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OutNav DEMO - The Wellbeing Service
Demo Organisation
Date produced • 16/02/2021
Date expires • 17/05/2025
This report has been created using OutNav developed by Matter of Focus.
Contents
1. Background
About this demo
This project is a demonstration version showing how your service or organisation might use OutNav to assess progress in relation to several aspects of your work:
- Supporting people to live better lives
- Sharing their learning and best practice
- Develop and deliver training
The pathways we have chosen reflect common pathways used by organisations we work with and might form the starting point for your own thinking about what you do. They also show the different ways that your organisation might use the tool, depending on your particular requirements. For example:
- Pathway 1 is most carefully evidenced, with data from case studies, a case note review, and information from the client management system.
- Pathway 2 is completed reflectively, giving the team space to consider the difference this systematic process of learning, reflection and reporting is making. There are no external expectations that they report on this process.
Within OutNav, the Library holds a copy of our evidence standards template which guides those working within OutNav on how to assess progress. This can be adapted by each organisation to reflect their own situation.
Aims and objectives
At the individual level, our aim is to support people to improve their wellbeing and to live better lives. We plan to achieve this by:
- Taking a person-centred approach and co-producing a programme of support with individuals
- Engaging and enabling people to identify what matters to them and establishing personal goals
- Providing training
- Signposting individuals to appropriate services
- Empowering people to manage their own wellbeing and achieve their personal goals
At an organisational level, our aim is to capture and share learning to improve the service. We plan to achieve this by:
- Routinely capturing learning and sharing best practice among practitioners
- Creating a practice of embedded learning
Context for delivery
The Wellbeing Service is based in a Scottish city and is run specifically to help people within the local community. It provides a statutory service commissioned by the local health and social care partnership and has been operating since 2016.
We provide a holistic service that helps people who are experiencing poor physical and mental health. We use an individualised approach in order to respond to people’s specific situations and empower them to make changes to improve their health and wellbeing.
Methodological approach
The work shown in this report has been carried out using the Matter of Focus approach. The Matter of Focus approach is a theory-based approach to outcome monitoring and evaluation, learning and improvement that builds on contribution analysis. In using the approach, we have gone through a logical and structured process of:
- Developing a theory of change for our project informed by an understanding of the context in which we operate.
- Agreeing one or more outcome maps that show how we think our activities contribute to outcomes, and what needs to be in place to make this happen.
- Identifying clear change mechanisms by which our project or programme works, these are shown in our pathways.
- Developing a plan to gather data to understand whether or not we are making the progress towards outcomes we hope. This includes integrating current data and information we collect, as well as capturing data specifically for this purpose.
- Systematically reviewing this data against each of the stepping stones for each pathway in the outcome map.
- Summarising key findings against each of the stepping stones to tell our contribution story.
This report has been produced in OutNav. OutNav is the online workspace developed by Matter of Focus to enable organisations and initiatives to understand and track impact, evaluate outcomes, monitor performance, and assess quality, so that they can make the best difference possible.
2. Our pathways
3. Risks and assumptions
Risks
- Economic crisis negatively impact services being delivered in the locality
- There are multiple things going on in peoples's lives that affect their ability to make a positive change
- People most in need of support are not in regular contact support with services and may not be referred
- Staff don't have the knowledge and skills or supervision to work in these ways
- Learning is not seen as valuable or generated in a form that is credible to influence change
- People are overwhelmed and confused by the variety of support for wellbeing
Assumptions
- Partners willing to work together in collaborative and multi-agency way
- Staff have the knowledge and skills to deliver this kind of support.
- There is sufficient time and resources for staff to be able to work with people in the way that works for them
- There are appropriate supports that people can be signposted onto
- Participants make and sustain change through the service and engage with services appropriately over the longer term
4. Pathway 1: Support people to improve wellbeing Pathway progress
Pathway legend Close
| Great Progress |
Some Progress |
Low Progress |
|
|---|---|---|---|
| High Confidence | |||
| Some Confidence | |||
| Low Confidence |
This image shows a high-level summary of how well the project is progressing and how confident the team is in the evidence. The key shows how the colour coding works.
See the standards against which progress and evidence have been assessed.
5. Pathway 1: Support people to improve wellbeing Detailed findings
Pathway: Pathway 1: Support people to improve wellbeing
Have good conversations with people about factors impacting on their wellbeing and what they can do to change
Our service supports people to make the positive changes in their life that they wish to see. We do this by providing one-to-one sessions with a practitioner and supplementary facilitated group sessions, which provide our clients with an informal network of peer support.
As a statutory service, most of our capacity goes towards supporting individuals referred to us through their engagement with other services. Individuals who feel they require our service can self-refer, but this accounts for the minority of our service users.
We operate on a first-come first served basis with referrals processed monthly. On average, the time between an individual submitting a referral and attending their first meeting is approximately six weeks.
Our flyer describes the support we offer, our approach and contact details for the self-referral process:
Once a referral has been processed, individuals are invited to attend an initial consultation at one of our centres. The individuals that our service caters for often have a variety of complex needs and we have learned to adapt to accommodate our clients. We offer telephone consultations or home visits, if necessary, to individuals for whom attending a meeting at our centre is not an option. These alternative arrangements are offered to all individuals.
Each month in 2023, we had an average of 204 good conversations with clients. This includes an initial meeting with a practitioner where clients can discuss the challenges they are facing in their own words. The client and practitioner then work together to establish personal goals and outcomes.
Our good conversations include follow-up meetings, where clients can discuss their progress towards their goals, learn new coping strategies and get further support. These conversations can take place at our centre, in clients' homes or over the phone, as necessary.
Given the range and complexity of the needs of our clients, the framework is purposefully loose as it allows it to be adapted easily to meet their needs. Whilst the final outcome varies between clients, a typical client journey involves helping them to define personal goals; building on the skills and resources that they already have; providing support to achieve these goals, and then reflecting on how their wellbeing has been improved.
We run group sessions and deliver wellbeing courses
Service Users Attending a Group SessionOur group sessions are supplementary to the one to one support we provide. They are facilitated by our practitioners and act as an informal peer support network for our clients. We host five tea and coffee meets a week. These are popular, with an average of 20 clients attending each session. These are important as they allow our clients to socialise in a safe and supported atmosphere.
We are looking to expand this service in the future by providing activity sessions for our clients, but we currently do not have the capacity to offer this.
Some feedback on the group sessions gained from a feedback wall:
We capture learning from our work and share best practice through regular reports
People experiencing poor health and wellbeing
We work predominantly with local people in our community. Over the last year (2023) we engaged with over 600 people, of which 88% were from the local community. This means we know we are engaging with our target audience. Our service is for people experiencing poor health and wellbeing, the complexity of lives is expressed through the variety of self-reported health conditions and inequalities. Some of the most frequently reported conditions and health inequalities are: depression, anxiety issues, chronic pain, mobility issues, alcohol and/or drug misuse, weight management issues, long term conditions, stress and chronic fatigue.
Of the individuals that use our service; 62% are female, 37% are male and 1% are transgender or non-binary. Our service caters to a wide age range of individuals, ranging from 18–86 years old, with the most common age category being 30–40.
As the graph shows the number of people using our service has increased over time. We expanded our capacity in 2021 and in 2023 which allowed more people to use our service. We have also strived to increase awareness of our service among health practitioners in the past two years which may have resulted in an increased number of referrals.
Additionally, as highlighted in the graph, there are still considerably fewer people attending their first meeting than are referred. This is likely a reflection of the complex and multiple issues that referred people may be experiencing, impacting on their ability to access the service once referred. However, this is an area we are working on by using multiple strategies to follow up referrals and make the initial meeting as accessible as possible. We have seen some progress on this issue with the percentage of referrals attending their first meeting increasing from 42% in 2021 to 54% in 2022 and 68% in 2023.
In 2023, we delivered a total of 2454 one to one conversations with clients and group sessions with a total attendance of 1352, as this chart illustrates. It should be noted, that these figures represent the total use of these services by our clients in that year, and that many clients made use of our services more than once, with the clients attending an average of 3.9 one to one sessions and 2.2 group meetings.
We are aware, however, that there are some people in our local community that could benefit from this service that are not currently accessing it. We have a limited budget and marketing expertise, therefore we have had to be creative with how we promote the service to these groups. To this effect, we have distributed our flyers through various new channels and organisations and will monitor future referrals to understand the impact.
This is a good conversation and I feel ready to make a change
Having good conversations forms the basis of our approach. It is about helping our clients to identify what matters to them, what their strengths are and then empowering them to make the positive changes they want to see.
Our case note review revealed that people overwhelmingly valued the service we provide. This process revealed several emergent themes:
- Rather than medical interventions, there was an emphasis by practitioners to understand the root causes of the problem
- There is a personalised/bespoke element to the service which resonated with individuals
- Individuals felt that their concerns were being listened to and that they were given ample time to express themselves
- Individuals were directed to consider solutions collaboratively - choosing what to do was important and provided a sense of empowerment
It is important that our clients feel that they can develop a meaningful relationship with their practitioner and that they feel they are being listened to. This is because having a strong rapport is fundamental to facilitating our clients' continued engagement with the service. We have recorded some informal evidence which supports our progress towards achieving this, but it is something we aim to formalise as we move forward in our data capturing processes.
A risk we have identified is that, given the complex needs of the people we work with, they will not feel able to make a change. Fortunately, over the previous year, we have found that a minority of our service users are in this situation.
The quotes below illustrate how some people who use the wellbeing service feel about it. This data was gathered from a feedback wall in the centre where clients could anonymously write their feedback, feelings and opinions of the service and the support they received:
This is for me
Rather than being a measure of progress, change or development, we take "this is for me" to mean; do people feel that the service we provide is supportive and will benefit them?
Our primary quantitative figure to support this is the number of individuals that continue to engage with the service after their initial consultation, which almost three-quarters (73%) do.
Additionally, some former clients/service users still maintain contact with practitioners and drop into the centre to catch up and let us know how they're getting on. This continued involvement with the service supports our understanding that we provide a type of support that is not available to our clients elsewhere.
These quotes, gained from the feedback wall in the centre, also illustrate clients feeling that the service is something that caters to their needs and responds to their experiences.
People feel this is relevant and important to their role
People know what matters to them and have the knowledge, confidence, skills to change
Part of our approach involves developing a detailed plan of support with people using our service. This plan outlines their personal outcomes and practical steps to take towards achieving these personal outcomes and highlights coping strategies found to be effective. We find that clients appreciate having a tangible/physical copy of their plan as it can be a motivational tool.
Part of our work is to help clients set practical/achievable goals, which can require some tactful negotiation.
One client approached us with an interest in returning to work following a bereavement. Following our initial consultation it became clear that other issues in their life had to be addressed first, and that returning to work would have been too much of a leap and may have had unintended consequences. Instead, we encouraged them to seek the help of a specialised bereavement counsellor and to implement a daily routine to regain some control and normalcy in their life.
Group session feedback showed that attending regularly was a positive indicator of increased knowledge, confidence and skills to change. Because of this, the service needs to ensure clients are coming regularly to group sessions and reach out to those who may need support if they are not attending. Of the clients who did attend the group sessions regularly, they reflected on having improved knowledge and confidence. However, no data was collected on whether they had gained skills relating to improving their wellbeing.
Some of our clients' aspirations for the futureSetting achievable personal goals is an important aspect of the work we do with individuals who engage with our service. The following table indicates the sort of personal goals that our clients set out to achieve and how many of our clients feel they have achieved them.
Access to a range of relevant community supports and services
People that use our service are referred to a number of services. Listed below are the categories of services that people have been referred to. (Note: some clients are referred to more than one service).
Specialist Counselling: 279
Financial Services: 194
Health Services: 364
Community and Support Groups: 404
Additionally, 30% of our clients received subsidised passes which provide them with access to some leisure facilities throughout the local area.
We have strong relationships with our partner organisations and have informal feedback from them which suggests there has been an increase in the uptake of their services as a result of our referrals. However, the extent of the uptake of this support is unclear to us as there are still improvements needed in gaining formal evidence from our partner organisations on the number of people who have been appropriately referred.
A recent case illustrates the typical support we provide: a client struggling with the social isolation of being a single parent. In addition to attending our group sessions, they were referred to a group for single parents which they attended. As a result of this combination of support, the client reported that they had learned strategies to cope better with the demands of being a single parent and that they had formed meaningful connections with other group members which helped to alleviate their feelings of social isolation.
People make changes and actively manage their wellbeing
For those who have been attending sessions, there have been a number of clients who have described a positive change to their health and wellbeing. People have mentioned making a number of changes to improve wellbeing independently. This was quite often as a result of feeling supported by their practitioner and the wider network that the group sessions provide. This included seeking out community groups, attending other events which they had been referred to and engaging with appropriate services.
We are yet to conduct a systematic review of client case notes to better understand our clients' outcomes, but this is something we aim to undertake in the future as it will give us a better understanding. The following quotes were surfaced during a recent case note review:
People access support from appropriate agencies
This is an area where our data capturing could be improved. What we know about our progress towards this stepping stone is informal and has not been collected in a systematic way. As detailed earlier in this report, we currently know services and organisations that we refer people to but we do not know the uptake of this, apart from what clients relay to us. We are currently in conversation with the local HSCP and relevant partner organisations about developing and implementing a formal way of recording successful referrals.
Informal feedback from reflective impact logs with people we support has been very positive for those who were referred to other services. For example, comments made by individuals who use our services include:
People have improved wellbeing
Informal reflections from clients captured during group and one to one sessions with practitioners suggest that the service is having an impact on the wellbeing of our clients. We frequently have clients tell us that they feel more in control of their lives; have an increased sense of confidence; have made new friendships; or are actively taking steps outside of their comfort zone in ways that they would not have done before being referred to the service.
Whilst we do know that we are improving the wellbeing of some of our clients - the lack of a systematic review of the evidence we have means we cannot be entirely confident in the extent of this progress.
The quotes below were gained from the anonymous feedback wall in the centre, and highlight the ways in which some clients have experienced improved wellbeing after accessing the service.
One case we are particularly proud of.
Services are used more appropriately
We know that a number of our clients have been successfully referred to appropriate services as a result of accessing support from the wellbeing service. This has surfaced during reviews of clients' case notes and practitioners' reflective impact logs.
However, there is not currently evidence being collected on the uptake of referrals to partner services, which we are working towards implementing. Until then, we can only rate the service as having no progress and low confidence. We hope to see this improve over the coming year as we begin to conduct a systematic review of our current evidence and a redesign of our evidence capturing practices.
Additionally, service provision in the local area is limited and there is an acutely high demand for those that do exist. This complicates our contribution to services being used more appropriately in the local area. Until there is an increase and diversification of the number and types of services provided which adequately meets the needs of the local population we cannot say with confidence that we are making progress towards this outcome.
6. Conclusions
Conclusions
Overall, we are making strong progress towards achieving our outcomes.
The services and activities we offer to our clients to support their wellbeing are robust, well received and grounded in a practice that enables us to met the needs of our clients no matter where they are on their journey.
Similarly, we know that the clients we attract are our target audience and we have continued to grow our service in this respect seeing year on year increases in engagement with our service.
The majority of clients that engage with our service report that we have helped them to develop a better understanding of themselves, and the changes that they would like to make and have then provided them with the necessary tools and supports to make these changes.
Areas that need development/we are still working towards is ensuring that services are used more appropriately. We are currently trying to implement a more formal and systematic inter-agency data capturing service to better understand the uptake and pathways of referrals to services throughout the local area. However, our primary challenge to ensuring the appropriate use of services in the local area is the diverse needs of the population and lack of services to refer people to. Without appropriate services to refer people to, it is difficult to ensure that services are used more appropriately.
7. Pathway 1: Support people to improve wellbeing Sources and Success Criteria
This table lists the sources of evidence and success criteria that we have referred to whilst developing the analysis presented in this report.
What we do
Stepping Stone
Source
Have good conversations with people about factors impacting on their wellbeing and what they can do to change
Client database
PID
Service charter
Success Criteria
Number of points of engagement by staff with people we support
Service is based on a strong evidence base and values
We run group sessions and deliver wellbeing courses
Group session database
Service charter
Service user feedback board
Success Criteria
Descriptions of what people tell us about the service
Group sessions are underpinned by a clear plan and values
Number of group sessions delivered per month
We capture learning from our work and share best practice through regular reports
Training feedback forms
Success Criteria
No success criteria
Who with
Stepping Stone
Source
People experiencing poor health and wellbeing
Case note review
Client database
Monthly reports
Success Criteria
Age, gender and SIMD of participants
Description of presenting issues
Number of people accessing group sessions each year
Number of people accessing one to one support each year
How they feel
Stepping Stone
Source
This is a good conversation and I feel ready to make a change
Case note review
Case studies
Service user feedback board
Supported person reflective impact log
Success Criteria
Description of what people tell us about the service
Staff report people feel this is a good conversation and they are ready to change
This is for me
Client database
Service user feedback board
Success Criteria
People tell us this
People use the service more than once
People feel this is relevant and important to their role
No sources
Success Criteria
No success criteria
What they learn and gain
Stepping Stone
Source
People know what matters to them and have the knowledge, confidence, skills to change
Case note review
Client database
Reflective Impact Log: Activity
Supported person reflective impact log
Success Criteria
Description of change in skills and confidence to manage wellbeing
Percentage of people for whom there is a personal outcome recorded
Summary of types of personal outcomes people are working towards
Access to a range of relevant community supports and services
Case note review
Team reflections
Success Criteria
Number of people accessing relevant services
Number of people appropriately referred to other services
What they do differently
Stepping Stone
Source
People make changes and actively manage their wellbeing
Case note review
Supported person reflective impact log
Success Criteria
People report making changes to improve their health and wellbeing
Practitioners observe people making changes
People access support from appropriate agencies
Case note review
Client database
Supported person reflective impact log
Success Criteria
Number of people referred to appropriate services
People tell us this
What difference does this make?
Stepping Stone
Source
People have improved wellbeing
Case studies
Monthly reports
Supported person reflective impact log
Success Criteria
% of people whose WEMWEB scores have increased from initial appt to review
People report improvements to their wellbeing
Practitioners observe changes to people's wellbeing
Services are used more appropriately
Case note review
Client database
Supported person reflective impact log
Success Criteria
Number of people referred to services
People tell us this
8. Our evidence standards
Progress ratings
Progress Statement
Criteria
Great progress
- Enough people and groups experience this in the timescale you have defined
- Risks have been mitigated and assumptions achieved
Some progress
- Some people and groups experience this in the timescale you have defined
- Some risks have been mitigated and some assumptions achieved
Low progress
- Not enough people and groups experience this in the timescale you have defined
- Risks have not been mitigated and assumptions found to be unrealistic
Confidence ratings
Confidence assessment
Criteria
High confidence
Most of these criteria apply
- more than one source of evidence with appropriate balance of types
- evidence collected purposefully and for this purpose
- reasonable number of responses
- no disagreement between evidence sources
- backed up by other research
- analysis is clear and purposeful (someone else could replicate and get broadly the same results)
Some confidence
Some of these criteria apply
- more than one source of evidence with appropriate balance of types of evidence
- evidence is collected purposefully and for this purpose
- reasonable number of responses
- no disagreement between evidence sources
- backed up by other research
- analysis is clear and purposeful (someone else could replicate and get broadly the same results)
And / or
- there is some disagreement or lack of clarity of the findings
- the data is mostly gathered opportunistically
Low confidence
Few of the above criteria apply AND / OR
- there is disagreement within the data
- assessments are based solely on an individual's perspectives
OutNav DEMO - The Wellbeing Service
Date produced: 16/02/2021
Date expires: 17/05/2025