Photograph: Orange football with foot on top holding ball in place. 
Photo by from Pexels

Vinnie is a 59 year old man who lives alone in a housing association flat and is not in contact with his family. He has few friends and no social life. When he was younger he played football. He has been unemployed for ten years. He was diagnosed with paranoid schizophrenia when he was 21, has uncontrolled type 2 diabetes (11% HbA1c) and uncontrolled hypertension at 165/110 (and is not taking his medication). Initially he was compliant with his anti-psychotic medication and engaged with health services. He attended a voluntary group, however it closed due to funding cuts. 

Feeling Overwhelmed
Vinnie’s GP changed and he has not attended for health check for the past two years. He is in debt, confused by universal credit and has been served with an eviction notice. He is being bullied by his neighbours, has been burgled and is too afraid to leave his flat. He has stopped eating, is dehydrated, has had a psychotic episode and become agitated and threatening with the staff in the tenants’ association office, who have called the police.

Responding to Vinnie's Needs
In our new model, Vinnie is included on his PCN’s serious mental illness (SMI) risk register, flagged up when he didn’t attend for his health check and when he was served an eviction notice. The multidisciplinary team has brought all their expertise together to support him with his issues, including resolving his housing – and providing a training session/liaison point on SMI to the tenants’ association.

He has been visited by the PCN team in his home to see how he wants to be supported and later at a café in his neighbourhood for on-going support, he has set goals for his recovery and a good life.  

He has a neighbourhood peer support worker, Quami, who also has schizophrenia and lives on the next estate, and he has linked Vinnie up to the PCN’s community connector, neighbourhood activities and the recovery college. A community diabetes nurse supports him with his diabetes and the PCN pharmacist with his hypertension, who he sees regularly for monitoring.

One Year On
A year later and through this support Vinnie has joined a football social club and a healthy lunch club. He has lost ten kilos and his blood glucose level is improved, down to 8% HbA1c and his hypertension is now controlled at 140/85.

Quami has helped him to make friends on his estate through music nights and he feels less lonely and agitated and has not had another psychotic episode. He has a crisis plan in place, with neighbours who support this. The tenant’s association are running regular mental well-being activities and have started a gardening club. He is also engaging with a men’s group.

He still has tough days, but he knows who to call and that spending an hour in the gardens digging will help with his anxiety. All of this has given him the confidence to contact his family and his son is coming to visit. He is training to be a football volunteer coach. Vinnie says that with his neighbours he is now thriving, and together they are all thriving.


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