SEL ICB (Bexley) Health & Wellbeing Coaching and Community Health & Wellbeing Workers (CHWWs) with Social Prescribing Service Specification

Description

NHS South East London Integrated Care Board (SEL ICB) is seeking to commission a Health & Wellbeing Coaching and Community Health & Wellbeing Workers with Social Prescribing Service for the London Borough of Bexley. This service is for those who live in the London Borough of Bexley or are registered with a Bexley GP practice. Following the publication of the NHS 10 Year Plan, Bexley Place is driving forward with establishing a Neighbourhood Health Service in each of its three neighbourhoods. A fundamental component of a neighbourhood health service is to support residents with the wider determinants of health which have an impact on how they are able to manage their long term conditions. The population in Bexley is diverse, both culturally and economically. The borough is split into 3 Neighbourhoods, these are: • Frognal (Sidcup & Bexley) • Clocktower (Bexleyheath & Welling) • North Bexley (Erith, Thamesmead & Abbey Wood) There are approximately 26,000 people living in Bexley who have 3 or more long term conditions. North Bexley is the most culturally and economically diverse part of the borough, with 15,995 residents living in the lowest 20% deprivation decile - this is 15% of the North Bexley population. In the other parts of the borough, the number of residents living in the lowest 20% deprivation decile is 2,774, which is 2% of that population. People living in the most deprived 20% of Bexley have a shorter life expectancy than those living in the least deprived 20%. For females, the gap is 2.2 years, and for males the gap is 5.2 years. Bexley Place seeks an established provider of voluntary services based in the London Borough of Bexley, with a proven track record in currently delivering social prescribing and peer support services. The provider must be an existing key partner of the integrated neighbourhood teams' development in the London Borough of Bexley. The provider must be able to mobilise within 3 months of the contract award. Due to different funding sources for these roles, the recruitment requirements are as follows: 2 wte Health & Wellbeing Coaches - community outreach - 3 years funding 5 Community Health & Wellbeing Workers - North Bexley (hyperlocal focus on Slade Green / Erith area) There is a likelihood that the provider will be asked to further expand this service with additional resource at a later date, however this will be dependent on further funding becoming available. The Health & Wellbeing Coaching service with Social Prescribing Service aims to: • Identify people who would benefit from Health & Wellbeing Coaching, through primary care, the community or self referral • Undertake proactive vital 5 checks through having a presence at key community engagement events and high footfall locations across the borough, to identify people who may have an undiagnosed CVD condition • To support residents to make positive health and lifestyle changes through motivational coaching and support • To signpost and connect people to organisations that can help them, and follow up on their progress and if they require further support • For residents to make health improvements following changes made as a result of their health and wellbeing coaching - reducing the risk of developing other conditions or exacerbating their existing conditions • For residents to feel more able to self-manage any conditions they have, with a reduced reliance on emergency care Community Health & Wellbeing Workers (CHWWs) are a model of social prescribing and are intended to be a highly local, preventative workforce that works directly with residents and households to improve health, reduce inequalities, and prevent problems escalating into crises. Lot 1: There are approximately 26,000 people living with 3 or more long term conditions in the London Borough of Bexley. Under this contract, the provider will be expected to accept referrals from neighbourhood partners, and residents themselves, for Health & Wellbeing Coaching with Social Prescribing - for those living with multiple long term conditions. Whilst the Health & Wellbeing Coaches will have a base at the provider's premises, the expectation is that they will work in multiple locations within the neighbourhood, to meet residents and to work with local partners. The provider will be expected to work closely with SEL Integrated Care Board (Bexley Place) to mobilise, deliver and evaluate the service model. The Commissioner may request that the provider modifies the delivery of the service if the findings from the evaluation or resident feedback gives just reason. The commissioner is seeking to achieve, via this procurement, a service and provider that is committed to supporting the development of neighbourhood models of healthcare. The 10-Year Health Plan mandates neighbourhood models of healthcare and these are currently being developed across England. In Bexley, by 2026, the borough will have in place three neighbourhoods each with a new integrated neighbourhood team. The contract period for the service will be two years (and 5 months) with the option to extend for a further two years. This is a Provider Selection Regime (PSR) intended approach notice. The awarding of this contract is subject to the Health Care Services (Provider Selection Regime) Regulations 2023. For the avoidance of doubt, the provisions of the Procurement Act 2023 do not apply to this award. It is NHS South East London Integrated Care Board's view, taking into account likely providers and all relevant information available at this time, that it is likely to be able to identify the most suitable provider for this service without running a competitive procurement. We are not required to actively invite anyone to express interest but rather seek to notify the market of the intention. For enquiries or to register interest, please contact kieran.james-paterson@nhs.net using the following reference: PRJ2285 Registered interest should be submitted no later than 23:59pm on Wednesday 26 August 2026. Details of the Award Decision-Makers: NHS South East London Integrated Care Board. Additional information: The aim of CHWWs service is to improve wellbeing, increase independence and reduce avoidable reliance on urgent and acute services. The service will: • Build trusted relationships within communities by being embedded in the neighbourhoods they serve and develop ongoing relationships with residents and families. • Provide 5 Community Health and Wellbeing Workers to be based within our most socially deprived communities in the North of the borough targeted at Slade Green/ Erith. • Identify, address and prevent health inequalities working proactively in a defined area of around 150-200 households. • To work in partnership with selected Bexley GP practices (via an honorary contract arrangement) to encourage uptake of preventative and relevant interventions and to be part of the core neighbourhood health teams to support residents. • Empower residents to take control of their own health and wellbeing ensuring they have access to appropriate support and aware of relevant services available. • Prevention centred, aiming to resolve issues at household level before they escalate to help reduce pressures on hospitals, GP practices and social care systems. • To undertake the necessary reporting required to assess impact on uptake of preventative interventions including immunisations, vaccinations, cancer screening, and health check interventions • Undertake all the necessary engagement support available to mobilise the service effectively • Take a whole-person, whole-household approach whereby, rather than concentrating on a single illness or condition, CHWWs look at the wider factors affecting health, including housing, finances, loneliness, employment, social connections, and access to services. • Improve access to services by helping residents understand, access and navigate health, care and community services. This includes signposting, advocacy and supporting uptake of preventive interventions such as screenings, vaccinations, immunisations and NHS Health Checks. • Support prevention and self-management encouraging CHWWs to help people take control of their own health and wellbeing through health conversations, behaviour change support and practical problem-solving. • Act as a bridge between communities and services working closely with GP practices, Integrated Neighbourhood Teams, local authorities and voluntary sector organisations, connecting residents with appropriate support. The key service requirements for this contract term are: • Provider organisation to be an established provider of voluntary services based in the London Borough of Bexley, with a proven track record in currently delivering, community engagement, peer support and social prescribing, together with having strong established links with grassroot organisations • An existing key partner in the delivery of the integrated neighbourhood teams in Bexley • Provider to ensure Health and Wellbeing Coaches and Community Health & Wellbeing Workers receive appropriate training prior to commencing their resident facing role • Provider to provide strategic and operational leadership to the Health and Wellbeing service • Work in partnership with Bexley GP practices to identify residents through active case finding who would benefit from their service • Be able to join up and integrate the data capture so the required health intelligence flows into the medical record • Health and Wellbeing Coaches and CHWWs to be part of the core neighbourhood health team, supporting residents who are living with multiple long term conditions to make positive changes • Provider to have established networks with community organisations that facilitates outreach into the local community (faith groups, local organisations, voluntary and leisure etc.) to raise awareness of their service and encourage self-referral • Provider to have established mechanisms to connect residents into volunteer-led activities taking place within their communities that may benefit the individuals physical, social or emotional wellbeing and lead to lifestyle improvements • Meet residents in a variety of locations including community locations such as Bexley GP Practices, community pharmacy and libraries. • To deliver motivational support and coaching to local residents with CVD conditions who are at risk of developing multiple long-term conditions, to make positive physical and mental health changes. This will include understanding any barriers and challenges they may be facing to make changes, and signposting/introducing them to services/organisations that may be able to help • Empower residents to take control of their own health & wellbeing by ensuring they have access to appropriate support, are aware of relevant services, and have a clear, person-centred exit strategy in place prior to discharge • To have strong established knowledge of local services available at a neighbourhood level, particularly those relating to weight loss, stop smoking, and improving physical/ mental health. • Undertake targeted community engagement campaigns to raise awareness of and improve uptake of targeted health interventions • Act as a champion of Health & Wellbeing, and the voluntary sector, locally, regionally, and nationally • Maintain accurate and timely records of coaching sessions and outcomes using agreed systems and tools • To evaluate and monitor the impact of the Health and Wellbeing roles, with regards to changes in health outcomes and feedback from residents following their engagement - this will be in line with the evaluation requirements for the project • Identify, report, and monitor any safeguarding risks and concerns.