The People’s Health Partnership Social Prescribing service has two social prescribers, including myself, working across nine GP surgeries and medical centres. It has been up and running since December 2019 and supports patients with a variety of social, emotional and medical difficulties.
When we first set up the service, we actively promoted it to ensure that it was well used. We arranged meetings with practice managers and lead GPs from all nine practices to explain the service and give staff the chance to ask questions. We also produced a document and leaflets highlighting the types of issues we could help with. Posters also promoted the service to patients.
Initially we took referrals from clinical staff, but patients can also self-refer using the forms provided in the waiting areas.
We created a database of existing community-based services and visited local voluntary services to ensure we better understood what each service was able to offer, develop links with them and map out referral pathways.
Referral process and initial engagement
We receive referrals from clinicians via the clinical computer software as a task. They include the reason for the referral and the social prescriber can access patient notes for more information on the individual and their circumstances.
Each patient referred to the service then receives an initial phone call from the social prescriber to tell them about the service and to undertake a brief initial assessment. At the end of the call, the first face-to-face appointment would be made, either at the surgery or the patient’s home, if required.
Appointments are 60 minutes to allow the social prescriber to fully discuss the patient’s issues and priorities and we have a maximum of six appointments per day.
The first appointment includes a guided discussion using a social prescribing measurement tool to explore the patient’s current situation, whether they have any long-term health needs, what kind of support network they have and what matters to them. This approach helps the person to reflect on what they can do and where they might need help or support.
All information collected is recorded in the clinical system, along with any referrals or signposting that has occurred.
Where appropriate, a patient’s goals and aspirations are also documented, printed off and given to them to provide a written copy of what was discussed. A more in-depth documentation of consultations is written into personalised support plan templates.
The results of social prescribing
During the initial few months of taking referrals we had positive feedback from both patients and GP surgeries. We have seen patients with a variety of complex physical, psychological and social needs.
As well as working with patients during one-to-one appointments there have been other projects to promote wellbeing. Plans are being put in place for a local diabetes support group to deliver expert talks once a month. This will allow patients and families to access further support and mean that GP time can be more focused in their appointments with patients.
We also plan to become a parkrun/parkwalk practice and set up singing sessions for asthmatic patients. Before the pandemic we were also delivering weekly group consultations in GP surgeries for patients with chronic health conditions, such as diabetes or asthma.
Challenges we’ve faced
However, we have faced challenges along the way. In the early days some of these related to the understanding of the service from staff at surgeries, logistical difficulties and managing referrals and work schedules.
Due to the nature of social prescribing we have also found ourselves working with some of the most complex patients from each surgery. This has led to people with complex mental health needs being referred for emotive and psychologically challenging sessions. We have had to consider how we work so that we don’t become burned out.
Social prescribing post-COVID-19
There is also a new uncertainty brought about by COVID-19. Both social prescribers are now working remotely and contacting patients via phone. Alongside our current caseloads we are also now supporting each surgery by phoning their vulnerable patients to ensure they are safe, well and have support to access medication and food.
These checks include ensuring that patients have a support network and asking if they would like regular phone contact from the social prescriber. For those who are isolated, we have offered emotional support via befriending services such as Chatterbox, Call in Time and Age UK.
We would like to retain these ‘wellbeing calls’ and continue to monitor those who are at risk. We have identified a number of patients in need of support, interaction or additional care who had not been referred to our service through this process.
The way we interact with patients has also changed since the pandemic, for example we now run our group consultations online. As well as the emotional support, health coaching or a referral to local community services that we were providing before the pandemic, patients now also receive practical support via local volunteer responders who help with transport, prescription collections, food shopping or befriending telephone services.
Due to the uncertainty and unknowns about COVID-19 we have had to be flexible and reactive and our connections with local services are more important than ever. Depending on how long this situation lasts, it may lead to a complete redesign of our service and how people engage.
One positive that has come from the pandemic has been feedback from vulnerable people about the informal support they are receiving from neighbours and friends. It has highlighted the importance of social connections, which go a long way to ensuring emotional wellbeing. This emphasises the important role social prescribing can play to help people access services and develop connections in the local community.
- Sapphire McCalla is a social prescriber for People’s Health Partnership Primary Care Network in Birmingham and the Midlands champion for the National Association of Link Workers
The National Association of Link Workers (NALW) is the only exclusive platform for social prescribing link worker professional excellence and support. For further information visit the NALW website. A range of case studies about social prescribing can be found here.