Supporting the introduction of social prescribing through integrated approaches to care

Lakeside Healthcare (Lakeside) is a GP partnership serving more than 170,000 patients at eight practices, working in 13 local sites across Northamptonshire, Lincolnshire and Cambridgeshire. Owned and led by more than 50 partners, Lakeside employs over 500 clinical and non-clinical staff.

People's health and wellbeing are often determined by social, economic and environmental factors that a GP cannot simply write a prescription for. As part of the drive to see more people benefiting from personalised care, NHS England committed in its NHS Long Term Plan to widen, diversify and increase access to the range of support available to people across the country through social prescribing.

At scale working presents the opportunity to push forward this agenda by rolling out social prescribing across multiple primary care networks (PCNs) to improve patient outcomes. With a focus on both prevention and effective intervention, Lakeside sought to alleviate the burden on NHS community services and trusts by de-escalating cases that could otherwise need immediate action by mental health teams, urgent care centres or emergency services.

The role of social prescribing empowers individuals to take control of their own health and well-being. It supports a wide range of emotional and social needs using community-centred approaches. Through collaboration and creating partnerships within communities, Lakeside has introduced social prescribing at several of its PCNs to enable patient care at a local partnership and community level. 

Personalised care for patients

Lakeside's social prescribers break down patients' concerns and together they set goals, covering aspects such as mental health, financial difficulties, housing, bereavement, loneliness and isolation, social care, weight management, domestic violence, and substance misuse.

The level of support provided by social prescribers depends on the patient, with an emphasis on personalised care. Some patients may require a simple signpost to another service and not need any further support, while others whose social situations cannot be easily overcome will work with the social prescriber for up to a year. 

Through the process, Lakeside has learned that there is no 'one size fits all' in its communities, but from exposure and learning it has become flexible and adapts delivery of personalised care across communities. For example, in one community where many patients feel isolated, weekly 'Wellbeing Walks' are offered. In another, they are working with the local rough sleeping outreach team to deliver medical and social care to the homeless community.

This holistic approach has highlighted the benefits of system working. In addition to local programmes, Lakeside has developed pathways for personalised care teams to support patients with early cancer diagnosis through one-to-one care. When a patient is newly diagnosed with cancer at their local trust, shared clinical information allows the partnership to offer social prescribing for those who could most benefit – particularly those living with significant uncertainty in the early days of diagnosis.

Lakeside can also direct patients to the most appropriate help, including from community, charity or NHS organisations. From reviewing the success of these pathways, the partnership has established an opportunity to deliver similar care to patients with dementia or who have learning disabilities and aims to implement these. 

By working at scale, Lakeside has managed to roll out the service across a much wider area than a single practice. Starting with just one social prescriber in 2019, Lakeside has now expanded the scheme across several of its PCNs, each with its own personalised care team lead who works with practices, systems and community assets to improve patient offerings and facilitate the sharing of best practice.

Lakeside's PCNs now have over 30 personalised care team members, including social prescribing link workers, health and wellbeing coaches and care coordinators.

Through effective information sharing, integrated approaches to care and a commitment to expanding the primary care team to better support patient needs, the scheme has resulted in an improved service for patients who previously felt isolated or let down by health services, building their confidence and offering support in a setting where they feel most comfortable. It presents the opportunity for personalised primary care and preventative approaches to manage people's concerns before they escalate, relieving pressure on the wider system.