live streamed classes) both Gwen and Arnold have continued to be active during lockdown.  They are feeling physically and mentally stronger and the classes and social sessions have provided an opportunity to socialise with others.

Case Study:  Edinburgh and Lothian Greenspace Trust

FT lives in Oxgangs and took part in our Fitness Roadshow, Gardening in the Park and Move & Groove sessions in Colinton Mains Park. When restrictions meant we couldn’t offer face to face activities FT joined our virtual catch ups and online exercise sessions.

FT said that she would never have felt confident enough to attend exercise sessions held in a centre.  By bringing exercise to her doorstep she felt able to join in as much or as little as she liked, with no pressure. Living with long term health conditions FT found that most exercise sessions are too strenuous.  She felt that she benefitted from spending time outdoors.  When the classes moved to the local park she became an ambassador encouraging others in the community along, explaining how it is suitable for everyone and how it can break isolation.

“The isolation before covid I thought was bad. Then the consistency of the sessions with out and about gave some structure to the week, and something to look forwards to.  These sessions have literally been a lifeline. I know of at least 3 others that don’t physically come out but watch from there windows and do the exercises, and probably laugh at our moves and grooves ? A friendly smile, along with fresh air has been the best medication offered. Kim and Ruth offer a safe, non-judgemental and kind space”

After a Move & Groove session in Oxgangs, she discussed a job she was trying to apply for.  She mentioned her difficulties as she didn’t have a suitable device and was using her mobile phone.

We got in touch with People Know How.  We heard about their services at the South East Voluntary Sector Forum and through the EVOC slack channel.  We explained the situation and that her daughter was also using a mobile phone for home schooling.  People Know How were able to provide a tablet free of charge.

Receiving a tablet made a huge difference to our participant and her family. We received this feedback in an email –

 “I’ve just spent the last hour in tears because that place you organised for a tablet just called and they are delivering one this Friday.  Thank you so much.  This is a life-changer.  This will make such a difference for me and my daughter.” 

FT was able to benefit from the tablet, making job applications easier.  They were able to access our online sessions such as yoga and gentle fitness.  It also made home-schooling significantly easier for her daughter.

Strategic outcomes:

  • Reduced social isolation
  • More aware of the importance of physical activity and healthy eating
  • Reduced digital exclusion.

Personal outcomes:

  • Improved health and well-being
  • More connected to the community
  • Opportunity to apply for work.

Wider impacts:

Building relationships, breaking barriers, learning new skills, building confidence and self-esteem, provision of an opportunity for wider community to interact safely, creating local support systems and feeling more positive about their neighbours and environment.

Case Study:  Edinburgh and Lothian Greenspace Trust

LS – Out & About – SE Edinburgh, Referred by social worker.

LS is a mother of 5 children. She has literacy issues and has been referred to the Cook Club to help with weight management.  LS has been doing well with losing weight but acknowledged that she needed to do more. As she is unable to read, she cannot follow recipes or look for healthier options in the supermarket and relies on her older children when needing to read anything. She also required help from her social worker to access Zoom so that she could participate fully in the sessions.

She started the sessions with very little experience of cooking from scratch. She said:

I’ve never done home-made food before.”

To enable her to participate fully in the sessions she was sent the original take and make recipe card and was also provided a pictorial, Easy Read version of the recipe. This resource will enable others with literacy issues to participate in the future. This resource shows step-by-step how to prepare the food with simply written instructions to familiarise the participant with keys words like ‘onion’ and ‘chop’.

LS was able to use the guide as reference. The on-line session was also run in such a way as to allow the participant to cook the steps in a friendly and non-pressured environment. Steps were checked with LS to ensure that she knew what was happening next. Questions and chat were also encouraged so that everyone felt included, no matter their kitchen experience or ability.

LS also participated fully in interactive information sessions around subjects that included salt intake, sugar limits and eating well at Christmas. These sessions encouraged engagement through visual guessing games and the facilitator discussing points and encouraging feedback and stories from everyone involved.

In later weeks LS also encouraged two of her children to participate with one joining in three sessions and one joining in on the final sessions. This demonstrated the positivity that LS was showing around her newfound abilities in the kitchen, and her keenness to pass on this learning to her children.

LS was quiet for the first couple of sessions but as the weeks progressed and she got to know the group and the facilitator, she became more chatty and able to share her views and cooking experiences. She participated fully, only missing one session of the eight due to digital connection issues.

After participating in half the sessions LS said about cooking food:

” It’s better than doing it from the freezer”.

At the evaluation at the end of the sessions LS said:

“Making food from scratch, it’s easier that I though. It’s good to learn new things and meet new people.”

LS’s inclusion in the group also seemed to foster understanding and positive attitudes in the rest of the group. Other group members felt at ease and were keen to acknowledge LS’s achievements and included her in all levels of discussion during the sessions.

Strategic outcomes:

  • Reduced social isolation since using the project
  • More aware of the importance of eating healthily
  • More able to cook healthy meals
  • Eating more healthily including increased consumption of fruit and vegetables
  • More able to plan healthy meals.

Personal outcomes:

  • Improved confidence in cooking
  • Continued weight reduction
  • Better understanding and confidence in using digital technology.

Wider impacts:

Less reliance/interaction with health services due to better understanding of healthy eating and continued self weight management.

Case Study: Positive Help

Michael is a 58-year-old man living with HIV and who stays on his own. He was referred to Positive Help towards the end of 2019 by staff at the Chalmers Centre. His adherence to treatment was good but he was depressed and isolated with low energy levels. He could drive but had lost his car during a PIP reassessment. There had been a successful appeal to get it back, but at the time of the referral he had yet to take action to go and get one. His poor mental health meant he had little motivation. Michael had also moved house shortly before lockdown and was having challenges changing his GP surgery. This resulted in difficulty accessing his methadone prescription, which in turn led to agitation and very low moods. Positive Help staff assisted him in accessing the paperwork required to change practices and talked him through what he would need to do. This was one example of the ways in which he reported feeling overwhelmed by tasks he felt had piled up and needed help to start feeling more motivated, independent, and less isolated again. Our priority for supporting Michael was to improve his social contact and support and to this end we offered him our Phone Friends service. These are Michael’s own words about the impact the weekly calls have made to him:

‘The pandemic impacted me really badly. My health got really bad and my car had been taken off me so I couldn’t get out. It was pretty awful. Also, living on my own and on the outside of town was very isolating.’

‘My Phone Friend John is a gentleman. He’s lovely and understanding and easy to talk to. We just seem to have got on really well and have got stuff in common. Talking to him definitely kept my head above water at the start. If I’d been left on my own then mentally I could have gone in a different direction.’

‘John’s given me motivation to get out of the house and exercise more. To get off the sofa and do stuff. I appreciate him doing that. It took me a while to take it on board but I have now and I’m feeling the benefits.’

‘I definitely feel like I have a better mental outlook for the future. Before lockdown I felt trapped, physically and mentally. I can make moves to tidy my life up now. I’m getting there. I feel I have more of a handle on things now, and some of that’s down to John. It’s been a bad situation but I seem to have come out of it with some positives.’

Strategic outcomes:

  • Promote healthy lifestyles including physical activity and healthy eating
  • Improve mental wellbeing
  • Support self-management of long-term condition.

Personal outcomes:

We were delighted to hear that having a Phone Friend has been such a positive experience for Michael and that the encouragement of the volunteer has helped him to feel motivated and empowered to make some healthy changes in his life. In supporting Michael with this service, we hope to have created positive momentum for him to live well in his circumstances and to continue to enjoy better physical and mental health.

Wider impacts:

Michael is just one of many service users we support who have experienced increased isolation due to the pandemic, and whose emotional and mental health have been negatively impacted as a result. Enabling service users to access the medication and treatment that they need is a significant part of the responsibilities of the staff team. In being able to provide a personal approach to our service users we are not only able to support them individually but are able to support the NHS and other services by reinforcing a preventative and therefore cost-saving approach.

Case Study: FAIR

M contacted FAIR as she did not have enough money to pay for her and her sons living costs, bills and food.  She has no family to support her and relies greatly on FAIR for support to manage her benefits and manage her finances. M has a learning disability, cannot read or write and has significant enduring mental health problems and experienced abuse as a child. M’s son has ADHD.

M needed urgent help as she disclosed that her finances were bad, and she could not afford her living costs.  She said that there were things for the home that she and her son needed. My contact has been with M over the phone, she has also been into her housing association to ask them to scan letters to email to me so that I can read them for her.  M is on Personal Independence Payment (PIP) and Employment and Support Allowance (ESA). Her son is a student, and she gets Child Benefit and Child Tax Credits (CTC) for him.

A benefit check was carried out to make sure she was receiving everything she should. Her benefits presented as correct for her situation. M had a cut in her benefits income a few years back when her Sons DLA stopped as he was no longer entitled to it.

I started to look for trust funds to support M.  I found one that may be suitable as it could support with living costs and for furniture etc as M has expressed the need for items for the home and decorating expenses.  The trust fund form required detailed evidence bank statements and an accurate break down of debt etc.  M had previously not fully acknowledged her situation as she felt she needed to play this down to survive day to day.  She disclosed that she had debt with a high interest lender which she used to pay every week when they came to her door before COVID. She had other loans and the interest for debt was so high she was frequently paying off huge sums from her benefit income leaving herself and her son short with no money for food.  She also had a credit card that had 30% interest rate.

I talked with M about how best to manage this and explained that her debt is very large and that I could try and help but that I may need to refer to Money Advice.

I did a Scottish Welfare Fund application for a chest of drawers, which was awarded.

Quickly we were awarded money from a trust fund which was given to FAIR to supervise M as she spent it.  This money lasted for a few months and it supported M to pay off her credit card.

I also undertook a debt in mental health form (DMHF) which her Doctor completed stating that M has significant mental health needs and that she cannot “understand the implications of borrowing arrangements and the effects of these on her repayment requirements over a period. She is also unable to adequately budget.” The Doctor stated that these problems would be likely to continue indefinitely. The DMHF was sent to places she owed other money to and the remaining debt was written off.

In addition, I achieved a Severe Mental Impairment (SMI) form from her GP which made her exempt from paying Council tax. I supported her with a PIP review form to maintain her existing PIP award. I achieved a grant for her son form the Scottish Government as a young carer and supported the award for her son from the Independent Living Fund (ILF) which awarded him expenses to learn to drive.  Unfortunately, he has not been able to start learning yet, but he is keeping the money safe until he can start learning.

Strategic outcomes:

Provide information and advice and promote income maximisation.

Personal outcomes:

M has been able to afford to live a healthier existence to afford to pay for food and bills.  Her mental health has improved, and she presents as happier and calmer when speaking on the telephone.  She is more hopeful for her future and her suicidal ideation has reduced.  Her isolation has reduced as she has been able to share her great worries about her finances, as before they were her guilty secret. Without this support M’s prospects were very gloomy as she was very low, anxious and spoke of wanting to end her life.  This is turn has promoted prospects for her son who is vulnerable also and was additionally burdened by worry.  He has continued his studies and moved towards independent living in student accommodation.  M was very understandably anxious about these changes but has manged them well and remains in positive contact with her son. M’s determination to pay of her debt and support to clear the remaining debt, will hopefully support her son to appreciate the importance of avoiding borrowing.  It is notable that M has remained worried that her son would spend the money awarded to him by the ILF (and is in his bank account) as he has not been able to book driving lessons.  However, this has not been the case and he is hopeful to start learning to drive soon. M has been bankrupted before and was worried that this would happen again which has been avoided.

Provide information and advice and promote income maximisation.

Financial outcomes, less stress and increased support.

Winder impacts:

M has been able to remain at home independently she has not had a breakdown which has led to additional care/health support being required.  She has been able to remain composed and supportive when her son recently left the family home supporting him appropriately with his choice to live independently.

Case Study: Cyrenians

JM is 66 years old. He recently moved in to a new flat provided by Edinburgh City Council. Before that, he lived in a veteran’s house. JM has lost contact with the residents / friends of the veterans home and was feeling increasingly isolated. Due to the restrictions caused by the Covid – 19 pandemic he is also unable to meet his social worker and his only daughter lives abroad. He spends all his time alone at home, only occasionally going to the local shop, but is not confident doing this due to current Covid – 19 situation.

JM was referred to Golden Years digital inclusion service by Family Housing Support. Cyrenians Golden Years Community Keyworker contacted JM by phone to complete a risk assessment. During the conversation it was agreed that JM’s best option would be a obtaining a Chromebook, an affordable, easy-to-use computer that would meet all his digital needs. The Digital Inclusion Key worker were able to provide a Chromebook and training to support JM to shop online and communicate with his daughter and his social worker.  JM could not afford to buy his own computer, however, the Keyworker advised that Golden Years will be able to purchase the device for him with funding from the National Lottery Community Fund.

The Keyworker met with JM at home (in accordance with Government Covid-19 guidelines PPE was worn during the whole duration of the meeting) and set up the device as well as provided the necessary training to get started. During the conversation it transpired that JM’s hobby is painting portraits from photos. When the Keyworker showed JM how easy it is to access photos taken with his phone on a Chromebook JM was delighted and encouraged to make the most of his newly learned skill. JM advised that it made him very happy that from now on he will be able to paint portraits while sitting in his garden.

The Keyworker contacted JM a couple of weeks later and JM reported to be very pleased that he is now in regularly contact with his daughter and the social worker via the video call application. He also said that the Chromebook is very easy to use, navigation is intuitive so there are no problems with it. He is also managing to shop online, use internet banking and feels more confident and aware of the Covid -19 restrictions as he can access the NHS inform website as and when required to keep up to date with the latest developments.

JM advised that he is ‘over the moon with the support and training he has received from Golden Years Digital Inclusion service’ and this has undoubtedly improved his independence and sense of wellbeing as well as enabling him to re-connect with his family, learn new skills and pursue his hobby.

Strategic outcomes:

Person Centred care, Prevention and Early Intervention

Golden Years Befriending Service provides support to older people affected by loneliness and isolation and often decrease in abilities. We developed a digital inclusion service. Depending on clients’ needs, we can advise and help sourcing funding (if needed) for a Laptop, Tablet, PC, Chromebook. We can also help to arrange broadband access and/or offer individual IT skills training/ refresh and support also on the device that clients already have.

Personal outcomes:

At present JM feels less isolated, enjoying his weekly meetings with his daughter and social worker. He is also able to access online shopping, banking, and engage in web browsing, connected with his friends via email or internet communicators, access healthcare services and further develop his hobbies despite the restrictions brought on by the pandemic.

Wider impacts:

JM is much more independent, happier and confident which means he is less likely to need to use front line service and hopefully live safely and happily at home for as long as possible.

Case Study: Rowan Alba

When SB (57) came to CARDS he was very confused, distrustful and in poor health. His volunteer took time to have repeated conversations about ARBD, what this means, coping with symptoms and the risks of drinking. Often his volunteer found it hard to locate SB and called the Alcohol Team to find him. The Team contacted CARDS each time SB was admitted to hospital and when he was discharged. This helped him feel less alone when he got home, limiting risk of relapse. SB was still often in hospital but his new awareness of ARBD led to him asking for an ARBD test. After diagnosis SB was offered treatment at Milestone House and his volunteer visited there. On discharge, SB heavily relapsed but due to strong relationships between his volunteer, the hospital and Milestone, early intervention was possible. SB is now abstinent and in touch with his volunteer every week.

Strategic outcomes:

Reduced social isolation, Support self-management of long- term condition

Personal outcomes:

Improved social connections, alcohol free lifestyle and improved mental and physical health

Wider impacts:

Early intervention resulting in reduced reliance on other services

Case Study:  The Ripple – Café Volunteer

Café Volunteer B – B has a history of PTSD (Post Traumatic Stress Disorder) and ACEs (Adverse Childhood Experiences).  Lockdown had left him with sense of despair and panic. By delivering food, we were able to keep in contact with him which gave him an opportunity to share his feelings of loneliness. When we started our own services of home-made food, we were able to create a volunteering opportunity which he readily agreed to and has a massive impact on his mood.  We were able to clear his rent arrears as well.

Strategic outcomes:

Reduced social isolation, improved mental health, increased community capacity and resilience, Improved income maximisation.

Personal outcomes:

Reduced loneliness, increased sense of well-being and self-worth, reduced debt.

Wider impacts:

B now volunteers and helps others in his community through the provision of home-made food.

Case Study:  MECOPP

Mrs M is a 39 years old Pakistani woman who lives with her husband, a 7-year-old daughter and her mother in law. Mrs M is the main carer for her husband who has recently had a stroke. She also cares for her mother who is frail and has difficulty mobilizing. Mrs M recently moved to Edinburgh so she doesn’t have any friends as she didn’t get any time to socialize due to lockdown in March 2020. Mrs M provides personal care for her mother in law and does all household tasks, provides transport for hospital visits and is also responsible for providing emotional and social support to her especially during the pandemic. Mrs M works fulltime and was struggling with her caring role due to a deterioration in her own health and not being able to give time to her daughter. Mrs M was under severe stress which impacted on both her mental and physical health. Mrs M found she spent most of her time juggling between work and taking care of everyone around her, it also included home schooling, going to the shops for grocery and other essentials, taking her husband out for small walks around the locality. Mrs M and her family were always in fear what if she got the virus and she will have to self-isolate and there won’t be anybody to care and support them or her.

The MECOPP worker supported the family with:

  • Referrals to social work for community care and carer assessments;
  • Referral for occupational therapy assessment (aid and adaptations in place as a result);
  • Providing information on SDS (ongoing application for direct payments);
  • Advice on legal aspects like applying for power of attorney;
  • Looking for volunteers for befriending from within the community once lockdown eases;
  • Providing information and advice on a range of services which may be suitable e.g. day-care opportunities; after school for her daughter.
  • Constant emotional support.

Personal outcomes:

  • Better mental health and peace of mind.
  • Reduced level of isolation.
  • Access to support that met client’s outcomes.
  • Access to information on SDS and better understanding.
  • Access to information on Power of Attorney.
  • Improved engagement with Mecopp worker that includes trustworthy relationship.

Case Study:  Phonelink

Mrs L was referred to us from the Western General in March 2020. We were asked to support her in taking her temperature daily to record while undergoing chemo.

In September Mrs L was told she was in remission and felt her life was just about to begin again.

One morning in October 2020 when she didn’t answer her daily call, the team knew something wasn’t right so called her son straight away as he lives in Peebles.

He agreed to drive up to check on Mum. He found her non-responsive in bed and quickly dialled 999.

Mrs L had suffered a massive heart attack and was quickly found and taken to hospital.

“On phoning my son he came from his home in Peebles and found me unconscious on my bed. He phoned 999. On arrival to ERI I was found to have had a massive heart attack. I have no doubt that Phonelink together with my son’s quick actions saved my life. It’s a 10 from me! Thank you all

Strategic outcomes:

Support self-management of long- term condition.

Personal outcomes:

Mrs L feels she can live well and feel safe at home knowing that Phonelink is in place to keep in touch twice a day.

Case Study: Cyrenians Befriending

RM is 66 years old. In 2013, he had a stroke. Before the stroke, he professionally repaired laboratory equipment, computers and other complex devices. As a hobby he dealt with modelling. As a result of the stroke, he lost feeling and control in his right hand, which made it impossible for him to perform work and continue on with his hobby. In 2013, he decided to construct a hand exoskeleton in order to use it to exercise his right hand. He started looking for projects to be implemented and contacted various types of start-ups to help him make the exoskeleton. Unfortunately, none of the companies he contacted were interested in his project.

In 2020, RM was referred by the Edinburgh Community Rehab and Support Services to the Golden Years Befriending Service. During his first meeting with befriender, RM introduced his idea and explained how to do it. RM had all the necessary materials and equipment to make the hand exoskeleton, he just needed someone to do it physically for him, as he wouldn’t be able to do it with one hand.

As work on the exoskeleton was about to begin, a strict COVID-19 blockade was put in place, banning a befriender from visiting RM’s home.  Instead of working at the client’s home, RM provided a befriender 3D printer so he could work on the project remotely from his home. RM sent designs, links and files via e-mail and befriender printed everything at his home. After printing all the elements, the exoskeleton was assembled.

During this time, lockdown was loosened and home visits were made possible. After the first fitting at RM’s home, it turned out that some of the “fingers” elements are a bit too small, the project had to be changed a bit and some elements reprinted. At the moment, the exoskeleton is built and RM and befriender are starting work on assembling the mechanism that moves the exoskeleton, and then they will program the computer that will control it.

Strategic outcomes:

Reduced social isolation; improved mental health; increased community capacity and resilience

Personal outcomes:

Since the beginning of work on the exoskeleton, the mood of RM has improved significantly. He started working on other 3D projects more often. He found common interests with the befriender. The prospect of doing this project motivated him to reorganize his life.

Wider impacts:

RM now plans to create a place where he will be able to put his computers and printers and train unemployed people how to use such devices.

Case Study:  Phonelink 

Mr P was referred to us in April 2020 from NW Homecare Team who were looking to temporarily suspend his homecare medication visits due to the pandemic.

We supported Mr P by reminding him to take his medications and give him information about when and where his medication deliveries were scheduled as this slightly panicked him.

We also remind him to wear his neck pendant as his point of contact voiced that he wasn’t wearing it and was worried about him being at home and not going out as much to maintain his mobility and becoming a falls risk.

After being re-assessed from the NW homecare team in October 2020, they found that Mr P had managed very well with the telephone prompts and also was enjoying the daily contact therefore Mr P’s homecare package was not reinstated and he is now a permanent client of Phonelink.

Mr P knows to tell our team that if he ever needs further practical help in the future, he is assured that we will contact Social Care Direct on his behalf.

Strategic outcomes:

Eliminated the need of a Homecare Package which has made savings for EHSCP and is what Mr P has stated he prefers regarding how he receives support.

Personal outcomes:

Mr P voiced that, although he appreciated the homecare visits, he feels more independent and he can maintain his own daily routine with the telephone calls and he is confident we are here if things ever change in the future.

Case Study: Phonelink

Phonelink has supported Mrs D for a number of years. Mrs D was recently taken to respite as she could no longer manage at home with the help from her husband. When this happened we offered to continue to check in on Mr D.
Mr D is a very proud man and very private but the team were getting concerned with some of the conversations especially when he mentioned that he had no food or heating. He had ended contact with his very limited family in Edinburgh therefore when we raised our concerns to them, they couldn’t help as he wouldn’t allow them to.

We felt it was best to contact Social Care Direct to submit a welfare concern for this man. The days following this Mr D had a fall and lay for a number of hours with no help. When we couldn’t reach him that evening, we alerted the family.

When the family entered the property they found that the house was extremely dirty, cluttered and cold with dog mess all over the carpets. Mr D was then taken to hospital and the necessary services alerted who then supported the family in cleaning the property while Mr D was treated in hospital. After this incident Mr D was assessed in the hospital as needing practical support which was put in place for him returning home. His dogs were taken to kennels.

Mr D is now home in his own property and managing well with carer support and we support him with taking his vital medications. He voiced that without the team support, he would’ve lay for days.

Strategic outcomes:

  • Promote healthy lifestyles including physical activity and healthy eating
  • Support self-management of long- term condition
  • Reduce social isolation.

Personal outcomes:

Mr D is now well kept, supported to eat well and has since applied to attend a Men’s group to reduce his loneliness. The Phonelink team have signposted him to this group and hopefully when restrictions lift, this will be accepted.

He has since reconnected with his family and is in such good spirits when we call. He voiced that he has now learned to trust people more and accept help when he needs it. Now he can focus on keeping his daily life on track in the hope to have his wife return home.

Case Study: ACE IT

Learner B is a woman in her early 60s who was looking for help with using her new Android Tablet which was given to her as a present. She found out about ACE IT through EDMesh, an Edinburgh based M.E. support group where a committee member recommended ACE IT.

One of our volunteers phoned her up and they arranged a suitable time for both to be on a call, with the appropriate arrangements and enough time for Learner B to understand and make notes. After this 1-hour appointment, Learner B requested to have recurring appointments at the same time every week.

Progress to date:

We worked with the learner from July 2020 until current date (April 2021) and together we achieved the following:

  • Email: sending and receiving emails, opening and including attachments. Organising emails in folders according to the subject or sender. Replying and continuing a thread.
  • Documents: Learner B is now completely capable of formatting a Word document in whichever style she wishes. She can also send, attach and download documents.
  • Online: Learner B is now fully able to connect on Zoom, use all its functions, including “share screen” and is comfortable and confident she can join a meeting independently and effortlessly without a tutor. In addition, Learner B has joined an art class online which lowers her feeling of isolation. She is also fully independent when it comes to social media, as she now follows several groups and pages and she can share her poems and art class makings.

Through the Helpline Learner B was able to attend regular lessons weekly, forming habits using the tablet, which doesn’t take a toll on her short-term memory loss. She has expressed herself that the regularity of the calls and the ongoing learning has helped her retain the knowledge, making it much easier to use the tablet when she is alone.

By using zoom weekly, she was confident in signing up for art classes weekly too, which reduces her social isolation and increases her mental health wellbeing.

Using the internet has given her access to more information, so she was able to follow the news, research on other health conditions and share her work on social media. Reducing her digital exclusion has resulted in the creation of an inclusive, mindful and creative community online around her.

Strategic outcomes:

  • Reduce digital exclusion
  • Reduced social isolation
  • Increased mental health.

Personal outcomes:

Our sessions were able to reduce Learner B’s digital exclusion and her social isolation. During COVID she felt excluded while the world was changing, as she has several health conditions that make her highly vulnerable. Since using her tablet she feels that connecting to Zoom and finding out how to use the device has given her a sense of independence. Being able to use a mobile device, she can now sit comfortably in any part of her house and focus on her writing, reading or emailing, the tablet “gives (her) freedom to do everyday things”. She is now fully able to download an app and work with it, practice and show her work through social media.

Wider impacts:

Learner B now feels she can reach the full potential of the device and can pass on her knowledge to others. Learner B has been compiling a book of notes- written by the volunteer – that may be useful to other learners in the future.

Case Study:  Care for Carers

B has been caring for his mum since he was a teenager, his mum has MS and B’s caring responsibilities have increased over the years. B has Bipolar Disorder and struggles with anxiety which can sometimes be made worse by his caring responsibilities. B also has two children, one has Autism and anxiety. A few years ago, B and family moved house to be closer to his mum because her condition was getting worse. B struggled with the cost of high rent and living costs and could not sustain their tenancy, they got into debt which became unmanageable.  B and his family have now moved into his mum’s home so that he can provide around the clock care.

B has attended one Christmas Open Day but had not engaged much with staff or other carers.

At the beginning of the national lockdown, Care for Carers set up a new Facebook group to support carers during that difficult time and B got in touch via Facebook because he had seen something in a newsletter about us being able to fund carers’ breaks. B told me that he was feeling more anxious than normal because of the lockdown and he was really struggling with living at his mum’s house because he felt that he never got any respite. His son who has Autism and anxiety was not getting the normal support he would get through school and B told me that he would only respond to him, not his wife, so he felt as though he was constantly caring between his mum and son. B was very concerned about the impact this was having on his mental health. I encouraged him to speak to his psychiatrist and B did do this.

B said that he really needed a break and we discussed what the options might be for this. At the time that B had got in touch with us it was during the strict lockdown when travel was not allowed. I had a chat with B about this and explained that the Carers Trust Grant application did ask for details about accommodation etc. and a traditional break might not be possible at that time. I asked B if there was anything that he might be able to do at home that would give him a break from his caring responsibilities and he told me that he would really like to do something with art because this is something he used to do when he was younger and it helped him to relax. We applied for arts materials through the Carers Trust Grant and were successful in obtaining this. B contacted me after he had bought the art supplies to say that he was getting a few hours a week to do art projects and this was having a positive impact on his mental health and also his relationship with mum and other family members.

I asked B whether he would be interested in joining any of the online events that we were running on Zoom as this might be another way he could have a short break from his caring role. He was interested in the activities but was quite hesitant as he did not feel confident using Zoom. I encouraged B and told him that he would not have to turn on his camera so others wouldn’t be able to see him and on this basis B decided to join one of the online Yoga and Relaxation sessions. I spoke to the instructor of the sessions and explained that B was quite anxious and not very confident on Zoom and the instructor had a long chat with him before the session. B got in touch with me afterwards to say that he had felt really supported for the session and  had enjoyed taking part. B said that before the lockdown he had wanted to try Yoga but had not felt confident being in a class where other people would be watching him so it actually worked out better to join on Zoom where he could turn off his camera and be anonymous.

Since then, B has regularly joined the Yoga and relaxation sessions without any prompting from me. He recently got in touch with me asking to join in three online Art sessions and this time B felt confident enough to have his camera on. During the sessions he was interacting with the other carers and making jokes with us. It was very heartening to see the difference in the carer from the first time that he contacted me, feeling anxious and extremely stressed to actively and enthusiastically engaging in activities that were giving him a break from his caring situation and building relationships with other carers.

Strategic outcomes:

Promote healthy lifestyles including physical activity, Improve mental wellbeing, Support self-management of long- term condition and provide information and advice and promote income maximisation.

Personal outcomes:

B was able to access activities which provided respite from caring and reduced his stress and anxiety and allowed him to form social connections with other carers.

Case Study: Positive Help – Supportive Transport

Sameena is a service user with HIV who uses our Supportive Transport service to attend medical appointments. She suffers from severe anxiety and agoraphobia, and before using our service, was regularly not attending her appointments due to fear around using public transport.

This was considerably worsened during the pandemic, as the government was routinely warning people against public transport and encouraging them to stay home. By autumn, it became essential that Sameena attended her medical appointments, but she was very anxious and not at all keen to travel.

Staff worked with Sameena to build confidence to attend her vital appointments but on the first 3 occasions her lifts were cancelled at the last minute due to her fears. We worked with her over the phone, discussing the details and providing gentle encouragement and support. In October, Sameena finally felt brave enough to use our support accompanied by a family member, and attended her first medical appointment in quite some time, much to the delight of her family and healthcare professionals.

Once home, she reported feeling really proud of herself, and continued to get more and more brave, using the Supportive Transport service to attend a number of other appointments that she had been delaying for long periods.

A few weeks later, Sameena attended an appointment entirely by herself, relying upon our Supportive Transport service to take her there and back. This was a huge personal breakthrough for her, and we were thrilled to have been a part of that.

Sameena said:

Thank you so much, if it hadn’t been for you I would have been really struggling’. .

Strategic outcomes:

  • Promote healthy lifestyles including physical activity and healthy eating
  • Improve mental wellbeing
  • Support self-management of long-term condition Promote healthy lifestyles including physical activity, Improve mental wellbeing, Support self-management of long- term condition and provide information and advice and promote income maximisation.

Personal outcomes:

We were thrilled to hear that our Supportive Transport has had a beneficial impact for Sameena and allowed her to get back on track with her treatment plan. We have provided Sameena with an increased sense of self confidence and empowerment, and the team were delighted to have been a part in her success.

Wider impact:

We know that Sameena’s story is one that has played out across the community during the pandemic, and are so glad to see first-hand the impact of our services upon people suffering from anxiety and fear of leaving their home. In being able to provide a personal approach to our service users we are not only able to support them individually but are able to support the NHS and other services by reinforcing a preventative and therefore cost-saving approach.

Case Study:  Changeworks Heat Heroes

Dorothy cares for her husband George who suffers from dementia with Lewy body, this reduces his mobility and means he feels the cold more. Their energy bills were very high, and she was unhappy at the service her supplier had provided. George had been needing more and more heat due his health, but their home had old storage heaters that were not always warm when they needed it

In December 2019, Dorothy attended one of Changeworks’ energy surgery sessions at VOCAL, for some advice on her expensive electricity bills. At the VOCAL surgery, Dorothy met the Volunteer Coordinator and discussed her situation with him.  The Coordinator looked through copies of her bills and although she had a complex meter, she did have options   Ewan guided Dorothy through the differences between suppliers to support her to make an informed decision. The Coordinator then arranged a home visit to double check the meter and heating set-up and to assist Dorothy on a call to the supplier.  The switch in supplier made a saving Dorothy £876 per year.

In addition, the co-ordinator identified that Dorothy may qualify for Scottish Government assistance for modern replacements. Ewan referred Dorothy to Home Energy Scotland and liaised with them regarding the application. Dorothy qualified for a new heating system which would be much more efficient and would give George the heat he needed, when he needed it.

Since George is elderly and has dementia and other related health conditions, he feels the cold more and living in his home with the older heating system was detrimental to his health. The new heating system, coupled with a much cheaper tariff allows Dorothy to set the heating as George needs it, rather than the heating regime being limited by their budget and the capabilities of the older system

“So glad that she met with Changeworks advisor, the help has been wonderful, and the service is real asset to the community. It took a huge weight off you my mind, not having to worry about electricity bills, allowed me more time to look after my husband and focus on my own health too”.

Strategic outcomes:

Maximised income, reduced anxiety, improved health

Personal outcomes:

Dorothy and George are warm and comfortable at home as it is now more affordable to heat. Dorothy is not worrying about high heating costs and is more confident operating her heating controls. Dorothy has increased confidence in dealing with her energy supplier and understanding her meter and tariffs. George is more comfortable in his home and his health is not impacted by the cold.

Wider impact:

Living in a warmer home will have a positive impact on George’s health and will reduce the chances of his health deteriorating.

Case Study: LGBT Health

Ronnie has wanted to access LGBT Health social events in Edinburgh for a long time but due to a range of ongoing physical and mental health problems, they have rarely been able to.  Then after Covid restrictions began, they experienced even greater physical isolation and barriers preventing their access to people, places and their community.

However, within 2 weeks, an Edinburgh Community Digital Programme began, launching with a quiz event hosted online via Zoom.

Alongside the emerging events programme online, the CDW also established a number of interactive Facebook groups, to encourage community members to share stories, talents and connection.  The Facebook groups complimented the events programme, mirroring the activities to provide a permanent ‘behind the programme’ space for event attendees to continue sharing their interests and receive news and event updates.

In addition to regular quiz events, the digital programme included Facebook Live events, social meet-ups, community discussions, film ‘watch’ events and live arts showcases, all accessible from anyone with an internet connection and computer or smart device.

For the first time, Ronnie could take part in a range of LGBTQ+ community activities, from the comfort of their own home and crucially, without the barriers related to their health issues being highlighted.  The quick to access and quick to leave nature of the events also provided reassurance and comfort in a way that in-person events rarely could.

“I simply wouldn’t be part of this community without these online events.  We all hate the Pandemic, but for some of us, it is our way back in to society.”

Strategic outcomes:

Reduce social isolation, Build strong, inclusive and resilient communities.

Personal outcomes:

Better community connections, feeling part of society and reduced loneliness.

Wider impact:

Ronnie has highlighted the importance of continuing with a blended programme of both in-person and digital events which can provide for many a “way back in” to their community and the opportunity to build on their social relationships.

Health and Social Care Partnership grant programme monitoring and evaluation 2021-22

This report provides an overview of the work carried out by organisations grant funded by the Edinburgh Integration Joint Board (EIJB) in 2021/22. 2021/22 was originally the third year of a 3 year, £4.9m grant programme.  In June 2021, the EIJB grant programme was extended a further year until 2023.  However, due to the continued impact of Covid restrictions and slow resumption of services for vulnerable groups, the grant programme was extended for a further 2 years until March 2025.

The grant programme helps realise two key priorities of the IJB’s Strategic Plan 2019-22:

Prevention and early intervention:  establish links with community resources and assets to ensure people have the opportunity to access preventative opportunities which will help them keep themselves as fit and healthy as possible

Tackle inequalities:  take action to identify those experiencing poorer health outcomes and address the barriers they face.

and works towards 7 priority outcomes:

The Programme was developed collaboratively in 2018 following extensive engagement with partners and stakeholders. An open invitation to bid for funding was widely promoted and support provided for small organisations lacking resources and expertise in application processes.

The EIJB grant fund was considerably over-subscribed and, following a robust assessment process, 3-year funding (subsequently extended to 6 years) was awarded to 66 organisations to implement activities and services aligned to the seven funding priorities of the Programme. (See Appendix 1)

The conditions of grant require that organisations receiving funding must complete annual monitoring returns using both quantitative and qualitative data. The information provided in the returns is compiled and used to complete this annual report.  The returns from organisations include:

  • Self-Monitoring Annual Returns (SMARs) demonstrating Key Performance Indicators
  • Case Studies (a selection of which are contained within Appendix 2

Due to difficulties caused by Covid-19 restrictions, organisations were not required to complete service user surveys during 2021/22.

Number of Service Users

As part of their annual returns, organisations provided an indication of the number of people who use their services. From these it is estimated that approximately 44,000 people took part in activities/used services funded through the Programme.  (Some participants may have taken part in more than one activity and so will be double counted.)  The pie chart below provides a guide to the number of participants for each priority outcome.

pie chart to describe participants.

The number of service users, approx. 44,000, was lower than in the previous year (approx. 50,000). The higher figure for 2021/22 was in part due to increased emergency community resilience work (Outcome 7).  This work was undertaken at the onset of the pandemic to ensure the immediate safety and welfare of vulnerable individuals who could not go out or were required to shield.

The annual SMAR returns from individual organisations also outline a number of reasons why attendance figures may have been slightly lower when activities returned to an in-person approach as restrictions eased, including:

  • The size of groups had to be reduced due to Covid restrictions
  • A reluctance from some people, particularly those with pre-existing conditions, to come back to in-person activities, partly due to anxiety and fear around Covid and confidence about re-engaging with society.
  • Disruptions due to staff and service users contracting Covid and requiring to isolate
  • People were not attending GP practices face to face and so were not aware of all resources available.
  • Staffing retention and recruitment difficulties
  • Case work was often more complex following the pandemic and often required more time, support and frequent appointments per person
  • Buildings, once opened, went into further lockdown following outbreaks of Covid.
  • Some participants chose to/were required to isolate for longer due to health conditions.

Targets

Despite the changing Covid-19 restrictions imposed, and the difficulties this brought, the returns show that of the 588 targets set, 514 were met (87%). This compares favourably with last year’s figure of 80% of targets met.

Customer Satisfaction

Because of the Covid restrictions this year, many organisations were unable to complete user satisfaction however from those which did, the average user satisfaction score was found to be 93%, an increase of 1% from the previous year.

Volunteer Numbers

  • Many of the organisations depend on volunteers to help deliver their programmes. In 2020/21, volunteer hours added a further 23% of hours worked by paid staff.  Without their involvement, the wide range of service provision would just not be possible.  The financial value of this volunteering is estimated at over £1.9m.  Equally important are the many benefits which volunteering brings to the individuals who volunteer, such as improved confidence, increased skills and social connections and improved physical and mental wellbeing.
  • The use of volunteers is often central to an organisation’s service delivery model however, the number of opportunities for volunteering was hit badly during the pandemic. and consequently, for many organisations, volunteer numbers have yet to return to pre-covid levels. A number of reasons for this was given:
  • Volunteer numbers had to decrease to be able to maintain physical distance and room capacity restrictions as part of the Covid risk assessment.
  • Some volunteers were not willing to follow Covid restriction guidelines as they felt that they were too onerous or volunteers required a great deal of supervision to ensure compliance.
  • uncertainty due to Covid for volunteers e.g., changing working patterns, working from home and the requirement to isolate restricted opportunities to volunteer
  • volunteers were unable to return when services reopened due to changes in their personal circumstances, ill health or the retirement of some longstanding volunteers.
  • volunteers moved on during the pandemic and some requested to reduce their time commitment on return.

Organisations are now rebuilding and diversifying their volunteering teams and working hard to get back to pre-Covid levels.

Organisations value the contribution volunteers make to the delivery of services and as such invest in volunteers and adopt Investors in Volunteers standards. These provide a good practice model for volunteer management to help ensure the volunteer has the best experience. Organisations must also provide volunteer training to cover the specific roles of the volunteer as well general issues such as confidentiality, health and safety etc. This training and the ongoing opportunities to develop skills and self-confidence are also invaluable for personal development and enabling volunteers to take on further roles both within and outwith the organisation.

Organisations welcome and support the personal development and onward progression of their volunteers, which sometimes may mean moving on to employment. This success however may mean ongoing recruitment and training issues for the organisations and this represents a significant investment of staff resource.

Additional Funding

The annual returns show that for every pound awarded through the programme, organisations brought in a further investment of £3.19 to the city. This equates to an additional benefit of funding leverage, estimated at approximately £13m. These figures are similar to last year’s figures.

Most organisations rely on this additional funding to ensure delivery of their services and organisations continue to be encouraged to maximise additional income as pressures on the EIJB’s budget grow.

In addition, the changing needs of their communities and the increasing demands on services as a result of the Covid restrictions have meant that organisations have expanded their reach, adapted their services or introduced new services where possible to meet the changing local needs. The flexibility of the EIJB grant programme and the sourcing of additional funding has allowed this to happen for the benefit of individual communities.

Additional Funding is secured through a variety of sources including donations from individuals, grants from a wide range of national and local trusts and investment from other statutory providers.

Additional Achievements

Many of the organisations funded through the programme were proud to acknowledge the awards which they had received over the course of the year. The awards recognised a whole host of achievements including those for community work, inspiring volunteers, partnership work and leadership awards, amongst others.

The well-deserved awards reflect and celebrate the efforts and commitments shown by organisations, staff and volunteers which have helped make a real difference to the health and well-being for so many residents of Edinburgh.

As noted, 2021/22 continued to be an extremely difficult year for grant funded organisations and progress in returning to pre-Covid performance was slower than expected. Varying levels of Covid restrictions continued into 2022 and organisations were required to adapt to several changes in government restrictions and guidance. This led to problems and frustrations for the management in grant funded organisations and for the service users.

Restrictions were eased at times through the year, however there were two further lockdowns and rules on numbers and mixing remained in force. Each change in Covid guidance, brought uncertainty and difficulties.  Fortunately, organisations could build on their experience from the previous year and were able to work with people as best they could, whilst ensuring their safety.

Outreach services continued to be provided through this time. Such services included meal delivery, telephone calls, welfare checks, delivery of activity packs, telephone welfare support, on-line one to one and group support and on-line group activities such as cooking classes and exercise classes. This helped ensure that people remained connected and helped reduce social isolation and physical and mental decline

In autumn 2021, when changes in restrictions meant that some buildings could reopen, organisations were required to carry out further risk assessments. This often led to the need for physical, and often costly, adjustments to the premises which included for example, installation of new ventilation systems, redesign of workspace to accommodate restrictions on numbers and rental of additional accommodation.  Some buildings remained closed to all but staff for extended periods with some CEC buildings still not in full operation as late as March 2022.

As face-to-face services re-opened, organisations were acutely aware that despite best efforts, many people who were struggling before lockdown had become even more withdrawn and isolated, were suffering from deteriorating mental and physical health and had little or no motivation.

Organisations also noted that many service users and referrals were now requiring a greater level of support than they might have in the past necessitating greater staff involvement in supporting them. Alongside this, many services, particularly counselling services, have seen an increased demand for services.

The significant impact on staff – increased workload, conflicting priorities, often lengthy waiting times to receive statutory services and an increased number of complex, often emotional referrals have resulted in organisations having to increase the health and wellbeing support for their own staff in order to retain staff and avoid staff burn out.

The grant programme had set reducing digital exclusion as a priority outcome as it recognised the important role which digital connection can play in maintaining health and well-being and recognised that it is often those who are older or those with lower household incomes who are digitally excluded.

The restrictions due to Covid however led to an increased reliance on digital technology and the negative consequences of being digitally excluded during Covid restrictions were worse than ever.

Throughout these restrictions, organisations had to work even harder to ensure that digital access was available to all those who wanted it and had to devise and implement various initiatives to address this:

  • Improving access: Organisations sourced additional funding or worked in partnership to acquire tablets/iPad/smartphones to donate or lend to those in need, including those facing financial hardship and those living with homelessness.
  • Improving skills: A range of work was carried out to improve digital skills and online security through various methods including online video resources, help sheets and how-to guides, one to one support, digital cafés and peer support groups.

Many of the organisations have continued to form strong working partnerships with other 3rd sector organisations, with public sector delivery partners and community groups. These partnerships have helped strengthen service delivery, strengthen referral routes and helped to increase awareness of service availability to ensure that people have access to the most appropriate service at the time when they need it.

Increased partnership working has also provided opportunities for organisations to discuss and find solutions to shared issues, particularly in dealing with the changing Covid-19 restrictions.  Organisations also shared resources, including premises, worked together to generate ideas, and carried out shared promotion and consultation.

The current grant programme has now been extended by 3 years to March 2025 to allow third sector organisations to consolidate their services following the pandemic.

An EIJB Innovation Fund was agreed during the Health and Social Care Grants Review in 2018. The purpose of the Innovation Fund was to encourage creative and innovative ideas in tackling and progressing the priorities of the Edinburgh Integration Joint Board (EIJB). The fund sought to identify and develop new models of service delivery with the aim to reduce pressures in the Health and Social Care System for adult services.

The priorities of the Innovation Fund focused primarily on prevention, early intervention and tackling inequalities and asked applicants to identify innovative solutions for problems which either service users, local communities or the city were experiencing.

The Innovation Fund had a budget of £362,000 which ran over a two-year period, April 2020 to March 2022.

Despite the restrictions of the Covid-19 pandemic, the EIJB Innovation Fund, has also progressed well during 2021/22 in what has been very difficult circumstances, with 5 of the 8 pilot projects now complete. These projects have provided important learning for tackling old problems with new collaborative approaches developed.

The innovation projects ranged from addressing new ways to support people with dementia to remain safely within community-based settings to establishing new effective collaborative partnerships between GPs and third sector organisations to address long-term conditions such as chronic pain. A full list of the EIJB innovation projects can be found in Appendix 3.

Of the 5 completed projects, 3 projects have been continued into a third year whilst they seek alternative funding and further develop their collaborative approaches, These include Scottish Alzheimers dementia project which has been highly successful in introducing smart technology in the care of people with dementia, Health All Round’s (HAR) Action for Pain project which in partnership with GP practices is developing alternative treatments for pain management and the Edinburgh Development Group (EDG) which is looking to develop a co-operative of community service providers in the South Queensferry area. Due to the impact of the Covid-19 pandemic, 2 of original innovation projects chose to delay the implementation of their innovation projects until 2023, these include Libertus hospital delay project which is developing a social aftercare project and the LGBT Health and Wellbeing’s Suicide Prevention Toolkit. These 2 projects will continue to develop their project throughout 2022-23. Only 2 of the original 8 projects have been unable to develop their projects with Lifecare withdrawing from the innovation programme in 2021 and Community Renewal Trust being unable to access A&E clients during the Covid pandemic for their innovative approach to Reducing Urgent Care Call (LUCs) – Health case management providing holistic long-term support for repeat users.

National Health and Wellbeing Outcomes

In addition to contributing to the 2 key priorities of the Strategic Plan – preventing poor health and wellbeing and reducing health inequalities – the services delivered also work directly to achieve the National Health and Wellbeing Outcomes those noted in the table below.

National outcome Achievement
Outcome 1: People are able to look after and improve their own health and wellbeing and live in good health for longer Provision of services to encourage healthy lifestyles and improve self-management and wellbeing continued and included activities to reduce alcohol intake, improve diet, improve mental health, help to access technology, encourage social interactions and connections and increase physical activity.

The programme also addresses the environmental and social factors that can act as barriers to health and wellbeing, for example, improving greenspace and maximising income.

Outcome 2

People, including those with disabilities, long term conditions or who are frail, are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community.

Over the years, the Grant Programme has helped build and create community capacity and resilience so that people can receive the care and support they need locally to help them stay independent.  This strong community foundation was relied on more than ever during the pandemic and the support which continues often proved to be a lifeline for many.  Services included, for example, telephone support and befriending, falls prevention activities, advice and support for carers, self-management programmes and one to one support.

Services are now adapting and providing additional and new services to meet the changing needs of the individuals, many of whom have increased frailty for example new short-term support for those coming out of hospital who have no family support.

Outcome 3. People who use health and social care services have positive experiences of those services, and have their dignity respected Due to the social distancing restrictions, the requirement for user surveys was removed this year however many organisations continued to gather feedback from their service users as part of their ongoing improvement plans.  From the feedback gathered it is clear that experiences were positive and the average user satisfaction rate was found to be 93%.
Outcome 4. Health and social care services are centred on helping to maintain or improve the quality of life of people who use those services. The grant criteria are built around the key components of a good quality of life including social interactions, personal income, physical environment, personal confidence and health

Grants through the programme are awarded to trusted, experienced organisations who have continuous improvement plans in place which take a person-centred approach.

Outcome 5. Health and social care services contribute to reducing health inequalities Edinburgh shows better than average levels of health and wellbeing, compared against Scottish averages, however, levels of health inequalities are worse than the Scottish average.

The Grant Programme began in 2019, with a key aim of redressing this imbalance.

However, the coronavirus and the restrictions imposed have highlighted and exacerbated the existing inequalities in our society.

Organisations adapted to the restrictions imposed and continued to provide their much-needed services to mitigate against the additional impacts which tended to hit the most vulnerable and disadvantaged the hardest.

Outcome 6

People who provide unpaid care are supported to look after their own health and wellbeing, including to reduce any negative impact of their caring role on their own health and well-being

A number of funded projects provide support for carers.  Now more than ever, this support is vital.

The impact of Covid on carers has been well documented and research3 has found that the coronavirus crisis is having a profound impact on carers’ lives.

The demands and stress on carers increased as daycare activities were suspended, packages of care were often reduced and respite was limited.  The uncertainty of when normality would return added additional pressure.

Caring behind closed doors Forgotten families in the  coronavirus outbreak April 2020, Carers UK

Outcome 9. Resources are used effectively and efficiently in the provision of health and social care services To ensure effective use of the limited grant budget, the criteria for grant funding was co-produced with stakeholders and a stringent grants assessment process was followed.

In addition, grant funded organisations complete and return annual monitoring returns.

Poverty

Throughout 2021-22, strategic partnerships have strengthened with staff investing a significant amount of time to develop effective collaborative ventures across the city. Organisations are actively involved in a wide range of partnerships including Poverty Commission, Local Community Planning Partnership, Preventing homelessness Working Group, and many others across the organisations.

EIJB grant funded organisations continue to deliver on the six areas for action identified in the Edinburgh Poverty Commission final report A Just Capital: Actions to End Poverty in Edinburgh (health and well-being; connections; fair work; a decent home; income security, opportunities to progress). Organisations endeavour to ensure that the experience of seeking help is less painful, less complex, more humane and more compassionate.

Many of the projects also work in partnership with other organisations on project delivery covering a wide range of projects for example Lifting Neighbourhoods Together – (project which aims to reduce poverty one household at a time), community pantries to improve access to food and finances, workshops, distribution of small grants for financial help with, food, utilities and clothing, developing long term support options and working with Health visitors and GPs.

Climate Change/Sustainability

The EIJB recognises the global climate change emergency and that everyone has a part to play if we are to reach Edinburgh’s ambitious net zero 2030 target.

A core aim of the Grant Programme –building strong, inclusive and resilient communities is in-step with the central aims of our partners’ sustainability strategies and aspirations of creating sustainable, 20-minute neighbourhoods.

Looking forward however, consideration should be given to what the Partnership can do to help organisations become more environmentally sustainable and support the behavioural change required to help Edinburgh reach its ambitious net zero target for 2030.

2021/22 saw the third year of operation of the EIJB Grant Programme (annual budget of £4.7m) which helped realise two key priorities of the IJB’s Strategic Plan – to tackle inequalities and promote prevention and early intervention; the 7 key priorities of the EIJB Grant Programme; several of the National Health and Wellbeing Outcomes; and developed strong links to the City’s Poverty Commission and its anti-poverty work.

At the beginning of the year, many organisations had hoped to return to pre-covid performance levels however progress has been slower than anticipated. The ongoing easing and tightening of Covid-19 pandemic restrictions, often with short notice, made it challenging and frustrating for organisations to move forward with their programmes, particularly in relation to re-convening groupwork sessions. However, despite these challenges projects have evolved throughout the year to meet changing service user needs and build local capacity.

In general, the return to normality is progressing well with many organisations redesigning their services to incorporate lessons learnt from the pandemic and develop new ways to deliver services to a wider group of service users. The stability and agility of third sector organisations during the pandemic has shown the important contribution the voluntary sector has in sustaining strong and resilient communities across the city.

Staff have welcomed the return to face-to-face service delivery however many organisations have acknowledged the value of hybrid working models and have indicated that they intend to continue to employ both face-to-face and online service provision.

Returns showed that approximately 44,000 participants took part in or received a service from EIJB grant funded recipients during 2021-22.2 and the average user satisfaction rate was found to be 93%.

The heightened reliance on digital technologies and the negative consequences of being digitally excluded continued. EIJB funded organisations continued to assist those that needed help in making the transition to the use of digital technology or provided alternative services where required.  However, the impact of the Covid pandemic has reinforced the continued need to reduce digital exclusion for the most vulnerable groups in the city.

The anticipated negative impacts of the pandemic restrictions are now being materialised with organisations seeing an increased demand for services and those who require services are often presenting with greater and more complex needs than had been previously experienced.

Appendix 2 provides case studies from projects funded through the EIJB grant programme and demonstrate how organisations have continued to improve the health and well-being of individuals in-line with the 7 priorities of the programme.

Organisation Project Activities Amount
ACE IT Digital Inclusion for Older People The project will enhance digital knowledge, skills and well-being in older people with staff, volunteers and other organisations via four services.

  • Moose in the Hoose for residents in care homes
  • Office – based one to one training sessions
  • Scam workshops with Changeworks
  • Outreach for older workers and people in retirement establishments
£62,225
Art In Healthcare  – Room for Art Room for Art Room For Art is a series of visual arts workshops delivered by artists throughout Edinburgh using an ‘art on prescription’ approach and an occupational therapy supported model of 1:1s to support self-management. Participants will be referred by professionals in statutory and third sectors working in partnership with Art in Healthcare.
£69,999
Autism Initiatives Diagnosis and support for autistic adults without a learning disability The Project will assist Mental Health Teams (MHTs), and the Lothian Adult ADHD and Autism Resource Team (LAAART), in Edinburgh by meeting those seeking an autism diagnosis; gathering information to support MHTs in their assessments; diagnosing those who do not meet their criteria for functional impairment, and providing post-diagnostic support. £82,626
Bethany Christian Trust Passing the Baton Project Through volunteer befriending and community groups for isolated and lonely individuals, the project aims to decrease social isolation and prevent homelessness in Edinburgh. £51,817
Bridgend Farmhouse Community kitchen Creating a community kitchen as an engagement tool to connect and engage a multi-generational, multi-cultural, multi-ability food community supporting each other to learn, gain confidence, reduce social isolation, and help each other become part of the wider community. Using local collaborations and food as the focus for building community capacity £24,978
Calton Welfare Services Welfare Services for Socially Isolated Older People The project will provide a Club for Socially Isolated Older People and a Day Care Service for Dementia sufferers, as well as providing Welfare Advice and Information for our service users and their carers and socially isolated older people in our area, and events throughout the year for older people. £16,381
Care for Carers Stepping Out Residential and Short Breaks for Carers To provide information, support and a range of organised, structured and supported short breaks (residential, day and evening breaks) to unpaid carers in Edinburgh. The short breaks aim to support and improve carers mental and physical wellbeing and enable them to feel able to maintain and sustain their caring role. £72,240
Caring In Craigmillar Phonelink We plan to extend “Phonelink”; our unique telephone support service, to all Edinburgh localities. CiC, currently offers reassuring & supportive phone calls, twice daily, 365 days, to vulnerable & elderly clients, living in their own homes with long term health conditions, additional support needs or at risk of social isolation £97,001
Changeworks Heat Heroes Heat Heroes provides support to people vulnerable to health impacts of living in fuel poverty. A team of 12 volunteers will be trained to support 1650 people to be in control of their energy costs, helping them be affordably warm and prevent health issues caused by living in cold/damp homes. £56,300
Community One Stop Shop COSS The project will deliver our existing project and ancillary services. We provide advice and advocacy for clients living in poverty and challenging circumstances within the Broomhouse and South West area. Continued provision of our Food Bank and support services, and our outreach services. We currently receive two smalls grants but as suggested have amalgamated them both for the purpose of this application for the first time. £23,000
Community Renewal Trust Health Case Management (HCM) Continuation and improvement of Edinburgh’s HCM service: intensive support for GPs’ 2% most complex adult cases. Our open-ended long-term community-based one-to-one support assesses need, introduces people to services and reduces demand for Primary Care. Our staff are experts in compassionate-listening, coaching, self-management and recovery techniques to foster resilience and wellbeing. £49,063
Cruse Bereavement Care Scotland Edinburgh Bereavement Services Cruse Scotland will provide a community-based listening/counselling support for over 850 people who are bereaved across Edinburgh.  On average clients will receive six sessions, which will improve their mental well-being and reduce their visits to GPs services.  The service is delivered by highly trained volunteers at an accredited standard. £34,000
Currie Day Centre Day Centre for Older People To enable Currie Day Centre to continue to run every Friday as a crucial and unique service for frail and isolated older people living in Currie, Balerno and Juniper Green.  Transport is provided, with a programme of stimulating activities, social opportunities and a nutritious two-course lunch. This organisation has ceased operation
Cyrenians Golden Years Community Connecting Service A preventative service to reduce loneliness and social isolation in older people by connecting them with their community and in turn reduce the number of people who need support of statutory services and increase the number of people who can live at home for as long as possible. £80,872
Drake Music Scotland Musicspace We propose to deliver Musicspace – a programme giving 80 disabled young people and adults in the Craigmillar area access to group music making activities which have proven benefits to mental health and wellbeing, physical coordination and social inclusion. £18,000
Edinburgh & Lothians Greenspace Trust Healthy Lifestyles in South Edinburgh The project is to provide a programme of outdoor activities that promote physical activity and healthy eating for those who face health inequalities. The work involves developing the successful programme that has been running since 2013. £120,425
Edinburgh Community Food Healthier Food, Healthier Lives, Healthier Futures

The project will promote healthy lifestyles by delivering community food and health work across Edinburgh. The key components will be a range of cooking courses, nutrition workshops, health promotion sessions, training and support. We will also provide greater access to affordable healthy food within communities.

£173,059
Edinburgh Community Health Forum Tackling health inequalities by building a stronger and more resilient 3rd sector To continue the work of the Forum which provides and coordinates tailored support, information and training to Forum members who are the managers of locally based community led health projects and to raise awareness strategically about the importance of addressing health inequalities. £53,680
Edinburgh Garden Partners  Befriending Through Gardening EGP and Edinburgh and Lothians Regional Equality Council (ELREC) will jointly deliver a befriending model, creating relationships through shared gardening within the black and minority ethnic (BME) communities. Using EGP’s established and successful model, 15 befriending partnerships will be created annually between socially isolated, predominantly older garden owners and volunteers. £23,270
Edinburgh Headway Group Early Intervention ABI Rehabilitation Support Project To provide an early intervention rehabilitation project for 20 adults in total with an Acquired Brain Injury to improve everyday functioning and encourage reintegration into the community. Our preventative support includes: independent living skills, physical activities, social opportunities, therapeutic creative activities, advocacy, complementary therapies and 1:1 Community Outreach. £46,142
Edinburgh Leisure Steady Steps Edinburgh Leisure are seeking funding for Steady Steps, a 16-week group based physical activity and exercise falls prevention programme which focuses on improving strength and balance to deliver positive health and social outcomes for around 2,328 older adults over three years. £140,122
Edinburgh Rape Crisis Centre Rape Crisis support Service The project will support the provision of our specialist, trauma-informed rape crisis support service for women, non-binary and trans people who have experienced sexual violence, including rape, sexual assault and childhood sexual abuse/exploitation.  The proposed activities of the service include trauma support, counselling, advocacy and group support. £74,226
Eric Liddell Centre Caring for Carers

Befriending Service

An emotional, physical and practical programme to support unpaid carers across Edinburgh delivered by the Eric Liddell Centre (ELC). This proposal will build on established experience/service delivery and increase the level of support being offered to carers throughout Edinburgh.

Provide emotional support through linking, matching and ongoing support service in which volunteer befrienders offer a socially supportive relationship to befriendees

£25,945
FAIR Ltd (Family Advice and Information Resource) FAIR – Information and advice for people with learning disabilities and their carers FAIR will:

Provide a welfare rights and financial capability advice service.

Produce an Easy Read Newsletter every 2 months that will include and share information from key stakeholders.

Work in co-production with the Health and Social Care Partnership to consult on the Strategic Commissioning Plan for People with Learning Disabilities.

£94,914
Feniks:  Counselling, Personal Development and Support Services Ltd “Reach Out, Help Within” Supporting Central Eastern European community in Edinburgh This project aims to tackle mental health inequalities and social isolation amongst Polish and Central Eastern European people in Edinburgh. We will employ two therapists/counsellors, a CEE Mental Health Service manager and a community development worker to improve the provision of the mental health services, integration  and cultural-bridging within the city. £78,600
Fresh Start Fresh Start:  helping people make a home for themselves
 Working with partners across Edinburgh and with volunteer  teams, we will support people previously homeless to ‘make a home’ in new tenancies providing goods and practical support to 5,000+ households and 1000+ places on gardening, cooking, and employability activities.  Service-users develop key lifeskills and access ongoing social and emotional support.
£88,179
Hillcrest Futures(formerly Gowrie Care Ltd)
Futures Hub
An accessible resource hub where vulnerable people who are, have been or are at risk of becoming homeless, can be supported to learn independent living  skills and experience social, recreational, employment and educational opportunities they would otherwise be excluded from. Promoting health & wellbeing, tenancy sustainment, recovery and social inclusion £94,487
Harlaw Monday Group Harlaw Monday Group Day Care Centre The proposal is to continue to operate a day care centre on one day per week  for those elderly people living in the Balerno, Currie and Juniper Green areas who have been diagnosed with mild to moderate dementia or cognitive impairment. This organisation has ceased operation
Health All Round Health All Round Community Health Initiative HAR is a community health initiative covering the Sighthill/ Gorgie ward of Edinburgh. We deliver a range of services to improve the physical, emotional & social wellbeing of local people. We specifically target low income and other vulnerable groups. £200,158
Health In Mind Craigmillar Counselling Counselling offered to people with anxiety, depression and similar issues living in the Craigmillar /Portobello area.  Self-referrals, and referrals through GP’s, voluntary organisations, social work or other professionals accepted.  This proposal funds direct counselling costs, with other staffing, direct costs and overhead funded by NHS Lothian. £13,000
Home-Start Edinburgh West and South West (HSEW) Promoting positive perinatal mental health Access to family learning from a perinatal stage provides opportunities for parents/carers to gain confidence in their role and has a positive impact on mental health and children’s learning outcomes/resilience.  Promotion of attachment is offered through Baby Massage and Peep.  Home-based support is available where required. £24,910
LGBT Health and Wellbeing Core Funding and Community Programme The project will support LGBT Health’s work to promote the health, wellbeing and equality of lesbian, gay, bisexual and transgender (LGBT) adults, as well as funding to continue established social capital work through our Edinburgh LGBT Community Programme of social, community engagement and volunteering activities. £98,500
Libertus Services Positive Futures – The Volunteering Project The project is a collaboration of 2 well established projects with proven track records based within Libertus Services.  Using the 5 principles of community development we aim to reduce social isolation, promote healthy lifestyles/mental wellbeing and build strong and inclusive communities by running groups for older people and recruiting volunteers £124,242
Link Up Link Up Women’s Support Centre Women’s Mental Health & Wellbeing services including:

  • 2 weekly evening peer support groups
  • weekend healthy eating lunchtime drop-in
  • weekend one to one support and initial assessments
  • week day, evening and weekend counselling service

creche services for mothers attending the weekend drop-in and counselling service

This organisation has ceased operation
Lothian Centre for Inclusive Living (LCIL) Lothian Centre for Inclusive Living (LCIL) We will deliver comprehensive benefit checks and follow up support to physically disabled people.

We will extend our Grapevine Disability Information Service to cover Universal Credit claims and raise awareness of the support we can provide, through collaborative working, with this new extremely complex benefit across the 4 localities.

£20,269
MECOPP  Jump Start MECOPP  Jump Start The project will deliver a ‘broad-based health literacy and health improvement service to Chinese people aged 40+ who are disadvantaged by age, disability or long-term health condition, economic or social circumstances through the provision of: health information sessions, educational workshops, physical activity programme and supporting civic engagement £31,446
MECOPP  BME Carer Support MECOPP  BME Carer Support Carer support service for Black and Minority Ethnic carers (primarily South Asian and Chinese) to include casework support, telephone based multi-lingual advice and information and carer training. Training on ‘achieving cultural competency’ will also be provided to health and social care staff. £64,794
Multi-Cultural Family Base Multi-Cultural Family Base – Syrian Men’s Mental Health Group Group supporting Syrian men newly arrived to Edinburgh under the United Nations Scheme for Vulnerable Persons Relocation.

The group will support 15 men per week with issues including integration, employment and English language. The project will also offer outreach and befriending, including for men who cannot attend the weekly sessions.

£16,788
Murrayfield Dementia Project Murrayfield Dementia Project Day resource for those with dementia £54,815
Om Music Sanctuary Om Music Sanctuary Om Music Sanctuary Om Music Sanctuary Om offers opportunities to learn and play music, for the mental health community. This funding will be for a free programme of weekly individual/group lessons, band rehearsals, weekly/Saturday ‘Music Café’ and concerts in the Stafford Centre. Om opened Nov/17, and we already have 70+ registered members. This organisation has ceased operation
Pilmeny Development Project Pilmeny Development Project (PDP) – Older Peoples Services PDP will deliver activities, services and opportunities within Leith and North East Edinburgh, reducing social isolation, promoting participation and inclusion of socially isolated older people in need of community-based support, using low level, preventative, early intervention and self-help approaches, which improves their quality of life. £73,898
Pilton Equalities Project Mental Health The Mental Health & Wellbeing Support Service (Neighbourhood Group)  The Service will provide support to older people with enduring mental health problems; who may have significant issues with substance dependencies; to remain and participate in the community.  The service aims to increase individual capacity; improve group co-operation and socialization; raise skills and confidence; encourage wellbeing preventing readmission to hospital. £89,674
Pilton Equalities Project  Day Care Services Pilton Equalities Project  Day Care Services PEP will operate 5 daycare clubs, a weekend provision, a visiting/assessment service across North Edinburgh for vulnerable older adults; reducing isolation and enabling older people to stay in their homes longer, and enhancing a level of independence and socialisation. This supports CEC’s Reshaping Care for Older Peoples prevention strategy. £87,670
Portobello Monday Centre Portobello Monday Centre The project will provide informal day-care once a week for our members (10 to 12) who suffer from dementia, whilst at the same time giving some valued respite for their carers. The service is run entirely by volunteers for members resident in the Portobello area. £4,453
Portobello Older People’s Project Portobello Older People’s Project Portobello Older Peoples Project is a lunch/social club that gives older people the opportunity to have the company of others and enjoy a hot meal. It supports people who are isolated and the aims are to reduce loneliness and social isolation, increase social connectivity and improve health & wellbeing. £15,769
Positive Help Positive Help Positive Help will deliver needs-led services to vulnerable adults affected by HIV/AIDS and Hepatitis C. Supportive Transport and Home Support enables service users to live independently, positively engage with health services, thus improving wellbeing and quality of life. These services deliver best value and reduce pressures on NHS and Council services. £49,166
Queensferry Churches Care in the Community Queensferry Churches Care in the Community Develop a Community Hub for older people living in the rural areas of  South Queensferry, Dalmeny, Kirkliston, Newbridge, Ratho Village and Station.  To ensure that older people are well connected, have a variety of support services and volunteering opportunities, therefore enabling them to participate and remain active in their communities. £44,308
Rowan Alba Limited Rowan Alba Limited CARDS is a city-wide volunteer led service which supports people with Alcohol Related Brain Damage (ARBD), who are at risk of developing ARBD and people whose alcohol use puts them at risk. We require funding to continue to deliver this service across all localities and improve health outcomes for people who use this service £50,423
Scottish Huntington’s Association Lothian Huntington’s Disease Service The Lothian Huntington’s Disease service will deliver an integrated Health & Social Care  model  of person-centred  care-management  to people impacted by Huntington’s disease across Edinburgh City. Providing specialist assessment, expert advice, information and one to one support to reduce social isolation, increased resilience, improved quality of life and well-being £33,610
Sikh Sanjog Health and Wellbeing Group The Health and Wellbeing Group, partnering with health organisations, will deliver a programme focussing on preventative measures by providing a safe space for ethnic minority women to access bespoke activities, designed to support their mental and physical health and wellbeing, reduce isolation and loneliness, increase confidence and develop interpersonal skills. £24,392
South Edinburgh Amenities Group SEAG South Edinburgh Amenities Group SEAG Utilise our specially adapted minibuses to enable elderly, frail and other vulnerable groups of people in our communities to access a range of 30 voluntary sector, lunch clubs, day centres, and dementia services, which will contribute to the passengers’ mental and physical well-being and therefore reduce their social isolation. £70,902
South Edinburgh Day Centre Volunteer Forum South Edinburgh Day Centre Volunteer Forum (SEDCVF) The grant is to assist with the running costs of five local day groups for people aged 60+ who are socially isolated in the SE area of Edinburgh.  The grant will be to employ trained care staff, transport and volunteer expenses. £25,000
Support in Mind Scotland RAISE for Carers Support in Mind Scotland RAISE for Carers We will deliver an integrated support, information and education service for carers of people with mental health problems/mental illness

Reception:  open access;

Assessment: compassionate response and review;

Information:  rights and services;

Support: crisis, emotional and practical;

Empowerment:  rights, advocacy and resilience for the future

£24,008
The Broomhouse Centre The Beacon Club The Broomhouse Centre The Beacon Club We are seeking funding to develop The Beacon Club: our services for older people with dementia in South West Edinburgh which prevents this long-term condition affecting their quality of life in old age. £54,808
The Broomhouse Centre on behalf of Vintage Vibes Consortium The Broomhouse Centre on behalf of Vintage Vibes Consortium A city-wide project to tackle isolation in Edinburgh’s loneliest over 60s through creating long term, locally based one-to-one friendships based on shared interests. This is a Vintage Vibes Consortium application for 2.5 Service Coordinators for 3-year period. The Consortium is a partnership between LifeCare and The Broomhouse Centre. £77,271
B Healthy together (The Broomhouse Health Strategy Group) Supporting Healthier Lifestyles To improve physical and mental health and wellbeing in SW Edinburgh, a recognised area of deprivation, we will deliver a programme of volunteering, healthy eating and exercise services.  Our comprehensive package of support will also help vulnerable people overcome barriers to effective parenting, build positive relationships and develop resilience £56,958
The Dove Centre The Dove Centre The Dove Centre is a social day centre whose aims are to help older people remain as independent as they can be through a variety of socially inclusive activities, learning, volunteering, fresh meals and fully accessible transport. £133,788
The Health Agency The Health Agency The Health Agency is an organisation that aims to promote and develop a community led approach to health improvement in an area that experiences a high level of social and economic deprivation £183,698
The Living Memory Association The Living Memory Association We will use reminiscence projects to decrease isolation and improve the health and quality of life of isolated older people and their carers. We will run groups, a ‘drop in ’facility, recruit older volunteers and work with those who are housebound offering a whole range of activities and ongoing support. £24,665
The Open Door Senior Men’s Group The Open Door Senior Men’s Group The group will continue to provide a safe and supportive space for men over the age of 60, who are at risk of social isolation, to meet, make friends and participate in a programme of shared activities one afternoon per week. £6,026
The Ripple Project The Ripple Project Using a community-led approach the Ripple aims to improve the quality of life for all ages living in our community by helping people to help themselves. £94,608
The Welcoming Association The Welcoming Association Welcoming Health is a programme of volunteer-led health and wellbeing activities for migrants and refugees in Edinburgh. It is designed to promote active lifestyles, improve wellbeing, reduce isolation and build community between locals and newcomers to the city. £15,339
Venture Scotland Venture Scotland We will deliver four weekend residential experiences, four extended 5-day residential experiences plus 32 x full-day outdoor activity sessions across Edinburgh’s four areas. The programme is designed to build physical, emotional and mental wellbeing, resilience, development of problem-solving skills, building positive relationships and the opportunity to experience meaning and accomplishment £49,615
VOCAL VOCAL This application seeks funding to allow an additional 100+ carers a year to access and benefit from professional counselling, to respond to a growing need for counselling support and help carers manage the severe emotional impacts of many caring situation arising from changing relationships and the effects guilt, anger and social isolation.  £52,607
Waverley Care Waverley Care This project will support populations affected by HIV and Hepatitis C to live healthy positive lives and to achieve their full potential. Through outreach, self-management programmes, peer mentoring, befriending and volunteer opportunities, we will address the health and social inequalities that impact on people affected by these conditions. £191,753
CHAI, Citizens Advice Edinburgh, Granton Information Centre, NHS Lothian Income Maximisation – Welfare and Debt Advice £961,923
Total £4,896,805
Case Study 1:  Health ALL Round – Active Steps: Make a Change
J contacted The Health Agency to self-refer to Active steps which is run in partnership with Health All Round. J wanted to lose weight and become more physically active, to help with his overall wellbeing, mobility and confidence.

J presented as morbidly obese at around 39 stone and had a range of health conditions due to his size including type 2 diabetes, venous leg ulcers, lymphedema, arthritis in right knee, right hip, right and left shoulders and lower back, depression and anxiety and intermittent problems with a hiatus hernia. He felt very self-conscious being in public due to his size.

An initial 1:1appointment was conducted during which an in-depth discussion took place about his wants and needs and what would be the best path for him. J agreed to attend the 8 week Make a Change course via zoom, designed to encourage people to lead a healthier more active lifestyle by providing people with practical tips and information to encourage them to make the changes they want. J attended the zoom sessions weekly and was very engaged with the programme.

To increase his activity further, J agreed to attend the supported gym visits at Engage, despite this taking him very far out of his comfort zone he was keen to try it. He attended the supported gym sessions every week, where his confidence grew and through continued support increased the duration, intensity and range of movement of his exercise programme.

Following 4 months on the initial Active Steps programme, J has now taken out an Enable membership which is the reduced price pathway to gym membership to enable him to attend more regularly and out with the supported gym visit times.

J’s overall wellbeing has improved in a number of ways:

·       His blood sugar levels have dropped and he is now in diabetic remission, he advises his medication has not been changed yet as it needs done by the hospital but says his nurse is very happy with the change in levels.

·       He has also noticed a massive improvement over the last few months in his venous leg ulcers due to moving more and feels the difference he’s experienced in such a short space of time, is similar to the difference that previously had taken a couple of years.

·       His general mobility has improved, he is moving more at home and is able to stand and walk for longer periods and at a quicker pace. He feels there has been improvement in his arthritis as well with his range of movement increasing and the pain decreasing.

Strategic Outcomes:
·       Promoting healthy lifestyles

·       Supporting self management

·       Improving mental wellbeing

Personal Outcomes:
·       Improve Mobility – J has become more independent as a result of increased mobility and is able to carry out personal hygiene tasks and become a more able carer

·       Improve mental health – J believes attending the gym has helped his mental health greatly. His increased confidence allowed him to be more open and receptive the counselling he is receiving and nurses treating his dressings have commented on his increase in positivity and how much more engaged he is.

·       Although J says he knows he has a long journey ahead to get to where he ideally would like to be in terms of his size, he feels he is on the right road and has the right tools to reach his overall destination.

Wider Impacts:
If J had not enrolled on the Active Steps programme his general health would undoubtedly be worse. He believes he would have made little progress by himself, his wounds as bad as they were and he would be on a degenerative slope in terms of pain management, mobility and his diabetes.

Through J’s positive engagement with the programme, he has increased his confidence, improved his mental health and enabled positive changes to his mobility and overall general wellbeing.  He has also inspired his elderly mother to enrol on the Active Steps programme and attend the chair-based exercise class whilst he attends the gym.

Case Study 2:  Caring in Craigmillar – Phonelink Project
A was referred to Phonelink in June 2020 following discharge from hospital. A had a stroke in 2019 and subsequently was re-admitted to hospital in May 2020 due to not medicating correctly as the stroke had left him so fatigued he simply couldn’t grasp which day and time it was to correctly navigate his blister pack. He also has a diagnosis of dementia.

We offered A 2 x calls per day to help him get back on track with this.

When A joined us he tended to stay home as he was worried the overwhelming tiredness he felt knocked his confidence using public transport. He still drives but felt unsafe using his car at the time.

After a few months of calls and keeping A right in taking his medication, we noted a massive change in his mood, and he started getting out in the community again. He reconnected with friends and joined a tennis group. The latter part of 2021, he reported being out and about every single day!

He reported to us that with taking his medication correctly he felt brighter and more able to reconnect with the life he used to lead.

A reported that the calls changed his life for the better. He cancelled his calls in March 2022 as he no longer requires a prompt now his life and routine are back on track and he knows to come back to us if his needs change in the near future

Strategic Outcomes:
·       Supporting Self-management

·       Improving mental wellbeing

·       Reduce social isolation

·       Promoting healthy lifestyles

Personal Outcomes:
With the help of the daily phonecalls and prompts to take his medication, A has been able get back to enjoying life and is now physically active and reconnected with friends.
Wider Impacts:
The support from Phonelink has helped A re-connect with friends and activities and improve his health and well-being to such a degree that he no longer requires the daily check-up calls.
Case Study 3:  Cyrenians: Golden Years Community Connecting Service
B had been referred by a Community Care Assistant to the Community Navigator for additional support with social isolation and loneliness. B is 64, lives with a number of long term physical and mental health conditions and has very limited mobility. She lives alone in a ground floor flat but her bathroom is not adapted to her needs and she struggles to navigate the steps to the main staircase.

During a home visit, where the unsuitability of her flat became apparent, it was also discovered that her low income caused her to struggle with her living costs, and that she would need support to access health care services.

As a result of work with B and a number of professionals over several months the following outcomes were achieved:

• Applications for welfare benefits and charitable grants were successful, leading to income maximisation, more sustainable money management and financial security

• B was made Gold Priority for social housing and is looking to move to a sheltered flat more suited to her needs

• Health services were accessed, including hospital consultations

• Daily phone calls from local voluntary organisation were set up to provide medication prompts and welfare checks; meals are delivered weekly by Cyrenians

• Increased confidence and motivation led to B reconnecting with family members, who now provide emotional and occasionally practical support

Strategic Outcomes:
Early Intervention and Prevention – As a result of joint working with the Cyrenians, B has avoided further deterioration of her health conditions exacerbated by struggling with meeting her living costs. By improving her socioeconomic situation, her access to more appropriate housing and relevant health care services, B is now able to remain living independently in the community.
Personal Outcomes:
B’s confidence increased significantly and her mood also improved enormously. She reported that she had ‘stopped worrying about the future’ and she feels much more relaxed and ‘way less anxious’. She is looking forward to moving into a new accommodation and remains in good relations with her family. She even occasionally ventures outside and meets with her daughter socially (something she would not dream of before due to low income and anxiety) as she no longer worries about her money and ‘what will people think’
Wider Impacts:
Tackling Inequalities – As a result of collaboration with the community navigator B’s  housing priority was reassessed leading to the offer of more suitable housing and her financial resources were increased through income maximisation services enabling her to gain more quality of life and independence. She also increased her social circle and developed stronger links with her local community which lead to increased sense of general well-being, connectedness and improved mental health.
Case Study 4:  Rowan Alba CARDS Befriending Service
D is a 56 year old female refereed via our community referral pathway.

She had been made homeless during the Covid19 pandemic due to her excessive drinking and had been placed in elderly sheltered accommodation. Initially contact was made by telephone, D explained she was in a very bad way. D was extremely reluctant to have a home visit as she was embarrassed about her living conditions but was assured by the service provider that she would not be judged and it was her wellbeing that was important. D agreed to a visit, and indeed her living conditions were bad. D was in poor physical condition, her house was messy and infested with cockroaches, she was lying on a mattress on the floor surrounded by discarded cigarette ends, food containers and empty vodka bottles, and she admitted she had given up.

A trusting relationship was built up over a number of visits and after several weeks D agreed to accept help with her situation. She was helped to move into supported accommodation in the Grassmarket.   D has become very houseproud of her new accommodation and she has been cooking and eating herself.

She has vastly reduced her alcohol intake and following a reassessment of her circumstances has been prioritised for Edinburgh’s Detox Clinic services. D has been attending alcohol recovery meetings and meeting new people. Initially, D was adamant that she didn’t want a volunteer assistance, however, D is now looking forward to meeting her new volunteer and has agreed to attend any outings or events run by CARDS. D is now an advocate for Rowna Alba’s services and often cites the service as “very humane” and has indicated that one day she would like to be a volunteer for Rowan Alba.

Strategic Outcomes:
·       Reduce social isolation

·       Promote healthy lifestyle

·       Improve mental wellbeing

·       Support self-management of long-term condition

·       Provide information and advice

Personal Outcomes:
·       Improved mental and physical health

·       Improved self-management of long-term alcohol condition including reduced addiction

·       Reduced isolation and more opportunities to connect to community

·       Improved confidence and self-esteem

·       Increased support to maintain a home

Wider Impacts:
Our support has reduced reliance on crisis services such as. A&E, emergency housing and social work.

Long term, through being supported to volunteer, clients contribute to strong and inclusive communities

Case Study 5:  Health All Round – Ecotherapy
J is a man in his late thirties who initially presented with suicidal thoughts and anxiety. Initially, the project was unsure if the ecotherapy group would be suitable for him, however, J was very keen to explore a closer relationship with nature, as well as opening up his social circle, and so he was offered a place on the ecotherapy programme.

During the first four sessions, J was very quiet and seemed to be on the periphery of the group. Although the group made him feel welcome, he was visibly shy and clearly uncomfortable within a group atmosphere. He did, however, continue to come along to the weekly group which occurs in various outdoor locations.

After several months of attending the group, one day, J was visibly excited and became very chatty during the group check-in. He said that the ecotherapy group had inspired him to drive to the Borders and climb a hill. Whilst he was up there, he had a moment ‘where I felt just amazing…my anxiety didn’t matter, my thoughts didn’t matter. There were little birds and squirrels all around me and the views were amazing. I felt like I was a part of something big and beautiful.’ Since then, there has been a clear change for the better with J.

J still comes to the weekly ecotherapy group and rarely misses a session. He is now one of the more active group members and he has become popular. He regularly updates us about a friendship that he has developed with a wild fox and he reports on how connecting with nature has been life-changing for him, reporting less anxiety and fewer suicidal thoughts. J has also started socialising with some group members outside of the ecotherapy group.

Strategic Outcomes:
·       Reduced Social Isolation

·       Improved Mental Wellbeing

·       Supporting self-management

Personal Outcomes:
·       J wanted to spend more time in the natural world

·       J wanted to be part of a group

·       J wanted to try this strategy to alleviate his problems with low mood, anxiety and suicidal thoughts.

Wider Impacts:
Building stronger, more resilient communities –

J’s enthusiasm for nature now inspires new group members and he has helped one or two new people to feel welcome in the group. He has gone from being a quiet presence who didn’t seem to be enjoying himself to someone who helps other group members to connect with nature and is an asset to the group.

Case Study 6:
N lives with his wife M. M phoned FAIR to ask for help with a Personal Independence Payment (PIP) review form.  They were allocated an Advice Worker who explains the work done to support them. The couple previously had help from an organisation that closed due to funding restrictions. N and M both attended a special needs school. M gets PIP Enhanced Daily Living and Enhanced Mobility. They get full Housing Benefit and claim as a couple for ESA and M gets the Support group component.

A home visit brought into focus the complexity of their case – M is house bound, she has diabetes and is very obese. She has not left the house in two years and has carers that come to the house to dress and wash her.  The PIP review was completed with both N and M. However, from further discussion, it emerged that N was not in receipt of PIP and had lost his DLA years ago when he began to care for his wife M despite his own limited abilities.

An advisor from FAIR wrote to N’s Dr to ask them about his needs, they wrote back stating that N had a learning difficulty and that he receives medication for migraines.  M had lots of professionals involved but no one was allocated to support N. They were needing to move house as it was not a suitable property for promoting M’s mobility or her personal care needs. FAIR ensured the appropriate Housing association was contacted to address these concerns.

FAIR continued to pursue Mr N’s situation and referred him to the NHS Community Learning Disability Team for a learning disability assessment and supported him through a PIP claim which was successful with both N and M being awarded PIP Enhanced Care and Enhanced Mobility claims.  Mr N was further supported a replace a lost bus pass lost years earlier and a new bank account appropriate for his needs.

Strategic Outcomes:
·       Provide information and advice and promote income maximisation.
Personal Outcomes:
·       Access to a named skilled Advice Worker

·       Personalised Support

·       Reduced isolation

·       Partnership work between agencies to get best outcome for client

·       Working towards better health outcomes

·       Better financial situation. Previously N was relying on food banks and pawning his possession’s and then buying them back paying 35% interest charges.

·       More able to get out and about with a bus pass

·       able to access FAIR independently to support him to manage his financial affairs

·       N able to buy a new washing machine with his PIP backdated money

·       in contact with the housing association and shower installed.

Wider Impacts:
N and M are incredibly vulnerable and need ongoing input from health and social care services.  M and N now have awards of PIP which will make them more financially secure.   They are both less isolated and there are plans for services to help them to work towards moving to a more suitable property and to be more organised in their home.  If N is diagnosed as having a learning disability, it will mean he will be allocated a Community Learning Disability Nurse and his health will be properly assessed and his future care needs better met.
Organisation Proposal Total Grant Award Yr1 2020/21 Yr2 2021/22
Alzheimer Scotland Digital Advisor for people with dementia £83,966 £41,983 £41,983
Community Renewal Reducing urgent care call (LUCs) – health case management providing holistic long-term support for repeat users £39,996 £19,998 £19,998
Edinburgh Development Group Keeping it local – Establishment of a community-based support workers co-operative in South Queensferry £55,489) £27,744 £27,745
Health All Round Lifestyle Management for Living with Chronic Pain – Collaborative GP and third sector initiative £79,066 £39,533 £39,533
LGBT Wellbeing LGBT Mental Health Project – Suicide Prevention Pilot £10,500 £10,500 0
Libertus Libertus Social After Care Project – addressing hospital discharge and readmissions £49,068 £49,068 0
Life Care Creating Connections – Prevention of hospital admissions and readmissions for older people £35,174 £17,587 £17,587
MS Therapy Centre Lothian Breathing better with MS – The development of a preventative model optimising respiratory function in people living with MS £8385 £8385 0
Total £361,644