10 ways social prescribing provided an environment for community resilience to flourish during COVID19
And how this learning, is better informing plans for the future
This blog is a reflective look back at how the social prescribing movement provided the foundation for a preventative and joined up community response to COVID, with social prescribing Link Workers at the centre of coordinating care and support.
We’ve listened to our network of Elemental customers including 4,100 GPs, 108 Social Workers, 854 Link Workers and 51,318 people who benefit from their 939 programmes and services they deliver first hand. They’ve been telling us that demand for their services increased dramatically during COVID, that new referrals routes were established to support more people and that the strength of relationships formed between health and social care, housing, local gov and community sectors enabled them to get ahead of the crisis.
Here’s what our growing network had to say:
‘We were able to easily identify the vulnerable in our community and contact those people as COVID was developing’
‘We saw an increase in referrals across social prescribing networks and programmes. We were able to mobilise our teams to build capacity within, assigning different levels of responsibility’
‘We provided people with the ability to get access to support more directly by providing self referral pathways directly to our Link Workers’
‘We were able to see the most common reasons for referral during COVID and as a result were able to source and invite partners to be part of our network so that we could tap into the support they provide- specifically befriending, mental health support and help with food distribution’
‘The landscape for what people were choosing to be connected to changed overnight’
‘Food security became one of the most important social support services’
‘The ability to remotely on board and train new staff on digital social prescribing tools was crucial in increasing support resource’
‘Housing associations highlighted the importance of social prescribing for customers and tenants’
‘We have been preparing for the short-term and long-term impact of Covid, getting out in front of the crisis’
National Government COVID-19 strategies, local authorities, Housing, CCGs and PCNs, all enhanced their partnerships with community, voluntary and social enterprise sector organisations, both as a means of enabling people to get the non medical support they needed during COVID and as a way to enhance the capacity for community resilience and social connectivity.
As we enter the next phase of COVID, and understand what is now needed from our statutory and community sector partnerships, community assets and service providers, we look to both our Link Worker community, and the communities they directly support, to understand what support they needed during COVID and what made the difference to them during lockdown.
We’ve listened to our network of Elemental customers including 4,100 GPs, 108 Social Workers, 854 Link Workers and 51,318 people who benefit from their 939 programmes and services they deliver first hand. They tell us that demand for their services increased dramatically during COVID, demonstrating the strength of relationships formed between health and social care, housing, local gov and community sectors, enabling them to get ahead of the crisis
They also tell us about how they provided a network of support for their Link Workers during this time to ensure that there were escalation pathways in place, safeguarding and support provided and reflective practice built in and around their teams.
Enhancing social support through digital
Elemental is a whole system platform for social prescribing, creating referrals, while managing and reporting outcomes and integrating with all leading clinical systems. The platform helps to report on the uptake and impact of social prescribing referrals, demonstrating the impact on the person, the community and the health and social care sector.
Expand the headings below to uncover what we learned during COVID directly from those using Elemental:
This ensured that the vulnerable people knew that support was at hand should they need it and helped to alleviate particular fears that people would have. This proved vital for many including Regional Clinical Lead, Dr Mohan Sekeram, who alongside social prescribing Link Worker, Ray Hautot, at WideWay Medical Centre, were able to identify vulnerable patients using Elemental e.g. elderly, people with Mental Health issues or those with carers. Watch the video below to hear what Mohan and Ray had to say.
“Elemental has made it so much easier for GPs to make direct referrals to the Social Prescribing team. Since Elemental has been implemented with the NHS software systems clinical staff can now make referrals more efficiently. We are very pleased about this time saving referral pathway.” Ben Halschka, Head of Social Prescribing, Merton Voluntary Service Council
Wellbeing4U, a social prescription service provided by Welsh Housing Association, United Welsh, adapted their services by coordinators being home-based to reduce the footfall of people in GP surgeries and to carry out telephone consultations rather than face to face appointments. Having the Elemental technology and laptop equipment made it easier to work from home and still provide a service.
The social prescribing service has adapted their way of working to meet the needs of the current climate and the lifestyle/behaviour changes people are being forced to make.
Matt Jon-Hutcherson, from Wellbeing4U, said “We are also using Elemental to pull off certain cohorts of people to contact, e.g. over 65s etc. We are supporting the advice and guidance around CV19 and befriending along the way. We are also delivering online classes and workshops via Zoom.”
The service has also adapted to only receiving digital referrals through Elemental where COVID19 advice and guidance has been added as a referral reason, or through email. They have also adapted their Healthful Network courses to be delivered online.
“Using Elemental has helped Wellbeing4u to create a cohort of patients referred specifically for COVID-19 which will assist us to provide data to the Health Board how we have responded to the current situation and will assist massively in our reporting over the next few months.” Emma South, Health and Well-being lead
Many regions were able to open up new and additional referral pathways into their support teams from council customer care teams, social workers, housing officers and crisis support teams. Referrals were made electronically – instantly and safely -with an update provided to those who made the initial referral.
In response to the Covid-19 Pandemic, Tandridge District Council had to quickly adapt their Wellbeing Prescription Service, which has now been operating remotely for over 10 weeks. In April alone, Tandridge District Council made over 105 referrals for Covid19 specific support. Although the service temporarily doesn’t have a physical presence in GP Practices, they are in regular contact with them, receiving new referrals daily and they are pleased to be able to confidently direct their worried patients to Wellbeing Prescription who can offer advice, support, be a listening ear or signpost onto other services.
“Elemental has enabled Wellbeing Prescription to make a seamless transition from face to face to telephone support. We are pleased we’ve been able to continue the vital work of social prescribing both to our current clients as well as to new clients. Elemental has allowed us to keep track of the ever-increasing list of COVID-19 specific services as well as ensuring we can accurately record the support we are offering while demonstrating how our service has benefited the local community.” – Nicola Boreham, Wellbeing Prescription Manager
GP practices and Primary Care Networks (PCNs) used text messages to contact their patients with a link to a self referral form that enabled patients to refer themselves directly to Link Worker teams rather than having to visit GPs for support.
In Knowsley, a text was sent by a group of GP practices to 52,000 patients and 80 self referrals were received in one hour. Careful planning was required that there was sufficient Link Worker support available so the text messages were staggered across specific periods of time. In the space of 6 weeks, Care Merseyside had an additional 342 referrals since implementing Elemental’s Self Refer.
Additional capacity was carefully managed in the Link Worker team by assigning new roles and responsibilities to volunteers who could support the Link Workers. Coordination of when the text messages were sent to patients was critical.
Regions were able to view a street by street view of the support that was needed and then coordinate and connect with providers of specific services.
The Bureau, a VCSE organisation that provides many vital community based services including the coordination and delivery of social prescribing in Glossop on behalf of Tameside and Glossop Integrated Care Trust, used Elemental to specifically record and track all Covid-19 referrals and the support provided to the rising number of people who needed their help. In the period March-June 2020, the Bureau received a total of 307 referrals for Covid-19:
There were a total of 13 reasons for referral during this time.
-Struggling with Independence
-Problems getting out and about
-Disconnected with the community
Of these, the top reasons for referral were as follows:
The Bureau also made a total of 500 onward referrals:
And prescribed over 300 interventions:
-The Bureau Daily Welfare Calls
-The Bureau 3x Weekly Welfare Calls
-The Bureau Weekly Welfare Calls
-The Bureau Essential Food Bag
-Prescription Pick-Up & Delivery / The Pharmacy Hub
-Adult Social Care
-The GoodSAM App
-Derbyshire County Council Covid-19 Response
-Citizen’s Advice (CAB)
-Derbyshire Carer`s Advice
-Living Life Well Derbyshire
The top 3 interventions were:
Training, support, access to technology and equipment, safeguarding supporting, escalation pathways.
During Covid-19, the Pathways Advisors at The Life Rooms, like many other social prescribing services, had to completely alter the way they worked with people. A service that prided itself on accessible, face-to-face support was reconfigured to take place via telephone. The Pathways Advisors have been taking incoming calls from both familiar and new users of The Life Rooms service since lockdown began. They have also been making proactive outgoing calls to The Life Rooms community and a number of primary care communities to offer support. They have been undertaking this work from The Life Rooms sites.
Working in this way has offered up a number of challenges and opportunities for the Pathways Advisors. Some of the challenges have included the change in dynamic moving from face-to-face to telephone contact, supporting people with needs that directly relate to the challenges of lockdown, and working with other organisations in new ways. These challenges have also brought opportunities because they have allowed the team to connect with people who may never have been able to make it to a Life Rooms site and therefore build relationships with communities and organisations that may previously have felt out of reach.
The Pathways Advisor team have coped tremendously with these changes in working practices, and have kept The Life Rooms users at the forefront of everything they do. However, it is expected that such a drastic change can also be hard at times, so it has been really important that the Pathways Advisors have been supported through this.
In the first instance, The Life Rooms structure is such that they have ‘Senior Pathways Advisors’ who can provide line management support for Pathways Advisors. They have been integral throughout this time in supporting the team through the changes. The Life Rooms also rapidly created a number of process documents, providing clear guidance on new ways of working and has communicated routes to support. A further support measure was implemented through the delivery of the service within Life Rooms sites.
. The Life Rooms offers a social prescribing model based in ‘community hubs’ so that as well as being able to signpost to wider community resources, Pathways Advisors can also offer support within The Life Rooms environments themselves. Whilst these environments have been sadly closed to the public during Covid-19, the Pathways Advisors have based themselves from these sites in order to provide telephone support. This was a deliberate move so that peer and managerial support was readily available to the Pathways Advisors at all times.
Equally, the Pathways Advisors were not having their home environments affected by having to deliver support from them, which has been challenging for many during this time. In addition to these support measures, the Pathways Advisors were given access to regular reflective practice sessions either via online video or in person. This allowed the Pathways Advisors a safe space to discuss practice, share experiences and learn from others.
Finally, challenges with mental wellbeing have understandably been exacerbated through the current pandemic. The Life Rooms sits within Mersey Care, a mental health and community Trust, therefore Pathways Advisors have effective links to mental health support for those they have contact with. Supporting those in mental distress can be challenging, but having links to a wider clinical support offer can certainly provide reassurance to Pathways Advisors. For instance, where the Pathways Advisors are faced with people in crisis, supporting access to appropriate crisis support is able to be done quickly.
Similarly, where clinical support offers within Mersey Care had contact with people who presented with significant social need, access to Pathways Advisor support was easily arranged. Having a social prescribing service as a key part of an NHS Trust therefore allows for a ‘no wrong door’ approach that assures that Pathways Advisors have routes to support when contacts may involve significant risk, and, ultimately, that the person they are in contact with receives support in a safe and effective way.
Food security is an extremely important element of community health and wellbeing. We’re finding more and more organisations in health, housing and Local Gov are identifying poverty and social isolation as a reason for referral into other services and it’s something that’s becoming a key catalyst for other health issues. Often it was access to food that was most difficult for people during COVID.
Scran Academy is a great example of how local leaders & agencies are uniting to be there for people when they need them most. Elemental are honoured to be the platform that is helping power food distribution in these communities.
Scran Academy offers more than just food, they offer daily, healthy meals. By delivering directly to doorsteps, they are supporting those who are unable to access food and/or lack the ability or resources to cook.
Using Elemental, Scran Academy can easily report on and measure what the coalition has achieved to date which include metrics like:
- 94,448 ready meals freshly prepared and delivered direct to doors
- 2,588 people supported so far
- 178 staff & volunteers have come together to give thousands of hours back to communities in Edinburgh
- Over 830 separate referrals from over 100 different agencies
- 20% of referrals have been made direct to the Scran Academy from family, friends or self-referral
- 36% of referrals represent single people, many of whom are socially isolated on their own
- 66% of referrals represent families and couples who have been disproportionately affected by lockdown through job loss, loss of free school meals and/or underlying health conditions
- 9% are facing homelessness or in temporary accommodation with no access to cooking facilities
- Over 400 people have been trained in Covid19 safety guidance and risk assessment
In parallel with an increase in the demand for Elemental’s platform, came a surge in training requirements to support the onboarding of new users of the platform and so, we launched the first phase of our enhanced Elemental Online Training Academy meaning Link Workers, GPs, Community Development teams, Housing Officers and Council staff could carry out all of their Elemental training, in their own time and at their own pace, on any device at home.
The Elemental Online Training Academy, which comprises self learning tools as well as live facilitated sessions carried out by the Elemental Training Team, is now freely available for all Elemental customers and means implementation and onboarding is now quicker, remotely supported and more effective.
“We have found that the Online Learning Academy has been really beneficial. We’ve had to quickly recruit Link Workers in response to Covid-19, so having the ability to have them remotely trained via the academy has meant that we can have them operational within 24 hours and operating as Link Workers.” – Cathy Connelly, CEO Care Merseyside
“Being Link Workers for Care Merseyside, using the Elemental Software has helped us gain a deeper knowledge and understanding in the Social Prescribing world. Training to and becoming a Link Worker has also enhanced our communication skills and confidence when talking and working with clients. We feel that this experience has not only been fantastic research for us, but it has been proactively educational and beneficial. We are so grateful to both Care Merseyside and Elemental for allowing us to come on this journey with them and hope to continue the rewarding work that is life-changing to so many people and we are so proud to be a part of that.” Anna Griffith, Malit in the Community
The lockdown has made it impossible for housing associations like Elemental customers Catalyst fulfill their community commitments as they would usually do however, Sahil Khan, Director of Catalyst Housing, makes the point that even if things never get back to how they were before COVID-19, the need for this work will still be there.
“Working in communities is a privilege that I’ve been able to enjoy throughout the whole of my career. It’s an important part of a housing association’s social purpose and many are dedicated to making their customers’ lives better. The ongoing coronavirus pandemic presents numerous, obvious difficulties to our society, but particularly when it comes to delivering community work.
We were running more than 100 community services, supporting thousands of our residents in the weeks leading up to lockdown, and all of it had to stop overnight: everything from creches to cafes, allotments, homework clubs, gyms, financial inclusion services, job clubs, older people’s activities, and much more”.
Catalyst remobilised a team of 20 staff from across the organisation and tasked them with making ‘wellbeing’ calls to some of their 30,000 customers in London and the home Counties. Since April, they have connected with 3,000 customers and offered them a range of support including signposting to local external services set up in response to Covid including befriending, mutual aid groups, food bank vouchers and food distribution networks.
They have been able to offer access to emergency fuel and food grants as well as providing digital devices and intensive training to digitally excluded households. Catalyst have referred people to their employment and training practitioners to help people looking for jobs or to develop new skills and have been able to offer access to our financial inclusion officers who have been helping with Universal Credit applications, Discretionary Housing payments and offering support about budgeting and bills.
“Even with lock down lifting, we recognise that the wellbeing project really brings us closer to our customers and gives them access to resources, information and advice when they need it most. We are looking to continue this work over the summer with a focus on family and employment support for our customers.” Sahil Khan, Director of Catalyst Housing
The COVID pandemic highlighted that when it comes to healthcare, our health system lacks a comprehensive and collaborative approach to keeping the population well preventing illness. There is more of a focus on measuring the progress being made in the healthcare system, rather than population health.
‘Population health’ is an approach that aims to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across the entire population.
This pandemic has demonstrated the need for place-based collaboration and partnerships. Every single one of our customers in health, housing, Local Government, Social Care and Prison Care have recognised the same priorities and responded quickly to help those that needed it most in our communities in a way that usually isn’t always possible.
Our hope is this level of partnership working continues long after lockdown ends.
Warm Wales is a organisation that works collaboratively with different agencies and providers of services. They were established in 2004 as a Community Interest Company, tackling causes of fuel poverty and reinvesting surpluses in the community, covering Wales & West of England. Their delivery has slightly changed due to Covid, but they are still able to record the person’s journey through uptake of different types of services and are able to see the real impact. They provide the Warm Wales and Healthy Homes Healthy People and are looking at working with GP practice and Health Visitors
‘For me what is really exciting is the opportunities that we have to link more and become more digital and with Elemental’s platform this will really help.
We don’t yet know the full level of impact that lockdown has had on people’s well-being and mental health, but we can anticipate that it will be substantial and that the health inequalities gap will widen. It’s daunting to think that things may never return to a pre-covid standard of care delivery but we now need to focus on community investment, collaborative working, multi-sector partnerships, social prescribing and what’s evident is that digital can tie all of these crucial elements together.
We’re committed to working with you to bridge the gap between sector, services and the community, and we promise to be with you, every step of the way.
3 Things to do now
Elemental is an award winning Tech For Good company that helps stakeholders in social prescribing and population health management to focus on the wider determinants of health: income, wealth, housing, education, transport, leisure and supports the adoption of health behaviours and lifestyles: smoking, diet, drinking, exercise. Elemental better connects stakeholders, providers of services and patients with health risks in the places and communities we live in whilst generating data that helps inform the design and delivery of an integrated health and care system.
Elemental is used by over 279 digital social prescribing hubs across the UK and Ireland to connect people into community based activities, interventions and support pre, during and coming out of this phase of COVID. Over 51,000 people are benefitting from either self referrals or referrals made by crisis support teams, customer care, clinicians, multi disciplinary teams or housing officers to over 800 social prescribing Link Workers.
About the author
Jennifer Neff, Co Founder/CEO Elemental
Jennifer has more than a two decades of experience in regeneration and social and economic development. She drives the sales, marketing and partnerships engine within Elemental and champions social prescribing on lots of different levels.
Jennifer is a thought leader on social prescribing, social innovation and Tech for Good. She is a TedX speaker and was voted one of the Masarati Top 100 Entrepreneurs in 2018. Jennifer also founded the Young Innovator programme in Dubai and supports young people to design and develop solution ideas around social innovation. Link Workers.