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Emerging from the pandemic to deliver greater social value

Published October 2022

1. Welcome from our Interim Chief Executive, Julie Sharma

Welcome to our 2021-22 Impact Report. 2021-22 was another year of change for Sirona, as we emerged from the pandemic a changed organisation; more resilient, and even more committed to local people in our communities, as we shared our vision of Improved Outcomes for All.

And ensuring this is for ‘All’ reflects our commitment to making our services really accessible, so we give everyone the opportunity to enjoy the maximum health and wellbeing they can.

If Covid-19 has shown us anything, it is the stark inequalities that have existed across our communities for a very long time. Did you know that across Bristol, North Somerset and South Gloucestershire, a boy born today in one of our most deprived communities will have a life expectancy of 10 years less than a boy born into our least deprived area? We need to ask ourselves what we can be doing better to address this.

Our vision is also about our colleagues. How do we ensure that we improve outcomes so there are equal opportunities for all, and so that Sirona is a great and inspiring place to work?

To support us in doing this we have set ourselves the Mission of One You, One Sirona, One System.

One You is about seeing everyone as an individual – putting them at the centre of everything we do, and seeing them as a person first, focussing on achieving their aspirations and tailoring what we do to their needs and unique circumstances.

One Sirona means harnessing the full range of talent and experience we have across the whole organisation and ensuring the ‘whole’ really is greater than the sum of our individual parts. Working together makes us stronger and better as we use our experiences of the past two years to develop and grow.

One System ensures that, in the same way as we will harness the strength of Sirona as a single organisation, we also work with others across our system to ensure that staff can fulfil their potential through working across boundaries easily if that makes sense for them, and / or services. We will also ensure that our communities receive joined up care to meet their needs, irrespective of which organisation is delivering that care and support.

Over the last year, we worked hard to embed technologies and innovations that we developed during the pandemic, with the aim of achieving more through our care and adding value to all that we do.

In some services we were able to support a greater amount of people through increased use of video appointments, as the examples in this report demonstrate. We also used digital apps, webinars and videos to support health promotion and self-management of care.

Effective collaborations with partners have enabled us to achieve more through our work. We have some really inspiring partnerships with a wide range of voluntary and community organisations as well as our local councils. They have enabled us to support local people to maintain wellbeing during some incredibly challenging world events, including the rising cost of living and an influx of vulnerable refugees from Afghanistan and Syria.

In this second year of our contract for providing adults community healthcare, we have worked hard to ensure that residents across Bristol, North Somerset and South Gloucestershire have equal access to the services we provide, and parity of healthcare experience. This has resulted in service transformation across our Stroke, Musculoskeletal Physiotherapy Service and our Learning Disabilities Liaison service, amongst others.

Ensuring equity is also key to the transformation taking place in our Public Health Nursing Services within our Children’s Services directorate. We want to ensure we have an equitable and evidence-based service across Bristol, North Somerset and South Gloucestershire for children, young people and their families; with a focus on prevention, early intervention and reducing inequalities. We also want to ensure services are placed-based and tailored to an individual’s needs.

We hope to consolidate this approach to reach more and achieve more in the future. Through our People’s Council we want to ensure that all members of the community have a voice in shaping the way community healthcare services are delivered, so we can continue to make a real difference for all by tackling what matters to you.

Case study: working with our community of colleagues

With over 3,700 colleagues in our organisation, living and working across Bristol, North Somerset and South Gloucestershire, we see our team as a community in its own right. Our co-workers contribute to the local economy, attend local schools and are active recipients of our care – as well as being the people who deliver that care – so we work hard to get their input on our activities in this area. We also use community spaces for meetings and clinics which supports local facilities to continue to thrive.

Looking after our team is also a huge priority for our organisation, especially after the pandemic. That’s why we introduced new wellbeing initiatives in 2021-2022, including an improved Employee Assistance Programme and wellbeing coaching and training. More recently we have continued with this work and introduced other initiatives, including protected breaks and learning time, team building budgets, an extra day of leave and thank you cards to all colleagues.

Staff numbers

Staff Numbers

2. Introduction to social value

As a Community Interest Company, social value is at our heart. It is written into our Articles of Association and drives our purpose to contribute to the wellbeing and resilience of individuals and communities.

What do we mean by social value? Social value is a long-term, ongoing commitment to achieving wider social, economic and environmental benefits through the work that we do. Through this report we aim to evidence how and when social value has been achieved through our service delivery, and the impact that this has made on our plans for the future. We want to build on this work to ensure we have clear data to illustrate the impact of what we are doing.
We are involved with a lot of people creating really positive benefits in our communities. Due to the wide and diverse range of our activities, it is not possible to report on all we do, so instead we have focussed on a representative sample we have developed and delivered.

We know that the work we do creates different outcomes and means different things to different people. The value that others place on these changes helps us decide how to build on these, and we use feedback to enable us to make these decisions.

2.1 Case study: The Sirona Foundation

The Sirona Foundation is a charitable company established to support the health and wellbeing of communities, especially in areas served by Sirona. The Foundation’s purpose is to fund equipment or projects that enhance health and social care services, so that local people using these services can maintain their independence, continue with their daily lives and achieve the best possible health and wellbeing.

Fundraising activity is often undertaken by Sirona colleagues. Over the last year, the Sirona Foundation has provided a new minibus for the Carrswood Day Centre in Bath, a local service for people with learning disabiliites, along with a roundhouse building to be built in the grounds of the Centre.

The Foundation also funds a Secret Santa initiative for vulnerable people who use our services during the festive period, with nominations made by colleagues from across our organisation. Last year, a variety of gifts were donated, including warm winter coats, blankets and shoes. The purpose is to ensure that those in need know that someone is thinking about them at a special time of year.

3. Embracing change

We have emerged from the pandemic as a more flexible and resilient organisation, with an improved ability to use technology to provide remote healthcare. Work to include video appointments began in 2020-21, and has steadily increased year on year. Where possible we give people a choice as to how they would like to be assessed, offering remote assessments, as well as face-to-face healthcare, depending on the service.

This has a number of advantages from a social value perspective. We know that not everyone can easily get to face-to-face appointments; by providing video appointments, we can increase the satisfaction of many individuals, who prefer to receive care in the comfort of their own home. By removing their need to travel, we also reduce the carbon footprint of our services.
We have combined this work with an increasing amount of digital healthcare, using apps and online programmes that encourage service people to self-manage their condition in the most effective way.

All of this is reflected in our data, which shows that for certain services a higher proportion of contacts are now taking place remotely and that this has had a positive impact on the overall number of people we are able to support:

Unique visitors to
Between October 21 and September 22: 194,307,
Top 10 visited pages:

1. Home page
2. Adults services
3. Contact us
4. Work with us
5. Minor injuries and urgent treatment
6. Virtual covid ward
7. Who we are
8. Yate Minor Injuries Unit
9. Single Point of Access (SPA)
10. Our Vacancies

3.1 Case study: Musculoskeletal Physiotherapy Service (MSK)

When our MSK Service first started delivering physiotherapy across Bristol, South Gloucestershire and North Somerset, there was variation in the way each area delivered their services. In addition, there was no shared resourcing between the three areas, which led to variation in the waiting times for people who needed treatment. This meant individuals in North Somerset were waiting 12 weeks to get an appointment, whereas people in South Gloucestershire were waiting almost a year.

Health equity is achieved when everyone can attain their full potential for health and wellbeing, regardless of who they are or where they live. As health equity is important to us, resolving these discrepancies became an overriding priority for the team.

To enable this, the service was reconfigured so people could choose where they could have an appointment regardless of their postcode. The workforce skill mix within the teams was also adapted, enabling greater capacity in some areas. The service also encouraged individuals to consider remote as well as face-to-face contacts. These measures worked and the service now has an average waiting time of between 10—12 weeks, in line with national standards.

As well as tackling waiting list discrepancies, the team submitted an entry to become a pilot site for an NHS England and Improvement initiative entitled The NHS Digital Weight Management Programme. Their aim was to remotely support people with osteoarthritis to self-manage their weight, so they can better manage their condition.

The 12-week online behavioural and lifestyle programme can be accessed via a smartphone or computer with internet access, and it involves a combination of digital weight management information and coaching, depending on the needs of the sevice user. The team hope that initatives like this will have a lasting positive impact on the health and wellbeing of those in their care – in addition to the direct benefits involved in terms of managing their condition.

3.2 Case study: roll out of myCOPD App

Supported by the West of England Academic Health Science Network, the health system across Bristol, North Somerset and South Gloucesterhire was awarded funding from NHSX’s Digital Health Partnership Award to roll-out a new app, alongside digital health champions, to support people with Chronic Obstructive Pulmonary Disease (COPD). myCOPD provides guides on self-management, how and when to take medication, pulmonary rehabilitation and more, to help individuals recover and manage their condition effectively at home.


How remote appointments are helping us to serve more people

Learning Disability Service:



increase in number of contacts: from 24,311 in 2020-2021 to 29,669 in 2021-2022


of contacts occurring remotely, 29% face-to-face

Covid Oximetry and Long Covid Services:


increase in number of contacts: from 2012 in 2020-2021 to 17,824 in 2021-2022.


of contacts occurring remotely, 3% face-to-face.

4. Working with our communities

Our work ensures that we have direct contact with the many diverse communities across our geographical area. We always work hard to maximise this contact so communities do not experience barriers to healthcare, and they are supported to take an active and engaged role in their health and wellbeing.

4.1 Case study: the invaluable role of our Health Links team

Our Health Links Team provide an essential interpreting and advocacy service to many of our diverse speaking communities, supporting residents whose first language is not English. The team provide immediate interpretation to people who require GP advice and appointments, and they also signpost and advocate for wider aspects of health and social care support. Over the last year, a variety of health promotion activities have taken place, including supporting communities to widen their social networks and to take an active role in their health and wellbeing. These have included:

  • Nordic walking coaching and walking sessions.
  • Mental health ‘check in and chat’ sessions for Bengali speakers.
  • Community badminton coaching and play sessions.
  • Planning work with Penny Brohn Cancer Care, a local cancer care charity, to engage seldom heard communities at cancer equity events.

4.2 Case study: working with The People’s Council

Our People’s Council is a group of individuals with lived experience of healthcare who provide feedback on our planning and decision making and help to shape our future plans.

Over the last few years we have increasingly worked with the People’s Council to help us decide on our priorities and to design and monitor our services. This ensures:

  • We find the best ways to support communities.
  • We meet the needs of the diverse population that we serve.
  • We provide real social value and make a meaningful impact.

4.3 How The People’s Council has guided us in 2021-2022

The impact we have made for our people and communities


Vaccination Service facts

We introduced a new digital consent system for children and young people’s vaccinations, the benefits include:

  • Environmental: no printing required, and we no longer need to travel to pick up the forms from schools.
  • Clinically safer: forms no longer ‘go missing’ and the system enables fast identification of outstanding consents.
  • Efficiency savings: parent/carers are able to see at a glance what they have consented to, and when children have had their vaccinations. No storage or achiving required.

“Just like to take this opportunity to say a big ‘thank you’ to you and all of your team for all that you are doing to getting the vaccine out to everyone and now, to our children. You are all amazing!!”

“I just wanted to thank you for being so kind and professional at my child’s school yesterday. You really helped to put my daughter at ease and the consent forms were quick and easy to complete. I appreciate how much pressure you are all under so a special thanks for everything you are doing.”

Working with our communities
working with The People’s Council
Board members

Recruitment of Board members.


Redesign of our Single Point of Access (SPA) service.


Focus groups for: developing our Hospital at Home Service and our Dermatology Service.


Feeding back on our Quality Priorities.

Vaccination Service facts

5. Partnerships and Community Development

Since emerging from the pandemic, a number of world events have impacted communites across our geography. These have included steadily worsening living and energy costs, the war in Ukraine and an influx of refugees from Afghanistan and Syria.

We maximised our social value by adapting our services and working in partnership with people and organisations across the area we serve. Our aim is to ensure the basic needs of individuals are met and local people are supported to manage their mental health in the best way possible.

We worked with six Lead Voluntary, Community, Faith and Social Enterprise (VCFSE) Locality Partners to work closely with the communities we serve:

  • Bristol North & West: Southmead Development Trust
  • Bristol Inner City & East: Wellspring Settlement
  • Bristol South: Knowle West Healthy Living Centre/BS3 Community
  • North Somerset Woodspring: Citizens Advice North Somerset /VANS
  • North Somerset Weston, Worle & Villages: Citizens Advice North Somerset /VANS
  • South Gloucestershire: Southern Brooks Community Partnerships

Through these relationships we were able to have a greater understanding of the needs of our very different communities.

Pictured above: A mental health and wellbeing event with RETHINK for the South Asian community.

5.1 Case study: Fishing for Wellbeing Partnership

Our Fishing for Wellbeing Partnership is a new initiative, organised by our Health Links Service and Wellbeing Leads, working in partnership with funders Wesport and The Angling Trust.

Shahnaz Chowdhury, from Health Links, thought of this opportunity to bring people together after the pandemic, while keeping in mind that fishing is a lifestyle in Bangladesh as fish and rice is part of their main diet. Shahnaz said, “When visiting Eastville Park during lockdown, I saw people fishing in the lake and the idea sparked from there.”

Fishing coaching took place by the harbourside and included groups from different communities including Bangladeshi, Chinese, Indian, Pakistani and Somalian. The Partnership found that fishing sessions were easy to plan, cost very little, and that they bought together people of varied ages, races and genders – making it a truly diverse and intergenerational activity.

Funding was sourced to provide fishing rods and equipment, and several members of the original group are now trained fishing coaches. The group is now a thriving entity in its own right and a successful example of a community asset transfer – where resources are handed over to local communities to run themselves.

Pictured above: a local community health event at Easton Community Centre, Bristol.

5.2 Case study: working with partners to offer support around rising costs of living

One in five British people say they can’t make ends meet as a result of rising inflation. With this stark fact in mind, our Wellbeing Leads are working closely with Bristol City Council and a range of voluntary and community service partners this year, to support people who are experiencing difficulties due to the rising cost of living.

The aim is to signpost people so they can get help and to support healthcare professionals so they share relevant information.

Planning work has focused on the following areas of priority:

  • A public campaign on getting ready for winter.
  • The development of 27 volunteer-led community hubs, to coordinate local responses and action.
  • Creation of welcoming and warm community spaces, which are well heated, have food and have charging devices– e.g. libraries.

5.3 Case study: community celebration to support mental health and wellbeing in ICE Inner City and East Bristol

Our Wellbeing Leads worked with Bristol University Researchers, Bristol Black Carers, Nilaari, CASS, Bristol Somali Resource Centre and the Independent Mental Health Network, to plan a free Community Celebration of Mental Wellbeing event in Bristol later in the year.

The event was planned for autumn 22 at the Wellspring settlement. The aim was to bring different people and communities together to find out what is available to support mental wellbeing. It included:

  • Somalian food.
  • An interactive drumming group.
  • Talks from Nilaari.
  • An interview panel of people who have used meaningful and fun activities to bolster their mental wellbeing e.g. fishing, nordic walking, football, paddle boarding.
  • Breakout tables with facilitators and interpreters, and support for Bengali, Cantonese, Mandarin, Somali and Arabic speakers and BSL signers.

5.4 Case study: Caring at Christmas

Caring at Christmas is a charity-led initiative which this year supported people experiencing homelessness over the Christmas period with a day centre, when other venues were typically shut. Food, clothing, support, companionship and activities were offered everyday for a week in a warm and inclusive space, and our mobile vaccination team were approached to offer vaccinations on site.

“We were very happy to support Caring at Christmas with an offer of on-site vaccines and pleased with the number we were able to give during a crucial time in the pandemic. Vaccination clinics are not easily accessible for people experiencing homelessness, and there is a high level of vaccine hesitancy in the population, so Caring at Christmas provided a great opportunity to deliver a high number of doses in a discreet and accessible setting.”

We vaccinated 34 people in total, six of whom had never received a vaccine before. In addition to our vaccine offer, specialist nurses from our outreach team who support people experiencing homelessness were able to come along too, to meet up with some people known to them, and to promote their service to others. Our hope is to expand our offer further next year with a more comprehensive health check provision.

mental health and wellbeing event

Pictured above: A mental health and wellbeing event with RETHINK for the South Asian community.

Fishing for Wellbeing
Fishing for Wellbeing
community health event

Pictured above: a local community health event at Easton Community Centre, Bristol.

5. Equalities

With support from our Partnership and Community Team, and our Equality, Diversity and Inclusion Team, we continue to amplify the views and voices of our communities, and to advocate for people who face barriers in accessing health services and support.

In addition to our Health Links interpretation service, we worked with our main language provider to provide essential interpretation and translation support for diverse speaking communities, as well as braille support. We also worked in partnership with our British Sign Language (BSL) provider to support Covid-19 vaccination films and promotions.

58 languages interpreted within Sirona over the last year


6.1 Case study: our work to reduce health inequalities in communities

Alongside equitable healthcare, it is important to us that everyone should have a similar experience of high quality healthcare – known as parity of experience. Over the last year, we have actively addressed reducing health inequalities. This is helping us identify innovative approaches to increase greater parity for our communities. Our Interim Chief Executive, Julie Sharma, leads our organisation in this area, and we have set up a new Health Equity Network Forum to share best practice and build on our commitments. We have also embarked upon an ambitious programme to transform our data records system, to align older systems, and to equip us to ask and record the many diverse needs and identities of the people we serve.

6.2 Case study: our work to improve Equality, Inclusion and Diversity (ED&I) amongst our team

A number of initiatives are helping us to improve ED&I within our large community of colleagues.

  • Alongside local hospital partners, we signed a pledge to promote greater support and fairness of opportunity to any nursing students on placement with us.
  • We worked hard to make it easier for our colleagues to update their personal information on our Electronic Staff Register (ESR) platform. This helps us to have a current picture of our workforce in order to identify gaps and emerging differences between colleagues. We promoted this via new colleague inductions, lunch time learning events and on our annual staff appraisal system.
  • We continue to support our three established staff networks:
    • The Global Majority Network (for Black and Minority Ethnic Staff)
    • The Disabled and Long-Term Conditions Network
    • Our Lesbian, Gay, Bi-sexual, Transgender and Queer (LGBTQ+) Network

The groups support the interests of our diverse team, and they also provide an invaluable equality lens, ensuring an inclusive response to our organisational development work. We also have a thriving colleague forum called Our Voice.

6.3 Case study: Sirona is recognised as a Diversity Champion

This year we were recognised as a Diversity Champion by Bristol City Council, for our commitment to championing diversity as part of the Stepping Up programme.

The award is given to organisations which have made an exceptional contribution to the programme, which aims to develop talent and ensure fair representation of Black, Asian and Minority Ethnic people, Disabled People and women in positions of leadership.

work to improve
Diversity Champion

7. Children’s Services

In 2021-2022 we started planning to transform our Public Health Nursing Service in Bristol, North Somerset and South Gloucestershire. The aim was to ensure we provide an equitable service across the area for children, young people and their families.

Our plans focused on prevention, early intervention and reducing inequalities. We wanted to ensure services were placed-based, easily accessible for families and tailored to an individual’s needs. We decided to implement the i-THRIVE service delivery model – an evidence-based framework supporting better outcomes through its integrated and needs-led approach.

A steering group involving partners, colleagues, key stakeholders, and people who use our service now oversees the five workstreams.

Our aim for the future is to co-create pathways services with different partners including schools and baby hubs, young people, and parent carer forums across our geography. The transformation is expected to take up to two years to deliver, with support adapting and improving as the service develops.

Like our Adult Services, our Children’s Services have built on innovations developed through the pandemic to provide more online support to children, young people and families. The following case studies give a flavour of the work we have achieved in this area.

7.1 Case study: school nurses plan text messaging support for young people

Over winter 2021-2022, our school nurses planned to launch ChatHealth, a confidential text messaging service to give students across Bristol, North Somerset and South Gloucestershire access to more support.

The service has now been formally launched and is open to young people aged 11-19, Monday to Friday from 9am-5pm, during term time and school holidays. Students can text our School Nurses on 07312 263093 to seek support on a range of topics, including mental health, bullying, relationships, healthy eating, body image, drugs and alcohol, and self-harm. Since the service was launched, nearly 1000 messages have been sent and received.

The service is designed to complement the existing School Nursing Service. Katy Green, School Health Nursing lead, said: “ChatHealth enables us to expand our service, with the same amount of staff, and support more young people in a safe way which is more convenient for them.”

7.2 Case study: school nurses and health visitors run free webinars for parents

School nurses and health visitors also planned a series of free webinars for parents and carers to offer tips and advice on issues such as healthy eating, emotional wellbeing, sleep and eating disorder awareness.

Sessions last between 30-40 minutes and are suitable for parents and carers of children and young people of all ages across our geography. A total of 1,755 parents and carers have logged on to sessions to date.

Katy Green, School Nursing Lead said: “We started running these sessions online during the pandemic and they proved so popular we have kept them going. Holding them online means more parents can attend to seek support on a wide range of issues which affect children and young people.

7.3 Case study: speech and language therapists plan video tips for parents

Parents can get help to support their child’s speech and language development at home thanks to a new video series by our Bristol Early Years Speech and Language Therapy team, which was planned during the 2021-2022 year.
The therapists filmed 10 videos which are a mixture of information sessions and tips to give parents and carers ideas on how to support their child’s communication. So far, the videos have been viewed 1548 times.

These videos, which are available on Sirona’s YouTube channel, show some simple ways to encourage language development through everyday routines and play. There is some advice to help preschool children who stammer or are having difficulty with speech sounds.

The team started making videos when the country first went into lockdown due to Covid, to ensure parents could still access the vital support they provide.
Helen Hollick, Head of Service for Early Years Speech and Language, said: “We wanted to give parents easy access to some early advice on how to help their children’s speech and language development at home.”

7.4 Scoping how the experience of autism assessment can be improved through digital tools

Over the winter, members of our autism assessment team worked closely with system partners and a specialist user experience technology partner, MadeTech, to scope how digital tools might improve the experience of the autism diagnosis pathway. The project was funded and managed by Bristol, North Somerset, and South Gloucestershire Clinical Commissioning Group.
Early identification of a child’s needs, and providing support and advice to parent/carers at the earliest opportunity is crucially important.  Currently the wait for an autism diagnostic assessment can take up to two years.

Together with our technology partner MadeTech and other system partners, we started scoping a variety of digital tool prototypes to support parents through the wait for diagnosis and during the assessment process itself. These included tools to support with:

Orientation: we planned a digital map of the assessment for parents and professionals alike. The map provides step-by-step guidance on the assessment process and it has stories from people who have been through the process previously.

Support and learning: we planned a guide or reference tool, something that parents/carers can use to increase their knowledge. This included:

  • Sharable cards that give an overview of strategies to try.
  • Filters that allow parents and carers to drill down into particular areas of need.
  • Video and notes to support parents in following the instructions for each strategy.

Recording and updating: we planned a collaboratively produced ‘tell it once’ digital record tool, which enables the shared documentation of an autistic child or young person’s needs and progress.

Monitoring and communicating: we planned a tool to support with tracking clinical interactions and the ability to spot problems that need attention and investigation. This included a digital dashboard that could be sent via email and a progress timeline, showing what’s happened, what’s coming next and the likely waiting time. It included a monthly email updates with a focus on things to do while waiting.

“It has been a brilliant experience I have learned so much and am confident these digital tools, once developed and available, will make a huge difference to our children and families”

Geraldine Bates, Head of Children’s Services,
Therapies, Autism and SEND

Children’s Services
Children’s Services

# of parents and carers who have watched health visitor webinars:

Fussy eating


Fussy eating
Safety at home


Safety at home
Infant feeding


Infant feeding

# of parents and carers who have watched nursing webinars:



Transition to primary school


Keeping your child happy and healthy


Transition to secondary school


Epilepsy awareness


Anaphylaxis awareness


Dental health


ChatHealth videos

# of parents and carers who have watched nursing webinars:





Confident communicators


Language development


Using songs to develop language




Singing with your child


Playing with dolls and teddies




Sorting Out Sounds part 1


Sorting Out Sounds part 2



8. Care in the community – a selection of Adult Services

Some of our Adult Services have undergone large transformation over the last year, as part of wider plans to provide a more equitable service for people across our geography.

8.1 Case study: establishing a seven day Hospital Learning Disability Liaison Service

During 202021-2022, we planned to expand our Hospital Learning Disability Liaison Service with the aim of improving the experiences of people with a learning disability and/or autism when using inpatient and outpatient hospital services.

The Hospital Liaison Nursing Team is employed by Sirona but is based in teams across Southmead Hospital which is run by North Bristol NHS Trust (NBT), Bristol Royal Infirmary (UHBW) and Weston General Hospital (UHBW) both run by University Hospitals Bristol and Weston NHS Foundation Trust. The service provides specialist knowledge and skills to enable people with a learning disability and/or autism to access effective care and treatment whilst attending hospital sites.

The aim is to ensure that delivered care is safe, caring and effective, and that colleagues are sighted on individuals to ensure care is person-centered and meets their individual needs.

There are approximately 20,000 adults predicted to have some level of learning disability across Bristol, North Somerset and South Gloucestershire, and around 5000 to 7000 adults with some level of autistic spectrum condition.
People with a learning disability are likely to die 20 years earlier than the general population (Mencap 2004), and the population have higher rates of morbidity, comorbidities and premature mortality than the general population.
When admitted, people with a learning disability are often subjected to diagnostic overshadowing which contributes to a poorer experience of care and poorer outcomes. A learning disability liaison function is cited across national and regional best practice guides as good practice to improve outcomes. It is an effective use of investment to prevent admissions, reduce length of stay, and protect acute capacity by supporting alternatives to hospital admissions.

8.2 Expanding our Integrated Community Stroke Service (ICSS) at Home

Across Bristol, North Somerset and South Gloucestershire, health, care and voluntary sector partners are working together to improve services for people affected by stroke.

Our vision is to provide seamless, multidisciplinary care, so local people have the best opportunity to survive and thrive after stroke.

In February 2022, as part of this work, we piloted our ICSS at Home service in North Somerset, with the aim of reducing the length of time that people are in hospital by providing high quality home-based rehabilitation, helping individuals achieve their personal goals. The service also provides advice and support to reduce the likelihood of further strokes and help people live well as they recover.

Care is provided by a multi-disciplinary team of therapists, registered nurses, assistant practitioners, rehabilitation support workers and administrators. Our team support people from the day they are discharged from hospital or a rehabilitation unit, for a time period agreed with individuals. Support includes personal care and meal preparation, working side by side with voluntary sector ‘life after stroke’ keyworkers to support people in the best way possible.

The pilot achieved its outcome goals and later that year, ICSS at Home expanded to Bristol and South Gloucestershire, to provide an equitable service to all people affected by stroke across our geographical area.

“I wish to thank you, most sincerely for the help and guidance you have provided during my rehabilitation.”

ICSS at Home service user in North Somerset


9. Specialist Services

Our Specialist Services have continued to adapt in the face of ever changing circumstances and world events. The services cited below have gone above and beyond to provide increased social value for people at a time of their greatest need.

9.1 Case study: fourfold increase in people served through The Haven

The Haven is our specialist primary healthcare service for asylum seekers and refugees who are new to Bristol, North Somerset and South Gloucestershire. An increase in the number of spontaneous arrivals in the UK and an influx of vulnerable refugees from Afghanistan, Iran, Eritrea, Sudan, Iraq, Yemen, Libya, Congo, El Salvador and Albania has resulted in a fourfold increase in the numbers of people which the team have supported over the last year. Around 1400 people have been supported across five dedicated hotels and other community settings.

During the course of the year, effective partnership working with Bristol City Council, UHBW and the voluntary sector enabled nearly all new Afghani refugees to have a chest x-ray at south Bristol to screen for tuberculosis (with almost 100% attendance at each of several screening days).

The Haven’s Service Manager Anne Gachango was formally recognised for her outstanding work during the pandemic, when she received a regional Excellence in Primary Care and Community Care Award in the NHS Parliamentary Awards.

Judges commented: “This is an excellent example of how to rapidly mobilise a response across healthcare, social care and third sector organisations to deliver services that meet a vulnerable group’s healthcare needs.”

Anne Gachango

Pictured above: Anne Gachango, Service Manager of The Haven

10. Our rehabilitation units

Our four Community Rehabilitation Units are Elton at North Somerset Community Hospital, South Bristol Rehabilitation Unit at South Bristol Community Hospital, Skylark in Yate and Henderson in Thornbury. For our units in Yate and Thornbury, we work in partnership with local Care Providers (Windmill Care and Order of St John’s Care Trust respectively), our hospitals and South Gloucestershire Local Authority to provide active therapy, nursing and medical input to over 500 people per year.

We work to support people to return to their own homes, wherever possible and to regain as much independence as they can, giving practical advice and therapeutic input to make sure everyone is ‘as great as they can be’.
We have worked hard to introduce social value at each of our units this year. This includes a greater emphasis on self-management of medication at our Elton Unit, to encourage people receiving healthcare to develop greater independence and to prepare for their return home.

10.1 Case study – donating 60 beds to a charity in Romania

In March this year we replaced all of the beds at our South Bristol Community Hospital rehabilitation unit, in order to create an environment that was more suitable for rehabilitation. The 60 beds that came out were Linet Eleganza beds with integral side rails – excellent hospital beds in good working order.
Using our partnership links, we donated the beds to a charity in Romania, where there is a huge shortage of such items. The charity was delighted to accept the beds, and Sirona also funded the transport costs to move them from South Bristol Community Hospital to the charity’s facilities ready for transport.

rehabilitation units

11. Closing remarks

This report outlines the many services we offer to the our people and communities and we hope it has demonstrated how we strive to deliver a personal, caring and effective approach to healthcare and the social value we bring to all the people we come into contact with.

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