JSNA Community Voice

1.1 Defining Community and the Community Voice for Richmond

For the purposes of this report, community is defined according to Public Health England ², which use a definition drawn from community development ³. In this context, the umbrella term ‘community’ is used to describe the relationships, identities, interests and connections which link people or give them a shared interest in an area, culture or activity. The groups and organisations consulted create these links, and identify which are communities in their own right, and their role across the wider Richmond community.

1.2 Understanding Health and Social Care Need in the Community

This chapter considers the wellbeing of the population in the widest sense, comprising not only physical and mental health, but also those needs which enable residents to live a full, thriving, healthy life. It seeks to find the common threads which provide a community perspective on health and social care need. However, this may look different for population groups, including the most vulnerable in the borough.

Responding to residents needs ensures the provision of the appropriate best services for local people. It means Richmond Council, South West London Clinical Commissioning Group (SWL CCG), and partners can better understand the local population and respond to the needs accordingly.

During the COVID-19 pandemic, needs will have developed, shifted and evolved, meaning community involvement in developing the JSNA is greater than ever.

For the purposes of this chapter vulnerable groups have been considered for different age groups to reflect the life course approach ⁴. These include:

• Start Well – (pregnancy, early years and childhood and adolescence) 0–18 year olds who are experiencing disadvantage, living in relative poverty or have low household income. In addition, those young people who have poor educational attainment, are known to the criminal justice system and those experiencing bullying or excluded from school
• Live Well – (adults of working age) 18-64 year olds who are homeless, unemployed, disabled, with serious mental illness, have drug or alcohol addictions, gamble, have poor relationships, or live with learning disabilities.
• Age Well – (Older people post retirement age) People 65 years + who are living alone or experience frailty or loneliness.

Vulnerability need not be a permanent state and is often more fluid and experienced differently across life stages and experiences. It should be noted that the groups outlined above are not exhaustive or exclusive. Residents may move in or out of these situations or be exposed to several vulnerable situations either alone or within their family.

1.3 Findings and Evidence of Need

The findings are presented to reflect the structure of the remainder of the Joint Strategic Needs Assessment; Start Well, Live Well and Age Well; and chapters on the wider determinants of health affecting health and social care needs. Responses were gathered via telephone calls and using the Microsoft Teams or Zoom video calling facilities with the stakeholder organisations identified and contacted as a part of the data gathering process.
Each section contains key areas of need highlighted by community and voluntary sector organisations in Richmond. Examples of good practice as well as gaps are included.

HealthWatch Richmond provided a summary of the evidence of health and social care need in the borough as identified during their consultation work across the borough over the last five years. This represented 2,200 experiences collected through approximately 250 visits to community groups across the geographic and demographic range of Richmond Borough. It is this large and thorough body of work which forms the basis of this chapter.

The table below lists the individuals contacted during the development of the chapter.

It should be noted that due to the limitations created by the COVID-19 pandemic there may well be areas of need which have not been identified during the research process. The findings presented are drawn from the respondents only.

2.1 Perinatal and Postnatal Mental Health in Parents

HealthWatch Richmond reported concerns regarding support for women with poor mental health during and after pregnancy. However, many experiences of mental health support during the antenatal period were positive, with individuals who needed help able to obtain access as well as caring, helpful support from the midwives. Postnatal experiences were mixed. Whilst health visitors gave advice where they were able, some advice was felt to be misguided. New parents reported being told to take antidepressants ‘at their own risk’ whilst breastfeeding, leading to the mother deciding not to take them as they felt unable to weigh up the benefits and risk without guidance from a professional.

Other issues included new parents not feeling listened to regarding their mental health concerns, not having opportunities to discuss their mental health, services being unreliable and often cancelled, and in one case a new mother reaching crisis point due to a lack of access to therapy.

2.2 Antenatal and Newborn Screening

Healthwatch Richmond gathered the views and experiences of 103 local women with due dates ranged from August 2015 to May 2018 who had received antenatal care ⁶. Overall, 86% of respondents rated their care as very good (44%) or good (42%), felt involved in their care and reported good access to information and emotional support and that the right amount of written and verbal information was given. The report suggested that more work should be done to ensure all women are informed about the available emotional support.

The report highlighted that approximately 1:3 women (29%) self-refer to hospital for their initial antenatal appointment and reported better experiences and fewer mistakes ⁷.

Feeding was reported as an area where there was a gap in antenatal information. A quarter of people who received information reported that they did not receive enough before and after childbirth. In addition, the research highlighted a potential gap in monitoring gestational diabetes as patients reported not receiving follow up blood tests post birth.

2.3 Health Visiting and Well-baby Clinics

HealthWatch Wandsworth provided anecdotal evidence from their discussions with young people around sexual health issues. They highlighted the need for opportunities for young people to discuss and understand risky behaviour. Young people reported that informed conversation helped them to avoid risky behaviour. There is a need to link risky behaviour and mental health support as young people were concerned about feeling safe, and the impact of peer pressure being more significant than the information available to them. There is a need for more information about sexual health through channels used by young people, including social media.

2.4 Childhood Obesity and Risk factors – Secondary School Children

HealthWatch Richmond regularly hold consultation events with Youth Out Loud! (YOL!), a group of young people from Richmond and Kingston who collaborate with HealthWatch to scrutinise local health services available for young people.

Discussions with school-aged children and young people indicated they generally understand what healthy eating is and, a lack of physical activity, and excessive sugar intake/processed food may result in overweight, obesity and dental issues.

Young people reported much of their information on eating healthily comes from school, but little changes as their living environment prevents them from making healthy choices.

Healthy foods were not always available for children at secondary school. Unhealthy snacks were seen as cheaper, more available and more filling than fruit and vegetable options. Young people suggested learning healthy cooking skills in school to support the lessons on healthy eating.

Opportunities to be physically active were reported as being limited by the amount of physical education (PE) hours in their timetable in comparison to sitting in lessons and studying at home. The time spent being inactive tends to increase as they progress further in their education. Young people requested further support in building physical activity into their lives. Lack of opportunities to exercise both in and out of school were highlighted by the SWLHCP research as a part of their patient/public involvement activities6. Respondents felt that there had been a lack of ambition with regard to developing physical activity for young people, and more work was needed for increasing opportunities outside of school.

2.5 Children and Young People’s Mental Health

In 2016, Healthwatch Richmond collected experiences from parents and schools on Richmond’s Child and Adolescent Mental Health Service (CAMHS) ⁸. The report found that many of the 1580 young people who had used the service felt they needed better emotional wellbeing services in and out of school.

However, the report also highlighted there were barriers to seeking support including stigma around mental health issues, a lack of understanding of their needs, or how to express them, which create obstacles for young people. Long waiting lists and high thresholds for CAMHS were and remain a significant barrier to accessing care. Accessibility to services was described even more difficult for individuals whose sexuality, ethnicity or gender made them less likely to access a service.

Follow up consultation with Youth Out Loud! in 2019 highlighted “Off the Record” as a safe and useful place to seek help or even just ask questions about mental health. People who went there described staff as friendly and helpful. However, the long waiting lists for counselling put people off seeking help. Online services are a useful way of obtaining new information safely, providing there is signposting to the most appropriate service, e.g., self-harming.

2.6 Positive Mental Health

In terms of prevention, young people at YOL! and Kingston and Richmond Youth Council (KRYC) reported to HealthWatch Richmond that working together or developing a whole school approach would help them develop resilience and better mental health. Where schools and other agencies communicate effectively and where the staff are friendly and approachable, young people feel able to share their feelings about their mental health. Young people’s suggestions for improvements included support around exam pressure, and a more in-depth approach to their mental health problems. Extra-scholastic activities were greatly valued in terms of time, space and perspective, as well as opportunities to talk to trusted adults. The SWLHCP also highlighted the importance placed on building mental health and resilience among young people in the borough through their patient and public involvement events. This continues to be an area of focus in the borough’s Health and Care plan ⁹.

2.7 Child and Adolescent Mental Health Service (CAMHS)

Healthwatch Richmond has attended three groups in the community where parents of young people and the young people shared their experiences of transitioning to adulthood.

The survey found that among all services, mental health is one area where young people and their parents do not feel well supported, a finding echoed by experiences reported to Richmond Council for Voluntary Services (RCVS). A main concern was children’s transition into adult services. It can be a vulnerable time for children and their families who felt they lacked support to identify appropriate pathways so children can learn to manage their mental health needs independently. This finding was supported by the Richmond community and voluntary services who reported that seamlessly joining child and adult services is a real problem and a more family-based approach is required.

Several other areas of need were identified by HealthWatch Richmond in the transition from child to adult mental health services including:

• children stop receiving care before the equivalent adult service has been organised
• children transitioned to adult services which were not appropriate for their needs
• gaps in support, and the services themselves being unclear about who should be giving that support
• GPs need to be more involved in the transition process and early planning
• commissioners should listen to young people and their families regarding their needs and tailor services where appropriate and possible.

2.8 Risky Health Behaviour - Young People’s Sexual Health

During YOL! meetings HealthWatch Richmond reported discussing sexual health with professionals from local providers. The discussion identified young people have many unanswered questions and are not sure where to get the information. They feel embarrassed to talk about taboo issues with adults so the first places they go to are friends and the internet. They feel their friends do not necessarily have the right answers and the internet is hard to navigate.

School sexual health information is not very helpful because the information is too general, and they do not feel comfortable to ask confidential questions. In addition, school-based information was often too focused on sexually transmitted infections (STIs) and very little on other topics such as porn, healthy relationships, self-eroticism and what is normal.

The NHS was considered helpful and reliable. However, young people were not clear on which online sources were available and reliable, suggesting a need to provide this type of information. School nurses were considered a good resource for asking questions, but they are not always available, and their visits were not scheduled.

3.1 Long Term Conditions

3.2 Mental Health in Adults

Between 2017 and 2019, Healthwatch Richmond spoke to 586 patients and carers about their experiences of mental health services in the borough. Patients reported using the Recovery and Support Team (RST) ¹⁰ service and the Richmond Wellbeing Service ¹¹.

HealthWatch Richmond reported that, for most people, the Richmond Wellbeing Service provided a high-quality Improving Access to Psychological Therapies (IAPT) service that was in line with NICE recommendations. Respondents appreciated the staff’s ability to pace sessions and build a supportive environment, so they feel comfortable to share their experiences. People with long terms conditions were especially positive about the service, with specific courses to help them live with a long-term condition. Areas of need identified included:

• issues around accessing the service
• a lack of available information on how the service works
• ensuring patents are being referred to the right level or type of treatment.

3.3 Crisis Care

Health Watch Richmond found that many users struggled to access crisis care when they needed it . The report suggested this may be due to the thresholds for referral into services. People approaching a crisis may be unable to access help in order to avoid escalation. Inevitably, this meant more people reported they experienced a crisis. Individuals who had extreme mental health needs were more likely to access care.

One in five respondents highlighted the key role GPs played in supporting people with mental health problems. Patients reported they valued the role GPs play as providers of urgent care services in the borough. Health and social care needs related to crisis care include:

• people who misuse substances have particularly limited access to mental health and crisis care
• lack of availability of enhanced out of hours care and a well-resourced point of access for urgent mental health support
• the Mental Health Support Line was felt to be caring, but unable to meet the mental health needs of many users
• ongoing support for people who have experienced a crisis to ensure they are able to make changes to their lives to enhance their recovery.
• the social prescribing service was thought to be vital in aiding recovery and self-management. Regarding the mental health needs of specific community groups, Richmond CVS highlighted that LGBTQ+ communities lack appropriately tailored mental health support.

3.4 Substance Misuse Support for Dual Diagnosis (Integrated Care/Treatment)

HealthWatch Richmond’s review of mental health services in the borough highlighted several areas of need for specific groups including individuals with dual diagnosis ¹².

People described gaps between services where they did not meet the threshold for one team but deemed too high risk for another service. Conflicting service thresholds are of significance for people with dual diagnosis as it can be impossible for them to access the right care.

Several people reported to HealthWatch they were denied access to the Richmond Wellbeing Service (RWS). As a result of the RWS assessment their use of alcohol or drugs was deemed prohibitive to engaging with psychological therapies.

Patients and professionals told us that they would benefit from a publicly available borough policy on patients with substance misuse to ensure consistency of care and equal access. Patients reported differing periods of abstinence before being admitted to the service. This lack of clarity can lead to patients falling between the gaps in services and feeling they have nowhere to turn.

3.5 Wider Determinants of Mental Health and Crisis Care – What Is Missing?

Consultation events run by HealthWatch Richmond identified the local services are meeting the needs of most of their patients12. Some are challenged by workforce issues and, despite efforts to provide good services, the system does not always work for patients. For most people the only thing that will prevent a crisis is getting prompt access to appropriate clinical services. Services need to be:

• accessible 24 hours a day, 7 days a week
• provided in a comfortable environment
• provided by compassionate staff who can access medical records
• co-ordinated from the first point of care to ensure that the right care is available when needed and to prevent gaps in service provision
• supported further by the voluntary and community sector
• peer support services should be better funded and expanded as well as the establishment of crisis cafes
• able to sign post users to further support for all aspects of their life during recovery.

Wider determinants of health including housing, physical health, income, employment and leisure all affect recovery and independence and should be recognised as contributors to poor mental health and risk of relapse.

3.5 NHS Continuing Healthcare

In certain circumstances, people with long-term complex health needs qualify for free social care arranged and funded solely by the NHS. This is known as NHS continuing healthcare ¹³. A significant number of negative experiences were reported to HealthWatch Richmond. The most frequent areas of need were in patients’ experiences of contested changes to care plans, and reports of a lack of information/support within the application process. Patients also reported agreed care plans were not delivered, funding not received, exacerbated by poor responses to queries and complaints made to Richmond Clinical Commissioning Group (CCG).

4.1 Falls, Fractures and Frailty

HealthWatch Richmond reviewed 47 experiences reported from people living with dementia or their carer/family who had been affected by a fall. Many respondents were positive about the care they received after being taken to hospital. Problems were reported on discharge when help with daily tasks at home was needed, but referral to social care did not always happen. Equally, a lack of referral to the Richmond Response Rehabilitation Team meant a lack of access to physiotherapy and occupational therapy. There were often long waits for adaptations at home such a shower rails, stair handles and hoists.

Feedback about the Falls and Balance Course run by Hounslow and Richmond Community Healthcare was very positive, with patients reporting it was helpful, and it made a difference to their physical health. However, HealthWatch Richmond reported having had queries from residents asking whether this type of support existed, suggesting eligible older people are not being referred.

In addition, HealthWatch heard from community members, concerned for neighbours or friends who are at risk of falling or repeat falling. This suggests the community can identify someone at need of support at home, but there is a lack of awareness of how people at risk can be supported.

4.2 Dementia Prevention and Care

HealthWatch Richmond reported on 75 experiences collected via community outreach from people living with dementia, their carers and family members, and professionals who care for dementia. GPs were reported to be sensitive and understanding to individual needs, proving to be reactive in providing urgent care when necessary. There were some reports of experiencing difficulties or distress attending GP surgeries, either due to a lack of suitable transport or reluctance on the part of the patient. Delivering services such as the flu jab via community services such as district nursing could address this need. Other issues include:

• difficulties accessing assessments from the occupational therapy team
• delays with adult social services providing support
• lack of information on the pathways process and how services work
• people with dementia being distressed by carers arriving late, affecting their ability to cope, and subsequently limiting their care
• frustration of people who felt they should receive services but did not meet the eligibility criteria
• carers and family members reported difficulties in coordinating different services, and highlighted a lack of communication between services, meaning services did not take full or co-ordinated responsibility for the patient
• carers of felt isolated and indicated they needed more support and respite opportunities
• the process of applying for Deprivation of Liberty Safeguards (DOLS) was described as frightening and intrusive.

Feedback from clinical dementia specialists (via HealthWatch Richmond) also highlighted several areas of unmet need including:

• inconsistency in the quality of social workers for patients with dementia
• a lack of information following diagnosis
• a lack of support for carers
  
• a lack of information on the criteria for accessing NHS Continuing Healthcare.

Wider support in the community was valued by . The Kew Gardens Dementia walks were praised for the peer support and were highly valued. Apps were also considered to be useful aids for to help them day to day and ensure they could be found if lost or confused.

4.3 Mental Health, Social Isolation and Loneliness

Key to mental wellbeing for people 65+ years the ability to build resilience and maintain good mental health is very important. Events such bereavement, loss of confidence through ageing and physical health challenges, were reported as detrimental to their mental health.

In 2019 during a Healthwatch Richmond consultation (Strawberry Tea Party) on the mental health of the 65+ age group, several issues and obstacles affecting older people’s mental health were identified:

• long waiting time for referrals made access to counselling difficult
• long waits for face-to-face or phone appointments with GPs
• concerns regarding future care needs and meeting payments for these, suggesting a lack of accessible information on what care options and support are available as care needs change or advance
• lack of mental health support for people moving from independent living into care homes
• lack of bereavement support
• challenges posed by lifestyle issues which could increase isolation such as access to transport, digital inclusion, and other enablers of independence
• access to physical therapies to manage long term conditions which might impact on mental health e.g., arthritis
• access to information and support regarding long term conditions and healthy lifestyles e.g., nutrition.

4.4 End of Life Care

End of Life care is an intensely personal and emotional aspect of health and social care. A local consultation by Healthwatch Richmond identified that setting a clear and agreed care plan, when the possibility of death is recognised, could improve end of life care experiences.

Ensuring a clear responsive plan means that the patient’s physical and emotional needs are addressed, allowing family members space to look after their own wellbeing and coping strategies.

The consultation highlighted the need to ensure care plans are carried out in an efficient and timely manner, with good co-ordination between services. Delays in care can lead to poorer quality of life and admission to hospital.

GPs were regarded as pivotal in developing end of life care plans. The main unmet need expressed was the lack of home visits and poor co-ordination of services through the GP surgery for people nearing the end of their lives at home.

5.1 Living With Disabilities - Adults With Learning Disabilities

Richmond CVS reported health inequalities are apparent for people living with a learning disability across the borough. There is anecdotal evidence, via consultation events run by HealthWatch Richmond, of significant variation in the percentages of people with learning disabilities registered with GPs and receiving an annual health check. People with learning disabilities and the organisations that support them, have also reported that the mainstream services which support healthy lifestyles (e.g., smoking cessation and weight loss services) are not readily accessible for people with learning disabilities.

HealthWatch Richmond reported on outreach sessions run for people living with learning disabilities. Respondents highlighted that healthcare staff were generally understanding and adaptive to their needs. Specific areas where staff have been supportive include:

• speech impediments
• motor skills
• wheelchair users
• difficulties in expressing their needs and feelings.

However, the sessions also highlighted some outstanding needs, many of which are reflected in Mencap’s Treat Me Well campaign ¹⁴. Understanding the range of needs of people with learning disabilities and identifying the preference of individuals is key to delivering appropriate care.

Other areas of need highlighted include:

• longer GP appointments to allow patients the time to understand discussions taking place and have the opportunity to talk through their care plan
• development of enhanced mental health services that understand and respond to the needs of people with learning disabilities
• support for child to adult transition of services
  
• current gaps in the transition process mean that people do not feel they have their needs met and struggle with maintaining their independence
• increased support for issues around sexual health
• taboos around sexual health means many people are unaware of the information and support available
• greater awareness of the role the voluntary sector in supporting people with learning disabilities in areas of difficulty in daily life such as providing information, safe spaces for discussion, and help with paperwork
• provision of quiet and calm waiting spaces for people with autism to avoid sensory overload.

5.2 Special Educational Needs and Disabilities

HealthWatch Richmond’s discussion groups on mental health and well-being, also spoke to parents of children with special educational needs and disabilities (SEND) about their health and social care needs. Responses were varied, with some families feeling well supported whilst other identified gaps in service provision. These included:

• Education, Health and Care Plans (EHCP) were not carried out properly by the school, others did not manage to have regular reviews, and others felt the ECHP did not reflect their children’s needs
• some children and parents explained anxiety and the challenges presented by mainstream schools can make attending mainstream school difficult
• some parents told us that their children had dropped out of education as a result of their attention deficit hyperactivity disorder or autism not being formally diagnosed and recognised.

6.1 Health inequalities

Health inequalities are disproportionate with avoidable differences in health across the population, and between different groups within society.

They result from the conditions in which people are born, grow, live, work and age, and impact on an individual’s ability to live a healthy life, how they feel and act which affects mental, physical health, and wellbeing. Richmond CVS reported that income and health inequalities persist in the borough, despite the perception that Richmond is solely a higher income area. This reputation has masked inequalities in the borough, which have widened due to the COVID-19 pandemic. They recommended the focus needs to be on reducing inequalities in all its forms, and this should be a key theme across all services in the borough.

6.2 Digital Exclusion

Digital exclusion was highlighted by a Richmond Borough Council and the voluntary and community services survey as a significant area of need for older people, particularly as access to services has changed due to COVID-19. The impact of digital exclusion has been magnified by the COVID-19 pandemic, contributing to existing overall inequality for Black Asian and Minority Ethnic groups and older people. In addition, people who are less confident about using digital devices, and accessing the internet, are significantly disadvantaged in accessing care. There is a need to increase access to digital services for older people who are not online. In addition, the provision of training and support to increase skills and confidence in accessing health and social care via digital channels requires development. The survey found that services have not yet had enough time to fully understand how they can develop their services to meet needs through online offers, meaning this is an area of need across health, social and community services.

6.3 Homelessness and Rough Sleepers

HealthWatch Richmond reported on 23 recent experiences recounted to them regarding health and social care needs for people who are experiencing homelessness. Professionals and individuals identified access to primary care was challenging for people who are homeless, despite proof of address not being required.

Often, services which rely on face-to-face interactions (e.g., transitioning through or between services), are not designed for remote engagement, making sustained contact challenging.

The lack of a permanent address remains a barrier and leads to gaps in several areas of health and social care including:

• dentistry services
• regular medication
• mental health services for people with substance misuse issues
• mental health care and services – it was recommended that appointments with the Home Treatment Team could take place at local community centres for people with no fixed address
• communication and co-ordination of care
• stable accommodation on discharge from health services, particularly for individuals in crisis.

Carers

Richmond community and voluntary services reported unpaid carers have been significantly affected by COVID-19 as support mechanisms for them and people they support, have been diminished. In addition, some carers have chosen not to use paid carers on account of COVID-19 related risk. This finding was echoed by the Richmond survey which highlighted that providers were seeing an increase in the number of people moving into caring as a result of the COVID-19 pandemic.

It was reported that carers have been neglecting their own health needs due to the increased pressures. Young carers dealing with additional pressures from school, peers, work and family were also adversely affected by isolation. Without opportunity for respite, unpaid carers reported increased stress and exhaustion. This echoes a wider concern from respondents regarding health deterioration and safeguarding. It is likely residents, especially those not currently in touch with community organisations, will need ongoing support to stay healthy, engage with meaningful activities, and manage their wellbeing. There is concern for carers of people with dementia, as it has been reported conditions related to dementia have worsened during lockdown, and people with dementia have been found to be particularly vulnerable to COVID-19.

HealthWatch Richmond

Healthwatch is the independent national champion for people who use health and social care services. HealthWatch Richmond works with to ensure that local NHS, Council, and community services are considering the needs of their users and responding to those needs.

Healthwatch Richmond carries out research, interviews, focus groups and consultation as well as an extensive programme of community engagement in order to understand people’s experiences of health and social care and be able to act on issues of importance to the community. Since April 2019, they have delivered 75 face-to-face outreach sessions targeting four demographic groups: under 21 year olds, over 65 year olds, the working age population, and disadvantaged and seldom heard groups. These sessions resulted in conversations with 1007 residents, recording 933 experiences of health and social care making their database is a rich resource in providing a voice for the local community.

Richmond Borough Council and VCS COVID-19 Response Group-VCS

Richmond Borough Council works to support the voluntary sector in Richmond providing a range of services including advice and support, fundraising and providing a voice for the sector. They act as a champion for the voluntary sector including the strategic lead for the children and young people’s voluntary sector. Richmond Borough also works to support the quality of local community voice and they manage a volunteer placement service.

Richmond Council for Voluntary Services (RCVS)

The RCVS is an independent infrastructure organisation providing dedicated support to the many across the borough. Richmond CVS supports all charity, community and voluntary activity in the London Borough of Richmond upon Thames.

South West London Health and Care Partnership (SWLHCP)

The NHS South West London Health and Care Partnership (formerly NHS Richmond CCG) commission most community - based health services, mental health and learning disability services as well as urgent care, rehabilitation services and non-emergency hospital care. The group cover the geographical area including Richmond, Wandsworth, Kingston, Sutton, Merton and Croydon.

Community and Partnerships Team and Prevention & Wellbeing Team (Commissioning)

Community and Partnerships Team and Prevention & Wellbeing Team (Commissioning), and Richmond Council also provided input, most particularly through the Community and Voluntary Sector survey conducted in May 2020, including responses from RUILS Independent Living, Richmond Carers Centre, Richmond Aid, HealthWatch, Cruse Bereavement Care, Age UK Richmond, Crossroads Care and Alzheimer’s Society Richmond.