How social prescribing is helping patients in our practices

A social navigator service in south Cambridgeshire helped to deliver a 20% decrease in GP attendance by patients using the scheme, explains Kelly Austin.

Kelly Austin
Kelly Austin

Granta Medical Practices is a group of five merged practices in south Cambridgeshire with a patient population of 44,000.

Through grant funding from South Cambridgeshire District Council and Cambridgeshire County Council we set up our social navigator service for an initial two-year period.

During the first year of the scheme, 164 patients were referred to the service within the first year. Although the service has seen mainly the older population it has been well accessed by younger age groups.

How the scheme works

Referrals were initially taken from clinicians within the surgery via a referral pathway built into SystmOne, which also indicted whether the patient was housebound and required a home visit, this sent a ‘task’ direct to the service.

Now we take referrals from the community teams, including reablement, as well as self referrals via referral forms or requests from patients via reception.

When we receive a referral myself or my colleague will telephone the patient, or appropriate nominated person identified by the referrer, to arrange a visit or appointment at one of our surgeries. The phone call is a useful fact-finding opportunity, and we also make use of the GP patient record to help us understand the patients’ needs.

On meeting the patient we then spend time with them to co-produce a wellbeing plan. As part of this meeting we also aim to unlock any issues that are a barrier to them, as well as identifying what is important to them, what their interests are, to help improve engagement with any activities we think could help, and we signpost and refer them to identified resources and services.

The results of social prescribing

Where appropriate patients are asked to complete the short version of the Warwick–Edinburgh Mental Wellbeing Scale (SWEMWBS) and the UCLA loneliness scales, which enables us to measure outcomes. These are repeated at intervals across the time the patient is enaged with the service.

We are currently looking at moving from this to the Patient Activation Measure (PAM) in line with the new NHS funding.

Within the first six months of year two of the service we saw a 20% decrease in GP attendance among the patients seen by the social navigation service.

Since the start of our service we have also engaged in our community further by:

  • Hosting a dementia support service from Alzheimer's UK in the surgeries once a month, allowing patients and families to access further support and allowing GP time to be more focused in appointments.
  • Becoming a Parkrun practice and promoting local Parkruns in our surgeries
  • Working with local council initiatives to set up New Age Kurling schemes
  • Hosting Cambridgeshire Hearing Help to deliver two-hour ‘living well with hearing loss’ workshops to patients
  • Delivering group consultations to patients with similar medical condition, including those at risk of diabetes to which social prescribing is crucial
  • Taking part in a Macmillan Cancer Support pilot to enhance our service for those patients who are living with cancer.
  • Becoming a dementia-friendly organisation and training staff to have a better awareness
  • Engaging our patient participation group to support initiatives such as the Chatty Café scheme within our patient population area.

Kelly Austin is a social navigator/social prescribing link worker in Cambridgeshire and East of England champion for the National Association of Link Workers

Annual Social Prescribing Link Workers Success Conference

The 2nd UK Annual Social Prescribing Link Workers Success Conference takes place on 9 October at Radisson Blu Edwardian, in Poplar, east London. The event will provide GPs and general practice teams with the opportunity to discover new updates and best practice and network with colleagues. Find more details here.

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