Changing the conversation about health

Enhanced Social Prescribing for Primary and Community Care in Southern Staffordshire

What is Social Prescribing?

Social prescribing is a way in which people with care and support needs, perhaps due to long term health conditions or simply being older or less active, can gain access to a variety of support from which they will benefit.

Importantly, this support either cannot be provided by social workers, doctors and nurses or it is increasingly expensive for those professionals to provide the support. Hence a secondary benefit is that professional support from the NHS and social services can be protected for those who really need it and for whom it remains the most appropriate care.

Social prescribing can include things like help with getting a job, housing, debt management and social contact such as befriending, luncheon clubs, leisure activities, getting outdoors and exercising, gardening, animal care, crafts groups or anything else really. This sort of help is often available through local charities, community and voluntary groups, social enterprises and informal self-help groups, as well as district councils and non-care departments of the county council (eg. country parks and libraries).

Unfortunately when people are in crisis or simply bearing the burden of a long term health condition, making themselves aware of the full range of help out there feels like a complex and uphill task, by comparison to calling a GP, a social worker or 999, where they know they will get a consistent and trusted response. Even if that response is not especially appropriate, not sustainable, treating symptoms rather than causes, and very costly.

Social prescribing means that the individual can build support tailored to them, over time, by collaborating with a support worker who does know, or who has expertise in finding out, what is available. Together with the support worker, the individual can discuss their needs and their assets, using both to identify the most appropriate, sustainable, support that they need to manage their own health and wellbeing more effectively and meet their own personal goals.

Thus responsibility for health and care remains with the person, rather than being inadvertently transferred to the ‘professional’ or institution.

The support worker can also help to break through any silos between services, in order to build the support around the individual. The support worker often also acts as a critical friend and/or a source of confidence in the early days when personal drive, confidence and will power can be at its most fragile.

Social prescribing is holistic, seeking to treat the underlying causes, not just immediate symptoms and recognises a person holistically according to the Five Ways to Wellbeing:

• Give

• Connect

• Keep learning

• Be active

• Take notice

Social prescribing usually includes a range of voluntary activity (give), being and socialising with others (connect), often an element of learning (keep learning) and physical activity (be active), and with a need to be aware of what is going on around (take notice).

An interesting side effect of social prescriptions is that those who have used them, often go on to want to volunteer and help others themselves, creating an increase in community capacity to share the benefits of social prescribing even further.

For more information see: or the National Social Prescribing Network

What is the evidence that Social Prescribing works?

Social prescribing is not a new concept. It has been around for about 15 years, in various forms, from basic signposting services to more holistic and active models involving referrals and active support.

There is a growing body of evidence demonstrating some specific benefits which may be achieved for patients and local health and care providers through social prescribing including:

• Improved health and wellbeing

• Reduced social isolation

• Increased engagement in health-related activities

• Reduced reliance on medical prescriptions

• Reduced hospital admissions and A&E attendances

• Reduced outpatient appointments

• Reduced GP consultations

Most specific detailed scheme evaluations have been undertaken in NHS settings. These include:

· 60% reduction in GP contact times in the 12 months following intervention compared to the previous 12 months (Bristol Wellspring Project; Kimberlee R. 2016)

· 25% reduction in A&E attendance in the social prescribing group, with a 66% increase in A&E attendance by the control group. (City and Hackney Clinical Commissioning Group & University of East London 2014)

· 17% reduction in A&E attendance and 7% reduction in non-elective in patient stays were reported in the 12 months post intervention compared to the 12 months before it from the most recent evaluation report from the Rotherham Social Prescribing Service (Dayson C. & Bennett E. 2016)

What makes a successful Social prescribing scheme?

Successful schemes are those able to blend all the ingredients well and at the same time:

The social prescribing service providers (mostly VCSEs)

· Wide range of high quality provision

· Flexibility of service, holistic and tailored approach

· Resources to deliver extra capacity if successful

· Access back into specialist support when needed (which may include statutory services)

The social prescribing support worker / broker organisation

· Up to date, local knowledge of potential prescriptions

· Awareness of local community and based near/in local community

· Independent from specific provision (especially when funding becomes available for providers)

· Skills with specific, targeted demographic groups (e.g. older people, mental health, learning difficulties)

· Listening & communication skills more important than clinical/professional qualifications

· Empowers patient, makes jointly agreed decisions

· Builds trust and empathy, which takes time

· Able to work with statutory sector colleagues

The patient/beneficiary

· Awareness of potential benefits

· Feels valued and given time

· Feels confident and willing to try

· Feels supported to maintain engagement, even if not working initially

The NHS / Social Worker

· Awareness of benefits

· Bought into local service, whether based in/with NHS or not

· Simplicity of referral, based on people not just information systems

· Gives confidence to patient/beneficiary

Current Implementation in Staffordshire

Staffordshire is no different from other parts of the country in terms of an ageing population and demands on social care and health. In some cases Staffordshire is experiencing higher than average demand on health and care services, especially for older people. It could clearly benefit from successful social prescribing services.

Developing countywide provision of enhanced social prescribing services for Staffordshire would build on existing assets but importantly would place community provision at the heart of health and social care assessment and referral, at the earliest possible stages.

There are some local schemes which broadly fall under the banner of social prescribing though none offer the full service outlined here. All are Health/NHS led, they include: Stoke and North Staffordshire Hub: CCG funded scheme hosted by VAST based upon a telephone and online referral platform. The initial successful pilot is now looking to expand to improve reach across the NHS organisations locally and geographically to reach better outside of Stoke. The scheme is also likely to become increasingly tied to the VCSE commissioning which in North Staffordshire remains quite substantial (some £5 million). Links to social care are currently quite limited.

Primary Care Support Service: Funded by number of individual GP practices Age UK North Staffordshire provide a person centred service based in the GP practice which is targeted at older people.

Care Navigation East Staffordshire: Virgin Care funded scheme as part of the CCG commissioned East Staffordshire Improving Lives Care Coordination contract. , Age UK South Staffordshire are subcontracted to provide the Care Navigation Service which has been developed to support older people to keep healthy, safe and independent in their own home. A few small grants have been given to the VCSE to support the scheme. There is currently no additional resource for expansion of VCSE services. However, the service also has a Volunteer Coordinator who recruits volunteers and builds community networks to support meeting the needs of the individual’s accessing the service.

Southern Staffordshire schemes: South Staffordshire Partnership – both SSCVA and Age UK South Staffordshire offer a service again targeted at older people and seeking NHS referrals through working closely with primary care multi-disciplinary teams and GP practices.

As far as we know there are currently no services in Tamworth, Stafford, Cannock or Lichfield.

What is possible in Southern Staffordshire?

Support Staffordshire is proposing an initial 12 month trial of the first social prescribing scheme across the whole of southern Staffordshire.

The proposal offers both a broad signposting function and an enhanced offer for more complex cases. The service would bring together the best elements of good practice to date which we know can make a difference to the individual and save public sector costs.

Signposting function:

Our ‘community navigators’ will offer a broad generic social prescribing function, advising and signposting to the wide range of local activities, perhaps providing a package of support and making the initial contact for the client. This service would be open to all local enquirers, but of specific relevance to local NHS staff who can refer their patients into the service. We propose this function is best delivered by Support Staffordshire, as we can take advantage of our existing wide knowledge of local communities through:

· Existing directory of more than 600 local VCSE organisations, growing all the time

· Established relationships with these local groups

· We are based in local communities

· Our social action programmes in local communities are already focussed upon reducing social isolation in older people

· Already jointly working with social care commissioners

Enhanced Social Prescribing:

The second worker/s, the ‘care navigators’, would offer a more in-depth support function, likely to be targeted at specific demographics (probably older people in this pilot) who require additional support, and referred by the community navigator, or NHS colleagues. The care navigator would need different knowledge and skills and could be recruited with/by an appropriate local partner organisation in the locality (for example An Age UK) in order to take advantage of the added value of links to that organisation’s expertise, knowledge and resources.

This navigator would have a smaller, more intense case load, having a person centred approach which would undertake a holistic assessment through ‘guided conversations’ and provide additional practical and logistical enablement support to clients.

Navigators will be most effective if they are based close to NHS colleagues in order to become integrated with wider teams providing support. Secondly, it will enable them to engage as early as possible in a person’s care and support journey.


An outline budget is as follows

Community Navigators x2 covering southern Staffordshire £42,000

Care Navigators x5 (one per district) £105,000

Equipment, expenses and training £7,000

Grant support for small VCSEs (£10k per district) £50,000

Management and overheads £30,000

Total £234,000

Appendix A – Further Examples of Social Prescribing Interventions and Activities

The Bromley by Bow Centre, Tower Hamlets, London

One of the pioneers of social prescribing within the NHS. Their website has information about the centre, how it operates and the services it provides.

Wellspring Healthy Living Centre, Bristol

Another NHS pioneer, which has been evaluated by the University of the West of England. Information about the centre is available at their website;

Social Prescribing Service, Rotherham

Delivered by Voluntary Action Rotherham, an established and frequently referenced service. More information can be found at;

Ways to Wellness, Newcastle

An established partnership in Newcastle including charities, social enterprise and the NHS, working in deprived areas of Newcastle.

City and Hackney social prescribing scheme, London

A well evaluated scheme which has focused on isolated people over 50 and those with type 2 diabetes.

Social Prescribing Age UK Yorkshire and Humber