Primary Care Networks Social Prescribing

Social prescribing is embedded in GP practices to give Primary Care Settings the flexibility to engage with Social Prescribing Link Workers to improve the health and wellbeing of individuals in their community.  

Through embedding social prescribers within the GP practice, they become a strong member of the multi-disciplinary team (MDT) to encourage everyone to work holistically to get the best results.  

Here instead of a patient seeing a doctor and then a Link Worker when starting their social prescribing journey, patients can see Link Workers straight away when they make an appointment. 

At this point, social prescribers can use health records from the GP’s clinical software to use a population health management approach. Link Workers can ensure every individual has access to the care and support they need when they need it, especially for more vulnerable and underserved populations in the community to make sure all services are accessible to everyone.  

Social prescribers within a GP practice therefore are essential in helping to create more person-centred care and can help raise awareness about the impacts the wider social determinants of health can have on an individual’s health and what are the best ways to manage them.

GP social prescribing has many benefits. One of the biggest benefits includes the flexibility to allow GP practices to use a variety of social prescribing models.

It’s up to Primary Care Managers  to decide and use whichever contractual arrangement they think will work best in their local area.  

At this point it doesn’t matter which model is used, what’s important is that all GPs, stakeholders,  other healthcare professionals and the Link Workers themselves are all in agreement in how to get the best outcomes.  

Embedding GP social prescribers therefore can results in multiple benefits for your local community. For example, it encourages closer working relationships and better co-production approaches across all primary care stakeholders. This is because Link Workers play a vital role within primary care settings to raise awareness about the effectiveness of social prescribing to increase engagement and improve outcomes further. This, in turn, helps GP practices to identify the unmet needs of their patients to reduce health inequalities and deliver more proactive social prescribing which adapts as needs change.  

Patients can easily work alongside Link Workers to co-produce their social prescription and agree to attend the services and interventions that matter to them. This prevents patients, stakeholders, and other healthcare professionals losing interest, by ensuring they are all in agreement in how to get the best outcomes.  

Through encouraging patient involvement from the start, they can also easily learn how best to cope with the wider social determinants of health in the future. This helps reduce dependency on GP surgeries as well as reduce hospital admissions. 

This is also a great opportunity for individuals living with long-term conditions to learn and understand how best to cope with their condition and engage in groups with people similar to them to prevent loneliness and improve outcomes further.

Embedding GP social prescribers across different primary care settings is important as it fosters collaborative work and provides evidence for social prescribing to secure more funding in the future, but more importantly it can result in multiple benefits for your local community. For example, it encourages closer working relationships and better co-production approaches across all primary care stakeholders. This is because Link Workers play a vital role within primary care settings to raise awareness about the effectiveness of social prescribing to increase engagement and improve outcomes further. This, in turn, helps GP practices to identify the unmet needs of their patients to reduce health inequalities and deliver more proactive social prescribing which adapts as needs change. 

The video below shows Kelly, a Link Worker at Merton Connected, explaining the benefits she has experienced since using digital social prescribing within her PCN. 

As discussed, social prescribing across primary care when implemented correctly can be very beneficial. Being able to prove its impact is vital to secure future funding and increase engagement with social prescribing.  

Measuring the effectiveness of social prescribing can be difficult however, so Primary Care Managers and Digital and Transformation Leads must be aware of how to be able to demonstrate both the return on investment (ROI) and the social return on investment (SROI) too.  

The National Academy of Social Prescribing (NASP) have demonstrated in a variety of ways the different ROIs and SROIs of social prescribing to help other organisations better present their evidence for social prescribing too.  

In their Evidence Review of Economic Impact of Social Prescribing they highlighted that for every £1 spent on social prescribing they was both an average £2.30 ROI and £2.86 SROI. They also noted that one of the best ways to present both the ROI and SROI simultaneously is to analyse the reduction in GP attendance and the cost savings that generates for each GP Practice. Hackney’s social prescribing service found they saw a £3.51 SRI for every £1 they spent as well as a huge reduction in their GP attendance.  

At Access Elemental Social Prescribing, we have also seen GP attendance decrease dramatically for our customers after they digitally transformed their social prescribing services. For example, Age Barnet UK found their GP attendance decreased by a staggering 65% in the first three months alone, and Action Together saw a decrease of 49%.  

With national averages seeing decreases of GP attendance being 28%, this demonstrates how our social prescribing software helps our customers go one step further to both help individuals and healthcare professionals too, by improving work-life balances and overall community wellbeing.

According to the Process Theory it is argued that for complex interventions to be successful it must go through 4 stages: 

1. Coherence – The initiative must be clearly understood and distinct from other approaches  
2. Cognitive Participation – Practitioners must believe and buy into the innovation  
3. Collective Action – Everyone must know how workloads will change and how it will fit within common practice  
4. Reflexive Monitoring – Assess whether it’s working and whether changes need to be made 

It is important to note, however, that most GP practices are currently in the coherence stage. This can be challenging as it does not leave much time to prove evidence for social prescribing before NHS England reviews the rollout to discuss future funding.  

With the funding from the Additional Roles Reimbursement Scheme (ARRS) due to finish in 2024, there is increased pressure for Primary Care Managers to secure more funding from alternative sources before one of their biggest sources runs out.  

Without this funding, many GP practices wouldn’t have been able to embed  Link Workers in the first place.  It was announced in the Investment and Evolution: Update to GP Contract Agreement 2020/2021 that all ARRS roles employed by 2023-2024 will be considered as part of the core general cost base beyond 2023/2024, but the limiting budgets mean Primary Care Managers need a plan of action in place if this funding does end in 2024.

To continue securing funding therefore GP practices need to ensure the rollout of social prescribing is successful and that they have a plethora of cases and data to prove that.  

This has not been the only challenge that primary care settings face some of the other major challenges include: 

1. Lack of awareness 
2. Limited time  
3. Limited resources and budgets  
4. Data privacy and Fragmented Systems  
5. Training and education  

For social prescribing to be successful across primary care it is vital that all primary care professionals know and understand what social prescribing is and the benefits it can have on their community. Without everyone on board, it will not be promoted properly or explained to patients correctly.  

Even little things like having posters in waiting rooms communicating about how social prescribing works in their GP practice can have a big impact, as it can help start the conversation and perhaps trigger a patient to realise that is the help that they need, or if not them another loved one.  

To do this, time is needed. Time is needed to onboard and train staff, time is needed to educate the community, and time is needed to be spent with patients to create their social prescriptions. But, as discussed already GPs are put under a lot of pressure and are very limited with time. Primary Care Managers and Link Workers can face resistance to learning new processes and systems, so any additional systems that are introduced to implement social prescribing must be easy and simple to use.  

Currently, there is a lack of interoperability and reporting within primary care to demonstrate the uptake and impact of social prescribing, and without that the roll-out of social prescribing, it  can be very limited meaning it is at risk of not reaching its full potential.

Primary Care Settings should recruit Link Workers/ GP Social Prescribers because they can act as the glue to bring care together across the community. It is integral to personalised care and helps to make what really matters to the individual the priority.  

GPs and Nurses are very well trusted in communities and through their promoting, patient engagement in social prescribing can increase. This will allow more people to get involved and get better health outcomes.  

One of our customers, Merton Connected, found that to start with GPs were only referring patients to Link Workers but now as their service has evolved and continues to do so nurses, healthcare assistants, and receptionists have been making referrals too.  

During the pandemic, their work didn’t stop, and they were able to work remotely but still access all the data and information they needed in one centralised place.  

Once Link Workers are recruited, it is essential that accessing clinical systems is easy to use and highly accessible, investing in digital social prescribing is the best way to do this.  

We know social prescribing works at Access Elemental, and we listen to feedback from Social Prescribers, Primary Care Managers, and end-users themselves on how we can improve their experience further.  

Through responding to Link Workers’ feedback our community referrals can be made 5 times faster than completing referrals manually. Nearly 50% of Link Workers who use our social prescribing software have stated that this has saved them up to 2 hours a week on administrative tasks and 66% of them feel it has helped reduce work-related stress and staff burnout.  

Merton Connected found through their local evaluation that recruiting Social Prescribers has been a great success. Their evaluation showed that in Pre-Covid’ times social prescribing reduced patients’ GP appointments by 33% and their A and E attendance by 50%. It also showed that their wellbeing scores improved by 77%.  

Social prescribing therefore allows clinicians to concentrate on medical problems whilst Link Workers can tackle health inequalities to close the inequality gap to improve the community’s health and wellbeing and have a better work-life balance in the process.

Since social prescribing was announced it was embedded in the NHS Long Term Plan, the NHS has released a variety of resources that can help PCNs ensure they deliver successful social prescribing.  

One of the most popular resources is the Social Prescribing Link Workers reference guide for primary care networks. This guide contains a wealth of information including what personalised care means and how social prescribing fits under that, as well as the importance of using population health management approaches.

It also provides checklists and planning templates to remind link workers what they should remember. 

Some of the key things to remember from the planning template include: 

• Ensuring representatives from your ICP, Local Authority, PCNs, VCSE leaders, existing social prescribing services, and people with lived experience are all involved throughout the planning process  
• Make sure PCNs use the national social prescribing SNOMED codes to capture details of social prescribing referrals  
• Ensure you all agree on your identified cohort according to your local population’s health needs  
  
  

Some of the key ideas and themes included in PCN checklists include: 

1. Partnership working and shared local planning e.g. How will you work alongside local partners to improve access to social prescribing in an identified cohort with unmet needs? 
2. Providing Social Prescribing Link Worker services – e.g. Have you worked through the job description and workforce development framework to ensure that the social prescribing link workers can provide dedicated support to individuals based on the question ‘what matters to me’?  
3. Working with people on ‘what matters to me’ – e.g. How will you ensure Link Workers will have the flexibility to spend time and build trust with people and organisations? 
4. Connecting people to community groups – e.g. How will Link Workers take people to community groups to introduce them and ensure they are comfortable and included? 
5. Access to IT systems, data gathering, and impact measurement – e.g. How will Link Workers establish or work with existing local data systems to gather core referral data? 
6. Safeguarding and quality assurance in onward referrals – e.g. How will you ensure your PCN works flexibly, inclusively and proportionately will small community groups who may lack formal policies to enable them to be involved in social prescribing? 
7. Equality, diversity and inclusion e.g. How will you support Link Workers to proactively work with and respond to the needs of all communities within a local area? 

As well as following NHS guidance and using their resources another big discussion point when embedding social prescribing within PCNs often revolves around the practicalities and how easy it will be to embed one service within another. How will Link Workers access the data they need? How can GPs keep track of patient’s progress?  

At Access Elemental Social Prescribing we understand these concerns and queries and we have made our social prescribing platform easy to use to allow all the information to be found in one place. We know how difficult it is to measure the impact of social prescribing and have become the first official social prescribing partner of the PRSB to have promote the importance of the new social prescribing standards.  

We were heavily involved in the development of these standards to help make it easier for your primary care settings to be able to show the true value of social prescribing. As we move forward with our partnership with the PRSB further we are also working towards becoming the first social prescribing software to be conformant to the new standards. 

Our software 100% interoperable with leading clinical systems including EMIS Web, SystmOne, and Vision through our two-way integration, as well as our Social Care Record and EPR system Mosaic and Rio, to make managing referrals easier. Here any Primary Care Professionals can make the referral within their clinical system to send through to Elemental in a matter of 4 clicks.  

Our software is 100% interoperable with leading clinical systems including EMIS Web, SystmOne, and Vision through our two-way integration, as well as our Social Care Record and EPR system Mosaic and Rio, to make managing referrals easier. Here any Primary Care Professional can make the referral within their clinical system to send through to Elemental in a matter of 4 clicks.  

GP practices also have the freedom to push back social prescribing specific SNOMED codes into the patient record and track individual health journeys to measure the impact of social prescribing by using tools such as ONS Wellbeing Scale, PAM, and SWEMWBS.  

At Access Elemental Social Prescribing we make the users of our software our priority and we have listened to our customers about what could be improved to make outcomes even better.  

For example, Link Workers no longer need to send structured text back over at certain trigger points and instead, they can send back free text at any point of a social prescribing journey. They can also send back attachments so more in-depth reports can be accessed and read by the GP to track health journeys better. 

We have also added additional SNOMED Codes to our social prescribing software as we are aware that social prescribing journeys are becoming more complex and not every area will use the same terminology.  

For more information on our recent enhancements download our summary guide of our webinar today to see how we can help make the transition of embedding social prescribing in your PCN even easier.

In this article, we have reviewed what social prescribing across primary care is, how social prescribers can be embedded within GP practices, as well as the importance of their roles.

We have reviewed the challenges of social prescribing within PCNs and why it is important to be able to have evidence for social prescribing to secure future funding.  

This article has also reviewed how best to make PCN social prescribing successful through following NHS guidance and their social prescribing resources but also through investing in digital social prescribing as it helps track, record, and monitor social prescribing journeys all in one place to make it even easier to track evidence for social prescribing.  

Here at Access Elemental Social Prescribing we want to ensure when social prescribing is used, regardless of the sector it is used in, that it is successful. For Primary Care Settings we know how important it is for Link Workers and GPs alike to be able to access the information they want and need and that’s why we have recently enhanced our two-way integrations with clinical systems to help your PCN implement social prescribing right to be able to have evidence for social prescribing to secure future funding.  

This article has also reviewed how best to make PCN social prescribing successful through following NHS guidance and their social prescribing resources but also through investing in digital social prescribing as it helps track, record, and monitor social prescribing journeys all in one place to make it even easier to track evidence for social prescribing.  

Here at Access Elemental Social Prescribing we want to ensure when social prescribing is used, regardless of the sector it is used in, that it is successful. For Primary Care Settings we know how important it is for Link Workers and GPs alike to be able to access the information they want and need and that’s why we have recently enhanced our two-way integrations with clinical systems to help your PCN implement social prescribing right.  

Equally, we know that for seamless implementations of new software, better funding opportunities need to be available and that’s why we are working hard to inform all PCNs, ICBs, and Regional Leads about the new NHS Reimbursement Fund which can be spent on multiple digital tools to modernise general practice including social prescribing.

For more information and tips from some of our customers on how best to implement social prescribing download our social prescribing guide today.  

Contact us and we can help start your social prescribing journey today to improve health outcomes, reduce dependency on GPs, but most importantly improve the quality of life for the patients in your local area.